Homebirth in the Hospital

For my Human Sexuality class, I had to pick a topic (childbirth) and write a research paper on it. Childbirth is a very wide term that incorporates so many different areas of birth. Below you will read my paper. It is long and, according to my professor, has some technical errors. Poo poo, I say! 😉 Enjoy!

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Giving birth, for many, is one of the most life-changing experiences one can go through. Whether it’s for the first or fifth time, every experience can be different. In the US, women have discovered ways to control her pregnancy, labor and the birth of her baby. She has many options which include giving birth at home with or without the assistance of a medical professional, in a birth center with a midwife or in the hospital, with an obstetrician or nurse-midwife. Safety concerns and control over one’s body seems to dictate how and where a woman chooses to give birth. While the safety concerns surrounding homebirth are greater than those of in-hospital deliveries, having a “homebirth in the hospital” is an option many women are seeking. They want the comforts of home while being in the hospital in case of an emergency. Discovering this balance and improving the birth experience for the woman and her family is quickly becoming the goal of many labor and delivery units across the country.

One of the most important criteria for obtaining the desired birth is who the patient hires for her prenatal and delivery care. Obstetricians (OB) are not well known for their hands-off approach to labor and delivery. Christiane Northrup, an Obstetrician, writes in her book Women’s Bodies, Women’s Wisdom, “For centuries, midwives helped mothers through the pregnancy and birthing processes, standing by them with medical and emotional aide. The very word obstetrics is derived from the Latin word stare, which means ‘to stand by’” (Northrup, 1998). A change in the management of labor and delivery occurred. Northrup goes on to say, “Modern obstetrics, however, has changed from a natural, patient ‘standing by’ and allowing the woman’s body to respond naturally into a domineering and often invasive practice” (Northrup, 1998). In this case, seeking the care of a Certified Nurse Midwife who is naturally-minded, hands-off except when necessary, and well educated in childbirth is the first step in having a homebirth in the hospital.

A Certified Nurse Midwife (CNM) is someone who holds degrees and education in both nursing and midwifery and can attend the births of low risk women in the hospital. “The modern midwife’s approach is to be proactive during pregnancy and childbirth. Instead of aggressively treating gestational problems with the latest medications and the most advanced technology after they arise, good midwives work closely with their pregnant clients to ward off problems before they start” (Margulis, 2013). Because of all the unknowns that come along with pregnancy, especially for first time parents, having a midwife who takes more time with her patient explaining what’s normal and what’s not will greatly benefit the parents, minimizing any fears present.

At times, CNMs may deliver babies at home. This is most common in states which have not legalized home births attended by Certified Midwives or Certified Professional Midwives. “Nurse-Midwives practice legally in all 50 U.S. states and the District of Columbia. Certified Professional Midwives are legally authorized to practice in 28 states. Certified Midwives practice legally in only three states” (MANA). The crucial credential missing between these women and the CNM is the nursing degree.

Once the pregnant woman has chosen her desired provider, she should next consider hiring a doula. “Doula is a Greek word, meaning ‘to serve’. A popular interpretation is ‘mothering the mother’. Doulas are not medically trained and do not provide medical advice” (Ross, pp.9). With this definition in mind, the expectant mother can choose a doula to help her while laboring. Often times the doula and the mother’s partner will tag team, taking turns assisting her in changing positions, providing nourishment, and suggesting ideas for continued pain relief. According to DONA International, an organization that trains and certifies doulas all over the world, having a doula present at the labor and birth of a baby has greatly decreased the length of labor and number of interventions, she has helped reduce the need for Pitocin and labor augmentation, as well as the mother’s request for pain medications and cesarean sections (DONA, 2003). “Having doula support gives couples the confidence to stay home for a good part of the woman’s labor and avoid early transfer to hospital” (Ross, 2012). The longer the laboring mom is able to stay home, the more likely she is to have less time spent in the hospital succumbing to unwanted, and often, unnecessary interventions.

The next step to obtaining a homebirth in the hospital is writing a birth plan. This step requires the woman to educate herself on the processes of both her pregnancy and the birth of her baby, usually by taking classes and reading materials on natural childbirth. She and her support person will sit down and discuss their goals for the labor and birth. She will clearly define the types of pain relief, laboring positions, and interventions she’s open to. Having a plan or a list of desires for the birth of her baby also assists the hospital staff in helping her reach those goals. Most people who write a birth plan understand that the health and wellbeing of the mother and baby are of utmost priority. Communicating their desires both verbally and on paper is critical. Knowledge is power and while laboring, the woman may forget what her goals are. A birth plan and her support people will be able to remind her of those goals when all her power is being focused on bringing her baby into the world. If the staff and her partner do not know what she’d like then reaching her goals will be much more challenging.

