Unplanned home births

[HotI]

Did you even read the rest if her post where she said she would be confident to leave you if you were in the care of an experienced midwife?

I did thanks. I also believe a woman has the right to choose. She has the right to call an ambulance or any other health professional and not have to accept everything they offer. Fine to talk about the reasons the HP recommends that you transfer, not fine to insinuate that your child will die if you don't follow my directions when there is no medical reason for that conclusion.

I think the issue of responsibility is important here. If you call an ambulance you defer responsibility to them and you should ask yourself is that what you want.

I disagree. Just because i call an ambulance does not mean i forfeit my rights of decision. Just because i enter a hospital, does not mean i accept all procedures that may be offered. Just because i invite a midwife into my home does not mean that i need to follow all her directions. Health professionals should be able to discuss why they are recommending a course of action, and benefits and risks of accepting or not the action, without threats of explaining to the coroner.

[Arcadia]

I think the issue of responsibility is important here. If you call an ambulance you defer responsibility to them and you should ask yourself is that what you want.

The death of a baby is never a card to be played, but it is an issue homebirthers get confronted with when we discuss our birthing plans with many people. By birthing at home we assume responsibility for our own and our baby's health, and if a midwife is present they share the responsibility.

If you birth unassisted and call the ambulance or go to hospital you transfer the responsibility to those personnel. Again a reason why women need a health care provider who can come to them!!! I think it's ridiculous there is no one for women to call who have specialized training in obstetrics.

[glenny_c]

I agree that a woman ALWAYS has the right to choose. My problem is with dismissing hp's fear as a "card" to be played.
When you have experience of bad outcomes it is very difficult not to let that colour your behaviour. What's wrong with explaining that risk? What do you think the ulterior motive is here?
Of course no one should be transferred without their consent but I can understand a paramedic being reluctant to leave a new mother and baby without adequate medical care. And if it was an unplanned home birth you could assume mum and dad aren't adequately prepared to deal with potential issues, or even recognise them.
I am not disagreeing with anything you said about woman's rights. I'm taking issue with the dismissive way you referred to a health professionals concerns as "playing a card".

[HotI]

I think we should name it. Health professionals should be called on it when they are using outcomes not supported by the evidence to coerce patients into actions.

I also understand that Nickle is not talking here to a patient, and that may not be how she would talk to a patient she was caring for, but i still find her comment inappropriate.

I have a good friend that is an ambo. I love her. I would not want her coming to my homebirth unplanned or planned. Ambos behaviour and thoughts are also coloured by their experiences, and i do get that. But if we have healthy mum with a healthy baby, in the case of the OP it would be her 4th baby, I don't see that discussion of the coroner is neccesary. Ambos and other health professionals have cover my butt clauses when a person refuses their help. If the risk is life threatening, and they believe the person is unable to make a rational decision then they also have options available to them.

[Little Chicken]

I don't think she is playing the dead baby card in that sense. I read it that she is saying that the person obviously felt the need to call an ambulance, and barring there being professional qualified help already on site, then she feels the best course of action is to go to hospital to at least be checked out. Because you know, health professionals have to live with their decisions, and have a tendency to replay things in their heads over and over again. And yes, one bad incident can affect how you deal with future scenarios, so maybe cut her some slack.

[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.

[glenny_c]

See, I don't see it that way at all. And that is perhaps coloured by my experience. Well, not perhaps- definitely coloured.
I don't see talking about a coroner as a threat, I see it as discussing a risk. You say a healthy mum and baby. I say, there is no one qualified there to make the assessment that they are healthy. Sometimes it's impossible to assess that properly.
My son was born healthy, or so I thought. Apgars of 8 and 9. Fed straight away. 6 days later he was in heart failure and bring rushed into his first open heart surgery. In my case, even the drs at his birth were happy that he was healthy. I'm not sharing that to scare anyone but to try and explain where I'm coming from.
I can understand why doctors would share the risk of mother or baby fatality when they have experienced it. They are human as well and are desperate not to repeat the situation. As I said, it may be a small risk, but it's there. Especially in an unplanned free birth situation where no midwife is present.
I know health professionals have ways to legally cover themselves if their advice is not followed but I would suggest that they ate mostly not thinking about the legal ramifications, rather the months of sleepless nights and guilt.

[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.

[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.

[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.

[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.

[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?

[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.

[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.

[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!