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Through networking and education, Midwifery Today's mission is to return midwifery care to its rightful position in the family, to make midwifery care the norm throughout the world, and to redefine midwifery as a vital partnership with women.
Lessons from a Homebirth Practice
by John Stevenson
© 2003 Midwifery Today, Inc. All rights reserved.
[Editor's note: This article first appeared in The Birthkit Issue 39, Autumn 2003.]
I was a doctor in general practice for almost 20 years. Then, quite accidentally, I became involved in homebirths when a patient suffering agoraphobia wanted to birth her baby at home. Bookings escalated so that within a year, I had to abandon general practice.
In my homebirth practice, I got to know each expectant mother well during routine prenatal checks, and I got to know her unborn baby as well as possible through heart rate, movements and size. The only routine test I ordered was blood group and Rh type. Other tests like ultrasound scans, X-ray or extensive blood investigations were only done if I had good reason to suspect something amiss. In the last month of a woman's pregnancy, I did the checks at her home to make sure I could find my way there when the call came and also because the mother usually didn't like travelling at the end of pregnancy.
When labour begins the mother is in charge, as she should be. All her attendants are there to help her and look after her as best we can. Her every wish is our command. When baby is born, we are all quiet while the parents welcome their child, and there is a flood of love that fills the birth room.
The first thing I noticed about homebirth was the serene joy of the parents, which in those days was something I never saw in my hospital experience. The second thing I saw was that an intense bond automatically takes place between mother and baby in the first half-hour, not in the first few weeks as obstetricians maintain. This bonding is vitally important. In my opinion, it is equally as important as safety because it affects baby's longterm welfare and mother's psychological health.
Bonding also involves the father and siblings present at the birth, but the maternal bond has a much higher order of intensity. It is automatic; you don't need to help it, but you do need to protect mother from embarrassment, humiliation or separation from baby. She needs to hold baby and check her/him as soon as possible (but after the few moments it takes to recover from the stress of giving birth). To aid this bonding, I even learned to resuscitate a shocked baby without cutting the cord.
In addition to these lessons, I learned in the first three years of homebirth practice that amazing safety mechanisms are built into both mother and baby. In the vast majority, these will ensure that baby will arrive safely without intrusive help. The first mechanism I will describe is the immense oxygen reserves of a term baby. The oxygen-carrying capacity is 40 percent or more greater than ours, due to denser haemoglobin concentration. In practice, the reserve is even greater than this because baby is not as active as adults or children outside of the womb. Oxygen supply from the placenta continues until the head passes mid-pelvis; sometime after that it is reduced due to shrinkage of the uterus involving the placental bed. Most babies are still pink at birth. Lack of oxygen turns the pinkness to purple, then to blue. But all these babies still have some oxygen reserve and are likely to breathe without help. When the oxygen reserve runs dangerously low, this is called shock. The skin circulation closes down, so that baby becomes a deathly pale grey and is unconscious so there is no muscular movement, and the heart rate is down to about 80. These three observations can be made in 15 seconds, and it is urgent to get oxygen into baby's lungs. I use my own breath rather than pure oxygen; baby's lungs are designed to utilise 20 percent oxygen, so my dead-space tracheal air is exactly right. (I have not yet given any baby an infection nor burst any lungs!) Inflate baby's lungs once, then listen to the heart rate, which should immediately rise to more than 100. At this stage you can reassure the parents that baby is all right. If the heart slows again before baby takes a breath, inflate the lungs a second time. If the heart slows a third time, another inflation can be performed. In my experience, I have never had to do it more than three times—and usually only once or twice. Once baby takes a breath, it needs no more help. With each breath, its strength will increase. But patience and confidence are necessary; it may be five minutes before baby is fully pink, 10 minutes before muscle tone returns and 15 minutes before baby cries. Reassure parents and give baby to mother as soon as baby starts breathing, while staying close and monitoring. Shock is rare if you don't use drugs. You might never see a case. (I have never used Apgar scores. I prefer to describe baby's condition in terms of colour, movement and heart rate).
The next safety mechanism is baby's ability to withstand shock (extreme oxygen lack). If you or I turned blue, brain damage would set in within minutes. Baby has a brain that can withstand an amazing degree of shock. If the heart rate is down to 70 or 80, you can expect full recovery if you act promptly, but if it is down to 30 or 40, you may be in trouble. Remain calm and confident and do your best; you will be surprised at baby's rallying and recuperative ability.
