Home birth: Sometimes nature forces plans to change

October 2010 Posted in Your Health

By Aurora Ellison

Guidelines for Home Birth
Risks defined as “absolute”
requiring hospital birth:

• Overdue baby (43 weeks)

• Triplets or more

• Placenta previa

• Pre-eclampsia, eclampsia (high blood
pressure in mother)

• Premature labor

• Drug abuse

• Severe disease in mother such as
AIDS or active cancer

• Non-absolute risks, may require
hospital birth

• Conditions requiring ongoing
medication

• Overweight or underweight baby

• Uterine anomaly

• Anemia

• Twins

• Malpresentation (e.g. breech)

• Psychiatric disorders

• Maternal exhaustion

• Previous cesarean section

(level of risk depends on type of incision)
Source: Oregon Health Licensing Agency.

After enduring vacuum extraction, cesarean section, and having a baby resuscitated immediately after birth, Jeannie and Mike Gearhardt decided on an alternative approach for their fifth child: home birth.

So the Gearhardts went midwife shopping.  The search started  — and ended — with Betty Griffith, a licensed direct-entry midwife who came highly recommended.

Mike brought pages of questions to the interview. Jeannie said they felt comfortable with Griffith because she “didn’t act like she knew everything.  She was open to whatever was needed,” even if that meant using the hospital. They were struck by Griffith’s cooperative attitude. She didn’t come across as controlling or “in charge.”

While Griffith was willing to help them attempt a VBAC (vaginal birth after a previous cesarean), family reactions were mixed. Mike’s sisters had had successful home births, so his side of the family was very encouraging. Jeannie’s parents, however, opposed home birth.

Jeannie’s mom, a nurse, didn’t think it was wise.

“She was there for the shoulder dystocia birth which was pretty traumatic,” Jeannie said.  The baby’s shoulder got stuck behind the mother’s pubic bone in the birth canal and the compressed umbilical cord began to lose oxygen.  The baby required resuscitation, but fortunately did not suffer brain damage.

Jeannie’s father also opposed home birth:  “I think he tried to do just about anything in his power to not have it happen.”

But Jeannie hoped that the freedom of movement at home might preclude some of the complications she experienced while confined to a hospital bed.  She looked forward to the relaxing environment of home after her “hectic” and “panicky” hospital experiences.

She attributed fear of home birth to lack of information.

“The knowledge isn’t out there about all the safeguards that a midwife is able to use at her discretion if things go wrong.  It is risky, but so is any birth.”

What if something goes wrong?

“In most cases, if something goes wrong there’s some warning… We’re looking for warning signs,” said Griffith. She said she asks three questions that help size up every situation: Is mom OK?  Is baby OK?  Does everyone (mom, dad, midwife) want to stay home?

“If the answer to any of these is ‘no,’ then we have to see if we can resolve it at home or transfer care [to a hospital],” Griffith said.

The most common unforeseeable problems involve the umbilical cord.

Griffith recalled one birth she attended where the cord was being pinched during contractions, causing the baby‘s heart rate to dip. As they prepared to move to the hospital, they found a position that took the pressure off the cord and the mother was able to deliver at home.

Licensed direct-entry midwives follow rules set by the Oregon Health Licensing Agency.  The OHLA decides which conditions are “absolute risks” requiring hospital birth.  For “non-absolute risks” such as twins or breech presentation, the OHLA requires the midwife to consult an experienced health care provider before attempting home birth.

In an emergency, LDMs are trained to resuscitate the infant or mother, administer oxygen and intravenous fluids, repair minor tissue damage, and give medication to treat hemorrhaging. LDMs are required to carry equipment for all of these treatments.

Plan B

When Griffith accepted Jeannie as a client there was one main risk factor: previous cesarean. Attempting a vaginal birth after cesarean is a risk because the uterus can rupture along the scar.  Also, the reason for the cesarean, such as slow labor or a large baby, may reoccur.

Late in the pregnancy, when the baby should have been settling into a head-down position, Griffith discovered a second risk-factor: the baby was breech. Ultrasounds are optional for low-risk clients, but in this case she ordered one to be certain. She was right, the baby was in the wrong position. With the compounded risk, Griffith advised the Gearhardts to find a doctor who would be willing to take over.

“Sometimes there’s good reason to do cesarean. If you’re in that category we need to think twice about whether it’s a good idea to stay at home,” Griffith said.

The Gearhardts hoped the baby would turn so they could attempt home birth, but Jeannie ended up having a cesarean section at Silverton Hospital.  The Gearhardts were thankful the transfer of care went smoothly.

“It was a great disappointment to them, but it was still a safer choice,” Griffith said.

Griffith has never had a problem transferring an expectant mom to a doctor’s care when it was necessary. She estimates out of the 20 births she attends each year she transfers one or two to a doctor’s care. Most of the time the change occurs before labor.  “We have a responsibility to not bring [the hospital] a disaster that we caused…[but] transfer care in a timely fashion.”

Looking to the future

Although the Gearhardts had a positive experience at the hospital, they still admire the philosophy of home birth. Jeannie said she respects the doctors’ expertise, but also values the rapport and relationship she experienced with Griffith.

In spite of Jeannie’s history of complications, the Gearhardts are optimistic about having more children and possibly the experience of a home birth. Meanwhile, eight-month-old Aiden Gearhardt is healthy and happily oblivious to the circumstances of his birth.

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