how to insist on a home birth??

[stella1w]

I was all set for a home birth until a 28 week scan (due to fall in the street) showed the baby was 95 percentile for abdomen circumference. Cue doctor muttering about shoulder dystocia and diabetes (though they refused to do the GTT at the time and later on said it was too late in the pg for it).
I am now 34 weeks and feel like I am being fobbed off by the midwives on the home birth issue eg. they are delaying me booking a home visit which is the first step eg at my booking appointment they ticked hospital instead of home birth despite my insistence.
A booklet by RCOG says 50 per cent of shoulder dystocia is with babies above 9.5 kg and 50 per cent below and that late scans are inaccurate (which is clear from various threads on this board).
However, it's very unclear to me if I have the right to insist on a home birth and if so, the best way to do it. Seems to me that each hospital has different policies and protocols (which also seems strange to me) and so much depends on the midwife you get. So far I have seen a different midwife every time and they kick off by not reading my notes and asking me how many weeks I am. Which doesn't inspire confidence. My care is also disjointed, with all antenatal being done at one clinic with totally separate midwives for delivery.
It's now too late for me to change hospital and I am furious they are stringing me along like this.
Advice on how to approach them would be great, particularly if anyway has any national policy/evidence I could use to bolster my wishes..
Thanks

btw, my first child was born after six hours, start to finish. Got to the hospital 9cm dilated and delivered her two hours later with minimal pushing and no pain relief. Midwife has said 2nd one should take three hours, so it could well be I couldn't get to the hospital in time and am wondering if I should just stay I intend to stay at home and they will just have to deal with it..

have a look on www.homebirth.org.uk/

essentially the decision IS yours.... it is up to YOU where you have your baby, and the midwifes etc can only advise.

Not only is the place of birth your choice, so is EVERYthing else.... if you dont want to lie on a bed you dont have to....
If you dont want an internal exam, they cant make you.... same goes for every element of everything they do....

as far as i understand they can only "not let" you do / use stuff thats theirs, for example NOT LET you use the birthing pool in the hospital.... and "refuse to administer" induction at home.

I think you also HAVE to be 37 weeks.... and before term midwives can refuse to attend a home birth as its not what they are trained to do

The homebirth website linked to is very informative. Other sources you might find useful include:

homebirthUK mailgroup
AIMS

It is not too late for you to change hospital if you want to do so. It might be awkward and cause more paperwork for the MW's, but if you no longer have confidence in the team with the hospital where you are booked and would feel safer and better supported if you changed then go for it.

The legal position is that the only way you can forced to attend hospital whilst in labour (or to accept any intervention) is if you are sectioned under the Mental Health Act. As a mentally competent adult the hospital do not have the authority to "allow" or "let" you do anything - although they often use language that makes it appear that they think they can.

Most PCT's have a policy of only supporting a homebirth between 37 and 42 weeks - some restrict that further (say 38-41). The logic behind that as I understand it is that anywhere between 37 and 42 weeks is considered "term" - a baby that is born pre-term is more likely to need a level of support that cannot be/is not provided in a home environment. Once you get into post-dates territory there are also issues that become more common that could be dealt with more effectively in hospital. BUT even then - you cannot be forced into hospital. You are not their employee. You are not bound by their protocols or policies. They can advise. You are not bound to accept that advice. That said, the further outside of the norm you take the parameters of your HB the less comfortable and confident the MWs will be. IMO I'm not sure that's fair on anyone involved.

Whether or not MWs have a legal obligation to support you wherever and whenever is a bit of a gray issue. They have a duty of care - if you call and say you are in labour and ask for help they have a duty of care to supply that help. But the labour ward might choose to supply that help by sending an ambulance. Or the labour ward might, genuinely, have no MWs to send so have no choice but to send an ambulance. You are under no legal obligation to get into that ambulance, of course, and anecdote says that women (or their birth partners) who are prepared to repeat "I am in labour. Please send me a MW. I will not come into hospital. I will not allow paramedics into my home" or words to that effect do get a MW.

re SD... Yes, 50% of cases happen in babies that aren't macrocosmic (I think you might have a typo - DD was over 4kg and she was big enough. I REALLY don't want a 9kg newborn!). However, less than 50% of babies will be macrocosmic, so SD will be more frequent in larger babies. That still doesn't mean its common - and IIRC the NICE guidelines seemed to say that it couldn't be predicted accurately enough to justify changing care plans to try and avoid SD (assuming no previous occurrence). I'm not trying to deny that SD is a genuine obstetric emergency and there are things that can only be done in hospital (both in terms of emergency birth, although rarely, and in terms of supporting the baby afterwards if required) - but that's very different to saying that nothing can be done at home. SD at home is not destined to end in a bad outcome any more than SD in hospital is guaranteed to have a happy ending.

