Home Birth

Today's episode is all about home birth! What is involved, who is a good candidate, how best to prepare for a home birth, and what happens postpartum. Thank you to registered midwife Heidi Machnee for joining us and sharing her research and expertise.

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[00:00:50] Dr. Alicia Power: Today we are lucky to have Heidi Machnee a registered midwife here in Victoria, BC, join us to talk about all things home birth. We'll review all of the evidence, risks to mom and babe, who's [00:01:00] appropriate, who's not, so Heidi, why don't you start by telling us a little bit about yourself?

[00:01:04] Heidi Machnee: Hi, I'm so happy to be here. I've been a midwife in this community for, since the summer of 2018, so just coming up on three years. So the caveat is that I am by no means the expert in home birth, but absolutely it's part of our scope and I have attended lots of home births and feel really excited to speak about it. My background is actually as a registered nurse. So I graduated from the University of Saskatchewan in 2006 and have worked as a pediatric nurse, so that's ages like zero to 17 and did that until I entered midwifery school and transitioned out. So I do have like a pretty lengthy healthcare background, but it's a background that I feel like really has added to my my, my skills and knowledge as a midwife, which is great. Yeah, so that's my background and and yeah, just happy to dive right into the content.

[00:01:48] Dr. Alicia Power: And can I just say that Heidi is also organized and she pulled together all of the articles for us to review before getting ready for this. So that is another piece that she did not tell you about herself. So why don't we get [00:02:00] into it. First, let's talk about what is home birth? What do we describe as quote unquote home birth?

[00:02:05] Heidi Machnee: Yeah, so I I think, home birth people generally think it's at your house, but there's another way of talking about it as an out of hospital birth. So for example, when I worked and lived in Penticton, there were folks that lived, a decent distance away, maybe like an hour or two outside of Penticton, were really keen to have an out of hospital birth. And we actually had births at the Ramada Hotel. So it's any site that is outside of the hospital. I know one of the midwifery practices in town has a little birth cottage that's in the back of their property. And so people use that as well. So yeah, it would be more just a birth that is occurring or planned to occur outside of the hospital.

[00:02:39] Dr. Alicia Power: Awesome. Thank you. Now let's, we're going to dig into all of the logistics around home births and who maybe, would consider it and who maybe shouldn't consider it. But why don't we start with talking about kind of the evidence around home birth and its safety. And this is very much specific to those people who quote unquote, I'm using my quote [00:03:00] unquote, my fingers here, qualify. And so that's a very specific population. So this is not all comers in pregnancy, everybody in the world. This is a very specific population, which we'll talk about a little later around who is appropriate for home birth from a safety point of view and a logistics point of view, all that type of stuff. Why don't we dig into that. We can talk about kind of safety for the delivering person and safety for the newborn baby and look at what they've looked at in their research so far.

[00:03:29] Heidi Machnee: Yeah, absolutely. Candidate selection is such a crucial part of safety. So yeah, so there's some really great kind of lists and examples I can give when we talk about that in a little bit. So yeah, I think a few caveats before diving into some actual research papers a little bit would be, obviously we all pop onto Google and do a Google search and random, multiple things come up. And I think it's what's so important is to always look at data that is reflective of our own community. So when you type in home birth, you're going to get information from the [00:04:00] Netherlands, from the UK, from birth attendants in low resource countries, from the US. And so how do you sort through, unless you have like a research background, how do you, as just as like a lay pregnant person make sense of what's coming up there when you do that search?

[00:04:15] I think speaking specifically to our neighbors to the south. And this is by no means a criticism, but it's just, it's an important thing to think about is that you're looking at a range of care provider training and skills. So in the US there are about four different paths to becoming a midwife. There's trained, lay apprentice birth midwives, there are home birth only midwives, there are certified professional midwives, there are certified midwives, there are certified nurse midwives, and all of them have different regulations, different kind of governing bodies, different education requirements.

[00:04:49] There's also differences among states. So some states, it's home birth is illegal. Some it's very integrated and supported. In some states, midwives have hospital privileges and then some they don't. [00:05:00] That is a, that has a huge impact. If you can imagine a scenario where a home birth only midwife in a state that does not support home birth runs up against a situation where, you know, for the safety of the client and the babe needs to transfer and guess what? That client's getting dropped off at the emerge. The midwife can't come in. Your care, you're transferring to a care provider that does not know this client at all. You're losing all sense of connection and continuity, not the safest way to transport. So I think that's, what's really important, even translating, there's this massive study called the Dutch home birth study, and there's even some people that critique the translation of that data. This is maybe like a generalization, but potentially there's genetic factors, Dutch folks being in general, can maybe a certain pelvis shape, maybe birthing in a certain way that it's, is maybe unique to that population.

[00:05:48] And it can, we can, we translate to that, to our population here in BC. Very important to do that, to look at our own data and what exists here. So there's two, two folks who have [00:06:00] done lots of research. So Eileen Hutton, she's done quite a few studies in Ontario. And then Patricia Janssen is someone who's done lots of research in BC. Those would be the people that I would generally, and the studies that I would generally refer my clients to, to have a peek at.

[00:06:16] Dr. Alicia Power: And we can, we'll link those studies in the show notes, so you guys can easily access those.

[00:06:21] Heidi Machnee: Yeah. Yeah, absolutely. I made a reference list so we can throw whatever is going to be helpful your way, definitely.

[00:06:28] As a synopsis so the SOGC, which is the Society of Obstetricians and Gynecologists of Canada, this organization that produces excellent, guidelines and supportive practice documents for, OBs and GPs and midwives. In 2019, so recently, they produced a guideline and, some of the points that it covered really speak to how we keep birth safe.

[00:06:47] Number one was an affirmation and an emphasis on the importance of choice for birthing people and their families. Understanding that they should have autonomy and they should feel empowered to make the right choice for them and how they [00:07:00] want to birth and where they want to birth. So that's really important.

