Home Birth - - What Medical Options/Tech do you Lose compared to small hospital?

[sste]

Not considering it personally (my risk profile is not a good fit - - nor my personality) but I have been thinking about this alot since the thread where I learned that many hospitals do not have an anesthesia person readily available. Learning that made me way more open-minded about home birth!

So, for me, I go to a large academic hospital and my reasoning is that I have: 1) 24-hour anesthesia and of course surgically trained ob so I can get an emergency c-section on the spot; 2) NICU; 3) crash cart, oxygen, other emergency stuff; 4) ability to transfer me to an ICU if that is needed. (BTW there are also downsides in terms of intervention and BF support with this type of hospital but I have been able to manage that through provider choice).

But, if you are low-risk and choosing a hospital that does not have an anesthesia person right there, does not have an NICU, or an ICU then I just curious as to what the advantage is over home birth? For example, do home birth providers have their own emergency oxygen? Can they shock (crash cart)?

Not asking this to provoke a heated ideological debate, I am just curious as to what are the medical technology/staffing gains from birthing in small hospital without anesthesia/nicu versus a home birth?

[wellyes]

First thing that came to my mind was having your OB or midwife present. You could hire a midwife for home birth but only a certain % will do it. If you want to use the practice that has given you ob-gyn care all along home birth isn't that much of an option.

UNASSISTED home birth is a whole other ball-o-wax.

[WolfpackMom]

Rapid transfer to a big hospital that can deal with high risk situations should an emergency come up?
ETA: If an emergency did come up a hospital would have more people on hand, some to deal with mom, some to deal with the baby should both end up in distress wheras at home you would prob just have your partner and midwife or doula.

[sste]

Oh, I didn't even think of that . . . I was assuming professionally (well-trained midwife) ASSISTED home birth!!

Coming from my perspective, I can't fathom unassisted birth in any setting.

I guess what I am wondering about is that in learning more about small hospitals it seems that many of the advantages that always drew me to hospital delivery aren't necessarily there . . .

[luckytwenty]

I'm just too much of a chicken to consider anything other than a big hospital with a NICU. Wouldn't trade the nicest doula or midwife in the world for that kind of peace of mind--I feel that way now, after having a difficult emergency c-section with my first child in which I got a staph infection and spiked a super-high fever...and I'm glad I felt that way before having him, when I was considering birth options. All the power in the world to people who are braver than me and are willing to go the extra mile for a more profound birth experience, but my personal take on it is that with anything life or death, every second can count. But again, I'm a chicken about this kind of stuff and never was that interested in the whole "birth experience," just wanted to get a healthy baby out of the 9 month ordeal!!

[bostonsmama]

You should also consider the infant mortality rate in home births vs those at hospitals. My guess is, and with any data you have to look at their inherent gaps, that less babies born at home (assisted) have complications than those born at hospitals, partly due to the fact that homebirths are uncomplicated, non cesarean, term, etc. Those w/ GD, pre-E, are pre-term, breech, etc, are usually born in big hospitals with access to crash carts, NICUs, on-call pediatricians, surgical OBs, etc...and to an extent, these conditions lead to higher rates of infant mortality. So...it's hard to accurately compare assisted homebirths vs smaller hospitals vs larger hospitals b/c it's not as black and white as more deliveries are complicated and babies need help/die at this place vs X place.

[sste]

Bostonsmama, I agree. I never was persuaded when people said research has shown that home birth is just as safe because of exactly what you say - - its not a prospective, randomized study. People like me and you with risk factors self-select out of the home birth pool.

But, that said, as someone who would never have remotely considered home birth, after hearing about the lack of anesthesia person at many small hospitals it has made me think twice. *If* I was a younger, low-risk mom who was about the same distance from the small hospital as the amount of time it would take the hospital to page in an anesthesia person . . . I would be asking alot of questions about the gains from small hospital versus home.

[swissair81]

Several points:
1. Unless it is referred to as an unassisted homebirth, all planned homebirths should have a midwife present.
2. Usually the midwife brings an assistant. One person for the mother and one for the baby.
3. Midwives are birth professionals. Therefore they have everything they need except a mobile OR. They bring oxygen & a whole lot of emergency equipment. Anyone who has ever worked in L & D has NRP certification (neonatal resuscitation) & midwives are usually trained in ACLS (Advanced CPR & Life support) as well.
4. Good midwives call 911 & get pre-clearance for an OR when things get sticky. You need to live within a certain distance from your closest hospital or you will risk out & no one will do a homebirth for you.

