Home Birth ‘Emergencies’

People often worry that in a homebirth there would be no time or specialist equipment to deal with emergencies.  However, the BirthPlace Study found that homebirth was as safe for babies and safer for mums than birthing in a consultant led hospital unit, and comparable with a freestanding midwifery-led unit, largely because being at home meant that there was simply less likely to be an emergency that needed treatment.  In order to get any kind of statistical significance at all several situations which can be treated at home or later on and which do not have long-term consequences were included as risks, and the study did not include other measures of success such as breastfeeding or mum’s emotional health which seem to be much better after an undisturbed home birth. Had they included long-term and emotional outcomes it is likely that homebirth would have shown demonstrably better outcomes for both babies and mums.

That isn’t always enough to allay fears that have sprung from years of exposure to dramatic birth stories, so I’ve listed some of the common things parents ask about, in no order other than the one I thought of them in:

Failure to progress
This is just not an emergency, often it is the result of trying to squash a naturally very variable process into a medical, tick-box timeframe.  Of course it doesn’t work like that.  It can also be the result of a woman feeling observed, exposed to environmental or care-giver fear or just trying to ‘play it safe’ without any actual cause for concern, resulting in woman and baby not having enough time or space to dance their own dance.  Have a look at this lovely article on checking dilation for an alternative view on labour progress.  If a labour is really not progressing due to positioning not being right for mum’s pelvis, then there are lots of things you can try to help baby change angle, and if all that doesn’t work, then transfer for more help can be calm, peaceful and well-supported without increasing the danger to either baby or mum.

Pain Relief
Your options for chemical pain-relief at home are limited, over the counter painkillers are generally considered safe for use in labour, but if you are in any doubt at all after reading the packaging you can always consult a medic or pharmacist.  Most midwives carry gas and air, occasionally women get pethidine or diamorphine on prescription, to keep in their fridge, just in case, particularly helpful to ease the pain and stress of a vehicle journey should a woman decide to transfer to hospital at any stage.  So, yes, your options are fewer, but before you decide that is not a good thing, here are some things that your anaesthetist might not tell you: women with epidurals report lower overall satisfaction after birth than those who did not have complete pain-relief, which suggests that pain is not actually the most important thing a woman is dealing with during labour.  The other important thing to remember is that most pain is related to tension and if you can reduce that tension and allow your own labour hormones (which also give you that ‘feel good factor’) to flow, your body’s own endorphins (natural pain-killers) will also flow and labour actually becomes easier to cope with.  That, in a nutshell, one of the ways I believe self-hypnosis works.  You can imagine that being relaxed is easier in your own safe nest than in a place you’ve not been very often, and one filled with people you’ve never met…  You can help yourself in hospital by making your room smell, feel and sound of home (take your own pillows, favourite room scents, cleaning products if you like, music, taking both your partner and someone whose job it is to protect your birth space so your partner can get on with supporting and nurturing you, but it is easier to achieve at home.  Water also really, really helps with that.  If you have no pool a bath or shower can be a substitute, and certainly better than nothing!  You can have pethidine or diamorphine on prescription for your midwife to use at home, but I would urge you to do some reading before you do that.  Midwives can use narcotic pain-killers, but they don’t carry the antidote used if your baby should have breathing problems associated with narcotics.  Both drugs are also associated with feeding difficulties and many women report that whilst they were effective pain-killers they did not like the ‘out of it’ sensation that is part and parcel of their effect.
Of course, if you do want additional pain relief, you can always, at any point, change your mind about place of birth and head for hospital and other options.  It is more difficult plan to go to hospital, decide you don’t like it and go home to complete labour and birth!

Baby not breathing
Midwives carry air resus equipment, which has been shown to be safer than oxygen.  Also, your placenta will carry on supplying oxygenated blood to your baby until your baby’s own oxygen levels are high enough, so if you leave the cord attached and pulsing you have plenty of time to wait for your baby to take a breath or to give a little help to inflate their lungs.  If longer-term breathing support is required ambulance crews carry the kit needed for transfer to a neonatal unit, but this is a rare situation with a healthy pregnancy and a term, spontaneous birth.  Induced babies are more likely to suffer these problems than babies who decide themselves that the time for birth has come.

