Not too long ago, I was participating in a phone conference with a number of fairly influential women, regarding national homebirth matters. One of the attendees was participating moments after managing a fairly complex hemorrhage within the hospital. Discussion matured, and a passionate debate unrolled regarding the level of care attainable, or would maybe most appropriate in the homebirth setting. My long-standing argument, which I’ve shared many times, is that homebirth-based midwives are not only capable of providing a higher level of care than a level one facility, but we are responsible to do exactly this. The location of such care is irrelevant.
My argument is beyond the comprehension of many however, which was validated even among homebirth allies when said midwife was leaving our conference call to attend to her client and another participant asked, “Can you imagine what would have happened had you attended this mother in the home setting?”
Most of us responded in frustration, “We’d have provided the same management!” Again, the setting itself has little to do with the level of care capable, but rather, it is the level of expertise among the staff and the equipment and supplies available that effect outcomes.
During my first year in practice, I attended a birth that was fairly uneventful. Wonderful waterbirth. At the time, I had the ambition of simply supporting the birthing couple in doing whatever felt right for their birth, and had yet to draw boundaries that while clients may not initially appreciate, are really in their best interest. Chiropractics for women who’ve had a previous cesarean for example, or childbirth classes for the first time momma. In this scenario, I was not yet encouraging mothers to step out of the spa to birth their placentas, and following this particular birth, momma stayed put for quite a little while. Once moving to the bed, the placenta birthed fairly quickly and all was well; however, as we assisted baby at the breast, mom gently laid back, closed her eyes and lost consciousness. She had very little visual bleeding. The experienced midwife (or nurse) is well aware that this can indicate the presence of a large clot occluding the cervix, and behind that is a boggy uterus hemorrhaging.
At the time, I was working with a phenomenal nurse, Paula Miller, and an apprentice with great instincts, Amy Kirbow. Not one of us spoke. In all sincerity, we all worked in concert. We had trained together, this exact scenario, a number of times. Paula obtained vital signs, while I assessed mom’s bleeding and fundal measurement, and Amy drew up medications to control the bleeding. Our initial efforts were minimally helpful. Additional medications were required, as well as a bi-manual massage, and intravenous fluids. While I pulled out a scary amounts of clots from her uterus, Amy hung IV fluids and Paula obtained intravenous access. Our client was quickly stable, and as we gathered ourselves, stepped back and took a deep breath, it was then, for the first time, that we pondered, “Should we transfer to the hospital?”
We hadn’t a moment to consider this before because we had so much to coordinate and all our necessary supplies were available to us, without any awareness that we hadn’t a brick and mortar hospital surrounding us. When we did appreciate our actual environment and societal expectation of being in the hospital for such event, we questioned, “What more could they do?” We were able to administer intravenous antibiotics with the entire team at her side for the rest of the day, and we could provide medication for her to continue taking for the next few days. A blood transfusion could be provided only in the hospital, but it didn’t prove to be necessary. Follow-up labs validated a significant hemorrhage, but her continued stability supported our decision to remain at home. Had she become symptomatic during her recovery period, we would not have hesitated to attain support from our physician colleagues.
To be frank, after this birth, I asked myself, “What the hell was I thinking – homebirth!?!” Then it occurred to me, had we been in the hospital, her outcomes might have been worse. In remote facilities, after the placenta is birthed and the perineum repaired, the physician departs. After mom is tucked in with baby on the breast, the nurse begins her postpartum tasks, gathering supplies, charting at the nurse’s station, and quite likely would not even present at the bedside to even recognize this hemorrhage, let alone coordinate it so smoothly. Even had they all been present, blood bank staff are not continually present in remote facilities, so even they would have had to travel from home.
Hemorrhages since have continued to prove the same. In fact, only once have we transferred because of a postpartum hemorrhage and that was because the Spanish-speaking mother transferred after our medical translator left and when she refused life-saving medications, I gave them against her consent. It was battery. I needed a translator to explain why I violated her. Upon arrival to the hospital, the nurse’s obtained a plethora of labs, including blood cultures. Once the physician arrived (having traveled from home) he interrogated the nurses, confirmed she was stable, demanded a translator and then released her within two hours back into our care with full support. This mother has since birthed two more incredibly gorgeous babies in our practice.
This past year, we experienced two of the most abundant hemorrhages I have ever witnessed. These scenarios are absolutely horrifying no matter your birthing environment. The variable determining whether any similar scenario will end well is the training of the team, and how well they communicate their actions. A homebirth-based midwifery team is uniquely equipped to work in concert. The American Academy of Pediatrics and American Heart Association recognize that communication among the team is critical. A group of experts who can not coordinate their management is recipe for disaster. Our practice routinely practices mock codes. We invest in high quality equipment, and bring in a plethora of supplies to each birthing scenario. We also staff each birth with a minimum of three trained attendants. Homebirth is not mutually exclusive from a very high standard of care. The variable is the competency of your team.