[daisymommy]

Several points:
1. Unless it is referred to as an unassisted homebirth, all planned homebirths should have a midwife present.
2. Usually the midwife brings an assistant. One person for the mother and one for the baby.
3. Midwives are birth professionals. Therefore they have everything they need except a mobile OR. They bring oxygen & a whole lot of emergency equipment. Anyone who has ever worked in L & D has NRP certification (neonatal resuscitation) & midwives are usually trained in ACLS (Advanced CPR & Life support) as well.
4. Good midwives call 911 & get pre-clearance for an OR when things get sticky. You need to live within a certain distance from your closest hospital or you will risk out & no one will do a homebirth for you.

:yeahthat: My midwife brought 2 canisters of oxygen--one for me, one for the baby, as well as a portable shock unit/defibrillator, shots of [what's it called?] for if you are bleeding too much and need to stop the bleeding, supplies for stitches, etc. Basically everything except the operating room :) Never had to use any of it, and 9 times out of 10 they don't need to. But I think most people have no clue that a midwife has just as much skill, knowledge, and training (and then some when it comes to delivering babies)--as an OB. She just can't do surgery or give an epidural.

With Andrew, I was at 10 cm. for over an hour, and had no urge to push. Were I in a hospital, as soon as they found me at 10 they would be telling me "it's time to push!" as though a magical turkey timer had popped up. My midwife was able to gently feel around and tell that his head and body was not lined up perfectly, and that no amount of pushing would be able to maneuver him out until he was positioned correctly. She had me in all kinds of funny positions to get him to line up right, including walking side ways like a crab up and down our flight of stairs. No doctor would have done that. I would have been pushing forever, and then He would have called it "failure to descend" and would have said I needed a C-section. Once he got into position, it only took a few pushes and out he came, no tears at all.

[Katigre]

In terms of your question, my midwife (CNM) said that she came equipped with everything in a Level III trauma ER (low level ER) - she had an O2 tank, was trained in neonatal resucsetation (sp?) and also had medication to stop a hemorrage - there were three levels of meds there. Methargine tablets, pitocin injection, and cytotec injection (which causes the uterus to contract back down. She was also trained in suturing and basic newborn assessment. We had a plan in place for if a transfer were necessary - what the nearest hospital would be and the route, what records to bring with us, etc...


Bostonsmama, I agree. I never was persuaded when people said research has shown that home birth is just as safe because of exactly what you say - - its not a prospective, randomized study. People like me and you with risk factors self-select out of the home birth pool.
That is why I say "Homebirth is just as safe as hospital birth for a low risk pregnancy" because I feel that is an accurate statement. (Some 'high risk pregnancies' like being over age 35 I also believe HB would be just as safe as a hospital for).

I do believe women should have the right to choose HB even in a higher risk situation (VBAC, twins), but would not make the above argument in support of it ("It's so much safer"). In those higher risk cases it should be acknowledged that there are greater risks for the baby (or mom) but that they are choosing that option anyway due to their specific circumstances/beliefs/intuition. (I.e., someone HBAC'ing would acknowledge that a rupture at home vs. hospital is more dangerous, but would still choose it b/c the risk of rupture is small and the risk of a repeat csection and those associated complications in the hospital is much higher).

I know in my case I had DS in a hospital (and had a great experience) and during my pregnancy with DD I felt very strongly in my intuition that a hospital would not be the best environment for her birth - I am so thankful I made the choice to homebirth (and had it as an available option, even though I had to drive an hour for my midwife appts). For another pregnancy I'm open to both hospital and home depending on the specific situation. :)

[SnuggleBuggles]

I'm just too much of a chicken to consider anything other than a big hospital with a NICU. Wouldn't trade the nicest doula or midwife in the world for that kind of peace of mind--I feel that way now, after having a difficult emergency c-section with my first child in which I got a staph infection and spiked a super-high fever...and I'm glad I felt that way before having him, when I was considering birth options. All the power in the world to people who are braver than me and are willing to go the extra mile for a more profound birth experience, but my personal take on it is that with anything life or death, every second can count. But again, I'm a chicken about this kind of stuff and never was that interested in the whole "birth experience," just wanted to get a healthy baby out of the 9 month ordeal!!

