Fetal Monitoring & Home Births

midwife2b · Jul 20, 2005

Hi, I have a nagging question that I wonder if anyone could shed some light on. Here goes - if a midwife is to do a homebirth, does she follow different regulations for fetal monitoring than those of the ACOG (SOGC in Canada)? That is, does she not have to start continuously monitoring and providing the usual interventions (IV, O2, repositioning, etc) for nonreassuring FHR? I mean, most babies have variable decels in the 2nd stage of labour. So if the MW hears them, does she not have to intervene? Obviously the risk for physical and neurologic sequelae is low (especially if low risk pregnancy), but do midwife patients have to sign a waiver that they won't sue if something does go wrong? Is their insurance sky-high like OBGYN's?

There is no electronic fetal monitoring. FHT's are heard with hand held doppler or fetoscope per guidelines. Vital signs are monitored about every hour. The midwives do have oxygen suction and recusitation equipment that is available at every birth, and oxygen can be given to the mom if needed. Maternal position can be easily changed to help relieve pressure off the cord, as there is no epidural or pain medication. You would be surprised (as I was) how much equipment the midwives have at their disposal for complications at a birth.

In my state only CNM's are allowed to practice legally. I don't know of any who do homebirths but there are lay midwives and CPM's who attend births. THere is a second person available to meet the AAP recusitation guidelines as well. I met one while I was in school who showed me the back of her van. She had everything, including intubation equipment- which fortunately she has never had to use. So yes, standards are adhered to, just in a little different way than in the hospital.

StBRN · Jul 20, 2005

I wanted to add something to my question: If the MW then intervenes and the FHR still has decels, at what point does she have to head to the hospital? I mean, a lot of babies will still have some decels (especially variable - although how can you tell with a doptone? What if they're late?) Again, just curious.

FrumDoula · Jul 20, 2005

Hi, I have a nagging question that I wonder if anyone could shed some light on. Here goes - if a midwife is to do a homebirth, does she follow different regulations for fetal monitoring than those of the ACOG (SOGC in Canada)? That is, does she not have to start continuously monitoring and providing the usual interventions (IV, O2, repositioning, etc) for nonreassuring FHR? I mean, most babies have variable decels in the 2nd stage of labour. So if the MW hears them, does she not have to intervene? Obviously the risk for physical and neurologic sequelae is low (especially if low risk pregnancy), but do midwife patients have to sign a waiver that they won't sue if something does go wrong? Is their insurance sky-high like OBGYN's?

I'm using a homebirth CPM for my upcoming birth. She does intermittent monitoring, which is the ACOG standard (it is not continuous for low-risk women). Like the PP said, she uses either a Doppler or fetascope, both of which have been proven to have equal efficacy to the EFM machines in the hospital. If anything, there are advantages to the Dop and fetascope, which allow for much more freedom of movement and immersion in water/birth tubs.

I am confident in her assessment skills and know she would transfer me to the hospital if something should be out of her scope. If there are non reassuring heart tones, she doesn't just transfer. She tries a host of things to normalize the baby. She carries a tremendous amount of equipment, and in CA, she also carries Pit and methergine in the event of postpartum hemmorhage. As part of the birth kit I ordered in preparation for the birth, I included a DeLee suction in there. She brings oxygen tanks and resuc stuff, too.

I did not sign a waiver releasing my midwife should something go wrong, nor did she ask me to. Midwives have much lower rates of litigation, especially CPM's, in part because their clients are low risk, and also because the relationship they foster is one of mutual respect. They also spend MUCH more time with their clientele, which allows them to spot and prevent problems far earlier (which can nip complications in the bud, thereby boosting the chance of a positive outcome and no suing). I've mentioned this before on the boards, but it's striking how different my experience has been compared to many of my doula clients. They wait in a waiting room for an hour to see their OB for a 10 minute appointment.

My midwife comes to my home, and we meet for 1-2 HOURS. We discuss nutrition, emotions, physical changes, etc. My husband and child are highly involved in my prenatal care. Any tests she needs to run, such as an OB panel, GBS testing or blood sugars, are done right there. Midwives are known for having better outcomes, even when compared with low risk OB patients, and I suspect this is a factor in litigation as well.