Taking childbirth classes is just as important as writing the birth plan and, often, classes offer help in writing the birth plan. “The classes provide training for the pregnant woman and her labor coach in breathing and relaxation exercises designed to cope with the pain of childbirth” (Crooks & Baur, 2014). There are many different types of childbirth classes offered and if the mother is seeking a labor and birth that is natural and “home-like”, then she will most likely be taking childbirth classes that cater to those desires. The Bradley Method is a very common child birthing class that people take. A fee is paid and an instructor meets with the couple, usually along with other couples, to discuss the specifics of her pregnancy, labor and birth with a more natural, pain-free type of birth in mind. “The techniques are simple and effective. They are based on information about how the human body works during labor. Couples are taught how they can work with their bodies to reduce pain and make their labors more efficient” (AAHCC, 2015).

Selecting the hospital in which the mother chooses to birth may be limited to the hospital in her area, however, if she is able to find a hospital that is Baby Friendly Accredited, then she is more likely to have many more options for her birth which are routinely offered by the hospital. The mother and her support people should take a tour of the hospital and ask questions. They should find out what the hospital standards are and use that information to balance out their birth plan accordingly. “Baby-Friendly USA, Inc. is the nonprofit national authority for WHO/UNICEF’s Baby-Friendly Hospital Initiative (BFHI). Our Mission is to assess, accredit and designate birthing facilities that meet the BFHI criteria for implementing the Ten Steps to Successful Breastfeeding and follow the International Code of Marketing of Breast-milk Substitutes — providing mothers and babies with the early support needed to achieve successful breastfeeding, an essential foundation for a healthy nation” (BFA, 2015). Initiating skin-to-skin and rooming-in with her baby are essential in allowing mom to bond with and have a successful breastfeeding relationship with her newborn. These small steps are essential in having a homebirth in a hospital. When one births at home, the baby is not taken away from her, she is encouraged to nurse as soon as the baby cues or starts doing the “breast crawl”, and she and her baby sleep in the same room. Those seeking a homebirth in the hospital will likely have these types of things on their birth plan.

Once the birth plan has been defined and the hospital for birth selected, the next step in obtaining a homebirth in the hospital is managing labor pains. Labor often starts off gradually and increases as contractions come closer and closer together. There are three stages to the laboring process. The first stage of labor involves the uterus contracting and the cervix dilating, usually the most painful part of labor. This stage can last several hours, especially for first time mothers. During this first stage of labor is when having a calm, quiet setting for the laboring mother is essential in having a homebirth setting in the hospital. Since this stage can last for a long time, it is important to allow the mother to eat and drink as she wishes while also resting when she is able. Some things that may help her manage pain include massage, a birthing ball to bounce and sit on, having a tub or shower to relax in, low lighting, quite, clustered care from the hospital staff, intermittent fetal monitoring, and the ability to move freely. These are all things she would be doing at home to manage her labor pains. There is no reason any of these things should be restricted in the hospital unless the mother has other risks associated with her pregnancy.

Labor is exhausting and it usually isn’t until transition when the most severe labor pains are present. Transition occurs just before the mother is fully dilated at 10 centimeters. Feelings of wanting to give up and asking for pain medications are common indicators that the mother is in transition and close to the second stage of labor, the pushing stage. During this portion of the labor, it is essential for the mother’s support people to guide her through the pains of contractions as they are likely on top of each other, offering little to no relief. Providing calming voices, massage and allowing her to vocalize as she feels necessary is all a part of labor and having a homebirth in the hospital. It is likely that the nursing staff and the midwife are preparing for the birth by setting up a baby warmer and sterile instruments for after delivery. While this scene is not one you will see at home, it is the part of delivery that the couple should expect from delivering in the hospital.

