Planning a Safe Homebirth- The Mother

Part II of Jane Hall's post Planning a Safe Homebirth::

So, you've found a great midwife who has impeccable education, a level of experience that you're confident in, a well run practice and she is well respected in her community for the standard of care offered?  Great!  You've managed the hardest part of planning a safe home birth, and can be assured that you have the safest attendant for birth in an out of hospital setting. 

Bottom Line:  While planning and having lots of resources and ideas for birth is a great idea, ultimately birth is something that you react to as it unfolds, not something you control and tell how to go.  Sometimes it is better to choose a small intervention earlier than to risk needing a bigger intervention later, and there is absolutely nothing wrong with deciding before, during or after birth that your needs are best met in ways that might not fit the "Crunchy Bible" but which will make for your best and most compassionate birth even if it's not the "most natural" one possible.

Here are things to consider in planning for your safe home birth:

1.  Know beforehand what hospital you would be transferring to should you need a higher level of care, and pre-register there.  Know how you're going to get to a hospital in an emergency (including emergency plans for immediate care for any other children at home), and make sure that you go over with your midwife under what situations you should call 911 immediately before labor, during labor and in the early postpartum period instead of calling her to come to attend you.

2.  In a situation planning a home birth, I would recommend accepting more testing than I might otherwise choose in a hospital birth setting because I want as much information as possible when making the choice to have a baby where there isn't a NICU down the hall.  Here are some common tests and why I think they're especially important in a home birth setting:

*  A dating ultrasound helps make sure that you are completely solid in terms finding the safe parameters for home birth, both on the earlier side and the later side. 
*  The Quad Screen is a screening test that identifies whether you are at increased risk for certain conditions.  It is not a test that "only matters if you're willing to have an abortion."  If a quad screen comes up with increased risk of neural tube defect, some neural tube defects can be treated in utero through surgery and early identification is helpful.  I would not choose to have a child with Downs Syndrome born at home because of the increased risk of heart defects that accompanies Downs, and having the concrete risk numbers to looks at makes for a more informed and more confident choice.
* An 18-20 week anatomy ultrasound can identify issues that make out of hospital birth dangerous for mother or child.  It can identify the rare cases where a baby's birth defect makes vaginal birth extremely risky, and can identify potential issues with that would threaten the mother's health as well, including issues with the placenta. 
* The glucose tolerance test is far from perfect, but gestational diabetes is real and it does result in many complications including an increased risk of pre-eclampsia, lungs that are slower to mature, excess amniotic fluid, low blood sugar for the baby immediately after birth and a real increased risk of stillbirth.  Identifying and treating gestational diabetes *is* important. 
*  Appropriate monitoring after your due date is critical in preventing stillbirth.  Work with your midwife to determine an appropriate schedule for non-stress tests and biophysical profiles.
*  Be prepared for induction of labor at 42 weeks, and be confident that getting that dating ultrasound way back in the first trimester will make sure that you are not jumping the gun earlier than necessary or risking going too late. 

3.  When it comes to a specific birth plan writing time, I encourage you to be flexible and to focus less on "natural" birth and more about having a birth that sets you off on the best footing to enjoy your first few days treasuring your baby.  Some fairly small interventions can make a big difference to you and your baby, including:

*  Group B Strep testing and treatment:  1 out of every 200 women who are positive for Group B Strep will have a baby become ill from Group B Strep disease.  Antibiotics decreases the risk of Group B Strep disease so that your chance becomes 1 in several thousand, not 1 in 200.  Part of safe home birth is knowing your GBS status, and appropriate treatment to prevent transmission to your baby.  There is no reason for antibiotics to keep you from being able to labor in a tub or in whatever positions you're most comfortable in.
*  Active management of 3rd stage:  After having a baby, you can use all of the energy you can get to recover and enjoy your babymoon.  Anemia from post partum hemorrhage is not worth risking to avoid one shot of pitocin, and waiting until you're already bleeding (ie. "physiological management of 3rd stage") means that you will be losing blood until the medication has a chance to kick in.  Active Management of 3rd stage, including every woman getting anti-bleeding medications, is actually a World Health Organization recommendation with solid evidence to support it. 

4.  Know when to call it quits:  Sometimes you *can* have a home birth but not without significant cost or risk to yourself and your baby.  The only safe home birth is the home birth that can be quickly abandoned when the needs of mom and baby are best met by being in a more advanced setting, and that doesn't just mean for dire, lights blaring emergencies.  Be willing to make the soft calls where technically you could "suck it up" and follow the Crunchy Bible but where doing so will put an additional burden on you that you don't need to carry. 

