Midwifery Care

Are you a good candidate for out-of-hospital birth?

Only women experiencing normal pregnancies should consider out-of-hospital birth. Fortunately, pregnancy is not usually pathological and most pregnancies proceed without complication. If it were not true, our species would not have survived so long.

To be certain you are a good candidate, I will evaluate your risk factors, both physically and psychologically. There are certain health factors that may make out-of-hospital delivery unwise. I screen for these possibilities by first asking questions about your health, reviewing your health history and blood work results, and then watching carefully for any problems throughout the prenatal period. Below are guidelines for my practice; these may be adapted to particular situations according to my judgment and experience.

Definite contraindications to out-of-hospital birth

  • Placenta previa
  • Breech presentation
  • Multiple gestation
  • Diabetes
  • Pre-eclampsia
  • Alcoholism
  • Blood disorders
  • Drug dependency
  • Delivery before 37 weeks gestation
  • Previous classical (vertical) uterine incision
  • Other serious health problems, such as epilepsy, tuberculosis, renal disease, cardiovascular disease, AIDS

Possible contraindications to out-of-hospital birth

  • Smoking
  • Hypertension
  • Sexually-transmitted diseases
  • Abnormal fetal growth
  • Poor nutritional status
  • Psychological problems
  • Polyhydramnios
  • Postmaturity
  • Active herpes eruptions at time of labor

Women/families who choose out-of-hospital birth are accepting a high level of responsibility for themselves and their baby. Clients need to be self-motivated to take on that responsibility, and to make necessary changes in their lives to ensure the best possible outcome. These changes may involve nutrition, exercise, stress reduction, devoting time for prenatal care and education, and avoiding substances that could be harmful to the developing baby. Time must be spent to gather birth supplies and prepare your home and family for the birth.

Out-of-hospital birth clients must agree to:

  • adhere to the guidelines provided for the course of their care
  • keep their appointments
  • read, research, prepare for their birth, including attending childbirth classes if possible
  • actively participate in all aspects of their care, and communicate any concerns that they may have
  • have the mother of the baby abstain from recreational drug use, alcohol, and cigarettes, & avoid exposure to second-hand smoke
  • eat plenty of fresh, wholesome foods and limit “junk” foods
  • exercise in ways appropriate for pregnancy
  • establish plans for securing medical assistance if it becomes necessary
  • make required preparations at home, including the selection of a support person for any siblings that will be attending the birth
  • breastfeed the baby
  • assume financial responsibility for services rendered

The physical and emotional environment of the client’s chosen place of birth should be conducive to having an out-of-hospital delivery as well. The client and her partner must both be comfortable with out-of-hospital birth.

Prenatal Care

Adequate prenatal care is required for each woman preparing for an out-of-hospital birth. This is a safeguard for her health, as it allows the midwife to watch for any risk factors that might make out-of-hospital birth unwise. It also offers the pregnant woman the opportunity to learn about the changes her body goes through as pregnancy advances. And it allows the midwife and client to develop a bond of communication and trust that is immeasurably helpful to both of them.

I expect to see all clients at least once a month until the 28th week, then every second week until the 36th week and once a week thereafter. This is the same schedule that is followed during standard obstetric care. Visits with me routinely last 45 -60 minutes each.

As part of your care, I do a home visit at 37 weeks to make sure the home is ready for your birth, check your supplies for birth, make sure I know how to get there, do your regular prenatal exam, and finalize plans for your birth.

Prenatal care includes monitoring blood pressure, fetal growth, fetal heart rate and position; urinalysis; monitoring of the iron levels in your blood; and screening for complications. Equally important is the time spent discussing nutrition, exercise, breastfeeding, family changes in pregnancy, general information on childbearing, techniques for labor management, pregnancy and birth technology, and health care alternatives. If any complications developed in a previous pregnancy or delivery, I request that the medical records of that pregnancy be obtained from the previous caregiver.

Ideally, I ask the client to arrange for a physician to “consult”, as an adjunct to my care. This doctor does not function as my “back-up” doctor nor have any official or legal relationship with me. Rather, he/she is someone who is willing to consult with the homebirthing family, to order any lab work or tests that are required, and to assume their care in the event that hospital admission is necessary. Clients may receive dual prenatal care from both physician and me throughout their pregnancy, or may only need to see the physician a few times, with more frequent visits with me. If I feel you need an ultrasound assessment, or you request one, your doctor will order it for you.

