Am I High Risk?

A list of the most common risk factors and whether or not a Community Midwife practice is able to serve folks with these factors or not.

by midwife P. Kayti Buehler

Am I High Risk?

photo credit: Anne Lucy Fotografia @annelucyfotografia

Many women seeking Community Midwifery or Community Birth ask us whether their unique risk factor would make our style of care unavailable to them. Here is a list of the most common risk factors and whether or not a Community Midwife practice is able to serve folks with these factors or not.

If you are high risk, it might be particularly important to you to have a few prenatal visits with a Community Midwife while planning a hospital birth. In most other countries, midwifery care is for EVERY ONE, standard. Folks who are high risk ALSO see a midwife because midwifery care is more comprehensive and necessary PARTICULARLY if you are high risk to help manage the entire experience of the pregnant person including social resources, mental health, additional education, additional complementary or alternative health care that would be helpful - everything besides dealing with the actual high risk medical issue. In other words - you’re still a pregnant person having a pregnant experience and therefore will do much better with the comprehensive guidance, care and compassion of a midwife along the way!

We cannot be your primary care provider if you are truly high risk, but we CAN offer a lot of other benefit. Here are the most common risk factors. Community Midwives generally agree about whether these risks would make it unsafe for you to plan a community (home or birth center) birth. As with all things, part of the journey is talking about your unique life factors with midwives you are considering working with to get their unique perspectives - something you cannot do in the mainstream medical system.

VBAC In general, a person who has had 1 prior cesarean is potentially a very good candidate for Community Birth.   If you have had 2 prior cesareans, you may need to interview several midwives to find a practice that is comfortable with the additional risk involved.
Why do community midwives support a family’s right to choose a VBAC and support it as is a safe choice?
The scar is more likely to give way during a VBAC labor than in a repeat C-section, but this risk is low. A uterine rupture will occur about once in every 238 labors after C-section. A catastrophic uterine rupture (meaning the baby is at risk from blood loss) happens about 1 in 5,200 times. These numbers include labors induced with pitocin, which makes it hard to compare to Community Birth where Pitocin induction is not done. For more information, we like these sites:
- Childbirth Connection

Age 35 Years and Older at the Time of Delivery In general, a person who is age 35-40 is a good candidate for community birth! We don’t know of any midwives who would risk you out for being in this age category even though doctors offices can use some pretty discouraging terms. Age 40+ does include some additional risk and should be discussed with potential midwife practices but as far as we know, there are no community midwives who would say no exclusively due to your age. So why are they making such a big deal about it at doctors offices? Why are they using the highly offensive and derogatory language, “geriatric” and “advanced maternal age?” (You can also see my article about the Caste system in medicine if you want to really look at the power dynamic involved here.) Here are the basics: As we age, it may be more difficult to get sufficient blood flow to the uterus to get pregnant. As we grow our babies, it may be that this (potentially) lessened blood flow to the uterus causes less blood to be delivered to the baby via the placenta. As we go into labor, it may be that the lessened youth and blood flow of the uterus causes us to have less strong contractions, resulting in a less robust labor pattern, or to put the baby at risk from insufficient placental flow.

First, statistically, the hardest part when we’re over 35 is getting pregnant. So if you’re reading this, pregnant, in your old old age, well, you’ve shown that your uterus still works pretty great.

Second, the concern about baby’s growth throughout pregnancy is addressed by your midwives measuring your belly and therefore measuring growth. So, if your belly is growing well, we can be confident your uterus is doing just fine!

Third, as we near the end of pregnancy, there is additional testing to confirm the health of the placenta and baby and keep going on towards a planned community birth. You can choose an ultrasound at 32 weeks for growth, and there is also Antenatal Testing, offered by community midwives at standard intervals, to confirm the health of the placenta and baby and keep going towards a healthy planned community birth.

Finally, when you are in labor, your community midwife team will listen to the baby’s heart rate throughout your labor to assure that the blood flow to your baby remains well. And if your labor does slow down, or you are slow to progress, you can always decide you want to transfer to the hospital. Hospital Transfer is always an option from a planned community birth. That’s why our care is the safest available maternity care.

