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Monday
Aug282006

Home Visits

It's always so much fun to do home visits at the end of the pregnancy. We go to our clients' homes so we know how to get there when we aren't in a rush or when it isn't dark outside. It's a great way to see what the clients' homes look like, what they find important (books, collections, etc.), how sanitary the house will be, what kind of food they are really eating (compared to what they said they were eating) and to be able to see everyone in their own element. Kids, especially, are a delight to observe as they come to life in their own homes. Even the ones who are the most comfortable at the office are transformed surrounded by their own toys and things.

It isn't an inspection (like that). I don't want it to sound like that at all. But, in many ways, it is the culmination of information we have gotten during the rest of the pregnancy. Women show their soft/weak spots during the home visit. Invariably, they will apologize for the mess, even when everything is meticulously in order. We are often served snacks or meals - and we admonish it is the LAST time they are allowed to serve us!

What we do inspect is the Birth Kit.

We have clients order a birth kit from Cascade (each midwife has her own quirks for what she wants in there) and then supplemental items to augment the kit and then separate them into three bags (usually brown paper) labeled MOM, BABY and WARM. We ask moms to please not throw the box away because we use it at the birth - it's the best garbage bag holder.

(From memory) My Cascade birth kit contains the sitz bath herbs, a package of industrial strength pads, a bag of safety pins, two stacks of chux pads, a peri-bottle, an instrument soak (single use), two plastic-backed paper drapes, a baby hat, a footprinter, a paper measuring tape, cord care (herbal), small and medium sterile gloves (10 each)... is that it? I'm going to add a small bottle of betadine in case I need to catheterize a woman. Used to have that and never needed it, so eliminated it. Then, when I needed it, didn't have it. Hard to gauge what to keep and what to eliminate. I did get rid of the bulb syringe. Can't see getting that back in there.

Preparation includes taking the sitz bath herbs and making an herbal infusion and wetting 4-5 of the giant-sized pads. Not soaking, but not dribbling. After the tea is made, the herbs are strained out if the woman wants to do that (some prefer to keep them in) and then the pads wet. Then they are wrapped in Saran Wrap individually. Once they are wrapped, they are put into a bowl (cereal-sized or larger) and plopped in the freezer. When they are frozen, they can be taken out of the bowl and stacked back in the freezer to await the birth.

In the MOM bag, we put the oh-so-unattractive mesh panties (which should have been washed), the peri-bottle, the remainder of the sitz bath herbs, a something if mom wants to wear it after the birth (a tee shirt, tank top, pajamas, etc.), a copy of her insurance card in case of transport and, in the winter, socks.

In the BABY bag, nice baby hats (not the one from the kit), baby clothes, diapers, diaper covers, the cord care herbs and the paper tape measure are gathered together. Some mamas want socks for the babies, too. The baby's thermometer goes in here, too.

The WARM bag is the bag with towels, washcloths, a couple of hats, including the one from Cascade.

Two sets of sheets, two plastic drop cloths, AA batteries and 9-V batteries (back-ups for the midwives), loads of towels (especially if there is a pool involved), Rescue Remedy, 2 large bottles of peroxide, any herbs, essential oils or homeopathics the woman prefers (I carry a supply of stuff, too), film, camera, music, a video camera and other individual desires are gathered and put into the box that we keep for the trash during labor. The box also holds the remaining chux, gloves, drapes and stuff, too.

If a pool is involved, the client has to have a new hose (can't have been used even once due to gookies that live outdoors inside hoses and spigots). We talk about how to turn the water heater UP unless there is another kidlet in the house, then they have to be really careful about the water being so hot. We explain how it can take two hot water heaters full before the pool is filled (especially the Aqua Doula). We explain that it is easier to cool water off than to heat water up, so hotter at first is better. We explain "going to the river" if the client has a blow up fishie pool. "Going to the river" is my description of bringing hot water to the pool from the kitchen and dredging cold water from the pool to be replaced with hot. Sometimes we have a chain and it is always amusing as pots, tea kettles, coffee makers and microwaves are utilized to keep water in fishie pools warm. More and more, I adore Aqua Doulas. They keep themselves toasty.

