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Ronnie Falcao, LM MS, a homebirth midwife in Mountain View, CA

Midwives Talk About Homebirth

I have been reading all the posts over the past few days regarding minimum number of births for safe practice, various routes to midwifery education, etc. Clearly this has touched a raw nerve in many of us. Rather than adding fuel to the fire, I would like to pose a question.

Many have mentioned that there are different skills required for home births than hospital births. My question is " How so? " I have attended births both in the hospital and at home. I have also given birth to one daughter in the hospital and one at home I have experienced both settings from both viewpoints, and don't really see how the skills differ from one setting to the other. In my opinion, the skills required for good midwifery care are the same in either setting--good assessment skills, good communication skills, good hand skills ,respect, compassion, and a strong desire to be with birthing women. I understand that in a tertiary care setting there are often residents or others who may perform some functions, but that doesn't mean we shouldn't also know how to do these same things. For example I think we should all know manual removal , bimanual compression, Neonatal resuscitation ( which is not the same as infant CPR ) and other rarely used but very important skills, regardless of the setting in which we practice.

So I am posing to the list--how are the required skills different at home and hospital?

Very first, I would like to respond with my opinion about the above statement...... I don't consider "respect, compassion and a strong desire to be with birthing women" to be skills that can be learned in any environment, if they are not part of who we are as people (almost said women there, sorry guys:-)) then we have no business training to be midwives by any route.

Secondly, while I agree that many of the skills needed to be a safe practitioner are common to hospital and home practises, many others are not. Many of the skills that you have learned in the hospital, I have not with homebirth training, such things as chemical inductions, electronics monitoring are just a couple that are real tangible. Skills I use at homebirths that are not taught in hospital training would run along the lines of using herbs, homeopathics and various comfort measures, and assessment of labor w/o high tech ( realizing that this is not universal to all hospital trained midwives, but I am amazed at the # of CNM's I have run into who can not listen to heart tones with a fetoscope.......including one who told me that it couldn't be done at 24 weeks.) I guess my main point is that good assessment skills and good skills for handling the unexpected are important for either home or hospital, but the tools to implement those skills are different.

Lastly, I don't think that any of the skills of a homebirth trained midwife can not be acquired by by a hospital trained midwife with further training, and I suspect that I could learn the skills I needed to function as part of a hospital team with further training.

I beg to respectfully disagree. I truly enjoy homebirth, and honestly find hospital birth to be more difficult because I have to constantly fight off nurses and physicians wanting me to do those medical interventions (EFM, Pit, etc.). I don't have to play "you and me against the world" with the laboring woman at her home. However, a whole lot of my patients live in isolated, substandard housing, and they honestly just want me or the physician to "take care of them." Many are not at all empowered to take care of themselves.

I purposely went to a very medically oriented CNM program (U. of Kentucky), because the medical model is NOT where my heart is. I wanted to know everything I could about high-risk pregnancy, labor & delivery, and to learn how to do those interventions, because sometimes they are indicated and come in very handy. My favorite rant is the appropriate use of technology-just because we have the tools doesn't mean we have to use them all the time.

I've not ever been to a homebirth. I guess what is different is perhaps the "tools" we use. There aren't meds in a home birth setting, or access to resuscitative equipment or operating rooms (and not that there should be). Also, in a hospital setting, for example when I first started at Cook County in June 1995, I hadn't done a birth in over a year, and had only done 21 supervised births as a student midwife anyway.

For my first several (11) I think, I had another seasoned CNM right there w/ me. For the next 10 or so, they were in the area and could be w/ me in less than 60 seconds if I so desired. By about #25 or so (25 at cook county), I was routinely in the delivery room by myself w/ a nurse and the woman and her support person.

I don't have a good answer as to why it would be different in the home setting. Perhaps, since most DEM's aren't nurses (and in my case labor and delivery nurse), so don't have the background knowledge. I was expert as fetal monitoring, labor support in the hospital, how to manage augmentations and inductions, do fetal testing (NST, CST, etc). I knew how labor progressed, etc. When I was a student midwife, the first birth I attended wasn't the first I had ever seem (not that that is the case w/ DEM's) So I had a lot to draw on that say an apprentice who takes up midwifery might not have had. I know we all come from various backgrounds so is hard to give a hard and fast answer.

