Homebirth: Interview with a Certified Professional MidwifeKateTietje
Today I’m talking to a Certified Professional Midwife about her experience with home births. Due to the current climate, with many still unsupportive of home birth, she’s asked not to be identified. She has, however, provided her bio so we can read about her experience. This is a follow up post to yesterday’s Home Birth: What if Something Goes Wrong?
In this interview, I propose a variety of scenarios to her: what if…? And she explains when (and in some cases, how often) she has run into this scenario during her 40-year career as a midwife, as well as what the outcomes were. It’s a pretty fascinating interview, really. I’ve read plenty of studies and talked to midwives at length and I was still surprised by some of the amazing stories she told me! Are you ready to hear?
The midwife sent me this brief biography: I have been in practice for over 40 years and have attended almost 1000 births. I am a Certified Professional Midwife (CPM) with current CPR and NRP certifications. I was an advanced EMT for 10 years. I am a midwifery educator and have done midwifery work on a local, statewide, national and international levels.
So, she’s pretty experienced. Here’s our interview:
1) Out of all the births you have attended, approximately how often do you transfer a mother to the hospital?
Approximately 15% of all clients transport to the hospital.
2) What is the primary reason for transfer?
The vast majority of that 15% are first time mothers who choose to go to the hospital for pain relief (an epidural) or because they are exhausted (and want an epidural so they can sleep.) I try to caution each first time mother (even if they are not my client) to eat, drink and rest in early labor. The problem is that most first time moms are so excited (and feel like they have waited so long for labor to begin) that they get a rush of adrenalin making sleep difficult or impossible. Having never experienced labor before, they often believe that the mild, early labor contractions they are feeling must surely be “active labor”. Sometimes, they are even afraid that if they sleep, they may miss the birth. I assure them that this will not happen. If labor begins in the daytime, I urge them to go about their normal activities and try to ignore the contractions as long as possible and nap, if possible. With the growing popularity of water labor (using a deep tub of warm water) there are fewer first time mothers who feel they need an epidural for pain relief. Still…I urge them to avoid getting in the tub too soon, as it can slow or stop early labor.
3) How often do emergency transfers happen?
True emergency transports are really quite rare…perhaps 1% of all clients. And even so, many of those arrive at the hospital with both the mother and the baby in good shape, because I would rather err on the safe side and regret an unnecessary transport later than wait too long and risk arriving at the hospital with either the mother or the baby in trouble.
4) Have you ever lost a mother or baby? If so, what were the circumstances? Do you believe that this would have been different if they had been in the hospital?
I have never lost a mother. Over the years, however, I have lost a few babies. Most of these were for inoperable birth defects. These deaths could not have been prevented no matter where the baby was born.
Interestingly, I have had two babies born with a diaphragmatic hernia. This is a defect in the baby’s diaphragm which occurs at approximately 10 weeks gestation. The diaphragm fails to close during development and the intestines fill the space above the diaphragm. Thus, the lungs do not have adequate space to develop.
The first of these two babies was born at home. His heart rate was always normal during labor, but when the cord stopped pulsing (providing oxygen) after birth, he became blue and limp. I used a mask and bag with oxygen to breathe for him and took him to the hospital. There they performed surgery to move the intestines back where they belonged and close the hole in his diaphragm. They then placed him on ECMO (similar to a heart/lung machine) which oxygenated him while his lungs were given an opportunity to develop adequately so he could breathe on his own. About a week later they were able to remove him from ECMO. This was many years ago and one of the first times ECMO had been used to resolve this problem, so he was followed for 9 years (the last I heard) and always demonstrated normal development and no brain damage at all.
The second of these two babies was supposed to be born at home, but both the mother and I felt we should go to the hospital. I cannot explain why as labor was progressing normally and there were no signs of distress. My best explanation is that our intuition knew it was time to go. The baby was born in a metropolitan hospital and much like the first baby, her condition worsened shortly after birth. The baby had the same surgery and treatment, but died a few days later. Although the cord was clamped and cut immediately at birth, I doubt this was the cause of death. I believe the difference in these two cases was that the first baby’s lungs were further developed at the time of birth than the second baby’s lungs and her lungs simply could not make the transition.
So here is an example of two babies with nearly identical problems and the one born at home survived and the one born in the hospital did not. I suspect the outcome would have been exactly the same regardless of where they were born.
5) Have you dealt with mothers who hemorrhaged at home? How have you handled that situation? What were the outcomes?
