Unplanned home births

[nickle730]

Hey Rosetti, I am a paramedic. We are called every now and then to unplanned home births. If you wish to see the average ambo in a panic, call for an ambulance with an imminent delivery! Whilst as a service we receive these calls regularly, the average individual paramedic will likely only deliver a few babies in their career. In my 15 years, I claim 9 (lol... 4 of those were already delivered by the time we got there, but I'll claim them anyway!) and that is considered a massive number. Unfortunately, many of the deliveries we are called to are for very prem labour and the outcome is often not good if delivered at home. The other calls we generally receive are for women whose labour progresses far more quickly than they expect. We also receive calls from women in early labour whose labour plan is to call an ambulance instead of a taxi or a friend. This is not an appropriate use of an emergency ambulance, but I digress.

If you deliver unexpectedly at home and call an ambulance, I will expect that you wish to be transported to hospital. Once you call me, I have a duty of care to you and in this case the only way to fulfil that duty of care is to transport you to specialist care so that you and your baby can be assessed by a professional qualified in this area. Telling the coroner that you just didn't want to come won't save my job and nor would it let me sleep at night if you are left unmonitored and something happens to you or your newborn. The other occasion in which an ambulance is called to assist a delivery is a home birth which is not progressing as planned. Again, you have been presented with a situation which has necessitated you calling an emergency ambulance, it follows that you need to be assessed in hospital even if we manage to deliver your baby at home. The only situation where I can imagine leaving a mother and newly born baby at home would be in the case of a planned homebirth. I would defer to the opinion of a suitably qualified midwife on scene and if I was satisfied that the emergency had passed I might be comfortable leaving you in the care of that midwife. I am not aware of any woman who has called an ambulance for a delivery and then wanted to remain at home.

Leave the cord alone. We generally clamp and cut the cord prior to transport if you deliver at home, or after delivery if you deliver in the back of the truck. Assuming the baby has a good 1 min APGAR, I am happy to delay the clamping if it is the mother's request.

We do receive obstetric training. I believe the student's coming through now spend almost a term on obstetrics. Not much compared to the three years MW's study for! When I trained, I also spent a placement at the RWH observing and assisting (where the mother was agreeable) with both vaginal and cesarian deliveries. But where a midwife will assist with hundreds of deliveries a year, I have assisted 9 on road in 15 years - I know who I would rather have assisting my birth!

I have read here on BB on several occasions 'ah well, if it turns to poo we'll call an ambulance'. This is not a good plan. Certainly, in an emergency we have the training and the equipment to assist you, but we simply don't have the experience or the exposure to be a good substitute for a well planned home birth or a delivery in hospital monitored by experienced MW's or an OB. I am not discouraging anyone from calling an ambulance for assistance with a birth, but we should be a last resort in an emergency not a part of your birth plan.

If you do need to call an ambulance, hopefully it will be me - I LOVE a childbirth and have considered returning to uni to study midwifery. I'd love to come and help you!

[Nelle]

Twice I've called an ambulance (once they arrived after the birth, and once they arrived in time to sprint me to the hospital with minutes to spare). =)

Personally I'd try to make it to hospital, just for the reasons Nickle stated—I love and appreciate knowing that paramedics are ready to come out and help, but they're not midwives and bless them, some can get a bit panicky (they try to hide it but when they are practically begging you to hurry and get to hospital, you know they REALLY don't want to be the ones in charge lol. And fair enough!).

So, I guess if I realised things were really happening and a car wasn't an option, I'd call an ambulance and hope to make it. The only time I wouldn't get IN the ambulance would be if I was pushing already, because it takes me about 10 minutes to do that and I'd rather birth at home than in an ambulance, and it makes no difference in terms of who is attending. Otherwise I'd hope to make it. I'd also try to be on speakerphone to a midwife, for a bit of guidance and peace of mind for everyone. If an expert can't be there, then at least having them consulting would be ace.

