Home vs Hospital: The Equipment

Home birth midwives carry with them certain items to use in case of an emergency - b/c no matter how low risk a mom might be, emergencies can and do happen in childbirth and as such, they need to be prepared. I've heard or read many, many times from mothers/fathers/couples that have chosen home birth (or freestanding birth center) that “their midwife carries with them all the necessary equipment in case an emergency arises.” So I want to present a clear cut list for each setting of the equipment available in case of an emergency.

There is a slew of equipment needed and provided in both situations that I am not going to get into - such as gauze pads, chux pads, sterile gloves, etc. What I'm focusing on is the equipment used either to detect issues or for life saving measures.

Here's what a (typical) certified home birth midwife will bring with her to a home birth:

• Fetoscope or Doppler (or both) - to detect the heart rate of the baby
• One oxygen tank
• Infant mask (used with oxygen tank)
• Adult mask (used with oxygen tank)
• Blood pressure cuff
• Suturing items - to stitch tears for the mother
• Thermometer - to check for fever for mother, which can indicate uterine infection
• Lidocaine - to numb mom locally while she is being stitched up
• Pitocin - in case of postpartum hemorrhage
• Methergine - in case of postpartum hemorrhage
• Bulb syringe - to clear airways of the baby, especially in case resuscitation is needed
• IV equipment - if mom needs antibiotics in case of GBS or prolonged rupture of membranes
• Pegnancy and labor records and charting, including blood type - in case of transfer, to ensure accuracy and increase speed
• A midwife may or may not have an assistant with her
• Midwife should be current in the following skills:
• Neonatal Resuscitation (chest compressions and mouth-to-mouth)
• Basic Life Support (some may have Advanced Life Support training)

I would ask your midwife ahead of time to make sure she carries (at least) these above items and has (at least) those certifications. The items should be in good working order, drugs should not be expired and midwife should be very familiar with exactly how to use each of these items and medications. Be your own advocate! Don't be afraid to ask questions ahead of time.

Now keep in mind, if the midwife is not certified she will not have access to things like Pitocin (or any medications), Oxygen, an IV, etc or any item that could get her in trouble with the law for practicing medicine without a license (at least, she will not have legal access to such items).

Ambulance:

A Paramedic will have the knowledge, skill and certain equipment to be able to help in the case of an emergency. However, while a Paramedic can certainly provide life saving support, they should not be considered a fool proof back-up plan. Quoting a Paramedic: “We can do neonate intubations but we do them SO seldom that it’s not a skill all medics are up to par on. This goes for babies & pregnancy in general. In an emergency childbirth scenario where minutes can make the difference in life and death, NOTHING in an ambulance can save a baby; it can only be a very temporary bandaid while we drive as fast as we can to the closest hospital.”

Response Time:
In a non-emergent transfer, travel time or response time will likely not be an issue. However, being "5 minutes from the hospital" may not be close enough when minutes can make the difference between a perfectly healthy life and death or neurological damage or injury or blood loss resulting in a transfusion or hysterectomy. Regardless of the scenario, emergency or not, a home birth transfer will take much longer than 5 minutes to get a laboring woman in her home (or birth center) to a hospital, in the right hands at the hospital, admitted, monitored and ready for a doctor to deliver a baby. I address this in my first blog post under the section "Is Our Hospital Really Close Enough" giving the example of a home birth transfer I attended as a doula; it was a very eye-opening experience for me. 

Hospital:

