Tuesday, November 27, 2012

A Mothers' Story of a Planned Home Birth Turned Hospital Transport

The number one questions I get asked during a free consultation for my midwifery services is:
What happens if there is an emergency?

How do you get to the hospital?

How do you know you are getting there in time?
I reassure the families that midwives are trained in dealing with normal birth. While we can handle a good majority of unforeseen complications at home we have keen eyes, the benefit of one-on-one individualized care, and intuition telling us when things might be safer in the hospital. 

Most midwives have a 3-10% transport rate. The vast majority of these transports, I would go as far as to say 95% of them are non emergent transports. 

Some examples on non-emergent transports in my practice might be:
Mother has a fever during labor

Mother's blood pressure is rising during labor

Mother is too exhausted to continue with her homebirth plan

There is unusual bleeding during the birth but mom and baby seem to be doing fine

After a long labor mother is not progressing and would like pain medication to see if it makes a difference

After pushing for many hours baby is not descending well into the pelvis

Baby's heart tones are not as reactive as they should be and may be too high or too low at some points

Baby has passed very thick meconium and giving us other warning signs that s/he may be in distress

Baby is born and there are obvious birth defects that many need further examination or baby might be showing signs of infection such as a temperature or fast breathing

Mother tore during the birth to the extent that she needs a surgeon to do extensive repair

In the case of a non-emergent transport in my practice the family and myself talk about all of the options. Based on our discussion and both of our intuitions we may make the choice  that the birth may need to be moved to the hospital as it has become higher risk. I call the hospital and inform them that we are coming. The hospital is wonderful here and myself and my clients have always been treated with respect. They ask for information about the client so they can pull records and contact their OB if they have seen someone during their pregnancy or call the on-call doctor if not. We all load up in the largest vehicle we have and the baby and mother are monitored on the way to the hospital. The nurse copies my charts and the family checks in and the situation is assessed by the medical staff. I remain with the family the entire time they are at the hospital acting as their doula and support person as well as answering any questions the doctors and nurses might have.

The majority of non-emergent transports still end in vaginal and often even unmedicated births. A small minority end up with a cesarean for various reasons.

In the case of emergent transport I would handle the problem as well as possible at home while calling in an ambulance to transport the mother or baby to the hospital. I would still also call the hospital and tell them we were coming and what to expect. This is important! If you know that the mother needs a cesarean quickly it is crucial for your midwife to have a good relationship with the hospital so that their points of view regarding what is occurring is respected. It is not easy to call in a c-section team STAT but if your midwife has shown competence in the past the nurse on call will have no problem doing just that.

Some examples of emergent transport in my practice might be (keep in mind that each of these complications are very rare most with less than a 0.5% chance of happening during a birth with a full term newborn and healthy mother):

Prolapsed cord where the cord comes out before the baby -0.14% of births usually caused by artificially breaking your water or twins

Placenta Separating from the Uterine Wall before birth-01% of pregnancies world wide with poor nutrition and drug abuse the main cause

Uterine Rupture-0.07% of births with most of them being to women with twins, a transverse baby, or a  previous uterine surgery such as a cesarean section

Postpartum Hemorrhage or greater than normal bleeding after birth-1.5% of all births. Using a midwife who is competent in herbal remedies to help stop bleeding as well as licensed so that they can legally provide I.V. therapy and anti-hemorrhagic medications such as pitocin reduces the need for transport for this reason

Fetal concerns such as trouble breathing- 10% of babies needs some assistance to breathe after birth which a qualified midwife is trained to handle at home and the baby breathes and the family stays at home.  1% of babies need extensive breathing support which would require transport

The families feelings about a transport are so important. How you feel about your birth is often more important that what actually happened at the birth. 

I asked a past client of mine if she would be willing to share her story of a planned homebirth that ended in a hospital birth. She very selflessly agreed. Here is her story in her own words.

