The world of medicine is like a bubble. A lot of people THINK they know what goes on there, but unless you're down in the trenches it's unlikely you do. So here is my semi-anonymous blog, here to tell you what really goes on in the life of a medical resident.

Sunday, September 25, 2005

Why Home Birth?

I mean, seriously! I'm the first one to admit that my experience in labour and delivery has been biased by the fact that both of my obs/gyn rotations have taken place in tertiary care centres, where all high-risk patients end up. Not to say that we don't see run of the mill deliveries as well, but we definitely see more than our fair share of complicated ones.

In the past two months, I've seen some scary shit. I've seen a maternal death secondary to chorioamnionitis (infection of the uterine contents) which also caused baby to be delivered stillborn at 20 weeks. I've seen a uterine rupture when a woman was VBAC (attempting to have a vaginal birth after a previous caesarian section)-- baby ended up with brain damage from sitting in the abdomen for 6 minutes between the time of rupture and the time they were able to get her out of the abdomen. Mom, amazingly, didn't only survive but was able to keep her uterus. I've seen more post-partum hemorrhages than I can count. I've seen the heart rate of full term babies inexplicably plummet during labour, requiring a crash c-section. When things can go SO badly SO quickly, how can you possibly justify giving birth at home? Regardless of how close you live to the hospital, any amount of time is too much when you're talking about a prolapsed umbilical cord or anything else compromising blood supply to the fetus.

Proponents of home birth often talk about stuff like 'feeling more comfortable at home' and 'not wanting to be exposed to germs in the hospital'. Personally, that's crap. So you don't feel comfortable in the hospital? How comfortable will you feel if something goes wrong that hurts your baby... and you have to live with knowing that the outcome could have been different had you compromised your 'comfort' for the sake of the baby? And germs? Please. First of all, we're not sticking women in labour in the middle of the infectious disease ward. Second, I'm sure if you had a microbiologist over to take samples and swabs from your counters, sinks and carpets, you'd be horrified at what's living in your 'clean' house.

Although I don't agree with it (obviously), I can still respect someone who decides to give birth at home if it's not your first baby (so you've proven that your anatomy can handle vaginal birth) and there is no reason to think that you're at risk of any complications. But no one is there to draw the line. Some midwives will allow you to home birth as a VBAC, for God's sake! I know a girl who decided to have a home birth in her parents living room in a hot tub. She's a good 250lbs. As I've learned recently, being obese puts you at much higher risk for a number of complications in childbirth... your risk of needing an emergency c-section is much higher, as is your risk of shoulder dystocia (baby getting stuck after the head is out) and macrosomic (really big) babies. Why would you risk a home birth in that circumstance?

Okay, rant over. For now.

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Anonymous Lindsay said...

You're comparing high-risk pregnancies to low-risk pregnancies. Studies have consistently shown that low-risk pregnancies have similar outcomes in either setting: planned homebirth with a skilled attendant and hospital birth with an OB.

I think you're looking at your experiences rather than the statistics.

7:16 PM

Anonymous Isabelle Faubert, Québec said...

See what you think and feel after your first child...! Giving birth and raising a human beeing is anything but statistics. A well-rounded physician should also have, from my point of view, a spiritual belief that allows him or her to think that there is something else than statistics and procedures. To have a little faith in life and in human beeings ability to be responsible for their actions should also be a requirement for beeing a supportive and a helping doctor besides procedures...

10:56 PM

Anonymous Anonymous said...

LOL, I doubt anyone will read a comment to a post nearly two years old, but here I go anyway. I just wanted to share some of the factors that went into our decision, to show that it's usually more complicated than a choice between "I want a nice birthing experience" and "I care about the safety of my baby above all." I think most moms -- probably including the high-risk homebirthers you mentioned -- would cut off their own heads if they thought it would help their children. But like most things involving families, the situation is usually far more complicated and less clear-cut than outside observers can guess.

I'm pregnant now. We wanted a midwife-attended hospital birth like we had for our last child, and in fact that's what we've been planning on. But for reasons beyond our control the midwifery practice where I've been getting my prenatal care now has an uncertain future: two of the three midwives have left in the last couple of weeks and there was talk that the whole service line might be closed! Now, I'm at 30 weeks... if I've got to find another provider I want to do so now, not wait and be left high and dry at week 37, KWIM?

We can't afford to go out of network, so that's out. The other two obstetrics practices in my network, in my area, are HUGE, for one, and for another just not open to our preferences - which include being able to move freely throughout labor, not being given an IV until

Why do I want to minimize interventions wherever possible? Not because I think doctors are bad or medicine is bad and "unnatural," etc. For one, it's because I think that in low-risk pregnancies like mine (singleton pregnancy, head-down baby, normal size baby, me a multipara with one unmedicated complication-free birth under my belt) routine interventions are actually LESS safe, and I think that the data bear this out. But for another, I think that it makes a difference in a kind of "outcome" that's really important but not measurable in medical terms: the psychological effects of birth on the mom. These effects go far beyond having a "nice experience" and really affect how your parenting starts off, IMO. In other words, if you have two births that end up with healthy moms and babies -- but one mom feels like something was being done to her, and the other mom feels like she an active participant -- I think that parenting this actually a lot easier for the second mom because she's not trying to process a somewhat-traumatic experience while also trying to care for a newborn on no sleep! Now, I don't assume that "being an active participant" means having an intervention-free birth: I'm sure a lot of moms would feel less traumatized with an epidural than without, and more power to them! However, that wasn't the case for us; and unfortunately no obstetrics practice in the area is willing to work with us

So we're considering a homebirth. It wasn't our first choice. But, we would have a certified nurse-midwife, I'm low-risk, and we're within a short ambulance ride of the hospital: when all of those things are true, the most recent studies have shown homebith to be comparably safe as hospital birth. I wouldn't even CONSIDER a homebirth if I had a risk factor... but honestly, I don't know the whole story behind other families and the factors leading to their decisions. In our case it's a little complicated, and there's a "back story" that most people don't know; I suspect that's the case for the high-risk homebirthers you mentioned. Or, MAYBE they're just uninformed or selfish -- but, could we at least have that conversation? To be honest, I haven't found many healthcare providers who are even willing to talk about factors like family dynamics, emotional well-being, and retaining a sense of agency during a medical event.

Of course modern medicine and ambulance services have made it possible for low-risk homebirth to be a safe option in the first place, and it gets my panties in a bunch when people on the OTHER side of the spectrum look down their noses at women who COULD have a "natural" birth but opt not to. Look, it hurts LIKE HELL; and if you're going to say that hospitals and medicine and doctors are "unnatural" then it seems like youv'e got to also say that higher rates of maternal and neonatal death ARE "natural." Could we ALL just agree to cut pregnant women a little more slack?

9:39 AM

Anonymous Anonymous said...

OK, it is quite obvious that you have seen your share of hospital birthing desasters. But it also apears to be quite obvious that you have not seen or experience many if any homebirths, or even birthing center births for that matter. I guarentee you that if you ever get to see or experience truely natural childbirth you will know EXACTLY why so many women choice to do it the way we were designed to do.

If you actually take to time to reseach what you are preeching you would be stunned at the results.

One more thing. I would be willing to bet that the woman whom experience a Uterine Rupture while attempting a VBAC was probly induced by the doctor either with patocin or cyrtotec. Thus increasing their chances of rupturing from .7% to 2.3%. A unnessary risk that most all doctors take, even with VBAC deliveries. but that's what happens when you have have all the emerency equipment down the hall and the doctors earn 3X as much by using it.

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