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

What happens in a home birth emergency?

I often talk to women and their families about the pros and cons of different birthing environments. All environments have upsides and downsides and, even though the risks of hospital birth are often not mentioned, they are important to consider too. But 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. I explain that, in many situations, there’s very little that would be done in a hospital setting that midwives (and our paramedic friends) 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 chance of particular situations occurring and whether their chance is greater or lesser than average. Like many midwives, I try to strike a balanced tone. Yes, it’s important to be honest about the fact that we can never eradicate uncertainty. To make sure people understand that poor outcomes can occur in any setting. To be clear that some environments protect against such outcomes (and not always in the direction you think. Being at home has huge advantages, because a woman’s body is more likely to be working optimally.) And to understand that, when unexpected things do happen, we have the training and skills to deal with them.

I’m always open to having more data on this, 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. 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.

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)

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