[00:07:02] The second thing is ensuring that there's excellent communication between the obstetric community in the hospital and the people that are facilitating out of hospital birth, so that there's emergency transport standards in place that the EMS in the community is super aware, that the OBs and the GPs and the LDR nurses are all super aware that home birth is happening in the community, and the ways that we communicate to keep everyone that potentially could need to be hands on deck in the loop when someone is birthing outside of the hospital.

[00:07:31] Dr. Alicia Power: And in Victoria, we are so privileged to be in a community that does that exceptionally well. We have such collaborative care in our community. Even during pregnancy, our obstetricians don't do any primary care. So they don't see patients or clients just themselves. They work with the midwifery or the family practice practitioners to combine forces to provide great care to people.

[00:07:53] So we are so lucky in our community that we have that. And I think that's a huge piece of the puzzle, and our [00:08:00] lDR staff, our nurses and labor delivery, our EMS staff, everybody is really on board and works well as a team, which we need to keep our parents and our babies safe, right?

[00:08:09] Heidi Machnee: Absolutely. Yeah that's exactly right, Alicia. Yeah, so quickly, since we're talking about Victoria for a second here, so what happens is like at 20 weeks and 36 weeks for GPs and midwives, we send a copy of the prenatal record to labor and delivery. There's this nice filing cabinet behind the desk, which has everyone's information. And so what happens is if I'm attending someone out of hospital, when that person is, kicks into active labor, I actually call the labor and delivery charge nurse. And I'm like, Hey, this is Heidi. I'm at a home birth. This is the client's name. They actually pulled the chart. And so they have them almost pre admitted, like they're, it's on their radar that someone is out there in active labor planning a birth at home. And so that if I were to say, hey, you know what, things are just not going super well. There's a few kind of, small concerns that are coming up. [00:09:00] Best thing to transfer in, they're like, yeah, got the file right here, totally aware of who this person is, and they've been kept up to date along the way.

[00:09:07] And then, if the person births at home and, babe and mom are great and everything's like looking super smooth, we call and close the loop. So we're like, hey. Baby boy born at this time. Everyone's doing great. And they're like, awesome. Congratulations. That's so awesome. Have a good night. And I made reference as well to the EMS. So ambulance attendants absolutely are fully aware that home birth happens in the community. So they're not surprised being like, what, a home birth? So there's all the, all kinds of pieces like that, that are really important again, to the safety of how we do things in Victoria.

[00:09:37] Dr. Alicia Power: Yeah. And so we're going to talk to a community, this ours, right? So the evidence that we're looking at looks at well established communities with home births, qualified attendance and appropriately selected people who are choosing to birth at home. So those are the studies that we're looking at. So let's talk about, do you want to talk about the one that was done in [00:10:00] BC?

[00:10:00] There was one study done in BC and it looked at all births from 2000 to 2004, I believe. And these were for pregnant people who qualified, again, my fingers are doing the quotation marks, qualified for home birth. So they met the criteria from a safety point of view. The pregnant person's medical stuff, the baby's medical stuff, all those types of things. And so they looked at all of the group of midwives who provided home birth and they looked at all of the deliveries that they did, whether they were in home or in hospital. And then they also did another comparison to a group of physicians who attended hospital based births of the same kind of cohort. So the same people who are low, considered low risk and would be appropriate for a home birth, but they chose to have a hospital birth with a physician instead. So tell us about what they found.

[00:10:44] Heidi Machnee: Yeah, so the summary statement for this study, which again was comparing midwife assisted births and with a comparable population into in the hospital by a midwife or a physician. So again, looking at similar populations that a planned home birth attended [00:11:00] by a qualified registered midwife was associated with really low and comparable rates of poor perinatal outcomes. And it was associated with reduced rates of obstetric interventions for the birthing person. So reduced rates of epidural needing oxytocin, like operative delivery, so forceps or vacuum or assisted delivery or C section. So reduced rates of obstetric interventions and other adverse perinatal outcomes. So we always look at those two things, like what are the, are there any benefits? And often we see in these studies time and time again, we see benefits to the birthing person. So decreased rates of obstetric interventions. And then the other question is. Is it safe for babes? How do they do? And in this study, again, just absolutely comparable rates of poor outcomes because in reality, poor outcomes for babes in birth are very low, whether you're looking at hospital or home, they do happen from time to time. But again, we want to make sure that those low rates are comparable across home versus hospital.

[00:11:58] Dr. Alicia Power: Exactly. And exactly. [00:12:00] So those bad outcomes. So we're talking about significant injuries to babies or death of the baby or death of the mom. That is extremely rare in our communities because we have such robust medical systems. So not comparable to third world countries, not even comparable to the states. A lot of people in the States don't really have access to high quality medical care because they have to pay for it. Like it's a very different population. So in our well supported collaborative care communities, these outcomes are extremely rare.

[00:12:27] So it's also hard for studies. They have to be so huge to really tell a difference, but these studies had good amounts of people. I think it was like 3000 in each group or something like that. And so a good amount, a good representative representation of kind of what we're looking at. So I think, it, it really, it really borne out the safety of home birth in an appropriately selected population who wants to have a home birth and that's another important piece of it is some people just don't feel, some people want to have a home birth because they feel so much more comfortable at home, and they've looked at the evidence and they feel really confident in their care team, and they know they're [00:13:00] close to a hospital and you know they're low risk and, but some people are very anxious and would be always be worried about that and so, they're not a proper candidate for home birth because they would always be concerned about what if something goes wrong, what's going to happen.

[00:13:12] And so they're not going to be, they're going to be more comfortable in the hospital. And the other piece of the puzzle that we have to consider, and we're sorry, I take, I go off on tangents. The other thing is your partner, right? So I was doing a home birth story with somebody the other day and her partner was totally on board and comfortable.