It's ok...
* to find out that this particular labor is way more painful than you anticipated and that you don't want to do it without medication 
* to have been really sick the whole week before labor strikes and be so dehydrated that you need fluids and rest
* to be exhausted by the demands of a particularly labor with no clear end in sight, and transfer for pain medication and for possible cesarean birth
* to have a bad PPH and transfer for a blood transfusion
* to decide that you want an MD to repair any tearing
* to have had a really really hard labor and be exhausted enough that you ask your partner to give your newborn a bottle of infant formula so you can sleep for 6 hours straight

None of those choices make you a bad mother or a wimp, or in any way compromise how beautiful birth is.  Some births demand more from us as mothers, and there is no shame or weakness in choosing to take advantage of the very safe resources that medical technology has to offer.  Birth is a miracle in any setting, and there is no intervention, no test, no procedure, or no safe choice in birth that makes it any less miraculous to welcome a new person into your life and into your family. 

Planning a Safe Homebirth- The Mother

Part II of Jane Hall's post Planning a Safe Homebirth::

So, you've found a great midwife who has impeccable education, a level of experience that you're confident in, a well run practice and she is well respected in her community for the standard of care offered?  Great!  You've managed the hardest part of planning a safe home birth, and can be assured that you have the safest attendant for birth in an out of hospital setting. 

Bottom Line:  While planning and having lots of resources and ideas for birth is a great idea, ultimately birth is something that you react to as it unfolds, not something you control and tell how to go.  Sometimes it is better to choose a small intervention earlier than to risk needing a bigger intervention later, and there is absolutely nothing wrong with deciding before, during or after birth that your needs are best met in ways that might not fit the "Crunchy Bible" but which will make for your best and most compassionate birth even if it's not the "most natural" one possible.

Here are things to consider in planning for your safe home birth:

1.  Know beforehand what hospital you would be transferring to should you need a higher level of care, and pre-register there.  Know how you're going to get to a hospital in an emergency (including emergency plans for immediate care for any other children at home), and make sure that you go over with your midwife under what situations you should call 911 immediately before labor, during labor and in the early postpartum period instead of calling her to come to attend you.

2.  In a situation planning a home birth, I would recommend accepting more testing than I might otherwise choose in a hospital birth setting because I want as much information as possible when making the choice to have a baby where there isn't a NICU down the hall.  Here are some common tests and why I think they're especially important in a home birth setting:

*  A dating ultrasound helps make sure that you are completely solid in terms finding the safe parameters for home birth, both on the earlier side and the later side. 
*  The Quad Screen is a screening test that identifies whether you are at increased risk for certain conditions.  It is not a test that "only matters if you're willing to have an abortion."  If a quad screen comes up with increased risk of neural tube defect, some neural tube defects can be treated in utero through surgery and early identification is helpful.  I would not choose to have a child with Downs Syndrome born at home because of the increased risk of heart defects that accompanies Downs, and having the concrete risk numbers to looks at makes for a more informed and more confident choice.
* An 18-20 week anatomy ultrasound can identify issues that make out of hospital birth dangerous for mother or child.  It can identify the rare cases where a baby's birth defect makes vaginal birth extremely risky, and can identify potential issues with that would threaten the mother's health as well, including issues with the placenta. 
* The glucose tolerance test is far from perfect, but gestational diabetes is real and it does result in many complications including an increased risk of pre-eclampsia, lungs that are slower to mature, excess amniotic fluid, low blood sugar for the baby immediately after birth and a real increased risk of stillbirth.  Identifying and treating gestational diabetes *is* important. 
*  Appropriate monitoring after your due date is critical in preventing stillbirth.  Work with your midwife to determine an appropriate schedule for non-stress tests and biophysical profiles.
*  Be prepared for induction of labor at 42 weeks, and be confident that getting that dating ultrasound way back in the first trimester will make sure that you are not jumping the gun earlier than necessary or risking going too late. 

3.  When it comes to a specific birth plan writing time, I encourage you to be flexible and to focus less on "natural" birth and more about having a birth that sets you off on the best footing to enjoy your first few days treasuring your baby.  Some fairly small interventions can make a big difference to you and your baby, including:

*  Group B Strep testing and treatment:  1 out of every 200 women who are positive for Group B Strep will have a baby become ill from Group B Strep disease.  Antibiotics decreases the risk of Group B Strep disease so that your chance becomes 1 in several thousand, not 1 in 200.  Part of safe home birth is knowing your GBS status, and appropriate treatment to prevent transmission to your baby.  There is no reason for antibiotics to keep you from being able to labor in a tub or in whatever positions you're most comfortable in.
*  Active management of 3rd stage:  After having a baby, you can use all of the energy you can get to recover and enjoy your babymoon.  Anemia from post partum hemorrhage is not worth risking to avoid one shot of pitocin, and waiting until you're already bleeding (ie. "physiological management of 3rd stage") means that you will be losing blood until the medication has a chance to kick in.  Active Management of 3rd stage, including every woman getting anti-bleeding medications, is actually a World Health Organization recommendation with solid evidence to support it. 

