Planned Out-Of-Hospital Birth

Aka: Planned Out-Of-Hospital Birth, Community Birth, Home Birth, Home Childbirth, Free-Standing Birthing Center

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II. Epidemiology

  1. Incidence of Planned Out-Of-Hospital Birth
    1. U.S.: 1.6% in 2018 (accounting for 1 in 61 births; births were at home for 63% in 1935)
  2. Locations for out of hospital Births (U.S.)
    1. Home Birth: 62%
    2. Free-Standing Birthing Center: ~33%
      1. As of 2016, U.S. had <400 birth centers, and only 119 are accredited by American Association of Birth Centers
  3. Provider Attendeding Planned Out-Of-Hospital Birth (U.S.)
    1. Midwives represent >95%
    2. Physician: ~4%
  4. Many U.S Home Births are performed in "maternity care deserts" where there are no obstetricians or hospitals
    1. More than 1000 U.S. counties with >5 million population have no obstetrician or hospital
  5. One third of U.S. out-of-hospital deliveries are not considered low risk (i.e. considered contraindicated by ACOG)
    1. Vaginal Birth after Cesarean (VBAC) attempts at home have increased despite increased risk
    2. Patients may choose risk of Home Birth, as many hospitals do not allow Trial of Labor after Cesarean
    3. Tilden (2017) Am J Obstet Gynecol 216(4);403 [PubMed]
    4. Barger (2013) BMC Pregnancy Childbirth 13:83 [PubMed]

III. Indications: Planned Out-Of-Hospital Birth

  1. Low risk pregnancy with single fetus in vertex position at Gestational age <41 weeks AND
  2. No prior Cesarean Section AND
  3. No underlying maternal or neonatal adverse outcome risk factors AND
  4. Patient understands the potential risks of out-of-hospital birth AND
  5. Midwife meets standards (International Confederation of Midwives Global Standards of Midwifery Education) AND
  6. Relationship with integrated and regulated maternity care system for Consultation and transfer to higher level of care as needed

IV. Contraindications: Relative

  1. Any failed indication criteria (see above) are considered an absolute contraindication
  2. Maternal age over 35 years
  3. Pre-existing significant medical conditions
    1. Significant Asthma previously requiring hospital admission
    2. Significant psychiatric disorder previously requiring hospital admission
    3. Substance Abuse or dependence
    4. Known cardiac disease or hypertensive disorders including Pregnancy Induced Hypertension
    5. Diabetes Mellitus or Gestational Diabetes
    6. Hyperthyroidism
    7. Bleeding Disorder or significant Anemia
    8. Thromboembolic disorder
    9. Hepatic or renal disease
    10. Seizure Disorder
    11. Vaginal Delivery limited by orthopedic condition
    12. Systemic Lupus Erythematosus
    13. Chronic infections (e.g. HIV, Viral Hepatitis, Syphilis, Tuberculosis, Active Genital Herpes)
    14. Pre-Pregnancy Body Mass Index >35 kg/m2
  4. Prior Obstetric complications
    1. Prior cesarean delivery or uterine surgery
    2. Prior Stillbirth (Intrauterine Fetal Demise)
    3. Prior Postpartum Hemorrhage
    4. History of Eclampsia, or Preeclampsia requiring preterm birth
    5. History of Retained Placenta requiring manual placenta removal
    6. Shoulder Dystocia
  5. Current Obstetric conditions
    1. Any condition requiring pharmacologic induction of labor
    2. Fetal Congenital Abnormality
    3. Intrauterine Growth Retardation
    4. Oligohydramnios or Polyhydramnios
    5. Placenta accreta (or placenta increta or percreta)
    6. Placental Abruption
    7. Preterm Labor
    8. Prolonged Rupture of Membrane without active labor
    9. Rh Isomimmunization

