You might think that being pressed for time would push me toward brevity and not prolixity, but you'd be wrong. Remember the homebirth discussion from Neonatal Doc's blog? It was mentioned in the first Pediatric Grand Rounds and I asked the host, Dr. Clark Bartram, for his opinion on homebirth. He gave a courteous and thorough response that included several questions. Instead of responding in a novel-length comment over there, I am posting here. (And posting. Aaannd posting.)
Just to recap, I have given birth four times: one hospital birth with an avalanche of interventions, one very nice hospital birth, one physician-attended homebirth, and one CNM-attended homebirth. I suspected that giving birth at home would be quite different, but I could not have imagined the reality. It made me wonder: why don't more women know what a great option homebirth can be? Why is there so much resistance to the idea in this country, when the evidence shows it is no less safe than hospital birth?
Right from the get-go, let me be clear that throughout this post I am talking about planned, attended homebirth by low-risk women carrying full-term vertex babies. Plunging in, then:
Going to the hospital can alter the course of labor.
When I first posted here about the debate at Neonatal Doc's, I said homebirth was like cross-country skiing and hospital birth was like ski-jumping. The birth stories we hear in this country are often litanies of intensifying woe: stalled labor! IV! pitocin! pain! analgesia! wait, there's still pain! anesthesia! catheter! fever! antibiotics! slow descent! worrisome monitor tracings! episiotomy! hasty instrumental delivery! baby snatched from the jaws of death by the hospital staff! And people say, "How could you ever do that at home?" Short answer: you don't. You just don't get on that train.
Summer observed, rightly, that sometimes hospital birth can be "a swoop down the bunny trail." And make no mistake: sometimes in a homebirth a crevasse opens up in the trail before you. But as a general rule, Homebirth = Less Drama.
In a hospital you can see lifesaving interventions used appropriately (transverse babies being delivered via C-section); you can also see potentially harmful interventions used inappropriately. My college roommate talks about her surprise, as a med student, at hearing orders like, "Go to 1732 and break her water. We're going to need that bed for someone else." The advantages of hospital admission are accompanied by disadvantages (MRSA, anyone?).
Another consideration: the hospital environment can have unpredictable effects on individual women. Many women can tell you what a drag it is to get in the car and drive to the hospital during active labor. Does the interruption have as-yet-unquantified consequences? As much as your conscious brain may think that the hospital is where you want to be for birth, what happens in your unconscious when you walk into a place that smells, to many people, like disease, death, and uncertainty? Is that part of why so many women undergo pitocin augmentation in the hospital? I just learned about a study that confirms my own experience -- women report that hospital birth is significantly more painful than homebirth. Most women in a hospital request pharmacological pain relief, and labor analgesia and anesthesia are not risk-free.
Hospitals can only go so far in providing "home-like" care.
It's possible to have a home-like birth in a hospital, but it's not easy. It's not the norm for women to deliver without intervention in hospitals, and that reality is reflected in staff preferences and practices. In my post on the interplay of birth interventions and breastfeeding problems, I wrote about a friend who was told at crowning that she couldn't stay on her hands and knees for delivery. Eight months later, another friend in another state had the very same experience. The nurse said, "I know your doctor thinks this is okay, but I'm not comfortable with it."
I wish I had been there to say, "She has a head in her vagina, and you're uncomfortable?"
In some cases I can see the hospitals' point. During my last birth, I wanted emphatically to be on my hands and knees with something firm beneath me. I found vocalizing to be an immensely helpful pain-management strategy -- it was like my voice was a valve and the pain just sprayed out of my mouth as I groaned. But if you're an L&D nurse in a typical hospital, do you want me crawling around on the floor while you're trying to assess me? No. Do I want to be crawling around on a hospital floor? No. Does anybody want me making that kind of noise when every other patient has an epidural? I assure you the answer is no. Safe and effective pain management strategies for mothers laboring at home may not translate well to the hospital L&D wing.
The issue is not only hospital culture but hospital economics as well. Homebirth midwifery is not focused on efficiency. My youngest son took some time to settle down after his birth, and the midwife watched him closely, with unobtrusive vigilance, to make sure his elevated respiratory rate was a function of his agitation and not an indication of a problem requiring intervention. She charted the decrease in breaths per minute while keeping a careful eye out for nasal flaring or blanching or chest retractions or whatever else. She stayed right beside us for more than three hours, making sure we were both doing well. A hospital nurse doesn't have that kind of time -- does she send him for assessment just in case? does she leave us to monitor his breathing while she tends to her other responsibilities? I much preferred knowing that my trusted midwife, licensed as an advanced-practice nurse and certified in neonatal resuscitation, was at hand to tell us if we had a problem.
Midwives bring something special to the table (or the floor, as the case may be).
I posted last year about how much I loved my midwife, but it bears repeating: she provided me with a fabulous blend of trust-the-process reassurance and appropriate watchfulness. Last April I sent her a wigged-out email -- "Itching! Cholestasis! Stillbirth!" -- and she wrote right back saying, "Here are the risks; here are your options. What do you want to do?" (Then it rained and I stopped itching. Allergies, not liver malfunction.)
During the pushing stage of my last birth I had a similar wigged-out moment, when the brief pause between delivery of head and shoulders made me think, "Overdue! Macrosomia! Shoulder dystocia!" But even in the moment, I knew that I was in the right position and that she knew what to do. (Turns out the shoulders were not stuck; she was just easing a loose loop of cord over baby's head.) Throughout my labor, she stayed quietly beside me on the floor, watching, waiting, encouraging.
Homebirth midwives practice physiological management of childbirth, which reduces the risk of some of Dr. Bartram's concerns. As an example, a baby whose mother was free to eat during labor is less vulnerable to hypoglycemia than a baby whose mother was restricted to a glucose IV. Another example -- mothers who can move freely often choose positions that allow minor malpresentations (occiput posterior or asynclitic) to resolve. Midwives spend a lot of time on patient education: how's your diet? what can we do about this hemoglobin? have you lined up postpartum support? After the birth we were given excellent when-to-worry guidelines that made clear whether to call the midwife, the doctor, or 911.
One reason I felt confident planning a homebirth is that my midwife is operating legally and had nothing to fear from a transfer to hospital care. When homebirth is driven underground, who benefits? Some mothers will wish to consider homebirth despite the opprobrium of mainstream obstetrics. Surely mothers and babies are better served by accredited midwives with a clearly defined scope of practice. Surely we can all agree that seamless, timely transfers, without added stress about legal trouble for the midwife, improve the odds of a good outcome. If you're opposed to licensing homebirth midwives, why? Who benefits when unlicensed midwives are the only available homebirth attendants?
A parenthetical note about mess:
Some people say, "Ewww, giving birth on your own mattress? Birth makes such a mess." My friends, go to the bath accessories aisle at Target. Behold: the shower curtain. Buy one. Buy two -- they're cheap. Make your bed and spread a shower curtain over it. Put something absorbent, either newspaper or chux pads, over the shower curtain, and put an old sheet on top of it all. Make a second nest in the living room floor if you think you might be a floor birther. After the baby is born, roll up all the squishy stuff in the shower curtain and sink into fresh sheets on your own bed. Bask in the cozy rightness of it all.
Since you will doubtless be breastfeeding and have no need of a Chief Cook & Bottle Washer, designate a Chief Cook & Towel Washer instead. CC&TW can chuck all the laundry in for a cold soak, followed when convenient by a cold wash. Check for any stubborn bloodstains before drying and spot-treat before a second cold-water wash if needed. Not a big deal. On to more pressing concerns.
(I am closing comments on this post so we can all talk down below.)
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