BBA

It's funny how things work out, I was going to write about a recent 'BBA' today and both Nee Naw and The Guardian wrote about this subject yesterday.

So here is a 'Born Before Arrival' from my point of view.

It started, as is becoming increasingly common, with Dispatch putting out a general broadcast over the radio to see if there were any ambulances available to deal with a baby about to be born at home. We were at the hospital just finishing off our paperwork so we offered up for it – paperwork can normally wait.

Whizzing round there we were first on scene and were met by the husband of the patient at the front door, he was looking a little bit stressed. He directed us upstairs where the mother and child were laying on the bed. The baby was wrapped in a blanket and was being held by the mum.

The calltaker was still on the phone, but hung up before I could say what a sterling job they had done. I would later contact Dispatch and tell them to let the calltaker know how things had turned out (something I probably wouldn't have even thought of doing were it not for Nee Naw's blog).

A quick chat revealed the mum to be a lot more chilled out than the father. I congratulated her on making it all look so easy while checking the baby out. He was happy, breathing and had all the required fingers, toes and other items of anatomy. The fluid on the bed was nice and clear, so it seemed that the child had not become 'distressed' during the delivery. A check of the mother showed that she was also in good health.

A second ambulance crew turned up, and as one of them has only been out a year, we let her deal with the final stages of the birth. She offered the chance to cut the cord to the father, but he was still a bit scared and refused, so she had to do it. I advised her as to the best way to do it without getting splattered in blood.

In cases like this we get the hospital to send a midwife to the house – if everything is fine then the mother and baby could stay at home. While home births are riskier to mother and child than hospital births, if there is a chance to avoid going to hospital it's a nice idea to take it.

The midwife arrived, and this is where I started to grind my teeth in anger.

She walked upstairs and didn't even say hello to the patient (or to us). The first words I heard from her were, “I'm going to inject you to deliver the placenta”. We confirmed that the baby was fine and the mother hadn't even been torn by the delivery.

But the midwife still wanted her to go to hospital. I asked her why and she told me that all home deliveries had to go to hospital because of policy. I'd never heard of this before, but I'm not about to argue with someone who is supposed to know what they are doing. So we took mother, father, child and midwife to hospital.

We settled the patient into the delivery suite and was just about to leave when another midwife grabbed me and said that she 'recognised' me. I always wonder what I've done wrong when someone says that to me – guilty conscience I guess.

It took a while to remember, but I realised that I used to nurse with her when I was an A&E nurse. We had a little 'catch-up' and I asked her why the other midwife had felt the need to drag our patient to the hospital.

There was no need I was informed, no change in hospital policy and no good reason why there should be any concern for the baby or mother. She had no idea why she had been forced to come to hospital.

Then the first midwife came out of the delivery room, sucked her teeth and told us that she was, 'going on her break'.

Suddenly I had a motive for her bringing the patient to hospital.

Of course, this is all supposition. I can't prove anything – even the rudeness of not introducing herself would be hard to claim as both patient and midwife are Nigerian, and so it could be a cultural thing. If I did complain I could be accused of not being 'racially aware'. Any complaint would have to come from the patient.

Normally when midwives come out to a BBA, they are lovely and we get on really well. In my area a lot of them have huge chips on their shoulders while the midwives from outside of my area are much nicer – but all of them have always acted with courtesy and professionalism. It's a shame this one had to spoil it.

But still – it was a good job with a happy ending. And we can do with as many of them as possible.

UPDATE: A slight change to the post due to the discussion in the comments to this post.

40 thoughts on “BBA”

  1. “While home births are twice as risky to mother and child as hospital births, if there is a chance to avoid going to hospital it's a nice idea to take it. “I'm sorry, but that is simply not true. Where are you obtaining your information from?

    There's a good summary of current medical evidence at at http://www.homebirth.org.uk/homebirthindex.htm) which I think you should look at, especially the findings of the “National Birthday Trust – Report of the Confidential Enquiry into Home Births”, which shows that home births, for the right women, are *at least* as safe (or safer) that hospital births, and this position is now accepted by the Department of Health, RCOG, NMC, RCM, BMJ etc. The huge huge weight of evidence and the experiences of women who have home births do not back your statement. Please contact either the NCT or homebirth.org.uk for more information.

    – Joint statement from RCOG & RCM is at http://www.rcm.org.uk/info/docs/Home%20Births_Joint%20Statement_1.pdf

    – NMC's position on homebirth is at http://www.nmc-uk.org/aFrameDisplay.aspx?DocumentID=1472

  2. There is no balanced information. If you quote a large, retrospective study that says homebirth is inherently safe for low risk women, you are then battered with some tiny, flawed foreign research that apparently negates all that. Physiologically, women tend to labour wherever they feel the safest; generally where there is good antenatal support that tends to be at home- where they feel supported. If they have been given NO information and just feel abandoned then they will not labour so well.