If the baby was already born, I think I'd still call an ambulance (if I didn't feel up to being driven), because I have no idea how I'd be able to tell if I'd torn, and I wouldn't mind being checked for blood loss, having baby checked over, etc. That's me, based on what's happened with previous births, those are things I don't think I'd feel up to monitoring and managing on my own. Maybe others would feel more confident to be independent there, but I wouldn't mind seeing a midwife I think. So, you don't HAVE to go to hospital, I'd just encourage you to consider, if you bleed, if you tear, if baby is a bit jaundiced, if you go into shock from a speedy delivery—are you resourced enough to identify that, and deal with it? I don't want to be alarmist or anything. Just have a plan, Stan.

I think the paramedics will call the hospital to tell them you're coming, so you don't necessarily have to call the hospital. I think mine called the hospital. They were on the phone to someone, lol.

I think on the birth form, they put the midwife who saw me when I got to hospital? If you didn't go to hospital (and you don't have to) I guess they wouldn't put a midwife?

As for having things on hand, your usual birth aids (for massage, relaxation, thirst, comfort), plus a few towels and a blanket. One towel to clean baby off, another to wrap baby in for warmth, and then a blanket for you both.

I've heard leave the cord (had not heard the thread thing, not hard to have thread on hand though!), but I guess if you weren't going to hospital you'd want to read up more about what you'd want to plan longer term.

There is a cheapish book (maybe free in pdf form, I'm not sure) called Emergency Childbirth, that might help you sort things in your mind as well. Just to help you identify what you are needing to consider (though with 4 kids of your own, I imagine you probably have a good idea of what to think about).

So there's my random thoughts. Based on past experience, I'd try to make it to hospital, because paramedics are not midwives. But if it all happens before you can blink, I've read that most full term babies that just come in a hurry tend to be pretty straight forward, and hopefully (with a bit of just-in-case preparation) you'll be fine. I can't imagine having the baby at home without then getting someone with a bit more expertise involved, but that's just me, and I'm sure a previous PPH and tear and shock and big babies and so on, absolutely influence that mindset. If you feel confident that you are equipped to identify any issues that might crop up and have the resources to deal with them, then it's definitely your call.

[Arcadia]

Just wanted to so thanks nickle for your post. It really helps to hear you write that. Even more reason there should be a mobile midwife service or a specialist obstetric paramedic service (thank call the midwives). There were more unplanned home/car births in victoria in 2008 than planned homebirths so it seems silly that we don't plan for it (don't know the current stats).

I think people need to understand birth is not necessarily an emergency and an ambulance will transport you to hospital.

Do any Obstetricians make house calls anymore? My dad is a country GP and housecalls use to be part of every day life. It seems to be a practise very much extinct.

[HotI]

If you deliver unexpectedly at home and call an ambulance, I will expect that you wish to be transported to hospital. Once you call me, I have a duty of care to you and in this case the only way to fulfil that duty of care is to transport you to specialist care so that you and your baby can be assessed by a professional qualified in this area. Telling the coroner that you just didn't want to come won't save my job and nor would it let me sleep at night if you are left unmonitored and something happens to you or your newborn.

Even the ambos play the dead baby card. noice.

[Cassius2]

Hi Rosetti!

Are you booked into a hospital?

Do you have an IM?

If you are booked into hospital without an IM then I would call an ambulance. that time after birth is always a good time IMHO to be close to your care providers (in planned HBs your IMs generally stay at least a few hours PP to watch you and baby...temp taking, obs on you and baby etc...and of course they are on 24 hour call after that). Even if the birth goes really well I would in my own situation want to still be cared for by someone else in the birth know ITMS. So in that case, yes, i would call an ambulance. and i think nickle answered your question about if you have to go quite well in the event of an unattened and unplanned birth at home:

If you deliver unexpectedly at home and call an ambulance, I will expect that you wish to be transported to hospital.

If you are booked into hospital but also have an IM the situation might be different. if the IM is there, they might be able to assist you and look after you at home if that is what you wish. If you still want to go to hospital then she/he will also still go with you.

if there is concern or history for PPH then ambulance might be advised by your IM for transfer etc.

things on hand for unexpected delivery...not much just have some towels on the ready. the most important thing would be to keep baby warm. lots and lots of skin to skin and a beanie and keep that baby warm! i would turn on the heating if the weather is iffy temp wise.
if you BF, get onto it. it helps with the placenta and bleeding.

i have very fast births so even with a planned HB i still have my 'grab' bag JIC i were to go into labour with nobody to help. this included:

several towels.

bunny rugs/wraps

beanies

rescue remedy drops

and (because i may or may not be a dirty hippy lol) some arnica at 200cH to help with bruising/swelling/bleeding (it is taken immediately after birth).

