Dr H Margaret

House Calls and Lifestyle Medicine

The Emergency Kit for Unassisted Homebirths

"What if something goes wrong?" Those familiar with hospital births have seen over and over again that what appears normal can suddenly turn to an absolute catastrophe. Those selecting homebirth believe that many of the emergiencies experienced in the hospital setting are prevented by giving birth in a physiologic setting. Studies like the CPM 2000 published in the BMJ support that low-risk women allowed to remain at home as they have chosen are at much less risk for morbidity increasing interventions than low risk women who choose to give birth in the hospital.

In addition to the benefits provided by a physiologic birth experience, the women who choose to give birth at home are also more aware of thier own responsibilities in preventing complications through maintaining a healthy diet and lifestyle. These healthful practices are also useful in preventing complications which result in obstetric emergencies.

However all collections of stories about homebirth, including those about unassisted homebirth contain stories with tragic endings. Most often cited for the tragedies which develop during the labor and birth process are shoulder dystocia, tight nuchal cord, post-partum hemmorhage and problems with infant resuscitation. Dystocia, hemmorhage and resuscitation of the newborn are also the areas of greatest loss in hospital births.

Sophisticated obstetrical services have protocols and drills dealing with these emergencies, their greatest liabilities. Those attending and assisting at homebirths, and those giving birth unassisted should be similarly concerned and have some preparation in handling these emergencies. The approaches used in the out of hospital setting are different than what will be used in a high-tech environment. However, low-tech approaches can be very effective when applied in an appropriate, timely manner.

The Kit Contents

The original D-I-Y homebirth emergency supplies kit is built from my own experience in hospital and homebirths, and study of these common childbirth emergencies. It represents to me a collection of supplies that can be used in a low-tech setting by participants and first responders to emergencies. Functionality and a reasonable cost were considered in preparing this kit. The original kit has been shared to friends and extended family several times during the years it has been around, at times being mailed directly from one completed birth to the next expectant family. The tools for emergencies and resuscitation have never been put to use, for this we are all grateful, but have provided a sense of preparedness consistent with our goal of a healthy mom and healthy baby.

  1. Airway

The largest section of the box contains supplies for clearing the baby's airway and initiating rescue breathing for mom or baby. Presented in order of most likely to be used:

My training in obstetrics gave me the impression that every baby had to be bulb suctioned after delivery of the head and before delivery of the body. More recently I have heard it presented that it is better to maintain the momentum of the birth in order to reduce risk for shoulder dystocia, and bulb suctioning can be completed after the delivery is completed. I have also heard and participated in many births where the bulb syringe is never unwrapped. For births which are taking place physiologicaly (usually squatting position so baby is drained out head down, or in the water where baby is brought up and allowed to begin breathing without delay) that the baby breathes well and does not seem to need any suctioning. If there was any suggesting that the airway needed to be cleared by more than a postural change the blue bulb syringe is cheap, safe and effective.

A small flashlight which holds an ordinary wooden tongue blade allowing illumination of the pharynx with one hand is included in the kit. This flashlight runs on standard batteries and has a small cost compared to a laryngoscope. The laryngoscope really is best used only by those who have been trained and practiced in a supervised setting.

The res-q-vac allows for thorough suctioning without setup of a pump. It also allows for one handed operation and can be used in conjunction with the light described above.

If a baby should need more than a few puffs of rescue breathing, use of a long stem mask can be helpful because if allows for easier observation of chest rise, abdominal distention and infant response. The bag-valve-mask set-up requires an O2 tank for operation and significantly more skill and practice for effective use. Brief periods of rescue breathing can be accomplished either directly mouth to mouth or with the long stem mask, but these are temporary measures pending the arrival of a 911 first responder with bag, O2 and additional skill.

Things are pretty serious if mom stops breathing, and a standard resuscitation protocol with 911 call should be initiated without delay. Initiation of rescue breathing is essential and can be accomplished directly mouth to mouth or with use of a pocket face mask barrier. 0. Tight Nuchal Cord
This pack of instruments is useful for claming and cutting the cord on the perineum if this is the only way to effect the delivery of the baby. It is very rare that this is necessary, more often the cord can be reduced or the baby delivered in a sommersault with the head kept near the perineum.

These are like hemostats only larger. With a stuck baby the cord often becomes engorged very quickly and small pointy hemostats are impractical for addressing the problem. The larger size instruments are expected to be easier and safer to apply for the less practiced user.

This type of scissors can be worked into tight spaces as would occur with a baby hun up by a tight nuchal cord. They are appropriate for cutting the cord between the clamps and also would be suited to cutting episiotomy if this appeared necessary. 0. Lacerations
A significant laceration is likely best repaired by a trained, skilled provider. Self management of minor lacerations, or larger repairs if there is no other option, are facilitated with the laceration repair kit.

Cyanoacrylate adhesive (super glue) is suitable for the repair of minor lacerations that are not bleeding and not gaping. It will not bear any strength in the case of a gaping wound.

  1. Pospartum Bleeding
    • misopostil 10 tablets 100 mcg each (1000mcg total)

Excessive bleeding following the birth is potentially life threatening. First line measures include effective uterine massage. Herbal tinctures susch as shepards's purse are also tried by some. However severe bleeding is an emergency and must be addressed without delay. Pitocin injection has been a staple in management of bleeding for many years, however injection in a home setting with unlicencsed, untrained persons is not likely the best option. Coming in to favor is misoprostil. The tablets are made for oral use but can also be administered effectively by vaginal route or rectally. 400mcg is often sufficient, but up to 1000mcg has been reported for management of severe bleeding, more is not always better, and paradoxical (opposite of intended) responses have been reported. Study of the use, effects, and risks of the medication is important so that best judgement can be made in determining its use in a homebirth emergency.

This syringe is prepared by taking a standard syringe cutting off the end until a tapered edge remains (allowing for rectal insertion) but enough room is present for easy insertion and the dispersion of the tablets inside the rectum. The Midwives Handbook recommends leaving the syringe in place after administration of the medicine to act as a plug and prevent the medicine from being expelled prior to absorption.

Packets of jelly are included and may be useful in lubricating for inserting the syringe, also use of some gel in the syringe to keep the tablets mobile and easily dispersed may be helpful. 0. Normal Birth This pack is the smallest of all, and the only one that has seen any use during the period of service of our kit.

A pair of sharp scissors is included for cutting the umbilical cord when all are ready.

A thick string, that holds a knot easily and will not slice into the cord tissue is most useful. String taken from general use or salvaged from other packaging must be well cleaned and sterilized.