  3. Fully seconding Kirsten's comment here. If you're going to make statements like that, you're going to have to back them up, Tom!FWIW, my third daughter was a planned homebirth who still managed to be a BBA – she showed up ten minutes before the midwives got there! It was a very straightforward homebirth, no complications other than being bloody quick! My first two births had also been very straightforward and fast, which was precisely why I'd wanted a homebirth. However I had to fight tooth and nail to get it, and thanks to people like you parroting misinformation that homebirths are risky, other women will have a hard time getting their homebirths too.

    A planned homebirth is a damned sight safer than a hospital birth.

    Normally you're very well informed and informative, Tom, so it's very dissappointing to see you get this one wrong.

    And I'm very sad the mother was not given an opportunity for a physiological third stage but was instead injected with syntocinon. I hope that mother presses charges of assault against the midwife, because that was what it was. At the very least I hope the family send a written complaint to the Head of Midwifery.

  4. For some reason this subject always seems controversial…Ah, here we go

    Intrapartum death not associated with congenital malformations or extreme immaturity (defined in the home birth group as an infant weighing <1000 g) was three times as frequent in planned home births than it was nationwide (3.0; 1.9 to 4.8)

    Then there is the Washington study.

    NICE says that there isn't enough evidence – and I trust them to be better statisticians than myself. But they do say

    “The guidance states: 'There may be a lower risk of perinatal mortality when care is delivered in a consultant-led unit.'”

    I'm not too sure that Homebirth.org.uk are the most impartial readers of research.

    The RCM link is fine, but they consider safety as

    “However, this is not to define safety in its narrow interpretation as physical safety only but also to acknowledge and encompass issues surrounding emotional and psychological wellbeing. Birth for a woman is a rite of passage and a family life event, as well as being the start of a lifelong relationship

    with her baby”

    I'm afraid I'm old fashioned and consider safety to be the whole 'breathing at the end of it' rather than some flowery description of emotional wellbeing. And yes, I know I'm being all 'male medical' about it.

    I may be wrong about the risks being double (although the Australian study says triple), but home birth is more risky.

    Another way to look at it – midwifes do 3+ years of training, at the hospital there are doctors with 8+ years of training. In a home birth you might end up with an ambulance man who has 20+ weeks training, with one day training in maternal emergencies and delivering babies.

    Sure, those aren't planned home births, but even if planned I'd imagine that most midwives wouldn't like to deliver a shoulder dystocia away from a hospital (and the page on *that* in the homebirth.org website scares the crap out of me).

    So I'll tell you what – I'll edit the post to remove the *double* seeing as the evidence isn't specific – but I'm still going to say that it's more risky.

  5. Tom, neither of those are UK studies and they aren't relevant to what happens here. In Australia and the US, women have a lot less choice when it comes to maternity care and they consequently they sometimes have to take higher risks to what we do in the UK. Additionally, they can be significantly further away from hospitals than most people in the UK are.”Homebirth.org.uk are the most impartial readers of research”

    They don't need to be for you to research the topic properly.

    “most midwives wouldn't like to deliver a shoulder dystocia away from a hospital”

    How are they going to do it differently in hospital? Shoulder dystocia doesn't happen at home as much, but of course midwives need to know how to deal with it. There isn't time to do much in hospital either. These are the NHS recommendations for Shoulder Dystocia http://www.pi.nhs.uk/reviews/oe/oe_shoulder_dystocia.htm. The Zavanelli manoeuvre is hardly ever done.

    “home birth is more risky”

    Where is your UK based evidence?

    “I may be wrong about the risks being double (although the Australian study says triple)”

    And that may be the case *in Australia*, but we're talking about in the UK, with the UK medical system and UK trained and certified midwives.

    “consider safety to be the whole 'breathing at the end of it' rather than some flowery description of emotional wellbeing”

    Choosing a homebirth has *everything* to do with safety and the whole breathing at the end of it. What else would be the primary motivation for choosing one? Do you really believe that any mother would choose to endanger her child so that she can have 'an experience'?

    “NICE says that there isn't enough evidence – and I trust them to be better statisticians than myself. But they do say “The guidance states: 'There may be a lower risk of perinatal mortality when care is delivered in a consultant-led unit.'

    Could you provide the link and context?

  6. 1) I agree that Australia and America aren't the UK – however there hasn't been a decent study in the UK concerning home birthing. So until there is, I'm afraid it's the best that we have.2) From what I can see homebirth.org.uk have an agenda that they are trying to push.

