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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Why I Won’t Have a Home Birth

Before I became pregnant, I was totally naive about birthing options. I only had a handful of friends who had children and all of them birthed in a hospital with an epidural for pain management. I never imagined anything different. I’m not sure when or exactly what prompted me to educate myself further as my pregnancy progressed but there was a little bug inside of me that said I should.

I do remember seeing 19th Kids and Counting and, mouth gaping, watched as Anna delivered her little girl at home with a doula. No problems, good pain control, healthy mom and baby. Seemed like the perfect scenario for a home birth. By the time I’d seen that we were already registered for Bradley Method classes. My mom is a huge advocate for natural birth and is very proud of how she was able to birth both her children naturally without interventions or pain medications. It was her encouragement alone that had me seeking out information on natural childbirth, hence why we chose the Bradley Method. But after seeing Anna’s awesome delivery, I was certain I could do a natural birth in a hospital, no problem.

Fast forward five months. After 12 weeks of childbirth classes and 12 hours of hard back labor, I was nearly passing out from the pain. I couldn’t relax and had been stuck at 4cm for a few hours. I learned later that my son was OP (occiput posterior) which was causing the back labor. I got the epidural and quickly opened from 4cm-8cm in less than a half hour. I was relaxed and it was working!

Later, when Logan was born he popped a hole in his lung. This is the only reason I need to know that we will have our next baby(ies) in a hospital. We’re lucky to live so close to not one, but two great hospitals, both less than 30 minutes away. Regardless, the time it would have taken to treat Logan would have been delayed had we been at home. This birth accident is reason enough for me to know that it’s right for us to birth in a hospital setting. I’d even consider a birth center (closest one is over an hour away). But birthing at home is too risky for me.

Maybe that’s fear, and the kind of fear that women need to let go of in order to have safer, less intervention type births. But I just can’t. And I won’t. For me, I’m not scared that something like that will happen again. I just know that if it did, I would forever regret our decision to have a home birth and I could not live with those emotions.

Other reasons why I won’t have a home birth:

  • Someone else cleans up the mess. I know the birth team (midwives/doulas, etc) at a home birth take care of this but what about smells and stains and…everything else? No thank you.
  • Regular monitoring. I am a need-to-know kind of girl and I don’t mind being woken up every 2 hours to make sure I’m not hemorrhaging and to get help with those first few nursing sessions.  Oh and some meds to help control the after birth pains. I’m all for that (does this make me a hypocrite? oh well if it does…).

I want to be clear about something. This post is in no way to offend anyone who is for home birthing. I AM FOR home birthing, it’s just not for ME. If you feel comfortable with the idea and have had a great home birth, that is wonderful!! There are personal reasons why I know, deep down in my heart, that it’s not right for us and if you talk to any midwife out there, she will NOT support a home birth if mama is way to anxious and worried about it. I’m jaded. It’s not fair, but we had no control over what happened. Had we birthed at home, Logan would have been whisked away via ambulance and it would have been even harder to be away from him all while I was a hot mess.

An OB was interviewed on the blog Birth Mama. She had a successful home birth and her answers are very moving. I encourage anyone, regardless of what your birthing preference is, to read it. Not all OBs are like those depicted in The Business of Being Born. She gives very honest answers and great insight to the matter.

Now, what say you, birthing fanatics?