Unplanned home births

[glenny_c]

Just to clarify, I have no issue with planned home births or even free births. I support parents who choose to birth this way 100%.
I'm just responding to a paramedic who is discussing a call to an unplanned home birth with nobody in attendance and parents who are unprepared.

[HotI]

Was just thinking about this is the shower.

What do you think is the ulterior motive here?

I think it is used as a way to silence women/people/patients. However, saying that your baby may die is even more powerful than you may die, and so it is directed more as a silencing tool to women. If you don't act for your child then you are not being a good mother, irresponsible, selfish...... Discussing the likely and unlikely possibilities can be done without threats of the coroner.

i have been at births when HPs have been 'overzealous', and also when they have been nonreactive/late acting. Both times ended in not good outcomes that could have been avoided, and both were influenced strongly by staff not listening to, or believing the birthing woman.

[RainbowRiver]

Eeek... Seems I've opened a can of worms on hb topic! in saying that, I'm seeing different views and opinions and its eye opening.

[Cricket]

I think what Nickle was trying to explain is that she can be called to trial for a bad outcome or a death that occurred after she left the scene. Her job could easily be lost, or worse. You can like or dislike that, but it IS a fact. That's why it can be difficult to do anything that is considered "higher risk" at home with a midwife, at hospital with a doctor, or ob, or whoever, or with a paramedic attending in an emergency. They have a professional responsibility to you, and they can face consequences if things don't turn out well. Again, that can restrict your options and impair your freedom, but that is the way things are right now.

So then what Nickle is saying is not "Your baby is going to die if I don't take you to the hospital" but more like "If something happens to your baby, and someone takes it upon themselves to prove that it happened because I didn't take you in, then I can be charged with negligence, or something like that, and lose my job and possibly be looking at penalties or jail time." She's the one that you are forcing risk on by refusing to go. If you want to take risk on yourself with your choices, be they well-informed or otherwise, then that's one thing. Forcing someone else to take on risk they are not comfortable with is something else.

[HotI]

If we go on your theory Cricket, then she is talking not out of professional experience but only career protecting - which is a much scarier thought, and not what i got out of her post.

So, people who are high risk are left with no support, can't ring the ambulance etc unless they are willing to adhere to whatever the dr/midwife/ambo suggests. Scary world this is becoming.

[nickle730]

You know what, I just typed a really long response. And then I deleted it all. Sometimes there is no point. HotI, I am a bloody good paramedic and I , like the vast majority of my colleagues, would only ever act in the best interests of my patient. If I don't have the area of expertise to determine that it is safe to leave you at home, I defer to specialist care by taking you to hospital. Arse covering? Yep, I'll own it. But more important to me than my arse is the health and welfare of you and your baby. Dead babies are not a card to be played, and as someone who has held more than my fair share of dead babies, I find it offensive to hear them referred to as a playing 'card'.

You do have the right to make choices about your medical care, and that includes refusing transport to hospital. But why did you call us in the first place if you don't want our care and treatment? Why call us if you don't want to go to hospital? If there is no emergency, we shouldn't be there. Your right to autonomy sometimes directly conflicts with my Duty of Care. Psych patients and alcohol or drug affected individuals are the most common patients where this occurs. I'm not comparing a pg woman to a psych pt or a drunk, but I don't think we've ever been called to a delivery where mum has refused transport, so I can only relate to the cases where people who I think should go to hospital refuse. It is my responsibility to do everything in my power to get you to the medical care that in my opinion you require. It is my professional opinion that a woman who has had an UNPLANNED and unsupported home birth should be assessed by a health professional with specialist knowledge - that would be a midwife or an ob. I recognise my own professional short comings and the fact is paramedics lack obstetric experience. For the drunks and the psychs, we ultimately call the police if we assess that the patient does not have the capacity to refuse and they are a risk to themselves or others. The police compel the pt to come to hospital, either physically or under the Mental Health Act. I can't imagine calling the police for a woman who has just delivered a baby. I would discuss with the patient the reasons I would like her to come to hospital, I would listen to her reasons for refusing and ultimately I would log the refusal with our central management, complete an incident report and fill in a patient care record meticulously detailing the efforts I had made to convince the patient to be assessed in hospital, I would then have the patient sign that patient care record. Yet, we are told time and again by our employer that none of this will offer us any protection should something happen to mother or baby. We are qualified professionals who should recognise if a patient is at risk - clearly we failed in that duty if the patient we leave at home dies. The Coroners Court is not a threat or a card, it is the place I or my colleagues end up if we screw up or fail in our duty of care to our patient and someone dies.