    3) Shoulder dystocia, I agree that the evidence is there that it occurs more often in hospital (and that is where hospitals should be changing their practice by allowing slow delivery) – but, the management you link to contains…

    2. Call appropriate staff:

    * Senior midwife

    * 2nd midwife

    * senior obstetrician

    * anaesthetist

    * paediatrician

    * Explain to the patient and family what is happening

    And while the Zavanelli manoeuvre is 'hardly ever done' that doesn't mean that it's never done – and then you are looking at a caesarean.

    4) 'Home birth is more risky – Where is your UK based evidence?” Where is you evidence that it isn't? the intrapartum care consultation on the NICE website says,

    Perinatal mortality involved 3 babies in 860 planned home births, 1 baby in 733 planned CLU births and no babies in 563 planned MLU births. No further details were given regarding the

    perinatal deaths. There were more low birth weight infants in the CLU group (p=0.04). Furthermore, there were 5 infants out of 860 in the home birth group who received assisted ventilation for more than 24 hours, but none in the MLU and CLU groups.

    It finishes that section of the guidelines with the conclusion,

    “With relation to womens and babies outcomes for home births, there is a lack of good quality evidence. Limited quality evidence shows less intervention and higher maternal satisfaction with a planned home birth compared to a planned birth in hospital. The evidence of overall perinatal mortality is ambiguous.

    However, there is evidence that booking home birth has a higher intrapartum- related perinatal mortality than booked hospital birth. In studies where information was given, hospital control groups generally consisted of higher risk populations than those groups planning birth at home.”

    The full document is here.

    The whole 'wooly-emotion' bit is from the document that you linked to. It struck me as strange as well, and trust me – there are crazy people out there who would rather have an 'experience'. Lets face it there are crazy people out there who beat their children to death because they think they are 'possessed'.

    The initial quote about perinatal mortality in consultant led units is from the initial NICE consultation.

    To be honest – I think that this discussion we are having (and I don't know about you, but I'm enjoying it) revolves around the lack of decent UK studies. NICE states that the UK studies aren't really up to scratch (same document, and yes I'm summarizing a bit) and I think that there really does need to be a decent study to sort it out once and for all.

    Kirsten – I take it you are a midwife? Might I ask whereabouts?

  7. Had something similar a few weeks ago. BBA, not a planned home birth but went well, mother asked me if she could stay at home so i decided to try and arrange a midwife to come out instead.The community midwife named on her green note's was not answering the phone so I phoned the delivery suite of the hospital she was booked for.

    The hospital she was booked at was not the closest to her house and they said that their community midwife's did not come out that far, so they gave me the number to the local hospital's delivery suite.

    The local hospital said that their community midwifes did not do home visits out of office hours so gave me a (familiar looking) number to try instead.

    The “familiar” looking number was the general enquiries number to or own control room!

    My own controller (bless her) contacted first response (who deal with out of hours GP visits) and they found a midwife for me.

    Midwife turned up and bullied the mother into going to hospital (and yes bullied is the right way to describe the way the midwife spoke to the mother). The midwife said to me “I never leave people at home” which after all the fuss I had gone thru to grant the mothers wish to stay at home was a bit frustrating to say the least.

  8. Im sorry but I am not medically minded like many of the other readers of this blog, but surely Tom is right about Home births being much more risky compared to giving birth in hopsital.If your at home and there is complications, you still have to get to hospital before you see a doctor whereas if your in hospital in the first place you will see a doctor much quicker.

    Like I said im not medically trained as of yet so I could be wrong and anyone out there who disagrees with me will tell me, but that is how I see it.

  9. Ugh! Reading about that first midwife really ticks me off.I gave birth to my daughter this past June and my midwife was awful. Amongst other things, she decided to take a nap for two and a half hours whilst I was on an epidural. I wouldn't be so angry if she had been looking after another patient (you do hear about how there is such a shortage of midwives), but she was actually sleeping in a back room and they couldn't find her for ages. My epidural wasn't working and I was quite frightened, as the pain didn't feel like the labour pains I had experienced previously.I have to agree that the emotional aspects of giving birth are so very important and shouldn't be under estimated, but that most women would not want to give birth at home if they felt that it would indanger their child. When you give birth you are overcome by such a mixture of emotions and you feel incredibly raw and vulnerable. One reason I would rather give birth at home is because there are no 'visiting hours.' I was fortunate enough to deliver in the afternoon, so that he could spend time with us afterward. But whilst I was in hospital another woman in my room gave birth just after 8pm (after visiting hours) and they actually threatened to call security to get her husband to leave once he delivered her to the post-natal ward. Whilst I couldn't have felt more safe with the surgical team that finally delivered my 10 lb 8 oz baby girl, or been more pleased with the day midwives and midwife assistants, at night (for some reason) the midwives ranged from lazy to just plain mean. I desperately wanted to go home. Once I got home I was able to get what I craved–to cuddle up in bed with my husband and make a little love sandwich with the baby. 🙂

  10. The opposing argument (and it's not without merit) is that there is the risk of hospital acquired infections, and that the midwives/doctors at hospital are too quick to reach for medical tools like forceps, drugs and caesarian sections (which have their own side effects and risks).And I can understand those concerns, but I think that with what little evidence there actually is, hospital births are safer.