Midwives notes will be in blue: Look at how relaxed she is here at 9cm dilated
Please tell me about your choice to have a homebirth:
I had been interested in homebirth for a while. A local midwife had given a presentation on homebirth in one of my developmental psychology classes a couple of years before I got pregnant and I really liked what I heard. When I brought up homebirth to my husband after I got pregnant he said absolutely not. So, I started seeing a female OB. I knew I wanted a female doctor because I wanted someone who had experienced what I was going through and could anticipate my questions and calm my fears. After seeing her for almost 20 weeks, I decided that she was not the person I wanted to be with me at my birth. She never took the time to talk to me about any questions I had, nor did she make me feel calm or comfortable. I always felt like she was in a hurry to get somewhere else and I didn’t want to feel hurried during one of the most important events of my life. So I decided to change care providers to a family doctor. I chose this particular doctor because I had heard really great things about him from friends and family. My first visit was great. He was supportive of my desire to have a natural birth and he spent time with my husband and I never once making us feel like he was in a rush to get to his next patient. I was excited to have a doctor that I felt would be supportive of my decisions.  
A few weeks after I switched doctors, my husband and I started taking DyAnna’s childbirth classes. One of my good friends had hired DyAnna  to be her doula for her hospital birth and told me how amazing DyAnna was and that I should take her childbirth classes. During the six week course of classes, I realized again how much I wanted a homebirth. I decided that if I couldn’t have a homebirth I at least wanted DyAnna to be with me as my doula at the hospital. 
When I was somewhere around thirty weeks, I was in for my doctors visit and he told me that was probably going to have to have a c-section because I was showing signs of pre-eclampsia. The “signs” he was referring to was that I had one episode of high blood pressure. Subsequent visits with him continuously got more negative. He never even pretended to remember me from visit to visit, he always asked if I was a new patient. He also made negative comments about my body while checking my baby’s heart tones. I left many appointments feeling embarrassed and ashamed. Since I was in my last trimester by then, I felt like it was too late to change care providers again. Then, at my last visit with him I gave him my birth plan. He read it and then told me that he was unwilling to follow it and that the things I wanted were unreasonable and crazy. The “crazy” and “unreasonable” things that I wanted were things like no deep suction, no vitamin k, no eye drops, and to delay clamping and cutting the cord. After telling me I was crazy, he again told me that I was borderline pre-eclamptic and that I was going to have to have a c-section. I was really upset after that visit and I immediately called DyAnna because I knew I could trust her to tell me what was really going on. She invited my husband and me to go visit with her and another midwife. We discussed the things that my doctor had said and they took my blood pressure and checked my urine. All of which were fine. There were no signs of pre-eclampsia. Then they asked if I would like to have a homebirth. I was ecstatic! It wasn’t too late to change care providers again and have a homebirth like I had originally wanted. This time my husband agreed since he had become much more educated about the safety of homebirth and we both knew we wanted these to amazing women to attend the birth of our child. We trusted them to tell us the truth at all times and I felt safe and comfortable with them.

What were some of your concerns going into your birth?
I was most concerned with the pain of labor. I had confidence that my midwives would take care of everything else. I knew they would be monitoring the baby and me so I wasn't concerned that anything bad would happen to us. I was only afraid of the unknown pain. Everyone told me that it was pain with a purpose and that made it easier to handle but that made no sense to me. Pain was pain right? Nope. Now, having gone through the pain of labor, I understand what pain with a purpose means and that makes it much more manageable.

How did your family react to your choice?
My family thought I was crazy. I’m sure they thought I was going to die. I come from a very medically oriented family. If you sneeze you take cold or allergy medicine. You have a sore throat you take antibiotics and go to the doctor and get tested for strep. They had a really hard time thinking that I wasn’t going to go to a doctor and that my baby wasn’t going to be born in a hospital. Some members of my family refused to talk to me about my plans for childbirth. Also it was suggested that I was letting others (meaning my midwives) make my decisions for me. It was really hard not to have the support I so desperately wanted from my family. But I was unwilling to sacrifice what I believed was best for me and my baby just to make my family happy. After my son was born, they still didn't want to have anything to do with homebirth or midwives. All I wanted to do was tell them how amazing my midwives were and what great support they had been and still were being but they wouldn't listen or let me talk to them about it. Now, over a year later they are fully supportive and have become more educated themselves about midwifery and homebirth.
How did your labor begin?
I was ten or twelve days over my estimated due date and I was miserable! I was huge and uncomfortable. Walking hurt, sitting hurt, standing hurt, and laying down hurt. My husband and I thought it would be a good idea to try to shake the baby out by taking our Jeep off-roading. Every bump would bring on a contraction and it would eventually get so painful that I would have to ask my husband to stop the Jeep so I could catch my breath. The bumps also made me have to pee so we were stopping the Jeep every five minutes so I could either climb out to take care of business or just catch my breath. My contractions would stop when the Jeep stopped so after an hour or so we gave up and went home. There were no more contractions. Since I was going to be pregnant forever I thought that there was no need to go to bed at a reasonable hour and I stayed up until 2:00 am watching old episodes of Lost. I finally decided to go to bed and just as my eyes started to close I felt a gush of fluid and my first real labor contraction began immediately after. So, I rolled out of bed, cleaned myself up and tried to not be excited because I knew I needed to sleep. Sleep turned out to be impossible because my contractions were coming every 3-5 minutes and they were hard. So we called our midwives and they headed over to our house. That was it! I was officially a woman in labor.