It really isn't that people who choose homebirth or alternatives to the traditional hospital birth want a "profound birth experience" as much as, imo and ime, that they have decided that they have a different POV on risks and benefits. For them, being in a hospital poses more risks than being at home. From your birth, had you contracted a staph infection after a vaginal birth, would you still think the hospital was the safer place to be since if you were at home you probably wouldn't have gotten it? Each and every birth option carries it's own set of pros and cons, risks and benefits. There is not a perfect solution for the low risk, healthy mom and baby. For me I think a hospital environment can be more risky and I know the safe guards that are in place for outside the hospital birth so I feel good about skipping the hospital. Yeah, I do care about the experience and see it as more of a means to an end (I figure you'll remember your births forever so might as well try and make them good memories) but more than that my comfort zone is just not at a hospital. Everyone will come to a different conclusion.

Beth

[Katigre]

It really isn't that people who choose homebirth or alternatives to the traditional hospital birth want a "profound birth experience" as much as, imo and ime, that they have decided that they have a different POV on risks and benefits. For them, being in a hospital poses more risks than being at home.
Yes, exactly.

[american_mama]

>>> First thing that came to my mind was having your OB or midwife present. You could hire a midwife for home birth but only a certain % will do it. If you want to use the practice that has given you ob-gyn care all along home birth isn't that much of an option.


I don't understand exactly what you are saying. One big advantage of a homebirth is that you will have 1:1 provider support for your entire labor, and that provider will be the same person who you got to know through your entire prenatal care. A homebirther doesn't have the disruption and uncertainty of dealing with whichever ob in the practice is on call, shift changes for nurses, providers with large caseloads who juggle patients in the office with patients in the hospital, or ob's who are there basically only for pushing or catching the baby.

Most homebirthers also get their prenatal care from their same homebirth midwife. They may also go to an ob simultaneously (the "just in case" option), but not plan to have him or her deliver the baby. Or they may have been going to an ob for most of the prenatal care but decide they are unhappy with that option and switched to a homebirth towards the end, in which case they are generally happier because of whatever drove them away from the ob.

[DebbieJ]

Several points:
1. Unless it is referred to as an unassisted homebirth, all planned homebirths should have a midwife present.
2. Usually the midwife brings an assistant. One person for the mother and one for the baby.
3. Midwives are birth professionals. Therefore they have everything they need except a mobile OR. They bring oxygen & a whole lot of emergency equipment. Anyone who has ever worked in L & D has NRP certification (neonatal resuscitation) & midwives are usually trained in ACLS (Advanced CPR & Life support) as well.
4. Good midwives call 911 & get pre-clearance for an OR when things get sticky. You need to live within a certain distance from your closest hospital or you will risk out & no one will do a homebirth for you.


:yeahthat: My midwife brought 2 canisters of oxygen--one for me, one for the baby, as well as a portable shock unit/defibrillator, shots of [what's it called?] for if you are bleeding too much and need to stop the bleeding, supplies for stitches, etc. Basically everything except the operating room :) Never had to use any of it, and 9 times out of 10 they don't need to. But I think most people have no clue that a midwife has just as much skill, knowledge, and training (and then some when it comes to delivering babies)--as an OB. She just can't do surgery or give an epidural.



All the above has been true in my experience as well. DS1 was born at home.

:22: :yay: :yeahthat: :rotflmao: (these are from DS1)

[daisymommy]

Ummm, yeah. I don't know anyone who's midwife that has been taking care of them for the last 9 months, isn't the one who is set up to be delivery their baby. Did you think otherwise?

I have only been to midwives for ALL of my well woman care, Gyno. care, and prenatal, pregnancy care for the last 8 years. They are also the same people who delivered my babies, including at home. That is standard procedure.

[Katigre]

ETA: If an emergency did come up a hospital would have more people on hand, some to deal with mom, some to deal with the baby should both end up in distress wheras at home you would prob just have your partner and midwife or doula.
My midwife always has a nurse present with her at a birth so that if there are complications each can focus on a patient - one for mom and one for baby.