We explain to dad/partner how to make the bed. Once labor seems to be going, take the nicer set of sheets and put them on the stripped down bed. Then take one of the drop cloths and put it over those sheets. Take the next set of sheets... the ones they don't really care about getting stained (they rarely are stained)... and put those over the drop cloth. Then, take the safety pins in the box and attach the whole shebang to the mattress (if the bed isn't a waterbed!)... sheets, plastic and sheets all get attached via pins to the mattress. This keeps everyone from sliding around if anyone is on the bed. If mom is on the bed, it isn't uncommon to have more than just a couple people there. We've slid around at births before and it ain't pretty.

After the birth, when mom gets into the bed to nurse after the placenta is born, she can be worry-free about not being totally cleaned up yet on the sheets. We wipe her off, but if she needs to be sutured, or if the placenta was just born, she isn't as clean as she would be with a shower. Once she gets up to pee and shower (usually at the same time), one midwife stays with mom and the other(s) strip the dirty sheet and plastic off the bed so mom can get into a clean and fresh bed when she herself is clean and fresh. It isn't uncommon for dad to climb in, too. Of course, we put chux pads down on the sheets no matter where in the process they are, too.

Before, during or after all the logistics discussions, we do a prenatal. Mom pees on a (urine) stick, we measure her fundus, palpate her 36-37 week baby and have a goodly discussion about the upcoming birth. We love when the cast of characters who will be at the birth is at the home visit, so we can talk about each person's roles and their worries or concerns about the upcoming birth. We talk about where mom thinks she might have her baby. We take a tour of the house, the kitchen, find where the bathrooms are and where the bags will be kept so that when mom is in labor, we don't have to bother anyone with where things are - they are free to be in labor and not in any entertaining mode.

We have brief discussions of food desires/needs, including mom's in labor and the midwives who will be hanging out for a number of hours in their home. For a long time, I took my own food, even carrying tons of it in my car, but families are so gracious and kind, I began to see my hoarding as my own food issues and got it all out of my car. I mean, stores are open 24 hours a day.

We encourage mom to have comfort foods on hand, whatever that means to her. Foods she enjoys eating when her stomach doesn't feel so good sits well for many women. I explain that most women in home births don't throw-up in labor, but if they do, it is not a problem at all... hard to be tense when you are barfing. Or laughing.

Common foods women choose in labor:

scrambled eggs
bagels and cream cheese
toast with peanut butter
peanut butter and jelly
protein drinks
smoothies
yogurt
fruit

Common foods the midwives request:

Sandwich fixings (turkey or chicken since this midwife doesn't eat red meat or pork)
eggs
bagels and cream cheese (almost 100% what we eat at shorter births)
Diet Coke (guess who asks for that)

We thank and hug everyone for being there, make sure there aren't any more questions or concerns and then pack up and head out after our 2-2.5 hour visit.

Just thought a little window into a home visit might be enjoyed.

Reader Comments (12)

good to see you recovering from the embarrassment.
I was wondering when you start back to school.

some other things we find out at home visits- if there are dogs or cats that will need any special attention - if there is more than one bathroom and if there isn't is there someplace we can go to the bathroom close by- or do we need to bring our own camping toilet ; ) - is there going to be room for us to sleep or get out of the family's way or do we need to have the car ready to sleep in and sit in or bring a lawn chair to sit on outside-
where a good place to put the tub might be if parents want a tub up for a water birth and the logistics of that like where to drain and where is the closest place to fill-
now to say for my clients (but not the mws that work with me) I don't have moms get hats -- but do get bulb syringes- I rarely/almost never use one but if need be love to have it on hand and most parents are use to using them to clear snocky noses when they get a bit older - so it doesn't go to waste if we don't use it at the birth.
I also want to know where towels are as well as where the birth supplies are so mom -who usually does have a running inventory in her head doesn't have to do that kind of mental work in labor-- are there any special details like alarms that need to be set.. cameras that have special instructions-- entry codes to gated communities as well as sign in procedures for some... there are places where I found out I needed my ice chest.

August 29, 2006 | Unregistered CommenterAnonymous

Thanks for this timely entry. My home visit is coming up with my midwife, and it gives me lots of ideas on things to discuss.

