Emergency backup plans
Home births constitute about one percent of all deliveries in the US and a much higher percent in other parts of the world. That's about 40,000 American babies born at home and doesn't include mothers who planned on having a homebirth, but for one reason or another, ended up transferring to a hospital.
Statistics on how often those transfers happen are hard to find. A 1991 British study claimed 40% of first timers and 10% of experienced mothers; and a 2005 Canadian study claimed 12% of homebirths end up transferring to the hospital during labor. Suffice it to say, it happens fairly often. The biggest reasons are:
- Labor goes on way too long without significant progress
- Her midwife detects a problem with either Mom's or baby's health
- Mom gets too tired or is in too much pain
- The umbilical cord falls into the vagina before delivery (prolapsed cord)
- The baby is in an unsafe position for vaginal delivery (breech, transverse, etc.)
- Mom starts bleeding heavily
- There's a lot of thick meconium (baby poop) in the amniotic fluid
- Mom develops a fever, high blood pressure or some other ominous symptom
- The midwife detects fetal distress
These transfers usually happen with a lot of stress and frequently a lot of drama and crises. Everyone's (patients, families, their homebirth midwife and the hospital staff) freaked out, frightened and worried. Once Mom gets to the hospital, an obstetrician steps in for the midwife and depending on the reason why she left home, the doctor and family make a new plan of care to get mom safely delivered. According to the Canadian study (mentioned above) about 97% of these women are happy with how things work out.
Sometimes, however, that new care-plan is so drastically different from the homebirth plan that doctors and patients have a tough time going with the flow. After the cozy, non-intervention approach mom was hoping for, a hospital birth includes a full load of interventions: fetal heart monitoring, IVs and sometimes Pitocin, epidurals, and c-sections; all administered by nurses and doctors who are essentially strangers. It causes culture shock and frustration for moms and hospital staff. That is, unless they already know each other.
Most "homebirthers" take prenatal education and childbirth preparation classes, study pain management techniques, prepare for breastfeeding and know everything there is to know about how to deliver at home safely. Some, however, fail to prepare an emergency backup plan in case they have to transfer to a hospital.
I talked to one woman who said her midwife recommended she make an appointment for a hospital tour and a meet-and-greet with their obstetricians, "just in case." The woman decided against that because she was confident in her homebirth plans and didn't want to plant any seeds of doubt in her mind.
Of course, you know what's coming here...she spent days laboring at home, developed complications, transferred to the hospital, was assigned to the exhausted obstetrician-on-call and nobody could switch gears to a new birth plan. Even though her homebirth hadn't worked, she fought hospital procedures long and hard. The hospital staff was frustrated because they had to take responsibility for a messy labor with potential for a really bad outcome. They didn't know this patient and she was treating them like the enemy. Neither side trusted the other. Eventually, there was a healthy baby, but only after a long, difficult labor that ended up with a c-section.
How could this experience have gone more smoothly?
- Keep an open mind that babies don't read birth plans and some births must happen at the hospital in order to be successful.
- Go for that meet-and-greet, tour the hospital delivery unit, meet a few nurses and become familiar with standard hospital procedures so they're not strangers.
- Establish care with a homebirth-supportive obstetrician during pregnancy in addition to her homebirth midwife. Then, if necessary, she could transfer care to that doctor during labor.
- Recognize that the hospital staff was not the enemy. They were trying to help and she was not their victim. Some labors take their own path. It's no one's fault.
- Recognize that if her birth was going to work out at home, that's where she'd be. Instead, she chose or needed to go to the hospital. It's different there.
Hospital staff could:
- Recognize that women in labor are stressed out, in pain and very often frightened.
- Address and talk about contrasting birth philosophies immediately after transfer to the hospital and figure out how to bridge the gaps.
- Assign nurses who are supportive of low-intervention and homebirth practices.
- Assign the patient to a certified nurse midwife instead of an obstetrician until an obstetrician is needed.
- Minimize interventions that aren't absolutely necessary and include mom and her family in all decisions and discussions.
- Check frustration and judgments at the delivery room door.
- Recognize that the patient is not a bad mother because she wanted to deliver at home. She's probably not irresponsible or negligent. She simply made different choices.
Many women choose homebirth because high intervention and c-section rates have made them distrust obstetricians and hospitals. Doctors and hospitals have to take some responsibility for that. But, when home birth doesn't work as planned, it's probably going to be a doctor and hospital that saves the day and patients have to take responsibility and let them. It doesn't have to be a battle. It's a birthday party, after all.
Jeanne Faulkner, R.N., lives in Portland, Oregon with her husband and five children. Got a question for Jeanne? E-mail it to firstname.lastname@example.org.
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