This question was answered for us by midwife Cara Muhlhahn

Q: Can you clarify some of the precautions midwives take to protect the mother and baby if complications arise during labor? At what point does the midwife know and make a decision to transfer to a hospital? And what happens if it’s too late to transfer? Can you explain what midwives do in the home when common and uncommon problems occur?

A: All midwives whether caring for women at home or in the hospital screen their moms for complications of pregnancy. This screening process is done initially and on an ongoing basis throughout the pregnancy. Midwives check for breech presentation, multiple pregnancy (twins), high blood pressure and concomitant conditions such as pre-eclampsia, growth delay, urinary tract infections, preterm labor, etc. Those are just some of the conditions of pregnancy that would potentially increase the risk of complications at delivery. Then of course, while a woman is in labor her baby is monitored, usually with a hand held doppler to ensure the baby is tolerating labor well. This judgement call is made by continuous assessments of the fetal heart rate, color of amniotic fluid, assessment of normal vaginal discharge (no bleeding), evaluation of vital signs, during the woman’s entire labor. I have found that rarely is a transfer necessary except when a baby experiences fetal distress. Fetal distress is not a sudden event, but rather something that occurs over time, which means that there is usually adequate time to initiate transfer to a hospital once the judgement call has been made. So, although fetal distress is not a common problem, it is the most common reason for transfer from home, at least in my practice, although transfer rates are under 10%. That means that 90% or more of women deliver at home with no, or readily manageable complications such as postpartum hemmorhage, need for minor resuscitative efforts, repair of deep perineal lacerations.

For good reasons every parent must feel that their place of birth is safe and secure. Public opinion is currently fashioned by Obstetricians who only know one system of technology based institutionalized childbirth. Therefore, they feel more comfortable with the hospital paradigm and the medical model. Because of this bias, families only ever question the safety profile of the site of birth, but not the system of clinical management that is responsible for making the judgement calls that result in good or bad outcomes.

Anyone who has witnessed and practiced homebirth for a very long time (and there are homebirth practices run by doctors as well as midwives), knows that breaking down the safety quotient into it’s requisite parts is not as simple as putting our faith in access to technology. Placing emphasis on the rapport between clinician and birthing mom results in a higher safety profile (of course that’s a hard one to study). One on one care throughout the pregnancy and birth as well confer many safety advantages that cannot be offered by a compartmentalized system of clinicians of varying experience such as exists in the typical hospital setting, i.e. nurses, interns, residents and attendings all caring for the same woman at different times. This discussion can continue on and I hope it does, but these are just some of my thoughts on factors that may affect one’s choice of setting for birth.


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