How midwives make a difference when there’s an emergency at home…

When I’m talking to women and their families about the pros and cons of different birthing environments (and yes, hospitals do have downsides and I discuss those as well), one of the questions I’m often asked is what happens if there is an emergency during a home birth.

My response usually includes describing (and, on occasion, giving interested dads-to-be a tour of) the kind of kit that home birth midwives carry in the boot of their car, and explaining that, in many situations, there’s very little that would be done in the first few minutes of an emergency scenario in a hospital setting that midwives (and, later, our friends the paramedics) can’t do at home or in the back of an ambulance on the way to hospital while the hospital staff are getting ready for our arrival.  I also talk families through the evidence on these issues, looking at the overall statistics and how this relates to their situation.  Like many midwives, I try to strike a balanced tone between being honest about the fact that we can never eradicate uncertainty and the possibility of poor outcomes in any setting, and reassuring families that such events are really unlikely and, when they do happen, we have the training and skills to deal with them.

I’m always open to having more data on these kinds of areas though, so I quite literally pounced on the latest publication from a Dutch project which has been researching homebirth emergencies.  This particular chapter describes a prospective cohort study of ambulance reports and medical charts of women who experienced a postpartum haemorrhage (PPH) after giving birth at home with a midwife.

7221229092_472b027941Here are a few of the key details:

  • “During the study period, 98 cases of PPH in primary care were reported, 72 of these occurred at home (73.5%). Of these, eighteen cases (18/72, 25%) were excluded due to incomplete documentation.”  (Stolp et al 2015)
  • “The median age was 31 years, similar to the average age of women who gave birth in the Netherlands in 2010. The parity of women in our sample (48.4% was nullipara) was comparable to the parity of the Dutch population of women that gave birth in 2010 (48.5% nullipara).” (Stolp et al 2015)
  • “The primary cause of PPH was uterine atony in 35/54 (64.8%) of cases, retained placenta in 15/54 (27.8%), genital tract trauma in three (5.6%), and incomplete placenta in one (1.9%).”  (Stolp et al 2015)
  • “Various measures were taken by the attending midwife in order to manage PPH. All but one woman (98.1%) received uterotonics. The midwife reported “genital tract trauma” as the cause of the PPH. Bladder catheterisation was performed in more than three quarters and uterine massage in 72%. Intravenous access was established in all women; in 33.3% by the midwife prior to ambulance arrival, and in 66.7% by the ambulance paramedics. Blood loss prior to ambulance transfer, as noted by the midwife or ambulance paramedics, ranged from 400 to 2000 mL (median 1000 mL).” (Stolp et al 2015)

I have quoted those bits because I think they’ll be of particular interest to many of the midwives and birth folk who read this blog, but my real reason for writing about this study is the overall finding that, even though half of the women had blood transfusions and two underwent procedures to stop their bleeding, all of the women fully recovered.  Furthermore, even when there was a slight delay in getting women to the hospital in the 45 minutes that is seen as optimal, the outcomes weren’t any worse.  Almost certainly, as the project author Marrit Smit has discussed here and in other papers relating to this body of work, thanks to the combination of a woman who was well suited to a home birth, a skilled midwife and a good ambulance service.

 

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Stolp I, Smit M, Luxemberg S et al (2015).  Ambulance Transfer in Case of Postpartum Hemorrhage after Birth in Primary Midwifery Care in The Netherlands: A Prospective Cohort Study.  Birth: Issues in Perinatal Care.  Online ahead of print. DOI: 10.1111/birt.12171
photo credits: Holland via photopin (license) and Katholikentag_6994 via photopin (license)

2 comments for “How midwives make a difference when there’s an emergency at home…

  1. Via
    July 27, 2015 at 11:17 am

    One point in the conclusion of the study makes me wonder if it can be relevant to the UK or if it is limited to the Netherlands. It is this: “…well-organized midwifery, and ambulance care in The Netherlands are likely to contribute to these findings.”.

  2. Comadrona Smith
    August 10, 2015 at 12:23 pm

    These findings would be similar in Australia, I’d guess (at least in urban areas). Everything described here I have personally done and had the same (good) result. Even though our paramedic response can be a little patchy at times, the midwives’ preparedness and skill has largely nipped the problem in the bud, or at least controlled it until hospital staff could take over.

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