Updated: Feb 10, 2020
Buckle your seatbelt for a long read! We share a TON of education in this post, knowing that those who have this question want it answered thoroughly! Please use this article as informational only- this is a sole reflection of how we generally handle complications in our practice and not to be misconstrued as medical advice or instruction.)
When you are considering and planning a homebirth, many new thoughts and concerns may come to mind. Not only are you taking on the giant responsibility of having a child but there is an added responsibility of doing this in your home and going against mainstream birth culture norms. You wonder, is this a good idea, is this safe, what if something bad happens? And even if you’ve reached a place of confidence with your choice, your friends and family may be very vocal about their own concerns for you.
Homebirth often get portrayed in 2 extremes- a dangerous event that could go wrong at any moment and should always take place in a hospital with standby emergency services; or a peaceful and twinkling family bathtub in your living room with kumbaya playing in the background. There’s room in birth for a vast array of experiences and outcomes, but midwives recognize that a huge majority of women (about 90%) are having a low-risk pregnancy and go on to have a low-risk birth. We proceed to expect and support a physiological process that does best with minimal intervention and interruption. If the majority of what we encounter as midwives is low risk and we plan to be non-intrusive with our care, do we even know how to handle complications and emergencies or are we only equipped to support beautiful and easy births?
Asking these questions is good!! Considering the pros and cons, risks and benefits, is a healthy sign of parenting. We would love to see more consumers prepared to ask about safety and outcomes in all birth settings with all types of care providers. “What if something goes wrong?” Is a common place to start, but it would be even more beneficial to ask questions like, “what are the most common complications, and how do you respond to ______ complication or emergency.” Can you see how you may collect different types of information with the way you ask questions? It’s valuable to know and understand what can actually go “wrong” and what is being done to protect health and safety.
Many people are surprised to learn what training, skills and equipment midwives have to handle complications. Many families assume that because we are providing care in homes that we do not have the resources to handle medical events. Kelly and Tiffany are licensed by the Medical Board of California (the same governing body that licenses physicians); we practice with autonomy and within the scope of a primary caregiver. We carry medical instruments, medications, oxygen, resuscitative equipment, and equipment to monitor vital signs of baby and mother. In fact, we provide every resource that a birth center does, we just bring it with us. What we do not have is an operating room, intubation equipment or blood products, and will always move to higher level care when these resources are anticipated or needed.
It’s important to note that the primary way we prevent complications to begin with is by taking a holistic approach to care. We believe that birth is a normal event, that usually unfolds best on its own. Midwives have set up prenatal care to spend 12-13 hours of time with each family learning their bodies and babies and establishing individual baselines for them. This allows us to address issues that come up in pregnancy and make preventative adjustments with nutrition, movement and loads of education. We enter the birth event together, with mutual trust and respect and a common goal.
It’s vital to recognize that birth is not without risk. No one can eliminate risk in any setting with any set of experience and skills. But HOW the risk is recognized and respected matters a lot. Midwifery care is an equal partnership of midwife and client. Your job is to learn the risk, weigh the benefits and make a choice comfortable and supportive for you and your individual family. Our job is to constantly assess the care we provide inside the framework of normal and respond with vigilance to the most common complications in order to restore normalcy to the birth event.
Not everyone is comfortable talking about these things. We recognize that many birthing parents would rather blindly trust, assume competency and hope that nothing goes awry in their positive thoughts birth bubble. We caution strongly against that approach, knowing from experience that unpacking facts and dispelling untruths always takes the charge off these topics. We by no means emphasize an expectation for complications in birth- but truly believe in the benefits of shared responsibility and decision-making.
We endeavor to be transparent about the risks. The 3 most common complications that we experience at homebirth are shoulder dystocia, hemorrhage and neonatal resuscitation. These complications rarely come out of nowhere, but more often get revealed inside a bigger story being told, with a few signs that warn us to be alert. Some examples of these signs may be a very long labor, uncoordinated contraction patterns, and a deviation in normal heart tones of the baby, just to name a few. Should we then transfer to higher level care when we see these signs at birth? The short answer is no. Very often we can bring these items back into normal, they self-correct or ultimately don’t cause any issues at all. Very rarely are a certain combination of these signs a precursor to complication, yet we remain vigilant just in case. Sometimes it does become obvious that higher level care is best for all, and recognizing these signs before an emergency occurs allows us to make a change in settings safely.