• All of the above listed home birth equipment and medications, plus…
• Electronic Fetal Monitor (EFM) - this detects the baby’s heart rate and the contractions. EFM vs Doppler gives nurses a much clearer picture of the baby's heart rate to make sure baby is getting all the oxygen baby needs. Heart rate variability is normal for the baby but it's important to know when changes to the heart rate occur in relation to when contractions happen. A heart rate of 155 BPM might sound healthy and wonderful when checked every 10 minutes or so but with decels at the end of a contraction, it can be a serious sign of distress. The decels may be so slight that unless you are looking at a print out (the EFM strip), you would not know they are happening.
• An endless supply of oxygen
• Cytotec - for postpartum hemorrhage
• Vacuum and/or forceps (though forceps are not common anymore) - if the baby’s health depends on immediate delivery, a vacuum can be used to help guide the baby through the birth canal while the mother pushes
• Blood Bank - for postpartum hemorrhage requiring a blood transfusion
• Operating Room and all personnel needed for an emergency c-section or for postpartum hemorrhage treatment/surgery (see Sara's birth of her son - an emergency surgical repair saved Sara's life after she suffered a cervical laceration; see Amber's experience as a doula and Becky's birth of her second child - immediate emergency c-sections saved the lives of those two babies)
• Ventilator - a machine that facilitates breathing (see Christine's Birth Story of Baby Penelope and how a ventilator saved her daughter's life when she was born)
• Specialized diagnostic equipment and staff
• A skilled team of nurses and doctors that are current in the following skills (these skills are frequently used either on the job or through hospital drills):
• Neonatal Resuscitation
• Advanced Life Support
• Intubation (and obviously the equipment for such) – provides a much more effective way to oxygenate a person (of any age) compared to resuscitation

Also keep in mind, to be trained in Neonatal Resuscitation or Life Support every few years and practicing only on a dummy is very different than using those skills on-the-job in a true emergency, on a real mother or baby. In a hospital, you have other sets of eyes and hands to help, to shout direction or take over in case someone freezes or forgets under pressure, you have a back-up for your back-up for your back-up. They will be able to tend to baby AND mother at the same time, if needed.

From a nurse midwife student: "Not only is there a team full of certified, competent people, but in a hospital, they are running dystocia drills or practicing for other obstetric emergencies. These are people who have practiced working together, who have assigned roles, and in addition to all the drills, have seen their share of real emergencies. They not only have a pediatric and adult code teams, but depending on size and type of hospital, they may also have OB rapid response and code teams as well,as they do in my hospital. It's a well oiled machine."

Nurses will keep a watchful eye on mother/baby in the hospital not just during the immediate postpartum period but for the length of their stay, checking vitals and looking for signs of infection, breathing complications, arrhythmia, postpartum hemorrhage, seizure, undetected birth defects, etc.

It is true that an Operating Room may or may not be available immediately when an emergency c-section is needed. In some cases, a doctor can have a baby born via cesarean in less than 5 minutes, including travel time from the Labor and Delivery Room to the Operating Room. In other cases, it may take longer depending on the availability of the Operating Room, anesthesiologist and obstetrician. However, the added commute from a home or birth center will certainly not help facilitate a c-section any quicker – in addition to travel time, the hospital must do its due diligence to admit the mother and monitor the baby and mother before performing any emergency surgery. 

Dear NUCB-aspiring Mama

Dear mothers-to-be:

This letter is especially for you if you are hoping to have a natural unmedicated childbirth (NUCB) with as minimal interventions as possible.

I hope your pregnancy is going well. I hope you are able to enjoy it as it truly is a miracle to have a life growing inside of you... this little life that you are going to come to love in a way that you cannot yet even fathom.

But right now, your focus may be on the birth. It's a big day!

You want to feel empowered, you want to feel fearless. You want to trust birth. I get it. I've been there and I know many other mamas that have been there, too. I'm a birth doula. My sole purpose is to be there for the mother to help her have the experience she desires. I cherish the role I have as a doula and take it very seriously. It is an honor and a privilege to be with a woman as her doula!

For my own personal reasons, my preference has been non-medicated, minimal intervention (unless interventions became needed, which they did not). It is how I gave birth to both of our children and going forward, if we decide to have more, it is still my preference. I truly understand the desire for a NUCB.

You may be thinking that fear has no place in birth. What you have read, what you have watched, what you have heard is all sending you the message that trusting birth is all you need to do. Trust your body, trust your baby, trust birth. You might be thinking that.... a hospital will turn your birth into a medical event; a doctor is only concerned with the bottom line; a "medwife" (a CNM) has become too brainwashed by the medical world. They all have fear in their hearts and minds and don't believe in the natural process of birth… or at least, they don’t believe enough.

