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Hospital births and obstetricians are not the enemies of low-intervention spontaneous vaginal delivery.
As an ob/gyn resident training on the west side of Los Angeles, I am used to encountering patients who have specific plans and expectations for childbirth. At our hospital we are very comfortable admitting mothers who have birth plans and we work alongside certified nurse midwives (CNMs), ally with doulas for birth support, and know not to ask our hypnobirthers about analgesia.
Our hospital’s labor rooms often receive home-birth transfers. Anecdotally, the most common reasons for such transfers are maternal exhaustion, pain, abnormal labor, or fetal concerns. When these patients arrive on the unit, they are often sneeringly referred to as having “failed home birth.” I refuse to use that label. Throughout the United States, more women are choosing to undergo out-of-hospital births; nevertheless, they make up only 1.4% of all deliveries. Oregon has the highest rate of home births at 2.4%, and Louisiana the lowest at 0.2%.1 The overall percentage of out-of-hospital deliveries is low, yet these births increased by 24% between 2008 and 2012. More so, the percentage of women undergoing a trial of labor after cesarean (TOLAC) is increasing, while the percentage of TOLACs in hospitals is decreasing. 2
The American College of Obstetricians Gynecologists’ (ACOG) Committee Opinion states “hospitals and birthing centers are the safest setting for birth,” but it respects the right of a woman to make a “medically informed decision about delivery (location)”. 3 More recently, the American Academy of Pediatrics (AAP) stated that “pediatricians should advise parents who are planning a home birth that AAP and ACOG recommend only midwives who are certified by the American Midwifery Certification Board.”4 Women who are home-birth transfers often arrive accompanied by a “lay-midwife,” aka a certified professional midwife (CPM) who does not have hospital privileges. Unlike CNMs, CPMs are direct-entry providers, without masters-level midwifery education.
I advocate vaginal deliveries, as would everyone with whom I trained. We promote TOLACs, admissions of women who are in active labor, no elective inductions of labor, and surely no cesarean deliveries on maternal request (CDMR). We understand that labor is natural and we trust “Mother Nature.”5 Hospital births and obstetricians are not the enemies of low-intervention spontaneous vaginal delivery. We know that home births have fewer obstetrics interventions, but are associated with concomitantly higher rates of infant mortality during the first month of life, and that babies delivered at home are more likely to have significant neurologic sequelae when compared to those delivered in a hospital.6 We train and practice with the understanding that a woman should be given the right to make an informed choice to deliver in a space that respects her dignity and safety.
There are two goals in managing labor: a healthy mother and a healthy baby. Without a doubt, there are many ways to get from A to B; however, just because a patient is admitted to a hospital does not mean she will get “medicalized.” I’m not sure how to dispel this myth. Yes, more often than not, we insert a peripheral intravenous (IV), anticipating active management of the third stage of labor or a possible emergent need for IV administration of antihypertensive medication. Yes, we do put the baby on the monitor, but the mother is generally free to move around on telemetry as long as there is no concern for seizing or having a stroke. And yes, we care about the mother’s health and safety, so we get vitals to give us a sense of where the woman is hemodynamically.
Recently, I was asked, for the first time, not to be part of a patient’s delivery (“I don’t want you to learn your interventional birthing on me”). I have often heard patients ask our medical students to leave the delivery room. In these cases, I respectfully tell the patient that this is a teaching hospital, and that this is the only opportunity for these students to learn the intricacies of our field before they graduate. With that explanation, patients typically agree to allow the students in.
I’m not sure why this patient’s request hurt me more than I expected. I felt a sense of foreignness as I walked out of her room. She wanted a vaginal delivery and that is exactly what I wanted for her, too. Why didn’t she understand? She saw me as the enemy of her natural birth. I had been the one who admitted her and detailed her birth plan requests into her medical record. I discussed our rationale for starting oxytocin (her membranes had been ruptured for 32 hours and she was not yet in labor). I put in her admission orders and excused myself while arranging her transfer of care to a non-teaching service. I cannot prove that she would have received better care on a teaching service, nor can I prove that she would not have, but I had to respect her choice. She ended up delivering vaginally 29 hours later with a complication of a shoulder dystocia and a postpartum hemorrhage.
After she delivered, I swallowed my pride and went to visit her on the postpartum unit. She apologized for asking me to leave and I told her I just wanted to check in on her. She later sent me a thank-you note for caring for her. Although I did not deliver her child, it is still one of the most special notes I have received. “I hope you are around to deliver my grandchildren,” she wrote.
Why are obstetricians often seen as the antithesis of natural labor? For all of us who go into practice aspiring to support natural births, if we are not exposed to these deliveries in training, we are unlikely to be comfortable advocating for them as attendings in the future. Hospitals, obstetricians, and especially resident physicians are seen as personifying medicalized birth. I hope we can end this stereotype. We know that the number of home births is increasing and that more women are looking to have low-intervention births. Hospitals should cater to this by promoting greater CNM collaboration, laborists, shared patient decision-making, and hospital-based birth centers. Hospitals and obstetricians should be seen as partners and allies of birth, not the enemy.
1. Centers for Disease Control and Prevention. Births: Final Data for 2012. Available at http://www.cdc.gov/nchs/data/nvsr/nvsr62/nvsr62_09.pdf. Published December 30, 2013, Accessed March 5, 2015.
2. Macdorman MF, Declercq E, Mathews TJ, Stotland N. Trends and characteristics of home vaginal birth after cesarean delivery in the United States and selected States. Obstet Gynecol. 2012;119(4):737-44.
3. ACOG Committee Opinion No. 476: planned home birth. Obstet Gynecol. 2011;117(2 Pt 1):425-8.
4. American Academy of Pediatrics. Committee on fetus and newborn: planned home birth. Pediatrics 2013;131:1016-20.
5. Dr. Barry Brock, Cedars-Sinai Medical Group; Los Angeles, California
6. Grünebaum A, Mccullough LB, Sapra KJ, et al. Early and total neonatal mortality in relation to birth setting in the United States, 2006-2009. Am J Obstet Gynecol. 2014;211(4):390.e1-7.