Do you have any experience with homebirths? Midwives? Planned unassisted births?

[JPINFV]

I too agree that the hospital is not the root of all evil and (assuming properly equipped), is the best place for resuscitation. However not all health care needs to be delivered in a hospital, even if there is a risk of resuscitation being needed.

 

[CAOX3]

I've had RNs removed from scenes by police before. Several probably could clawed my eyes out without any qualms. Luckily, in New York, in the field, an RN carries no more weight (legally) than a non-trained bystander.

Don't get me wrong; I've used RNs a lot, too. I have been grateful for their help. But if you get in the way or make my job any harder, you will be leaving.

This is what I was commenting on.

Make your job harder? Yeah why would you allow true education and years of specialized experience get in you way. (most midwives here ARE CNMs)

See here is the problem, I know some fantastic educated and experienced paramedics, part of that is understanding your limitations. In not saying kiss anyones butt or bow down but she is an invited specialty health care provider and in most cases will be a valued member of the team if you have the forsight to recognise this.

Of course if there is blatant disregard for care then by all means remove her however I would guess this is more the exception then the rule.

Listen some EMS professionals are egomaniacal megalomaniacs they question everyone from the tow truck driver to the cardiothoracic surgeon its hilarious and disgusting.

 

[LucidResq]

I'm looking over the research, but I'd like to point out that from what I'm seeing this high infant mortality rate idea everyone keeps citing is based on one study with 20-25 year old data from Australia exclusively:

Perinatal death associated with planned home birth in Australia: population based study

I'm still browsing for more current and global research.

 

[abckidsmom]

Here's an article for you all to consider, it's from the New Yorker and entitled "The Score; how childbirth went industrial."

Read more http://www.newyorker.com/archive/2006/10/09/061009fa_fact#ixzz1PwqGlvrb​

Not much room for midwives is there?

We tend to have blinders on when it comes to understanding how little we know in modern medicine and how much of what was sound, time-tested intervention we're actually losing. The pattern is to de-bunk the past, which includes a whole lot of "art", and embrace technology. That happens to include limiting us to that which goes on in the Institiution, thereby taking the patient away from the home and power away from the common folk.

But who pays the price? That is a lot of the gig -- many people are forced to place themselves in financial jeopardy (at the least!), to be treated by cookie-cutter technology that often misses more than it catches.

But what I'd like you to hear in the article is how head, hands and heart in our most sensitive of life events has been summarily replaced with costly, and often de-humanizing, technology.

Midwives are artists that work with their hands. According to the article, Doctors, once carrying on that tradition, have abandoned it in favor of cookie-cutter procedures designed to limit liability. That does not necessarily protect anyone but the Doctor.

What about unplanned homebirths? I finding it amusing that people wait until contractions = 2 mins apart before calling an Ambulance. Zipped one lady to hospital in the wee hours of this AM, contractions were 45 seconds apart on arrival.:lol:

Homebirths have 7 times the mortality rate. Considering that all planned homebirths generally involve a healthy mother and foetus with no major complications, the fact that these neonates are 7 times more likely to die is disturbing.

Not just that but many normal births suddenly become complicated.

I am a he/male/man btw

I wanted to put these two posts together because they are really quite related. Modern birth has lost some of the key mechanisms that increase interior pelvic diameter and introduces gravitational forces that fight the birth process. Other biped mammals would NEVER give birth laying down, much less on their back.

Modern birth frequently goes bad BECAUSE we do not use prehistoric, time tested techniques to assist women in labor.

 

[LucidResq]

Here's one from 2000-2004 in Canada that shows physician-attended hospital births with a slightly higher (but likely statistically insignificant) infant mortality rate than planned home births AND midwife-attended hospital births.

One from 2009 that has a sample size of over 1/2 a million women from the Netherlands showing no significant difference between hospital and home birth in regards to mortality/morbidity.

With more current research from many other parts of the world with larger sample sizes show opposing information to the one, old Australia study... I think it's hardly sound to state "infants born at home are 7 times as likely to die as those in the hospital". I do understand there are also modern studies from other countries that show a higher mortality/morbidity rate... But I guess the take-home point is statistics are just that - numbers created by people with their own motivations... and looking at the big picture of research and statistics is a weak point in EMS.