4.  Know when to call it quits:  Sometimes you *can* have a home birth but not without significant cost or risk to yourself and your baby.  The only safe home birth is the home birth that can be quickly abandoned when the needs of mom and baby are best met by being in a more advanced setting, and that doesn't just mean for dire, lights blaring emergencies.  Be willing to make the soft calls where technically you could "suck it up" and follow the Crunchy Bible but where doing so will put an additional burden on you that you don't need to carry. 

It's ok...
* to find out that this particular labor is way more painful than you anticipated and that you don't want to do it without medication 
* to have been really sick the whole week before labor strikes and be so dehydrated that you need fluids and rest
* to be exhausted by the demands of a particularly labor with no clear end in sight, and transfer for pain medication and for possible cesarean birth
* to have a bad PPH and transfer for a blood transfusion
* to decide that you want an MD to repair any tearing
* to have had a really really hard labor and be exhausted enough that you ask your partner to give your newborn a bottle of infant formula so you can sleep for 6 hours straight

None of those choices make you a bad mother or a wimp, or in any way compromise how beautiful birth is.  Some births demand more from us as mothers, and there is no shame or weakness in choosing to take advantage of the very safe resources that medical technology has to offer.  Birth is a miracle in any setting, and there is no intervention, no test, no procedure, or no safe choice in birth that makes it any less miraculous to welcome a new person into your life and into your family. 

Planning a Safe Homebirth- The Midwife

This is written by my good friend Jane Hall, who happens to also be a homebirth mother::

Planning a Safe Homebirth

For women with full term, head down singleton babies where mom and baby are both healthy, home birth with a qualified attendant can be a safe choice to make.  However, because of the basic risks involved with not being in a hospital settings if serious complications occur, there are some critical issues to look at when planning your home birth, both in terms of choice of midwife and in terms of how to plan your birth in ways that minimize risk.  As a mom planning a 4th birth at home, here is how I make sure that I am planning home birth in the safest manner possible.

Midwife:

Bottom line: if your midwife doesn't cut it, you are not safe at home.  End of story.  If you cannot find a good enough midwife, hospital birth is the safest and most responsible choice even if it's not the setting you prefer.  Keep an open mind and high standards, and remember that a solid attendant matters more than being in the home setting.  Here are things to consider:

1.  Education:  Education matters.  It does.  All of the studies demonstrating that home birth is a reasonable option are from countries where midwives have university education and are able to practice in either home or hospital settings.  If your midwife is not educated enough to be able to practice in any other first world country, look elsewhere.  This is the person you are entrusting your life and your baby's life to;  it's ok to say that the person responsible for safety in your birth should at least have a bachelor's level of education in midwifery.  You don't feel guilty about expecting college education from your child's teacher, and shouldn't feel guilty or unreasonable about expecting it from the person you are hiring for your birth.

2.  Experience:  Without a high enough volume of births, your midwife will not have seen enough to recognize complications before they have the chance to spiral out of control.  You don't want to be your midwife's first placental abruption or first encounter with respiratory distress in an infant.  I take this a step further and will not choose a midwife without extensive hospital based experience.  Women with complications are rightly in hospitals, and I want a midwife who has seen the worst that nature can throw at birth so that she has a better chance of recognizing a pattern of a complication that leads to an emergency when minutes are brain cells and can be the difference between life and death.  

3.  Practice:  How your midwife practices will tell you a lot about whether she is a safe attendant for you to plan home birth with.  For example:

* Does your midwife carry malpractice insurance?  If not, there needs to be a very good, verifiable reason. 
* How many clients is your midwife willing to take on in any given month?  Too few births and she maybe out of practice, too many and she could be so exhausted and burned out that she could miss the early signs of problems or could miss your birth entirely.
* How smoothly does her practice run?  Are appointments timely?  Lab results readily available to you?
* Who else attends your birth?  Do not under any circumstances give birth with a midwife who is willing to attend you without a second trained set of hands in case both mother and baby are experiencing complications at the same time.  My preference is for the assistant to be a registered nurse, and the midwife and assistant should know eachother and work well enough together as a team to provide seamless care in emergency situations.
*  Does your midwife have oxygen, IV fluids, antibiotics to treat for Group B Strep, medications to treat bleeding, and other equipment necessary in an emergency?

4.  Integrity and Professionalism:  Your provider's good character is your defense against unethical care.  Here are things to consider:

*  What do other medical professionals in your area think about your midwife?  Do they feel comfortable collaborating with her when clients need more advanced care outside her scope of practice, or refer patients seeking home birth to her?
*  Is your midwife willing to lie or violate professional standards of care in her care?  Is she willing to lie about performing tests or about their results? 
*  Verify that your midwife's license is in good standing, and that she participates in peer review.
*  Find out what continuing education your midwife participates in.
*  Google your midwife and see what people are saying about her online.  Many more cautious midwives can be unfairly described online as "medwives," and it's worth raising any complaints you find that concern you with your midwife to gauge her response.  
*  Look at your midwife's social media presence and how it lines up with HIPAA requirements.  Your protected health information should stay protected and not be spread all over your midwife's Facebook page.