Yes, I have seen hemorrhage about 6% of the time.
First, it is important to rule out those at risk for hemorrhage before labor begins. Anyone with a hemoglobin of less than 12 (anemia is diagnosed as less than 10) would not be a good candidate for a home birth. Anemia does not cause hemorrhage, but it does two things that would put that mother at risk. The “heme” on red blood cells carries oxygen to the brain and muscles. A low hemoglobin means that less oxygen is delivered to the brain and the muscles. Muscles, including the uterus (which is a muscle), require oxygen to function well. And it is the contractions of the uterus which stop bleeding after the birth, so it is important that the uterus gets enough oxygen to contract well after birth to prevent hemorrhage. Adequate delivery of oxygen to the brain means the mother can tolerate a great deal more blood loss before losing consciousness. We test all clients at 28 weeks when their blood volume is fully expanded and their hemoglobin has returned to normal (it tends to be low during the 2nd trimester) to make sure they have a hemoglobin of 12 or above. If it is low, there are a number of things they still have time to do to raise their hemoglobin before they go into labor, including dietary changes, taking spirulina (blue-green algae) and Chlor-oxygen (chlorophyll). We retest until their hemoglobin reaches 12 or recommend a hospital birth. It is also important to make sure the placenta is not located low in the uterus or covering the cervix. We check for this prenatally.
Second, in labor we would transport a mother who was having a prolonged labor with weak contractions that are too far apart and too short to achieve dilation of the cervix. This may be as a result of a hormonal imbalance. Any mother who requires pitocin (the synthetic form of the naturally occurring hormone oxytocin) to progress in labor, is at risk for hemorrhage following the birth.
On rare occasion, however, without any of these forewarnings, a mother (usually after an unusually fast labor) may still bleed excessively following the birth. There are many things I have done to stop the bleeding. I will try to list them in order, although sometimes I do not follow this exact order, depending on the situation and how rapid the blood loss is.
· Put the baby to breast to cause the uterus to contract
· If the placenta is not out and efforts to get it out fail, manually remove the placenta
· “Guard” the uterus use your hand to massage the uterus and make sure it does not fill up with blood
· Give the mother herbs, such as postpartum formula or cramp bark
· Give the mother methergine tablets (if the bleeding is slow but the uterus will not stay firm)
· Tell the mother to stop bleeding this works surprisingly well!
· Give the mother an injection of pitocin to make the upper segment of uterus contract
· Give the mother an injection of methergine to make the lower segment of uterus contract
· Do bimanual compression squeezing the uterus from above and below to stop the bleeding
· Pack the uterus with sterile gauze to apply direct pressure on the bleeding vessels.
· Use a bulb syringe to slowly put warm water into the rectum until it comes out again. This water is rapidly absorbed by the body and will maintain her blood volume until the bleeding is under control.
Although none of my mothers have died and none were transported to the hospital for hemorrhage, some require a week or so of rest and spirulina or Chlor-oxygen to recover from a significant blood loss. I suppose they could go to the hospital to get a unit or two of blood to speed the recovery process, but most would rather not do this.
6) Have you dealt with any babies born not breathing? How do you handle that? What is the usual outcome?
We are all trained in neonatal resuscitation. We practice these techniques and renew our certification on a regular basis. Fortunately, babies who do not breathe at the time of birth are rare. Again, prevention is the best treatment! We monitor fetal heart tones throughout labor, transporting any mother whose baby demonstrates a poor rate or pattern. Sometimes, simply having the mother change her position (get off her back!) can resolve the problem.
We have all our home birth clients prepare a “resuscitation board” using a covered cookie sheet with an attached neck support for the baby. This provides a solid surface near the mother, even if she gave birth underwater — on which to perform CPR should it be required.
The first thing we do differently than the hospital is to NOT clamp or cut the cord until after it has stopped pulsing, providing a gentle transition for the baby from getting all its oxygen from the cord to using its lungs to get oxygen. Generally, the cord will pulse at least 5 minutes (I had one baby who did not breathe for 12 minutes, but his heart rate, color and muscle tone were good and his cord continued to pulse strongly!). Typically, in a hospital birth, the cord is clamped and cut immediately..this is especially true for a baby that requires resuscitation.