I would recommend maybe thinking of a safe space if you are worried about a precipitous birth where you feel that you could birth feeling safe and easily accessible to the ambos etc...like for instance, somewhere near the front door if you are on your own and need to open up when they arrive...you could still be feeling quite shaky etc.

do you have neighbours that you could call upon in the interim between calling an ambulance and them arriving? someone that could help with kids/door opening etc? maybe have a key under a rock at the front door lol!

[Eenee]

Leave the cord alone. We generally clamp and cut the cord prior to transport if you deliver at home, or after delivery if you deliver in the back of the truck. Assuming the baby has a good 1 min APGAR, I am happy to delay the clamping if it is the mother's request.

Is there a reason why you have to cut the cord? why not leave it intact? Surely leaving the baby to an oxygen source if it has poor apgars would be the best course of action. In some hospitals they actually have special resuscitation tables that allow the baby to be resuscitated whilst cord attached as evidence has suggested this to be the best for baby. And in speaking to midwives where they don't have these 'special' tables they say there is no reason baby cannot be resuscitated while cord attached. Not judging just curious why poor apgars would make you sever a cord that is supplying an excellent supply of blood and oxygen, especially onside ring there is a lot of evidence and studies to support this now. Maybe paramedic education needs to be updated on this, actually I think in some hospital setting this needs to be updated also.

[Livinthedream]

Is there a reason why you have to cut the cord? why not leave it intact? Surely leaving the baby to an oxygen source if it has poor apgars would be the best course of action. In some hospitals they actually have special resuscitation tables that allow the baby to be resuscitated whilst cord attached as evidence has suggested this to be the best for baby. And in speaking to midwives where they don't have these 'special' tables they say there is no reason baby cannot be resuscitated while cord attached. Not judging just curious why poor apgars would make you sever a cord that is supplying an excellent supply of blood and oxygen, especially onside ring there is a lot of evidence and studies to support this now. Maybe paramedic education needs to be updated on this, actually I think in some hospital setting this needs to be updated also.

I would have thought that trying to resuscitate a baby in the back of a moving ambulance with an external blood supply attached to it would be quite dangerous. What if the cord tears or breaks? Then you have a non breathing bleeding baby.

[HotI]

my experience is only following car accidents, but if they need to do resuscitation it happens before the person is transported.

[nickle730]

my experience is only following car accidents, but if they need to do resuscitation it happens before the person is transported.

Hey HotI, we often continue resuscitation efforts en route to hospital - in the case that there are any signs of life (a person in cardiac arrest often still makes some respiratory effort, for example), drug overdose, hypothermia, drowning, children or where the family requests that resuscitation efforts continue are some of the scenarios where we would likely continue resus during transport. A person who is in cardiac arrest due to a traumatic cause is less likely to be successfully resuscitated, but we still often continue resus efforts on these patients en route to hospital. We only cease - or don't begin - resuscitation when our efforts are clearly futile or if it is a case of an obvious death (rigor mortis, lividity, decapitation etc.).

Sorry for the multiple responses to other posts, I don't know how to respond to multiple posts in one go.

[nickle730]

Is there a reason why you have to cut the cord? why not leave it intact? Surely leaving the baby to an oxygen source if it has poor apgars would be the best course of action. In some hospitals they actually have special resuscitation tables that allow the baby to be resuscitated whilst cord attached as evidence has suggested this to be the best for baby. And in speaking to midwives where they don't have these 'special' tables they say there is no reason baby cannot be resuscitated while cord attached. Not judging just curious why poor apgars would make you sever a cord that is supplying an excellent supply of blood and oxygen, especially onside ring there is a lot of evidence and studies to support this now. Maybe paramedic education needs to be updated on this, actually I think in some hospital setting this needs to be updated also.

