Episode 10 Homebirth

Homebirth might be considered pure midwifery led care. What can I do as an obstetrician to try and understand why women chose homebirth? What can I contribute to the my local homebirth team and the women they care for?

You can find out more about me on Twitter @FWmaternity and @TheObsPod please check out #MatExp matexp.org.uk for ideas about how to improve maternity experience.
 
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Thank you all for listening, My name is Florence Wilcock I am an NHS doctor working as an obstetrician, specialising in the care of both mother and baby during pregnancy and birth. If you have enjoyed my podcast please do continue to subscribe, rate, review and recommend my podcast on your podcast provider.
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If you want to get in touch to suggest topics, I love to hear your thoughts and ideas. You can find out more about me on Twitter @FWmaternity & @TheObsPod as well as Instagram @TheObsPod and e...

Transcript

Episode 10 Homebirth

Florence Wilcock: [00:00:00] Hello, my name's Florence. Welcome to the obs Pod. I'm an NHS obstetrician hoping to share some thoughts and experiences about my working life. Perhaps you enjoy, call the midwife, maybe birth fascinates you, or you're simply curious about what exactly an obstetrician is. You might be pregnant and preparing for birth.

Perhaps you work in maternity and want to know what makes your obstetric colleagues tick or you want some fresh ideas and inspiration, whichever of these is the case. And for that matter, anyone else that's interested? TheObsPod is for you.

Episode 10. Wow. Made it to double figures. I'm really excited by that and I want to pause and say [00:01:00] thank you. Thank you for listening. Thank you for making what, to be honest, is a little bit of pleasure and enjoyment for me in these troublesome times, playing with a little bit of creativity. Thank you for making it worthwhile.

Thank you for listening and joining me as I experiment with this new medium. I find it really fulfilling that some people want to join me and listen. So as we hit double figures, well hey, little bit of a celebration. So for episode 10, today we are going to talk home birth. And this is a hot topic. So since I started my podcast, a few people have been asking, am I going to talk about home birth?

And some of you are going to. Think, why is she talking about home birth as an obstetrician? Home birth has got nothing to do with obstetricians, and some of you are going to think home [00:02:00] birth is a dangerous thing and that women should give birth in hospital. And some of you are going to think that hospital is a dangerous thing and women should give birth at home, and some of you are going to have no idea at all.

So I'm going to do a little bit of exploring about home birth. And how obstetricians fit into home birth and try and do a little bit of myth busting about home birth. But as usual, with all my episodes, this isn't a big scientific examination of the evidence. These are just my thoughts. So obviously home birth is particularly topical at the moment.

During Covid, while our hospitals are doubled down dealing with this very nasty, infectious virus, why on earth would you want to go there to give birth? [00:03:00] So it's also something that perhaps we need to think about a bit more. For me, the story of home birth started really with the publication of the Birthplace study and that looked at the outcomes for mothers and the outcomes for babies in healthy women who were otherwise deemed what we call low risk planning, a home birth in the.

And that study demonstrated that these women will experience less intervention, less complications with no negative impact on the health of them or their baby. That's pretty amazing. And you'd think after that, that home birth rates would be soaring. The contrast is true nationally. Home birth rates remain very low, only about 2.3%.

So I mentioned in one of my [00:04:00] previous episodes the publication of Better Birth, the National Maternity Review in 2015. And that we've been going through a maternity transformation program ever since. This has an aspiration to change the care that we deliver. Moving to local maternity systems, an increase in continuity of care, which I talked about last week, and safe and personalized care being a key element.

So knowing the midwife, looking after you in. And as part of the mainstay of that, there's quite a lot of discussion about place of birth and should women be giving birth in midwifery ledge units, whether they are freestanding, so set apart from the hospital or alongside as part of the hospital, or whether women perhaps should be giving birth at home, and making sure that women know that those choices are available

so I thought quite a lot about the fact [00:05:00] that although in the birthplace study it details that you need to have the collaboration of obstetricians, pediatricians. anaesthetists and ambulance services to enable midwives to deliver good quality home birth service. That as an obstetrician, I didn't really know very much about home birth.

How could I, all I would see is the woman. Who is transferred in from a home birth because something is going wrong, something is going awry, she's developed a risk factor, or she or her baby have had a complication. So my only experience of home birth was quite negative, quite skewed. I had no experience of home birth as a medical student, and when I talked to the midwives, Um, on [00:06:00] my maternity unit and the midwifery students on my maternity unit, they don't have much experience of home birth either.