[american_mama]

I am generally a supporter of homebirth, but I do think you have to honestly acknowledge some of the limitations of homebirth. Not all homebirth midwives are equally trained (in part because of licensing issues) and I don't think all of them come with the medications and supplies mentioned above. Not all are trained in suturing a tear, for instance, or aren't as proficient at it due to smaller caseloads and a low rate of tears in the first place. I don't think homebirth midwives use forceps or vaccuum, although on the upside, I think they are more trained in using positioning during labor to get babies in a better position in the first place. I don't think any homebirth midwife can do a blood transfusion, whether due to limitations of knowledge, equipment, or access to blood. Homebirth midwives don't have ultrasound, although I don't hear hospital stories were it was used during labor despite its availability, so perhaps it's just not used in labor. And lastly, not all homebirth mothers live close to a hospital, so if the homebirth midwife needed to transport, there is still sometimes considerable time involved before hospital care is available. For a mom who "just" needs an epidural or a "routine" C section (which is probably the bulk of trasnports), this time difference is probably not life or death. In an emergency... maybe.

I had my last child at a small-medium private hospital in a town with one other hospital, a large , very well regarded academic medical center. The private hospital is not that small, about 175 beds and 1,000-2,000 births a year. My sense is that most women in my town who can choose their hospital choose to give birth in the private hospital because it's more personal, no residents, no med students, and the more popular ob practices only deliver there.

Still, I was told different things by different nurses at this hospital. Some told me there is not a pediatrician or ob on site 24/7, but that all providers with privileges at the hospital were required to live in a certain time distance of the hospital. I did not ask if there is an anesthesiologist on site 24/7; I get the impression there might be. I have never heard anyone complain about time waiting for an epidural at this hospital. My midwife said something about how on weekends (when I gave birth), it is very quiet with few/no ob's around (because ob's don't spend tons of time with their laboring patients and because any induced or caesarean birth won't be scheduled for a weekend). One nurse contradicted that when I asked and said there is always on ob on site, usually the lowest ranking ob's at the largest private practice in town. She also said they've never had a problem getting a pediatrician available, her example being a very large pediatric practice that is in sight distance of the hospital and which is open every day of the year until 8 pm. She mentioned a birth they had once where the baby was born near death and they had two or three pediatricians at the hospital in a very, very short period of time. This hospital also has a small pediatric floor, so maybe there is always a pediatrician there who could be paged to L&D.

I believe some of the L&D nurses at this hospital received extra training in neonatal resucitation, but perhaps whatever training they had was standard. One nurse told me about a patient who arrived at the hospital in active labor at 20something weeks, and they called the academic medical center (which is about 3 miles away) and the NATS team (neonatal transport or something) was at the private hospital in 5 minutes. The nurses at the private hospital seemed very confident and comfortable with their ability to handle things. I did not ask the doctors or midwife, but I think they are very comfortable with it too. Locally, you never heard bad things about this hospital.

Lastly, my neighbor delivered twins at this private hospital. I think for twin births, the hospital pages the family pediatrician when mom is admitted and the pediatrician is required to be at the birth. Her second twin was born blue and not breathing, and the private ped was in the room already and got the baby to breathe very quickly. For me, I had a completely normal delivery of a healthy baby on a Sunday afternoon and the pediatrician on call for our practice came in just for us around 7 pm to do the standard neonatal assessment. Then someone from the practice rounded at the hospital every morning and saw all the babies from their practice. Like many hospitals, this hospital does not have a NICU or nursery; rooming in is standard.

Compared to a homebirth, a hospital birth really shortchanges the follow-up care. I think a lot of homebirth midwives do several visits after the birth, not just to assess any medical issues but also to help with breastfeeding issues, infant care, and emotional support. Ob's and hospitals.... well, I bet we all know new moms who feel kicked out of the hospital and left on their own until a cursory 6 week follow-up.

To flip your question a little bit, a lot of people, no matter what kind of birth they prefer, seem not to blink at the option of a birth center birth. But what does a birth center, which many people seem comfortable with, offer that a homebirth does not? If the answer is nothing... why does the birth center seem comfortable if a homebirth does not?

[SnuggleBuggles]

To flip your question a little bit, a lot of people, no matter what kind of birth they prefer, seem not to blink at the option of a birth center birth. But what does a birth center, which many people seem comfortable with, offer that a homebirth does not? If the answer is nothing... why does the birth center seem comfortable if a homebirth does not?

