Thursday, July 18, 2013

transferring to hospital

I am reflecting on a few recent situations in which I have made the 'call' that we need to go to hospital.  In my mind there has been no doubt. 

It's fairly clear to me, that when a woman and baby are strong and well, home is ideal.

But ...

when the mother is not well, physically or emotionally, it's not good at home.  Even a mother who has no continuous support in her home - should she be left alone a mere 3 or 4 hours after the birth, when I pack up my gear and go home?

Midwives have a set of guidelines, published by our College (ACM), to set down systems for decision-making about consultation and referral (see previous post).  They do not actually address homebirth, but are a list of the conditions in which a midwife would expect to work collaboratively with an obstetrician or an obstetric unit in providing maternity care - meaning that the woman is in hospital for the birth and any other continuous acute care. 

The ACM Guidelines list hundreds of 'indications' for consultation (with) and referral (to) specialist obstetric or newborn or other medical services.

Rather than focus on 'indications' or medical/obstetric conditions, I prefer to turn the coin to the other side, and ask the questions:
"Is the mother well?",
"Is the baby well?"

If the answer to each is "yes", there is no reason to intervene prior to the onset of labour, so we wait for labour to establish spontaneously.  This is the only woman who, in my opinion, is fit to proceed with home birth. 

If the answer to either is "no", the hospital probably has real advantages.  Homebirth requires strength, and intentionality about wellness.

Many women who plan homebirth have serious concerns about what might happen in hospital.  They know about continuous monitoring in labour, and scheduled vaginal exams, and narcotic analgesia being offered at the time when they are vulnerable to suggestion.  They know about protocols for normal progress; about high rates of inductions and augmentations, and all-time high rates of caesarean births.  They know about babies's cords being cut, and babies being separated from their mothers. 


When I say to a woman, who has gone to considerable expense and trouble to plan homebirth, that I want her to go to hospital to give birth to her baby, I know that she may experience difficulties with the system.  Hospitals are not committed to protecting, promoting and supporting natural physiological processes in birthing.  Hospitals are concerned about patient/staff ratios, availability of emergency services, and a hundred and one issues that make hospitals relatively safe places for the majority of patients and staff and visitors.

Transferring care from planned homebirth with a humble midwife, to a hospital with 'teams' of midwives, nurses, and a heirachy of doctors from the new Resident to the obstetric Consultant, can be a daunting process.  I will recommend that transfer if I believe the woman's and her baby's needs are likely to be better served in hospital than at home.   The best is all that I want.

The person who owns the natural processes in birthing (and nurturing of the baby) is the mother.  She is the only one who can give permission for a staff member, or a privately employed midwife, to take her pulse, or listen to her baby's heart beat, or assess her cervical dilation and the station of her baby's presenting part.  The mother owns her body, regardless of where she is intending to give birth.

This ongoing process of decision-making is guided in my practice, not by a 84-page spiral bound guidance manual, but by the two simple questions:
"Is the mother well?",
"Is the baby well?"

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