Ethical Dilemmas in L&D Nursing

rbytsdy · Dec 12, 2009

Oh, you are right! There is no risk free birth which means there are certainly issues that can come up in homebirth. But moms know that. No woman is forced to chose a homebirth because a hospital won't allow her in the door. Most women chose homebirth because the hospital won't support the birth they desire. Moms choose homebirth knowing the risks vs being forced into a repeat c-section (which has a lot of risks for both mom and baby) vs being able to make the choice of birthing lady partslly after a cesarean (or making their decision for a repeat c-section).

Here is the crazy thing though. If I knew before my 1st baby, what I know now, I would have had a homebirth. I picked one of the best hospitals for having a baby in my state (even the governor's wife birthed at my hospital). I was totally low risk and didn't have 1 problem my whole pregnancy or labor. But my labor took a long time. Even without 1 fetal decel, they whisked me off to the OR just 9 hours after I arrived in early labor (2cm) telling me my pelvis was too small. So the regional perinatal center/level III NICU took my low risk birth and turned it high risk and have now made all my future births high risk b/c they got tired of waiting around for me. No one thinks about the flip side to homebirth: when a low risk hospital birth is turned high risk and puts future births at risk. Pretty crazy. My baby's apgars were 9 and 9. She was in perfect health. Unfortunately, homebirth was not an option for me the 2nd time b/c my state prohibits midwives from attending homebirth VBACs (I could have done it illegally but I wasn't comfortable with that option).

littleneoRN · Dec 12, 2009

The metaphor would go the other way around, that a midwife would not let a patient homebirth but would encourage a hospital if the patient was high-risk. And I surely hope that happens sometimes...

Sorry to hear about your negative experience.

rbytsdy · Dec 12, 2009

I'm pretty active in the local childbirth community and I can assure you that no midwife (at least not one that I have met) would encourage a high risk mom to homebirth. They wouldn't risk the mom or baby's health and they wouldn't risk their license. It's not worth it. Midwives will get crucified for a homebirth that goes badly. Now, if i had coded on the table, no one would think any less of my ob. He did "all that he could." No one would have said, "Did she really even need that c-section?"

There is a homebirth midwife in NY that got totally crucified because in 800 births, she finally had a baby that died. She worked on that baby for a long time trying to resuscitate it but nothing helped. There is no evidence whatsoever that the baby would have lived had the mom been in the hospital but the couple was angry and went on a morning show to talk about the dangers of homebirth. Labor had gone fine and there was no indication for a c-section until the last minute when it still would have been faster to birth the baby lady partslly vs getting the mom into the OR. I cannot help thinking that the couple made the choice. The midwife was responsible and really did everything she should have done. Baby had been doing great during labor. This poor midwife is devastated about the outcome and it's coming back to haunt her.

Of course, the definition of high risk is a little more vague. My state prohibits homebirth after cesarean, multiple births, GD moms, suspected macrosomia, before 37 weeks & after 42, breech, pre-e, etc. No midwife would allow a mom with severe pre-e to birth at home or a mom in labor before 37 weeks to birth at home. But breech? Some midwives are very comfortable with that, especially frank breech. My risk of uterine rupture is 0.4% (without induction agents or pit). The risk of cord prolapse is about the same. So I think that's a fair risk to take at home, especially since many ruptures occur slowly whereas a cord prolapse has to get into the OR stat. So there is room for debate there but my local midwives are very cautious and will transfer a mom for prolonged labor, dehydration, any signs of distress, etc. They don't play around with that.

Smurfette752, BSN · Dec 17, 2009

*coming out of lurk-dom*

Here's what I don't "get." You say that your state "prohibits HBAC" But Excuse me, isn't (or rather shouldn't) that be the WOMAN'S CHOICE???

I literally do not understand how any doctor, hospital, midwife, state government etc...can tell a woman that she CAN NOT do something with her own body!??? I mean yes, I suppose they can say that they won't care for you or take you on as a patient, but it is still the woman's choice. If a VBAC woman was walking through the doors of a VBAC BANNED hospital at 10 CM, would they then roll her into the OR? NO. It makes me so angry that a woman refusing a c-section would have the child services after her, child services should be taking kids away from people who ACTUALLY abuse them...not someone who was doing the BEST THING FOR HER BABY. And these arrogant doctors who get a COURT ORDER to do a c-section....I'm not sure there is anything that makes me more angry...(except maybe circumcision! LOL)

Ok, sorry! LOL I just had to get that out there!

rbytsdy · Dec 17, 2009

Oh, sorry - let me be more specific. The law in my state prohibits a midwife from legally attending a HBAC. I could have a UBAC or even as a midwife who is unlicensed or licensed in another state. But if anything happened, I'd have to transfer on my own and risk getting CPS involved because, clearly, my efforts to have a normal natural birth indicate that I will be a bad mother. And I do know 2 women that had CPS called (one after a hbac attempt). Of course if I chosen a completely elective c-section, CPS wouldn't bat an eye even though I was subjecting my baby to heavy doses of drugs unnecessarily (I know epidurals are mostly safe but nothing like that is 100% safe; adverse events do happen but no one cares (i.e. cares enough to take legal action) except when an adverse event happens to a mom who was attempting something more natural).

I makes me angry as well. My state prides itself on supporting a "woman's right to choose." That does nothing but anger me because they sure aren't supporting my right to choose how to birth.

Most of the hospitals I called that "ban" vbac said that if I arrived 10cm dilated they would probably "let" me vbac. But if I was only 5cm, I would "have" to have a c-section. No one I talked to knew what would happen if I refused the c-section. I guess that doesn't happen too often.

Smurfette752, BSN · Dec 17, 2009

That is so sad, and sickening!

I live in Massachusetts, where things are pretty liberal as far as birth goes. I am a nursing student, and also a homebirth midwifery student...so I see all perspectives. I've also had a c-section and hope to have an HBAC someday, I'll take a VBAC though!

The "system" scares the heck out of me...I mean come on...the proof is in the pudding, VBAC is FAR safer than a RCS, and please, calling CPS, I think calling CPS on someone who chose to VBAC is ABUSE!