  11. Ive been having a think about this argument about whether home or hospital is better, and although I personally believe a hospital birth would be safer (yes i am being biased), it also depends on the individual cases history, if previous births have been fine with no problems a home birth is probably better, but if its a mothers first birth then hospital birth is better because emotions can be mixed and nerves can be very high and a hospital can provide that much needed support

  12. The majority of women in the world give birth at home!I supose we in the UK are fortunate to have good healthcare that enable more babies (And mothers) to survive!

    Kate

    (not a midwife or a mother ….. yet!)

  13. Why do midwives have a chip on their shoulder? Is it because of a lack of variety, or do they feel inferior to other medical staff around them?

  14. For what it's worth, I think your both right. The risks between a home birth and a hospital one vary depending on the circumstances of the mother, and cannot be given a value that applies to all. Hospital births would be safer for a first time mother, despite the risks posed by infections or forcep happy doctors, and home births would be just as safe, if not safer, for someone with a history of easy births and a partner who isn't scared to help.There does need to be some more research on this so people can make a more informed choice.

    In reference to midwives, how much actual authority have they got to drag a new mother off to hospital? Surely they go by the same guidelines the Ambulance service do, if the patient says no, then it's no?

  15. I dont have an opinion either way except to say that the parents should be informed of the pros and cons of both and make a decision accordingly but as we speak my collegues are working out how to suture a facial laceration on day old baby caused by a pair of delivery forceps.

  16. Not medically trained, but as baby had made that risky journey, and arrived in the world safe and well,had the risk element of home birth now passed?

    Not wishing to be melodramatic, but when my son was born (9 months, 12 hours and 23 minutes ago) had we not have been in hospital for that emergency c/section to be performed, then he might well not be here today.

  17. I had a completely normal pregnancy and my midwife frequently offered a home birth. Thank goodness I declined. My labour was completely normal and “text-book”, but despite this my baby didn't breathe for 17 minutes and had a whole team of drs, midwives, nurses and anaesthetists working on her, using extremely complicated-looking equipment. Thankfully my baby made it and is now a perfectly healthy child – but what if she'd been born at home? I agree that for the right women, a home birth is a great option, but how do you know who those right women (and right babies!) will be? I fitted the criteria perfectly for a home birth but my baby would never have survived if I'd chosen that option. The reasons for her being “flat” (as it was so delicately described) have never been establised.

  18. I wanted a home birth, I read the magazines, quizzed the midwifes (who sniffed at the idea) and researched the matter as much as I could. In the end pressure from family, friends and midwifes made me opt for the hospital .. thank God! Everything was fine and wonderful and would have been so much better in the comfort of my own home, until the babies heart unexpectedly decided to stop beating. There was no time to administer an anaesthetic for a caesarean section, so they hovered him out using a ventouse. Something very similar happened with the next birth too. Luckily in both cases the baby was successfully resuscitated.In both cases there would never have been enough time to get to the hospital from home, yet there had been no indications of a problem during the pregnancy or the labour, which in my opinion makes home delivery far more of a risk, and one I'm so glad I was talked out of.

  19. No answers to this argument but my wife bought a book that has a great history of Birth, a little gory at times (from a mans perspective 🙂 but charts the rise and fall and rise again of midwives and has some very interesting insightshttp://www.amazon.co.uk/Birth-History-Tina-Cassidy/dp/0701181192/ref=sr_1_12/202-4669570-8844660?ie=UTF8&s=books&qid=1190278971&sr=1-12

    Pete

  20. Please rest assured, it's gory from a female perspective too! :)Suffice to say that if I could UN-know what the Zavanelli manoeuvre is (I googled it after reading the comments) I'd be a slightly happier woman.

    That aside, I'm no fan of a lot of aspects of modern medicine: the power of the big pharma companies, and the blind faith that causes things like the seroxat tragedy…. but it seems to me that a lot of childbirth complications are mechanical rather than chemical, and therefore having the tools on hand to deal with that makes perfect sense.

    Though taking an already safely-delivered baby and mum into hospital does seem like the worst of both worlds to me.