I suppose if you translate my experience to homebirth, maybe it would be an assistant of many years who also taught CBE (like I did) and then started to change roles w/ supervision. That person probably wouldn't need 100 births to start soloing. I like the 40 observes w/ 60 observed before becoming primary method. I also like that idea of a dollar for each birth, that's way cool and validates the person and their growing body of knowledge!

It sounds like a good system that you have. I did want to point out that we do use herbs in a home birth and although we do not use pain relieving meds, many do carry pit and meth. We do carry resuscitative equipment, O2, bag and mask. We, of course, do not intubate, but certainly must know how resuscitate.

I know that many midwives do things in a lot of ways, but for me I could take on a client right now if I wanted to and I would have my senior midwife with me every step of the way for guidance. I think this is also a pretty good system. So, right now I have been to 27 births and not caught any. I have had my hands into things so to speak (compresses, oil, helping with compound presentation, etc.) and I feel quite confident that I could catch a baby. Most of them come out pretty well on their own [grin]. When I do make that first official catch odds are I will have my senior midwife right behind me to jump in if necessary.

We are also knowledgeable in fetal monitoring, augmentation, labor support etc. What we are mostly is expert at watching women and knowing when to stop watching and do something and when it is fine to just let well enough alone.

Actually, the homebirth CNM carries meds to deal with bleeding, oxygen, ambu-bag, suture stuff, etc.. There are lots of tools available to the home birth midwife. Some DEMs carry some of these, others might choose to rely on herbs instead. There are some different skills for each situation though, including some that might seem simple such as working harder at home to prevent tearing. Also, the home birth midwife works mainly with women who choose to have completely unmedicated births (those who realize they wants meds get transferred- yes, I know about the availability of meds in some of the free-standing birth centers now.). The hospital based midwife sees a lot of medicated births. I heard of an OB that attended a home birth as a favor to a friend of his. He was out of his element and so chose to just watch until the husband needed help with the placenta. Until you've been there, it might be hard to see the differences.

Hi- I just wanted to respond to the following post. I am a DEM midwife who carries all of the mentioned medical supplies and herbs. I really would not feel comfortable at a birth without either group. This makes me wonder if you all think there is a difference in practice between the homebirth CNM and DEM?

In our midwifery study groups, we have studied Varney extensively. We always are amused when the instructions say to call for a doctor, as in the SD section. Calling for a physician must be stated 10 times, or so in that section. Well, in a homebirth setting, we have dads, grandmas, and a two year old who is stepping on the sterile instruments, but when we look around the room during a shoulder dystocia, it's just us -- no OB down the hall. We have to be able to handle obstetrical emergencies without calling anyone. Most emergencies have to be handled before an ambulance and EMTs could arrive. Now I would not say for a minute that those of you who practice in a hospital setting aren't capable of handling those situations, but we absolutely have to. There is no one to rely on. No obstetricians, no neonatologists, no resuscitation team. We have to know without hesitation, how to resuscitate, stop a hemorrhage, get out a stuck baby, extract a surprise breech, and recognize fetal distress without an EFM. (and we have to do all of that after having been up for 48 hours with no sleep)

We also have to know how to calmly transport, keeping mom and dad (and grandma, for sure) calm and moving toward the door. Who is going with, who is staying? Who is monitoring the baby? What about the oxygen? We are on the phone to ambulances, back up doctors, getting slippers, and newborn diapers, baby sitter for the two-year old, and warming up cars, and covering our butts. Transport is an art all on its own.