My response is long again! Not what I intended. Thank you to those of you who defended my previous post, your support is very much appreciated.

I actually returned to this thread because I woke up this morning and felt concerned that I may have discouraged people from calling an ambulance to assist with an unplanned delivery. You should call. We do have training, limited as it is, we have the capacity to contact a specialist hospital for guidance if the delivery is difficult. And whilst our obstetric experience is limited, our resuscitation skills are second to none IF they are required. Because, you know, we'd like to avoid those 'dead babies'.

[RainbowRiver]

FWIW, Nickle, I cannot thank you enough for your replies. Good or bad, you don't need to defend your reply. Your posts have answered my questions and I think anyone that has you turn up to treat them, are lucky buggers. There's a risk where ever you birth and whoever attends, are just doing their job.

[Mum2twoBoys]

I can see the legal part of negligence of a hp. If you are calling an ambulance you are putting them in a position where they owe you a duty of care. And legally and ethically, as a health carer, it is our responsibility to meet that duty of care to the best of our ability. Just as nurses are expected to continue resuscitation measures on a pt until a dr has declared them deceased, unless unsafe to do so. And in a way that duty of care does make them fully responsible for your care, until someone more experienced/trained takes over.

By saying this I'm not saying a hp has the right to force care, but it is their obligation to try to enforce the best care possible.

[Nelle]

Legal stuff sucks sometimes hey. It's annoying that the autonomy of parents is compromised because people can be a bit litigatious if they don't want to take responsibility for their own choices. I'd have loved to be a candidate for hospital-linked home birth, and a history of fast births made that one of my safest options, but a previous PPH meant that I was 'too risky' for the hospital to insure the home birth, even though that placed me at higher personal risk. It's crazy. I don't know how much weight a waiver would carry, I know I'd be happy to sign a waiver saying that I was the one making the call to stay home.

FWIW, I play the 'dead baby' card to myself. I just assumed most parents did when working through any tricky logistics? I play the 'dead child' card when I am teaching my kids about road safety, choking or allergy hazards, electrocution, water safety, and so on. Death is a hazard of being alive. I am totally entirely confident in my ability to birth babies, and have done so very successfully and safely in the past. I'm not alarmist, I don't expect things to go wrong. I do like to have a contingency plan. If someone goes into a birth situation entirely unaware of all of the risks and possibilities and options available to them, I wouldn't call them fully informed.
I hated the birth class where they showed us forceps, ventrouse, various machines—scared the crap out of me—and I was cross about them playing the 'danger danger' card. But they (even being a low-risk birth centre) saw the need for those things arise from time to time, and I guess playing that unpleasant card meant I was informed, even though I never needed that level of intervention. Every deck of cards has crap and useless ones that come in handy sometimes.

I don't appreciate fear-mongering about work-throughable scenarios, and I have definitely come across that in health professionals, easily. I didn't interpret Nickle like that though—perhaps it helped me to remember that a paramedic is less likely to be called out to a straight-forward, complication-free 6 hour textbook labour, and more likely to be called out to a premature situation, transfer, or very quick/rushed situation, and risk management is more of an issue for them.

[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!

[Frangipani Lou]

We had an unplanned spontaneous home birth and it was brilliant. We were blessed that there were no issues. We called an ambulance and we couldn't slow down DD's arrival so they talked us through the birth and were brilliant.
The Ambo's arrived 3 minutes after DD was born into her daddy's arms.
The ambos clamped the cord and DP cut it. I delivered the placenta at home and we went to the hospital. The midwife that looked after us there was on the forms.
Nickle, it was good to read your experience and learn about the other side of the story.
I now know that when I'm lying on my side and convulsing forward that a baby is imminent!