[00:13:24] But she said to me, you know what, if my partner hadn't have been comfortable with a home birth, we wouldn't have chosen that because if he had been anxious the whole time, then that would have made me anxious. And so then it wouldn't, it defeats the whole purpose. And so it was just an interesting perspective as well. Again, yeah, in an appropriately chosen population, there are benefits of birthing at home if that is your wish after you've had a really good discussion with your care team, and all of the other kind of pieces are there. So that's really great. What other study did you want to chat about?

[00:13:53] Heidi Machnee: I think and again, so if, if I pull out one of the main studies from Eileen Hutton, so she's the primary [00:14:00] researcher in Ontario, so she looked at outcomes associated with planned place of birth among women in low risk pregnancies so this was in 2015, and so they looked at, I think, around 12, 000 planned home births and about 12, 000 planned hospital births.

[00:14:15] Again, looking at similar populations, not looking at one high risk group and one low risk group. And they really found, again that in this study, that planned home birth attended by a regulated midwife, where home birth is well integrated into the healthcare system, was not associated with difference in serious neonatal outcomes, but again, found fewer inter partum adverse sort of outcomes or fewer in labor interventions for the birthing person. So yeah, so I mean it's it's showing itself to be consistent across, two part, two parts of Canada where midwifery again is well integrated. There's lots of midwives doing birth in both of our provinces, so it's nice to do a bit of a scan across Canada and see similar outcomes coming up. I think something-

[00:14:57] Dr. Alicia Power: And also both of those provinces are very well regulated as well. Exactly. [00:15:00] There's exactly clear guidelines that come out from the College of Midwifery around appropriate selection and good documentation and good information to get out to soon to be parents and stuff as well, which I think is also really important. Sorry, interrupted you.

[00:15:12] Heidi Machnee: No, that's okay. And then I just, I actually wanted to just scoot back to a couple points from that SOGC guideline. We talked about integration into the healthcare system, but that for specifically for midwives, so that, a) that they have hospital privileges. Just because you're a registered midwife does not mean that you can just perform, that you can just do home birth. We talked about that example in the US right? So you have to have hospital admitting privileges so that if something comes up, you get to stay with your client. You get to stay with that birthing person and be like, we're going to head to the hospital, but I'm going to be your person. I'm going to stay with you. And we're going to consult the OB and ask for, some of the things that we need to move your labor forward or whatever.

[00:15:51] The importance is, as well as, is having, we'll probably get to this a bit later, but having a second very qualified person available at the home birth so that you're not alone. [00:16:00] You have two people there. Ideally one person-

[00:16:02] Dr. Alicia Power: Because let's remember, we have two. Exactly. We call them patients, you call them clients. Sure. We have two people to care for. We have a mother, or a parent, a pregnant person, delivering person, and we have a newborn baby. So we need one person there, who's qualified, who can manage any obstetrical or neonatal issues at the birth. So we have that in hospital with our, we always have we have two nurses in the room and the care provider. And so the same thing at home, you need at least one person to support each of those people that you're caring for.

[00:16:32] Heidi Machnee: Absolutely.

[00:16:32] Dr. Alicia Power: Yeah. Okay. Can we talk about the Netherlands study a little bit? So I thought this was a really cool study. So in the Netherlands, they have a huge, I'm not going to remember, I wrote down the numbers, but I don't know where it is. They have a huge amount of home births, right? So about, I think over 50 percent of their pregnant people deliver at home. I'm assuming those are the low risk population. And so they have a really, a really good data set, but like Heidi was saying before, it's interesting when you look through the study. And [00:17:00] so their studies show that there's no adverse outcomes to having a home birth. And again, a well supported, I suspect they have a very well supported home birth kind of program and their kind of population is well versed on it. It's a part of their community. And so it's very common in their community. They're very much prepared.

[00:17:17] So it was interesting though, reading through kind of the outcome. So certainly more of the people who chose to have a home birth were of a bit older age, a bit better, higher socioeconomic status. And they were having not their first baby, but their subsequent babies at home, versus people who either choosing hospital or were unclear and then the data supported that, home birth is safe, but the poor outcomes there weren't again, very, poor outcomes don't happen that often in such well supported communities happened with younger people or people who were not of Dutch descent. And again, that's, there's probably a genetic piece like those Netherlands people. They're very tall, right? They're [00:18:00] very tall. And so they're very well proportioned for giving birth. Whereas other members of communities, right? I always say to people of, who are very petite, pregnant people who have chosen to create a human being with a very large person that sometimes our bodies are not meant to, it's more challenging for us to push out babies that are not of our dimensions. And so that, that may have also been, I'm trying to say that politically correctly like that may have also come into place, right? So certain ethnicities have just naturally more challenges with childbirth than others, and we know that. And so that was a really interesting kind of finding, I thought, out of that study.

[00:18:40] Heidi Machnee: Yes. Yeah. And it's, it's a huge cohort. Like they looked at 500, 000 low risk planned births and then, like a home cohort and a hospital cohort. But again, even in the Netherlands, it was like low risk, unless you keep saying this low risk clients who are, screened and appropriate candidates in a maternity care system that facilitates choice that they're, [00:19:00] Midwives are properly trained, they have a really good referral system, great transport plan from home to hospitals. All those factors play in. But yeah, that's, it's a really, it's a great data set. It's a huge, a huge population that they looked at, which is really cool.

[00:19:13] Dr. Alicia Power: Yeah. All right. So from the data, it looks like in communities like ours in Victoria, well supported, good integrated teams, good healthcare systems, that home birth and the appropriate selected population is, we can consider safe. As long as you've got good, cool, and we'll get into all of the other stuff. So can we back up the bus a little bit and talk about how do we determine whether it is safe for a pregnant person to consider a home birth? What are the things that you think about as a midwife who provides home birth?

[00:19:45] Heidi Machnee: Yeah, so I feel really well supported by our college. So we have excellent documents and guidelines, which really helped us support our scope of practice. Cause let's be honest, like as midwives, we always say we are experts in, normal birth, [00:20:00] that's like this, like midwifery catchphrase that, that is used, and I think. I think for us, our college really recognizes that we're not high risk specialists, although we have, we have training to absolutely be able to recognize emergencies, that's why we have incredible obstetricians in our communities that can support us when things move outside of the range of normal.

