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Allana Hearn

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Is it safe? Home birthing POLICY Antenatally:
- any serious medical condition
- cardiac or renal disease with failure
- multiple pregnancy
- proteinuric pre-eclampsia or eclampsia

At the onset of labor:
- active genital herpes
- pre-term labor prior to 37 weeks of pregnancy
- breech or other abnormal presentation
- severe hypertension

After the onset of labor:
- temperature over 38 degrees Celsius on more than one occasion
- prolapsed cord
- hemorrhage unresponsive to therapy.

Postpartum - maternal:
- haemorrhage unresponsive to therapy

Postpartum – newborn:
- Apgar score lower than 7 at 10 minutes
- suspected seizure activity CMBC Clinical Conditions Requiring Hospital Delivery Eligibility:
(1) screening for clinical risk factors
(2) determining whether other conditions for safe home birth can be met
Conditions Required:
- planned
- attended midwife and second attendant
- necessary equipment
- midwife maintains relationship with backup physicians
- an alternative emergency plan College of Midwives of BC continues…. Medical Services Plan of BC began covering Midwife care in 1998.
- “CMBC endeavors to unite practitioners (midwives, physicians, nurses, hospital staff and ambulance personnel) with the common goal: that home birth be made as safe as possible for mothers and babies in B.C.”
“Throughout pregnancy and childbirth, midwives have the duty to fully inform the women in their care about the safety, efficacy, risks and benefits of care options and to support women in making decisions about their care, including their choice of birth place.”
College of Midwives of British Columbia, 2010 The College of Midwives of British Columbia (CMBC) the College declared their support of home births.
- Declares a women’s right to personal autonomy
- Physicians ensure an informed decision is made.
- Educate on the benefits and potential adverse outcomes and consideration of and emergency plan.
College of Physicians and Surgeons of British Columbia, 2009 College of Physicians and Surgeons of British Columbia A 1986 report from the World Health Organization reported
“Home is the most appropriate birth setting for most childbearing women. Women (and their attendants) choosing this option must be provided with necessary diagnostic, consultative, emergency and other services as required, regardless of place of birth”
World Health Organization, 1986 World Health Organization References Better evidence
Most studies are cohort or observational studies
Women self-select their birthing location. Healthier moms may choose to birth at home.
Many studies do not use "intention to treat"
The Cochrane Review “Planned hospital birth versus planned home birth” from Sept 2012 identified only one RCT study which met the inclusion criteria What additional information might be needed?
Perineal trauma*
In particular, less 3 or 4 degree perineal tearing
Incidence of blood loss >1000mL
Postpartum hemorrhage
Intrapartum transfers of care from midwives to other clinicians Decreased adverse
maternal outcomes
Induction or augmentation of labour
Use of pharmaceutical pain relief
Operative vaginal delivery
Electronic fetal heart monitoring
Cesarean birth Decreased
Intrapartum Interventions The studies show that planned home births with a RM have either comparable or lower rates of perinatal mortality.
Among unplanned home deliveries neonatal mortality increases almost 100 fold.
Mortality rate increaseswhen birth attendants are not integrated into the health care system or when higher risk women are included.
Location and midwife. Perinatal mortality rate decreases with the use of a midwife in the hospital as well as in the home. Perinatal Mortality

“Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal interventions” Janssen, 2009 What do we know? LITERATURE
Meconium staining/aspiration
Assisted ventilation and oxygen therapy beyond 24 hours
Premature births
Low birthweight
NICU admission
Birth injury

