Watch how and why homebirth increases the risk of neonatal death

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When obstetricians counsel patients about the dangers of homebirth they usually stress three points. The first is that a life-threatening emergency can happen with no warning. The second is that a normal birth is a retrospective diagnosis. The third is that the baby will be dead long before there is time to get to the hospital. Predictably most homebirth advocates will dismiss all three reasons. It would be so helpful if obstetricians could show patients what might happen. Now we can.

Homebirth and unassisted birth advocate Rixa Freeze has done what is de rigeur for homebirth advocates: she recorded her labor and birth in excruciating detail and than offered publicly it for the world to admire. I had no intention of watching it, but several people e-mailed me and urged me to do so.

The video includes the immediate aftermath of the birth when baby Inga became profoundly blue and lost all muscle tone due to lack of oxygen. Ultimately Rixa was forced to provide mouth to mouth resuscitation and fortunately, the baby responded. When I first watched it, I was so angry I was shaking, but then I realized that Rixa has done obstetricians a wonderful favor. She has inadvertently produced the ideal teaching video for demonstrating how and why babies die in increased numbers at homebirth.

Before you click away to watch the video, let me set the scene. Rixa is a healthy woman who prides herself on the care she takes with diet and nutrition. She had a completely uncomplicated pregnancy and a short, uncomplicated labor. She was as perfect a candidate for homebirth as there could be. There was absolutely no reason to assume that the baby would have any problems.

You can find Inga’s birth part 2 (surprise unassisted birth) in the pull down menu on Rixa’s YouTube page.

I realize that I could embed the video here, but frankly, it makes me sick and I’d prefer not to even catch a glimpse of it. The relevant portion of the video begins at 7:50 and resolves by approximately 10:01.

In a long post that included endless detail about the labor, Rixa dismisses her daughter’s near death experience in a few brief sentences:

Soon after the birth, Inga lost muscle tone and color. I quickly realized that I needed to perform mouth-to-mouth. Fortunately, I became certified in neonatal resuscitation several years ago, so I knew what to do. It was tricky getting the angle right, since the cord was short. I gave her five breaths. After each breath, she coughed and perked up a bit more.

But by posting the video, Rixa helpfully and inadvertently demonstrates that several important claims of homebirth advocates are nothing but nonsense:

1. Delaying cutting the cord does NOT prevent neonatal hypoxia. The circulation through Inga’s umbilical cord appears to have shut down promptly (possibly because the cord went into spasm when exposed to air). She was born relatively well oxygenated, failed to breath and quickly became profoundly hypoxic, cyanotic and floppy. One minute Apgar score appears to be either 1 or 2 ( 0 for muscle tone, 0 for grimace, 0 for skin color, 0 for respiration and 1-2 for heart rate).

Moreover, if you want the baby to get the benefit of delayed cord clamping the baby must be LOWER than the placenta. Otherwise, because of gravity, the baby may be transfusing the placenta. So to the extent that any blood transfer was taking place while Inga was becoming cyanotic, Inga was probably sending blood away from herself and back to the placenta.

2. Skin to skin contact cannot keep a wet baby warm and it is critical to keep a hypoxic baby warm. By refusing (or forgetting) to dry off and wrap the baby, Rixa and her husband made a bad situation worse by adding cold stress to hypoxic stress.

From Neonatal Resuscitation:

Preventing heat loss during the resuscitation is essential…

Several factors lead to increased heat losses in the newborn infant. The neonate has a large skin surface area–to–body weight ratio, which increases heat and fluid evaporative loss. The fluid loss from the skin … results in massive heat loss… Animals ordinarily attempt to decrease heat loss by decreasing exposed surface area (ie, “curling up”). This reduction in exposed surface area is accomplished by assuming a flexed position; however … depressed infants are unable to accomplish flexed positioning…

The video makes this quite clear. Inga is wet and cooling and as she becomes hypoxic, not only can’t she curl up to conserve heat, she basically becomes unconscious and is as exposed as she can possibly be.

Why is this a problem?

Infants who experience heat loss … use more oxygen. Increased oxygen consumption can be dangerous in infants who are experiencing respiratory compromise. The addition of cold stress in infants who are poorly oxygenated potentially can lead to a change from aerobic to anaerobic metabolism… [C]old stress can lead to both metabolic acidosis and hypoglycemia. Infants with asphyxia have thermoregulatory instability, and hypothermia delays recovery from acidosis.”

3. ANY baby, no matter who the mother is, how healthy she thinks she is, how well she thinks she ate, how fabulous her labor is, can fail to breathe at birth. In other words, a life-threatening emergency can develop from one second to the next without any warning at all.

4. There needs to be someone available who knows how to perform neonatal resuscitation. In this case, starting the resuscitation was enough, but that was purely a matter of LUCK. It easily could have ended very differently.

The only problem appears to be that Inga, who tolerated labor well, and was therefore uncompromised at birth, nonetheless failed to breathe. She only need a little, non-technical help to get started. But Inga could have been born already compromised by lack of oxygen during labor. In that case, she would have required a lot more help. She might have needed real and prolonged positive pressure ventilation, she might have needed CPR, she might have needed intubation. Had she been born requiring any of those things (and none of them were available) she likely would have died.

Fortunately, there was only one complication, a neonatal complication Had there also been a maternal complication, a disaster may have ensued. If Rixa began hemorrhaging, it is possible that she would have been able to perform even the minimal resuscitation necessary. In that case, her husband would have had to choose between attending to the baby or attending to her. That’s not a choice any husband and father wants to face.

5. Had the baby not responded in short order, there NEVER would have been enough time to get to trained medical professionals and save the baby’s brain and life. This is an outstanding illustration of how fast a baby can begin to die even if that baby was not suffering from low oxygen before birth.

All in all, Rixa and her husband, in an effort to brag to the world, have produced a fine teaching video on why and how babies die at homebirth.

A disaster can arise literally from one second to the next. In a true life threatening emergency there isn’t nearly enough time to get to the hospital. And an uncomplicated birth is a retrospective diagnosis. There was every reason to believe that this would be an uncomplicated birth, but it wasn’t. Though Rixa seems to be in complete and utter denial about how close she came to losing Inga, anyone else can see the truth.

Fortunately, Inga did come around relatively quickly. Even though her 1 minute Apgar was only 1-2, her 5 minute Apgar was fine. It is unlikely that she sustained any permanent damage in what turned out to be a 2 minute hypoxic episode. That’s the best part of this video and it was purely a matter of LUCK.

Hopefully, after viewing the video no one, not even a homebirth advocate, will be able to dismiss the very real dangers of homebirth: a life-threatening emergency can happen with no warning, a normal birth is a retrospective diagnosis, and in a life threatening emergency, the baby will be dead long before there is time to get to the hospital.

  • Busbus

    A midwife cannot intubate, nor can she perform any other life-saving maneuver that requires a team of neonatal experts and equipment. Furthermore, even a midwife would have been in trouble if Rixa and her baby had needed immediate medical attention. Yes, one midwife is better than none (IF she is qualified – and that’s a big if among American homebirth midwives), but she cannot replace a hospital with its emergency resources and personnel.

  • Jodi

    all of the problems that you stated would have been avoided with a qualified Midwife in attendance. This is not a homebirth issue, it’s a choice issue. She had an UNASSISTED homebirth.

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