[00:20:17] So our college really supports us with kind of guidance around screening and this idea of candidate selection. And it really is it begins the, at the first meeting when you do a history and physical with someone. Sometimes clients come into care who have, serious medical conditions. They have, heart or kidney disease, they are insulin dependent diabetes. They maybe have triplet, a triplet pregnancy, all examples of people that probably would not be, considered low risk and won't be and will not be considered low risk at any point in their pregnancy. So those would be people that we would absolutely encourage to birth in the hospital, at the onset of labor. So then that's again another point where we evaluate. Hey, are we still low risk? Are we still good to do this? [00:21:00] Important that the person is termed. So anything less than 37 weeks and zero days is considered preterm and we would absolutely advise the person to birth in the hospital so that there's a pediatrician present in case that little kiddo just needs a little bit of extra help on the outside. So You know so term making sure the baby has head down, confirmed head down. So that is not a bum coming down and it can be -

[00:21:22] Dr. Alicia Power: We can be surprised sometimes.

[00:21:23] Heidi Machnee: Hey, I and I've done it. I've been like at home and I'm like that is a scrotum I'm feeling and yeah, and we need to go to the hospital and we have to-

[00:21:34] Dr. Alicia Power: Yeah, we have one of our colleagues in our community has a saying if you haven't missed a breach, you're not doing enough deliveries. Exactly. Or you're not doing enough obstetrical care, right? And it happens. So sometimes we're surprised that there's, oh, there's a bum, not a head. Okay!

[00:21:49] Heidi Machnee: Exactly. And so then, and then through throughout labor, with someone at home, we are constantly, scanning the environment, assessing the client, really taking in data on an [00:22:00] ongoing basis. And it's not just like a one time check in. So in labor, there can be things that also preclude someone from continuing at home. So if the birthing person spikes a fever, that's usually not a good sign. If they have a true fever of 38.5 or above, generally speaking, that is that is a reason to have a bigger care team involved. If, as we're listening with the Doppler regularly, as we would in the hospital, that baby's heartbeat tells us something that is not normal. That is also a reason, obviously, to move to a hospital and have a bigger care team involved. So we're getting into a little bit of maybe what it would look like to transfer from a home birth to hospital birth.

[00:22:37] Dr. Alicia Power: Yeah, I just want to, I want to back up. So in terms of kind of high risk pregnancies, we're talking about certain medical conditions. So diabetes, heart disease, brain disease. So if you've had multiple strokes in the past, you're not going to qualify for a home birth. If you have, other diseases like that, that need extra monitoring and care in your pregnancy. Now in Victoria. We have a different system than [00:23:00] many communities, so most of those patients or clients would not be cared for by a midwife in some other communities, but in Victoria we work really well collaboratively, so they see both the obstetrician and the midwife or whatever specialist they need to, and same with family doctors.

[00:23:14] In some communities we wouldn't be able to care for those patients, they'd go on to a higher risk, but in Victoria we have such a great community that we're able to. Other things that can come up during pregnancy. So having a placenta previa or a low lying placenta, you're not going to qualify for a home birth cause that's really dangerous. And there'd be some kind of other things that come up with, so if you get gestational diabetes, I'm not sure if diet controlled is okay for home birth versus if you're on insulin, then you would be at hospital because we need to be very carefully monitoring your blood sugars. What about gestational diabetes? Does that qualify?

[00:23:45] Heidi Machnee: Yeah, so I think controlled, diet controlled gestational diabetes. I've definitely had some clients that have like, with an OB consult and really good informed choice discussions have had a, have had home births at now, especially if we're like, wow, this baby's a perfect size seven, five [00:24:00] on ultrasound, like looking great. Everything's been like beautifully controlled with diet. You're not a high risk person and often you're discharged out of the. the gestational diabetes program and turned back over to the, okay, you're healthy and normal. Other things that can come up is if, like maybe with your first birth, you had some blood loss that was outside of the normal range of blood loss after the baby was born. So you have a history of a postpartum hemorrhage. That might be a reason you would want to have a serious conversation about, Hey, maybe the safest place is to be in the hospital. If you are someone who's had a prior cesarean section, I think that the strong recommendation from care providers in this community is that if you're trying for a vaginal birth after having a cesarean that the safest place would be to be in the hospital.

[00:24:39] If we on ultrasounds know that there's something going on with that baby, that's not totally normal. So that baby is not growing perfectly. Looking a little small, there's signs of, that there would be a need for a pediatrician to be present at the delivery, then obviously, that those clients would absolutely be recommended to have a hospital birth.

[00:24:56] Dr. Alicia Power: Same thing, probably, if you have a very big baby.

[00:24:59] Heidi Machnee: Yeah, sure.[00:25:00]

[00:25:00] Dr. Alicia Power: Other things that we look at is the amount of fluid in your uterus around your baby, because we know that's a sign of how well your placenta is working. So I'm assuming that if we diagnose you with an oligohydramnios or very low fluid, we worry that your placenta is not functioning well. So we want to be very vigilant around those babies during delivery, because sometimes they can get stressed a little bit more easily. So that would be another reason kind of that you would. qualify for a hospital birth.

[00:25:22] I have a couple of questions for you, Heidi. I'm going to put Heidi on the spot. She said, I don't want to just be lecturing. I'm like, don't worry about that. I'll bug you a lot. What about, so sometimes oftentimes actually we see nuchal cords on an ultrasound. We're doing an ultrasound for another reason. And we see nuchal cords. We, I, as care provider, I don't tell the patient that because, they're going to be, my patients are in hospital, we're going to be closely monitoring it, and if it becomes an issue, it's fine. My son was born with two nuchal cords and it didn't really become an issue until, he was almost out, but then he was out, he was fine. But in terms of a home birth planning, if that came up in an ultrasound, would is that something that obviously you would have a discussion with your client around, but is that something that you would advise having a [00:26:00] hospital birth or not?