I know some of the midwives that work in my hospital home birth absolutely terrifies them. That is the very last place they would want to be because their skills are more in keeping with being in hospital. Likewise for the home birth midwives, they can be less familiar with the hospital environment. So it seemed to me that to get wider adoption of home birth, we need to make sure that our staff are adequately trained and have experience so that we can make home birth a reality for the women who want it and for whom it's sensible.

I can quote the evidence about home birth. I can talk to women about the [00:07:00] birthplace study, but. I didn't have any understanding of the qualitative advantages or disadvantages of home birth. How does it feel to be that woman at home? So two or three years ago, I thought I should remedy this and try and get some experience of home birth.

So I contacted my local home birth team of midwives and asked if I could follow them round a bit in my work. I started by spending a day visiting women in their own homes, and my immediate impression was of a power shift. So we don't consciously think about power very much, but when they come to hospital to see us, they are coming to us.

They're coming to my environment. When we go into women's homes, we are going into their environment. We're guests in their houses [00:08:00] and they're comfortable and confident, and we are the visitors. So there's a subtle shift in the relationship and. It brings a much more holistic approach to care, listening to women and addressing their needs first, and then the midwifery check almost being a little bit an afterthought just before we depart.

And it's also much easier to see what's the context of that woman's life if her children, birth partner, pets. And so on around her. And in one house we went to, a woman was actually going through building work, so people in and out of her house. I was really impressed by the incredibly detailed antenatal preparation.

So both a focus on the very practical aspects as such as how we might easily identify your house at three o'clock in the morning. As well as [00:09:00] discussion of the clinical issues, transfer rates, possible emergency situations and complications. So there's an enormous amount of discussion, antenatal education.

And agreement of plans and clear contingency plans in advance. The midwives build up trust over several visits so that by 36 weeks they've developed a plan. And it seemed to me this is something that isn't unique to home birth. This is something we should be doing with all women. To some extent at that 36 week appointment and over the appointments before that very detailed preparation for birth.

So I started to build my own relationship with the home birth team. They, I think, became a little bit more relaxed with me, and it also made me see how. Small things might [00:10:00] derail a woman's home birth and the role that an obstetrician can play in kind of balancing things up and thinking actually this minor problem is that likely to impact on birth is.

Home birth's still a safe and realistic choice, or do I now need to advise something else so that I could use my common sense and think realistically about how I talk to women, rather than perhaps the easy option of saying, perhaps home birth isn't for you. Perhaps you should be in hospital. And I also start to actively suggest home birth in my clinic because of my trust and knowledge of the team.

So some of the women I see who I'm saying, actually, no, you don't have a problem, that's fine. You can go back to being cared for by your midwife. I might suggest perhaps you could consider Home birth [00:11:00] or have you thought about home birth? This is the team. This is their information. Perhaps have a think about it.

Do you want to ask me questions about it? Babies are quite unpredictable. They often come at night, and so although I'd spent quite a bit of time with the home birth team, I hadn't actually experienced home birth one day in my antenatal clinic. I meet a woman who's having her third baby and she happens to be in early labor.

So the contractions have started, but she's not yet established. She's planning a home birth purely from a practical perspective. Her second labor was very rapid, and she's worried about getting into the hospital, so I ask her whether if she does go into labor later on that day. Whether she might be willing for me to attend with the midwives, [00:12:00] and I'm absolutely delighted and very indebted to her when she agrees.

I receive a call a little bit later on in the afternoon to say she's in labor. She's eight centimeters. Would I like to come out and join? So I rush from the hospital and jump in my car, and my immediate thought as I'm driving is that the labor journey is reversed. So she's at home relaxed in her. Own safe environment and it's instead me, the health professional who's anxiously driving, trying to find whether I'm going the right way.

Will I arrive in time? Will there be somewhere to park? As fate would have it, I get stuck behind a learner driver bus. I'm in a hurry. [00:13:00] Can't they see that? It's frustrating. I do arrive in time and I'm welcomed by the two grandmothers who open the front door and usher me in up to the top floor to a light and airy bedroom.

The woman's kneeling on a pillow by the side of her bed using gas and air. Her partner's encouraging her and the two midwives are already present, and I'm totally struck by the aura of calm in the room. The bed is certainly not for lying on. She's standing, rocking or perch, sitting on the edge using it to support her or kneeling on the floor.

Leaning over it, the bed becomes a prop rather than the focus of her birth. In the contrast to the hospital, there are no distractions. There are no other women requiring our attention. We can [00:14:00] completely focus on her. In total privacy, we listen to her baby's heartbeat. We're a guest in her home, in their bedroom, at their birth.