Greater rates of breastfeeding at week 1 and week 6 Decreased adverse
neonatal outcomes Late First stage or Second stage of labour
  Provide assistance to the midwife
Provide support to the woman
  Check layout of supplies to ensure accessibility of drugs and instruments
  Auscultate, record and report the foetal heart rate to the midwife
  Check, record and report maternal blood pressure and pulse to the midwife
  Document in the health care record at the direction of the midwife
  Provide assistance to the midwife
  Ensure warmth and safety of the newborn
  Check, record and report the condition of the newborn to the midwife
  Assess Apgar scores and report them to the midwife
  Document in the health care record at the direction of the midwife
  Provide assistance to the midwife
  Provide support and assistance to the woman
  Check, record and report maternal blood pressure, pulse, fundus and lochia to the midwife
  Document in the health care record at the direction of the midwife
Emergency Situation
  Phone Emergency Medical Services
  Assist with neonatal resuscitation
  Assist midwife in setting up intravenous/drug therapy for postpartum haemorrhage
  Check maternal blood pressure and pulse
  Assist with CPR
  Assist in preparation for transport
  Document in the health care record at the direction of the midwife NURSING
IMPLICATIONS Background & Rationale Home Birth Background Decline of Home Births in Canada
(1900's - 1950's) Should women have the right to decide who will attend their birth regardless if they are a medical professional or not? Home births were routine from the begining of humankind up until about 100 years ago.
Attendees to home births, generally women and midwives, started to change in the 1600’s with increasingly scientific medicine and invention -> Decline in home births across Canada was influenced by many factors including:
Centralization of medical knowledge in faculties of medicine and male run hospitals.
Superiority of physician knowledge and skill.
Decreased physician respect for female intellectual ability.
Failure of midwives to organize and lobby for professional status.
Women’s increasing demand for physician services. Rationale for Inquiry *As the number of physician attended births increased, so did the number of hospital births.

*1912 Medical Council of Canada formed and midwifery practice was eliminated in most locations.
Demand for home births is on the rise (eg. In the US home births increased 29% from 2004 to 2009).
Home birth is increasingly covered in the media and discussed throughout our social networks - is the information accurate and scientific?
We have integrated midwifery into our health system - are there policies in place to ensure safety, are they sufficient?
As nurses we should be able to direct our patients to reliable data in order to make informed decisions about their birth plans and care. First be educated yourself!
What is the current research/evidence saying
Assist families in making an INFORMED CHOICE
What are the benefits
What are the risks
Who can perform homebirths
What research has been done Patient Education Nurses may have to care for mom coming into hospital from failed home birth
Assist in labor and delivery
Be compassionate!
Build relationship - trust
Support mothers
Emotional disparity of birth expectations
Mom's may feel disappointed On Hospital Transfer Decline & Rebound In developed countries, home birth declined rapidly over the 20th century:
United States - 50% in 1938 to < 1% in 1955
United Kingdom - 80% in the 1920s to 1% in 1991
Japan - 95% in 1950 to 1.2% in 1975 (Cassidy, 2006, pp. 54–55.)
Reemergence of home births to mainstream culture began in the 1960's (Jackson, 1995).
In 1993 the BC government decided to integrate midwifery into the health care system in order to give women choices in birth care and settings. Regulations for midwifery have been put into place across most of Canada: Female midwifery was eclipsed by the male obstetrical system by the end of the 19th century. (Bourgeault et al., 2004) Meanwhile in Canada... Some medical professional question the safety of home births after the BC Health Minister endorsed the practice

