interesting website - GP talking about home births, experience of midwives and breastfeedng etc

[mogwai]

Stumbled across this and I think it's very interesting.

It's basically a blog written by an NHS GP.

If you scroll down his pages, there are some very interesting discussions about homebirths and breastfeeding. The arguments stirred up are worth reading, but be prepared to get addicted!

nhsblogdoc.blogspot.com

Is that a twitching eye I see there?

Speak to The Hand!

I'll bet you're still lurking though....

She's not you know!

labour can be a frightening experience for some, who can blame people for choosing to give birth in the welcoming and familiar enviroment of their own home.

Am v. much in favour of women having choice re. home births. However, I chose hospital because so many friends before me had started with intention of having home births but then had to go into hospital. Statistics are: of 7 friends who wanted first baby at home (and started off at home), 2 safely delivered at home. The other 5 had to go into hospital, where 2 ended up C-section. All babies safe and well, thankfully. The 2 who did deliver safely at home both had their second babies at home. But one of these women had to go into hospital after because of retained placenta (both times). Like Tutti Frutti, my DD would not have survived if I'd been at home, and no complications at all in pregnancy. Hope this adds something to the discussion.

interesting to see so many posts bemoaning how confusing contradictory evidence is , just imagine if you are the gp trying advice women and to be honest in the current litginous society we practise in i find it very hard not to be completely defensive and advise hospital delivery . The idea behind informed choice for patients is they look at all the fact and opinions and stats presented by the medical fraternity and then make up their mind taking responsibilty for hteir own health. so you can't moan about docs not giving out clear advice because when we do like dr crippen and say we think hospital births are safer you critise us for not being pro home births , you have to make up your own mind.

Well, I'm trying to do as you suggest Mummydoc.

And believe me, in trying, I do sympathise that it must be very difficult for a doctor who is asked their opinion. You simply don't have the information necessary to help you give that advice: mass studies don't help the individual decision.

It must also be particularly difficult when the government appears to be putting pressure on doctors to offer advice that some will find uncomfortable.

However... whilst I try to 'take responsibility for my own health' ie spending hours reading studies and practically taking a home course in statistical analysis, I am presented with extremely categoric views from one quarter that one of my potential conclusions is just wrong. Because it doesn't agree with someone else's analysis, even though I can see flaws in that analysis.

Ultimately, you're right, of course. I must make my decision and live with the consequences. I am after all adult. But I don't think you can blame patients for being confused and possibly a bit reluctant to engage in the process when some doctors are, frankly, insulting to those who don't share their views.

I agree that hospital births can lead to higher levels of intervention. I chose a hospital birth for lots of reasons but I did want to try an be as active a participant as possible. I achieved that by having a doula. For me this was an accceptable half-way house. I had the security of instant halp available if things went wrong and also a very strong advocate for me and what I wanted during the birth.

As I see it many of the problems with hospital births are that women are not prepared for the way hospitals work. This is because it is very difficult to get this information in advance but doulas who have assisted in a lot of births are experienced in this and can deal with all the stuff we don't want to when in labour. Dh was great but he too would just not have known wyat to ask for.

My doula was fantastic and although I ended up with a drip induced labour which lasted 9 hrs I had no epidural (something I wanted to avoid) and I moved around as much as I wanted to (which was quite a lot). To be frank a lot of the yoga, breathing stuff I did beforehand was useless but my doula kept me focussed and was absolutely indispensible.

I wouldn't have a birth at home as my age and other factors do put me at a higher risk and like all those mothers who claim that they don't want to give their child the mmr because of a small if not negligible risk, I too do not wish to put my baby's life in any more risk than it already is in the process of birth. The risk to my baby of a home birth may not be much greater than a hospital birth but it is nontheless greater - to me that is a no brainer.

Hi again Gizmo

"In the meantime, on the subject of informed choice, how do you suggest I deal with the fact that my GP, and a number of prominent obstetricians, seem to have no difficulty with the idea that homebirth is an appropriate choice for people like me? Presumably they have access to the same data as you yet they are drawing different conclusions? "

_

That is a perfectly fair question.

It would be easy to say arrogantly, well, they are wrong and I am right, but it is not as easy as that. It does not change my opinion.