I chose a birth center vs a homebirth for ds2 for a few reasons. The main reason was that it is unlcear to me the legal status of homebirths in my state. I think it is legal but it isn't easy to do. I met a few women in my prenatal yoga class planning a home birth and they were using the same midwife- I think there was really only one in our area. I didn't feel like investing the time into figuring it all out, to be honest. I felt that I could get the same kind of experience at the birth center and it was an easy option.

Another logistical thing was just home prep. I wanted to labor in water but didn't want to go through lengths to get a birthing tub...when I knew the birth center already had one (though legally not allowed to deliver in it in my state).

The mess factor was something else. During labor I wondered why I didn't just have a homebirth because I didn't end up wanting water and was managing very well at home. But, then I had a ton of show and there was a big bloody trail on the floor. Thankfully it wasn't my floor so I didn't have to think anything of it.

Before the birth, before being pg with ds2 in fact, I didn't think I wanted to have the baby at home. Weird but I wanted to bring the baby home from somewhere. That went away and I got away from that feeling. But, the logistical things remained.

Plus, I had learned about the birth center way back in college and was always intrigued and inspired to use it. I think it was just something I wanted to try. If we have a 3rd it will be at the birth center as well.

Beth

[wellyes]

I don't understand exactly what you are saying. One big advantage of a homebirth is that you will have 1:1 provider support for your entire labor, and that provider will be the same person who you got to know through your entire prenatal care. A homebirther doesn't have the disruption and uncertainty of dealing with whichever ob in the practice is on call, shift changes for nurses, providers with large caseloads who juggle patients in the office with patients in the hospital, or ob's who are there basically only for pushing or catching the baby. I had a CNM at my hospital birth who stayed with me. I said that you may have to change care providers to do a homebirth because the ob-gyn practice I'd been going to for YEARS before thinking about having kids was who I wanted to partner with in labor but they don't do homebirths. I'd have to interview & hire someone specifically for that scenario. Not a bad thing necessarily, but it is a factor in decision making.

I chose a birth center vs a homebirth for ds2 for a few reasons. The main reason was that it is unlcear to me the legal status of homebirths in my state. I think it is legal but it isn't easy to do.Yeah. I have a friend in a state like that (RI) who wanted a home birth but legally midwives hands are really tied -- which is a shame. She found a midwife who was willing to assist but only if she was called in when it was too late in labor for her to transfer to a hospital. Which, to me, is absolutely ridiculous. Anyway that friend ended up opting for unassisted home birth and it worked out well.

[daisymommy]

"But what does a birth center, which many people seem comfortable with, offer that a homebirth does not?"

Good question ;) This is what I asked my mother--a Nurse--who was practically begging me to have my last baby at the birthing center instead of at home. Not sure what she thought they had there that we wouldn't have at home.

FWIW...after she was there to lift Andrew up onto my chest after he was born, and she saw how safely it all went, she was singing a different tune, and very impressed.

[sste]

Sorry if my original question seemed unclear . . .

I guess what I am getting at is that I realized in the posts last week that I had a certain set of assumptions about what would be available to me medical technology-wise at ANY hospital and what would NOT be available to me in a hypothetical home birth (or birthing center too).

And with the post about the variability in services offered in small hospitals and the frequent lack of anesthesia on-site 24-7, I realized that some of my assumptions were WRONG!

So, I was interested in learning more about the technologies/interventions/emergency services available in different settings.

FWIW, I will personally never deliver outside of a large, academic hospital for a whole host of reasons specific to my situation and personality but I am not anti homebirth. And I suspect that birthing centers located close to larger hospitals are going to be the trend of the future . . . it seems to me just as the pp mentioned that if small hospitals don't offer the true surgical/nicu services then what is the gain versus a lower-infection, well-staffed, cozy and personable birthing center located in similar proximity as a small hospital to a major hospital center?

Also, not saying that small hospitals are bad - - they are some lovely small hospitals near me that are more like birthing centers than anything else. Just that there isn't this huge difference that I imagined between at least some small hospitals versus well-trained midwife-attended homebirth with emergency equipment in tow/similarly well-equipped and staffed birthing center.

[essnce629]

With Andrew, I was at 10 cm. for over an hour, and had no urge to push. Were I in a hospital, as soon as they found me at 10 they would be telling me "it's time to push!" as though a magical turkey timer had popped up. My midwife was able to gently feel around and tell that his head and body was not lined up perfectly, and that no amount of pushing would be able to maneuver him out until he was positioned correctly. She had me in all kinds of funny positions to get him to line up right, including walking side ways like a crab up and down our flight of stairs. No doctor would have done that. I would have been pushing forever, and then He would have called it "failure to descend" and would have said I needed a C-section. Once he got into position, it only took a few pushes and out he came, no tears at all.