  21. Without wanting to discount the experiences of the previous writers who were lucky to have their babies in hospital, in the vicinity of specialist teams despite earlier considerations of a home birth, I'd like to add a different view.I'm Dutch and now living in London. My first baby was born in hospital, my second at home – both while we were still living in the Netherlands. Being pregnant with my third here, my GP told me I had to leave her practice if I really considered another home birth ('We don't do home births here'). It's funny how perspectives can differ even with little physical distance between countries: in the Netherlands, about a third of the babies are born at home and as far as I'm aware, there's no more risk attached to a home birth than to a hospital birth. It might be on the contrary, even, given that all pregnancies with medical complications or other known risks are referred to hospital upfront anyway – and if things turn difficult during the actual delivery, you would also go to one of the nearby hospitals. (Sorry guys, no research at hand to back this all up… but then again, someone would tell me that data from another country aren't valid here anyway 😉 )

    Luckily, the midwife practice in our local hospital is very supportive of home births and – with three weeks to go before my due date – we're still hoping to welcome this baby to our family at home.

    What tips the scale for me in opting for a home birth? Mainly, it spares me the disruption of having to move to hospital during labour – which may slow down the contractions, lengthening the birthing process, increasing the likelihood of getting exhausted and thus the need for pain medication and other medical procedures which may have been avoided… also, without getting all woozy over it, I strongly prefer the privacy and familiarity of my own home, both during labour and in the aftermath, over the bureacracy and procedures necessary even in the friendliest hospital. Needless to say that my husband and I have very fond memories of the home birth of our son, during which we felt so much more in control than during the hospital birth of our daughter.

    I do find that, given the commonality of home births in the Netherlands, midwifes over there are better prepared to deal with them in terms of information available, equipment that they have (although they don't have TENS-machines or gas and air, both of them were new to me) and moral support to both the mother and the partner. Still, I fully trust the midwife team that I've met here to do a great job. In the end, the basics of giving birth remain very much the same independent of the actual location of the event.

    The thing I guess I am going to miss is the lovely Dutch system where a specially trained nurse comes to your house for three to eight hours a day up to eight days after delivery (mostly based upon your need but obviously also influenced by the availability of these special nurses and your insurance level), – she takes care of both mother and baby, gives a lot of hands-on training in babycare and breastfeeding, makes sure that any visitors are both well looked after and shooed out of the door soon enough, and keeps the household running at a basic level including doing the laundry, some grocery shopping, cooking if needed, helping out with any older children… but somehow we'll manage without this luxury too.

    Don't get me wrong: if the need arises, I'll be glad to have our baby in hospital and I'll be thankful for all medical procedures that might be necessary. But I sure am hoping this baby will arrive as quickly and safely as our second one, the delivery made so much easier because I feel confident and strong in my own home.

  22. Well this makes a refreshing change from rants about ambulances being 'maternataxi' for ladies who have twinges. :)As for home births, informed choice, discussion, facts, review, plan A plan B, think again, change mind, plan C.

    But pleeease dear medical profession listen to the mum. It's as though every one either 'owns her' or just wants where it is convenient for them.

    Women are so vulnerable to emotional bullying when they are 'belly up.'

  23. It might be on the contrary, even, given that all pregnancies with medical complications or other known risks are referred to hospital upfront anywayThey try to account for that in the research, most often by only counting babies born of a certain weight or above.

    Our health visitors visit new mothers, but not anywhere as much as you have experienced with your previous midwives.

    Good luck with the birth. Let us know how it goes.

  24. I don't have any particular opinion on home births as if I ever have a baby it would be high risk and need consultant support throughout.However on the subject of cultural differences Tom, I suspect it's a common excuse not to deal with poor standards. I was once told by ward staff and a PALS officer (not a volunteer) that the reason I'd been treated so badly by a consultant (he'd screamed at me in front of a ward full of people) was that he was Greek and that I had to understand that Greek men had a different attitude towards women so I shouldn't complain.

    I didn't, they successfully intimidated me out of it, which is why this kind of behaviour continues. The individual's nationality of course wasn't known to me nor had I even considered it as a factor until I was told that must be the reason!

