Unplanned home births

[Mum2twoBoys]

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.

Yes I cop a bit of flack for being a nurse and having a hb. But I think that everyone has the capability of educating themselves. But what you've said might ring true, in regards to experiences affecting hp methods. I, tap wood, have never had to deal with the unexpected death of one of my patients, but have dealt with patients loss of autonomy. And so with my nursing, I find that I try to be as holistic as possible and give all the facts, without using scare mongering. I know it's a bit off topic, but makes me wonder, if I do my midwife training, am I likely to want to be an IM due to being an advocate for hb. I like the idea of working in a hospital, educating mothers and pushing for their rights. But in this day and age, am I likely to feel pushed out by other hp who are all about protecting their jobs and the hospital, rather than the patient?

[nickle730]

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.

Arcadia, I understand and agree with what you are saying. It is impossible not to be affected - professionally and personally - by past experiences and this helps to form our view of future experiences. I think this is true of everyone, in many situations. Another consideration in this instance is that that past experience also affects the expectations of the Ambulance Service as an organisation, and therefore the directives that we as individuals are given in terms of our practice.

I would like to be very clear that I would never stand in front of a patient and say 'hey, you need to come to hospital because otherwise I might end up in the Coroner's Court'. We are having a discussion on a forum and I am trying to explain the reasoning behind the the clinical decisions I would make at work and therefore what my, or my colleagues, recommendation would be in the given situation. Fear for my own job lags a long way behind patient welfare.

Building a rapport with any patient is of the utmost importance. We walk into people's lives, often in the time of their greatest crisis, we ask them the most personal of questions, we invade their personal space and then we ask that they trust our judgement and accept our advice. It is fortunate that most people have a pre existing respect for paramedics - we are pretty proud of being voted the 'most trusted profession' by good old Reader's Digest year after year! A rapport can only be built on a basis of respect and communication which goes both ways, and I am proud that I offer bother of those qualities to every patient.

[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!

[nickle730]

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.

Hey Meow, We will have observed you for only a short time - if we spend more than 20 minutes on scene we receive a 'please explain'. Clearly, some cases take more than 20 minutes, but my point is that we are not able to sit around for an hour or so sipping tea and commenting on the beauty of your healthy newborn... as much as I would like to!! Nor or we permitted to sit around on scene waiting for you to deliver stage three, which may take quite some time. Yet, there is not a gnat's chance that I could justify leaving you at home to deliver the placenta by yourself.

Assuming your delivery is unexpected but straightforward, baby is well, you don't appear to be bleeding excessively, I can't (in all my lack of obstetric experience!) see any tearing which might need immediate attention and you conveniently deliver your placenta promptly, I still have a DoC to you to ensure that you have been adequately assessed by an appropriate HP, and in this case, I am not the most appropriate HP to assess you. Remembering that we are discussing a home birth which is both unplanned and unsupported. How could I assess you and your baby for 20 odd minutes and then leave you to care for yourself - and not just be able to justify those actions, but feel comfortable walking away from you? If you have an IM present, and you called us because she just couldn't make it in time, and she is now on scene and she assesses you (with her appropriate experience and qualification) and she determines that it is safe for you to remain at home then I would be able to walk away knowing that you were being cared for and monitored by an appropriate person. But consider the fact that that MW will stay with you and your baby for numerous hours - there is no chance that an IM would assist with a delivery and then leave 20 minutes later, even if all appeared well. Why would a paramedic leave you?

[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.

[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.