Labor and Delivery

Once you are in labor, my assistant and I will come to your home whenever you call. I know that birth is a normal life process that proceeds best when interfered with as little as possible, and my role at your birth is primarily as a guardian or “life guard”. A life guard’s care is only really needed if an emergency arises, but you don’t need him to help you swim normally. In the same way, I watch carefully and intervene only if needed. I will monitor the baby’s heart rate on a regular basis, and provide as much or as little labor support as you request, but otherwise I will attempt to remain in the background.

Of course, if you need emotional support or specific guidance during the labor, I will provide this as well. Some women need someone to hold their hand and talk them through every contraction. Some women need privacy and silence, and prefer me to sit invisibly in the corner and watch. Some even ask me to remain in another room and come in only to check on the fetal heart tones and to assist the actual delivery. Every woman is different and every birth is different. There is no right way to give birth, there is only the way that works best for you. I will give you the space and assistance to find that way. I will make suggestions for comfort measures and position changes if there is a need. These comfort measures may include, heat, cold, herbs, aromatherapy, homeopathy, massage, water, movement, music, food, beverages, time alone with your partner, prayer, rituals, hugs, empathy, or other things.

You may labor and deliver in whatever room you like, in or out of the bed, presuming it is clean and safe and there is room enough for you and one other person! You may also assume whatever positions you like. I have no restrictions or preferences about this, and have found that women in labor instinctively know how to move their bodies and what positions to assume to let their babies out. Of course, if you are having trouble and need assistance, I will provide guidance and suggestions to facilitate the delivery of your baby.

“We try to give a birthing woman freedom to find the right position for her own needs and comfort. Unfortunately, in our society we think of birthing as something done while lying down.” – Michel Odent, MD

Once born, the baby is handed directly to you, where he/she will stay as long as you like. There is no mother-baby separation – where would we take your baby anyway? There is no baby warmer in your home, and science has shown that baby only needs the heat of your body to stay warm. He/she will be suctioned only if absolutely necessary, not on a routine basis; most babies do not need any suctioning at all. Baby is placed on your belly, skin-to-skin with you, dried off with warm towels, and then you are both covered with a warm blanket. The cord is not cut until it stops pulsing, usually after the placenta has been born. The placenta is delivered in a gentle and unhurried manner, inspected for normalcy, and disposed of according to the family’s wishes. Apgar scores are assessed and documented, and all information is shared with you. Finally, when both mother and baby are stable, the family is left alone for private bonding time.

What if you need to go to the hospital?

Occasionally, complications of labor or delivery may occur that indicate that transport to the hospital would be wise. They don’t occur frequently, and if they do, we accompany you to the hospital, make all of your prenatal and labor records available to the hospital staff, and facilitate a smooth transition. Most often, transfer to the hospital is not an emergency and occurs in our own vehicles rather than in an ambulance. Once in the hospital, our roles become that of labor support people rather than midwives.

Complications which MAY require transport to hospital during labor, birth or postpartum

  • Irregular, depressed or accelerated fetal heart rate
  • Thick meconium staining
  • Prolonged lack of progress in labor
  • Elevated maternal temperature
  • Poor infant response after birth
  • Infant abnormalities
  • Retained placenta
  • Extensive perineal or cervical lacerations
  • Maternal hemorrhage

Postpartum

After the birth, my assistant and I will normally do the following before we leave:

  • Check your uterus, bleeding, and vital signs
  • Make sure you have something to eat
  • Make sure you have emptied your bladder
  • Help establish breastfeeding
  • Assess your perineum, give instructions for care
  • Help you get cleaned up
  • Do a complete newborn exam next to the parents
  • Go over specific instructions for the postpartum period
  • Clean up

Follow-up care

I will call you several times during the first 36 hours after the birth to check on things and will visit you in your home around between 24 and 48  hours postpartum to assess mom and baby personally, and to do the newborn testing that is required. I return again on day 3 or 4, to check for jaundice and assist with any breastfeeding problems that may have arisen.  The birth certificate application is also completed. I am available for phone consultations at any time and will do additional home visits within the first 6 weeks if you or baby have any problems.

I ask that you have the baby seen by a family practitioner or pediatrician within the first 2 weeks to establish care and to confirm that he/she is healthy and normal.

You may come to my office for your final postpartum visit 6-10 weeks after the birth. At that time we can discuss family planning and well-woman gynecological care.

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