“Being clear about what it is that we fear is as important as determining the difference between reasonable risk and unreasonable risk….We must decide not only what we are frightened of but what the probability of that particular outcome is. We must learn to adjust our risks (of which there are many in life) by improving the odds of success.”Paulina Perez
Countless studies and statistics cite the advantages, safety, and equal/superior outcomes of home and birth center births. Expectant couples frequently respond: “Sounds so wonderful, I’d love to give birth in a birthing tub…..but….. what if something goes wrong?” Ask people what might go wrong and why they’d better be in a hospital in case it does, and they don’t really know. Let’s objectively address these fears about “mysterious” dangers, state what they are, the incidence at which they occur, and how they are handled. There is no endless list of things that can “go wrong” and there is no magical way that these things are prevented in hospitals.
Addressing the issues realistically should make informed choice easier, as well as help those who choose out-of-hospital birth to confront the challenges and accusations they may face.
Those seeking an out-of-hospital (OOH) birth will choose a Certified Nurse Midwife (CNM) or Licensed Midwife. A CNM is a nationally credentialed and state licensed professional, legally allowed to practice out-of-hospital birth in their state. They are ACOG (American College of Obstetrics and Gynecology) approved, with an advanced degree after the RN. Midwives face huge opposition in the U.S., unlike other countries that have recognized the superior outcomes of Midwifery care for healthy low-risk pregnant women.
Screening and Prenatal Care
Moms are CAREFULLY screened for any risk factors (eliminating them as a candidate for an OOH birth), plus given top quality prenatal care to keep them low-risk. Midwives monitor what the mother eats (which OBs typically do not), intake of iron and protein, rest, exercise, mental health. This preventative care is optimum for insuring a low-risk birth. Rather than wait for an unexpected complication to occur, the midwife works to eliminate the possibility of complications prior to birth.
The same prenatal schedule as that of an OB is used. Visits are once a month to 28 weeks, twice a month to 36 weeks, then once a week. However the initial exam is approximately 1.5 hours, after which the average visit is 1/2 hour. Midwives believe in spending time with women, getting to know them well and answering all questions respectfully. It is an investment for the midwife in the labor going smoothly.
Lab work (iron, diabetes, etc.) is usually done in the office. Ultrasound may be referred out. A CNM has one or more doctors as backup.
How Complications are Handled
The serious unexpected problems that may occur at birth are hemorrhage or a baby needing help breathing. What people find hard to believe is the fact that these complications are rarely seen at an OOH birth.
In the case of hemorrhage, Pitocin or Methergin is injected, exactly the same procedure as in a hospital, stopping the hemorrhage. The mother is stabilized, and transported to a hospital.
The extremely low incidence of hemorrhage is attributed to: a) superior prenatal care aimed at building and strengthening the mother’s blood and circulation through good nutrition, and screening out any hematocrit risk factors associated with bleeding; b) no use of Pitocin (or Cytotec/Misoprostol) during labor. Pitocin is a synthetic hormone commonly used in hospitals, creating strong forceful contractions which peak faster, last longer, come closer together, and are hard on the uterus and the baby; c) the Third Stage of labor (expulsion of the placenta) is managed naturally and gently.
If a newborn needs help breathing, a midwife is trained and prepared in the same procedures and equipment as a doctor or paramedic – an oxygen bag/mask. A tight umbilical cord around a baby’s neck would be clamped and cut, as in a hospital setting. If there is a need to clear meconium and/or resuscitate a baby, a certified midwife has the same intubation skills as hospital personnel, and recertifies every year.
An unanticipated cord prolapse (rare incident of the cord coming down before the baby) would require a transport to the hospital, with the mother put in a position to relieve the pressure on the cord.
Shoulder dystocia, the rare event of a baby’s shoulder caught under the mother’s pelvic bone, is dealt with in exactly the same way as in a hospital – various physical techniques and maneuvers to dislodge it. At this point, it is too late for a cesarean, so whether a woman is in or out of a hospital, the same techniques are applied. Both doctors and midwives are trained in managing shoulder dystocia.
There is always a contingency plan utilizing the nearest hospital for the true rare emergencies of cord prolapse or placental abruption. An abnormal fetal heartbeat would necessitate a transport. The most common transport is for non-progress or slow labor in first time mothers, after all other measures have been tried, including rest.
Comparison to Hospital
All midwives carry: oxygen and masks (mom & baby size), laryngoscope, Methergin/Pitocin, standard equipment to check mom’s vital signs. The Doppler, a hand-held fetal monitoring device, is used with the same Standard of Care time frame protocols as in a hospital. IV equipment is available in the event of dehydration (women are encouraged to drink fluids), as is local anesthetic for repair of any tears.
Not available at an OOH birth: blood transfusion, vacuum extraction, narcotics for pain relief, epidurals, operating room.
Warm water is the #1 pain reliever at an OOH birth. In addition, the woman receives encouragement, privacy, support, massage, freedom of movement (letting her body & instincts guide), physical techniques for coping with pain and aiding progress, freedom of pushing position and pushing with natural urges. Drinking and eating are encouraged for endurance and stamina.
Why does almost one out of three women birthing in a U.S. hospital receive a cesarean section to deliver her baby, compared to one out of 20-50 women birthing out of a hospital?
There are philosophical differences between the medical model (birth as crisis waiting to happen, must be controlled) vs. the midwifery model (Continuity of Care, birth is natural, takes time, women need privacy and support; the body knows what to do) which have led to different systems of care. Midwifery is a “hands-on” approach. Some labors have and always will be longer and harder than others. The Midwifery Model respects these variations and their relationship to fetal malposition, birth environment, and mom’s emotions.
The midwife pays close attention to the presentation of the baby’s head and body. If the baby is posterior (facing front), asynclitic (body and head at odd angles with one another), or has a deflexed head (not centralized on the cervix for effective dilation), there are many methods to improve and optimize the baby’s position. This will save the mother many hours of painful and slowly progressing labor, decrease tearing, hemorrhage, instrumental delivery, and cesarean section.
In the hospital, this is not done. Most staff don’t diagnose or attend to the baby’s position. Instead, a “slow” labor will commonly be conveyed by the nurse to the doctor by phone. Women are given Pitocin to speed up the labor, and an epidural to ease the painful Pitocin-induced contractions (more forceful and frequent). Now the baby, already in an unusual or difficult position, needing even more time than usual to negotiate, descend, and rotate its way through the pelvis, is being pounded by the uterus and forced down in a bad position, and the woman is not mobile to stretch or open her pelvis. The woman may (or may not) reach full dilation, but she may then require a cesarean because her baby is “stuck.” Or, the baby has gone into distress from the high doses of Pitocin that squeezed it unnaturally.
Finally, the midwife knows this particular woman. She has spent hours with her and trust has developed. A labor may stall due to fears, unresolved issues, problems with husband or family, or worries about parenting. Midwives will not hesitate to address these issues during labor, frequently with amazing and immediate results!
If you are a woman who wants to know that pain medication is available, the hospital is absolutely the right choice for you. There is nothing wrong with this choice and nothing heroic, nor irresponsible, about a woman choosing an out-of-hospital birth.
If you are a woman who feels discomfort at the thought of giving birth in a hospital, laboring with a nurse you don’t know, or being subject to practices that go against your instincts to any degree, please consider an out-of-hospital birth with a Certified Nurse Midwife. Don’t stop at “but something might go wrong.” Questions you, your partner, family, and friends may have about the unknown can be defined and answered. If there is ever a time in one’s life to make informed choices, giving birth to your baby is that time.