Yep, me too! With DS2 I was at 10cm for at least 4 HOURS with zero urge to push and no pressure or anything! I didn't even go through transistion before that! I may have been 10cm for longer but the first time my midwives checked me (when I asked them too) I was already 10. After 4 hours I told them they could go ahead and break my water so we could get the show on the road! With DS1 when my water broke he was crowning seconds later so I knew the 2nd time around would probably be similar. They broke my water and I had 20 minutes of intense contractions and then DS2 all of a sudden popped out-- head and then body, no tears or anything! No way would a hospital let me walk around at 10cm for 4 hours without trying to intervene!!!!

I've had 2 homebirths and both times had 2 providers present. With DS1's birth I had my midwife and her assistant, who was an apprentice midwife. With DS2's birth I had 2 midwives who worked together and attended all births together. They all carry basic birth supplies and emergency supplies. I was also required to have my birth kit which had a bunch of supplies in it as well (towels, cord clamp, sterile gloves, chucks pads, sitz bath herbs, lube, etc).

[american_mama]

I understood the original poster's question, but my short answers may be lost in my long one. I'll summarize.

I think a homebirth does NOT have these medical options that are at a hospital birth:

* variation in a homebirth midwife's training or use of medications (i.e. IV antibiotics for Strep B, for hemorrhage)
* variation in a homebirth's midwife's ability to suture a tear
* no forceps or vaccuum available at a homebirth
* no blood transfusions at a homebirth
* no ultrasound, if it's even used in labor anywhere
* no epidurals and I think no injectable pain relief (Nubain/Stadol)
* time to transport to a hospital rather than already being there. I have definitely read birth stories and known homebirthers who did not live close to hospitals.

What homebirth midwives do seem to usually have is oxygen, resucitation training, a partner for more helping hands, a plan for transport if necessary, a doppler for monitoring baby's heart rate, and expertise in normal, low risk births.

Also, it seems like the one thing that first interested the original poster was the fact that smaller hospitals don't have an anesthesiologist on-site 24/7. There may be rules at hospitals that mitigate this disadvantage (i.e. an on-call anesthesiologist must be within a certain travel time to the hospital). Also, I assume there would be times an anesthesiologist would be necessary for other medical emergencies, not just labor, and the hospital would have to have a plan for all scenarios.

I'm wondering if there is a difference in epidural rates at small hospitals vs. ones with on-site anesthesia. I don't know, but epidurals-on-demand are such a big part of American birth control (eta: funny typo, I ment to say "birth culture"), I'd be surprised if there was a difference.

[essnce629]

For a mom who "just" needs an epidural or a "routine" C section (which is probably the bulk of trasnports), this time difference is probably not life or death. In an emergency... maybe.

The #1 reason for transfer in a homebirth is failure to progress-- usually in first time moms. The second most common reason is exhaustion, also usually in first time moms. For failure to progress you are usually transferring to be able to use pitocin to get things going again after all the position changes and other midwifery tricks haven't worked. For moms who transfer due to exhaustion, an epidural is usually what they are seeking. Transfers are rarely an emergency needing a crash c-section, as a huge part of a midwife's training is preventing and recognizing when things are heading down the wrong path and transfering to the hospital long before things become emergent. If the majority of transfers were emgencies needing crash c-sections, the infant mortality rate of babies born at home would probably be higher. But it is not-- it is EXACTLY THE SAME as babies born in the hospital to other low risk women. But the morbitity rates in homebirths are significantly less when comparing LOW RISK women who plan homebirths vs LOW RISK women who plan hospital births. I think the overall c-section rate of women planning homebirths ends up being 3% (it's around 1% for non-first-time moms), while the overall c-section rate of LOW RISK women planning hospital births is about 22% (overall including ALL women it's 32%). This is a HUGE difference, and one women should be outraged about! Why on earth do 22% of LOW-RISK women planning hospital births end up with a c-section while only 3% of moms planning homebirths do??? Even the World Health Organization says the overall c-section rate should be no higher than 10% (ideally it should be around 7%). We obviousely have a major problem in the way handle birth here in the U.S.