Bleeding in labour
Small amounts of blood are normal, larger flows are an indication of a problem and likely to result in a blue-light transfer for emergency help.  In a hospital setting it is more likely that you will be reliant on a monitor trace, which may be less sensitive than your 1:1 midwife and certainly does not listen to your concerns.  There are always some situations where the outcome is not good, regardless of where labour takes place.  Those situations are tragic, but are not necessarily any less frequent in a hospital.

Shoulder dystocia
Labouring on your back increases the risk, as does induction, forced pushing and having an epidural.  These are all less likely (or not possible) at home.  If you want to read more about managing dystocia, Home Birth UK has some good info here.

Cord prolapse
Where the cord comes down before or alongside the baby.  This is very, very rare if baby has his head (or his bum) over the cervix and into the pelvis, as the cord simply can’t slip through.  If your forewaters break under the pressure of the baby, then it is likely that your cervix is tightly covered, if your hindwaters leak but the cushion of forewaters is still there then the cord is contained.  Artificially breaking waters at home is potentially a dangerous thing to do, because with you on your back gravity could pull your baby away from the cervix and create a space for the cord to slip past with the flowing amniotic fluid.  This is an intervention which is at best probably unhelpful as it does not seem to shorten labour, but can make it much more painful, and at worst is best reserved for when there are surgical facilities close on hand.

Bleeding after birth
Midwives carry syntometrine, the same drug used in a hospital setting.  Syntometrine is as effective given to stop bleeding as it is at preventing it.  Also as your own oxytocin levels are likely to be higher at home than in hospital, post partum haemorrhage is less likely in a home birth.  Ambulance crews carry IV fluids and stocks of universal donor blood.  If you want to know more about the third stage of labour, options, complications and treatments, then AIMS have a fantastic book on the subject called Birthing Your Placenta.  If you want to read before you buy I have a couple of copies.

Baby is coming bum first
Babies can turn, even in labour, and most do.  That aside, breech is just a variation of normal and breech babies can be born safely.  You are more likely to get a hands-off (the safest way for breech babies to enter the world) birth at home with a competent and experienced midwife.  The Term Breech Trial (the study that threw the baby out with the bath water and resulted in section being recommended for breech babies) was found to be seriously flawed and actually showed no long-term differences, and so is not reliable research showing that caesarean is the safest way to deliver a breech baby.  I have several books on both ways to try to turn your breech baby, and ways to birth him.  An undiagnosed breech baby stands a much better chance of a peaceful and hands-off birth at home than in hospital…

Fetal distress
Closely linked with maternal distress.  In a spontaneous labour with 1:1 care this is actually rather rare, and is more likely to be picked up early by a homebirth midwife, before it becomes a problem.  Although we hear lots about  ‘non-reassuring’ monitor traces often those babies are born perfectly healthy, an Apgar score of 9 or 10 might suggest there was a problem with the trace or the interpretation rather than the baby.  Also, very strong induced contractions and epidurals dramatically increase the chance of a baby becoming distressed, and this is not a possibility in a homebirth!

Cord round the neck
I’ve lumped this in with ‘true knots’ and other cord compression issues…  If a baby is healthy and well, and the blood is flowing well in their cord, then it is impossible to knot or loop it tight enough to stop the flow, like it is impossible to knot a hose with the water turned on.  If a baby is already compromised and flow is low then a tight knot is a symptom rather than a cause.  A baby in the womb is not breathing, so a cord round the neck is not going to strangle them.  The answer is, don’t panic, the loops of plump, juicy cord will slip off during or just after birth.  Probably the worst thing to do is to locate and cut the cord, as this makes sure that your baby has no back-up from your placental oxygen supply.  My fourth baby was born with his cord looped several times round his neck, I know first-hand how hard it would have been to pull it tight!