A wonderful home birth
Spent last night attending a first time labouring woman. What a wonderful birth this morning. Regular strong contractions 3:10 in first stage then went to 1:5-1:7 in second. Her partner was a very supportive doula. He said he just did what he did by intuition. I joked that he must have been a midwife in a former life.
Second stage was about 2 hours only very active pushing in the last half hour. The woman found sitting semi-prone most effective after trying everything else. It felt odd not receiving the baby with a woman in all fours position as that’s how the women have all birthed recently at home. Baby born “face to pubes” – haven’t seen one of those for a long time. A little spiral skin tear with the shoulders. Many hugs and joyous yelps. The neighbours were waiting for the announcement and the shout went out-IT’S A GIRL- a few cheers came back and another can of lager was opened by the friend downstairs. I really love being a midwife to this new family.
Having been midwife to two births this last week, both young primigravida women, both not wanting any drugs for pain relief, I live in hope that we are seeing a renaissance of younger generation women who are not so fearful of childbirth and choose not to be crippled labourers but use the pain to birth their babies powerfully.
NHS Community Midwife
It is so nice to hear of well-informed, open minded, GPs. I have just been speaking to a woman from South Yorkshire who went to her female GP saying she wanted a home birth. Her response: “No, you don’t want that, they are messy and people die”….
The next time someone talks about the risks of home birth, I suggest that you point out to them that the Confidential Enquiry into Stillbirths and Deaths in Infancy found that of the PREVENTABLE infant deaths obstetricians were responsible in 49% of the cases, hospital midwives in 18%, the family in 10%, community midwives in 6%, GPs in 6%, pathologists 2%, anaesthetists 1% and paediatricians 1%. It is time we spoke out about the risks of hospital birth and stop supporting the myth that birth in hospital is safe. This report indicates otherwise.
Beverley Lawrence Beech
See also “Safety In Numbers – how many midwives at a birth?” by Chris Warren, from Midwifery Matters 90, Autumn 2001.
AIMS is receiving calls from women who have been told that due to midwifery shortages they will not be able to send two midwives to the birth, and as it is ‘unethical’ to send one the woman, surprise, surprise, will have to come into hospital.
I am collecting information about which Trusts have dictated that two midwives must attend a home birth and what scientific evidence they have to support this practise. Or what information anyone has on their rationale for this practise. Please let me know what happens in your area.
Beverley Lawrence Beech
In our area (rural, on the edge of the Scottish Highlands) our policy is for two midwives to attend home birth; “for safety – just in case both Mother and Baby need “medical” attention at birth”. Some of the areas are quite remote and can be very difficult to reach especially when there is a good deal of snow lying around. We do not work with G.P. cover but, of course, have all the usual back up services. As far as I know, we have no scientific evidence to support this practice; the rationale or lack of it – it has “always been”.
It can be very difficult getting enough midwives to cover, especially in the winter months with adverse weather conditions. Since we are a small group of midwives, it is nigh impossible to cover more than one home birth at any one time. If we have two women with the same EDD and both are requesting home birth, we can give no guarantee that we will be able to attend. Our midwives’ unit requires cover by two midwives and a home birth requires another two midwives. Four midwives out of our small team is half of our work force! As a firm supporter of home birth, I find this is particularly frustrating and tiring. It does not instil a great deal of confidence in our pregnant women, at a time when they need us most. We just don’t have the numbers of midwives to guarantee that women will fulfil their need to birth at home. Very sad, very frustrating (for all concerned).
Having said all that, I would not like to find myself in the situation of being the only midwife at a remote farm in the hills if things were to go wrong. But again, who would? I am a firm believer in women’s ability to birth their babies. For me, I consider it much safer practice to have two midwives attend a remote home birth. I would very happily attend a home birth on my own if I were town or city based, i.e., with back-up only minutes away.
A few of my thoughts – not scientific, but what I think and feel. I wish you well in your quest for evidence and would love to hear the outcome.
Funnily enough I was discussing this very subject today. Someone in our group thought that a local unit had changed the policy recently from one to two midwives because of some sort of directive, possibly from the RCOG. I personally think its to do with the ever increasing presence of risk management.
I understand that Trusts can ‘legally’ do this if their midwife shortages are such that by sending midwives to attend homebirths they threaten the safety of the majority of women having babies in hospital by drawing on hospital staff – if you see what I mean? Is this justification? I am acutely aware of colleagues working on labour wards with only 50% of the usual staffing – they already regularly draw on community midwives on call, to supplement the hospital. How far has this madness got to go?
