Risks & Benefits of Hospital Birth vs. Birthing Center

klone, MSN, RN · Feb 1, 2011

The woman with the lady partsl laceration - did she have an epidural? How was second stage? How was crowning?

The woman who was abrupting - you don't think the decels would have been picked up via auscultation? You don't think the midwife would have picked up on an abruption through assessment?

We're ALL glad that in true emergencies, there are hospitals available.

For every birth story you can tell me about a woman or baby who would have died if she had been at home, I can tell you a similar story about iatrogenic morbidity/mortality that probably would have been prevented in a non-hospital setting.

The facts remain that for low risk women, birthing at home or in a FSBC is AS safe, if not SAFER, for the mom and the baby, than being at a hospital.

chanelagonzalez · Feb 1, 2011

The patient with lady partsl lacerations did not have an epidural, did have natural labor and a precipitous one at that. Just very quick and uncontrolled pushing we believe led to the terrible destruction at the lady partsl vault. And the abrupting patient, the strip was beautiful before the prolonged decel. There were no signs of distress. Mod variability with accels down to the 60s. Like that. We believe the knot in the cord was getting tighter as the baby tried to descend , along with the abrupting placenta caused the abrupt decel.....

klone, MSN, RN · Feb 1, 2011

OP, did you know that controlled studies have found that continuous fetal monitoring does NOT result in better outcomes than intermittent monitoring? However, continuous fetal monitoring IS associated with a higher rate of C/S.

While I know it's scary, the idea of not continuously monitoring labor patients (believe me, I deal with it myself - I just got a job as a backup attendant to a homebirth midwife, and the idea of NO EFM at all kind of scares me - there's definitely something reassuring about seeing those accels on paper), the fact is, continuous monitoring doesn't HELP, but only increases maternal morbidity.

Elvish, BSN, DNP, RN, NP · Feb 1, 2011

No one who works in a hospital sees the good homebirths, because they never set foot in the hospital, and they don't make headlines because they go off without a hitch.

We had a baby who died a couple days after a botched VE, and which by default would not have happened (nor would VE even have been necessary) had she delivered at home. We've had mothers end up in ICU s/p NSVD after postpartum hemorrhages caused by atony from over-Pitting a uterus until it just gave out. I can tell horror stories too, but that's not really the point. The numbers are pretty clear that for healthy women having healthy pregnancies the risk for home birth is about equal to or less than the risk for hospital birth.

In a real emergency, a good midwife will pick up on stuff early and transport early. But it's not good policy to have CPMs out there practicing with no physician backup in case they do have to transport. That's what you get when CPMs (who are NOT 'lay midwives') are not allowed to legally practice. (Personal beef about my state's politics...)

RadBSN · Feb 1, 2011

I don't think midwives could pick up on a tight nuchal cord too quickly since many do not use continuous fetal monitoring. I have assisted many deliveries to babies born with tight nuchal cords and the outcome was great. But, in this rare particular case, it was a combo. of the nuchal cord, a true knot and a short cord that was causing an abruption... Also, the hemorrhage i mentioned was from terrible lady partsl lacerations leading all the way to the lady partsl fornix which took a significant amount of time to repair and an EBL of 3000 cc. I know these instances are RARE, just glad that these patients were at my facility and not at home or in a BC. . I do admit that i am biased... and a bit naive when it comes to BCs... I appreciate all the opinions so far!

I think that getting opinions is great, but it would really behoove you to go out there and do some research. Check PubMed and CINAHL for studies on continuous EFM v. intermittent fetal monitoring, midwife attended deliveries, pick up a copy of a midwifery journal, etc.

We could really "what if" the situation and the scenarios to death, because there will always be these crazy situations that happen and we wonder what would have happened if... You say that the mom with the severe lady partsl lacs had them as the result of uncontrolled pushing, maybe a midwife would have been in there and able to help the mom control her pushing avoiding tears. Or, maybe, if she was at home the same thing would have happened and the midwife would have called 911 to transport her to the hospital for a repair and transfusion.

carrotstix · Feb 1, 2011

I am very pro midwifery, Baby Catcher is one of my favorite books. However, I was concerned the other day when I stumbled across a certain video on youtube. It was a homebirth VBAC of twins. As a NICU nurse the thought gave me chills. Apparently this woman had traveled out of state to find a midwife (not a CNM) to do this with her. Luckily her outcome was positive but that just sounded so risky to me!

JeanettePNP, MSN, RN, NP · Feb 1, 2011

I am very pro midwifery, Baby Catcher is one of my favorite books. However, I was concerned the other day when I stumbled across a certain video on youtube. It was a homebirth VBAC of twins. As a NICU nurse the thought gave me chills. Apparently this woman had traveled out of state to find a midwife (not a CNM) to do this with her. Luckily her outcome was positive but that just sounded so risky to me!

On the one hand... yeah, sounds irresponsible to take such a risk. On the other hand, being a double-triple-quadruple high risk pregnancy is like a green light to give every intervention in the book and basically make the mother spend labor strapped to bed with IV's and monitors. If there were some kind of happy balance... a carefully monitored pregnancy, in hospital, but hands off unless a complication develops, fewer women would take these risks.

gjwandkids · Feb 1, 2011

Let me start by saying that I'm not a nurse...I'm a nurse's wife.

I have however given birth to nine children. 3 in hospital, 2 at home, 1 transport, 2 at home, 1 hospital-in that order.

5 different hospitals and 4 OB's, 1 CNM in 4 different states. 3 different midwives for the home-births due to one retirement and one move on my part.