 

[zmedic]

I had a bad experience with a mid-wife. She tried to deliver a breach at home, with no resuscitation equipment, and didn't call us until the baby was out and not breathing. Baby died. Responsible midwives have the gear to resuscitate, a plan to get the mother to the hospital when things START going badly, and the humility to recognize when the situation has gone beyond their level of training.

 

[Aidey]

Here's one from 2000-2004 in Canada that shows physician-attended hospital births with a slightly higher (but likely statistically insignificant) infant mortality rate than planned home births AND midwife-attended hospital births.

http://www.ncbi.nlm.nih.gov/pubmed/19624439

What sucks is that you can't tell from the abstract WHY the women chose the birthing method they did. It may be that the physician attended births were deemed more complicated ahead of time, hence why they were physician attended.

Here is another study that indicates home births had triple the mortality rate, however it was a meta-analysis and includes no numbers, which makes it hard to assess the quality of the study.

 

[LucidResq]

I'm not trying to get into a study-score-point-board competition - and as I said there ARE several legitimate studies that show higher mortality rates in home births. As you said, some of these patients may have been turned away or chosen NOT to see a midwife due to risks such as gestational diabetes, preeclampsia, etc. The only point I'm trying to make here is that it's a stretch to say home birth is definitely dangerous, or definitely NOT dangerous.

IMHO the only thing these studies show is a need for more research. It's all very limited right now.

However, I think completely condemning someone who wants to deliver at home or in a birthing center is taking very limited and aged data way too far.

Personally, I hope to deliver my children at a birthing center. A strong candidate is one that employs several highly-educated CNMs (including a former coworker of mine who is a highly educated and experienced DNP, CNM and WHNP) and is half a block from a very good hospital.

I agree, delivering 50 miles out in the sticks from a hospital is a bad idea. As is having a lay-midwife without a back-up plan or a provider not prepared to resuscitate. Don't knock every woman who doesn't want to deliver in a hospital or every midwife, though.

Although anecdotal my former boss, an experienced OB-GYN, was very skeptical of midwife-assisted births. She spent a day at aforementioned birthing center and totally changed her mind, and said she would much rather deliver at a birthing center than hospital if she had a non-complicated pregnancy.

 

[Farmer2DO]

This is what I was commenting on.

Make your job harder? Yeah why would you allow true education and years of specialized experience get in you way. (most midwives here ARE CNMs)

See here is the problem, I know some fantastic educated and experienced paramedics, part of that is understanding your limitations. In not saying kiss anyones butt or bow down but she is an invited specialty health care provider and in most cases will be a valued member of the team if you have the forsight to recognise this.

Of course if there is blatant disregard for care then by all means remove her however I would guess this is more the exception then the rule.

Listen some EMS professionals are egomaniacal megalomaniacs they question everyone from the tow truck driver to the cardiothoracic surgeon its hilarious and disgusting.

I'm an FTO and a preceptor for paramedic students and interns, as well as basic EMT new hires. I regularly tell my fledglings that there is something to be learned from almost everyone you encounter. Healthcare is truly multi-disciplinary; I'm all for taking someone else's experience and knowledge into account and using them. What I'm not willing to do is be treated like a second class citizen, or to blindly let someone else give bad advice or provide bad care without somehow stepping in (even if it's only to offer my opinion). This thread offers the example of a midwife trying to force a VERY BAD option on a family that might cause a bad outcome to a patient that is not able to offer their input. Another thread talks about a nurse that didn't even come out from behind the bullet proof glass to evaluate the "psych" patient that had an unexplained altered mental status with significant tachycardia, also unexplained. She was marginally helpful and only provided limited information when it was dragged out of her. So yeah, these nurses don't get my respect. I will try to provide care for the patients in whatever manner I can, which will start with being polite. But when they actively work against the best interest of the patient, there's a problem.