The usual practice with home birth midwives in my part of the states is that the midwife has a number of birth assistants on whom she can call if she has no other midwife to help her.
I started my apprenticeship in this way after my midwife described to me a recent birth where an Amish primi had not only a surprise breech but also abrupted; both mother and baby needed major help. The midwife had to work on them both by candle light on a remote farm with no phone. They both did fine, but I don’t think she or anyone working in remote areas should have to go it alone.
Maybe the midwives in Britain could find willing hands in the community to help them out. They would not have to be apprentices/ students. Although I am certified in neonatal resus and CPR (and I have had to use those skills a couple of times) mostly I am the fetcher and carrier (doula really) for the midwife so that she can give her full attention to the mother. I do the same thing as a doula in the hospital and I know it enhances the experience for the parents in both settings.
Community midwives in Nottingham are employed by a separate Trust to the hospital midwives, therefore we are not called upon to work in the hospitals when they have midwife shortages. We can offer to in dire circumstances, but need to go through our community manager for her support/approval. I understand from midwives in other areas that this is not the case and the hospital trust has the power under the terms of their contract to direct the community/integrated midwives’activities “to cover the needs of the service” in the labour suite. I can’t imagine a NHS Trust legally getting away with not providing a midwife to attend a woman birthing at home if one is called for.
Fortunately, in our Trust, officially providing a community midwifery service for homebirths is a priority activity and is funded for this. In the past there were some hiccups about women with complicated situations but I feel they are far more sensitively addressed and planned for these days since “Changing Childbirth”. Yet we sometimes hear of individual midwives undermining a woman’s plans but this has been taken to Supervision. It is usual that everything else gets dropped in favour of attending a woman having a homebirth, planned or otherwise. We have extra rosters for midwives with competency in waterbirths to attend women wanting to use a pool at home. However, sadly, there is no guarantee that the midwife will be known to the woman.
Tradition is that two midwives attend but sometimes only one is there for a variety of reasons, but this should never effect the woman’s plan to birth at home. Normally, the second midwife is not called until very near the birth time.
My feeling about it is that I mostly like the second midwife there. Her understood role is to attend any problems the baby might have after the birth. As this is very rare she usually ends up making the tea. On occassions, I have felt the second midwife bring a fresh energy into the room, which after a long labour has really helped all of us especially if they bring a smile and a bit of laugh with them. A good second midwife hopefully like the first midwife settles into the background respecting the unfolding physiological processes unless called upon by the woman’s wishes or necessity to do otherwise.
One nice story a friend told me about herself giving birth at home in Nottingham 30 years ago was that her midwife was rubbing her back during a contraction and the second midwife rubbed the first midwife’s back and my friend rubbbed the second midwife’s back and then they swapped about and apparently joked a lot. Don’t ask me if the midwives had backache in sympathy or whether they were just worn out themselves or were using it as a form of distraction for my friend but it is an extraordinary image. She had a lovely baby girl a few hours later. Just as an aside, this strong, clever, confident daughter has not been keen to move out of that loving home even to this day.
We must keep the right to HOMEBIRTHS and having the right for a NHS midwife to attend, FOREVER IN THE UK.
Here in Ontario, the standard is that we have two registered midwives at the birth. In practice, one midwife (primary) does the initial assessment and care. We stay with women when they are in active labour, once it appears that the woman is moving towards second stage, the second midwife is called. The primary midwife will have set up the resus equipement, oxytocin and other supplies earlier. Now obviously it takes judgement to know when to call your second midwife. Sometimes, if it has been a long labour, the second will be callled to give a break. Often, you get a nap for an hour or so and then the baby is coming. Rarely, we miss births as seconds and with experience, you don’t call your second too soon.
I have practised here in Ontario, which is a very large province of the second largest country in the world. We have severe weather in all seasons. Some midwives’ practice in rural areas and I did for two years. Rural can appear to be a problem, but traffic in built up areas can be much worse. Front wheel drive gets you through most snow, ice is the only thing I dread. We did two home births last January on the night of a huge snow storm very little trouble aside from making sure we could dry off from the snow on our trousers.
You need to have reliable pagers and cell phones. The second midwife usually leaves about an hour after the birth and helps with the clean up, does the baby exam (it depends on the situation, if suturing is needed, how tired each of you are. We also do our own pre and postnatal care so we try to minimise the changes needed for the following clinic days.