[00:26:01] Heidi Machnee: I don't think so. Obviously, yes having a conversation with a client, making sure that they're really well informed about the findings of that ultrasound. In my experience, and again, I have not been practicing that many years, but in, in what I've read and conversations that I've had with experienced, long term mid midwives, I think the important thing is to not presume something's going to be a problem because nine times out of ten, nuchal cords are absolutely not problematic. There's this really interesting technique. The baby's, if the baby's born and you feel, Oh yeah, there's a loop of cord around the neck. There's this really cool maneuver where you can do what's called somersaulting the baby out. And it's, it works beautifully. And it's rarely are those nuchal cords problematic.

[00:26:38] Now, sometimes they are, but it's before the baby comes out. So if that nuchal cord is tight, we're going to hear the baby's heartbeat do some changes when we're listening with a Doppler. And if we hear those. And within a short period of time, if they're not responsive to, changing the birthing person's position or trying something different, we don't mess around. We transfer in absolutely. [00:27:00] So sometimes nuchal cords can cause some, fetal heart rate decelerations in labor. And then we just take those seriously because when the baby's still on the inside, we don't really know what's causing that deceleration and we take them all very seriously. But yeah, but I don't think of the finding on an ultrasound would preclude someone from a home birth.

[00:27:17] Dr. Alicia Power: Awesome. Another thing that might come up during labor is if there's meconium. So what meconium is when baby has their first poop inside. Can be totally normal, especially if you're over your due date, but sometimes can lead us to think that there might be something going on with baby that we need to be a little bit more careful around. What about meconium in labor?

[00:27:37] Heidi Machnee: Yeah, absolutely. So now we're getting into reasons that we would recommended a transfer from home to hospital. And these are conversations that we have 36 weeks or even prior to with clients, so that they're not surprised. We're not springing something on them at the, at their, beautiful planned home birth. And we're like, oh, we're seeing this thing. We got to go. And they're like, what? They're well informed. They know what these things are. These [00:28:00] kind of like yellow and orange flags that come up on the field that are like, hey, you know what? We need to expand our care team. That's what's safest for you and babe. And we really hope that over the course of the person's pregnancy, they develop a trust in us, so they're like, yeah, my midwife's got my back, like they know what's up and they're gonna, they're gonna make the safest recommendation for me. I always say they're common sense things. Like when I read this list they seem to me to be quite common sense. They're not, what were you going to say, Alicia?

[00:28:24] Dr. Alicia Power: Oh, I was going to say again, that's another thing, having a really good trust in your care provider. And another thing that I think is really important that we don't, I always. I have the utmost respect for midwives because they, I think, are put in situations that I am never put into, and one of those is, some people, choose are very, for whatever reason, and it can be a history of trauma. It can be a history of we don't know the reasons people do the things that they do. And oftentimes, sometimes we find out, but sometimes we don't, are very scared of the hospital and very scared of the kind of medical system for [00:29:00] who knows why in people's history.

[00:29:02] And they are very adamant about wanting a certain thing, wanting a home birth, wanting to stay, far in the country, whatever that is. And we have this amazing group of colleagues called midwives and doulas, but midwives, whose role is to support people in their informed choice. But it gets, it can get into a tricky situation, I imagine, if your care provider doesn't actually feel like you're making a safe choice, or you're going against the kind of mandated guidelines that you're trying to follow, but the patient is making the choice that they truly, honestly believe is the best choice for them and their family.

[00:29:36] And so I think it's really important for people to recognize, and we don't have to go into, we're not going to go into the debates about that but having trust in your care provider. And also recognizing that they are a part of this experience as well. And so if they feel unsafe in an experience, that's an important thing to listen to and recognize as well. I don't know if that's something that you come up with very often, but I think it's, I [00:30:00] think it's a really important thing for - there's we are, we, our job is to create an opportunity for a pregnant person and her baby to have the best birth they can. But also our job is to keep them safe. And sometimes those two things can be at odds with each other. And we have what's called these moral, I forget what the term is, but like this moral dilemma on supporting, doing our job to support the pregnant person in their decisions, but also doing our job to do what we think is safest for them and their baby.

[00:30:31] I, again, don't get into that situation very often because I don't do home births. We have occasionally had patients who have just had a home birth at home, sometimes accidentally, and then they come into hospital, but sometimes planned and never talked to anybody with us and they didn't have any care team there. But we would never go to somebody's home to support somebody who we don't believe kind of qualifies, 'cause we don't do that. I'm rambling a bit. Sorry.

[00:30:54] Heidi Machnee: That's okay. Yeah. This is a whole other podcast. But I, I think if I can speak just a few points [00:31:00] to that, I think it is just so important that, that, my personal perspective is that regardless of someone's choice, that they continue to feel respected, they continue to feel heard, that our care still remains trauma informed, it remains kind of harm reduction a harm reduction approach and it honors the story that's coming behind that, those decisions that person makes.

[00:31:25] There's actually a really cool obstetrician named Dr. Andrew Kataska who has done quite a bit of research around what we, what he calls informed refusal. So again, so knowing that your care provider has a strong, you know, I recommend that you do not have a home birth. And this idea of informed refusal and how to continue to hold space for that person in a respectful way that's not coercive or demeaning or bullying, but yet still tries to honor, yeah, the sort of moral peace for the care provider.

[00:31:57] So yeah, so I think, it's not often that we come [00:32:00] up with it, but absolutely I have in these last three years of practice. Absolutely. I have had situations like that. And there's lots of things that we do. We continue to communicate with our broader team. We write letters that are on the patient's chart. We, we have conversations with the OB. We ensure that we're doing everything that we can to support ourselves and to support the client and to continue to make things safe. And let's be honest, someone having an unattended, unassisted home birth is less safe than having a midwife there, even if, or a care provider there, even if it's not what we would have recommended. So anyways, but I think maybe, yeah, we'll have to close that out. We digress, sorry.

