Homebirth?Homebirth?

Max Brinsmead MB BS PhDMax Brinsmead MB BS PhD

December 2014December 2014

Homebirth?Homebirth?

Hotly debated for most of my 40 Hotly debated for most of my 40 years in practiceyears in practice

Often from a biassed viewpointOften from a biassed viewpoint Doctors vs midwivesDoctors vs midwives Patient vs carerPatient vs carer

And sometimes patient’s carer vs And sometimes patient’s carer vs “system”“system”

Now we have definitive and Now we have definitive and objective data based on RCT’sobjective data based on RCT’s

This talk based on 2014 NICE This talk based on 2014 NICE GuidelinesGuidelines

Every low-risk woman may Every low-risk woman may choose… choose…

A PLACE OF BIRTHA PLACE OF BIRTH– Obstetric UnitObstetric Unit– Alongside Midwife-led UnitAlongside Midwife-led Unit– Freestanding Midwife-led unitFreestanding Midwife-led unit– HomeHome

Provided that each are Provided that each are appropriately staffed and appropriately staffed and facilities optimal for transfer facilities optimal for transfer upwards as requiredupwards as required

Low risk multiparous womenLow risk multiparous women

Rates of intervention are lower if Rates of intervention are lower if she chooses to deliver in a she chooses to deliver in a midwife-led care settingmidwife-led care setting– Home, stand-alone or alongside unit Home, stand-alone or alongside unit

compared to an obstetric unitcompared to an obstetric unit And the outcomes for the baby And the outcomes for the baby

are no differentare no different About 1:10 will require transfer About 1:10 will require transfer

to an obstetric unitto an obstetric unit

Low risk multiparous womenLow risk multiparous women

Low risk multiparous womenLow risk multiparous women

Low risk nulliparous womenLow risk nulliparous women

Rates of intervention are lower if Rates of intervention are lower if she chooses to deliver in a she chooses to deliver in a midwife-led care settingmidwife-led care setting– Home, stand-alone or alongside unit Home, stand-alone or alongside unit

compared to an obstetric unitcompared to an obstetric unit Outcome for the baby is slightly Outcome for the baby is slightly

worse for planned homebirthworse for planned homebirth About 4 women in every 10 will About 4 women in every 10 will

require transfer to an obstetric require transfer to an obstetric unitunit

Low risk nulliparous womenLow risk nulliparous women

Low risk multiparous womenLow risk multiparous women

NB: This data relates to the UK and is NB: This data relates to the UK and is not applicable to all settingsnot applicable to all settings

All healthcare professionals All healthcare professionals involved need to know…involved need to know…

What constitutes a low-risk womanWhat constitutes a low-risk woman What local facilities are available What local facilities are available

including…including… Access to midwives and the liklihood of Access to midwives and the liklihood of

receiving one-to-one continuous carereceiving one-to-one continuous care Access to medical staff and facilitiesAccess to medical staff and facilities Access to pain relief including anaesthetistsAccess to pain relief including anaesthetists Transport and transfer facilities availableTransport and transfer facilities available

Reasons for Transfer to an Obstetric UnitReasons for Transfer to an Obstetric Unit

Medical Reasons to suggest an Obstetric UnitMedical Reasons to suggest an Obstetric Unit CardiovascularCardiovascular

Confirmed cardiac diseaseConfirmed cardiac disease Hypertensive disorderHypertensive disorder

RespiratoryRespiratory Severe asthma requiring Severe asthma requiring ↑Rx or hospital↑Rx or hospital Cystic fibrosisCystic fibrosis

HaematologicalHaematological HaemoglobinopathyHaemoglobinopathy History of thromboembolismHistory of thromboembolism Bleeding disorders inc. von Willebrands & ITPBleeding disorders inc. von Willebrands & ITP Antibodies that cause neonatal haemolysisAntibodies that cause neonatal haemolysis

InfectiveInfective Previous GBS-affected infant or high riskPrevious GBS-affected infant or high risk Hepatitis B/CHepatitis B/C HIV carrierHIV carrier TB or Toxoplasmosis under treatmentTB or Toxoplasmosis under treatment

Medical Reasons to suggest an Obstetric UnitMedical Reasons to suggest an Obstetric Unit EndocrineEndocrine

HyperthyroidismHyperthyroidism DiabetesDiabetes

ImmuneImmune Systemic lupus erythematosusSystemic lupus erythematosus SclerodermaScleroderma

RenalRenal Abnormal renal functionAbnormal renal function Any disorder requiring a renal specialistAny disorder requiring a renal specialist

NeurologicalNeurological EpilepsyEpilepsy Previous CVAPrevious CVA

GastrointestinalGastrointestinal Liver disease with currently abnormal LFT’sLiver disease with currently abnormal LFT’s

Psychiatric Psychiatric – – requiring inpatient carerequiring inpatient care

Past Obstetric Reasons to suggest Obstet UnitPast Obstetric Reasons to suggest Obstet Unit

Stillbirth, Neonatal Death or any loss Stillbirth, Neonatal Death or any loss related to previous obstetric difficultyrelated to previous obstetric difficulty

