Interview question #3:
What is involved in giving birth at home? What materials and resources does the midwife bring? What is the process like? What happens if there are complications?
Safety of Home Birth: For healthy women with normal pregnancies, the safest form of maternity care is called “physiological management”. Physiological management is the evidenced-based model of maternity care and is associated with:
· the lowest rate of maternal and perinatal mortality
· is protective of the mother's pelvic floor
· has the best psychological outcomes
· the highest rate of breastfed babies
This differs greatly from obstetrical management, which routinely uses drugs and medical and surgical procedures during labor and birth. At present, the only circumstance that permits the mother’s labor to be managed physiologically is community-based midwifery care in the family’s own home or an independent birth center.
Dependence on physiological principles results in the fewest number of medical interventions, lowest rates of anesthetic use, obstetrical complications, episiotomy, instrumental deliveries, Cesarean surgery, post-operative complications and delayed or downstream complications in future pregnancies. Physiological management is both safe and cost-effective.
Physiological: to be "..in accord with,
or characteristic of, the normal functioning
of a living organism”
(Stedman’s Medical Dictionary definition of “physiological” – 1995)
Scientific Studies on Home-Based Birth Care: The British Medical Journal (BMJ June 18, 2005), a recently published a prospective study on community-based midwifery in the US by certified professional midwives providing care to women who intended to deliver at home when labor began. The formal conclusion by the authors was that: “Planned home birth for low risk women in North America using certified professional midwives was associated with lower rates of medical intervention but similar intrapartum and neonatal mortality to that of low risk hospital births in the United States.”
Specific results included an overall hospital transfer rate of 12.1% for women who intended to deliver at home when labor began. Total medical intervention rates (after transfer to the hospital) included an epidural rate under 5%, episiotomy of only 2.1%, forceps rate of 1.0%, vacuum extraction under 1% and very low caesarean section of 3.7%. These rates were substantially lower than for a similar group of women having hospital births in the US. The intrapartum and neonatal mortality among low risk women at start of labor was 1.7 deaths per 1000 planned home births. According to researchers: “This is similar to risks in other studies of low risk home and hospital births in North America.”
Client Selection for Primary Midwifery/Home-Based Birth Services: Professional midwives (both LMs and CNMs) offer home-based services to essentially normal healthy women enjoying a normal pregnancy who plan to labor at home and, assuming (a) continued good health of mother and baby and (b) normal spontaneous progress without complications, give birth at home.
Non-medical Criteria: Home-based birth services require that the client’s living arrangements provide adequate space, sanitation, light, heat, hot water, availability of telephone, transportation and plans for emergency evacuation to a hospital. Clients are usually required to read and sign appropriate informed consent or waiver of standard care documents. Many midwives require parents-to-be to agree to medical consultation and/or hospitalization if serious medical complications arises either during the pregnancy, the intrapartum or immediate postpartum/postnatal period.
Physician Consultation, Referral: Professional midwives engage in an ongoing process of risk assessment that begins during the initial consultation and continues through the completion of care. In addition to assessment, this includes risk prevention, risk reduction and referral or transfer of care to a physician or medical facility whenever necessary or at the mother’s request at any time during pregnancy, labor or afterwards.
Hospital transfer rate: This varies widely for different midwives and different patient populations. However, in general, it is between 10 and 30 % for first-time mothers and usually less than 2% for those having a second and subsequent pregnancy. The Cesarean section rate in a recent prospective study on community-based midwifery in the US by certified professional midwives (published British Medical Journal June2005) was 3.5 % for mothers who began spontaneous labor at home.
Routine Antepartum Care: I schedule routine prenatal visits on a regular basis, with a full assessment of maternal and fetal wellbeing at each visit. This includes an interview on your physical and psychological wellbeing -- appetite, sleep, any illness, signs of complications or pre-term labor, how often the baby moves, any emotional or family upsets, etc. Then I do a standard prenatal assessment including blood pressure, deep tendon reflexes, tracking uterine height, fetal heart tones, fetal position & size, amniotic fluids levels and additional lab tests if indicated. Return prenatal visits usually takes about 25 minutes, leaving plenty of time to discuss social and psychological topics, answer questions and address your concerns about labor, birth or the new baby.
Standard diagnostics evaluations during 2nd & 3rd trimester: AFP at 16 weeks, ultrasound at 18 weeks for fetal anatomy, gestational diabetes screening at 24-26 weeks, antibody screening at 28 weeks for Rh-negative mothers, repeat CBC at 30-32 weeks (blood test for anemia & platelets), GBS culture at 35-37 weeks, herpes culture if indicated, additional ultrasounds as needed, NST if questions about fetal wellbeing, biophysical profile for post-dates. With appropriate informed consent, you may decline the above listed tests unless critical to my continued care.
Home Visit at 37 Weeks: I do a home visit in order to find your house, meet your spouse (and other family, friends who may be present during labor), do your normally scheduled prenatal care, discuss what supplies your need, how to recognize labor & time contractions, when to call me, what to expect during labor, etc. Last but not least, I conduct a ‘practice labor’, which is a walk-thru, talk-thru of the stages and phases of labor and how to help your family help you to best cope with early labor. This is meant to compliment, not replace, standard childbirth education classes.