The populations that midwives serve may also play a factor in litigation, too. They usually serve the Amish, religious Christians and crunchy contingent who do not expect their midwives to always have a perfect outcome (an impossible and punishing standard for midwives and OB's alike). Many of their clients are pretty mainstream, too, though, and lest you think that midwives completely escape the lawyers, let me assure you that they are often pursued legally, though often more by doctors and the AMA than their clients. Still, some parents have sued or brought up a complaint with the state board. It happens, just like the OB's, and it's a risk that midwives take.

This was a great question, by the way, and I'm glad you asked it. Too many people think midwives are medically irresponsible and sit around aligning your chakras and lighting incense instead of taking care of the mom in appropriate ways.

One last caveat: given the variability of state laws around midwifery, it is possible that midwives in certain states are better able to care for their clients, particularly during transfer, than other midwives. If it's a felony to practice midwifery in one state, you can bet that affects practice. It's a shame, too, because then everyone goes underground and endangers lives unecessarily. So sad.

Alison

MS Kathy · Jul 20, 2005

I wanted to add something to my question: If the MW then intervenes and the FHR still has decels, at what point does she have to head to the hospital? I mean, a lot of babies will still have some decels (especially variable - although how can you tell with a doptone? What if they're late?) Again, just curious.

And they usually have repoir with the midwife because of the intense one on one time they have spent together during they pregnancy. I know that if my midwife didn't get a good doptone reading, she wouldn't wait 4 hours to check again,she'd intervene and change positioning, then check again. For some families this isn't emergent and they try something else for some they head to the hospital right away. I think each midwife has some type of these are my rules agreement signed early in pregnancy so that no one is surprised.

Kathy

SmilingBluEyes · Jul 20, 2005

I'm using a homebirth CPM for my upcoming birth. She does intermittent monitoring, which is the ACOG standard (it is not continuous for low-risk women). Like the PP said, she uses either a Doppler or fetascope, both of which have been proven to have equal efficacy to the EFM machines in the hospital. If anything, there are advantages to the Dop and fetascope, which allow for much more freedom of movement and immersion in water/birth tubs.
I am confident in her assessment skills and know she would transfer me to the hospital if something should be out of her scope. If there are non reassuring heart tones, she doesn't just transfer. She tries a host of things to normalize the baby. She carries a tremendous amount of equipment, and in CA, she also carries Pit and methergine in the event of postpartum hemmorhage. As part of the birth kit I ordered in preparation for the birth, I included a DeLee suction in there. She brings oxygen tanks and resuc stuff, too.
I did not sign a waiver releasing my midwife should something go wrong, nor did she ask me to. Midwives have much lower rates of litigation, especially CPM's, in part because their clients are low risk, and also because the relationship they foster is one of mutual respect. They also spend MUCH more time with their clientele, which allows them to spot and prevent problems far earlier (which can nip complications in the bud, thereby boosting the chance of a positive outcome and no suing). I've mentioned this before on the boards, but it's striking how different my experience has been compared to many of my doula clients. They wait in a waiting room for an hour to see their OB for a 10 minute appointment.
My midwife comes to my home, and we meet for 1-2 HOURS. We discuss nutrition, emotions, physical changes, etc. My husband and child are highly involved in my prenatal care. Any tests she needs to run, such as an OB panel, GBS testing or blood sugars, are done right there. Midwives are known for having better outcomes, even when compared with low risk OB patients, and I suspect this is a factor in litigation as well.
The populations that midwives serve may also play a factor in litigation, too. They usually serve the Amish, religious Christians and crunchy contingent who do not expect their midwives to always have a perfect outcome (an impossible and punishing standard for midwives and OB's alike). Many of their clients are pretty mainstream, too, though, and lest you think that midwives completely escape the lawyers, let me assure you that they are often pursued legally, though often more by doctors and the AMA than their clients. Still, some parents have sued or brought up a complaint with the state board. It happens, just like the OB's, and it's a risk that midwives take.
This was a great question, by the way, and I'm glad you asked it. Too many people think midwives are medically irresponsible and sit around aligning your chakras and lighting incense instead of taking care of the mom in appropriate ways.
One last caveat: given the variability of state laws around midwifery, it is possible that midwives in certain states are better able to care for their clients, particularly during transfer, than other midwives. If it's a felony to practice midwifery in one state, you can bet that affects practice. It's a shame, too, because then everyone goes underground and endangers lives unecessarily. So sad.
Alison