The problem is that there is not enough data comparing home births with hospital ones. The data that there is however most definitely does NOT prove that hospital is safer. If it did, this would be easy.

The only way to find out would be to study 10,000 low risk pregancies and half/half home and hospital deliveries.

Can I say right away that I agree with the many women who say that having babies in hospital can be awful. It can. It frequently is. The midwives are understaffed. Women are left alone in labour. Some midwives are very brusque and bossy, and give women who "do not do as they are told" a very hard time. (Some midwives are lovely - but you do not know in advance if you will get one of those!)

Let me try not to be emotive, but be purely factual.

1. There are no obstetric flying squads in most of the country. Therefore, if there is a disaster, there will not be time to get mother and baby the medical care you need.

1. Can you predict which women will have disasters? Only partially. You can assign the "high" risk women to hospital, and only let the "low" risk have home births.

1. I worry about the unexpected. From the mother's point of view this is catastrophic post partum haemorrhage. Third stage of labour. Placenta comes out in pieces, the uterus does not contract down and the women bleeds. I saw two of these in hospital when I was doing obstetrics. We are talking an collapsed unconscious woman; blood spurting out like you would not beleive; anaethetists sweating (literally) as they squeeze colloid and O negative into several drips. Obstetrican trying to stop the bleeing, and in one of the two women having no alternative but to do a hysterectomy. Both women suvived. If they had been at home, they would have died. I am sure of that.

1. Prolapsed cord. That is the big one. The cord comes down. The baby does not. You may be able to push the baby back up above the cord (I have done that and sat on the trolley with my hand pushing the baby up as we were wheeled at speed to theatres for a LSCS). If cannot push the baby up, you have minutes to get the baby out or it dies.

For those reasons, I would never advocate a home birth.

There is, however, a rational counter arguement which goes like this: I accept the dangers of cord prolapse and PPH (and one or two other things) but they are very rare. I will take that risk and have the home delivery. The plus side for me is that I do not take the risk of hospital acquired infections, a succession of bad tempered midwives, and a higher risk of post natal depression. The only other plus is the fact that it is more pleasant to be at home...but that is selfish. The baby does not mind a hospital delivery!

__

I guess I am a worrier. With our four children (my wife is a doctor as well) we could not have contemplated the risk of a home delivery. If one of them had died at home of something that could have been dealt with in a hospital, we could not have lived with ourselves.

And what I believe in for me and my family, I also believe in for my patients. It would be hypocritical to do anything else.

Read the other article I did (nhsblogdoc.blogspot.com/2006/05/home-delivery-lunacy.html) and in particular look in the comments at the stuff written by Amy Teuter.

Best wishes

John

Bumping because mears is around.

at this thread. I only have a minute but Dr Crippen, so what do you say to Marjorie Tew, author of \link{http://www.amazon.com/gp/product/1853434264/104-7439193-4055118?v=glance&n=283155\Safer Childbirth?} She is a statistician, hardly Ms 'touchy-feely' - she deals in cold, hard numbers.

Dr C, have you had spent plenty of time with midwives attending normal births at home and in hospital? Because if your experience of childbirth is a brief stint in obstetrics and if what you saw were mostly problems then, well . But I don't know you and I could be wrong, please do elaborate.

And Gizmo, please, please, do a search on mn on home birth before you decide!

I think 'Dr Crippen' moniker in spectacularly bad taste actually.

DrCrippen - as a midwife working in a major teaching hospital I have to disagree with your comments regarding homebirth. There are inherent risks delivering in hospital and lets not be kidded that it is safer. Homebirth usually occurs where there is a low risk pregnancy, all is normal and labour starts off on it's own. Cord prolapse in this situation is very rare. I would advise you read 'Safer Childbirth? A critical history of maternity care'by Marjory Tew (who is a statistician). Published by Free Association Books, London.

I have seen cord prolapse at home with mum transferred in by ambulance and good outcome (not a planned homebirth BTW).

I have seen horrendous outcome of cord prolapse in hospital due to induction and mismanagement of labour.

Not meaning to be offensive, but GPs no 'bugger all' about homebirths in the main IME.