1. Shoulder dystocia is when the baby’s shoulders get stuck on some part of the pelvis while it is being born. Most of the head is usually born and then despite maternal pushing effort, the rest of the baby can not be born right away. Again, a huge part of managing shoulder dystocia is avoiding it in the first place. Only about 30% of shoulder dystocia occurs with large babies; the other 70% are due to malposition of the average-sized baby.
The best thing we can do to avoid this complication is leave birth undisturbed whenever possible and set up the support a birthing mother needs to move freely and instinctually throughout her labor. Waiting patiently for babies to come, and leaving hands off during the delivery allows babies to make the full rotation needed for the shoulders to clear the pelvis on its own. Rushing or assisting this process can very well become the cause for babies getting stuck.
But even the most patient and trusting birth attendants will eventually encounter a shoulder dystocia. We act quickly to first change the position of the mother. A huge majority of the time, this frees the baby instantly. Mom turns over, or lifts a leg to get out of the birth tub and baby comes shooting out. If not, we have several systematic maternal positions to move mom through that all change the diameter of the pelvis in order to shift and make room for baby. When these don’t work, we enter the vagina with our hands to manually reduce the baby’s shoulders and rotate them to fit through the pelvis.
The baby always comes out with the proper use of these methods. Our approach is to recognize and resolve a shoulder dystocia as quickly as possible. It’s common for a baby to need resuscitation, and a mother to bleed heavier than normal after a shoulder dystocia. We expect and respond quickly to both possibilities.
2. Neonatal resuscitation is a series of actions used to assist a newborn having difficulty making the transition from intrauterine life at the time of birth. Babies go through a major physiological transition to begin breathing air and oxygenating through their lungs instead of their umbilical cords. Some babies, due to various issues, often unknown, need a little extra help initiating this transition. 1 in 10 babies will require some level of resuscitative intervention. That may seem like an uncomfortably high rate, however the first step in resuscitation is 5 breaths to inflate the lungs of the baby, which quickly assists over 90% of babies who need help, in the span of only about 20 seconds. We use positive pressure ventilation with a neonatal bag and mask to force air into the lungs, which pushes the surfactant out of the alveoli and stimulates independent breathing and normal transition.
Many people are surprised to learn that babies are born looking kinda blue or purple. Not all babies begin crying when they are born and crying is not necessary for good transition and oxygenation. At the birth, we wait a full 60 seconds for babies to begin breathing on their own, which oxygenates their blood with air and turns them pink. The average adult has a blood oxygen saturation of 98-100%. It takes a normal newborn about 10 minutes to reach 90% saturation, and we are patient with the process.
For babies who need more help than those first few breaths, we continue with resuscitative efforts to breathe for the baby with the bag and mask. Rarely a baby will require chest compressions to stimulate necessary cardiac function but we are trained and prepared to perform a full resuscitation with oxygen while initiating emergency transport for the baby. Less than 1% of babies will require a medical intervention that we can not provide at home. When transport is necessary, we travel with the baby and continue breaths and compressions.
Once again, our goal is to intervene with the intention of restoring the event to normal, while utilizing the advantages of understanding the physiological nature of birth. We never rush the baby off to a station on the other side of the room. We make every effort to resuscitate while the cord is still intact, keeping the baby’s present source of oxygen flowing by allowing the placenta to finish delivering about 1/3 of the baby’s blood volume. We also set up our equipment in a way that allows us to resuscitate while the baby is still being held by the mother, or just next to the mother- often asking the parents to talk and welcome their baby as we work together.
