The Nurse–Midwife and Crisis in a Home Delivery

Twenty-seven-year-old Melissa Owens was eagerly awaiting the birth of her first child. Married for 3
years, she and her husband Roger had recently opened a small business in a growing suburban
community. When it became apparent Mrs. Owens was pregnant, she and her husband visited Nurse
Midwives, Inc., a home birthing service available in their community. The emphasis on prenatal nutrition
and childbirth preparation classes as well as the opportunity to give birth to their firstborn in their own
home appealed to the Owenses’ belief in birth as a natural body process. They were also strongly
attracted to the relaxed approach of the four certified nurse–midwife (CNM) partners and their
agreement that Mr. Owens could participate in the birth as much as he and his wife desired. During the
months of pregnancy, Mr. and Mrs. Owens attended the biweekly childbirth preparation classes given
by their nurse–midwife, Ms. Lisa Bennington, and her partner, Mrs. Betty Thornton. A friendly and
supportive relationship developed between the couple and the nurses based on their mutual beliefs
about the birth process and the value of early infant–maternal bonding in the family setting. Because
Mrs. Owens had enjoyed a healthy, uneventful pregnancy, Ms. Bennington anticipated no problems
during labor and delivery. Now, in her 41st week of pregnancy, Mrs. Owens began to feel the long-
awaited contractions signaling labor. Called to the Owenses’ home, Ms. Bennington found her patient in
the early phase of labor, 4 cm dilated and 70% effaced. Her amniotic membranes were intact and Mrs.
Owens seemed in good health and spirits. The baby’s presentation (head or vertex) and position (left
occipitoanterior) were considered favorable for both mother and baby. In minimal pain, Mrs. Owens
was encouraged to walk around the house to stimulate labor.

Mrs. Thornton soon joined her partner at the home. She confirmed Ms. Bennington’s findings, which
were discussed by phone with the nurse midwives’ obstetric backup, Dr.Lester Holmes. A strong believer
in the overall safety of hospital delivery but supportive of the midwives’ practice, he encouraged them
to call him if any unexpected problems developed during Mrs. Owens’s labor. Within an hour, Mrs.
Owens’s amniotic membranes ruptured and the labor contractions became stronger. As time passed,
everything seemed to be progressing normally until Ms. Bennington noted a marked decrease in the
fetal heart rate during contractions. After a contraction, however, the fetus seemed to regain its normal
heart rate. Both nurse midwives noted this pattern over several strong contractions. Changing Mrs.
Owens’s position did not seem to alter the pattern. They realized that an unexpected problem (i.e.,
umbilical cord compression) could be developing. Because Mrs. Owens was now almost fully dilated,
birth of the baby could occur within a short time. Their concern about the fetal heart rate thus needed
prompt attention. According to their contractual agreement with Mr. and Mrs. Owens, the nurse
midwives explained the decelerations of the fetal heart rate during contractions, its possible meanings,
and the various choices that might have to be made. Mrs. Thornton thought Dr. Holmes should be
contacted to arrange immediate transport to the hospital. She considered any change in the status of
the fetus during labor at home a good reason to change to a hospital delivery. Ms. Bennington,
however, did not think that the situation warranted hospital delivery. She thought home delivery was of
such value to the parents and the child that some minimal risk to the fetus was tolerable. She also knew
that her patient felt very strongly about bearing her child at home with her husband’s participation. Ms.
Bennington strongly supported these wishes. Her own belief in home rather than hospital delivery
encouraged her to avoid transporting any patient to the hospital unless a dramatic change occurred in
the fetal heart rate or other problems became evident. At this point, Mr. and Mrs. Owens voiced their
own insistence on home delivery unless some definite danger to the life of their child was evident.

Ms. Bennington considered the possible choices she could make. She could yield to the Owenses’ wishes
to stay at home unless more than minimal risk to the fetus was evident. She could observe the fetal
heart for another 30 minutes, which was as much risk as she personally thought acceptable. She could
defer to her partner’s judgment that the technological advantages of a hospital delivery room were
immediately warranted by the situation. She could even choose not to make a decision by calling Dr.
Holmes to ask for his guidance. She felt sure, however, that he would recommend immediate
hospitalization.