Homebirth? Max Brinsmead MB BS PhD December 2014

Homebirth? Hotly debated for most of my 40 years in practice Hotly debated for most of my 40 years in practice Often from a biassed viewpoint Often from a biassed viewpoint Doctors vs midwives Doctors vs midwives Patient vs carer Patient vs carer And sometimes patient’s carer vs “system” And sometimes patient’s carer vs “system” Now we have definitive and objective data based on RCT’s Now we have definitive and objective data based on RCT’s This talk based on 2014 NICE Guidelines This talk based on 2014 NICE Guidelines

Every low-risk woman may choose… A PLACE OF BIRTH A PLACE OF BIRTH –Obstetric Unit –Alongside Midwife-led Unit –Freestanding Midwife-led unit –Home Provided that each are appropriately staffed and facilities optimal for transfer upwards as required Provided that each are appropriately staffed and facilities optimal for transfer upwards as required

Low risk multiparous women Rates of intervention are lower if she chooses to deliver in a midwife-led care setting Rates of intervention are lower if she chooses to deliver in a midwife-led care setting –Home, stand-alone or alongside unit compared to an obstetric unit And the outcomes for the baby are no different And the outcomes for the baby are no different About 1:10 will require transfer to an obstetric unit About 1:10 will require transfer to an obstetric unit

Low risk multiparous women

Low risk nulliparous women Rates of intervention are lower if she chooses to deliver in a midwife-led care setting Rates of intervention are lower if she chooses to deliver in a midwife-led care setting –Home, stand-alone or alongside unit compared to an obstetric unit Outcome for the baby is slightly worse for planned homebirth Outcome for the baby is slightly worse for planned homebirth About 4 women in every 10 will require transfer to an obstetric unit About 4 women in every 10 will require transfer to an obstetric unit

Low risk nulliparous women

Low risk multiparous women

NB: This data relates to the UK and is not applicable to all settings All healthcare professionals involved need to know… All healthcare professionals involved need to know… What constitutes a low-risk woman What constitutes a low-risk woman What local facilities are available including… What local facilities are available including… Access to midwives and the liklihood of receiving one-to-one continuous care Access to midwives and the liklihood of receiving one-to-one continuous care Access to medical staff and facilities Access to medical staff and facilities Access to pain relief including anaesthetists Access to pain relief including anaesthetists Transport and transfer facilities available Transport and transfer facilities available

Reasons for Transfer to an Obstetric Unit

Medical Reasons to suggest an Obstetric Unit Cardiovascular Cardiovascular Confirmed cardiac disease Confirmed cardiac disease Hypertensive disorder Hypertensive disorder Respiratory Respiratory Severe asthma requiring ↑Rx or hospital Severe asthma requiring ↑Rx or hospital Cystic fibrosis Cystic fibrosis Haematological Haematological Haemoglobinopathy Haemoglobinopathy History of thromboembolism History of thromboembolism Bleeding disorders inc. von Willebrands & ITP Bleeding disorders inc. von Willebrands & ITP Antibodies that cause neonatal haemolysis Antibodies that cause neonatal haemolysis Infective Infective Previous GBS-affected infant or high risk Previous GBS-affected infant or high risk Hepatitis B/C Hepatitis B/C HIV carrier HIV carrier TB or Toxoplasmosis under treatment TB or Toxoplasmosis under treatment

Medical Reasons to suggest an Obstetric Unit Endocrine Endocrine Hyperthyroidism Hyperthyroidism Diabetes Diabetes Immune Immune Systemic lupus erythematosus Systemic lupus erythematosus Scleroderma Scleroderma Renal Renal Abnormal renal function Abnormal renal function Any disorder requiring a renal specialist Any disorder requiring a renal specialist Neurological Neurological Epilepsy Epilepsy Previous CVA Previous CVA Gastrointestinal Gastrointestinal Liver disease with currently abnormal LFT’s Liver disease with currently abnormal LFT’s Psychiatric – requiring inpatient care Psychiatric – requiring inpatient care