The vast majority of nurses (or pick your profession) are professional, competent and caring. I work extremely well with almost all of them on a daily basis. I often collaborate with them in regards to patients that will be or were under their care, and I often get compliments for the appropriateness of my care and handoffs. We all encounter the ones that have no desire to work together though, and routinely make bad decisions. That's what this thread was started about, and that's what I'm commenting about.

 

[Journey]

What I'm not willing to do is be treated like a second class citizen, or to blindly let someone else give bad advice or provide bad care without somehow stepping in (even if it's only to offer my opinion).

The midwife also should not have to abandon her patient to see that your needs are met. Her concern is with the patient and not whether you feel her attention to the patient makes you feel like a second class citizen.

You mention a multidisciplinary approach but you fail to differentiate that different professions also acknowledge their own strengths and weaknesses. If the midwife called you, she may have realized that more help is needed but that does not mean you force her from the picture. You also have your own opinion which may be based more on personal or religious beliefs rather than education. Even the posts on this forum give the young, inexperienced and under educated a skewed view of medicine with a mix of very good and very bad advice or information given. It is not always easy for those who do not have much experience or education in many of these areas to sort out the bs from the good stuff.

This thread offers the example of a midwife trying to force a VERY BAD option on a family that might cause a bad outcome to a patient that is not able to offer their input.

You are making a guess here and have no idea how much education, discussion and liability control steps are taken during the few months leading up to the birth. The parents make an informed decision and don't just call up a midwife from the yellow pages when the baby is popping out.

Another thread talks about a nurse that didn't even come out from behind the bullet proof glass to evaluate the "psych" patient that had an unexplained altered mental status with significant tachycardia, also unexplained. She was marginally helpful and only provided limited information when it was dragged out of her. So yeah, these nurses don't get my respect. I will try to provide care for the patients in whatever manner I can, which will start with being polite. But when they actively work against the best interest of the patient, there's a problem.

This was a prearranged direct admit to a psych facility that appears to have been located in a hospital. You have NO idea what type of assessment was done by the RN or any other healthcare professional prior to the arrival of an EMT-Basic.

Also, if this psych ward is inside a hospital, medical care is provided with all the same workup that can be done in the ED but in an environment which is less frantic to the patient and less dangerous for other patients as well as the staff. Hospital Rapid Response and Code teams also respond to these units. EDs do not always have a safe area for psych patients and sometimes they get tied up next to a frightened toddler.

In that situation, I would say the RN gave enough information for that level of provider and maybe as an EMT he didn't see or hear the whole picture. But, neither you nor I were there to know what happened and this EMT/OP might just want to bash and trash RNs which you are very willing to feed into.

When you enter a patient area with a chip on your shoulder it shows. And, it will probably set the feelings of the other health care professionals (RNs/MDs) for the EMTs who will be delivering or picking up patients from that facility after you.

 

[Sasha]

Journey!! Welcome back!

 

[Aidey]

I too agree that the hospital is not the root of all evil and (assuming properly equipped), is the best place for resuscitation. However not all health care needs to be delivered in a hospital, even if there is a risk of resuscitation being needed.

I agree somewhat. There are a number of people walking around who are ticking time bombs just waiting to collapse in the bathroom of their 3rd floor walk up and we don't encourage them to be transported proactively. More realistically, how many high risk patients are sitting in nursing homes right now receiving care there? I really don't have a problem with that.

However, a newborn has needed 5-7 minutes of supported ventilations falls into my category of patients that REALLY should be transported. Especially when it was an uncomplicated delivery with no obvious reason for the distress. No cord around the neck, no prolonged time in the birth canal, no meconium etc.

I can understand not transporting a newborn with known complications that will cause it to die shortly after birth. I have heard of at least one couple who knew ahead of time the baby would have anencephaly and chose a home delivery, thus allowing the baby to die at home.

 

[Journey]

However, a newborn has needed 5-7 minutes of supported ventilations falls into my category of patients that REALLY should be transported. Especially when it was an uncomplicated delivery with no obvious reason for the distress. No cord around the neck, no prolonged time in the birth canal, no meconium etc.