I've had a demorol birth, a nubain birth, a natural hospital birth, 2 natural homebirths, 1 natural hospital birth, 2 natural homebirths and 1 epidural hospital birth.

I've given birth with and without an episiotomy and all of my children were over nine pounds at birth (no I have never had gestational diabetes although they test me every blessed time I'm pregnant).

I am also studying towards my CPM, as is one of my daughters. I belong to a midwives organization for my state and have been to a number of conferences that offer training and networking opportunities.

So I've had a wide variety of experiences with birthing environments and also birthing practices.

Here are my thoughts on this subject for the OP.

For a low risk mother home is a generally a better environment.

The mom and the baby are already immune to any of the germs floating around.

The mother is more relaxed which makes labor less painful and generally shorter.

The mother and the father are both very well informed about the birthing process.

The father is able to support his wife and participate in the birth of his child to a far greater degree at home than in hospital.

Most home-birth midwives are very well trained, and able to pick up on a complication before it becomes a crisis. At which point they will transport.

In the case of my transport I actually made the call to transport before the midwife. Something just felt off and I made the decision that it would be better to go in. (Everything turned out fine, but I still believe I made the correct decision in that case.)

Most midwives have a limit as to how far from a hospital they will attend a homebirth, just in case the rare complication happens that they can't safely handle at home.

I'm sure there are bad midwives out there. I am equally sure there are bad OB's out there. That doesn't make the whole profession bad in either case. However in the case of a bad midwife, she probably doesn't end up with a lot of clients...word of mouth is a powerful thing.

In some cases hospital is the better place to birth. For instance I would not counsel a VBAC at home (and I know exactly two midwives who will take that kind of client). If the mother feels safer at the hospital that's where she should be. If the mom has a tendency to bleed she shouldn't be at home etc...a number of midwives I know won't take a first birth for home, although there are some more experienced midwives I know that do.

But the bottom line is that in most instances home is better for the baby and the mother. Many other countries are already aware of this, and support their midwives who attend at home. Midwives and OB's work together to serve the mothers instead of against each other as is sadly the case all too often in the United States. (And midwives are just as guilty of hurling accusations against OB's as OB's are guilty of hurling them at midwives..)

I would love to see all birth attendants work together in this country, I think it would serve women better. To the original poster, I want to thank you for asking about it rather than deciding to condemn home-birth because you work in a hospital. Please research the subject from both sides thoroughly. I second the suggestion on the video.

If you like to read I suggest starting with Spiritual Midwifery by Ina May Gaskin. Be aware that she's quite earthy in her usage of language and that many of her early clients were hippies. It is however a most informative book about birth in general and home-birth in particular.

Pax Christi,

Wendi

SBarn · Feb 2, 2011

"If there were some kind of happy balance... a carefully monitored pregnancy, in hospital, but hands off unless a complication develops, fewer women would take these risks"

My thoughts exactly. I am not a nurse yet, but I wanted so badly to have a natural labor and delivery. When I went in for my last appointment before my due date my OB told me we had to schedule an induction for my due date, that it was unhealthy and risky to let the pregnancy go past that. I cried and begged and he agreed to let me go 2 days after my due date. I got to 8 centimeters and ended up with a C Section because my son's heart rate was decelerating so much. Even though I had done a lot of reading and felt confident that my son would be better off waiting until labor naturally started, I felt pushed and bullied into agreeing with the induction. I felt that if something did go wrong after I had refused the induction that I couldn't live with myself. Now I have no idea whether or not we will decide to do a repeat section or a VBAC whenever we have our next child. There should be a middle ground between birthing at home and being pushed into an induction.

kythe, LPN · Feb 2, 2011

In my city, we have a free-standing birth center that has been open for 27 years and does a few hundred births per year. They are run by CNMs and employ L&D RNs also. They have never been associated with a hospital, but they are only about 2 minutes from the nearest one. Including those transferred to the hospital during labor, they have never lost a mother or baby. To me, this does speak for the safety of the environment.

As with all midwives, they accept only low risk women. The definition of "low-risk" has changed over the years. Back in the 80's, they used to accept VBAC clients and also delivered several sets of twins. Now, these women are risked out. Prenatal visits range from 15 minutes to an hour each, depending on which visit it is. The same standard testing is done as what you see in any OB office.

The biggest difference you see in care is in labor. They have no continual fetal monitors, but just use intermittent monitoring with a doppler. They do far less cervical checks than hospitals tend to do, generally just one upon admission and one at the beginning of the pushing stage. They encourage women to use movement and positioning to aid with labor progression. They have tools such as birth stools, birth balls, oversized tubs and a waterbirth tub, and they encourage doulas.

The home-like atmosphere doesn't detract from safety. I wish more hospitals acknowledged this and adapted their practices.

RooseveltERoosevelt · Feb 2, 2011

When I was in nursing school, I did my OB rotation at a hospital where there was actually a birthing center inside of the hospital. It allowed for women to have the more hands-off midwife experience, but if something arose and they needed to be in L&D, it was a matter of moments for them to be there. I even met someone who had delivered her first in the BC and with her 2nd developed a condition (I can't really remember, but I want to say thrombocytopenia) that necessitated a delivery in L&D, but because it was the same hospital, her midwife was still able to deliver her baby, and she was back to deliver #3 in the BC. It really seemed to be a great compromise of both worlds.

chanelagonzalez · Feb 2, 2011

A birthing center inside of a hospital. Now that is an idea. Where is this located? Again, thanks everyone for the opinions. I have done a small amount of research on the subjects of inductions vs natural labor and hospital deliveries vs out of hospital and I do like to hear what others think. I appreciate the stories !