Home Versus Hospital: Where to Hatch Your Hatchling

this is a long post. sit down somewhere comfy. get a nice cup of tea/whiskey (not whiskey if you’re currently pregnant, thank you very much). take breaks if you need them. if possible, stroke a cat while you read it, like doctor claw in ‘inspector gadget.’ 

or skip the whole thing and just watch this video, which will explain everything. please do not overlook the most epic of all cosby sweaters.

in full disclosure, let me tell you (again) that i am a physician assistant. i practice traditional american medicine. and i had my ownself a very traditional hospital birth with pain control through an epidural and labor augmentation with pitocin. so both professionally and personally, i am coming from the traditional medicine camp. but i in no way discount ‘alternative’ birthing methods and think it’s important to examine them all. there is a crazy ton of info out there on this subject and i have supplied you only the tiniest taste of it all. if you have questions along the way, i can help you do more research on any specifics, lemme know. also, i know nothing about you or your pregnancy and you should ALWAYS consult your practitioner with any and all questions/concerns and to address all issues of how/where/when you are going to give birth.
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i’ve become sort of a go-to for pregnant friends and friends-of-friends who know that i am practicing in western medicine, but also am something of a hippie in my personal life.

when these ladies are putting together their birth plans and debating pain management methods, what interventions they do/don’t want, and where to deliver, they come to me to help them navigate all the options.

and there are lots of options! and it can be overwhelming and confusing.

there is lots of material out there. some info is well-constructed and researched, some is panic propaganda. both the natural birth and the traditional medical approaches are guilty of that at times. also, it seems obstetrics is also very prone to trends (eg: c-section rates and epidural usage, breast feeding, etc goes in and out of ‘fashion’ over the years), usually started by a new documentary or a study some celebrity is talking about on oprah.

and everyone we know has a dramatic birth story and an opinion they want to share and we all are susceptible to peer pressure. and we all desperately want to make the right decisions for our tiny ones and for ourselves for this major moment of our lives.

so what are the goals in having a baby? this seems like a stupid question but isn’t as simple as it sounds (GET IT OUT!). to birth a healthy baby (liveborn, without lasting injuries from lack of oxygen during the birth process) and to give the patient authority and dignity. some of this involves pre-planning (considering a birth plan and discussing all the possible contingencies) and then assisting her in making decisions during the course of the labor and delivery.

so let me start out by saying that there isn’t one method that’s right for everybody. we all have our own needs and fears and perceptions of how it should/shouldn’t go. and none of the child birth methods that we’re going to talk about are completely wackadoo crazy. you will hear ranting and raving on all sides of the issue about the other camps being fascists or hippies or other nonsense. try to shut it out and focus on the goals.

that being said, safety has to be the #1 goal.

i’m going to get a little nerdy here for a split second to explain my view on safety:

in medicine, we look at data over time to see successes and failures and we draw conclusions from this that we then use in providing care. by practicing “evidence based medicine,” the decisions we make with/for our patients are based on the judicious use of the current data. obstetrics in general is a little harder to get quantifiable data, because no one wants to be a test subject when they’re pregnant and another person’s life is on the line. ie: often drugs, herbals, foods, and activities cannot be definitely classified as safe for the fetus or not, because the risk of testing it is too high. but we gather and use obstetrics data to the best of our ability.

also, in healthcare, there’s an effort to make success/failure data available to the public. drug side effects, infection rates, mortality numbers, incidents and accidents, etc are published so that we can compare methods, facilities, practitioners, etc. so we have fairly accurate data on births in hospitals and certified birthing centers.

(interestingly, the data that we report and how we report it is standardized for the US, but varies significantly country-to-country. for example- it is often quoted that the US has an unexpectedly/unacceptably high infant mortality rate for a wealthy developed nation- but we count ‘against ourselves’ every single livebirth that results in death, whereas other countries have more conservative rules about gestational age/weight, etc that qualifies as infant loss…also, premature birth is a big culprit in infant mortality and we americans are highest in fertility treatments/multiple births, diabetes, among other factors contributing to premie births…so we have to be wise in how we interpret data. big picture stuff).

it seems data on home births is a little harder to come by, so comparisons are more challenging to make. we rely on self-reporting of the patients or the midwives, but it’s not quite as standardized as in healthcare facilities. (and when rare unfortunate events occur during a home birth and a mother has to be emergently delivered at a hospital, any untoward outcome goes then on the hospital’s failure rate).

so, what conclusions have we drawn from the available evidence comparing home births versus birth centers/hospital births?