Has the Dr managed to explain why a large abdomen (which is squishy) makes shoulder dystocia (problem with bony things) more likely? Have any of the other measurements on your baby been large?

Where to go from here - first off decide whether to change hospitals or stay put. Have you contacted the hospital you'd like to change to?

Assuming you're still not being supported in your plans for a HB, write to the Head of Midwifery stating that you have been advised of the risks related to SD but that you have also been advised that, given the short duration of your first labour, this labour may be too short to allow you to get to hospital safely. As such, you have decided that a homebirth is the best option for you to birth this baby safely and you expect to be supported in you plans for the birth of this baby in your home. You might want to ask her to inform her MWs that this is your decision such that your antenatal appointments can cover any issues relating to HB that need to be discussed in the next few weeks. As you are well into the third trimester you anticipate her reply within however many days you think reasonable. Send it by a method such that you will have proof its arrived. If you join the mail group or talk to AIMS I'm sure someone will be happy to supply you with a more detailed template to use :).

So basically, yes - just tell them you intend to stay at home and let them deal with it :o

I had the same issue as you before DS was born. I was lucky enough to have a couple of experienced HB midwives supporting me who were able to provide a wealth of research papers and advice about their own expertise for me to come to my own conclusion that i) the consultant hadn't made enough of a case for increased risk of shoulder dystocia because of the size of my baby ii) the likelihood of a better outcome was not significantly greater if in hospital and iii) the ultrasound results were notoriously unreliable. My (only) DS was born at home without any complications at 9lb 2 oz.

Ultimately, it is your choice and only you can weigh up the pros and cons in your particular situation.

In terms of preparing, agree with Tangle's excellent advice on your rights and how to insist on them. But, if you can afford it, perhaps also consider an independent midwife who will support your choices and fight the battle for you?

PS. DS measured 99th percentile. Turned out he wasn't particularly big (9'2" yes, but not a true whopper), but he was 58cm long - so tall and very skinny just like his dad and grandfather. The ultrasound just picked up on his squashed up abdomen.

Excellent post Tangle.

Agree that (especially in London), I think its much more likely that an ambulance would be sent, as there genuinely are no spare midwives floating around that are either competent in supporting someone labouring and delivering at home, or that are confident enough to do so, and its probably unfair to expect that a midwife with little current delivery experience should attend you. Its unfair on you as well as unfair on her.

However, just because the ac measurement is on the big side at a scan 6 weeks ago, I dont see this as a particular risk factor for a homebirth - to get an estimated fetal weight, they need a lot of other measurements also and Id like to see them to put the ac in context. I think it would be worthwhile doing another scan in a couple of weeks and also its never too late to do a GTT (better to catch it early but better late than never).

I had a similar situation recently with one of my homebirth women who had a big baby previously with a very difficult labour so a bit of reluctance from the medical staff this time. I had her scanned at 38 weeks (just to make sure it wasnt 5kg+) and the scan and by palpation suggested that baby was about the same as last time, so we changed consultant to a more supportive one, discussed the risks and agreed to transfer in if things were going very slow or anything outside the norm (basically a low threshold for transfer). Everything went beautifully and we had a fast and easy homebirth of a 91/2lb baby.

It may be a good idea to change to a more supportive hospital as Tangle suggests to get better midwifery support if this is an option, or go and see the person in charge of the team that do homebirths and discuss it with her.

btw - which hospital are you with?

Thanks all for the good advice

I am booked in at the PRUH in Orpington. I haven't been at all impressed with their antenatal care, but was sticking with them because obviously they are the only hospital in whose catchment area I would be for a home birth. I have heard, for example, that other hospitals would in theory be happy to give me a home birth, but I would live too far away.