“Some mothers enter the pushing stage gradually. They feel a lot of rectal pressure at the peak of each contraction. As their bodies dilate the last 2 centimeters or so, this pressure builds until the feelings associated with dilating are taken over by the sensation of pressure and fullness, and you can do nothing else except push” (Drichta & Owen, 2013). The second stage of labor is much faster than the first stage. For some it can take only a few pushes to get her baby out while for others it may take a few hours for the baby’s head to descend past the cervix and birth canal. If the mother has declined all pain medications up until this point, then she should be fully capable of pushing in a position which feels best to her. This includes squatting, hands and knees, and side-laying. All of these positions work with gravity and the shape of the mother’s pelvis to ensure that pushing is effective.

Part of having a homebirth is not being directed or instructed on when to push. Self-directed pushing as the mother feels the urge to do so should be well supported in the hospital. Only if the baby or mother was showing signs of distress would directed pushing or pushing in a certain position be important. The last part of this stage which should be defined in the birth plan would be who is going to catch the baby as she slips into the world. At home, the mother and/or fathers are encouraged to catch their baby. The midwife will assist the head out as it crowns and direct their hands into a position to catch the baby. This option may not always be available in the hospital, depending on their guidelines, however if the desire is there then it should be encouraged.

After the baby has been born, she should be placed directly on her mother’s bare chest. The second stage of labor is now complete. A common practice in home births, which is also increasing in hospital births, is delaying the clamping of the umbilical cord. This is the lifeline between the mother and baby. As the baby takes breaths and begins to cry, the pulsing blood through the umbilical cord from the placenta decreases. Many couples request that the cord is left pulsing for several minutes to allow for the blood from the placenta to be received by the bay. Doing so has many benefits, the greatest of which is a lower risk of having iron deficiency issues in the first six months of life. “Several systematic reviews have suggested that clamping the umbilical cord in all births should be delayed for at least 30–60 seconds, with the infant maintained at or below the level of the placenta because of the associated neonatal benefits, including increased blood volume, reduced need for blood transfusion, decreased incidence of intracranial hemorrhage in preterm infants, and lower frequency of iron deficiency anemia in term infants” (ACOG, 2014).

The third and final stage of birth is the release and delivery of the placenta from the uterine wall. As soon as the baby has been born, hormones race through the mother’s body, signaling the change. This biological message expels the placenta as its job of nourishing the fetus has come to an end. The delivery of the placenta also signals the uterus to continue to contract and shrink which should, in most healthy cases, stop excessive bleeding. This stage of labor can be handled the same at the hospital as it would at home. The mother may need to give a few small pushes, but abdominal massage and pulling on the cord to get the placenta to come out faster is not necessary. The midwife will inspect the placenta to ensure that all its parts are intact. If the mother happens to retain any part of the placenta, she may experience continued bleeding and clotting issues.

Birth, while not a disease or illness, can come with a host of risks. People who want to give birth in the hospital but also desire home qualities are usually doing so just in case something were to happen in which a fully-staffed medical team would be necessary. Maternal risks include preeclampsia, which is pregnancy-induced hypertension, gestational diabetes, placenta previa, where the placenta covers part or all of the cervix, being Group-B Strep positive, placental abruption, wherein the placenta prematurely detaches from the uterine wall prior to the birth of the baby, infection, and postpartum hemorrhaging. All of these risks also pose different risks to the unborn baby. Fetal-specific risks include a cord prolapse, where the cord exits the birth canal before the head, causing life-threatening pressure to the cord and cutting off blood supply to the baby. Other risks to the newborn are meconium aspiration and shoulder dystocia. For many of these situations, the baby may need to be delivered by cesarean section to ensure the life and safety of both mother and baby. These are also risks which a homebirth midwife is not equipped to handle at home. If any of these things were to arise during a labor at home, immediate transfer to a hospital would be necessary. Something like a placental abruption offers very little in the way of time. It usually occurs quickly and without warning. For this reason, giving birth in the hospital would be safest. Labor and delivery nurses and the extended staff of midwives and obstetricians are trained to identify these kinds of risks quickly.

If a mother has a known risk factor, such as preeclampsia or Group-B Strep (GBS) positive, are risks which can be easily managed in the hospital with medications such as magnesium for the preeclampsia and antibiotics for GBS. While these risk factors exist, it is not out of the question for a mother to be able to still have a homebirth in the hospital. She may require extra attention and monitoring, however, none of this should discourage her from having a natural birth if she so desires. The key is to be open to the necessary interventions that will keep her and her baby healthy and safe. If she lacks an openness to the required protocols of the hospital, she may become disappointed and unhappy with her birthing experience. Should an emergent risk arise during the labor or birth, the mother’s midwife and hospital staff should clearly explain everything that is happening and ensure that she understands the procedures that need to be done are to keep her and her baby safe. Too often staff do not inform their patients well enough about what is happening and this can leave her feeling very confused and hurt.