V. Precautions

  1. Out-Of-Hospital Birth here refers only to a planned Community Birth
    1. Unattended Home Birth (free birth) and precipitous delivery are not addressed here
    2. Unattended Home Birth (free birth) is associated with 90 fold increased maternal mortality
  2. AAP and ACOG have statements regarding planned Home Birth
    1. AAP and ACOG point out that hospitals and accredited birth centers are safest birth locations
    2. AAP does not recommend Home Birth, but recommend a second provider for newborn if Home Birth is performed
    3. ACOG lists strict indications, highlighting risks and benefits (as below)
  3. Midwives
    1. Midwife should meet standards (International Confederation of Midwives Global Standards of Midwifery Education)
    2. Guidelines vary by U.S. state, as to who may assist a planned home delivery
    3. Midwives in U.S. have 4 distinct pathways of education (Certified Nurse Midwife, Certified Midwife, Traditional Midwife)
      1. Certified Nurse Midwives are nurses who are also midwives trained at a formal college program
      2. Certified Midwives (direct entry midwives) are non-nurses trained at a formal college program
        1. Most certified midwives are Certified Professional Midwives, undergoing additional certification
        2. Additional Certification may be in the form of accredited program or portfolio evaluation process
      3. Traditional midwives may not be certified, licensed or undergo formal training
  4. Emergencies
    1. Standardized protocols should be established for safe and timely Emergency Transport and hospital evaluation if needed

VI. Efficacy

  1. See complications below
  2. Unattended Home Birth and precipitous delivery have different risks and outcomes not addressed here
  3. Compared with hospital birth, Home Births have lower rates of obstetric intervention
    1. Decreased risk of assisted Vaginal Delivery
    2. Decreased risk of cesarean delivery

VII. Complications

  1. Per ACOG, Planned Out-Of-Hospital Births approximately double risk of these adverse outcomes
  2. Neonatal Death (1-2 per 1000 planned Home Births)
    1. Neonatal death rates increase to 1 in 78 for home Breech Delivery
    2. Neonatal death rates are also higher for Home Births to Nulliparous mothers, and Gestational age >41 weeks
  3. Neonatal Seizures or serious neurologic dysfunction (0.4 to 0.6 per 1000 Home Births)
    1. Risk increases 8 fold over in-hospital delivery if home Vaginal Birth after Cesarean section
  4. Low APGAR Score

VIII. Management: Newborn Care

  1. Prepare for delivery
    1. Adequate Resuscitation equipment
    2. Healthcare professional present, dedicated to the newborn and qualified in Neonatal Resuscitation (e.g. NRP)
    3. Available Emergency Transport and hospital facility if needed in emergent need of higher level of care
    4. Increase Temperature in the room to prepare for newborn
  2. Post-Delivery
    1. Initial
      1. Warm and dry the newborn
      2. Newborn Resuscitation as needed
    2. Exam
      1. Assign APGAR Score at 1 and 5 minutes
      2. Perform complete Newborn Exam including newborn Vital Signs
    3. Medications
      1. Ophthalmia Neonatorum (Gonococcal Conjunctivitis) prophylaxis with topical Erythromycin ointment
      2. Hemorrhagic Disease of the Newborn (Neonatal Vitamin K Deficiency) prophylaxis with Vitamin K Administration
      3. Hepatitis B Vaccine
    4. Consider newborn risks
      1. Group B Streptococcal Sepsis
      2. Hypoglycemia
      3. Congenital Heart Disease
      4. Hyperbilirubinemia
    5. Follow-up
      1. Arrange for medical provider follow-up for newborn
      2. Newborn Hearing Screening
      3. Newborn Screening

IX. Management: Hospital Transfer Indications

  1. Peripartum Transfer Indications
    1. Preterm Labor (Gestational age <37 weeks)
    2. Umbilical Cord Prolapse
    3. Fetal Malpresentation (e.g. Breech Presentation)
    4. Prolonged Rupture of Membranes without Active Labor
    5. Maternal Exhaustion or Failure to Progress (Labor Dystocia)
    6. Active Labor Anesthesia requested
    7. Chorioamnionitis
    8. Fetal Distress or fetal demise
  2. Postpartum Transfer Indications
    1. Postpartum Hemorrhage
    2. Retained Placenta
    3. Perineal Laceration Repair requiring obstetrician (e.g. fourth degree Laceration)
  3. Newborn Transfer Indications
    1. Congenital malformation
    2. Low APGAR Score
    3. Hypoglycemia or poor feeding
    4. Newborn Respiratory Distress
    5. Neonatal Sepsis suspected

X. References

  1. Lang (2021) Am Fam Physician 103(11): 672-9 [PubMed]
  2. Snowden (2015) N Engl J Med 373(27): 2642-53 [PubMed]

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