August 29, 2006 | Unregistered CommenterLaborpayne

How much eating is possible during middle and late-stage labor? At my (induced, hospital) birth, they told me it was 'clear fluids only' after the pitocin drip was started, and then I was vomiting up water after they broke my amniotic sac. Later, my obstetrician relative laughed that I'd wanted to eat during labor at all--she said 'your stomach shuts down when you're really in labor, and you can't digest anything anyway'. Tell me what you know about this.

August 29, 2006 | Unregistered CommenterAnonymous

Loved this post, too. Different than most you write, but also interesting.

If you go for cloth diapering, how 'bout cloth for Mama too?

August 29, 2006 | Unregistered CommenterThe MSILF

you know, I use a small aquarium pump to drain water from the fishy pools so we can add more hot water. I loathe buckets and boiling water, so I don't do it very often.

I'm a fan of the fishy pools because they're not so deep (which is nice when you want to nurse your babe in the water after the birth without water to your neck), they've got soft sides to lean over, soft bottoms for your knees and bum (and those aquadoula liners sometimes have folds that hurt to kneel on!) and they are sooooo much cheaper!

I like the aquarium pump - you can hook the hose right up to it and it will empty a whole fishy pool in a matter of an hour.

Don't get me started on Cascade. The owner has a horrible work ethic, she loathes homebirth midwives (I used to work for her, I know!) and she has done some things that I feel are not worth spending money there. In addition, she is emotionally abusive to her employees.

This was a nice post about the home visit! I love going to people's homes. I used to only do home visits, but got too busy and my life too hectic. In a way, I really miss it.

August 29, 2006 | Unregistered CommenterSage Femme

We just had our home visit this morning!

Very exciting. Reminds me that I'm really going to have a baby! I will look over your list of things and see if there's anything more I need to add. I know I need two drop-cloths and some alkolol.

August 29, 2006 | Unregistered CommenterLindsay

I am sending you abstracts about bulb suctioning - sorry they are so old - I guess studying the use of bulb suctioning is no longer of concern ....

Am J Perinatol. 1990 Jan;7(1):87-91.

Comment in:
Am J Perinatol. 1991 Nov;8(6):422-3.

Efficacy of bulb versus DeLee suction at deliveries complicated by meconium
stained amniotic fluid.

Locus P, Yeomans E, Crosby U.

Department of Medical Education, St. Paul Medical Center, Dallas, Texas 75235.

A combined obstetric-pediatric approach to the management of deliveries
complicated by meconium-stained amniotic fluid has been recommended to decrease
the incidence of meconium aspiration syndrome. Although pharyngeal suction with
a DeLee catheter is generally recommended, many obstetricians prefer to use a
bulb syringe for suction at the perineum. A thorough review of the literature
reveals no prospective studies in humans comparing the two techniques. In the
present study, these two techniques of pharyngeal suction were prospectively
compared at deliveries complicated by meconium-stained amniotic fluid. Of the
total 2874 deliveries, 127 (4%) were complicated by moderate or thickly
meconium-stained amniotic fluid, and 107 of these were included in the study.
There were 53 infants in the DeLee-suctioned group and 54 in the bulb-suctioned
group. Of the 107 studied infants, four (4%) developed meconium aspiration
syndrome, three in the DeLee group and one in the bulb group. There was no
significant difference in the amount of meconium found below the vocal cords,
comparing pharyngeal DeLee suction to bulb suction (0.22 cc versus 0.24 cc; p =
NS). In conclusion, the data fail to support a significant difference in
efficacy between bulb and DeLee suction in clearing the naso- and oropharynx of
the neonate of meconium in cephalic-presenting vaginal or cesarean delivery.

PMID: 2294916 [PubMed - indexed for MEDLINE]
-------------------------------------------
J Perinatol. 1987 Spring;7(2):111-3.

Intrapartum suctioning of meconium: comparative efficacy of bulb syringe and De
Lee catheter.

Cohen-Addad N, Chatterjee M, Bautista A.

Department of Pediatrics, University of Medicine and Dentistry of New Jersey,
Newark 07103.