Having a homebirth in the hospital is possible. Certain steps need to be taken prior to and during the labor to ensure that as many of the mother’s goals are met. She and her support people need to clearly communicate what they would like to see happen and to feel confident in the interventions they may decline unless medically necessary. The expectant mother and her partner need to understand the ins and outs of her pregnancy and labor by taking classes, having a hospital tour and educating themselves so that they are well-prepared for their baby’s impending arrival. Having this knowledge will give them the proper ammunition needed to meet their goals while in the hospital. The mother must be upfront with her midwife about her health and pregnancy history and discuss her options freely. All this and more will help enhance her child birthing experience and goal of having a homebirth in the hospital.

References

Crooks, R., & Baur, K. (2014). Our sexuality (12th ed.). Redwood City, Calif.: Wadsworth

Cenage Learning.

Drichta, J. Owen, J. (2013). The Essential homebirth guide. New York, New York: Gallery

Books.

Margulis, J. (2013). Your baby, your way. New York, New York: Scribner.

Northrup, C. (1998). Women’s bodies, women’s wisdom: Creating physical and emotional health

and healing (Completely rev. and updated. ed.). New York, New York: Bantam Books.

Ross, S. (2012). Doulas: why every pregnant woman deserves one. Summer Hill, Australia:

Rockpool Publishing.

American Academy of Husband Coached Childbirth. (2015) The Bradley method classes.

Retrieved May 3, 2015, from http://www.bradleybirth.com/WhyBradley.aspx

American Congress of Obstetricians and Gynecologists. (2014). Timing of umbilical cord

clamping after birth. Committee opinion No. 543. Retrieved May 3, 2015, from

http://www.acog.org/Resources-And-Publications/Committee-Opinions/Committee-on-

Obstetric-Practice/Timing-ofUmbilical-Cord-Clamping-After-Birth

Baby-Friendly USA. (2015) Mission and vision. Retrieved May 5, 2015, from

https://www.babyfriendlyusa.org/about-us/about-baby-friendly/mission

DONA International. (2003). Why Use a Doula? Retrieved May 1, 2015, from

http://www.dona.org/mothers/why_use_a_doula.php

Midwives Alliance of North America. Legal Status of US Midwives.  Retrieved May 1, 2015,

from http://mana.org/about-midwives/legal-status-of-us-midwives

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Home Stretch and some Links

Hello readers!! I am now 37 weeks pregnant and ready to have a baby whenever he/she is ready!! This is the last week of school, only two more assignments to go and then I’m DONE. And my last day of work will be May 17th unless I or baby decide otherwise. I’ve been painfully tired lately so blogging and just about anything else productive has been on the back burner.

However, I still try to get some reading in. Here are some links to check out that I found interesting and beneficial. Enjoy! Next time I write will most likely be after I have a new baby in my arms!

Postpartum Rest 

Michelle Kay Newborn Photography

Breastfeeding in Public article.

Cesarean Sections broken down part by part on Birth Without Fear

Tips for Writing a Birth Plan

 

Guest Post: Planning a VBAC

A fellow blogger recently posted her plans for a VBAC (vaginal birth after cesarean . Ashley’s post is beautiful and encouraging. She writes over at Our Happily Ever Afters and already has two beautiful children. Check her out and enjoy this lovely post.

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Our Plans for a VBAC

As far as our birth plan goes, that’s also different from last time. To quickly recap, Kurt was in residency when Evy was born. We had to make the decision to induce labor or run the risk of Kurt not being present at her birth, were I to go into spontaneous labor. For us, this was not even a question. So I was induced at 39 (almost 40) weeks. When I went in for the induction, I was not even 1cm dilated, and my body had shown no signs of labor being imminent. After 9 hours of Pitocin, Stadol (otherwise known as the drug from you-know-where), and NO progression (I only got to a 3) at 4:00pm my doctor recommended a C-section. More background: my mom had 4 C-sections and so that was very familiar to me. I had no fear of them, and at that point it was the logical decision to make. At 4:12pm, in the operating room, Evy Kate made her beautiful appearance. Kurt and I were besides ourselves with joy and it was absolutely the most amazing moment of my life up to that point.