As far as due dates: in ten years I have only had two situations when we had simultaneous births going on. We all know how unreliable due dates are +/- 3 wks before and two weeks after. We explain in early care that the chances are small (each midwife books 4 primarys/month) but they know that either we will try and get some other practice to provide emergency back-up or move to the hospital. Once we had two planned hospital births. (at that hospital the nurses did not help the midwives) The two of us just moved back and forth between the two.
In our unit we have 2 midwives for a homebirth, the rational being 1 for the mum and 1 for the baby if there are any complications. In the area there are 7 teams, and the practice is to call the ‘on-call’ midwife from a neighbouring team when the labour is well established. Usually there is no problem providing this back up, but the situation could arise when a 2nd midwife was not available. I don’t believe that we have a protocol for this situation…I guess it would be up to the individual midwife..in the 1st instance the supervisor would be informed, and then it would be taken from there.
I work at Guys, and it is our ‘standard practice’ to have two midwives at a home birth when the woman is in second stage. However, we are suffering appalling shortages, which are particularly bad in the community, and it is often a major drama to find someone to be your 2nd. Midwives vary in their reluctance to do home births alone. I recently did one, and in second stage the fetal heart rate became appalling, in fact slowed to virtually nothing. Because there was no other midwife there, I asked the husband to call an ambulance because I knew if the baby wasn’t born pretty soon he would be tough to resuscitate. And he completely froze. Totally panicked and was unable even to lift the phone, let alone speak. As it was the baby came flying out and was fine with a few minutes of resus. But it made me realise why we have someone else there – because you can’t rely on anyone else to keep their head in an emergency.
Brenda mentioned that the practice of having two midwives ‘has always been’ . Always from when? I don’t think, for example, that midwives in the 1940s went out in pairs, and cynic that I am I do not think this policy started until the late 1980s, when the evidence of the safety of home birth emerged and hospitals had to find another reason for arguing against home births and, of course, if two midwives attend the costs escalate enormously.
I agree with you, attending a home birth at a remote farm is scary, but perhaps this has more to do with the confidence of the midwives and her training than reality or the risks of an unmanageable disaster occurring. Julia Allison’s book on Midwifery practice in Nottingham makes illuminating reading about perceptions of risk.
The midwives in the US attend a birth one at a time, but they also have a nurse and sometimes also a doula in attendance with the family. That way you have back up of hands, but still a lower cost of total attendance at the birth.
When I booked my home birth with Greenwich Healthcare Trust (booked directly with the community midwives), my named midwife took care to explain to me that I might have heard stories about women who booked Dominos being told they had to come straight into hospital because of a shortage of community midwives, but that I should not worry about this being applied to home births. Their policy was that home births took priority for community midwives, and that if the midwives on call from my team were busy, they would keep looking until they found one from another team. She stressed that there was no way that I would be denied a home birth for budgetary or staffing reasons.
A second midwife is called for the second stage, and they could not say which team that midwife would come from. I requested female midwife care only, but the supervisor explained that while they would guarantee a woman as my main midwife, in exceptional circumstances there might be only a male midwife available as the backup midwife. She said that in that scenario, if it was acceptable to me, the male midwife could wait in another room and only come in if he really was needed. This assurance was more than I needed – I would have managed fine if a male midwife had turned up as the backup – but I greatly appreciated the lengths that both my midwife team and their supervisor went to, to reassure me and to show willing to make whatever arrangements were necessary.
I was later told by an independent midwife who teaches midwives for Greenwich, that she and her team partners had a ‘bank midwife’ contract with Greenwich so that if they simply *cannot* find a community midwife to attend a home birth, she or another independent midwife will attend instead. They are on very good terms with the health authority, and have no trouble accompanying their transferred clients into hospital, or attending those clients who want to give birth in hospital but with an independent midwife.
In 1930, when I was born, midwives did not usually come in pairs. If complications occurred, as they did with my birth, a back up GP came to the house. GP’s were on call 24 hours and of course made house calls in those days. Our local GP in Harrow, Middx ran his own “health service”. I think it cost about half a crown a month, and that included everything. Bandages, most prescriptions, etc., If you couldn’t afford that, as many families couldn’t in those days, there was no charge. For any hospital treatment, we had the Harrow Voluntary Hospital, where the nursing staff had to pay for their first three years of training, then after getting their SRN, they received a small stipend. GP’s and surgeons volunteered 10 to 20 hours a week, and only the maintenance staff, administration staff and ancillary workers got paid.
An august but very kind lady called the Lady Almoner would come round the wards and inquire as to a patient’s financial resources. If you could you would make a contribution. If not, there was no pressure or feelings of shame. Very benign I remember.