excellent post.

It is good and only right people have choices. But along with RIGHTS come RESPONSIBILITIES for client and caregiver---and all of us should be aware of these.

midwife2b · Jul 23, 2005

"Too many people think midwives are medically irresponsible and sit around aligning your chakras and lighting incense instead of taking care of the mom in appropriate ways."

:rotfl: I don't have any chakras to align, and incense makes me sneeze. I do believe I am a safe practitioner who listens to my clients. I am not going to be involved with homebirth, but my studies have led me to believe that it is quite safe if everyone is educated and prepared.

breastfeedingRN · Jul 26, 2005

I'm using a homebirth CPM for my upcoming birth. She does intermittent monitoring, which is the ACOG standard (it is not continuous for low-risk women). Like the PP said, she uses either a Doppler or fetascope, both of which have been proven to have equal efficacy to the EFM machines in the hospital. If anything, there are advantages to the Dop and fetascope, which allow for much more freedom of movement and immersion in water/birth tubs.
I am confident in her assessment skills and know she would transfer me to the hospital if something should be out of her scope. If there are non reassuring heart tones, she doesn't just transfer. She tries a host of things to normalize the baby. She carries a tremendous amount of equipment, and in CA, she also carries Pit and methergine in the event of postpartum hemmorhage. As part of the birth kit I ordered in preparation for the birth, I included a DeLee suction in there. She brings oxygen tanks and resuc stuff, too.
I did not sign a waiver releasing my midwife should something go wrong, nor did she ask me to. Midwives have much lower rates of litigation, especially CPM's, in part because their clients are low risk, and also because the relationship they foster is one of mutual respect. They also spend MUCH more time with their clientele, which allows them to spot and prevent problems far earlier (which can nip complications in the bud, thereby boosting the chance of a positive outcome and no suing). I've mentioned this before on the boards, but it's striking how different my experience has been compared to many of my doula clients. They wait in a waiting room for an hour to see their OB for a 10 minute appointment.
My midwife comes to my home, and we meet for 1-2 HOURS. We discuss nutrition, emotions, physical changes, etc. My husband and child are highly involved in my prenatal care. Any tests she needs to run, such as an OB panel, GBS testing or blood sugars, are done right there. Midwives are known for having better outcomes, even when compared with low risk OB patients, and I suspect this is a factor in litigation as well.
The populations that midwives serve may also play a factor in litigation, too. They usually serve the Amish, religious Christians and crunchy contingent who do not expect their midwives to always have a perfect outcome (an impossible and punishing standard for midwives and OB's alike). Many of their clients are pretty mainstream, too, though, and lest you think that midwives completely escape the lawyers, let me assure you that they are often pursued legally, though often more by doctors and the AMA than their clients. Still, some parents have sued or brought up a complaint with the state board. It happens, just like the OB's, and it's a risk that midwives take.
This was a great question, by the way, and I'm glad you asked it. Too many people think midwives are medically irresponsible and sit around aligning your chakras and lighting incense instead of taking care of the mom in appropriate ways.
One last caveat: given the variability of state laws around midwifery, it is possible that midwives in certain states are better able to care for their clients, particularly during transfer, than other midwives. If it's a felony to practice midwifery in one state, you can bet that affects practice. It's a shame, too, because then everyone goes underground and endangers lives unecessarily. So sad.
Alison

Awesome post! I plan on having my baby with the care of a CPM at home this time. I couldn't have said it better, so I won't even try!