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Out-of-hospital birth: What if something "goes wrong?"

Addressing the Fears of Out-of-Hospital Birthing

 

Countless studies and statistics citing the advantages, safety, and equal / superior outcomes of home and birth center births are read by expectant couples, frequently with the following response: “Wow, great, sounds wonderful, gee I’d love to give birth in a birthing tub.....but..... what if something goes wrong?” In my years as a childbirth educator it has always been fulfilling to objectively address peoples’ dark and vague fears about these “mysterious” dangers. We must directly state what they are, and inform on how they are handled. There is not an endless list of things that can “go wrong” and there is no magical way that these things are prevented in hospitals. 

 

The natural birth movement is making strides in acknowledging the need to not judge women for choices made based on the information they receive. [We CAN judge the lack of accurate information available]. I feel more progress is needed in the area of addressing the REAL BOTTOM LINE: the FEARS that are behind the choices. It’s not enough to tell women how empowered they can be by saying no to authority and having the beautiful birth they desire. A few women have one ear open to this, and have done some research. The bottom line reason for the choices people make is fear for their baby’s well-being. Everyone is out there thinking that birth is dangerous for mom and baby, and to be safe is to be in a hospital, protected from what might “go wrong.” Ask these people what can go wrong, and why they’d better be in a hospital in case it does, and they don’t really know.

 

Addressing the issues should ease fears of all concerned, not to mention making it easier for those who have chosen an out-of-hospital birth to confront the challenges and accusations they may face.  Accurate and realistic information allows people to make informed choices, accept responsibility, and be empowered in the process. 

 

Caregivers

Those seeking an out-of-hospital (OOH) birth will first choose their caregiver, a Certified Nurse Midwife (CNM) or a Licensed Midwife. A Certified Nurse Midwife is a nationally credentialed and state licensed professional, legally allowed to practice out-of-hospital birth in their state. They are ACOG  (American College of Obstetrics and Gynecology) approved, with an advanced degree after the RN. Midwives face huge opposition in the U.S., unlike other countries that have recognized the superior outcomes of Midwifery care for healthy low-risk pregnant women, and Obstetrical care for high-risk complicated pregnancies.

 

Screening

Out of hospital moms are CAREFULLY screened for any risk factors (which would eliminate them as a candidate for an OOH birth), plus given superior prenatal care to keep them low-risk. The midwife monitors what the mother eats (which OBs do not), her intake of iron and protein, her rest, her exercise, her mental health. This type of preventative care is optimum for insuring a low-risk birth. Rather than wait for an unexpected complication to occur, the midwife works to eliminate the possibility of complications prior to birth. 

 

Prenatal Care

The same prenatal schedule as that of an OB is used. The woman is seen once a month until 28 weeks, then twice a month until 36 weeks, then once a week. The difference is that the initial exam is 1 1/2 hours, after which the average visit is 1/2 hour. Midwives get to know their women well; they believe in spending time with them. It is an investment for the midwife in the labor going smoothly. Questions are answered; concerns are treated with respect.

All lab work (iron, diabetes, etc.) is usually done in the office. Women may be referred out for ultra sound if needed (not required); some birth centers have ultra sound.

A CNM has one or more doctors as backup. The doctor may see the client one time, if a home birth is planned.

 

How Complications are Handled

The serious unexpected problems that may occur at birth are hemorrhage or a baby needing help breathing. What people find hard to believe is the fact that these complications are rarely seen at an OOH birth.

 

Hemorrhage

In the case of hemorrhage, Pitocin or Methergin is injected, exactly the same procedure as in a hospital, stopping the hemorrhage The mother is stabilized, and transported to a hospital.

The extremely low incidence of hemorrhage is attributed to: a) superior prenatal care aimed at building and strengthening the mother’s blood and circulation through good nutrition, and screening out risk factors (any hematocrit risk factors associated with bleeding); b) no use of Pitocin during labor. Pitocin is a synthetic hormone commonly used in hospitals to mimic the mother’s Oxytocin, creating strong forceful contractions which peak faster, last longer, come closer together, and are hard on the uterus; c) the Third Stage of labor (expulsion of the placenta) is managed more naturally and gently. The mother is less likely to bleed. 

 

Newborn

If a newborn needs help breathing, a midwife is trained and prepared to do the same thing and use the same equipment as a doctor or a paramedic - an oxygen bag/mask. 

A tight umbilical cord around a baby’s neck would be clamped and cut, as in a hospital setting. 

If there is a need to clear thick meconium and/or resuscitate a baby with intubation, a certified midwife has the same intubation skills as hospital personnel, and recertifies every year.  

An unanticipated cord prolapse (rare incident of the cord coming down before the baby) would require a transport to the hospital, with the mother put in a position to relieve the pressure on the cord. This would have been diagnosed through fetal monitoring, the same as in a hospital.

Shoulder dystocia, the rare event of a baby’s shoulder caught under the mother’s pelvic bone, is dealt with in exactly the same way as in a hospital - various physical techniques and maneuvers to dislodge it. At this point, it is too late for a cesarean, so whether a woman is in or out of a hospital, the same techniques are applied. Both doctors and midwives are trained in managing shoulder dystocia.

 

Contingency Plans 

There is always a contingency plan utilizing the nearest hospital for the true emergencies of a cord prolapse or placental abruption. An abnormal fetal heartbeat, signifying one of the potential problems above, would necessitate a transport. Shoulder dystocia, hemorrhage, or resuscitation are dealt with on the spot, with the same techniques and equipment as in a hospital.  The most common transport is for non-progress or slow labor in first time mothers, after all other measures and techniques have been tried, including rest.  The midwife stays with the woman at the hospital.