As teenagers we used to volunteer for relief work there, rolling bandages, switchboard relief, mortuary work. A lot of the local schools would send their older students there to help out whenever there was an a rush of causalities from large accidents or bombing raids. It was a fascinating place to work at. Got my interest very early on in my life!
The almoner turned into the hospital social workers, now they are few and far between since we have the glorious health service.
Our area has 3 teams, 2 group practices, and 2 areas where group practices are being set up. We cover some very remote rural districts – a primigravid woman was transferred in to the unit by air ambulance back in the summer. Each area has an on-call midwife, so we back each other up.
It used to be the policy to have two midwives attend a birth in second stage IN THE UNIT – but this was revised last year, so a second is called for only if needed. We also no longer routinely have resuscitaires in the birthing rooms. (Yey for normality!) However, it’s common practice to have two midwives at a home birth, one for Mum, one for baby – I personally find this very reassuring, since I would hate to have to deal with a PPH and flat babe at same time!
I have attended three births recently when there has not been a second available – (admittedly, the second incident was as much a communication prob – I thought I’d requested a second midwife, the Labour ward manager thought I would be phoning back once I’d reached the woman’s home and done an assessment). This was brought up at supervisor’s meeting, and is thought likely to occur more frequently as more women exert their right to stay at home for their birth. (The area as a whole has a 10% homebirth rate, our patch is 18%.)
We were told to call paramedics, if second midwife not available.
Midwife, Devon, UK
I work in South Yorkshire and all women who request home births get one and yes we send two midwives in case there is a problem with either the delivery or the baby.
I am a one of four midwives in an independent midwifery group practicing approximately one hour from our nearest base hospital in the Wellington area of New Zealand. Our practice is mainly based around home-birth and the local birthing unit. It is our practice to have two midwives attend a birth at home.
The woman ideally meets the second midwife in the antenatal time and is familiar with the woman’s wants and needs. The second midwife is called mostly near the time of birth, or sooner if and when some moral support is required or for relief when the labour has been long and the primary midwife requiries a rest. Mostly the second midwife arrives before the birth but on occassions babys’ come when they want and the second mdwife makes it for the placenta or to make the cup of tea. We have found this support reassuring and safe for the woman, family and midwife.
On occassions the second midwife will also attend the births at the Birthing Unit as support for the woman and midwife. The birthing unit has one employed midwife in attendance 24 hours a day to support women having a post natal stay. She will also give support at birth if her work load permit.
It is more than sad that healthy well nourished women in good housing, with sanitation may feel they can not have a homebirth with a midwife and the midwives have to deny them that possibility of a family centred birth because she (the midwife) has to have another midwife with her and one is not available.
Particularly when you remember that many women all over the world, through history have safely birthed without a midwife, whether they have been healthy or not well nourished or not housed bad or not.
When are we as a society going to accept that no matter what we do something may go wrong, at any time, that death is a risk of life; that we can not save everyone and in fact in trying to do so we we do them and ourselves a disservice!!
How do we deal with that fear of something going wrong in modern society ?
I am so privileged to have worked and traveled in developing countries. I wish it were a prerequisite for all western policy makers.
Guidelines/Criteria for Home Birth
Julia Allison’s brilliant book “Delivered at home” contains a fascinating account of how women chose home birth in Nottingham, and of how midwives attempted to select women for hospital birth if they felt it was indicated. There were also guidelines from the health authorities but the women didn’t respect them and were often able to have the home births they wanted by simply not booking for care in time to be given a hospital bed. Among the reasons to try and get women into hospital were lack of indoor plumbing, or distance to source of clean water. Good to keep things in perspective.
(With deep reservations about written guidelines unless there is latitude for midwifery and maternal judgment)
‘In the last 50 years, there have been massive changes in the pattern of bacteria which live in the gut and the friendly bacteria which helped to protect against allergy have been reduced.’
This has probably happened he says because of lifestyle changes such as the switch from away from home to hospital deliveries, and the increase in Caesareans.
‘Babies being born in hospital rather than at home among family members are being delivered and handled by strangers rather than family members and they don’t share the same bugs as the mother,’ he says.
The whole article is on msn.co.uk.
On this site:
Safety In Numbers – how many midwives at a birth? by Chris Warren, from Midwifery Matters 90, Autumn 2001.
On other sites:
Home birth Reference Site (www.homebirth.org.uk)
British Medical Journal correspondence on home birth (www.bmj.com/cgi/content/full/320/7237/798)
AH updated 14 October 2001