10 Minutes is not enough time.

Have you ever tried to hold your breath for ten minutes? Its not actually that easy to do. When I was competitive in synchronized swimming, I was able to get to able up to two minutes. Not spectacular, but not bad (I was eleven at the time). I still swim laps on a single breath because it was the way I tried.

However, how can I ask a baby, without any training whatsoever to hold their breath for ten minutes? I am often surprised that women think that home birth is as safe as hospital birth, and then in the same breath say that the hospital is only ten minutes away. I learned very early in training that ten minutes can be a very long time, and most babies don’t have intact brains after that time.

Compare the following two stories – both true, but long enough ago and identifiers removed.

Case 1:
Mom really wanted a VBAC. She had a vaginal delivery for her first, but that was a small infant born four weeks early, something around 5 1/2 lbs. Next baby held on to 41 weeks and weighed over 8 lbs. labour stalled at 8 cm for several hours before she consented to a c-section. For her next pregnancy, she decided to have a home birth, but again went to 41 weeks. Her midwife encouraged her to deliver in hospital, especially because this baby was palpating large. She refused. She found support to have people with her to deliver at home. They became concerned when she had been labouring for 12 hours without progressing to transition. They broke down and called the midwife, who came to her house to again encourage her to transfer to the hospital. She refused, and legally the midwife had to stay. The midwife called the hospital to left them know of an attempted HBAC and that she was encouraging them to come in. The hospital already had a copy of her records. Of the next two hours, there was no progress, and the midwife call a more senior midwife to see if they could convince the mother to transfer. The midwife had already gotten an IV started, and continue to discuss with her client and family that this was not looking promising. Shortly after the arrival of the second midwife the patient complained of increasing pain. On examination, there was increasing bleeding and the baby was no longer palpable in the pelvis. The midwife correctly identified a rupture and called 911. A second IV line was started and on route to the hospital, her blood was taken to be dropped of in the lab for emergent results upon arrive to hospital. The midwife called the OB on call (in house with anesthesia) to update them on the clinical scenario. Upon arrive, the patient were brought directly to the operating room for assessment. She was unstable and fetal heart rates were undetectable. An emergency c-section was performed to deliver a stillborn infant. Mom had a hysterectomy, but actually did ok. Time from rupture to delivery was only 30 minutes. I am not sure how things could have possibly gone more smoothly or faster for a homebirth transfer. I was impressed with the midwives and hospital team. They saved this woman’s life, but it was unfortunately too must time to save the baby.

Case 2:
A mom tried to have a homebirth for her first, but ended up transferring in and having a c-section. She was determined to do it “right” the next time, but decided to try in hospital after discussing options with her midwife. She needed an induction at 41+3 days. We used a cervical catheter, AROM and eventually oxytocin. She had continuous electronic fetal monitoring. Eventually she asked for an epidural. She too suddenly had increased pain. The oxytocin was stopped and mom was examined. No presenting fetal part and heavy vaginal bleeding. A second IV was started as she was transferred to the OR. She had already had a sample sent to the lab and blood was requested. An emergency c-section was performed, and the baby was in the abdominal cavity. Baby needed resuscitation, but eventually did fine without any long term consequences. Mom saved her uterus and has had a third baby by elective c-section. Time from rupture to delivery was 7 minutes. Still a long time to hold you breath, but at least the baby has a chance.

Yes, uncomplicated deliveries are exactly that – uncomplicated. But there are known complications that occur at predictable intervals. If there is a 0.5% chance of uterine rupture, most women will concern it low risk. Consider the obstetrician who works in a center with 4000 deliveries a year. If only ten percent of those are VBACs, they will likely see at least 2 ruptures a year. That is scary enough. A patient with a rupture at home is more scary. I might be able to save the mom, but by the time they identify the problem, arrange transportation and contact me, I likely won’t be able to save the baby.

Help is no just “10 minutes away”. Not if you are at home.

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2 thoughts on “10 Minutes is not enough time.

  1. Although I agree with what you are saying, I think it is really important to distinguish between hospitals with different levels of care. Level I and II hospitals do not always have the required MD staff in-house, and therefore may have timelines that are more similar to homebirth.

    1. Ocuinn, I agree. There is a big difference in a hospital that is staffed with MDs in house 24h a day. When I worked in smaller centres, I found that my threshold for intervention was much lower, because I couldn’t take the chance for things being more urgent. It takes time to call the staff in to help perform a c-section. I probably did more forceps deliveries in the smaller centres as well, sometimes the baby just needs to be delivered quickly. An interesting thing that I noticed, there is generally a different population base in the smaller centres, often more women having their second or more baby. It is amazing how much easier the second vaginal delivery generally is (although not always, I admit). One of the rural hospitals I did locums had a large Amish and Mennonite population. By the time their had their eight baby, there labours were so quick, but the time I could recognize a concern, they were fully dilated and delivering with the next push. I think if we could all start with our second baby (assuming a normal pregnancy and vaginal delivery for the first), the role of medical intervention would decline incredibly. Its the first pregnancy that is often the hardest.

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