Intrapartum suctioning of the newborn's pharynx with a De Lee catheter (DL) has
reduced the incidence of meconium aspiration syndrome (MAS) in neonates born
with meconium staining of the amniotic fluid. However, the bulb syringe (BLB) is
used more often for this purpose because of greater technical convenience. In a
prospective study, 60 offspring of such deliveries received intrapartum
pharyngeal suctioning either by BLB (29 cases) or by DL (31 cases), according to
random selection. The presence and amount of meconium in the trachea, incidence
and severity of MAS, and mortality from the disease were similar between the two
groups. This study suggests that the BLB is as effective as the DL for
intrapartum removal of nasopharyngeal meconium in deliveries with meconium
staining of the amniotic fluid. Since the BLB is easier to use, less expensive
and probably safer, our results suggest that it may be the preferable method.

PMID: 3505604 [PubMed - indexed for MEDLINE
----------------------------------
Perinatol. 1988 Spring;8(2):127-31.

Delivery room management of meconium staining of the amniotic fluid and the
development of meconium aspiration syndrome.

Hageman JR, Conley M, Francis K, Stenske J, Wolf I, Santi V, Farrell EE.

Department of Pediatrics, Evanston Hospital, IL 60201.

A 1-year prospective survey of obstetric and pediatric management of meconium
staining of the amniotic fluid in 464 patients was undertaken. Pharyngeal
suctioning before delivery was performed using bulb syringe (N = 130), De Lee
suction catheter (N = 186), or both (N = 98); endotracheal intubation after
delivery was also done in 413 instances. Using any of the three suctioning
techniques, no differences were seen in Apgar scores, respiratory rates,
presence or absence of meconium on or below the vocal cords, or development of
meconium aspiration syndrome (MAS). If meconium was present on the vocal cords,
it was present below the vocal cords in 76% of the cases. If no meconium was
visualized, it was found below the vocal cords in only 7% of the cases. Of the
142 infants with meconium below the vocal cords, 10% developed MAS and all 14
survived.

PMID: 3193263 [PubMed - indexed for MEDLINE]

Related Links

August 30, 2006 | Unregistered CommenterAnonymous

Okay, can you tell school is in again? Sorry for the major delays in answering/writing.

Anon: Exactly! Same things. We never thought of a camping toilet! I always groan when there is one toilet in the house. What a dandy idea! Do you think it would be crass to put the mom on the camping toilet? ;) (just kidding)

I always have my car ready to sleep in. Always. I always carry pillows and blankets.

Anon 2 brings up a great topic: something I think I will address in a separate post... eating and drinking in labor.

Sage Femme. Do tell! First, I LOVE LOVE LOVE your idea of the fish tank drain!!!!!!!!!!!!!!!!!!!!!! Thank you SO so much for that idea! Gonna buy one TODAY. Have a birth coming up with a fishie pool. Can't wait to try it out! Woo hoo!

Please tell me where you buy your supplies. I appreciate your sharing your inside information. I haven't ever had anything but good from Cascade, so interesting indeed, your experiences. Thanks for sharing them.

As far as cotton pads for mama, my apprentice is going to write a post about postpartum pads for mama... she used them and LOVED them, said they are way better. Funny, she never told me she used them! And I was her midwife! I will surely be looking into offering this to women. Thanks for bringing it to light!

August 31, 2006 | Unregistered CommenterNavelgazing Midwife

Thank you for that post,I think it's interesting to hear the other side. Though I'm not pregnant, I do hope one day to have a home birth. I find it reassuring to hear that there really are midwives who do all that-paying attention to the Mama's needs and wants and those of the whole family. I was beginning to wonder if that's just something you read about in books!
I feel compelled to share with annonymous that with my first daughter's birth (pictocin also) I couldn't have cared less about eating, but I was never so thirsty in my entire life. And all I was "allowed" was ice-chips and then after labor (which I threw up anyway) some water breifly. Then they took it away!! So very cruel! To this day, 5 years later, I still remember how intensly thirsty I was and no water allowed.

August 31, 2006 | Unregistered Commentersajmom

you know if a laboring woman would be more comfortable on the camp toilet- fine with me...
so I do take a bed roll but my car needs some serious perging if I also need to sleep in it-not only equipment but other things I carry around with us

August 31, 2006 | Unregistered CommenterAnonymous

That list of foods is common (apparently, I've discovered!) post-surgery, too. ;)

Hh

Hey! I haven't been to your blog in such a long time and see you've got a post that I just started a video series on. Great minds and all :)

I added a trackback to send viewers your way too :)

Kris

September 5, 2006 | Unregistered CommenterKris, CPM

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