[00:32:33] Dr. Alicia Power: Okay, we're going to go back. Okay, so let's talk about some reasons that we shouldn't have a home birth baby wise. So those would be like, known, known issues that can come up at birth that they're going to need extra support, or we highly suspect that, right?

[00:32:45] So that's less than 37 weeks, that's kind of babies who aren't growing as we would expect, that's baby was with like known structural anomalies, those types of things would be contraindicated to having a home birth or to suggesting a home birth. In [00:33:00] terms of, is there like a guideline around distance to hospital? Do you guys have a discussion around that?

[00:33:05] Heidi Machnee: Yeah. Some, if you look at I just reviewed like a PowerPoint presentation around like rural birth in Alberta, but I think the 30 minute rule is because that's even for, I think for GPs and, if you get, if you have privileges to admit patients to the hospital, they ideally say you need to be able to live within a 30 minute distance. So if you have a client that's like, I'm heading to the hospital that you could be there ideally within 30 minutes to meet them there. And so I think that's the general rule. There are people like Shawnigan Lake or Mill Bay, or, like people over the Malahat, and then it's okay you got to think about distance. You got to think about weather and is it snowing, winter and traffic, and there's so many things. And that's why, again, sometimes we have folks who, live a bit further away, but choose to have their baby at the little birth cottage, or they choose to have a hotel birth so that they can be closer.

[00:33:50] Yeah, I think that's definitely a piece of it. I'm just going to back up a little. So we started talking about reasons to transfer and, and again, I talk about this with my clients so that they're super well aware, but I have [00:34:00] broken it down into a fairly concise list. So if we look about, if we look at like the birthing person, things in labor, why they might want to transfer in to the hospital, sometimes it's maternal, it's the person's request. They're like, that's it. I just have a feeling. I just want to go to the hospital. And we're like, cool, let's pack up and go no problem.

[00:34:17] Sometimes it's for pain control. Sometimes people just are like, I need that epidural. I want that epidural. And we're like, okay let's make a move. Sometimes despite all our tricks and tips and things the person just isn't progressing in labor. Stuck at six centimeters, no matter what we're trying, just still at six centimeters. And we just know that we need a few little tools at the hospital. Sometimes it's exhaustion. If the person has been in labor for, a long early labor and it's just fatigued, sometimes an epidural can save that person because they get to rest and then get their energy back for the work of active labor and pushing that's to come. If there's any abnormal bleeding during the labor, if the person spikes a fever, if the blood pressure rises. So those would be things in labor that we would be like, okay, you know what? We need to expand our care team.[00:35:00]

[00:35:00] Postpartum for the birthing person. So sometimes there's a little bit more blood loss than we're comfortable with. We have all the tools and tricks at home that you would have access to those kinds of initial steps to managing. a bleed that's a little bit more than what's normal. And most of the time these postpartum hemorrhages respond beautifully to those first line therapies. If not though, we don't mess around. It's like a call to 911 and we move in. If there's any significant tearing, which again is rare to have what we call a third and fourth degree tear, not common in any context. But if there are situations where it's hey, actually, you need an obstetrician to do this repair, I'm not comfortable doing it, we would move. In sometimes the placenta is a little bit stubborn and doesn't want to come out within a safe timeframe. And so then we move in. So those would be factors postpartum.

[00:35:45] When we look at baby in labor, so Alicia already mentioned meconium. So meconium is baby's first poop. Sometimes they're rascals and they take that poop on the inside. So when the water breaks, we see evidence of kind of this brown, green, yellow tinge [00:36:00] or flex in the fluid. That can mean if the baby is like 41 weeks and two days and they're just like ready, like their little anal sphincter is ready to poop. And sometimes it's just this little squirt of fluid. And it just means that the baby is like mature and ready to be born. But sometimes it can mean that there's been an episode of distress for the baby that they've had an episode of lack of oxygen, for example, and we can't always tell what that is. We want to make sure that they don't breathe any of that into their lungs when they're born. And so having a pediatrician at the birth is recommended and closer monitoring so that would be a reason we would have a conversation about going in.

[00:36:32] If that baby is born and there are, there's, I know, abnormalities, things, physical things that we're finding on our assessment that we're like, wow, that was not seen on ultrasound, we need evaluation with a pediatrician we would move in. Fetal heart rate, sorry, I guess that was postpartum. Fetal heart rate abnormalities. So again, dips in that heartbeat that are not responsive to the birthing person changing positions IV fluid, we don't mess around. We make a move quickly to have a closer [00:37:00] monitoring of that baby. Again, a surprise breach or if that baby is malpositioned in any way. So sometimes that actually means that the baby is, sunny side up or they're they're head down, but they're backwards and things. It's just messing with the progress and labor. Those are things that will make us think about going in. And then postpartum, so again, an abnormality on the babe or a physical feature that was not picked up on ultrasound that we would want to be explored sooner rather than later. If that babe isn't transitioning well from inside to outside, they're breathing a little bit too quickly, not controlling their temperature really well, needing a more kind of challenging resuscitation. It's not just a few, not just a little bit of stimulation and a few puffs of air, but a bit more of a resuscitation to get them going on the outside. Obviously, we would not hesitate to move it to the hospital. So all those things I think are again are common sense and they really make sense in the context of safety.

[00:37:49] Dr. Alicia Power: Yeah, totally. And I think that's another piece of the puzzle is like hoping for a home birth, but not having your heart set on one, right? So when you are thinking about home birth, planning for a home [00:38:00] birth, but also recognizing that there's a lot of things that may derail that plan for you and having, so what we call birth preferences as opposed to a birth plan. And we've got a great kind of download that you can fill out and start thinking about those things, but what would you like? But if something happens, when are you okay to change that plan? And so having preferences that you think about, but recognizing that there's, we have little control over these processes. These little babies have a mind of their own sometime. And so then we have to modify our plans. And that's those are those reasons that we would you would transfer in. So when you are chatting with people about home births, talk to me a little bit about, like, how do you get their environment set up properly? What's the conversation around that? Is there like a purchasing list that they get and they have to grab all this stuff. Like how does that kind of work?

