I attended a wonderful birth recently. Mom wanted a home birth, dad wanted to support mom and baby total had its own ideas on entering the world.
My impression of homebirths may be somewhat skewed by my habited of reading the internet. I will admit to finding websites at two in the morning with my nursing and midwifery colleagues and laughing about some of the things we find. Some things are not so funny, and down right dangerous. Being in Canada, I can see the creep of the American Homebirth Culture coming in. I want to tell my patients that this is Canada. We have well trained midwives, an integrated system and universal coverage. Quite a bit different from what women are complaining about under the American system. We are very open to natural child birth, but we understand that some intervention early on may actually prevent greater complications down the road. Some patients really don’t understand this, but once and a while, I think that patients learn that we are actually just there to help in the hospital.
The couple was sweet, and low risk. Really, no reason not to try to have a homebirth, except she was a primip. After being stuck at 6 cm for a few hours, she agreed to her midwife’s advice and transferred into the hospital. I, as the obstetrician on call was consulted. I examined her and found the head we engage, but minimal mould and no caput. Her contractions had spaced to every 5-6 minutes, and I doubted that they were very strong. Essentially a stalled labour. This needed treatment.
The couple wanted to wait some more. They didn’t want the cascade of intervention. However, we were able to sit and have an informed discussion. I was worried about a prolonged labour and increased risk of postpartum hemorrhage. I was worried about uterine atony and fatigue and the longer we waited to make a decision, the greater the risk of a surgical delivery. I was worried the mom would be so fatigued that she would “miss” the delivery from pure exhaustion.
They understood clearly, it was about them and their baby. It wasn’t about me and my agenda. I was in house for the next 18 hours, so was pretty sure no matter what, I would be attending delivery. My only agenda was a safe baby and safe mom. I was not going to rush off to a golf game, and honestly, I don’t really get paid more for a C-section.
After some discussion, they agreed to the epidural to help more rest and relax. Once she got it, she wondered why she didn’t get it hours ago. I suspect next pregnancy she will ask for it earlier. She agreed to the oxytocin to help her tired uterus. It did need to b flogged a bit. We hydrated her and gave her some sugar. Labour is like a marathon, you need to maintain your energy levels to get through it. We didn’t starve her, we didn’t restrict her to a bed (we have the so called “walking epidural”). She choose to lay on her side and sleep for several hours.
Interventions were successful. She reached fully, the head was occiput anterior, and quite low. My only concern was that it was a little ascynclitic. twisted to one side. I find this happens more often in women with adequate pelvises but crappy contraction. The baby just takes its time and somewhat of a scenic route. I relayed my concerns, recommended that if pushing wasn’t effective, I would recommend another intervention.
We she was determined to do it right. She pushed longer than I would have recommended. The head didn’t budge. I came back and discussed the risks of forceps, vacuum and C-section. Somewhere along the line, forceps have gotten a bad name, but I don’t know if they truly deserve it. Yes, there is more risk to mom’s bottom end with forceps, but I would pick that over a suction cup to the top of my baby’s head. I offered trial of forceps or vacuum or C-section and let them decide. I explained the potential risks and benefits of each. I explained that based on my examination, I would expect this to be an easy delivery with forceps, I just needed to straighten the baby’s head out, and forceps were my best tool. Again they wanted time to discuss, again I reinforced the risk of delayed decision making. She was increasing her risk of post-partum hemorrhage.
Finally, after being fully for five hours, they consented to the forceps. The team was assembled, her bladder was emptied and the forceps were applied easily. As soon as the head was straightened out, it started to descend with the next contraction. One pull and the head was crowning and I removed the forceps. Mom delivered the baby’s head. No shoulder dystocia (yeah!) and I rotated the baby to face mom, who than pulled her own baby up onto her belly. Cord clamping was delayed by a minute and the paediatrician assessed the baby on mom’s belly. No concerns, no marks from the forceps. Everyone was happy.
Then my work really started. She only had a small second degree tear, but as soon as the placenta delivered, the bleeding started. This is were I did not want to be. An hour later, several litres of blood on the floor, the postpartum hemorrhage is under control and mom will be fine. We have a good team and things went well. It did take a lot of intervention to control the bleed though.
I went to round on the couple the next day. I asked how she was feeling. She regretted not coming to hospital sooner. She was happy that she was risked out of homebirth for the next baby because she didn’t have to worry about peer pressure in making her decision. Her husband wanted her to have an epidural sooner next time, because she enjoyed the labour so much more after. They were so surprised at what the a forceps delivery actually looked like, and wondered why they bothered to push for several hours, when the problem was so easy to fix. They were thrilled with the nursing care they got in hospital. They were so thankful to not have to clean up the blood that was in the OR, it was kinda impressive.
I asked them how this was going to change the way they take about birth with the friends. Mom was going recommend epidural. Dad wanted to name the baby “Forceps” because he now thought they were as cool of tool that he had every seen.
They will be back. The ironic thing is, her next delivery would likely be straight forward and short. If we could all start having babies with our second child, my job would be so much easier.