ACOG (american congress of obstetrics and gynecologists, the group who sets the standards for all licensed in ob/gyn care), says this, in summary- full article here:

Summary
Although the Committee on Obstetric Practice believes that hospitals and birthing centers are the safest setting for birth, it respects the right of a woman to make a medically informed decision about delivery. Women inquiring about planned home birth should be informed of its risks and benefits based on recent evidence. Specifically, they should be informed that although the absolute risk may be low, planned home birth is associated with a twofold to threefold increased risk of neonatal death when compared with planned hospital birth. Importantly, women should be informed that the appropriate selection of candidates for home birth; the availability of a certified nurse–midwife, certified midwife, or physician practicing within an integrated and regulated health system; ready access to consultation; and assurance of safe and timely transport to nearby hospitals are critical to reducing perinatal mortality rates and achieving favorable home birth outcomes.

so, it is under this recommendation that i am going to proceed in my discussion. AND PLEASE NOTE, I AM ONLY TALKING ABOUT SINGLE BABY PREGNANCIES, HEALTHY MOM/BABY, ON TIME (NOT PREMIE/OVERDUE), IN HEAD-DOWN POSITION. there are a lot of variables that will require you to have a more traditional hospital birth for the safety of you or the baby. what we’re discussing here is a very normal pregnancy/anticipated delivery. and as always, discuss all your questions/concerns with your practitioner who knows you, your history, and your baby.

1- where to deliver. home versus alternative birthing center versus traditional hospital setting. (a brief analysis- there are facilities/experiences out there that vary from this)

home: in your own home, in bed or tub or inflatable mini-pool, on a pile of cushions, etc. usually attended by a *midwife. Pros: autonomy and self-determination. comfort of your own home. able to have any/all family by your side, including other children, no restriction on how you move, what you eat, very minimal monitoring, uses natural methods of pain control and “augmentation” (moving along) labor. lower rates of interventions (episiotomies, synthetic induction, C-sections, etc) than in a hospital birth. generally speaking, your caregiver will be with you throughout the whole process. once baby is born, both mom and baby are already home and will stay home with minimal postpartum checks by midwife. Cons: statistically infant mortality rate 2-3 x higher than hospital birth. less standardized care/reporting. with limited monitoring we may not know that the baby is struggling until it is too late/takes too long to get to emergency services (can lead to death/disabilities). limited options for pain control and labor augmentation. limited to low risk/healthy mothers and babies. generally not covered by insurance- paid out of pocket.

*midwives- different types/different training/different laws they practice by, etc

alternative birthing center: typically a special area within/near a hospital focused on a more natural birthing experience. usually run by midwives but with emergency services (per MD’s) available. monitoring follows a standard protocol but women are encouraged to otherwise be up and active using hydrotherapy, birthing balls, etc. Pros: “the best of home and hospital,” autonomy and self-determination. less clinical environment than hospital. less restrictive monitoring, fewer interventions that traditional hospital birth, but emergency services available quickly. adhere to strict safety guidelines and standardized care/reporting.  mother will stay in setting for a few days so any postpartum issues (for mom or baby) can be addressed. encourages use of natural pain control and labor augmentation. most likely will take your insurance (ask) Cons: generally speaking- limited access to pain control/labor augmentation (would need to be transferred to traditional labor & delivery floor if required epidural/pitocin, etc). not in your own home. only available for low risk mothers and babies. generally speaking, your caregiver will be with you throughout the whole process, but some staff may change with their shifts and if a c-section is required, care will change hands to doctors and Labor & Delivery staff (who you may/may not know)

traditional hospital setting: in a Labor & Delivery unit, birth is generally attended by Ob/Gyn MD’s, nursing and anesthesia staff. a doula may be hired by patient as a ‘birth coach’ to be part of patient’s care team. IV access of mother, frequent monitoring of mother and baby is required.  Pros: follow strict safety guidelines, sterile techniques, and standardized care/reporting both before/during/after birth. pain control and labor augmentation available, primarily through medicine (epidurals or other IV pain meds, pitocin, etc) although more natural options are available. your caregiver can help you through any type of birth you require (vaginal or c-section, same MD). mother will stay in setting for a few days so any postpartum issues (for mom or baby) can be addressed. takes insurance so out of pocket costs should be almost nothing. Cons: restricted food/beverages. restricted movement if using an epidural or if more monitoring required. possibly will receive more interventions than otherwise would at home/birthing center and some patients feel like they have less self-determination in hospital setting. generally speaking, your caregiver will be with you throughout the whole process, but other staff may change with shift changes.     

