Archive for August 4th, 2007

As a community midwife I offer homebirth to all my ‘low-risk’ women. ‘Low-risk’, how do I decide if someone comes under that umbrella label? To be honest it’s a tick the boxes scenario. Are there any medical conditions; clotting disorders, raised blood pressure, heart conditions, psychiatric illness, diabetes, recurrent herpes, severe asthma, anything which may make labour and birth problematic. If the woman has had babies before were there problems with the birth? A caesarian section, large baby, stillbirth, haemorrhage. Has the woman had more than four pregnancies? How about this pregnancy? Has everything progressed normally? Is baby small, large. Is it twins, or more? Is it in a ‘normal’ position. Is the Mother’s blood pressure within normal limits, and where is the placenta? What about her age? Over 40, under 17.What about her physical stature, under 5ft, overweight, underweight. So, if I see that she has none of these exemptions, and nearly as many again. I can offer her a homebirth. Currently, in my caseload, I have a homebirth booking rate of 10%, about 15 women a year. My policy is to mention homebirth as a possibility at the initial booking meeting, when the woman is 10 weeks pregnant, and then to discuss it again around 28 weeks. By this time the women are starting to anticipate the birth, have booked their antenatal classes and I have got to know her better. At this stage many women will decline in which case I accept their decision but say that should they reconsider please let me know. Those who express an interest or their partner is unsure I arrange a home visit for when they are 34 weeks to discuss it all. Finally, at 36 weeks, I complete all the paperwork for the homebirth, visit her at home to ‘fine tune’ the preparations and leave a bag of midwife essentials.

During the week I did a 36 week homebirth visit. Lovely lady, 1st baby (not something that precludes a homebirth). Her pregnancy has been problem free but she has had concerns about toxoplasmosis as she works with small animals. Early on she requested a blood screen, incredibly there is no sign that she has ever had the illness so she has no immunity. This has concerned her and I have had several discussions with the microbiologist as to if we should be conducting further screens. His advise is that if she is adhereing to safe practice, hand washing, wearing gloves, washing vegetables etc. further blood tests are pointless. To make her happy I did a further screen 2 weeks ago, still negative. Back to the homebirth booking, we had done all the paperwork and I had given her our leaflet about homebirth and preparing for it, room temp., lighting, feeding the midwives etc.  She has bought a ‘pool in a box’  so we talked about labour and birth in the pool and how it would be her Husband’s responsibility to fill, top it up, and empty it. Another thing we make sure all couples requesting a homebirth are aware of is demand and our limitations. There are only 2 midwives ‘on-call’ so if two homebirths happen at the same time it is first come, the second couple will have to go into hospital.

I had finished all the information giving and was just doing an antenatal ‘check-up’ when L mentioned a rash she has. Several years ago she was stung on the arm by a jellyfish and this has now erupted in a small, blistery rash, but she also has a similar rash elswhere. L saw the G.P who gave her hydrocortisone ointment but it has no effect. My thought processes slowly creaked into action. ‘Are the palms of your hands, soles of your feet itchy?’ No. Hmmm. Unlikely it’s cholestasis but………….. After some deleberation I decided to err on the side of extreme caution and contacted the day unit for L to be assessed the following morning. When I spoke to her yesterday all had been well but the results of the bile tests will be another week. We discussed how to proceed with the homebirth and agreed that we will put it on hold until all the results are back, if L goes into labour before then she will go into the hospital, not ideal but a safe response to a possible complication.

If you go to this site there is lots of information about homebirth in the UK, it is all straight own the line, and from a ‘users’ perspective a good resource. From an NHS community midwives viewpoint, well this one anyway, it raises many issues. Advise is given about how to demand a homebirth and how to ensure these demands are met and this worries me from a safety angle. In an ideal world there would be enough midwives to go round, but there arn’t. They discuss how all hospitals have ‘bank’ midwives they can call upon, yes, but only if the bank midwife agrees to work. If extra staff can’t be called in then the service is functioning a level which could be considered unsafe. It is all very well saying ‘Many homebirth advocates feel that it is still important to stand your ground in this situation. If the labour ward is really this busy, is it a safe place for you to labour? You do not need to feel guilty about making the labour ward manager’s job harder; while she may have a tough job, you are having a baby. She has ward crises every week and, by next week, will have forgotten that you ever existed. You, on the other hand, will remember this baby’s birth for the rest of your life.’ but if 1, or 2, midwives have to be taken away from labour ward to ensure that one woman has her ‘birth experience’ is it not making the situation worse? Maternity units do close, temporarily, to new admissions if they are too busy for the number of staff. Is it right that for the sake of one woman other women may be redirected to different hospitals, it is their ‘birth experience’ as well. Yes, put pressure on the Trusts to increase staffing levels but there are safer ways to do it.

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