PPH and Neonatal Resuscitation: Home v. Hospital BirthThread
Oct 15, 2011 11:28 PM
I tried to broach this topic on somebody else's blog. I only received one response from an anti-homebirth troll and another defending me from the troll :-),,,,but still no answers. (The very act of a woman weighing her birth options can elicit some pretty strong emotions!) I'll try again here, hoping for only polite and informative answers. :-)
The two biggest reasons that "concerned" individuals try to talk me out of homebirth are post-partum hemorrhage and the need for neonatal resuscitation. From having had two homebirths, I know directly and personally that my midwives are capable of handling both. I'm preparing to give birth to my third and will most likely use these midwives again.
But specifically how do the protocols for each scenario differ in home v. hospital settings?
For PPH, my midwives used active third stage management that includes immediate clamping, Pitocin, methargine, and misoprostol (in that order, depending on severity). Clients are free to decline these interventions hassle-free. The one difference that I can think of is the lack of access to an immediate transfusion. How *immediate* does a transfusion have to be? Am I at any disadvantage not having that immediate access?
For neonatal resuscitation, I know that they use suctioning equipment and positve-pressure oxygenation. Am I at a disadvantage not having immediate access to intubation?
Are there any other differing protocols/procedures/equipment that I would experience in a hospital setting, and would I be at any disadvantage not to have them employed?
I'd love to hear what you--and the data--have to say on this matter. Thanks.
Oct 21, 2011 02:21 AM
For starters, you are at substantially less risk for postpartum hemorrhage birthing at home because conventional obstetric management exposes women to treatment that increases their risk of excessive postpartum bleeding, notably, oxytocin induction and augmentation of labor, especially using high-dose regimens, preventable cesarean surgery, preventable instrumental vaginal delivery, and unnecessary manual placental removal. Next, we actually have some data coming from low resource environments. In a Vietnamese trial, outcomes were compared between one district in which midwives were trained in active management of 3rd-stage labor (AMTSL) versus other districts in which midwives administered oxytocin as needed. Most women in both groups gave birth in community health centers. Virtually identical percentages experienced measured blood loss of 1000 mL or more (0.7% AMTSL vs. 0.5% control), despite 97% being given postpartum oxytocin in the AMTSL group compared with 15-30%, depending on comparison district, given oxytocin therapeutically. The take-home for you and other low-risk women planning home birth with a qualified birth attendant is that severe bleeding is rare and that it can sucessfully be treated should it occur.
Home-born babies are also at decreased risk for breathing problems, again, because they and their mothers are less likely to be exposed to narcotics, which depress respiration, unphysiologic pushing position and technique, and early cord clamping. Furthermore, typical hospital resuscitation procedures are actually counterproductive, if not downright harmful. Immediate cord clamping is problematic for any baby because it deprives the newborn of a substantial percentage of its blood volume, and blood flow to the capillaries surrounding the lung alveoli is an important factor in initiating and maintaining respiration, but cutting the cord on a baby who isn't breathing so that it can be removed for treatment is like cutting the air hose of a diver. So long as the cord is intact and the placenta attached, the newborn will continue to receive oxygen via placental circulation. Oxygen and suctioning, if necessary, can be carried out with the cord intact. As for intubation, a 10-year-old trial showed that, intubation and suctioning were not needed for meconium aspiration in a vigorous newborn, but I would bet that most hospital-born babies with even minimal meconium staining--let alone aspiration--continue to be intubated thus exposing them to its harms.
(The information and studies cited come from the 3rd stage and newborn transition chapters in Amy Romano's and my book, Optimal Care in Childbirth, due out next spring.)
All Times America/New_York
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