- Some medical professions stated, "What can look like a low-risk pregnancy can develop complications in a moment" - Discussion of many peoples opinions both for and against home births Second Birth Attendant In the majority of home births in BC, midwives are the primary caregivers.
College of Midwives states 2 trained and certified professionals must attend each birth.
Second birth attendants include:
Second midwife, physician, RN, NP, paramedic or respiratory therapist Lay literature is highly variable in quality and opinion
Lay literature is often unscientific and based on an expert’s opinion
Dramatic and unfortunate unplanned births are reported heavily in the media
Public opinion is varied, lots of confusion exists
Academic literature is fairly consistent, but there are still few RCTs
Information provided by the College of Midwives is detailed and comprehensive vs College of Physicians is vague and open to an individual’s interpretation Academic research, lay literature and public opinion How do they compare? What's out there? Ministry pays $500,000 to cover the cost of the second professional for a home birth.
2004 Canadian Institute of Health Information states: $2,700- Normal Hospital Birth
$3, 200- Caesarean Section
$1,364- Home Birth Discussion Bochove, D. (2011, August 26). Are home births safe?. Macleans. Retrieved from http://www2.macleans.ca/2011/08/26/dont-try-this-at-home/Bourgeault, I. L., Benoit, C. and Davis-Floyd, R. (2004). Reconceiving Midwifery. Montreal, QC: McGill-Queen’s University Press.Cassidy, T. (2006). Birth. New York, NY: Atlantic Monthly Press.College of midwives of British Columbia. (2005, October 3). Statement on home birth. Retrieved from http://www.cmbc.bc.ca/pdf.shtml?Registrants-Handbook-13-01-Statement-on-Home-BirthCollege of physicians and surgeons of British Columbia. (2009, November). Professional standards and guidelines, home births. Retrieved from https://www.cpsbc.ca/files/u6/Planned-Home-Births.pdfDowswell, T., Thornton, J. G., Hewison, J., & Lilford, R. J. L. (1996). Should there be a trial of home versus hospital delivery in the United Kingdom? Measuring outcomes other than safety is feasible. British Medical Journal, 312, 753-757.Drife, J. (2011). The start of life: a history of obstetrics. Postgraduate Medical Journal, 78, 311-315. doi:10.1136/pmj.78.919.311Dedyna, K. (2012, November 1). Health minister encourages home births in low-risk cases. The Victoria Times. Retrieved from http://www.timescolonist.com/news/local/health-minister-encourages-home-births-in-low-risk-cases-1.5626Health minister supports home births. (2012, November 3). Vancouver Sun. Retrieved from http://www.canada.com/vancouversun/news/westcoastnews/story.html?id=8154d880-8f4d-4ae5-a024-6095efd11d67Hutton, E., Reitsma, A., & Kaufman, K. (2009). Outcomes associated with planned home and planned hospital births in low-risk women attended by midwives in Ontario, Canada, 2003-2006: A retrospective cohort study. Birth, 36, 180-89.Jackson, M. E. & Bailes, A. J. (1995). Home birth with certified nurse-midwife attendants in the U.S. Journal of Nurse-Midwifery, 40, 493-507.Janssen, P. A., Lee, S. K., Ryan, E. M., Etches, D. J., Farquharson, D. F., Peacock, D., & Klein, M. C. (2002). Outcomes of planned home births versus planned hospital births after regulation of mid-wifery in British Columbia. Canadian Medical Association Journal, 166, 315-23.Jannssen, P., Carty, E., Reime, B. (2006). Satisfaction with planned place of birth among midwifery clients in British Columbia. Journal of Midwifery & Womens Health, 51, 91-7.Janssen, P. A., Saxell, L., Page, L. A., Klein, M. C., Liston, R. M., & Lee SK. (2009). Outcomes of planned home births with registered mid-wife versus planned hospital birth with midwife or physician. Canadian Medical Association Journal, 181, 377-83.Keirse, M. J. (2010). Home birth: Gone away, gone astray, and here to stay. Birth, 37, 341-46.Lindgren, H., & Erlandsson, K. (2010). Women’s experiences of em- powerment in a planned home birth: A Swedish population- based study. Birth, 37, 309-17. Mitchinson, W. (2002). Giving birth in Canada, 1900-1950. Toronto, ON: University of Toronto Press. Retreived from http://books.google.ca/books?hl=en&lr=&id=GoBa8ZHCOTYC&oi=fnd&pg=PR9&dq=medicalization+of+birth+canada&ots=DqKJ-TCVx4&sig=pFXDRxR-PbgjqMCqUgpl-LGJjPg#v=onepage&q=medicalization%20of%20birth%20canada&f=falseMontagu, D., Yamey, G., Visconti, A., Harding, A., Yoong, J. (2011) Where do poor women in developing countries give birth? A multi-country analysis of demographic and health survey data. PLoS ONE 6: e17155. doi:10.1371/journal.pone.0017155 Olsen, O. (1997) Meta-analysis of the safety of home birth. Birth, 24, 4-13.Olsen, O., & Clausen, J. (2012). Planned hospital birth versus planned home birth. Cochrane Database of Systematic Reviews, 2012. doi: 10.1002/14651858.CD000352.pub2Slivinski, A. (2012, November 2012). Home births promotion draws opposition. 24hrs Vancouver. Retrieved from http://vancouver.24hrs.ca/2012/11/13/home-births-promotion-draws-oppositionWeb, K. (2012, December 1). Home birth sparks dispute between B.C. birth attendants and college of midwives. Metro Vancouver. Retrieved from http://metronews.ca/news/vancouver/461127/home-birth-scare-sparks-dispute-between-b-c-doulas-and-midwivesLouis Pasteur picture: http://www.bbc.co.uk/radio4/youandyours/ian_wilmut.shtmlForceps picture: http://en.wikipedia.org/wiki/File:Smellie_forceps.jpgAnesthetic picture: http://www.blatner.com/adam/consctransf/historyofmedicine/4-anesthesia/hxanesthes.html Is it that birth is complicated and therefore requires interventions and relocation from home, or that well marketed interventions have complicated births and removed women from home?
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