[essnce629]

I had my last child at a small-medium private hospital in a town with one other hospital, a large , very well regarded academic medical center. The private hospital is not that small, about 175 beds and 1,000-2,000 births a year. My sense is that most women in my town who can choose their hospital choose to give birth in the private hospital because it's more personal, no residents, no med students, and the more popular ob practices only deliver there.


As a doula who has attended several births in the hospital you gave birth at, I can tell you that that hospital is not the norm when compared to other hospitals in the U.S.! I was told by a childbirth educator at your hospital that the epidural rate was just 30%, while the university hospital's rate was 85% (which is the nationwide average). Your hospital had labor tubs in every room, all monitoring was done with a doppler so that mom didn't have to be in bed and could even be monitored in the tub, IVs were not routine, mom was allowed to eat whenever and whatever she wanted, and the nurses were very well educated and knew how to support a natural birth. It's no coincidence that their epidural rate was so low. Even I, a hardcore homebirther, would have no problem birthing in that hospital if I had to! Compared to all the births I've attended at different hospitals in San Diego, your hospital is almost like a free standing birth center in comparison! You are very lucky!

[DebbieJ]

I've had 2 homebirths and both times had 2 providers present. With DS1's birth I had my midwife and her assistant, who was an apprentice midwife. With DS2's birth I had 2 midwives who worked together and attended all births together. They all carry basic birth supplies and emergency supplies. I was also required to have my birth kit which had a bunch of supplies in it as well (towels, cord clamp, sterile gloves, chucks pads, sitz bath herbs, lube, etc).

Shelly and Seannie? They attended DS1's birth. LOVE them!

[swissair81]

I understood the original poster's question, but my short answers may be lost in my long one. I'll summarize.

I think a homebirth does NOT have these medical options that are at a hospital birth:

* variation in a homebirth midwife's training or use of medications (i.e. IV antibiotics for Strep B, for hemorrhage)
* variation in a homebirth's midwife's ability to suture a tear


Neither of these are true. Okay the midwife probably doesn't have antibiotics, but the use & effectiveness of antibiotics to treat GBS is controversial anyway. Midwives have methergine & pitocin for hemorrhage & they absolutely can suture tears. They just can't fix something very extensive that needs an OR (like if a woman tore straight up the birth canal or had a cervical laceration, she might need to be admitted for that). Otherwise you are kind of shortchanging midwives.

[daisymommy]

I think many people do not realize that many midwives are Nurse Practitioners--very close to being a doctor.

[Katigre]

Neither of these are true. Okay the midwife probably doesn't have antibiotics, but the use & effectiveness of antibiotics to treat GBS is controversial anyway. Midwives have methergine & pitocin for hemorrhage & they absolutely can suture tears. They just can't fix something very extensive that needs an OR (like if a woman tore straight up the birth canal or had a cervical laceration, she might need to be admitted for that). Otherwise you are kind of shortchanging midwives.
Actually it depends on what classification of midwife (and how the state licensing works). Like in my state a CPM is not considered 'licensed' so they cannot carry some of the meds you listed nor can they do sutures. But in other states they can (according to my understanding). A CNM can do all of the things above.

[swissair81]

Actually it depends on what classification of midwife (and how the state licensing works). Like in my state a CPM is not considered 'licensed' so they cannot carry some of the meds you listed nor can they do sutures. But in other states they can (according to my understanding). A CNM can do all of the things above.

I don't know anyone who has used a homebirth midwife who hasn't been able to do those things. You also forgot to mention that some midwives are not able to do those things legally, but they do them anyway. Like the whole underground midwifery movement in NYS now.

[Katigre]

I don't know anyone who has used a homebirth midwife who hasn't been able to do those things. You also forgot to mention that some midwives are not able to do those things legally, but they do them anyway. Like the whole underground midwifery movement in NYS now.
I know of hb midwives who will not suture a tear and send the mom to the hospital for anything requiring stitches (usually a 2nd degree or more). I also know of HB midwives who do not carry prescription drugs for hemorrage and instead have herbs or else ask the mom to get her own methargine to have on hand for the birth. Again, there is some variety among practitioners in what they do and don't provide. What my midwife provided is on one end of the spectrum ("uber prepared") and not necessarily normative for the entire field.

(I say the above based on knowing women who have homebirthed with CNM's, CPM's and lay midwives in over a dozen states).