What you may not realize is that those seeds of fear have already been planted in you. You likely now fear interventions, hospitals, hospital personnel - if you are giving birth in a hospital (especially if it's not your first choice to do so), you may be thinking you are going to have to put up a "fight" to get the birth experience you are hoping for. Your mind and body are being conditioned to tense up when you head to the hospital. This is not going to help you emotionally cope with labor nor is it going to help your body if you are full of tension. You may be like me -- some one who had no reason to fear a hospital other than b/c of what I was led to believe by others, by books, by movies but NOT by personal experience.

Or you may fear your hospital b/c you had a bad experience with a prior birth. Talk to your doctor about it. Tell him or her that you need help processing it. Your doctor and the nurses that assisted in your birth are the ONLY ones who know the details of your situation. Perhaps in hindsight certain measures were "unnecessary" but at the time, they may have been the safest, most ethical way to proceed. For anyone else to make assumptions on whether or not your birth should have unfolded the way it did is JUST making assumptions... and filling your head with fear and doubt and anger and essentially, making you feel foolish for consenting to the measures taken. Don’t allow someone take advantage of you like that.

Perhaps your experience was traumatic, you may have been neglected, you may have had a horrible care giver, etc. If that is the case, I am truly sorry and I hope that you are able to speak to a professional to work through what happened. A fear of anything that can lead to anxiety attacks or irrational choices (such as avoiding hospitals or proper medical care at any cost) is not healthy and can be dangerous.

While I have seen and greatly appreciate the strides our maternity system is making, not all hospitals are perfect. Not every care giver is going have A+ bedside manners and not everyone will be in a wonderful, welcoming, plenty-of-sleep-and-able-to-brighten-your-day mood every single day at their job - we are all human. We all have off days. Not all hospitals have beautiful, updated maternity suites and can provide the ambiance and experience you would get in the intimate setting of your own home. But birth is not just about ambiance and experience. More than anything, it's about having a healthy and safe baby and mom. If it wasn't, there would never be any home birth transfers. The end goal ultimately (and rightfully) outweighs the process - any ethical birth worker would agree.

You may be thinking that your desire for a natural childbirth is setting you up to feel empowered. And it can be a very empowering experience! But I have heard many, many times that it ends up doing the opposite. Women end up feeling like they have failed completely if their birth experience doesn't end up the exact way they hope. It may be a smaller matter that ends up bugging you for days or weeks or maybe even longer... or your "worst case scenario" may have unfolded -- even with a healthy baby to hold and your body recovering well.

A less than ideal birth experience is not the worst case scenario. In this day and age in our country, the loss of a baby or mother in childbirth is so rare that it's easy to take for granted that childbirth is not without risks. Our perinatal mortality rate here in the USA is fantastic. But it is not perfect. No country in the world has a perfect perinatal and maternal mortality rate. Loss happens. It happens b/c childbirth is not without risks -- no matter where you give birth, no matter how healthy a mother and her baby may be, no matter how low risk a pregnancy might be before labor begins.

While the birth experience is important, it is not everything. We don't get pregnant to just give birth. We don't carry a baby for 40 weeks to just give birth. Labor and birth are a matter of hours (maybe days) but raising your child is what you will (hopefully) do every day for the rest your life.

While, to you, your birth experience may inspire you as a mother - it may help you personally feel more connected or fit to take on the ups and downs as a mother - but it does not mean that someone whose experience was the complete opposite will be any more or less fit to be a mother, any more or less connected, any more or less anything. Our babies - whether they are born vaginally, surgically, or by someone else's body - are our children. Our bond with them is beyond so much more than any single moment in time.

Please don't lose sight of what it's all about. Don't go into your birth thinking it will be a fight. Ask questions (please do!) but don’t attack anyone or assume they are against you. There are so many hospital personnel that love their job and want to do everything they can to give you the experience you desire. Go into your birth with a kind heart and open mind, with good energy, a welcoming attitude and the excitement that you will soon meet your baby! And please, don't let your plan become so rigid that it becomes an obsession – especially at the potential risk to yourself or your baby.

At the end of the day, you can love your birth experience as much as you want, but it will never love you back. Your child will.

Sincerely,

Doula Dani