I have tried to switch to UCH because they are near my work, but they won't take me at this stage because they are already full up for my due date. As for switching to another hospital it is so hard because apart from the paper work, it is hard to work out how supportive they might be of certain issues.

There's a real difficulty in getting the midwives (and I see a different one each time and it's chaotic) to focus on the actual birth. They just seem to want to do urine and bp. They are being passive aggressively vague about doing the home visit and I have been told no decision about place of birth would be made until the 36 week which would give next to no time to either switch hospitals or even get stuff ready at home for a home birth.

However will follow the advice above..

I realise they can't force me into hospital but it does look like they could refuse to come out to me and tbh, it's stressful enough arguing with them at this stage, let alone while in active labour!!

Not wanting to book a HB till 36 weeks does seem to be quite common. I can see the MW's point of view - doing the paperwork takes time, and any number of issues may crop up that would make them advise against a HB at that point so the potential for wasting time they don't have is significant - but it really doesn't help the women like you (and I had similar problems) who are sure of what they want and would like to get it organised.

Incidentally, a HB visit isn't essential before you have a HB. It may be policy - and its kind of sensible, as it gives the MW's a chance to make sure they can find the house and that you have electricity and running water, etc - but we've been through that one already! Similarly, they don't have to have delivered the birth pack before you go into labour. It might slow them down slightly if they have to come to you via the hospital, but it doesn't mean that YOU have to go to hospital.

(in the end we got so fed up of our CMW's attitude to HB that we booked IMs. We didn't do it till 36 weeks, but it was the best decision we ever made and the best money we ever spent. We suddenly felt that the MW's were there to provide us the information and help us to make the best decision for us - and that they'd then give us their full support. You can find IMs here. Its worth talking to them even if you're not sure you could afford it - many are very flexible on payment terms and/or will consider an exchange of services. IIRC one of mine was getting her kitchen done, decorating done, and had her freezer stocked by various clients!)

Have a look at these phrases by Mary Cronk. I don't think I ever used them in an ante-natal setting, but knowing that I could use them helped me to remember that it was MY decision.

re. "will a MW come out in labour", that ones tricky. As Mintpurple says, if there are no experienced MWs then there are no experienced MWs. But equally, there are some experienced MWs who are designated to attend HBs (albeit not enough) - so there's still a reasonable chance that you'd go into labour, call up and get sent a MW without a problem at all, even if you do nothing. What you decide to do our get your birth partner to do if its not that straightforward is up to you.

Talk to AIMS and/or join the mailgroup and put your position in writing to the HoM. It really is worth doing - I've read a lot of stories on the mailgroup where women have done exactly that and, suddenly, nearly all the resistance they've been facing has vanished. Its amazing (and quite sad) how putting the exact same words you've been saying for weeks on a piece of paper can make them be heard. There are some very experienced ladies and MWs on the mailgroup who've been through this and/or guided their clients through this process and who'd be very happy to support you to do the same :)

Just an idea. I have heard on one of these HB forums of a woman who found an IM who was also an agency MW for the mother's hospital and when on the day the hospital told the mum that no midwives are available to attend her HB, she basically pointed out this IM and they had to book her through an agency.

Don't know if this is how it can work, but maybe worth exploring.

As far as I know, sending an ambulance for a woman instead of a midwife if there are not 'spare' midwives is incorrect. The hospital has been given x weeks notification by the woman that she intends to have a home birth therefore they have time to plan their rota for the labour unit and the home birth team. They can also call in bank midwives to cover shortages due to illness or unexpectedly busy. Short of that, sending an ambulance is denying the woman midwifery care just like it would be denying a woman care if she walked into a unit and she was told that they are full.

It is no different than telling a woman that she must come to the unit because they are busy and can't spare a midwife.

Am I getting this wrong?

stella, you come across as mindblowingly selfish and ignorant, as do some of the other posters on this thread. You confirm all the stereotypes of women who want homebirths - utterly selfish and more interested in your own experience than your unborn child's safety. This is not about you, it's about your baby's safe delivery into the world.