[00:38:46] Heidi Machnee: Yeah. So I think, most midwifery clinics have their sort of little like cheat sheet list of these are the things that are good to have on hand. Honestly, you don't need a lot. So if you're planning to use your bathtub or your shower, have a birth tub to use in labor,[00:39:00] having, I say go to Value Village, give them a couple washes, have a stack of old towels, like a nice stack, give yourself like eight nice towels, have lots of good receiving blankets and not your like pristine white muslin ones.

[00:39:11] We want that baby to be able to have warm, receiving blankets, keeping them dry, keeping them super cozy. So a stack, sometimes you show up and there's two receiving blankets. I'm like It's not really enough. So like 10 receiving blankets. A shower curtain or a mattress protector to make sure that you are not destroying your mattress with fluids that come -

[00:39:29] Dr. Alicia Power: And I learned the other day, to double make your bed.

[00:39:33] Heidi Machnee: Yeah, exactly.

[00:39:34] Dr. Alicia Power: Mattress protector and a sheet and then another mattress protector and a sheet. So after you deliver, you can just go back and take off the top layer. Put, I learned that. The other thing I learned is have an extra big hot water tank if you're getting a birthing tub.

[00:39:47] Heidi Machnee: Yeah, definitely. You can run out of hot water pretty fast. That's one thing that I hear some people say. They're like at the hospital you never run out of hot water. I'm like, that's very true. So some people will have -

[00:39:56] Dr. Alicia Power: No tubs here in Victoria though.

[00:39:58] Heidi Machnee: No! Showers, but no tubs. [00:40:00] So yeah. And then a lot of midwives will do, they will do like a antenatal home visit, like around 36 weeks to get the lay of the land. Be like, okay. See where you live. Google Maps was a bit weird, so now we totally know. We ask people to have their lights on. They'll tie a couple balloons if their house is down a dark driveway and, maybe in Saanich or something. So tie some balloons so that there's an obvious sort of the house numbers are well lit. Tricks like that are important, right? Because you're often showing up at two o'clock in the morning and you're like, it's super dark, I can't see where I'm going.

[00:40:30] It's simple things like having like electrical outlets in the right spots. So we always, one of the key things is having like a table height area where we can have a baby station. So if that baby needs a bit of help and our attention, we can get to that baby and have a place that's set up. And we have a suction machine. We have, a heating pad. We have a few things that require having access to a, just like an outlet. And so some people will have one of those kind of like those power bars. So we make sure people have things like that.[00:41:00] An area is clear. It's clutter free. If you're planning on using water and planning to have your baby in the tub, we also say you need to have an alternative spot. You do need to have your bed made, or the, the couch prepared or something. Because often we do say, hey, you know what, I need you to get out of the tub. Like I can't assess properly. I need you to move out of the water for safety. And you need to have a second. place set up there.

[00:41:22] Making sure that there's an area like a cleared sort of dining room table where you can pull up, pull out our charts and our computers and do our charting. So it's pretty simple things, but it really is nice to have the lay of the land before. I've been in situations where I've birthed in very cluttered, very chaotic, tight environments, and it didn't feel good. So lots of midwives will say, ah, I could birth a baby in a closet. Like we don't need a lot. And it's true. We don't need a lot, but we do bring a level one hospital to your house. And it's. It's a kind of contained, nicely packaged little unit of supplies that we bring, but it's, it still is a decent amount of stuff and we need to be able to set up so that we can like access all of our emergency equipment, in the rare [00:42:00] times that we need to use it, we need to be able to have it laid out so that we can be like, boom, grab, boom, grab like everything. So cleared off dressers, that tidied area, super important.

[00:42:11] Dr. Alicia Power: And then, so you brought, what does the midwife bring to the birth? What kind of equipment do you guys have with you? You briefly talked about that.

[00:42:19] Heidi Machnee: Yeah, so when I heard someone say a level one hospital, I was like, yeah, that's actually pretty accurate. So if you break it down, think about the birthing person. So we have all of the birth instruments that you would have access, we actually get them from the hospital. We have a program. So birth instruments for the delivery, suture instruments for after birth. Afterwards to do any kind of gentle stitching, afterwards if needed. And then emergency equipment for the birthing person. So we have an oxygen tank. We have all of the medications required needed like needed for a postpartum hemorrhage management, for example.

[00:42:50] We have a full resuscitation kit for babes. So we have again oxygen and the suction machine. The ability to give them like breaths of air if they're not breathing on their own, the [00:43:00] ability to intubate them to put a breathing tube down their throat if they are really not breathing on their own and need that extra support. Emergency equipment for babe, if they're requiring even an extra level, like something like epinephrine the ability to put in like IV catheters and urinary catheters. So we bring all of that sort of emergency equipment to start an IV to give someone IV fluids. Yeah, so really, any of that first line stuff that you would find in a labor and delivery room, we have that with us at a home birth.

[00:43:28] Dr. Alicia Power: Awesome. And then the other thing is that you also bring a friend.

[00:43:32] Heidi Machnee: Yeah. Yeah, exactly. So usually it's one midwife that would attend. So if someone calls and we go and assess them and we're like, great, like you're five to six centimeters. You're in active labor. Awesome. Often it's fine. We set up our equipment. We monitor the babe and listen to the heart rate every 15 minutes as same as we would in the hospital. And yeah, so if it's someone who's, having their second baby, we anticipate that things might move quickly. We would definitely say eight centimeters, we're gonna call our second attendant to [00:44:00] come. First time mom, often pushing is, can take a little while. And so we just, it's that anticipatory timeline around when to call your second attendant to come. The second attendant, most in most cases is another midwife, but in Penticton, for example, there was a bunch of the labor and delivery nurses that were certified to be our second attendants.