    Bendy Girl

  25. I have to say that I read the original post and thought 'I totally agree; I agree with what you say about cultural differences and also about the way that SOME midwives unfortunately behave'. However, some of the comments on here are misinformed and also unhelpful.First, obstetric emergencies are rare and very rarely do you get something that happens with no warning whatsoever. Where there are warning signs at a planned home birth, we transfer. End of story. Or rather, we explain why we want to transfer and the woman decides. Where you hear stories about 'everything was perfect and SUDDENLY me and my baby nearly died', there is usually a catalogue of contributing factors that were either missed entirely or, because the person having that experience is not medical, they don't realise the significance of things like having an epidural and augmented labour, induction, continuous fetal monitoring etc, which can actually increase your risks of certain things, not lower them. Occasionally these freak rare things happen but not USUALLY. Therefore we should not increase the risks for a disproportionate number of women 'just in case'.Also, who do you think looks after women in a hospital? A midwife. Doctors only get involved where there is a problem (at least they do in my unit) and a lot of women will never see a doctor in their pregnancy. Doctors are specialists in the abnormal; midwives are trained in the normal; how to spot it, and keep it that way. I know that not all midwives act like that but my colleagues and I certainly do. Yes, websites like 'homebirth.org.uk' have an agenda but they also have a lot of empowering and positive information, which on the whole will benefit women a lot more than going into labour terrified by scaremongering and horror stories, which will increase fear and stress levels to an extent that it stalls her labour, thus being a self fulfilling prophecy. Looking at overseas studies aren't a fair comparison either, as for instance, the US and Australia follow a very medicalised and not at all holistic model of care. It would be better to look at the stats from somewhere like New Zealand to give a better comparison.As a midwife I am proud of the work I do and also proud that I can help my clients feel able to make their own choices based on the best evidence. I am a practitioner in my own right and as such make clinical decisions; sometimes this means liaising with doctors and sometimes not. Just because some midwives are unhelpful doesn't mean we all are; I've actually met some supremely rude and arrogant EMTs who have been rude to me, abusive and insulting to my colleague, showed no respect to the client etc to the point where a client complained about the crew, but I don't take this as 'all LAS are awful'. So don't judge us all as being the same because I'm sure you wouldn't like it either.

  26. the US and Australia follow a very medicalised and not at all holistic model of care.This is not true. It varies greatly, here (Australia), from home births to the whole surgical box and dice (that would be me).

    The majority of women in the world give birth at home!

    Yep, and some of the maternal and infant death rates are shocking, not to mention things like fistulas.

  27. Sorry- you are right, Australian midwifery is improving towards a more midwife-led model- but knowing some of those who are working to implement better models for women, I know what it's been like traditionally for a long time.Essentially what we need to be moving towards is a culture where people actually recognise that for healthy, well women, birth is not inherently dangerous and that without interference, babies will be born safely. There are teams of midwives who take on clients from all medical backgrounds and still achieve over 50% homebirths, without emergencies or morbidity and mortality- because the conditions are right and the woman is comfortable and feels safe, a very basic need when in labour. Whether a woman is in hospital or not, if we are intent on interfering all the time without even realising it, we are scuppering women's chances at the outset.

  28. So Tom – midwives train for 3 years and docotrs train for 8+ years………ok.An SHO when starting their obs and gynae rotation will have about 8 WEEKS experience! There are obs and gynae registrars at my hospital with less than 3 years experience of obs and gynae. I rememebr as a 2nd year student midwife been asked by the oncall SHO in the assessment centre to explain what a doppler was. This was after he'd asked me what he needed to do about the woman with reduced fetal movements. He didn't have a clue. Another SHO once during a speculum asked me if that was the cervix as he wasn't sure what one looked like. Midwives will have a lot more expereience that doctors. At a recent shoulder dystocia in the hospital the McRoberts manoever didn't work and the registrar panicked – luckily 2 expereinced midwives saved the baby's life. The dr admitted afterwards that she hadn't remembered what to do. I don't feel inferior to doctors at all – quite the opposite most of the time.

  29. I have to say that I don't like the way there seems to be an agenda to either persuade pregnant women that they ought to give birth at home, or the opposite. I am very chary of home births myself – for the simple reason that had my mother chosen a home birth, I would certainly be dead. Fortunately for me, anyway, she had already tried that, and there is a little coffin under the ground to show the results.I would rather be safe.

  30. No persuasion here- just it makes me very annoyed that people seem to think that women should be TOLD one way or the other. Informed choice means being given all the information and being able to choose for themselves. Being told 'hospital is really safe and home is dead dangerous' is completely baseless, especially when we know that once you get to hospital you increase your risk of iatrogenic complications… something that again increases with continuous fetal monitoring in low risk women.And then we have to deal with the fallout for women who have been told that they need doctors and hospitals to have their baby, and it's a horrible, disempowering experience. I've looked after too many women who've had health professionals tell them they MUST do one or the other thing, forced into having interventions they didn't want and sometimes didn't need… I've looked after people with genuine tokophobia and PTSD as a result, and met people who have decided never to have another baby as a result of a bad first birth. Hospitals and doctors undoubtedly have their place and I'm really grateful for the ones I work with as they also have the women's best interests at heart (ie HER interests) rather than their own agenda.