Gentle tactile stimulation (rubbing the baby’s feet and/or back) while keeping the baby covered and warm, is usually all that is required. If that is not successful, I use a bag and mask to inflate the baby’s lungs (5 puffs is usually enough). The bag could be attached to a source of oxygen, although the latest evidence suggests that additional oxygen is not necessary. Neonatal resuscitation teaches us a specific set of steps to follow (assessing color, heart rate, respiratory rate, muscle tone, response to stimulation) at critical times following birth and when it is necessary to initiate the next step (such as heart compressions).
The usual outcome when a baby does not breathe at birth is that tactile stimulation is enough to jump start him/her. Occasionally, full resuscitation is required, but if you follow the resuscitation steps properly, the baby recovers well. If not, you could always transport the baby while resuscitating…but I have never had to do this.
7) Have you dealt with cord prolapse? What happened?
I have only seen a cord prolapse once. In that instance, I felt a loop of cord in the bulging membrane. In this particular instance, the fetal heart tones were normal and it was still early in labor. We transported the mother to the hospital in a knee-chest position to keep the baby up off the cord. (If fetal heart tones had been affected, I could have transported her in that position using my hand to push the baby’s head up off the cord) The physician who met us at the hospital, prepped her for a cesarean and then used a tiny needle to put a small leak in the membrane. This allowed the fluid to leak out slowly (instead of in a gush) and as the fluid leaked out the loop of cord slowly slipped back up above the baby’s head. She delivered vaginally without incident.
8. Have you dealt with labor that did not progress? How do you handle that? What happened?
Unfortunately, slow progress, especially for first time mothers, is not all that unusual. The first line of defense is prevention. Prenatally and in early labor, it is important to make sure the baby is in a good position anterior (not posterior) with the head tucked well.
In labor, the most important thing to do is be patient. Although there are lots of “rules” about how fast labor should be, women are all unique and rarely follow the rules. If the mother is well hydrated and rested (even if only dozing between contractions) and the baby is tolerating labor well…I wait! In fact, I would discourage the mother from doing anything to speed up labor. Sometimes, the best thing to do is provide the mother with privacy in a dark, quiet, comfortable space with as few interruptions as possible.
If her labor pattern is erratic and not progressing normally, or if the baby is no longer tolerating labor, or if her membranes have been ruptured for a long time, I would consider transport to the hospital. If she is in active labor with a good pattern of contractions, but is unable to sleep or even doze, a warm shower or birthing tub will often help. Given enough time, most babies come out by themselves.
9) Have you dealt with badly positioned babies (breech, sunny-side-up, hands up by face, etc.)? What happened?
I have seen quite a few posterior babies which I believe is due, at least in part, to our culture. Our furniture (and even our cars) these days is designed to encourage the mother to slouch, rather than sit up straight or in a straight backed chair. We spend little time on our hands and knees (scrubbing the floor, gardening, etc.). Consequently, I educate my clients to move and sit in a manner that tilts the uterus forward and uses gravity to help the baby’s back remain toward the front of her body (away from her spine). Posterior babies can come out that way, but the labor is usually longer and more painful.
I have attended a number of breech births, although most will turn prenatally all by themselves. There are a number of techniques that will encourage the stubbornly breech baby to turn. However, on rare occasion, a baby will turn to breech in labor. I am not comfortable delivering a breech baby for a first time mother because it takes so much longer for a first baby to move through the birth canal, potentially compressing the cord for a long period of time. However, if it is not a first baby, the best thing to do is keep your hands off! I teach workshops on how to master breech birth, but the first rule is to let the baby maneuver its way out all by itself. They know what to do! I only help if it is absolutely required.
If the hands are up by the face (most often in rapid labors) this is generally not problematic, although the likelihood of a tear is greater due to the larger diameter coming through.
10) Have you dealt with women who tore? How do you handle that?
Anything other than a minor “skid mark” (shallow split in the skin that does not require suturing) is really rare unless the mother has had a previous episiotomy (which is more likely to tear open). Early in my career, I did suturing, but it has been so long since I have seen a serious tear that I am out of practice now. I attend workshops to practice suturing skills, but hope I never need them. For a severe tear, I have a backup (hospital based) midwife, who sutures on a regular basis in her practice, that I could call upon. Most minor tears (1st and 2nd degree tears) actually heal better if they are not sutured and there are fewer infections and fewer problems with being stitched up too tightly.
11) What was the most difficult situation you ever faced? What happened?
The most difficult situation is the loss of a baby. Although most cannot be prevented no matter where the baby is born, it is extremely sad for the family and for me.
Thanks to our midwife for answering these questions!
Does any of this information surprise you?
Top image by mbaylor