A “medwife” reflects on 3rd world birth and American homebirth

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A new guest post from the “Medwife“:

I’m a Medwife and I take call, about 72-96 hours a week to be exact. My phone rings at all hours of the day and through the night. The inevitable page comes through at family reunions and playoff games. Everything from the usual Friday afternoon 30 minutes after office closes “I think I have a UTI” to the Saturday morning 5:00am “I think I have a yeast infection”, spaced between “My pessary fell out” or “I can’t find my IUD strings” and the “Can I take Robitussin while breastfeeding” or “I think my water broke”. Top it off with a few late night calls from the ED and few more from Labor & Delivery and it’s a full time effort to be sure. Add in a few less common favorites “my nipple ring got stuck in the shower curtain” and you just never know what concern is waiting at the other end of the receiver.

But there’s that one call that makes time stop, a stomach churn and the thud of one’s own pulse resonate as whooshing sound through a medwife’s ears: “The baby’s not moving.” Silence. Now I’m not a fan of discussing Monistat-7 at 5:00am on Saturday morning, but “the baby’s not moving” is why it’s impossible to become complacent in the usual barrage of ringing during call hours. It’s the call that makes you hold your breath, the call that makes you wish warp-speed time travel existed and the call you never dismiss. When you’ve done this long enough, you know the last words you always hear before you diagnose a stillbirth are: “The baby’s not moving”. The dreaded call came in last night, despite 8 weeks of discussions on kick counts and a full 24 hours after the last perceived movement. In anticipation of her arrival to Labor and Delivery, commence the breath holding, conduct a review and mental checklist of risk factors (Primigravida, IVF and Gestational Diabetes) and recall last evaluation in office (48 hours ago, Glucose well controlled, Reactive NST, BPP 8/8, AFI 14).

Upon arrival to L&D, the mother was placed on the fetal monitor and a reactive NST was obtained. (Exhale). An ultrasound was ordered and returned a BPP 6/8 with AFI 10. It took a long discussion to convince her it was in her baby’s best interest for continuous monitoring over night with a repeat BPP in the morning. In the morning, the BPP had decreased to 2/8 and new onset of oligohydramios with an AFI of 4, which prompted the move towards a 36 week induction. Her labor progressed with an epidural in place and she proceeded to spontaneously deliver a growth restricted infant. The baby was handed to the Neonatologist for evaluation with Apgars 9-9. A placenta with a velamentous insertion and a hypocoiled cord was delivered. Mom and baby remained stable postpartum and Hepatitis B vaccine was given.

The decision-making was quite straight forward and outcome excellent, not something case studies are made of. However, sitting with this well-educated recently emigrated family awaiting their baby’s safe arrival was a good reminder of how fortunate we are to have the model of care we do in the US:

Health Care Providers: Although providers are available in her country, many women seek care with traditional healers and the extent of physician care is often limited to emergencies. The mother received care in an office and hospital setting with a CNM, Obstetrician, Perinatologist and Endocrinologist according to established standards of care. An Anesthesiologist placed an epidural and a Neonatologist was present to provide resuscitation care at birth.

Gestational Diabetes: When we discussed Gestational Diabetes, the father informed me it is rare for such a diagnosis in his country and that Diabetes is usually only diagnosed in older adults. When I asked him how many women in his family may have been screened in his country, he replied that they simply don’t test for it. No test, no diagnosis. He seemed a bit taken aback when I further discussed the actual rate of in his country is in fact 11 times as prevalent as US Caucasian rates.

Ultrasounds: The father commented on the number of ultrasounds performed during the course of pregnancy. In his country, it was rare to have even one. He questioned the utility or overuse of imaging. She had multiple early IVF ultrasounds for location, number and viability, as well as a third trimester growth ultrasound with weekly BPP/AFI after 34 weeks. Final ultrasound identified a baby with a significant perinatal morbidity risk.

Epidurals: The mother was unable to explain the concept of epidural pain management to her family in her country of origin. They couldn’t understand the concept of controlling pain in labor or the safety of doing so. She eventually gave up. Although she had planned epidural placement from the onset of pregnancy, yet was still quite delighted in how it removed an element of fear of the process of labor.

Hepatitis B Vaccine: The parents consented to Hepatitis B vaccine administration to the baby at birth. In fact, the father had a smile when we asked “You can do that right here? He can get vaccinated?” His response perplexed me until I realized the magnitude of Hepatitis B infection in his country and the relatively new program of pediatric immunization schedules with a history for very low compliance.

As I head home at the end of the day, I am reminded of how grateful I am to be a part of the US healthcare system, its technology and the safety it provides. How differently that phone call could have turned out if the system wasn’t there? How different it would have been if this family was in their country of origin with a perinatal mortality rate 8x’s higher than the US? How different this outcome could have been?

But then again, if we replace the country of origin with US Homebirth… would it really have been any different at all?