Knowing the necessary supplies for a homebirth is a necessity. Putting all of your stuff, and all the mom's stuff in an orderly fashion is an art form. Keeping things sterile, keeping things dry, not spilling the oil, using plastic in an effective and attractive way, making sure the room is warm, my watch and their clock are synchronized, the candles are lit, camera loaded -who's taking pictures-can they work the camera?-- and the right cd is in the player-- all important. Finding the bulb syringe after a shoulder dystocia (it's ALWAYS under the mom's left hip, always!) is a highly developed talent. We don't have anyone handing us anything. Even if there are two or three of us, our jobs are usually divided so that we are all doing valuable work -- one is on baby, one on placenta, one charting, for example). We usually aren't waiting on each other, so everyone has to be aware of the room, and the set up , all the time, and then when she starts pushing in the laundry room, between the washer and dryer, and she won't move, everything changes - fast.

The biggest complaint that I have heard from homebirth midwives is that care givers who don't usually do homebirths leave right after the birth. Wait a minute....what about the placenta -- frozen, cooked, or in the trash? And speaking of trash -- where is it? What if the dog gets into it? Are there glove wrappers, dirty chux pads? This house must look exactly like it did before the birth before we can go home. What about laundry? At least get one of the helpers to put on a cold soak. My senior midwife always taught us that there can absolutely be no blood anywhere -- not in the shower, not on the toilet seat, not in the placenta bowl. Peroxide on the blood stains on the carpet. Who is going to do all of that? The mom has to be fed, cleaned up, sutured, pads on, her baby has to be nursing. No one will do these things except us. There are no nurses to call, no cleaning ladies or aids, no lactation consultants. Some of us have observed that in-hospital midwives think that the job is over when the baby is out. Not so at a home birth. There are definitely a separate set of skills for homebirth caregivers.

I will readily admit that I am totally lost in a hospital setting. I can never find anything, can't get gloves that fit, can't ever work that bright light, don't know where the mirror is, don't know how to work the bed or the call button. I think that I am really good at catching a baby, but I always look and feel foolish in a hospital. I was astonished at one hospital birth, when the CNM called in a resident to get out a placenta, when the cord broke. I would have been in and out, before the doctor even showed up, because at home, I would have to do it. I'm sure she could have too, but she had to follow her protocol.

I am always nervous when I hear of an OB nurse who is going to attend a friend at home. As Betsy stated earlier, you can attend lots of births as a nurse, without knowing how to catch a baby. I always think that those births must be tense, because the nurse usually doesn't know how to make the homebirth relaxed and nice. (Not arguing the point of whether she knows enough or not) We take great pride in knowing how to "do" a homebirth, and that involves a lot more than catching the baby.

It is a separate set of skills.

I loved this post! I had a hard time really trying to figure out the difference between homebirth and hospital birth skills and then I read your post and said, "Yes, that is the difference." I forgot about the laundry, blood stains, scared relatives, what to do with the placenta (how many do you have in your freezer?), driving like a race car driver to make it to the birth, trying to tell the father that you are a vegetarian when he is serving cold cuts, and the list goes on. Even though we are all "with women" we are with women differently, and that is cool. I admire anyone and everyone who wants to do this difficult, rewarding and extremely important work.

We take great pride in knowing how to "do" a homebirth, and that involves a lot more than catching the baby.

i've never been to a home birth, but i've always felt like that's what i want to do eventually (so why am i not a DEM? well, that's a whole 'nother question...) and i liked your post a lot. I was just talking with a midwife who's planning to leave ncb soon (has been there for many years, only place she's ever worked) and when i asked her about starting her own practice (not even home births!) she said "well, maybe, but i don't think i'm ready to take on that level of responsibility" -- and i have to say i was kind of shocked, because i've always thought of her as a midwife who DOES take full responsibility -- but it got me to thinking (yet again) what it means to work in a hospital, how (for me anyway) the one reason to be there is exactly what you're describing (or not describing, rather)-- not so much the technology of the hospital (mostly i just resent that) but the feeling that you're not in it alone, that there is a senior midwife, or a doc, down the hall if you get in over your head. I do want that responsibility of being out of hospital (like i said, eventually :-) ) in part because i want the control that goes along with it -- and because i firmly believe that normal birth really doesn't belong in a hospital, so if i want to participate in NORMAL birth, neither do i.

i don't know what spending a lot of time at ncb will do to me vis-a-vis being a homebirth midwife later on. i don't think, though, that it will "scare" me out of wanting to do homebirths, as some other midwives have said it did for them -- i've seen moms & babies saved by being in the hospital, and i've seen them severely damaged.