Hey Eenee, our practises are all evidence based and in terms of obstetric guidelines, we follow the recommendations of the RWH (in Vic). Our training is to cut the clamp and cut the cord after the baby is delivered. There was a thread a while ago which addressed the reasons a baby couldn't be resuscitated (in a pre hospital setting) with the cord still attached, but I don't even remember what the thread was originally about! A lot of it is based around OH&S; we often worked in very cramped conditions and if we did need to commence a full resuscitation on a neonate, our goal would be to do so in a clear area with room for not only up to 4 paramedics, but all of our equipment. Effective CPR requires a firm surface such as a floor or, in the case of a small child we often use a dining room table with clear access all sides. A resuscitation between mums legs on a bed or in a cramped bathroom etc. poses avoidable risks to both the operator (the paramedics) and the mum. It is very unlikely that a neonate would be in a rhythm which would be suitable for defibrillation, but if perchance the baby did require defib, this should never be delayed and could not be performed whilst attached to mum by the cord. Most parents (myself included!) would be distressed to see their newborn child receiving CPR and the logistics of performing a resus between mum's flailing legs, most likely with her reaching for her precious baby (I would be!) are impossible. We do often continue resus en route to hospital - if there are any signs of life, in children and certain other cardiac arrest situations - and obviously it would not be possible to transfer a baby to the ambulance with CPR in progress if he or she were still attached to mum by the cord.

In the case of a newly born healthy baby, I am very happy to delay clamping the cord. Heck, if your cord is long enough for you to safely hold your baby and walk to the stretcher, if bub is doing well and there are no signs of a PPH, I'm happy to not clamp the cord at all and record that this was the request of the mother! Our current guidelines state that clamping the cord provides stimulus for the neonate to breathe (remember, evidence based on the advice of the RWH!), but I would try tactile stimulation and happily use some oxygen or light respiratory support in the first instance before clamping the cord. This would take about a minute and most babies respond well to tactile stimulation (vigorous rubbing with a towel for example, we don't turn them upside down and spank bums!). If that first minute APGAR is poor, it is a good indication that bub is may require further support and it would be at this point that I am considering the logistics of a full resus - which hopefully won't be required.

The tables sound magnificent, and there must be good evidence surrounding the practice of leaving the cord intact in order for hospitals to use them. That evidence has not yet filtered through to Ambulance practice and will only occur on the recommendation of RWH. Do you know if they are used in Australian hospitals? Unfortunately, the fact that the environment we work in in pre hospital care is so uncontrolled that 'best practice' sometimes must be replaced by 'best possible practice' and for all the reason discussed above, a full resus with cord attached would not be possible in a pre hospital setting.

Each time a new recommendation is made by the RWH, our training is updated. Once the new guideline is passed, it can take around 12 months to get us all through the training program. The most recent change to our obstetric guidelines was breech delivery, which was altered around twelve months ago. We now perform a cesarian for all breech deliveries... No. No, we don't. (It's humour there... don't hang me for it!) Anyway, the point is, our training is updated when there is evidence our practice should change, but it does take time, both to approve the changes and to facilitate the training.

On a personal level, I'm all for delayed cord clamping and would be pleased to have this introduced into paramedic practice in the case of a neonate not requiring full resuscitation and where the mother was agreeable. Quite honestly, many paramedics have very little experience with childbirth or babies - young people who haven't had kids of their own, older blokes who stayed well away from the business end when their own children were born - and I think that there would be a lot of paramedics who simply wouldn't consider delaying clamping of the cord. Hmm.. maybe there is a professional challenge in this for me!

[HotI]

Hey Eenee, our practises are all evidence based and in terms of obstetric guidelines, we follow the recommendations of the RWH (in Vic).

That actually explains a lot. Many of RWH practises are not evidence based.

My ambo friend had a similar explanation re baby resus. For OH&S reasons, ambos have to practise safe lifting techniques etc and it is much easier on their backs to resus a small baby on a table at hip height than on the floor where mum is. The job is very physical and i understand their need to protect themselves from injury too.