    My personal agenda is to get my clients as well prepared and well informed as possible, and then to support them through their choices. To me, it doesn't matter how or where they ahve their baby as long as they make the choice with the correct information, and they aren't going to discover two years down the line that they were deceived about something to do with their care, and then they suffer becuase of it.

  31. I agree that it should be an informed choice (I'm all for them). Unfortunately you have people on both sides of the fence thinking that *their* way is the only way – and with no solid local evidence to back it up I'd wager that some of these HCPs can bully people one way or another.Which is a bad thing.

  32. Yes- whereas my way of working is very much that if I'm not bullying people into doing something, and they make their own choices, then they have to take responsibility for them, and I am not liable for other people's mistakes. Ultimately it lets you sleep easier as you aren't foisting your beliefs onto others…

  33. Apologies for disappearing. I hate it when work interferes with the Internet :-)To be honest – I think that this discussion we are having (and I don't know about you, but I'm enjoying it) revolves around the lack of decent UK studies. NICE states that the UK studies aren't really up to scratch (same document, and yes I'm summarizing a bit) and I think that there really does need to be a decent study to sort it out once and for all.

    You keep saying there hasn't been a decent study in the UK, but there has been a large retrospective study of almost 6,000 women in the UK. The National Birthday Trust study is referred to and accepted by NMC, RCM, RCOG etc. There hasn't been a prospective randomised study of that size, but it would be impossible (and unethical) to do one. The NICE figures you quote were from a small study in Canada; again not in the UK, and RCOG criticised that draft on quite a few points and, AFAIK, those guidelines haven't been released yet. There is a lot of evidence that birth in home is as safe as hospital birth for the right women with the right support and infrastructure, but it's not for everyone.

    The 'logical' conclusion that hospital must be safer does not take into account:

    – how home birth really works. People seem to think that if you plan a home birth, you're stranded and you can't have an emergency caesarean if you need one

    – how many of the problems in hospital are caused by being in hospital

    – how rare unexpected catastrophic events during labour really are, things like AFE, heart attack, cord prolapse in low-risk women, uterine rupture etc

    I am actually planning a home birth in December with an independent midwife.

    Q: What will happen if I needed an emergency caesarean?

    A: I will transfer to the hospital. It's around 10 minutes drive and I could be in theatre within around 30 to 40 minutes. This is around the same time as I'd probably have to wait if I was on the ward to begin with. Please note that 'emergency' caesareans just means unplanned, which is different to a 'crash' caesarean.

    Q: What will happen if I haemorrhage after the baby is born?

    A: My midwife will give me Syntometrine and phone 999.

    Q: What will happen if I become exhausted, labour doesn't progress or I change my mind

    A: We'll go into hospital. Home birth is not all or nothing.

    Q: What will happen if the baby needs resucitation?

    A: My midwife has up-to-date resucitation skills, equipment and oxygen and will set up an area for that when she arrives.

    Q: What would happeen if there was a shoulder dystocia

    A: My midwife would have to deal with it, just like she would have to in hospital. In hospital, there are more people to call on for assistance, however you cannot guarantee that they will be available and I may well have two midwives all to myself at home.

    It would be ridiculous for me to suggest that there are not situations where being in hospital might make a difference, but they are catastrophic events which are exceptionally rare. It is even rarer for these events to occur no signs in low-risk women and I am more confident that my midwife will pick up a warning sign than if I was on a labour ward sharing an overworked exhausted midwife who I've never met with 10 other women. Those catastrophic events which could have better results have high mortality/morbidity results in hospital too.

    I wouldn't choose a home birth with a lay midwife as some American women have to do. I wouldn't plan a homebirth if I didn't have fantastic medical back-up not very far away; mother nature has a higher tolerance for dead babies than I do. If I had a heart condition, or developed pre-eclampsia or had any medical reason to attend hospital, that's where I'd be. If the nearest medical facility to me was 2 hours away, you get the picture … In the UK, we are exceptionally lucky that it's possible to have the advantages of having your baby at home with the safety-net of back-up should your birth *become* a medical issue.

    You mention that the criticism of hospital births is hospital acquired infections and doctors/midwives being too quick to intervene. Those definitely are things that people point to, but it's not the primary objection. Being in hospital inhibits labour; women just don't labour well there. We are mammals and how we are feeling has a very definite effect on labour. Adrenaline antagonises oxytocin so if we are afraid, angry, embarrased or scared then our body tries to stop labour. So doctors and midwives offer to augment the labour with syntocin. The effects of the syntocin are very powerful contractions. The contractions are powerful and very painful and the syntocin doesn't stimulate the release of endorphins like oxytocin does, so mum asks for an epidural. Baby then may be malpositioned or distressed due to the artificial contractions, mum being on her back and/or the epidural and an instrumental or surgical delivery ends up being needed. Mum then tells everyone baby would've died at home and the doctors saved the baby's life. Make no mistake, I respect obstetricians and what they do and I will be very grateful to have one if I need one, but it';s very important for women to have the typical “cascade of interventions” explained. Once you intervene in labour, the next intervention often becomes necessary and that's how we end up with a national c-section rate 10% higher than the WHO says is acceptable. It's the commonest childbirth story today and it is simply not possible to say that a child wouldn't been saved if they had been at home/in hospital. All that wooly emotional stuff is actually a really important part to having a good *safe* labour.