While I am not in the homebirth scene (yet!) either, I think your NCB experience WILL be valuable, you are seeing many things and seeing how to and not to manage them. You'll tuck them away and carry them w/ you always. Two of Chicago's busiest homebirth CNM's were at Cook County (where I'm at) when the first got out of school!

You're right though, there's ALWAYS someone there, we're never alone!

Varney practices in a university setting with OB/GYN residents around all the time (I believe--some of you may know for sure). Those of us who do hospital birth in smaller hospitals, out of a tertiary care center, have to handle emergencies by ourselves. Yes, I have an doc on backup call, but he or she is not necessarily there--they're supposed to be within 30 minutes, but that depends on the weather, the fog (bad at night here in the mountains) and the time of day (one lives 20 minutes away, and if you get her out of bed in the middle of the night, you know how it is--she has to dress, brush hair and teeth before she leaves the house to be presentable when she arrives). Usually it's just me, one RN from L&D, and if we're lucky, one RN or LPN from nursery. Additionally, now I'm precepting 2nd year family practice residents--they're following ten patients each through their entire pregnancy and being on call for the deliveries. They are an extra pair of hands, but a pair of hands that know surprisingly little sometimes (which is OK as long as they'll admit what they don't know, which one of them has trouble doing--the other 3 are fine.)

This is the case with most CNMs that I know. I AM the resuscitation team (unless by chance there happens to be an OB doc or anesthesiologist around in the middle of the night who can intubate). The RNs have NRP, but it's usually just mom, dad, maybe mom's mom and sisters, me, and one RN. I'm really supposed to call a physician before I do a manual removal, but we've discussed it, and if the woman is hemorrhaging, I'll go after it, doc or no doc--in fact one of them taught me a neat trick to remove most of an accreta with ring forceps (basically a curettage--I know, it sounded weird to me before he showed me, but it works and is no more difficult than manually removing the placenta with your hand). And I am NOT waiting 30 minutes for the physician to come for shoulder dystocia--although I'll make the nurse call them from the birthing room. I have not yet had to extract a surprise breech, and would probably be killed if I failed to diagnose one in labor--although these things happen (saw a few babies as an SNM at a university hospital with several FSE puncture holes on their butts!) We do have EFM to recognize fetal distress, but EFM is a mixed blessing. Sometimes you see things that are not normal, but are not clearly abnormal or problematic either, and then what do you do? (You continue to watch, of course, but sometimes you have to fend off a knife-wielding physician who has also been up for 48 hours just like I have, and is rapidly becoming more committed to getting this over with so we can sleep vs. committed to normal vaginal birth).

Finding all the supplies in the hospital is a joy too, especially if there have been a lot of births lately and things are not restocked yet. You don't get the privilege of checking your own birth kit. You have to try to find all the things that you need, and anticipate all the things you might need, figure out what you have and what you don't, and try to tell the nurse the complete list of what she needs to go get at one time. As someone who used to be the nurse, trust me, nothing drives you crazier than having someone send you for a list of 20 items one piece at a time--A.K.A. Nurse Aerobics. Run to the supply room, run back. Run to the med cart, run back. Run out to call the pharmacy, run back. Run here, run there--by the time you're back, the birth hasn't even happened yet, you've put 100 miles on your shoes & legs, and you're exhausted. I like to have a nurse around who's not exhausted or angry with me! They're much more helpful that way. Staffing of nurses is pitiful too--if there's more than one woman fairly close to delivery, or if one nurse has to circulate a C-section, you're down to one for the whole L&D unit, and although your patient close to delivery is normally her highest priority, she can't just ignore the other patients--she (or you) has to go check on them. If I want a nurse to go do something for me, I have to watch the rest of the floor, or do it myself. Sometimes you can pull some help off postpartum or nursery, and they're supposed to be cross-trained, but an experienced, willing L&D nurse beats the heck out of an unwilling, inexperienced but cross-trained postpartum or nursery nurse. Many of them can't do an accurate vag exam, can't monitor without EFM, can't read EFM strips, etc. They can sit with women (very helpful), and take vitals, and hang IVs and meds, and answer call lights, but it's not the same.