When I got pregnant this time around, a VBAC (v*g*nal birth after Caesarean) immediately came up for discussion. We decided that we would ask my doctor at the time what her policy was for this. She immediately said that she wouldn’t do that, and no doctor in town would. Baffled, I left the office and went home to talk with Kurt. He had also been doing more extensive research on this topic and had become insistent that I be given the opportunity to try a VBAC. He even went to his hospital of employment and after talking with MANY staff members, was appalled at the attitude of most physicians regarding this topic (it basically boils down to fear of malpractice suits, but mostly their general unwillingness to labor with their patients and do whatever it takes to see a VBAC through). Almost every nurse that Kurt talked with was so thankful he was bringing up the discussion because they all agreed it was ridiculous how hardly any doctors are willing to give that option. We felt like it was an uphill battle to even get the hospital to acknowledge that this was evidence-based medicine and if they keep denying this service to women, it will have very negative effects. We’re hoping that more physicians in our area get on board!

We both felt (and still feel) very strongly that medical evidence and research OBVIOUSLY support this option, as opposed to multiple C-sections. Thus the search began for an OB who would allow me to try. We found one in our whole city (praise the Lord!). I absolutely love her and her bedside manner is awesome (unlike my last OB in Mississippi). She definitely agreed that it’s worth a try, and she’s willing to monitor my labor for as long as it takes. I’ll pause here and give some facts/info about why I’m choosing to try a VBAC.

-If you allow yourself to go into spontaneous labor on your own and do not take labor-inducing drugs (like Pitocin), you have a 70%-75% chance of having a successful VBAC. It also helps if you hold off on getting your epidural until after you get to around 4cm or so.

-Most doctors refuse VBACs because they are afraid of malpractice suits. This stems from the fear of uterine rupture (your C-section scar rupturing because of the pressure of natural labor). However, this only happens in about 1% of VBAC situations. 1%!!!

-The more C-sections you have, the higher your risk grows for complications. Kurt and I do not want to have to limit our family size due to the fact that I’m looking at major surgery each time. Obviously, God is in control and He knows what’s best. We follow His leading at all times and this includes when we pray about the size of our family. But I would feel better knowing that I’m not significantly multiplying my risk if I get pregnant one more (or several more) times.

-There are so many more facts and research you can read that I’ve not included here. This is a great website if you want to learn more about a VBAC.

Now for my disclaimers and thoughts:

-I am NOT trying to “redeem” Evy’s birth or trying to “redo” my experience with her birth in any way. I am NOT anti-C-section, and I don’t view Evy’s birth as a failure IN ANY WAY. I was trying to think of the perfect way to say this, and this is what I came up with: Evy’s story is her story. I have NO REGRETS and I look back very fondly on the whole experience. There were certain elements that weren’t fun, but I know without a doubt that we made the best decisions for us at the time. I simply view this as Lynley’s story, which could potentially be different, or it could be similar to Evy’s, ending in a C-section. They both have unique birth stories (and Liam has his unique story). I view them all separately, and not like I have to redeem one because of another.

-I absolutely, 100% believe that there is no right or wrong way to give birth. I’ve never found an article that I feel articulates this exactly as I would, but I found this one! I’m very careful about articles I post or share, because personally, I want people to really understand my position on something. There are lots of good elements in the article, but I particularly like that it points out that “bullying” can come from both sides. Just like doctors can bully women into having unnecessary C-sections, people from the natural-birth camps can make women feel like complete failures who haven’t made it into their “club” if they choose to have an epidural or other interventions. Birth is a miracle. Period. Life is entering the world, and shame on anyone who tries to nullify that by demeaning any woman’s experience.

-I feel like I’m in the middle of things, in that our plan includes non-intervention (going into labor on my own, trying to labor at home at first, no epidural until regular contractions are established and I’ve progressed to at least 4cm), but it also includes intervention (I definitely plan to have an epidural, I don’t mind monitoring, I’m not opposed to an episiotomy if it’s necessary, etc.). IT IS OKAY to desire elements from both schools of thought! You’re not a sell-out if you don’t wholly subscribe to one philosophy.

Who knows how Lynley’s story will go? God does. I feel like we’re making the best choices for us this time around (just like we made the best choices for us last time around), but ultimately we trust the Lord with Lynley’s birth and we will ask Him for His wisdom in everything. Ultimately, “Many are the plans in a person’s heart, but it is the LORD’S purpose that prevails.” (Proverbs 19:21) I am so thankful for that promise!