The room is quiet. We're focused on her efforts at laboring and birthing her baby, and we wait patiently for her body to do what it needs to do. In a hospital setting, there would be people knocking on the door, have you got the keys? Can I relieve you for break? You would hear noises outside in the corridor.

However much you try, there would be interruption. I am really struck by the concentration, all four of us, her partner, two midwives, and myself solely focused on her as we wait for the [00:15:00] arrival of the baby. We are caring for her. We're listening into the baby's heartbeat. We're doing the necessary checks.

But we are very much a supporting act. Unobtrusive just there to help her through this labor there alongside her in that calm, in her own bedroom, she can focus in onto herself and her body. The relationship feels very different to a hospital birth. Soon. Her waters break during a contraction and contrary to the popular myth that there'll be a massive mess, the deluge is swiftly dealt with by the midwives with some old towels that she was asked to have ready.

We encourage her to go with her body and she stands leaning on her partner and soon we can see the baby's head with [00:16:00] support and encouragement. A baby boy is born. The woman is elated, but exhausted. The baby has immediate skin to skin with his father while she sits on the side of the bed. We need to check if she needs any stitches after the placenta's delivered.

In practical terms, this means I'm sent down to the kitchen to break the news to the waiting grandmothers and to look for a torch. Her partner follows me down the stairs and introduces the new baby to his grand mums. Who are delighted and excited, we return upstairs to the birthing room. The improvised resuscitaire on the chest of drawers is moved and a temporary weighing scales is set up.

The midwives tidy equipment while I help the woman bath dress and settle into [00:17:00] bed with her baby cradled in her arms to start his first. And it feels unbelievably right. He's arrived in his family home rather than in an alien hospital room. There's a sense of place. He's arrived at the heart of their family.

The grandmothers bring refreshments and we have an impromptu carpet picnic, chatting and relaxing with the couple while the baby feeds. Reflecting on what we all just experienced, both parents comment, this was a world apart from their previous births. The atmosphere's relaxed as we remain in the bubble of birth.

The couple tell me that there was some concern from some of their family members. It wasn't an obvious choice. It was something the rest of the family viewed as rather eccentric. Rather [00:18:00] unusual, one of the midwife starts to pack up the equipment, noting what needs restocking, and showing me exactly what they carry with them.

They have emergency cards and drugs for cord prolapse, excessive bleeding, stitching, and resuscitation of the baby. They also have some London ambulance calling cards developed with the Mama Academy to try and help ambulance dispatchers understand the urgency and the need for ambulance for transfer if required.

It's then time for her to leave and do the paperwork whilst the other midwife and I stay until the baby's two hours old to complete the final checks on Mom and son. We're just about to leave. When the baby's brothers arrive back from nursery, they may have been out, but their mother and their new brother [00:19:00] is home ready to meet them.

It just feels unbelievably special. This birth has a degree of intimacy that I hadn't previously encountered. It was amazing. I don't want to sound like a home birth evangelist, it's not for everybody, but it did make me wonder why more women don't choose this sort of care. What is it that they're frightened of?

What is it that makes them think hospital is a safer place? And it also makes me think about. The detailed antenatal preparation, and could we do that better for all women, not just women who are thinking about home birth? In obstetrics, we talk quite a lot about risk, and we know that we should frame risk both [00:20:00] ways.

So if we're talking to a woman about the risks of home birth, what might go wrong? What might be needed in terms of transfer and what the risks are. Why aren't we talking to more women about the risks of hospital birth? We know that despite our best efforts, women who come and birth in an obstetric unit are more likely to have intervention and are more likely to have an emergency Cesarean.

Or an assisted vaginal birth, they're more likely to have tears and need stitches. And of course there is a place for that. And of course there is a need for intervention and for some women, hospital is definitely the safest place. So I don't want to scare [00:21:00] people and put them off coming to hospital, but I do want to try and understand.

What it is that means we assume hospital is the safest place when the evidence actually says the opposite. For some women whose pregnancies are uncomplicated, so as I mentioned, I experienced that birth a few years ago, so in the intervening time. What have I done about it? So it'd be wonderful if I could say my local unit's home birth rates are booming as a result of my efforts, but that simply wouldn't be true.

We are increasing the numbers of home births and we do have some new specific home birth team midwives, but home birth remains a minority choice as a result of [00:22:00] my experience. I did write an article, home Birth, an Obstetrician's View for a magazine published by the Royal College of Obstetricians and Gynecologists, with permission from the woman I shared my experience of her birth.

And through that I try to bring the ideas I had about home birth. Its qualitative benefits. and what it felt like to a wider obstetric community. covid has had its own problems, although intuitively an increasing home birth rate should result from covid initially, there were a lot of difficulties with a lot of units having to suspend their home birth services, either because of issues.

