Planned Out of Hospital Birth

The Saskatchewan College of Midwives (SCM) defines an out of hospital (OOH) birth as a birth conducted by a midwife, and occurring in a location where other specialized medical care (obstetrical, paediatric, surgical and/or anaesthetic skills) is not provided on site. Such sites may include homes, birth centres, nursing stations and some hospitals. (1)

Available evidence confirms that a planned OOH birth is a safe option for low risk/well-screened women when the birth is attended by a registered midwife and a qualified second attendant, and when appropriate emergency equipment and the integration of Midwifery into the regional obstetrical program is in place.

Client evaluation for the appropriateness of OOH birth is a complex process involving:

• informed choice
• skilled interviewing
• prenatal, intrapartum and postpartum observations and measurements
• opportunities for the client to alter identified risk factors
• the midwife’s judgment
• ongoing midwife-client communication

CONTRAINDICATIONS

Certain contraindications exist to planned out of hospital birth. These include:

• Multiple gestation
• Breech presentation or other types of non-vertex presentation
• Preterm labour prior to 37 weeks of pregnancy
• Documented evidence of change in fetal status in a post term pregnancy of more than 42 weeks
• Planned OOH VBAC is contraindicated in the following circumstances (2)
• One previous lower segment caesarean section before 26 weeks
• Interpregnancy interval of less than 18 months
• History of impaired scar healing
• Prolonged active phase of labour with lack of progress
• Any Condition included in the SCM policy Mandatory Discussion, Consultation and Transfer of Care.1 Definition approved by SCM Council November 2012
  2 See policy for Vaginal Birth after One Previous Low Segment Caesarean Section

Clients with the following conditions are carefully reviewed and may or may not be advised to give birth in a hospital with specialist services depending on the specific and overall clinical and/or psychosocial profile:

• Previous obstetric history of complications requiring the care of a specialist, that are likely to reoccur in current pregnancy
• Women with high BMI over 40 (3)
• VBAC4
• Previous stillbirth or fetal anomaly
• Client requesting care outside the standards of practice5
• Any other condition of concern to client or caregivers

The midwife shall obtain the best available and most reliable documentation regarding mitigating factors with respect to the client’s previous deliveries.

OTHER CONSIDERATIONS

• Distance and time required to access specialized care
• Access to telephone
• Weather conditions
• Availability of emergency support systems
• Family supports
• Condition of the woman’s birth environment
• Other psycho-social factors

PREPARATION

In preparation for an OOH birth, the midwife will ensure that the following are completed:

• Arrange for a second birth attendant, in accordance with the Standard for the Use of a Second Attendant. This second attendant must be skilled in handling both maternal and neonatal emergencies.
• Establish links with the nearest hospital or health facility capable of dealing with an obstetrical emergency.5
• Initiate discussion with the client early in pregnancy regarding choice of birth place and continue throughout the course of her care. This discussion must include:
  • The woman’s unique circumstances including relevant clinical and non-clinical factors.
  • Current information and evidence that relates to the risks and benefits of each birth setting.
  • Current information regarding RHA, hospital and community standards related to the woman’s situation (eg. Emergency transportation, fetal surveillance, newborn monitoring).
  • Current information regarding local hospital’s obstetrical capacity and resources available at the time of birth.
  • Perinatal complications that may arise and how the outcome may be affected by place of birth.
    This discussion must include: placental abruption/antepartum haemorrhage, postpartum haemorrhage, shoulder dystocia, cord prolapse, undiagnosed twins, undiagnosed breech/malpresentation, meconium stained fluid, neonatal resuscitation and intubation, abnormal fetal heart tones, uterine rupture and anaphylaxis.
  • The effect that transport time to the nearest hospital with obstetric services may have on her birth outcome. A delay in receiving specialist care could contribute to a poor outcome for mother and baby including severe disease, disability or death.
  • How the skill, experience and number of attendants might affect the outcomes of the complications.
  • Consideration of how the woman and her support system may react in the event of a bad outcome.
  • The woman may change her decision about place of birth at any time. o Document discussions regarding choice of birth place.

(3) See policy Mandatory Discussion, Consultation and Transfer of Care.
(4) See policy Vaginal Birth After One Previous Low Segment Cesarean Section 5 See policy Client Request for Care Out of Scope

Essential equipment and supplies for a planned out of hospital birth

Midwives who attend out of hospital births are responsible for having well-maintained equipment, supplies and medications that may be required during labour, birth and/or the postpartum period.

Adopted and Adapted with Permission College of Midwives of Manitoba

Saskatchewan College of Midwives Administrative & Professional Practice Policy Manual

REFERENCES

British Columbia Reproductive Care Program. (2000). Maternity care services in rural communities: Consensus symposium update. BCRCP Perspectives, Spring, 2000.

Chamberlain, M., Moyer, A., Nair, R., Nimrod, C., England, J., & Smith, M. (1996). Evaluation of the Birthing Project in Rankin Inlet, N.W.T. (Unpublished).

College of Midwives of British Columbia. (2005). Statement on Home Birth. Registrant’s Handbook.

College of Midwives of British Columbia. (2005). Indications for Planned Place of Birth.

Registrant’s Handbook.

College of Midwives of Ontario. (1994). Indications for planned place of birth. Registrant’s Booklet.

Dimond, B. (2000). Is there a legal right to a home confinement? British Journal of Midwifery, 8(5):316 -319.

Government of Alberta. (1992). Report of the midwifery services review committee.

Government of British Columbia. (1998). Saxell, L.: Research studies on out-of-hospital birth. Handbook for midwives and health care professionals. Ministry of Health and Ministry Responsible for Seniors.

Government du Québec. (1998). Midwifery pilot projects: Final report and recommendations. Pilot project assessment board.

Mehl-Madrona, L., Madrona, M. M. (1997). Physician- and midwife-attended births. Effects of breech, twin, and post-dates outcome data on mortality rates. Journal of Nurse-Midwifery, 42(2):91-98.

Murphy, P. A., Fullerton, J. (1998). Outcomes of intended home births in nurse-midwifery practice: a prospective descriptive study. Obstetrics and Gynecology, 92(3): 461-470.

Olson, O. (1997). Meta-analysis of the safety of home birth. Birth, 24(1):4-13.

Society of Obstetricians and Gynecologists of Canada, Society of Rural Physicians of Canada, College of Family Physicians of Canada. (1992). Guidelines for physicians and nurses in maternal/fetal transport (No.16).

Society of Obstetricians and Gynecologists of Canada, Society of Rural Physicians of Canada, College of Family Physicians of Canada. (April,1998). Joint position paper on rural maternity care. No. 72. http://www.sogc.org/SOGCnet/sogc_docs/common/guide/library_e.shtml. Suarez, S. 1999. Guidelines for informed consent. Candidate Information Bulletin. The North American Registry of Midwives.

The House of Commons. (1992). Health committee Second report: Maternity Services, Vol 1. London: The House of Commons.

Walsh D. (2000). Evidence-based care series 1: Birth environment. British Journal of Midwifery, 8(5): 276-278.