Dear Henci,

I just had one of the hugest learning curves and interesting experiences of my midwife life! I met some lovely people in the "brithing community" here and they asked me to be their midwife for a homebirth on their farm which is 2.5 hrs out of the city with a small government hosptial withing 20 minutes from there.

I ended up agreeing to attend the birth as a friend who happens to be a midwife. They had ultimate faith in the growth and birth of their unborn child, 15 years since number 2 had been born at home on the farm with a village (un-trained) midwife. They had no sonography, no blood tests and a few prenatals by me on times when we could meet up which was quite random because of our busy schedules.

On the day she went in to labour we had planned to meet and talk about what they wanted to happen during the birthing process and what did they want my role to be and I was going to suggest a blood test so at least we knew the blood group incase of emergency and a sonography if they were willing. I have attended hundreds of births before in the Philippines where no sonography was done as the women could not afford their food for the day, let alone a sonography. However having worked for the last 2 yrs in a city where most people have multiple sonographies in pregnancy I thought to ask for one at the end was an "ok" request from the midwife!

We ended up never having the discussion because she went in to labour and I was attending another birth at the other end of the big city! The husband went to a local private nursing home who said they would not help them at all with no blood tests or sonography and especially no HIV test which is mandatory here!

So I arrived to my lovely G3 friend , aged 42 and waited and checked heart tones and all vitals were normal...  22 hours later on a journey full of massage, love, comfort of their own home, encouragement, sensitivity, quiet, peace ... a tiny little girl arrived with waters intact! She was 2.1 Kilos and obviously IUGR ..... There was a velamentous insertion of the cord and I was completely in awe of how their bodies had worked together and how the waters had stayed intact protecting the baby from any danger of breaking the vessels and potential hemmorhage or demise! I was also very thankful that all were ok!

If they had had a sonography the velamentous insertion would have been detected. Then they would have been encuraged to have had a c section? It would have sewn a seed of fear or doubt in their beautiful faith in the process of home birth and the perfect workings out of it.

If we had gone to a hospital(without a sonography) the doctor may well have done AROM which is a very common procedure here, and that would have put the baby in potential or even fatal danger!

So was I stupid to attend this birth? It was the first I have ever attended as a sole midwife!  I always work in pairs!

The family are total believers in health and organic farming and haven't been worrried about a thing. The baby seems to be thriving, breastfeeding well and has no jaundice and no anomalies that can be seen or heard! The family don't have a desire to see a doctor.

I am out of my box totally with all of this but in another way completely honour them and their choices. I can advice kangaroo care, increased breastfeeding, sunbathing and a doctor's visit but it's up to them what they do! They are a unique and beautiful family and it was an honour to be part of the whole process. The "fragile" situation of the cord and seeing such an IUGR baby shook me but the faith of these people has overidden these events!

I have been googling "velamentous insertion" and wondered if you have any studies on this .....

Thankful all was well at this HOME BIRTH!!

Lina

This is such an interesting story.  I, too, made a choice not to have a routine ultrasound in my pregnancy and never had a reason to have an indicated ultrasound so went into labor having had no ultrasound.  My water broke at the beginning of labor and after a very straightforward, rather short labor I gave birth to a healthy baby only to discover afterwards that I had had a velamentous insertion (as well as a succenturiate lobe). I have thought long and hard about what my birth would have been like if the placental abnormalities had been diagnosed prenatally (often, by the way, ultrasound misses them.)  I imagine I would have even considered having an elective c-section.  On the one hand, I feel so thankful that I planned a home birth because of the things you mention - I don't think that my baby would have tolerated pitocin, me pushing on my back, AROM, etc.  But I'm sure if I'd had a ruptured vasa previa and a baby that died or was severely injured, I would have felt very differently and would have accepted any level of intervention to assure a healthy baby. 

What is absolutely insane is that there isn't a "curtain number 3" to choose, which would be truly home-style, midwife-led care in a hospital setting with interventions the woman herself chooses (or not) to ensure safety. I actually have pretty good midwifery options in my area and am a midwife myself so I imagine I would have been able to advocate well for myself and my baby, but I still believe I would not have been supported to make an informed choice to have few interventions with a known placenta abnormality.  In fact, I imagine I might have not even been given the choice to labor, much less have a choice in what kinds of labor interventions I would accept or not. 

I support a woman's choice to have a planned home birth even when she has a risk factor or, for that matter, to avoid the testing that would tell her if she had a risk factor or not. But I wish that all hospitals provided informed choice and midwifery care, so that for those marginal cases where things will probably turn out OK but there's a higher-than-normal chance that things could go horribly wrong, women could still be the central participant in decision making and arrange her birth setting to meet her cultural and personal preferences. 

-Amy

I agree with Amy and would add another potential problem with conventional management: What if, as is common, the obstetrician or midwife practiced active management of third stage (the time from the birth of the baby to the delivery of the placenta), one element of which is pulling on the umbilical cord (cord traction) to deliver the placenta? Clinicians aren't supposed to do this until they have indications that the placenta has completely detached, but they don't always do what they're supposed to do.

-- Henci

As it happened, even the gentle traction that my midwife used while I was trying to birth my placenta was too much, and the cord detached from my placenta entirely. I needed additional measures (pitocin and some manual techniques by my midwife) to birth my placenta because I was having excessive bleeding.  The placenta was quickly delivered and my bleeding stopped easily. I never had any symptoms of excess blood loss or anemia. 

-Amy

I rest my case.

-- Henci

wow that's so interesting to hear from both of you... My computer is not working so well and I forgot to check back on here!(my loss but now my gain :) )

I did no active management of the third stage and waited and waited ...She was on the birth stool and was not bleeding and baby was skin to skin. The cord was all spirally and looked really strong until the placenta eventually came out! I have good photos of it all....and continue to be happy that all went well.

The little girl is growing well, solely brastfeeding. She has not met a doctor and probably never will! The family are all so healthy and have organic healthy lifestyles.

As always.... I learn from every experience.. every mum.. and every baby .. one by one..