I was taught that if the cord is around baby's neck, it should be pulled loose and passed over baby's head. If it is too tight to pull loose, then it should be double clamped and cut between the clamps in order to prevent the cord breaking or the placenta being pulled off the uterine wall.
I did this at first but then began to wonder if it was really necessary. I now feel sure it is not. I have not done this for 25 years now, and I have never had a broken cord nor has the placenta ever been pulled off the uterine wall by a tight cord. I have had only one case (out of 1,400) where the tight cord held baby's head close to the perineum so that baby doubled up to birth the hips and legs. But there was no problem, and the cord stopped pulsing in its own good time.
Several unusual births convinced me that baby has considerable control over labour. It seems that baby can release some type of chemical, like a hormone, through the placenta into mother's circulation to counteract the oxytocin and restrain labour. In one case, a baby had a very tangled cord (discovered after birth) and it stopped second stage completely for half an hour, presumably to give it a chance to wriggle and loosen the cord. I think it is baby's influence that reduces contractions coming every two minutes in late first stage to contractions that come every five minutes in second stage, presumably to modify the stress of moulding. Another clue is that stillbirth labour is usually intense and rapid. I feel so sure of baby's influence on labour that I assert it is quite wrong to take over and hurry it because baby might have good cause to restrain it. As someone recently said, if you induce a mother, her body is not ready to give birth. Sometimes a long first stage labour comes to a stop and mother feels sleepy. In this situation, it is essential to let her sleep and, if she wants to, take refreshment.
Early in my homebirth experience I learned that as labour progresses, mother's pelvic and perineal tissues become soft and elastic to an extraordinary degree. The reason is so obvious: How else could a woman give birth to a baby through such a narrow channel without tearing? It is a fact that some mothers do tear, but if we are patient and careful enough, the tears are few and trivial. Stitches are often unnecessary. I have often wondered, but do not know, whether the softening agent affects the whole body or just the pelvic tissues. Although the standard teaching is that a large episiotomy is essential for breeches or forceps, I don't agree, and simply never do episiotomies. With care, breeches and forceps births can be managed without a tear. Incidentally, I firmly believe that midwives should be allowed to use forceps because I feel sure that they would be more careful and gentle than male doctors usually are, and it would save a lot of hospital transfers.
Occasionally there is obstruction because baby's head doesn't enter the pelvis; maybe it is deflexed or in the occiput transverse position. One trick is to ask mum to walk with exaggerated hip movements. If there is a stairway in the house, she could do this up and down the stairs, with an attendant steadying her. Another trick is to have her lie supine, while you feel for a shoulder, then dig the fingers of both hands into the suprapubic area and lift baby away from the pelvis. Baby often takes the hint and repositions its head. This lifting manoeuvre has to be done firmly and efficiently because mum will be tired and tender at this stage of labour. Alternatively, you could get mum to kneel down with her shoulders and head on the floor so that her back is sloping down from the pelvis. Facing her feet and with one arm across her back, you can do the lifting manoeuvre more gently, aided by gravity. These tricks work so often that it is crazy not to try them, and, again, it often saves a hospital transfer. On two occasions I have seen the head descend to perineum with the next contraction after the lifting manoeuvre.
When I started attending homebirths, I checked foetal heart rate hourly in first stage and quarter-hourly in second stage. Now I might check it on arrival, then not again unless mother asks me to. I do not do vaginal examinations either, unless asked to, but I do understand that an apprentice midwife needs to learn from them. If blood pressure has been within normal limits during pregnancy, I do not measure it during labour. On rare occasions, I arrive at a house, park my gear in the corner, greet the family and check baby and find that contractions have stopped. I say to the mother, "I will go and sit in the kitchen until you call me." It is handy to have a book with you for such eventualities.
I never use suction on baby. When I started homebirths, I purchased a suction tube with a mucus trap; it is still in my bag in its original sealed wrapper, unopened. If baby is rattley or breathing is laboured, I put it into drainage posture: with one hand under the body and the other under the forehead, I slope baby's body about 45 degrees with bottom up high and extend the head slightly so that the mouth faces the floor. Aided by gravity, baby is quite good at expelling mucus and clearing the bronchial tubes. This drainage posture might have to be repeated sometimes, until breathing is quiet and easy. I think that suction is an unwarranted, intrusive assault on the defenceless baby, and I know that many mothers see it this way. I have witnessed it done in hospital, and the suction empties baby's stomach, which may be good for the obstetrician's peace of mind but is no help to baby.