[Arcadia]

I think this discussion has become unhinged by the gap between a health professional offering objective care to a person versus the subjectivity of the health professional (their experiences and fears) impacting on the decisions they make or choices they make available to a patient (stay with me here because i know all experiences will impact hp). In this case, bringing up the coroners court becomes a 'card' because it is an emotive and subjective experience linked to the health professional that is used with moral weight to push the decision making processes of the mother. I agree we all need to know risks, but in a highly emotive situation like birth bringing up litigation and the subjective experience of the hp doesn't help.

Now I know this isn't a real- life situation and no hp is truly offering advice here in a professional capacity, but I can see how it plays into the same old 'dead baby card' issue homebirthers always face. I have already thanked Nickle for her informative post and I really appreciate how her own subjective experiences necessarily influence her opinions. My dad is a GP, my sister a nurse, their experiences have undoubtedly impacted their treatment of patients. I think when it is blatantly put to a person that 'hey this is what I've seen so be warned' it skews their autonomy to make a rational decision, because now they're weighed by your experiences and not by broader risk analysis or facts (and I think this is why obstetrics in general is going towards more medical models, because the rare complications start informing the majority).

As for refusing Ambos treatment or other health professional, I think this is a grey and scary area (for my brain anyway). I can't see why you would call 000 and then refuse treatment offered BUT I think a woman should always be able to refuse treatment from any hp. I think it is dependent on expectations and understanding of what that hp offers, as well as trust in that hp, which ultimately they need to instill in you.

[meow]

But why did you call us in the first place if you don't want our care and treatment? Why call us if you don't want to go to hospital? If there is no emergency, we shouldn't be there.

I just wanted to address this question. I think you would be called because the baby is being born quickly with no option for any other health care providers to be present. For me, I would be calling so that you were present in case the baby or myself needed resuscitation. Surely that's what most people are calling for in that situation and that is considered enough of an 'emergency'?

One the baby is born and presuming mother and baby observed to be doing well I think we (by we, I mean society collectively) can respect the parents autonomy to allow them to decide what the next course of action is? They may decide they want to see a health professional (most likely hospital staff given an unplanned homebirth would be a mother who is booked into and intending to birth at a hospital) later in the day, or the following day or they may decide they want to go to hospital straight away. Surely your duty of care has been fulfilled as you attended the birth during the potential time of emergency and now your care is no longer required.

[Ca Plane Pour Moi]

Thanks for this thread. I love the calm, considered and informative replies. It has really helped me in planning for my choices too. Thank you all.

I have no advice I choose to give here as it would not be helpful, but look forward to reading more!

[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.

[Lisa]

I have a few questions if anyone can answer them or share their experiences!

1. If you should have an unplanned hb, who do you call afterwards (Ambulance or hospital etc)?
2. What gets put on the birth form where it asks for attending dr or midwife?
3. Do you have to go to hospital?
4. What items do you need on hand JIC you end up with unplanned birth?
5. What do you do with the cord (clamping wise)?

Thanks

I had an unplanned home birth with my last child.
1. If you should have an unplanned hb, who do you call afterwards (Ambulance or hospital etc)? - We called an ambulance. Midwives & Obs had told me due to my higher BMI and the fact that I'd already had 5 previous births, I was at risk of PPH. This is the only reason we called the ambulance. If that fear hadn't been put in my head, we wouldn't have called at all. I'd never had a PPH before and as it turns out, I never had one.

2. What gets put on the birth form where it asks for attending dr or midwife? -Nothing. She had BBA put on the forms - Born Before Arrival. Nothing was filled out at the hospital at all so DH had to write a stat dec for her birth certificate stating that he had witnessed me give birth to a live baby girl at our home address.

3. Do you have to go to hospital? - No and if I was to do it over again I probably would still have gone just to get us checked over.

4. What items do you need on hand JIC you end up with unplanned birth? -
We just had an extra doona and loads of towels underneath me to catch the mess. I would suggest having something close by to put the placenta in. DH put it in an old salad bowl! Lol.

5. What do you do with the cord (clamping wise)? - the ambulance arrived about 5 mins after the placenta was birthed. On my requested, they waited until the cord stopped pulsating before clamping was done and then dh cut the cord.