For more information, we like these sites:
- Homebirth Reference Site
- Evidence Based Birth

GBS Positive in a Previous Pregnancy
To be honest, folks, this one should just be thrown out the window. If you were GBS positive in a previous pregnancy, or if you’ve already been confirmed with GBS in this pregnancy, you are a fine candidate for community midwifery. No Sweat. In fact, your midwife team is far more likely than a doctors office to help you clear GBS from your vagina. Ask your midwives once you’re in their care and they will help you. Cause that’s what midwives do. Midwives help people out. Get it? Help people out? Little people. Tiny ones. :)

Diabetes or Gestational Diabetes Ok now this one is a little more nuanced…

Overt Diabetes Type 1 or Type 2, diagnosed prior to pregnancy Unfortunately because these conditions almost universally require medications and or close following of the growing baby by ultrasound, if you have diabetes mellitus you are not a candidate for community birth. As mentioned above, many families with this condition do choose to get prenatal care with a community midwife to get the additional support we offer. Contact our midwives to seek personalized information.

Gestational Diabetes
1- Managed by diet and exercise: your community midwife team can continue to provide primary maternity care and plan for a community birth if you are managing your blood sugar with diet and exercise. You will be carefully monitoring your blood sugars daily in order to track this. Your midwife will guide you through this process. Community Midwives are uniquely skilled in this area to provide you with the dietary nutritional and coaching needed to help you create a health blood sugar for yourself and your baby.

2- Uncontrolled by diet and exercise: If your blood sugar levels cannot be kept within the prescribed numbers, numbers which have accepted by midwives and obstetricians alike, you will not be able to keep your community midwife as your primary maternity care provider and would need to be in the primary care of an obstetrician. Your midwife can help identify these doctors if you need. Your midwife team can also help with concurrent care, counseling, and guidance if you choose.

What if they said I have a Big Baby?
Many families come to Community Midwives because they were told by an OB that, based on ultrasound, their baby is “too big” and they were likely to need a c-section or it was strongly recommended that they induce labor as early as 39 weeks in order to prevent complications such as a shoulder dystocia.

Community Midwives understand that you make a size of baby your body can deliver. 

Every baby grows differently - some are bigger, some are smaller. Ultrasounds are often wrong - they can be off by a whole pound or more - and we’ve met many babies who were much smaller than the ultrasound predicted!
Some Facts:
 - We’re really good at resolving shoulder dystocia.
-  A baby’s position is more likely than their size is to effect whether they can be born vaginally. 
-  Most of the women who have come to us with this “diagnosis” have normal vaginal births with us
-  If you try for a vaginal birth, chances are 90% (with us) that you’ll get it. If you go for an induction, your chances of c-section are 50%. If you go straight to c-section, the chances of c-section are 100%.

High Blood Pressure If you have high blood pressure coming into your pregnancy, you would not be a good candidate for Community Birth but should see a community midwife for prenatal care visits for all the reasons stated at the top. If you develop somewhat elevated blood pressures during your pregnancy with a community midwife, your team MAY be able to help you keep it within normal through diet, herbs, homeopathy, and exercise. If you do develop high blood pressure, and it cannot be lowered with alternative medicine, you would need to be in a hospital for your delivery. Your midwife team will still stand by you for support and guidance if you so choose.

Cholestasis If you have had cholestasis in a previous pregnancy, community midwifery may be exactly what you need to have a healthy, full-term, uncomplicated pregnancy this time around. Many of the midwives listed are skilled and experienced in helping folks with cholestasis in a previous pregnancy to not develop it again. Check with the midwives you’re interested in to see if they are experienced and knowledgeable in this area and if they are not, ask for referrals to midwives who are. You can also email us at [email protected] to ask us!

Placenta Previa or Partial Placenta Previa This one is very nuanced. If, for example, on an early ultrasound your placenta was mildly covering the os, it is likely to move up and out of the way, making you a fine candidate for community birth. Your midwife team can monitor this with ultrasound as your pregnancy advances and you can decide together if community birth is right for you.

If on the other hand your placenta was completely covering the os, and did not move by 32-26 weeks, you will likely need a c-section, to prevent injury to your baby. Talk with one of our midwife practices about your unique situation.

Rh (-) If you know you have an Rh Negative blood type, simply tell your midwife when you come into their care. Midwives are able to order the tests and Rhogam you need to keep your baby safe.

Multiple Risk Factors or Risk Factor Not Mentioned Here If your risk factor is not mentioned here, you can certainly ask the midwife team you are interested in for their thoughts on your risk level and whether community midwifery care is appropriate for you. Also please email us at [email protected] so we can consider adding it to this list! This list is not comprehensive and is not to be construed as medical advice. These are guidelines to help you determine whether you are likely a good candidate for community midwifery. We’re glad you’re here and we welcome you, no matter whether you are high risk or low risk. We may not be able to be your primary care providers but chances are good you’ll love the care and information we give.