Homebirth risk factors

[valancystirling]

Something that has particularly struck me recently is the thought that perhaps the average person believes that homebirth is something that anyone can choose under any circumstances. The Pang study cited by ACOG apparently seeks to perpetuate this misconception for its own charming reasons about which I shall not speculate in this post. I seek to give insight into the true nature of homebirth, and the process by which homebirth is achieved.

Apparently it is not commonly known that midwives screen prospective homebirth clients. There are a number of factors they look at in deciding who is a good candidate and who is better off in a hospital. These reasons include the following and probably others specific to a midwife's own experience and comfort level.

There are certain health factors that may make home delivery unwise. We screen for these possibilities by first asking questions about the client's health, reviewing their health history and blood work results, and then watching carefully for any problems throughout the prenatal period. Below are guidelines for our practice; these may be adapted to particular situations according to our judgment and experience.

Definite contraindications to homebirth

Placenta previa
Breech presentation
Multiple gestation
Diabetes
Pre-eclampsia
Alcoholism
Blood disorders
Drug dependency
Delivery before 36 weeks gestation
Previous classical (vertical) uterine incision
Other serious health problems, such as epilepsy, tuberculosis, renal disease, cardiovascular disease, AIDS
Possible contraindications to homebirth

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

Should your pregnancy fall outside the parameters for a safe homebirth, we will refer you back into medical care. Should you so desire, we will be happy to continue to support you in the role of a doula (childbirth assistant) as you plan your hospital birth.

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

from http://www.lovinghandsmidwifery.com/homebirth.htm

Although, I have to clarify, multiple babies does not necessarily rule you out for homebirth. Many midwives are comfortable delivering twins and some will even do triplets. Doctors have standardised many birth scenarios, and as such have generally made it uncommon practice to do vaginal breech deliveries, or vaginal multiple deliveries. I read some stats on this recently and am trying to remember where. But just because most doctors choose to preemptively perform c-sections on these potentially complicated birth scenarios does not mean that multiples or breech babies HAVE to be c-sections. Probably in a lot of cases a c-section is a good idea, but it's not across the board mandatory, though I suspect many doctors might feel uncomfortable outside their standardised comfort zone.

It's also important to note that while midwives can detect many of these risk factors at the beginning of a pregnancy, several can pop up at any time during the pregnancy, including during labor, and the midwife is responsible for judging for the entire pregnancy whether or not the status of her client has changed. Pre-eclampsia, placenta previa, and preterm labor are examples of issues that could develop later in the pregnancy and which a midwife would recognize to eliminate homebirth as a reasonable and safe option for a given client.

Comments

[loki-quinn.livejournal.com]

Great post, I just want to add that gestational diabetes and diabetes prior to conception are two different things that will be treated accordingly by your midwife. That was my biggest fear since I was considered pre-diabetic in the last pregnancy even though I now know there were a lot of other factors.

[valancystirling.livejournal.com]

I've been wanting to learn more about that. Specifically, to refresh my memory about what things can lead to GD.

What has been your experience with treatment during pregnancy (either one) being pre-diabetic?

[valancystirling.livejournal.com]

I agree--I'd feel much more comfortable having multiples in a hospital.

I need to post next about the Dutch model of care for pregnant women. All pregnant women start out with a midwife, and are ONLY seen by an OB if a complication arises. Women have to pay extra if they want an OB but are not deemed to NEED one.

I'm not completely sure about this, but it seems rational that if you have a history of NEEDING a NICU, higher level or not, that it might not be prudent to disregard your history to have a homebirth. Yes, each pregnancy has the potential to be completely different from all your others, but still. I think your confidence level would be compromised worrying about it, and so much of the benefit of homebirth is being comfortable and more able to relax in your own home. If *I* had serious concerns or doubts or even random baseless ones, I would go to a hospital for sure.

[kitchenwitch.livejournal.com]

Hi! I thought we hated each other, but I don't remember why. I'm sure it had to do with me being a bitch at some point. ;)

I'm diggin' all of these midwifery-related posts. It makes me so very sad to see preeclampsia on the "definite contraindications" list, since I had it with my daughter and really, really want a homebirth for the next time around. Or does it just refer to current, and not historical, issues? My understanding about preeclampsia is that it usually doesn't happen more than once unless you've got a new mate.

[valancystirling.livejournal.com]

I know, I had the same feeling about hating each other but couldn't remember why either. But I keep seeing you pop up on the good parenting communities, and it seems we're sort of in the same place in some things.

I need to learn more about preeclampsia. I know it's hugely diet-related, but there could be other factors I'm not aware of.

As far as I'm aware, a history of preeclampsia wouldn't necessarily put you into a higher risk level, but that you would be monitored more closely during the pregnancy. I'll look into it and post something.

I had a homebirth with my first and am trying to come up with a plan for a second one (homebirth midwives are scarce around here). I'll be posting lots more on the subject, so any other specific questions you have, let me know and I'll try to cover them.

Preeclampsia

[kitchenwitch.livejournal.com]

I'm not so sure I think it's diet-related. If diet is the overwhelming causative factor, I should've had it at week 20, not week 39. :) I struggled getting a large amount of protein in my diet because I enjoyed eating sugar too much while I was pregnant! A large amount of protein and small amount of sugar are central tenets of the Brewer diet.

My midwife (a CNM) believes in the theory that preeclampisa is linked to an immune response to semen. (Google "preeclampsia semen" for a bunch of articles/discussions... There's at least one journal article out there, too.) It seems that women who stick with the same partner are very unlikely to have a reoccurrence of the disease, but if they switch partners, the risk goes up. It's quite interesting!

Re: Preeclampsia

[valancystirling.livejournal.com]

Wow, I had honestly never heard about that. I'll definitely look into it soon--that's very interesting.