Was the beginning of your labor what you expected?
It was not. I didn’t expect my water to break before I had any real contractions. I also didn’t expect my contractions to be so hard and close together at the very beginning. I had no idea what to expect. I guess I sort of expected to never go in to labor! It was so exciting though. I was finally going to have my baby. It was an exciting and happy time. I wanted to call everyone that I knew and tell them that I was in labor and I was finally going to have my baby!

How were you treated by your birth team in early/active labor?
They were all wonderful! My husband was incredible. He was my rock throughout it all. My midwives were excited for me and were helping make me comfortable in any way that they could. I decided that I needed some things from the store and they were more than happy to run out and get whatever I needed. They were patient and loving and made me feel totally at ease.

What are some of your favorite memories about that time?
My favorite memory of early labor is everyone sitting together watching The Best of SNL Commercials. In particular I remember “I’m not a woman anymore, I’m a mom”. That was a lot of fun. My midwives were great. They were there for me when I needed them and they faded into the background when I didn’t. I wanted my husband to be near me at all times. I had thought that I wouldn’t want him touching me but it turned out that I wanted him next to me holding my hand or something the whole time. He was wonderful. He got in the birth tub with me even when he didn’t want to and was an active participant throughout my whole labor. He was there giving me sips of water and bites of food and helping me position myself to ease the pains of labor. I felt closer to him at that time than I ever had before. It was a time full of love and tenderness.

What tools did you use to cope with your labor pains?
Counter pressure on my lower back was a life-saver. At times it seemed to almost take the pain completely away. Water also helped. Being in the birth tub took all the pressure off my body and helped me to relax which, in turn, reduced the pain. I don’t remember doing much of anything else to help with pain. The counter pressure and the water were the two big ones. I suppose deep breathing and keeping my body relaxed helped also. Oh, I would also grab a body part of whoever was closest to me when a contraction started and squeeze as hard as I could until the contraction was over. 

Tell me about when things changed in your labor and why you decided it would be better for your baby to be born at the hospital?
I’m not really sure. I guess I started to question whether or not my baby would be born at home when my midwives took turns checking my cervix and said that I just wasn’t dilating fully. They asked if they could try to help my cervix out and told me exactly what they would be doing and I agreed, but when they started it was just too painful and I asked them to stop. Of course, they immediately stopped but my concentration had been broken and I was no longer relaxed and the pain seemed to overwhelm me.  I tried to tough it out for what seemed like hours but was probably not a very long time. I was determined to not wimp out though. I wanted a homebirth more than anything. I did not want to end up at the hospital because in my mind bad things happened had the hospital. I was technically fine and there was nothing wrong with my baby and I felt like I had no reason to go to the hospital. I think it was around 5:00 pm (my husband says it was only 3:00 pm) when my midwives said something like “It is okay to go to the hospital if you feel like you need to. No judgments.” I had known that all along, but having them say it out loud gave me the courage I needed to make the decision to go to the hospital. I don’t know that I ever thought it would be better for my baby to be born at the hospital but I felt like he just wasn’t going to come out at home. On top of that, I was in excruciating pain and there was no break between contractions. It was one on top of the other each one more painful than the last. And I still wasn’t fully dilated. So I asked to be taken to the hospital. Midwives Note used with permission: She had followed a wonderful labor pattern up to 9 cm but then had no change for over 4 hours with extensive non-typical pain and baby not engaging deeper into the pelvis.

How was the transport handled?
My midwives were amazing. The instant I said I wanted to go to the hospital they were making preparations. They called the hospital to let them know we were coming, they found me stuff to wear and helped get me presentable, and they got their van ready to go so all I had to do was be half carried to the car. I didn’t have to worry about anything and neither did my husband. They took care of everything. 