3. Postpartum hemorrhage is often defined as a certain volume of blood loss after the birth. 500 ml is the standard threshold. Midwives are trained to estimate blood loss in order to calculate this number. However, we won’t use the volume as the only rule of thumb for treating excessive bleeding. Many women lose 500 ml and more and tolerate it well, and likewise some women lose less and experience compromise because of it. We assess blood loss along with other signs of low blood volume: primarily evident in vital signs and feedback from the postpartum mother about how she is feeling.
It’s very normal for there to be a lot of blood with birth, 500 ml is 2 full cups. We see average estimated blood loss in the 300-400 range. We have attended births where there was 50 ml of blood loss, and births where there was over 1000 ml of blood loss. There is a huge range of experience here.
When we make the assessment that there needs to be an intervention to stop the bleeding, we first locate the source of the blood. It could be a laceration, a problem with the placenta, blood clotting issues or a lack of tone in the uterus. 70% of all heavy bleeding is caused by the uterus not doing its job to stay firm and contracted after the baby is born.
The uterus begins to involute (get smaller) right after the birth, and is responsible for most of the mechanism that causes the placenta to release and be born. The muscles cramp and clamp down to help all the little capillaries at the placenta site to close off and form an internal scab to slow bleeding naturally. When the uterus is soft, the capillaries are open and thus let blood flow through. To get the uterus hard and clamping again we use our hands to stimulate contractions and expel clots or assess for retained tissue. Our first line of treatment are herbs. We carry many different strong and potent herbal tinctures to be used for different bleeding scenarios. If these measures are not stopping the bleeding fast enough we have 3 pharmaceutical medications with us that are anti-hemorrhagic, one of them being the all-familiar pitocin.
If blood loss exceeds what we can reasonable manage at home, we activate EMS and administer IV fluids and oxygen. We continue to provide care through transport, as EMS does not have anti-hemorrhaging medications. About 1.5% of homebirth mothers transfer postpartum for higher level care- usually for retained placenta or the need for blood products.
We are pretty passionate about the physiological process of birth, if you’ve noticed. The best thing we can do to treat a postpartum hemorrhage is to prevent it in the first place. Our clients get nutrition recommendations and a close eye on their lab work during pregnancy. At the birth when it is time for the placenta to be born, we wait patiently for the body to do its job. During this phase of labor we encourage skin to skin, baby bonding and the first latch which all cause the right hormones to be released and contract the uterus on its own.
We do not over-stimulate the uterus with a lot of touching/ checking/ rubbing at this time, we do not pull on the cord to assist with placenta delivery (in the absence of other bleeding signs) and expect mothers to birth the placenta on their own instinct and effort. This is an extremely important part of respecting the design of birth and protective sequences already in place. Again, we are alert and vigilant as we monitor for all the positive signs of normal while remaining prepared to intervene as soon as necessary.
When more is required: At any time (during any birth) that we feel hospital based care is more appropriate for continued interventions or recovery we activate EMS. Although these complications can be extremely intense, it’s unusual for there to be a necessity to transport. Midwives are well trained and particularly versed in handling these complications and returning the event back to normal status. We always discuss the possibility, risk factors, protocols and management techniques for complications with every client at their home visit. They see some of the equipment and medications we bring, practice some of the positions we use, and learn what to expect from our care if we need to intervene. We find that educating families, being transparent about our limitations and allowing the normal process of birth to unfold in its own timing all go a long way in approaching complications that can occur at homebirth.
Because we value the relationship aspect of midwifery care, we rely heavily on mutual respect and trust with our clients. Emergencies call for quick action, but preparing for complications can be a conversation. Each family has the opportunity to ask for individualized care and protocol that will make them comfortable. Sometimes this means a request for more frequent testing, monitoring or prevention. (For example, someone with a history of traumatic postpartum hemorrhage may like to have a hep-lock administered in labor.) The bottom-line being we work and collaborate with each birthing mother’s needs and desires to make her birth the best possible one.
This information will stimulate a lot of thought and feeling and we want to hold space for the integration of these ideas. Reach out with any additional questions you have on our Contact Form, there is so much more to share for those that are increasingly interested in this topic.
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