Previous nenonatal encephalopathyPrevious nenonatal encephalopathy Pre-eclampsia requiring pre-term birthPre-eclampsia requiring pre-term birth Placental abruption with sequelaePlacental abruption with sequelae EclampsiaEclampsia Uterine ruptureUterine rupture PPH requiring additional measures or PPH requiring additional measures or

transfusiontransfusion Retained placenta removed in theatreRetained placenta removed in theatre Caesarean sectionCaesarean section Shoulder dystociaShoulder dystocia Previous myomectomy or hysterotomyPrevious myomectomy or hysterotomy

Pregnancy Reasons to suggest Obstet UnitPregnancy Reasons to suggest Obstet Unit

Multiple birthMultiple birth Placenta previaPlacenta previa Pre-eclampsia or gestational Pre-eclampsia or gestational

hypertensionhypertension Placental abruptionPlacental abruption Anaemia – HB < 85 g/litreAnaemia – HB < 85 g/litre Intrauterine fetal deathIntrauterine fetal death Induction of labourInduction of labour Substance abuseSubstance abuse Gestational diabetesGestational diabetes Malpresentation including breechMalpresentation including breech BMI >35 at bookingBMI >35 at booking Recurrent APHRecurrent APH SGA, oligohydramnios confirmed by scanSGA, oligohydramnios confirmed by scan

Individual assessment required forIndividual assessment required for

Anaemia HB 85 – 105 g/litreAnaemia HB 85 – 105 g/litre Hepatitis B/C with normal renal functionHepatitis B/C with normal renal function Previous fractured pelvisPrevious fractured pelvis Spinal abnormalities, neurological Spinal abnormalities, neurological

deficitsdeficits Inflammatory bowel diseaseInflammatory bowel disease Previous stillbirth non recurrent causePrevious stillbirth non recurrent cause Previous Pre-eclampsia at termPrevious Pre-eclampsia at term History of baby >4.5 KgHistory of baby >4.5 Kg Extensive perineal 3Extensive perineal 3rdrd/4/4thth degree trauma degree trauma Clinical or ultrasound suspicion of Clinical or ultrasound suspicion of

macrosomiamacrosomia Para 4 or morePara 4 or more Current psychiatric outpatient careCurrent psychiatric outpatient care

Individual assessment required for…Individual assessment required for…

Age >35 at bookingAge >35 at booking Major gynaecological surgeryMajor gynaecological surgery FibroidsFibroids Cone biopsy or LLETZ cervixCone biopsy or LLETZ cervix BMI 30 – 35 at bookingBMI 30 – 35 at booking Single Antepartum haemorrhage of Single Antepartum haemorrhage of

unknown causeunknown cause Previous baby required exchange Previous baby required exchange

transfusiontransfusion

Intrapartum Reasons to suggest Obstetric UnitIntrapartum Reasons to suggest Obstetric Unit Maternal PR >120 twice and 30 min Maternal PR >120 twice and 30 min

apartapart BP >160 syst or 110 diast once or BP >160 syst or 110 diast once or

>140/90 twice 30 min apart>140/90 twice 30 min apart Proteinuria 2+ with BP >140/90Proteinuria 2+ with BP >140/90 Temp >38 once or >37.5 twice 30 min Temp >38 once or >37.5 twice 30 min

apartapart Vaginal blood loss other than a showVaginal blood loss other than a show Ruptured membranes >24 hrsRuptured membranes >24 hrs Abnormal painAbnormal pain Malpresentation including cord feltMalpresentation including cord felt Transverse lieTransverse lie High head in a nulliparaHigh head in a nullipara Suspected IUGR or anhydramniosSuspected IUGR or anhydramnios PolyhydramniosPolyhydramnios

Intrapartum Reasons to suggest Obstetric UnitIntrapartum Reasons to suggest Obstetric Unit Meconium that is dark, thick, tenacious or Meconium that is dark, thick, tenacious or

lumpylumpy FHR <110 or >160 bpmFHR <110 or >160 bpm Any FHR deceleration detected on Any FHR deceleration detected on

ausculatationausculatation Reduced fetal movements in the last 24 Reduced fetal movements in the last 24

hrs as reported by the womanhrs as reported by the woman If fetal death is suspectedIf fetal death is suspected First stage delayFirst stage delay is <2 cm in 4 hrs for is <2 cm in 4 hrs for

nullip and multip or “slowing in the nullip and multip or “slowing in the progress of labour” for multipsprogress of labour” for multips

Delay is >3 hrs active 2Delay is >3 hrs active 2ndnd stage in nullips stage in nullips and 2 hrs in multipsand 2 hrs in multips

Failure of the head to descend or rotate Failure of the head to descend or rotate over 30 min active pushingover 30 min active pushing

Transfer to an Obstetric UnitTransfer to an Obstetric Unit

Discuss and explain to patient & Discuss and explain to patient & othersothers

Arrange transport, alert obstetric Arrange transport, alert obstetric unitunit

Midwife who cared for her to Midwife who cared for her to accompany her if possibleaccompany her if possible

Make her as comfortable as possible Make her as comfortable as possible & allow her to move as she wishes& allow her to move as she wishes

Companions to travel with her if Companions to travel with her if possiblepossible

Keep mother and baby together if Keep mother and baby together if possiblepossible

Records to accompany themRecords to accompany them

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