[00:44:19] And so Alicia made reference to this, but usually the primary midwife who's been there through the whole program, that their whole kind of progressive labor would stay attached to the birthing person and be like, going to deliver the baby, going to be responsible for managing any stitching or bleeding or anything like that. And the second attendant is there to receive the babes. So they're there and they're trained with something called neonatal resuscitation. Something that all OBs and GPs and every labor and delivery nurses and everyone is trained in regularly. The ability to really support a babe that's not transitioning well on the outside. So that's who that second person is there for.

[00:44:54] Dr. Alicia Power: Awesome. Okay. You've had great discussions through labor, you and your client have deemed they're [00:45:00] appropriate for a home birth, you've gone to the client's house, you've got it all ready, you've gone there, you've set up all your stuff, you've delivered this little beautiful baby's now lying on their parent's chest and starting to try to breastfeed, and then what? How long do you stay at the house for? What do you do over the next few days? Because I, in the hospital, we've got our amazing postpartum nurses to show you how to birth a baby and help you with breastfeeding and all those types of things. I imagine for a first time parent, especially in the time of COVID when they don't have much support 'till you can come in like, you guys, I know you guys do amazing follow up and are very much there over the next few days supporting but what does that kind of postpartum piece look like?

[00:45:41] Heidi Machnee: Yeah. So it looks very much so if you have your baby in the hospital, so either the midwife or the LDR nurse stays for about two hours in the delivery room with you. And the main things that we're looking for is, is this baby transitioning well? Are they breathing beautifully? Are they pink? Are they alert? Do they have nice strong tone? Are they like cuing at the [00:46:00] breast? Are they doing all their normal newborn things? Is their newborn exam really normal? Making sure that for the birthing person that they've got a bit of Tylenol and Advil on board that they're bleeding is safe, their uterus is nice and contracted helping them with breastfeeding getting them up to empty their bladder, helping them to have a shower There's just like this range of things that we make sure are attended to in that first kind of two hours So it's really the same things. Often midwives will stay between two and three hours but for sure before we drive away we are making sure like that baby has latched and had a good feed, bleeding is like absolutely normal. Mom's been able to pee. Like we, we don't leave until we know that all of these boxes have been ticked. And we just, it's actually just like such a beautiful moment to tuck this family into their bed and be like. Okay, great. So one, they have access to the pager. So there's, at any point, day or night a midwife can return to assess if they have questions or they can call with questions.

[00:46:54] Our college guides us to, within the first 24 hours of birth, to do a return home [00:47:00] visit. So we don't go longer than 24 hours before we see them again at home. And so that usually it's like day one, day three, day five, day seven, or day one, three, six. And we, we see them very regularly in that first week, again, making sure that breastfeeding is going well, that, pain is well controlled, baby's still looking beautifully normal. And so I think yeah so we do a lot of follow up. It's a lot of education as well. So it's, hey, these are the reasons. I want you to call me. We talk about what's normal bleeding and what's not normal bleeding. We talk about normal newborn behavior in that first week. And like at any point, if there's anything that is concerning, give us a call. So we really empower these folks with information so that they know what to look for and they know when to call us urgently. If there's anything.

[00:47:42] Dr. Alicia Power: And great follow up too which is I think another really important piece is that excellent follow up, which is great. Awesome. Thank you. That was a pretty comprehensive thing. Oh, one other thing I wanted to, if we plan, so you guys bring this huge kit to the home to plan, just in case. And then if you don't need it, wonderful. And [00:48:00] I'm presuming you also get your clients to plan for going to hospital. Making sure that they've packed their hospital bag and all that good stuff and everything.

[00:48:07] Heidi Machnee: Absolutely. Yeah, we always say that. Especially if we've got to move quickly. And again, the caveat is that... The vast majority of transfers are not urgent and then they're in your own car, like they're not that it isn't like we always call the ambulance. It's actually quite rare that we would actually need an ambulance transfer. Lots of times it's just in your own car. But yeah, always planning always having that in the back of your mind. And, I just, I'll just close, I listened to this podcast recently. I don't, maybe some of the birth, a lot of the birthing world maybe knows about it, but it's called The Longest Shortest Time. And it was, it was talking about this idea of feeling like a failure if you didn't accomplish your goal of, a certain type of birth, whether that's, birth without an epidural or a planned home birth or something. And how, the commentary of this host was that, sometimes this description or this idea of a planned home birth is so intoxicatingly like attractive that it really gets [00:49:00] people into this tunnel vision of I have to have that.

[00:49:03] And then if it doesn't happen, then it ends up leading the person to feel like they failed somehow. And it's just so important that people just really try to work with their care provider around setting like really reasonable expectations, we know from the research that even for folks that plan a home birth that doesn't end up happening at home actually have better outcomes. So it's. It's just, again, what Alicia said, just being really fluid and flexible. And if I've learned anything, and I'm sure Alicia can echo this, birth is so humbling. And it takes us on journeys that we don't expect sometimes. And and I think having a really like humble and open attitude towards birth for all of us is just like a really good place to be.

[00:49:40] Dr. Alicia Power: So I agree 100%, which is why Dr. Sarah and I started doing this because we think it's so important and we see people coming out of their experience, disappointed or traumatized from it because they had this vision in their mind of what it would be like and they didn't get there. They were healthy their baby was healthy and I [00:50:00] know that's their ultimate goal, but they didn't get that vision that you know they had imagined or society had told them that they should have or whatever it was and so we want to like present good, evidence based stuff that is, and realistic expectations so that you can go in and have that ability to be fluid with your plans and really come out of it remembering that, that moment that your baby was first put on your chest and you felt them and you heard them, and that warmth and you look at your partner, if you have a partner, and just see the love in their eyes and that, that's what we want people coming out with. Yeah. Not disappointed because they didn't get x, y, or z within that process. So I agree with you a hundred percent. Awesome. Thank you, Heidi. Such a great chat. Sorry guys, that was a long one, but I think, I hope a really good one. All right.

[00:50:42] Heidi Machnee: Thank you so much. Yeah. It was a pleasure being here.