Were you scared? What were you thinking of while going to the hospital?
No, I was in too much pain to be scared. All I could think about was the pain. There was no room for any other thoughts in my brain other than “It hurts! It hurts!” 
How were you treated when you arrived at the hospital?
The hospital staff seemed to not know how to deal with a woman coming in who was in full blown labor. They tried to stick me in a wheelchair, which I know is protocol, but what woman who is dilated to a 9+ and having never ending contractions is going to be okay with sitting in a wheelchair? The poor girl with the wheelchair seemed to not know what to do when I refused to sit. I don’t remember much about what happened after we got to the room because of the pain, but I do remember that they were asking me endless questions that I didn’t know the answer to, nor did I care to answer them. It was really irritating to be asked stupid questions when I was clearly not in a state of mind to be answering them.

What did the doctor say about your reasons for going to the hospital and what course of action was taken?
I don’t remember what he said about my reasons for going. I just remember him giving me pitocin to try to make me fully dilate. I finally got an epidural and I have to say it was nice to be pain free. I think it was about an hour after being on pitocin that the doctor came back in and said that there had been no change. I told him that I wanted to continue to wait and see what would happen.  Three hours later, after no changes with my cervix he came back in and told me I had two options. I could have a non-emergent c-section immediately or I could keep waiting until it became an emergency c-section. I was devastated. My beautiful, spiritual, and sweet homebirth had turned into a major abdominal surgery. After many tears, I decided to have the c-section sooner rather than later. I was terrified. I knew I needed to have my husband in with me during the surgery and I really wanted my midwives to be there with me also. I needed their support. They understood things better than I did and I wanted them to stay with me. I wanted my husband to be with our baby at all times and I knew that he would be leaving when they took our baby out while the doctor put me back together. I needed my midwives there with me to support me when my baby was taken away and my husband was gone. We were told that they would not be allowed in to surgery with me. I was really upset that they wouldn’t be able to come. My nurse who had barely spoken to me other than to ask me the stupid intake questions said “Don’t worry. I will be in there with you.” It was not comforting. I remember laughing to myself when my midwives responded to her statement with something like “She doesn’t know you so that’s not helpful.” It was nice to have them there to stand up for me.

When you went in for your cesarean what were you feeling?
I had a lot of emotions. I was scared and really really sad that I didn’t get to have the birth that I had been hoping for.  I was also happy that I would get to see my baby soon. I was worried about being alone during the surgery since I had told my husband that he needed to be with our baby at all times. 

Are there any details you would like to share about the surgery?
I remember that the nurse who told me she would be in there with me spent the whole time flirting with the doctor who was performing the c-section. She never said one word to me and the doctor only said things like “Tell me if you can feel this.” They were flirting and giggling the whole time! It was not how I imagined childbirth at all. The only person who actually spoke to me was my anesthesiologist. He was really nice. He asked me if I was nervous and explained what was going on and asked me questions about myself to help me relax. Midwives note: The official diagnosis was cord entanglement  Cord was around the neck twice (which is not usually a problem) then around the chest and shoulder and around the abdomen and each leg preventing further descent into her pelvis.

When did you get to see your baby?
I saw him for about 10 seconds as they carried him out of the room. They didn’t show him to me or let me touch him though. I finally got to see him around thirty minutes after he was born and my surgery was finished and I was back in my room. But I was shaking so bad from the epidural that I couldn’t hold him. 

Did you still feel supported by your midwives at the hospital?
Yes! They were incredible!  Every time the doctor or a nurse said that I had to do something or they had to do something to me look for them to shake their heads no or nod yes. I had taken DyAnna’s childbirth classes and I had felt informed and knowledgeable about things that they hospital might want to do that are unnecessary but in the moment, I couldn’t remember anything so I needed them to help support me in my choices that I had already made but couldn't remember at the time especially when they went against the hospitals routine. They kept me entertained and did their best to keep me positive about the experience. They were also a huge support to my husband. After we got to the hospital he was able to shower and take a nap for a few hours. He told me he wouldn’t have felt safe or comfortable doing that without our midwives there to be with me. They stayed with me until after my baby was nursing and I felt comfortable enough for them to leave. They came back to the hospital to check on us the next day also.