[swissair81]

I wouldn't deliver with anyone who would not have meds for hemorrhage on hand. That is foolhardy & dangerous. Especially if you are talking about someone like me who is already higher risk for hemorrhage, because of the number of children I have.

And I would be really pissed if my birth went perfectly & then had to go to the hospital because the midwife was unable to suture. I would rather have a baby in a birth center & stay put & be able to enjoy my baby without traipsing around. JMHO.

[Katigre]

I wouldn't deliver with anyone who would not have meds for hemorrhage on hand. That is foolhardy & dangerous. Especially if you are talking about someone like me who is already higher risk for hemorrhage, because of the number of children I have.

And I would be really pissed if my birth went perfectly & then had to go to the hospital because the midwife was unable to suture. I would rather have a baby in a birth center & stay put & be able to enjoy my baby without traipsing around. JMHO.
Not every woman lives in a state with birth centers or legal homebirth midwifery (or in an area with legal midwives). If you choose a homebirth in that type of situation then you know going into it what your midwife can/cannot do. Some women feel very strongly about being at home vs. in a hospital (and often do not have good birth options). Again, I am just explaining that there is large variation among midwives b/c 'homebirth midwife' is not a uniform category in terms of equipment and training. I went to my initial HB midwife appointment with a 2 page list of questions because there is so much variation.

[swissair81]

I understand what you are saying. I was simply saying that I personally do not consider a homebirth with a midwife who cannot take care of the above mentioned things to be within the realm of acceptable risk.

[sste]

This brings up a good point - - one which I think is part of the reason people like me, who aren't terribly knowledgeable about this stuff get leery of home birth - - there is a lot of variability by midwife classification AND by state.

To me the midwife/np who sutures/brings anti-hem. meds etc seems like it should be standard of care for home birth in an ideal world - - I see your point swissair that without that it is risky. And avoidable risk.

We have our fantastic doula because despite her training (cnm) she can't practice in our state independently.

[bcafe]

In WI CPM's are licensed and carry O2, pitocin(for uterine contraction post birth if needed), and definitely suture. I am sure there is more but I don't feel like checking my info right now. My midwife is great and if a transfer was deemed necessary she takes off the midwife hat and puts on the doula hat. Swissair, out of curiosity why would having 3 children already put you at higher risk for hemorrhage?

[swissair81]

Causes

The following are potential causes of postpartum hemorrhage:

* Anticoagulant medications
* Birth trauma (lacerations of cervix and/or vagina)
* Bleeding disorder
* Failure to deliver placenta
* Large baby
* Medications that relax the uterus
* One or more previous pregnancies
* Overdistended uterus
* Rapid or prolonged labor
* Retained products of conception after delivery of the placenta (eg, small pieces of placenta and/or fetal membranes)
* Uterine atony (loss of tone of the muscles of the uterus)—most common cause
* Uterine infection
* Uterine inversion (caused by failure of the placenta to detach from the uterus)

The risk increases with each pregnancy & furthermore I have a long & illustrious history of rapid labors (to the point that my doctor has tried to get me to agree to induction to ensure that I don't give birth alone at home or on a roadside somewhere.)

[essnce629]

Shelly and Seannie? They attended DS1's birth. LOVE them!

DS2 was born in VA. We moved back to CA when he was 9 weeks old. I'll keep their names in the back of my head for future doula clients or if there's ever a DC3!

[essnce629]

I think many people do not realize that many midwives are Nurse Practitioners--very close to being a doctor.

95% of certified nurse midwives (CNM) attend hospital births and the rest usually work in freestanding birth centers. Very, very few attend homebirths and when I looked into schools to become a CNM, none of them had rotations in homebirth. All the birth experience was either in the hospital or birth center. I was in nursing school and want to become a homebirth midwife one day, but I will become a Licensed Midwife and Certified Professional Midwife, not a nurse midwife. I will attend a 4 year program most likely that is 100% centered around homebirths and all the birth experience will be at homebirths.

[swissair81]

Maybe it differs by state. I know of CNMs here who do homebirths. I actually considered her this time. I was so high risk earlier in my pregnancy though & there was possibly damage to the placenta, so my dh & parents begged me not to. My OB (who is rather natural minded) was highly uncomfortable with it given my medical history. I contacted her just for the heck of it & I risked out in a serious way.