'Midwives are the comprehensive schools of obstetric care. A cheap and cheerful option for the common folk, but do not expect the “great and the good” to use them.'

Mears, I wouldn't waste my breath if I were you

Top post Mears!

Can anyone remind me why the WHO thinks it's a bad idea to have such a high rate of c/s as in this country? It's my understanding that a lot of drs choose to have hospital birth to eliminate 'risks' that Dr Crippen refers to. But isn't it also the case that in this country, the way we treat women in hospital (understaffing etc etc) results in many of the c/s that WHO says we should be avoiding. Agree that c/s likely to result in live birth, live mother, but how will we avoid the unnecessary ones if we all end up in hospital...?

I've just browsed his blog on home birth and have decided I spectacularly disagree but can't be arsed to argue about it. I had my 2 home births and very nice they were too.

Thanks for the info, folks. I have been researching this for a while and I shall certainly check out Marjorie Tew's site.

Thanks also, Dr C, for your further comments. I do understand the risks, for both me and the child: the risk of PPH is not to be discounted, but personally is not for me as significant a dilemma as imposing the extra risk on the baby.

On balance, my current position is that I am prepared to take the extra risk, because in my case I do believe it to be really small - I am literally 10 minutes (probably less if blue lighted) from the hospital and at present am a very healthy, normal second pregnancy. I will probably be paying for a private scan late in the pregnancy to check positioning and, if possible, rule out placenta previa etc.

I am more concerned about the very real probability that labouring in a stressful (hospital) environment could stall my progress and lead to interventions, which, while necessary for a hospital labour, would not have been necessary at home. Interventions which themselves pose some risk to the baby. Not to mention the near certainty that labouring in my local hospital will put me at higher risk of a repeated dose of PND and put a major barrier in the way of establishing successful breastfeeding, as it did the last time.

Mears, nice to hear your point of view as well. You don't fancy a holiday in Cambridge do you? About the end of September? It's very nice down here at that time of year

gizmo - not sure which side of camb u r, we are east team and my mw sent to for a 37 wk scan (i had it a couple of days early as ds1 was bang on 37wks) just to double check positioning - apparently new policy for rosie area teams with new consultant (this was jan 06). friend is 35wks with 3rd and wanting 2nd home birth - i'll ask her if mw suggesting scan for her. good luck with the birth. sorry lack of caps - am feeding.

Hi Catherine

Oooh, that's interesting. I'll ask my midwife. She's part of team attached to my doctor's surgery - you know I really need to get a grip on how midwifery services are structured in Cambridge, I'm getting very confused - and she hasn't mentioned any late scan yet, although we have discussed homebirth at every visit so far.

Rest assured, the next time I see her, she's going to be in for a lot of detailed questioning!

Sorry Gizmo didn't mean to sound quite so stroppy, I to feel i need a degree in stats some times... I am on the side of DrC but am biased by the fact both my pregnancies were "perfectly normal healthy pregnancies" and both times I and the babies would have died if not for being in hospital. First time round I was helicoptered to hosptial ( was living in oz at time) it took 10 mins but in that time I delivered a spetacularly tiny baby who had to be resussed by the flight crew ( not docs ) with my non medic husband having to assist, and i was haemorraghing as Drc describes...it took 5 years to feel we could try again and then I had a placental abruption in the hospital thank goodness, but in the rush to theatre my husband was told the baby would die and then when she was delivered safetly that I only had a 50/50 chance...now imagine your husband in those 2 senarios but at home ....I know it all sounds rather amateur dramatic ish but this does happen....but i do agree there are just as many good home birth stories around...good luck with yours.

Wow!

You must be made of tough stuff, Mummydoc. Trust you and yours made a full recovery.

Well, my DH would probably be terribly British and repressed about it all and just do what the midwives/paramedics tell him to do, before having a nice cup of tea to steady his nerves.

Just for interest's sake (and I appreciate you probably weren't in a position to clock watch at the time!) do you have any idea how long it took from the moment the abruption was diagnosed to operating table?

gizmo, my first baby was still born as a result of placental abruption..however, the abruption happened 3 months before he was due, so i wasnt in hospital anyway.
the hospital assured me that placental abruption was rare.