How was your nursing experience at the hospital?
That first night it was fine. My midwives were there and helped me get everything figured out. My baby had no latching problems and everything was going well. The next day, a lactation consultant showed up and asked how things were going. I said we were fine and didn’t need any help. She insisted that we did, then she reached out and grabbed my breast and started squeezing it. Then, she began smashing my baby’s face into it. I am a very private person and she was up in my very personal space doing things that I didn’t want done after I had told her I didn’t want help. It was a horrible experience. I was used to my midwives gentle touch and they always asked and waited for permission before they touched me anywhere. On top of the awful lactation consultant I had hospital staff coming in and out of the room messing with my IV and trying to talk to me and whatever else they do while I was trying to nurse. All I wanted was to nurse my baby in peace without being exposed to everyone under the sun. Overall I hated trying to nurse my baby at the hospital.

When did you go home?
I went home two days after the c-section. It was a horrible transition from the hospital to home. First off, could barely stand upright and walk much less do anything else like carry my baby. After spending the first couple days of my baby’s life in the hospital it seemed unnatural to be caring for him at home. I sort of felt like “What do I do now?” While the transition to motherhood can be strange for homebirthing women as well, I am positive it is a much more strange experience for women who have to bring their babies home from the hospital. Birthing at home naturally leads into motherhood. Bringing a baby home from the hospital is not.

Did your midwives clean up the homebirth supplies before you got home?
Of course they did! They even fed our cat since we were in such a hurry to get to the hospital we hadn’t even thought about it. When I got home from the hospital there was no sign that they had even been there. Our house was spotless.

How was your experience physically once you got home?
It was really hard to do anything. I couldn’t lay flat so sleeping was difficult, I couldn’t bathe myself or do any other basic self-care. I could barely dress myself. It is impossible to recover from a major surgery and care for a newborn at the same time. My poor husband had to do everything for us. I was so tired because I wasn’t sleeping well and I thought I was going to go crazy not being able to do anything for myself.
Did you feel supported by your midwives postpartum?
Again, they were amazing! I saw them many times after my baby was born. Our first visits were in the hospital and in my home then, when I was more mobile, our visits were in one of their homes. I saw them at least ten times the first six weeks of my baby’s life. They cared about how I was doing physically, spiritually and psychologically. In contrast, I saw the Obstetrician who did the c-section two times in the same six week period and he only cared about how my incision was healing not about how I was doing psychologically.
At one point, I started having panic attacks from lack of sleep and some other things. My midwives came over immediately and offered their support. They talked to me about my concerns and shared their own experiences and offered to help in any way they could. They even offered to come stay with my baby so I could get some much needed sleep. I wouldn’t have trusted him to anyone else during that period. I also called and texted them many times throughout the first few months of my son’s life. They were always happy to answer any questions or concerns that I had. I have no words to express how grateful I am to them for being so supportive and loving during that time. They are wonderful women. And I love them!

How did you feel about the transport?
While It wasn’t my dream childbirth experience, I was mostly just happy that my baby was safe and healthy and so was I. I wished I hadn’t had to go to the hospital, but I couldn’t see how anything could have been different. We tried our best to have a homebirth and it just didn’t work out. I was disappointed, but that didn’t outweigh the joy of having a beautiful healthy baby.

How do you feel about your overall experience 18 months later?
A few months ago I went through a period where I was really angry that I had to go to the hospital. I felt like there was something wrong with me and I was feeling down in the dumps spiritually. I was feeling like if I had been more righteous, prayed harder, and had more faith then I wouldn’t have had to go to the hospital. I talked to my husband about my feelings and he helped me understand again that we actually were blessed during that time. Our son had been born and he was perfect. He was always fine and so was I. We don’t always get what we want and we need to be thankful for the blessings we have been given. Now, looking back at all that we went through it was such a good bonding experience for my husband and me. We are closer than we were before all this happened and I still feel like I had a homebirth. 

How do you feel about homebirth after your experience?
I am passionate about homebirth. It is such an empowering experience. It is also beautiful, spiritual, and gentle which are things that I don’t associate with hospital birth. I hope to have my future children at home.  While I admit that the hospital can provide necessary life-saving options, I don’t believe that all women need the hospital for childbirth. I love the experience I had at home with my midwives. And I wish that all women could have that same experience.

Midwife Note: I just love his little squished and off center nose that was caused by him hanging out in the birth canal for so long

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