Community-based Midwifery care for Planned Labor and Birth at Home:
Early or latent labor: Most midwives ask the mother-to-be to call them whenever they think they might be going into labor. This phase normally lasts from 4 to 48 hours, during which the midwives are in frequent telephone contact and may even make a house call(s) to evaluate the situation. It’s important that the mother continue to eat, drink, void regularly, walk about during the day, rest at night and, as much as possible, retain their sense of humor.
Intrapartum care for active labor & birth: The primary midwife or a qualified assistant comes to the mother’s home from the time labor is well-established (usually about 4 centimeters cervical dilation, earlier if needed) until mother and your baby are in stable condition after the birth (approximately 2 to 4 hours). Midwife presence for a first time mother usually spans 10-15 hours.
Equipment and supplies: Midwives bring standard midwifery equipment and disposable supplies for normal labor, birth & immediate postpartum. This includes fetal/maternal monitoring equipment (Doppler, BP cuff, stethoscope, etc). Some midwives also have access to portable electronic fetal monitor. Other supplies includes sterile delivery instruments, local anesthetic, sutures, baby scales, oral vitamin K and comfortable measures such as drinking straws, heating pad, shower stool, birth stool and various other useful materials. Midwives also carry standard emergency drugs, sterile needles and syringes, oxygen, IV fluids, and neonatal resuscitation equipment for first-responder care in case of a maternal, fetal or neonatal emergency. For some midwives their emergency equipment includes pulse oximetery.
Active Labor: During the first stage of active progressive labor the fetal heart tones are typically monitored every one-half hour using a Doppler and more frequently during second stage (pushing phase). For most births a second, experienced midwife will be called a couple of hours before the baby is expected to be born and she will stay for a couple hours afterwards.
Immediate care after the baby is born: The midwives and assistants stay a minimum of two hours after the birth (or as long as necessary). During that time they make the new mother and baby comfortable, keep them both warm and help establish bonding and breastfeeding. They also make sure that the new mother is fed tasty nourishing food and has plenty to drink. For the first hour or so most midwives do no ‘procedures’ beyond comfort measures and checking on the well-being of mother and baby.
Before leaving the parents’ home, midwives get the mother up to the bathroom, help her shower and dress and make the bed with fresh linens. A newborn exam and gestational age assessment is performed on the baby and the baby is weighed, measured, diapered and dressed. If there is any potential medical problem for either mother or baby, one of the midwives will stay until both mother and baby are stable. If medical care is required after the birth, midwives typically accompany the family into the hospital and stay as long as necessary.
Emergency Care during Labor, Birth or Immediately Afterwards: Two kinds of emergency problems associated with childbirth are bleeding problems for the mother and breathing problems for the baby. As part of my national certification and state licensure as a midwife I am also certified in neonatal resuscitation by the American Academy of Pediatrics. I carry emergency oxygen and injectable anti-hemorrhage drugs (oxytocin). Use of these emergency procedures is rare and when necessary are usually effective. If such first-aid measures do not resolve the problem, EMTs would immediately be contacted and the mother and/or baby attended by paramedics while being transported to the hospital by ambulance. I have transported one mother by ambulance for a retained placenta and excessive bleeding after the birth. Thus far no mother or baby has suffered any serious complications due to the decision to labor or give birth at home.
Elective Hospitalization: Responsibility for the mother and baby’s medical care will be taken over by the physician and hospital staff if a client is transferred to obstetrical care during labor. Midwives customarily accompany the mother to the hospital as an advocate and support person and remain until after the birth. After release from the hospital, the midwife will (at the mother’s request) resume normal midwifery care during the postpartum and new baby period, including home visits, routine office visits and nay extended postpartum or ‘second nine months’ care.
Follow-up Postpartum/Postnatal Care, Breastfeeding: The new mother or baby will be seen postpartum / postnatally anytime, day or night, and as frequently as necessary, should there be a problem. The midwife or a qualified assistant provides scheduled home visits 30-40 hours postpartum and again between 72-90 hours (3rd or 4th day), unless a problem or possible complication requires earlier or more frequent home visits or referral to medical care. First-time breastfeeding mothers will be seen again at 7 days if there is a question about the baby’s wellbeing. The birth-related work the midwife is not concluded until the baby is nursing well.
Newborn Metabolic Screening: Many midwives also will do the standard newborn genetic screening text sometime during the first week of the baby’s life or it can be done at a local hospital recommended by the family’s physician.
On-going Pediatric Care: Midwives recommend that the parent make arrangements for newborn evaluation and on-going care with a pediatrician or family practice physician before the baby is born. They usually can provide the names of pediatric care providers that are philosophically compatible with your choice of community-based midwifery care. If problems or possible complications are detected at the time of the birth or immediate afterwards a pediatric evaluation or hospital transport will be necessary.
Extended Postpartum/Postnatal Visits by the Midwife: Assuming no problems, the midwives typically sees mother and baby routinely at two and six weeks.
Birth Certificate: The profession midwife is responsible for registering the baby’s birth and either files the birth certificate directly or assists the parents to file the appropriate forms.
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