They may not always need to be transported or taken back to the NICU. That is why we do a 10 minute APGAR. If the baby is then not doing what he should be at 10 minutes, we take it back for observation. If we haven't intubated the baby before that time for any obvious reason, chances are the mother will have him in her arms at the 11th minute.

This is where those with a lot of experience delivering and assessing babies should not be kicked to a curb by someone who may never have seen any birthing process and probably doesn't know how to assess a well baby to any great extent. However, I doubt if any midwife is going to leave the birthing room at 11 minutes like a NICU team does once they are satisfied the baby is breathing and pink. A midwife should be capable of doing a S.T.A.B.L.E. assessment just like a NICU team may initiate with someone else following through with it. I think some of the posts here have failed at the "E" where you do not rush in telling everyone or acting like they are idiots and misinformed.

Maybe if you had offered to do most of the components of S.T.A.B.L.E. (including "E") along with heart sounds and looked like you actually knew a little about babies, you might have made a stronger argument than just the emotional pleading based on you own personal beliefs rather than medicine.

You may also not be aware of your own anxiety or as some prefer the term "adrenaline rush" at these scenes. There have been times when turning over a patient to some IFT ambulance crews have been difficult due to the reactions and actions of the team. I would imagine the RN in the psych thread probably had some of those thoughts.

 

[abckidsmom]

They may not always need to be transported or taken back to the NICU. That is why we do a 10 minute APGAR. If the baby is then not doing what he should be at 10 minutes, we take it back for observation. If we haven't intubated the baby before that time for any obvious reason, chances are the mother will have him in her arms at the 11th minute.

This is where those with a lot of experience delivering and assessing babies should not be kicked to a curb by someone who may never have seen any birthing process and probably doesn't know how to assess a well baby to any great extent. However, I doubt if any midwife is going to leave the birthing room at 11 minutes like a NICU team does once they are satisfied the baby is breathing and pink. A midwife should be capable of doing a S.T.A.B.L.E. assessment just like a NICU team may initiate with someone else following through with it. I think some of the posts here have failed at the "E" where you do not rush in telling everyone or acting like they are idiots and misinformed.

Maybe if you had offered to do most of the components of S.T.A.B.L.E. (including "E") along with heart sounds and looked like you actually knew a little about babies, you might have made a stronger argument than just the emotional pleading based on you own personal beliefs rather than medicine.

You may also not be aware of your own anxiety or as some prefer the term "adrenaline rush" at these scenes. There have been times when turning over a patient to some IFT ambulance crews have been difficult due to the reactions and actions of the team. I would imagine the RN in the psych thread probably had some of those thoughts.

Smart words here.

 

[johnrsemt]

Not trying to sound dumb; but what does S.T.A.B.L.E. stand for? Never heard of it. may have heard of it with out the acronym

thank you

 

[Journey]

Not trying to sound dumb; but what does S.T.A.B.L.E. stand for? Never heard of it. may have heard of it with out the acronym

thank you

S = Sugar and Safe Care

T = Temperature

A = Airway

B = Blood Pressure

E = Emotional support

http://www.stableprogram.org/

http://www.stableprogram.org/stable.php

It goes more indepth for assessment to what happens after birth than what is covered by NRP which is primarily resuscitation.

The Pre-transport Stabilization Self-Assessment Form - has interesting information you can include in your report.
http://www.stableprogram.org/docs/pssat_form.pdf

There is also a cardiac module although it probably would not be necessary at a first reponder level. However, it is interesting.

 

[Aidey]

They may not always need to be transported or taken back to the NICU. That is why we do a 10 minute APGAR. If the baby is then not doing what he should be at 10 minutes, we take it back for observation. If we haven't intubated the baby before that time for any obvious reason, chances are the mother will have him in her arms at the 11th minute.

This is where those with a lot of experience delivering and assessing babies should not be kicked to a curb by someone who may never have seen any birthing process and probably doesn't know how to assess a well baby to any great extent. However, I doubt if any midwife is going to leave the birthing room at 11 minutes like a NICU team does once they are satisfied the baby is breathing and pink. A midwife should be capable of doing a S.T.A.B.L.E. assessment just like a NICU team may initiate with someone else following through with it. I think some of the posts here have failed at the "E" where you do not rush in telling everyone or acting like they are idiots and misinformed.