 

Comparison to Hospital

Birth Centers and Home Birth midwives carry: oxygen masks, Ambu bags (mom & baby size; attached to oxygen tank), laryngoscope (for intubation directly into the lungs - rarely needed), Methergin and Pitocin for hemorrhage (rarely needed), standard equipment to check the mom’s vital signs. The Doppler, a hand-held fetal monitoring device, is used with the same Standard of Care protocols as the hospital fetal monitoring machine: every 30 minutes in First Stage labor; every 5 minutes for Second Stage labor. IV equipment is available in the event of dehydration (women are encouraged to drink fluids), as is local anesthetic for repair of any perineal tears.  

 

Not available at an OOH birth are the following: blood transfusion, vacuum extraction, narcotics for pain relief, anesthesia (ie. epidural) for pain relief, operating room.    

 

Warm water is the #1 pain reliever at an OOH birth. In addition, the woman receives encouragement, privacy, support, massage, freedom of movement (letting her body & instincts guide), vocalizing, physical techniques for coping with pain and aiding progress, praise, freedom of pushing position and pushing with the natural urge. Drinking is required and eating is encouraged - endurance and stamina are enhanced by fuel.

 

More Answers

Why does almost one out of three women birthing in a U.S. hospital receive a cesarean section to deliver her baby, while perhaps one out of 20-50 women birthing out of a hospital require a cesarean?

 

There are several important issues involved, such as the development of electronic fetal monitoring, legal liability, economics, and philosophical differences between the medical model (birth is a crisis waiting to happen, needing to be controlled) vs. the midwifery model (birth is natural, takes time, women need privacy and support; the body knows what to do). The most important answer, rarely discussed, lies in the lost art of technical midwifery care, which has been replaced by obstetrics in the hospital system. It is somewhat simple. Midwifery is still a “hands-on” approach to birth. If there is a problem  (a long slow labor, a back labor, a post due pregnancy), the midwife is there and she is getting her hands in to find out what is going on. Many problems are and always have been due to the position of the baby - it’s body, it’s head. Throughout time some labors have and always will be longer and harder than others. The midwife is actually feeling the sutures on the baby’s head to discover which diameter of the head is presenting (smaller diameter - flexed head with chin down is the ideal position). If there is a hand in the way, she may move it out of the way! If the baby is trying to look up, she may push his head down again! If an arm or hand is up, she will be able to explain to the woman why her back is hurting so much or why pushing is taking longer. If the baby is posterior (facing front) or asynclitic (simply put, the body and head are at odd angles with one another), the midwife may even put the mom in a squatting or hands and knees position, hold the baby’s head through a contraction, and rotate it. This will save the mother many many hours of painful and slowly progressing labor.

 

In the hospital, this is not done. In fact, many doctors no longer even tell the mother what position her baby’s body is in before labor, nor do they examine the baby’s head position during labor. Instead, when a labor is considered to be slow, commonly the nurse will convey this to the doctor by phone. The woman will then be given Pitocin to speed up her labor, and an epidural to ease the pain of the Pitocin-induced contractions (stronger, more forceful and frequent, and virtually unmanageable). Now what is happening is that a baby who was in an unusual or difficult position to begin with, who needed even more time than usual to negotiate, descend, and rotate its way through the pelvis, is being pounded by the uterus and forced down in a bad position. The woman may (or may not) reach full dilation, but she may then require a caesarean because her baby is “stuck.” Or, the baby has gone into distress from the high doses of Pitocin that squeezed it unnaturally. Lo and behold, another “dangerous” birth requiring a c-section!

 

Finally, the midwife knows this particular woman. She has spent hours with her and trust has been developed. Sometimes a labor may stall due to “psychological dystocia.” Perhaps the laboring woman has fears, unresolved issues, problems with her husband or family, or worries about having this baby - either birth or parenting. Midwives will not hesitate to address these issues during labor, frequently with amazing and immediate results!

 

Conclusion

If you are a woman who wants to know that she has pain medication available to her, than the hospital is absolutely the right choice for you! There is nothing wrong with this choice and nothing heroic, nor irresponsible, about a woman choosing an out-of-hospital birth.

If you are a woman who feels some discomfort at the thought of giving birth in a hospital, laboring with a nurse you will not meet until you are already in labor, or being subject to practices that go against your instincts to any degree, please consider an out-of-hospital birth with a Certified Nurse Midwife. Don’t stop at “but something could go wrong.” Questions you, your partner, family, and friends may have about “what if something goes wrong” can be answered. If there is ever a time in one’s life to make informed choices, giving birth to your baby is that time. 

 

BIBLIOGRAPHY

Bennett, V. Ruth, & Brown, Linda K., Editors.  MYLES TEXTBOOK FOR MIDWIVES, 12th Edition.  London: Churchill Livingstone, 1993.

 

Davis, Elizabeth. HEART & HANDS: A Midwife’s Guide to Pregnancy & Birth, 2nd Edition. Berkeley: Celestial Arts, 1992.

 

Goer, Henci.  OBSTETRIC MYTHS VS. RESEARCH REALITIES. London: Bergin & Garvey, 1995.

 

Oxorn, Harry, B.A., M.D., C.M., F.R.C.S.(C.).   HUMAN LABOR & BIRTH, 5th Edition. Connecticut: Appleton & Lange, 1986.

 

Varney, Helen, CNM, MSN, DHL, FACNM.  NURSE MIDWIFERY, 2nd Edition. London: Jones and Bartlett Publishers Inc., 1987.

 

Interviews with the following midwives:

Tonya Brooks, Director. Natural Birth and Womens Associates, Los Angeles

Pat Chisolm, CNM.  Beverly Health & Birthing Center, Los Angeles

Felicia Forrest, CNM.  Home Birth Service, Los Angeles

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