"you just tell them you intend to stay at home and let them deal with it".
Actually unbelievable.You have been told that you are at risk of shoulder dystocia. Do you understand how serious that can be?It can leave your child with permanent damage! Maybe the doctor was 'muttering' about shoulder dystocia because he knows that too, given that he is the professional here - unlike the posters here!

Why on earth would you play russian roulette with your child's health like this?
If anything goes wrong you will have noone to blame but yourself. I hope you think it's worth it.

Someone mentioned mental competence - I genuinely wonder with posts like this.

I'm not looking for a debate and am not interested in your replies - I'll be hiding this thread. I find it so appalling and upsetting when I see threads like this with mothers who seem to care only that they get the birth THEY want and fuck everything else. Honestly, women like you make me so angry. Think of your baby for God's sake.

I am not normally a vitriolic poster and I know you don't care about my reply, but I can't not post.

Do you know anything about how homebirth works at all? Are you aware, for example, that HB midwives carry resuscitation equipment for the baby if necessary or of the existence of the Gaskin Maneuvre (sp?) in incidences of shoulder dystocia? Or that transfers to hospital occur at the first indication of a problem?

A healthy mum and healthy baby is the best outcome, but you, camillabelle, seem to think of a pregnant woman as a womb on legs. Who cares if she is terrified and browbeaten in an unfamiliar environment as long as the baby is ok? And if she dares to feel stress, of course that's her fault, isn't it? Oh, and if she dies, that is also ok, isn't it as long as the baby is fine?In your view, she counts for nothing.

But maybe, just maybe, a woman who feels she has some control over where and how she gives birth will be less stressed and have an easier birth which will help her heal faster and in turn allow a better bond with her baby. And that is surely good for the baby.

A woman's birth experience is very important to her mental health and to say that it is selfish for her to care about how she feels, I find to be misogynistic in the extreme. It is to say that she counts for nothing except as an incubator.

sorry to hijack stella. You go for your HB. Don't let anyone put you off.

also meant to add: the resus equipment is in case the baby needs it which most don't.

well said mumwithdice

and the fact that (low risk) mums and babys are less likely to die if they have a home birth, than if the same low risk mothers choose to go to hospital!

check out my story on www.homebirth.org.uk
under gestational diabetes and large babies

which one is yours?
can we have a link please

Isn't it the case that midwives at home don't have as much or as sophisticated resuscitation equipment as a hospital would? And that you can't know in inadvance whether your baby will need the more sophisticated equipment or not? Isn't there evidence that the gaskin manouevre statistically makes no difference compared to other positions to releasing shoulder dystocia? And doesn't the first indication of a problem with shoulder dystocia occur at a stage of labour where you're very unlikely to have time to get to hospital for full resuscitation if needed?

FWIW I support women's right to give birth where and how they choose. We have a right to autonomy over our own bodies. And of course mental health matters. But shouldn't our decisions be based on the best medical advice for our specific situation? The OP's specific risk of SD isn't something anyone on this thread is qualified to judge because we don't know all the facts. Isn's it irresponsibile then to advise her one way or another? However well intentioned we might be, no random poster on the internet will ever have to answer for a bad outcome. How likely it is or isn't to happen is one question, but as I understand it the bottom line is that if you do experience a shoulder dystocia, experiencing it in hospital gives both you and your baby a better chance of surviving healthy. No amount of positive birth anecdotes, feelings of control or relaxation can change that.

Im really surprised at how this thread has taken a turn for the worse....

From what you have posted so far, there is no real reason to deny you a home birth at this time, and like I said in an earlier post, I would want to do a palpation and a rescan (I know they're not that accurate but they will give you a very rough idea of the babys weight) at about 37 weeks and make a decision at that time. You may find a more supportive consultant, certainly worth asking in clinic, and you had a very normal last birth to support your request.

Every decision you take in pregnancy has, to some extent, to be risk assessed by yourself and by the hospital staff. Shoulder dystocia is a definite risk, as are many other things in labour and the outcomes are not always good, at home or in hospital, but you have to consider whether having better resus equipment in hospital for baby and more staff outweighs the benefits of birthing at home. You have to be prepared to accept the consequences of what you are doing and that basically is the crux of getting informed consent.