Having the supplies handy when she decides to push somewhere other than the bed happens to us, too--fortunately, most things are on wheels and we can get them to her.

Myself and the nurse have to light the candles (all the while making sure no one is around to catch us--candles are a big violation of hospital policy), put in the CD, make the hospital setting accommodating to the mom's wishes, make sure mom and baby are stable, mom is sutured, comfy, cleaned, has ice pack and/or pads on, is covered in clean gown and sheet, has food/fluids, has baby nursing, instruments are out of the room, blood-stained things are bagged up, floor & bloody mess is cleaned up before family who was not in the room for the birth come in. We don't have to wash the laundry, but at night we do have to make the sandwiches (unless she wants to order out). It's sometimes hard to keep the hospital birth relaxed and nice, too.

Then I have to go fill out six or seven forms and write my notes.

There is no one around handing me things (wouldn't that be nice, though?) The days of staffing like that in the hospital are over. Just wanted those of you who don't practice in a non-tertiary care center to know how things are out here in the sticks.

I generally think that much of my nursing background is not really helpful to my midwifery practice. As others have said, though, there are some general ways of collecting data and assessing clients learned in nursing school that have always framed my way thinking, as well as many practical skills learned that come in handy.

It hit me yesterday that, even though I have a homebirth practice, I probably do look more like a CNM than other midwives without nursing background do. I was doing an initial hx and physical on a new client who is pregnant with her 5th baby. The last 3 were homebirths done by a couple of different midwives other than myself. She expressed surprise that my history was so complete, and then was really surprised at my initial exam. She said that no one had done an initial exam other than a belly check before. So I found swollen nodes in her neck (not surprising since she has had a URI), a fairly loud heart murmur (which no one has apparently noticed before), developing varicose veins on the back of one leg that even she hadn't noticed before, and very thin perineal skin where a previous laceration hadn't healed well that I will make a note of working with closely during the birth. Was my time wasted? Did I put her through an ordeal that wasn't really necessary? I don't think so. I think we owe it to our clients to assess them completely and not just assume health because they look fine with their clothes on. And maybe that is where my nursing background feels useful to me.

I've been chewing on this since the question was first asked, and being a CNM who has done lots of hospital births as well as homebirths, it seems that I should have something to say.

I think midwifery IS different between hospital and home in ways that are hard to describe. It depends somewhat on the size of the hospital and the size of the practice, but certainly the simple fact that homebirth midwives have complete continuity of care may be quite different from what hospital midwives do, esp. if in the larger, higher volume services. There are no shifts to work - at home, we follow that woman from the first phone call through the first 3-4 hours postpartum, and then have the follow-up homevisits to boot. Obviously, we don't care for more than one client at a time (usually) at home. We can "manage" labor with more autonomy at home - even the most flexible hospital midwives have hospital policies that can't be ignored (I know - I tried to ignore them for years....). We don't have nursing staff at home to keep an eye on things while we go home for dinner, do clinic, deliver another client, or whatever. I feel much more accountable at home - I'm it - the buck stops here. In the hospital, there are so many other staff involved, and usually that physician just around the corner.

I've practiced in 3 different hospitals and most of the midwives I know have hospital-based practices of varying sizes, so I'm pretty familiar with where those CNMs are coming from. Most of them wouldn't want to do births outside of the hospital because that would mean leaving their safety zone. Personally, I don't feel the hospital is a safety zone for normal birth and, like others have mentioned (Nora), I've become weary of constantly fighting to keep birth normal in the hospital. So it's been a huge relief to move out of hospital practice back into the home, but there is also a much greater sense of responsibility for my clients. I have to be more independent and more secure - have more faith and less fear. Some of the practical skills are different, but one also has to have a lot of confidence to be a good homebirth practitioner.

I wish that I could concisely put down all that I think about this, but it would be far too long and involved, probably saying nothing significant, so I'll stop with this.