Just after the birth, mother is very busy (though she mightn't look it) adoring and checking baby. For this reason, it is best to wait several minutes before asking her to tell us if she gets more contractions or a pushing urge. Meanwhile, we unobtrusively watch for bleeding.
Clamping and cutting the cord at once deprives baby of up to a cupful of its own blood, which is very wrong. When contractions begin, mother is usually reclining, so it is propitious to help with gentle cord traction, but only during a contraction. If the placenta is slow to descend, gentle wobbling traction might help. But sometimes mother might prefer to get up and squat over a dish. Normally there is no hurry to birth the placenta. It is usually delivered between 10 and 30 minutes after the birth. If it gets near the hour, it is best to get mother to squat, and with help, use uterine massage and gentle wobbling cord traction to deliver the placenta. If you wait longer than an hour it seems to become more difficult, due to regression of the cervix. The exception to waiting is, of course, excessive bleeding. An ounce or two should draw no comment, but if more is lost, I scoop it up and place it in a quart glass jug. When it gets to a pint—and only then—I advise the mother that she is losing too much blood and we should get the placenta out. A pint loss is not serious, but I take action then because it might become considerably more if delivery of the placenta is difficult, as occasionally it is in such cases. Usually bleeding stops when the placenta is delivered; sometimes there is persistent bleeding from the lower segment, needing massage of the uterus, and possibly elevation of the feet. An injection can usually be avoided and should never be given before the placenta is out. If the cord breaks with haemorrhaging, then manual removal is necessary. It is easier than you might expect, but care is needed to separate the placenta in one piece; bits left behind could cause big trouble later. It is uncomfortable for mother, so talk to her reassuringly while your hand is inside. A rare complication is concealed bleeding; with a fundal placenta which separates, a quart of blood can accumulate behind the membranes, and is an awful shock to the attendant when it starts gushing out. So it is worth checking at 10 or 15 minutes that the uterus is not expanding and softening. Palpation should never be painful; the attendant should be very aware of the mother's sensitivity.
The last birth I attended, less than a month ago as I write, was a primip aged 28 who had a perfectly normal pregnancy but came into labour two weeks early. (I will deliver a baby at home up to eight weeks early, but that baby would need hospital transfer after the mother had the first hour with it. By six weeks early, there is a possibility of staying home). Her contractions began on awakening at 6:30 and were mild all morning. In the afternoon they became stronger, and at 4:30 there was a bloody show and SROM. Pushing began at 7:30; I arrived at 7:50 (after a 100-mile drive). The head came into view about 9:00 p.m. It was well in view by 10:00 and looked very dark; I presumed it had black hair. But as it neared the perineum, I could part the hair and realized that the scalp was a deep blue-black. I became worried but said nothing (the mother later told me she knew). I used my Doptone to listen to the heart just above the pubis, for only a few seconds, as mother was stressed. It was strong and regular—slower than 140 but I judged still above 100—and the well-spaced contractions assured me that baby was in control. Sure enough, when it was born at 10:37 it was pink, except for the scalp, which was blue and deep, dark blue over the large caput, obviously due to the tourniquet effect of the vagina and pelvic tissues over the three-hour-plus second stage (which would never have been allowed in hospital). My only contribution to this woman's birthing was to twice ask her to tell us if she needed help to change position (which she didn't), to briefly check the heart about 20 minutes before the birth, and to twice use the drainage posture on baby to improve his breathing. I had the honour of delivering the 7 lb 13 oz (3 1/3 kg) baby because the father backed out at the last minute. I felt this birth was a very special and beautiful experience for me.
There is one possible catch about my teaching. Fortunately for me, almost all my clients were very strong-minded, warm-hearted, highly motivated people into healthy living; they often cross-examined me at the first interview, and financial considerations had nothing to do with their choice. This is because in Australia, people who cannot afford an obstetrician are able to use public hospital facilities at very low or no cost. Highly motivated and healthy people are easy to look after, whereas people who want homebirth because they can't afford hospital might have diet, general health or other problems needing investigation.
My homebirth experience was a steep learning curve. Among the many lessons, I learned that women need respect and helpful support from their medical adviser during labour and that such respect and support is actually a safety factor.
John Stevenson worked in various manual jobs until one day he heard a medical student describing his study course. He decided right then to become a doctor. After eight years in his homebirth practice, the College of Obstetricians contrived his de-registration, without ever speaking to him about safety or statistics. Subsequently, Dr. John has continued to attend births but has to make it clear to clients that he is not a registered doctor.
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