2. what kind of pain control. sorry, but having a baby hurts! if you’re trying to figure how much it hurts- here’s a little tidbit: when we ask patients to rate their pain for whatever they’re going through, say a sprained ankle, we say: “Please rate your ankle pain from a 1 to a 10, 10 being the worst pain you’ve ever felt- like child birth.”  🙂 

how you handle the hurt will be part of what determines where you deliver.

epidural- catheter placed by anesthesiologist into your lower back to deliver narcotic pain medication that blocks sensation of nerves to your lower body. greatly decreases pain of labor, but not feeling of need to/ability to push. choosing an epidural will likely require you have a traditional hospital birth. they are safe, highly effective for pain control, and decreases need for other systemic pain medication. can be re-dosed as needed during labor to make mom comfortable.  may cause side effects like nausea, low blood pressure for mom, headache. injection causes localized pain briefly. there is some association with slowing down labor and possibly then requiring labor augmentation/more interventions in birth. (no longer associated with higher c-section rate). speaking of c-section- if you have an epidural in and require a c-section (reasons for this will have to be on another post later, message me if want to know now), they can quickly start the operation and you will not feel it. if you do not have one, depending on what kind of distress you/the baby is experiencing, they may be able to put one in quickly (in this case, it would be a “spinal” which is the same thing, just with a single long-lasting dose of meds, not a catheter to transmit it over time) or, in an extreme emergency where you or the baby is seen to be in imminent danger, there is a chance you would be put under general anesthetic (put to sleep) for the birth.

IV pain medication– does not dull pain completely in lower half of body but offers some relief. everyone reacts differently to narcotics- can cause nausea/vomiting, sleepiness. can generally be given in hospital or birthing center.

natural pain relief- hypnobirthing, massage, breathing techniques, meditation, etc. some options. of course you can employ these methods in any birthing environment (and should!). everyone’s pain tolerance is different. pain is definitely a mind-over-matter thing. you just have to decide what your threshold is and choose your care team/birthing location accordingly.

3. what kind of ‘labor augmentation’ do i want? labor can take a long time, especially for a first time mom. sometimes monitoring shows that the baby is in distress and needs to be delivered or there is an issue with the mom’s health and labor needs to be moved along. in order to get a baby out, the cervix needs to dilate fully to make room for the baby’s melon and the baby needs to move down into the mom’s pelvis. then contractions need to become regular and strong enough and close enough together so that the melon (and the rest of the bebe) can be pushed through. oxytocin is the big hormone involved in all that happening. your body is making and releasing it during the labor/delivery process.

ways to to ‘ripen cervix’– a balloon-type device might be inserted to mechanically dilate cervix, or they might use medications topically on the cervix (like misoprostol). used in traditional hospital settings, may/may not be available in birthing centers, not available in home birth.

pitocinaugmented (synthentic) Oxytocin given by IV. will increase the strength of the contractions and should progress labor along. using pitocin will require additional monitoring and there is some association with need of further interventions. there are certain circumstances where it is not used (re: certain baby and placenta position, disorders of mom/baby, etc). available in hospital settings- not available in most birthing centers or at home.

non-medical ways- patient’s nipple stimulation, change positions, walk/move, among others. available in all birthing settings (unless, again, confined to bed because of monitors or epidural is in place).

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SO…,.that was a lot. holy monkeys. i am all worn out. and that’s just the tip of the iceberg. please feel free to comment or message me so we can discuss anything further. and don’t forget to talk to your own personal practitioner who knows you and your baby with all your questions/concerns. don’t make any plans or changes without consulting your practitioner.

and if i just made it all the more confusing- think of this. you don’t NEED to have a huge complicated birth plan. find a practitioner and a facility you trust will help you have a healthy baby and will give you authority of your own care and dignity in your experience. then be flexible and allow whatever happens to happen. certainly, no matter what type of birth you have, the more flexible, open-minded and relaxed you can be, the more successful and satisfying an experience you will have.

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