For all my patients who want a home birth, I will talk through the risks and benefits of home birth versus hospital birth, so that there is no doubt in their minds that having a baby anywhere carries a risk (as does crossing the road, or having a bath - but subconciously before every action, you have risk assessed it and decided to go for it). I discuss in detail what we as midwives will do or suggest at a HB for each situation and document this, and the woman and her husband have to agree that they are happy to continue with the home birth, and if they dont like my suggestion, they are perfectly free to make their own decision about their care. For example - if there is meconium in the waters when they break and we have time to transfer in, then thats what Id like to do. If the woman refuses then so be it, I wont be happy about it and will try to persuade her to go but ultimately, I will support her in what she wants and do my best to achieve a good outcome. And I will document this which covers me in my duty of care.

If you have a big baby, then you have an increased chance of a shoulder dystocia, but that chance is still fairly small, and as midwives we are all trained to deal with it - incidentally we use the McRoberts manoeuvre, not the Gaskin - but its ultimately your decision to risk assess the situation and make a decision that you are comfortable with. There are no guarantees that baby will be ok at home any more than there are in hospital, and if there is any sign of slow progress or anything to suggest that the baby may be likely to have a SD, then it would be reasonable to transfer in.

What Im trying to say in a rather rambling way is that the choice is yours - if you feel happy and comfortable in your decision then go for it. Get a more supportive consultant and tell them your plans and ask to be booked for a homebirth. Any negativity or resistance which you feel is unwarranted, speak to the midwife in charge of the homebirth team or usually a call to the head of midwifery works wonders. Good luck:)

www.homebirth.org.uk/

not sure if that takes you straight to my story though - it is on there

camilla

OP I had the same experience with the PRUH. The midwives and consultants seems to pick up on the most minor things and decide that's it, no HB. being a first time mum and not being able to cope was the highlight of the supportive experience I got from them (not).

In the end I booked an independent midwife and had DS at home. U fortunately I ended up losing blood - but was fine, need stitches but no transfusion. However on arrival at hospital, they ignored my I'M and decided DS had a chest infection despite agpar scores of 10 and he was given antibiotics. Which he didn't need so we were kept in for three nights unnecessarily. One of the midwives on duty made a pointed remark about the number of newborns who had been taken to special care by a particular paediatrician on that night for "possible chest infections". I was so angry that babies who really needed those beds could have been denied a space.

Anyway, you should give birth where you feel most comfortable. Tell them you're having a homebirth unless they can give you medical evidence as to why not (it's worth digging out the intra-partum NICE guidelines via google)

camillabelle I'm totally with you

To quote a letter from a retired (female) GP, "the only safe homebirth is one with hindsight"

I love the notion that all those demanding home births are so happy to be taking up lots of resources ie lots of midwives which may put at risk babies born in hospitals.

Don't need my morning coffee now I'm so steamed up.

And I don't give a flying fuck if I'm flamed now. It's all about the baby.

"it's all about the baby"

Please explain to me why so many women en up with c-sections? You think that 1 out of 4 women really need one? Or forceps? Or to be cut? Something is seriously wrong with the way we treat child birth in the western world. It's not a bloody illness.

Mums should be given the right to give birth somewhere that is comfortable, relaxing and where they feel safe. Unfortunately most hospitals with their understaffed wards and MRSA, bright lights and factory farm approach just don't cut it. So people choose to do it at home, because if they are low risk, then it is better. For mother and baby. Until health care professionals recognise the childbirth is not to be treated in the same way as a disease by looking at it is a negative event to be "overcome" then people will want to do it at home.

how does having my hb tie up the resources of "lots of midwives" and put babies in hospital at risk? I'll be in labour- I'll need mws there whether it is hospital or home! And my mw has said that I will be safer at home- I had a very rapid labour last time and they would prefer if I was at home, with the correct equipment laid out ready to be grabbed the minute the mw is through the door rather than risk him being born in transit with no support or equipment available.

I don't believe that anyone having a planned hb enters into it unaware that there may be risks, as others have said it is a case of weighing up those risks and deciding on the appropriate course of action for you and your baby. Sometimes that may differ to the course of action that others may take- everyone has there own perception of risk based on their own experiences and fears. Even medical professionals can come to different conclusions based on the same evidence.