Maybe if you had offered to do most of the components of S.T.A.B.L.E. (including "E") along with heart sounds and looked like you actually knew a little about babies, you might have made a stronger argument than just the emotional pleading based on you own personal beliefs rather than medicine.

You may also not be aware of your own anxiety or as some prefer the term "adrenaline rush" at these scenes. There have been times when turning over a patient to some IFT ambulance crews have been difficult due to the reactions and actions of the team. I would imagine the RN in the psych thread probably had some of those thoughts.

In the interest of not hijacking this thread I gave the very simple rundown of the call. In the long run, I was hardly able to do ANY assessment once the baby was breathing adequately on his own becuase the midwife took him and gave him to the parents and then stood between us as she proceeded to rant about modern medicine. How if he was taken to the hospital they wouldn't let the parents take him home, and how the hospital would force the parents to leave him there with the threat of calling child services even if nothing was wrong with the baby.

That their other children might be taken away and they would have to go to court to get them back. The word "patriarchy" was used. The entire time this is happening the parents have the baby and no assessment is being done by anyone. When ever we tried talking to the parents directly she interrupted and talked over us.

It was a cluster and she was totally unprofessional and her opinions/comments seriously made me think she was more concerned about politics than the baby's health.

 

[fortsmithman]

In the interest of not hijacking this thread I gave the very simple rundown of the call. In the long run, I was hardly able to do ANY assessment once the baby was breathing adequately on his own becuase the midwife took him and gave him to the parents and then stood between us as she proceeded to rant about modern medicine. How if he was taken to the hospital they wouldn't let the parents take him home, and how the hospital would force the parents to leave him there with the threat of calling child services even if nothing was wrong with the baby.

That their other children might be taken away and they would have to go to court to get them back. The word "patriarchy" was used. The entire time this is happening the parents have the baby and no assessment is being done by anyone. When ever we tried talking to the parents directly she interrupted and talked over us.

It was a cluster and she was totally unprofessional and her opinions/comments seriously made me think she was more concerned about politics than the baby's health.

That is not how the midwives in my town operate. They always display a great deal of professionalism, and only do child births in the hospital here in town. If the birth is expected to have complications then the expectant mom is flown out to our capital city where there are specialists to deal with it. Our midwives would not have acted as the one you dealt with did.

 

[Journey]

In the interest of not hijacking this thread I gave the very simple rundown of the call. In the long run, I was hardly able to do ANY assessment once the baby was breathing adequately on his own becuase the midwife took him and gave him to the parents and then stood between us as she proceeded to rant about modern medicine. How if he was taken to the hospital they wouldn't let the parents take him home, and how the hospital would force the parents to leave him there with the threat of calling child services even if nothing was wrong with the baby.

That their other children might be taken away and they would have to go to court to get them back. The word "patriarchy" was used. The entire time this is happening the parents have the baby and no assessment is being done by anyone. When ever we tried talking to the parents directly she interrupted and talked over us.

It was a cluster and she was totally unprofessional and her opinions/comments seriously made me think she was more concerned about politics than the baby's health.

As soon as we are satisfied the baby just needed a push to get started, usually right after the 10 minute mark, the baby can go to the mother. If the baby latches on to the breast, that takes care of a few assessment details or at least they can be deferred for a little while.

Some of the concerns the midwife stated were not unfounded. There seems to be a religious or some cultural issues here where in another situation, I doubt if the midwife would have been so protective. Hospitals do have attorneys, judges and CPS on speed dial for these situations. And yes, they can remove the child from the parents for various reasons. It will be the parents then who must prove they are innocent of all wrong because religion is a touchy subject and no one like to address it in a straight forward manner in the courts. Jehovah's Witnesses are definitely examples of what steps can be taken. Once blood is administerd to the baby the parents may voluntarily give up their rights and the baby is placed in the adoption process. The court of course would prefer a nice family with "normal" religious beliefs to take custody.