    There's something very wrong with the way we're doing birth in hospitals for healthy normal birth, but at the same time the NHS does provide an outstanding obstetric and neonatal service to women who need it too. Unfortunately, I think that increased litigation is causing the NHS to approach maternity services more and more like American obstetricians which isn't a good thing for anyone, but I'd love to see more midwifery like the Albany practice in Peckham (http://www.albanymidwives.org.uk/albanymidwiveshomepage.htm) where women don't choose home or hospital until they're in labour, which is similar to the Dutch model where home birth rates are over 30%.

    Babies do die at home, but they also do in hospital too. There are some babies who might die at home who wouldn't in hospital (although there's also a whole question of 'In what condition?', but there are babies who die in hospital who might not have in other circumstances and all of those situations are unbearably tragic. I have researched homebirth (and not just from reading homebirth.org.uk!) for many many years and I've read the anti- and pro- research and if I really thought for a second that I was risking my unborn child's like, there isn't any chance I would continue with that. My mother-in-law was a community midwife with the NHS for 25 years and she is the one paying for our independent midwife to have our baby at home. I know that in that time she never had a situation at home where a women couldn't be transferred in time and I know that if she had any reservations about her long awaited grandchild, she wouldn't be encouraging it.

    I'm not a midwife, but if you're interested in the topic please join http://health.groups.yahoo.com/group/ukmidwifery/ where you can discuss it to your heart's content and ask some of the most experienced and well-known midwives in the country as well as medical students, Professors of midwifery and others.

    Best wishes,

  34. It would be nice, though, if we could have properly balanced information given. For some people, home will be better, for some, hospital will be better, and for others, there's probably not much in it and the decision hinges on “what if something goes wrong” and the standards of service available locally.Instead, according to the (admittedly small sample of) women I've known who've given birth in the last few years, the people one would hope can give this balanced information are either madkeen on homebirth OR madkeen on hospital, and both types get their respective points across by recounting horror stories of what happens in the Other Option compared to the fluffiness and safety of Their Way.

    The only real effect this approach had for my little sample, is to absolutely terrify the women in question (not to mention their partners) about the dangers of giving birth in ALL its forms.

  35. HI TOM, I AM AN EMT FROM WEST MIDS AND QUITE FRANKLY MATE I AGREE WITH YOU, MY BACKGROUND IS SIMILAR TO YOURS, A&E NURSING THEN EMT, THE BEST PLACE TO GIVE BIRTH IS IN A DELIVERY SUITE , HOW CAN IT BE LESS SAFER THAN DELIVERING AT HOME IT'S AS CLOSE TO A CONTROLLED ENVIRONMENT AS YOU CAN GET, JUST ABOUT ALL EVENTUALITIES COVERED, I HAVE BEEN PART OF A CREW THREE TIMES NOW IN TWO YEARS THAT HAVE DELIVERED AT HOME AND AS NICE AS IT IS I HAVE TAKEN FAR MORE TO THE LOCAL MATERNITY UNIT AND BEEN FAR HAPPIER AND MY NERVES LESS FRAUGHT.

  36. You may be interested that this story is on the BBC Newshttp://www.bbc.co.uk/mediaselector/check/player/nol/newsid_7010000/newsid_7011000?redirect=7011012.stm&news=1&nbwm=1&bbram=1&bbwm=1&nbram=1&asb=1

  37. Yep, pretty true- I remember a long standing joke that the 3rd year student midwives were there to train the SHOs and it was pretty true…Big city hospitals it doesnt' tend to be so much of an issue. District Generals, and smaller units, full of people on GP training schemes who did 4 weeks of O&G in their 4th year at uni… sometimes they are the only doctor immediately there on the ward. I would rather have an experienced midwife. We all used to feel desperately sorry for the new SHOs, coming in without a clue and being told they are responsible for 2 lives. Some of them had only seen 3 normal births in their life, so how on earth do they know what is ABnormal?

    Luckily where I trained, adn where I work now, the doctors are all very pro homebirth and pro normality and aren't scalpel happy, which is much better in the long term for all concerned.

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