About the ambulance being able to [00:23:00] support transfer into a unit or because of issues with midwifery staffing or personal protective equipment. P P E. Fortunately as we've passed the first peak, the ambulance services do seem more able to resume the support of home birth services, and we are seeing increasing numbers of women.

Wishing to birth at home. Our local statistics are good. In the last year, 85% of women who started labor at home had a home birth, and 95% of women who started labor at home with the team had a vaginal birth and nearly 50% didn't need any stitches. Those are fantastic outcomes. I am now the go-to consultant for the home birth team.

Any woman who's wanting a home birth, who needs some obstetric input comes my [00:24:00] way and we can have a conversation with me understanding her choices, the care she's receiving, and how that may or may not play out, and what is safe at home and what isn't. I can give advice. And I can chat back and forth with the home birth team to try and support them and give them the backup they need to continue the service with me in the background.

I'm happy to say I've had two medical students in the last year come and do their UK elective. At my unit, both of whom have gone out for a week with the home birth team, this is fantastic because they, as doctors moving forward, will have a better understanding of the context [00:25:00] of uncomplicated birth, uncomplicated pregnancy.

They're both considering careers in obstetrics and that would be amazing. But even if they don't and they go into other specialties, they'll carry that knowledge with them and challenge people's assumptions. So now we come to today's Zesty bit. So the zesty bit today. Is for staff who have no experience, who work in maternity but don't understand and don't know anything about home birth.

Try and find out. Try and talk to some women that have had home birth. Talk to your home birth midwives. See what you can do to organize and rotate out to a home birth. Try and make sure you're having the conversations with the women so that you are informing them correctly of information and not bringing your own unconscious bias [00:26:00] into the choices you are suggesting.

We need to remember, if we're going to explain risks and benefits to women that. Their wider families and friends are also people that will need to be influenced for the women themselves to feel they've made a safe and rational choice. If you're an obstetrician, what could you do during your training?

Could you take a week of study leave and go out with your home birth team? I think this would be fantastic to do at ST1/2 level when you are learning the mechanisms of birth and learning how the body works to go out and experience that as a part of your core training. And I'm really hoping that I can help make that a reality.

If you're a woman [00:27:00] and you're giving birth, have you considered home birth? Perhaps it's not for you. Perhaps you've got an underlying health condition. Perhaps you think you will want an epidural, but if you don't, It's worth exploring home birth, even if you don't ultimately want it and you want to give birth in hospital, or you need to give birth in hospital because of other health issues.

What can you do that shifts that power, brings that control back to you? Could any of your appointments be at home? I know that's a bit tricky in the situation of covid I know that you could have an appointment outside, you could have an appointment on neutral ground so that it's not always you coming to the hospital.

And the [00:28:00] reality of that is difficult in a healthcare system with finite resources, but it's worth having those conversations and perhaps the development. More video consultations and phone consultations in the future in the wake of Covid will help with that rather than you having to come and see the teacher, as it were.

See the obstetrician at the hospital. For this episode, I would particularly like to thank my local home birth team and the local families that let me into their homes, and I'd especially like to thank that woman and that family that let me witness such a special event in their lives. The birth of their third.

I contacted her to ask her express permission for the recording of this episode, and I do hope that she [00:29:00] will feel I have done her justice and used my experience of her birth to try and improve things for other mothers and benefit other midwives and obstetricians who have not had the advantage of seeing home birth firsthand.

So I do hope with this episode I've given you some food for thought and perhaps increased your knowledge about home birth, and I very much hope that home birth has a big, bright future ahead of it. For some women, for the women who feel that is the right choice for them, who. At home in the safest place for them with the whole maternity team supporting them in that choice.[00:30:00] 

So I do hope you've enjoyed listening to the obs pod. If you have do, like subscribe or leave a review and join me again to explore more about the life of an NHS obstetrician. I'm finding it really exciting to have people listening and give me feedback about what they've found interesting. So please do recommend the obspod to other friends, colleagues, or people who you think might find it interesting

I'd love it if you'd share with me what you've enjoyed about listening and if you've done anything differently. As a result, I can be found on Twitter. @FWmaternity and @TheObsPod and and please do check the MatExp hashtag [00:31:00] #MATEXP and the website matexp.org.uk for more information and ideas on how to improve women's experience of maternity care.

Finally, I'd like to reassure you that I take confidentiality very seriously and although I'm talking about experiences from my working life, I'm taking great pains to make sure that I anonymize the stories and talk in more general terms so that I keep confidentiality of my women I currently care for and have cared for in the past.

Very safe. Many thanks for listening.