Past Obstetric Reasons to suggest Obstet Unit Stillbirth, Neonatal Death or any loss related to previous obstetric difficulty Stillbirth, Neonatal Death or any loss related to previous obstetric difficulty Previous nenonatal encephalopathy Previous nenonatal encephalopathy Pre-eclampsia requiring pre-term birth Pre-eclampsia requiring pre-term birth Placental abruption with sequelae Placental abruption with sequelae Eclampsia Eclampsia Uterine rupture Uterine rupture PPH requiring additional measures or transfusion PPH requiring additional measures or transfusion Retained placenta removed in theatre Retained placenta removed in theatre Caesarean section Caesarean section Shoulder dystocia Shoulder dystocia Previous myomectomy or hysterotomy Previous myomectomy or hysterotomy

Pregnancy Reasons to suggest Obstet Unit Multiple birth Multiple birth Placenta previa Placenta previa Pre-eclampsia or gestational hypertension Pre-eclampsia or gestational hypertension Placental abruption Placental abruption Anaemia – HB < 85 g/litre Anaemia – HB < 85 g/litre Intrauterine fetal death Intrauterine fetal death Induction of labour Induction of labour Substance abuse Substance abuse Gestational diabetes Gestational diabetes Malpresentation including breech Malpresentation including breech BMI >35 at booking BMI >35 at booking Recurrent APH Recurrent APH SGA, oligohydramnios confirmed by scan SGA, oligohydramnios confirmed by scan

Individual assessment required for Anaemia HB 85 – 105 g/litre Anaemia HB 85 – 105 g/litre Hepatitis B/C with normal renal function Hepatitis B/C with normal renal function Previous fractured pelvis Previous fractured pelvis Spinal abnormalities, neurological deficits Spinal abnormalities, neurological deficits Inflammatory bowel disease Inflammatory bowel disease Previous stillbirth non recurrent cause Previous stillbirth non recurrent cause Previous Pre-eclampsia at term Previous Pre-eclampsia at term History of baby >4.5 Kg History of baby >4.5 Kg Extensive perineal 3 rd /4 th degree trauma Extensive perineal 3 rd /4 th degree trauma Clinical or ultrasound suspicion of macrosomia Clinical or ultrasound suspicion of macrosomia Para 4 or more Para 4 or more Current psychiatric outpatient care Current psychiatric outpatient care

Individual assessment required for… Age >35 at booking Age >35 at booking Major gynaecological surgery Major gynaecological surgery Fibroids Fibroids Cone biopsy or LLETZ cervix Cone biopsy or LLETZ cervix BMI 30 – 35 at booking BMI 30 – 35 at booking Single Antepartum haemorrhage of unknown cause Single Antepartum haemorrhage of unknown cause Previous baby required exchange transfusion Previous baby required exchange transfusion

Intrapartum Reasons to suggest Obstetric Unit Maternal PR >120 twice and 30 min apart Maternal PR >120 twice and 30 min apart BP >160 syst or 110 diast once or >140/90 twice 30 min apart BP >160 syst or 110 diast once or >140/90 twice 30 min apart Proteinuria 2+ with BP >140/90 Proteinuria 2+ with BP >140/90 Temp >38 once or >37.5 twice 30 min apart Temp >38 once or >37.5 twice 30 min apart Vaginal blood loss other than a show Vaginal blood loss other than a show Ruptured membranes >24 hrs Ruptured membranes >24 hrs Abnormal pain Abnormal pain Malpresentation including cord felt Malpresentation including cord felt Transverse lie Transverse lie High head in a nullipara High head in a nullipara Suspected IUGR or anhydramnios Suspected IUGR or anhydramnios Polyhydramnios Polyhydramnios

Intrapartum Reasons to suggest Obstetric Unit Meconium that is dark, thick, tenacious or lumpy Meconium that is dark, thick, tenacious or lumpy FHR 160 bpm FHR 160 bpm Any FHR deceleration detected on ausculatation Any FHR deceleration detected on ausculatation Reduced fetal movements in the last 24 hrs as reported by the woman Reduced fetal movements in the last 24 hrs as reported by the woman If fetal death is suspected If fetal death is suspected First stage delay is <2 cm in 4 hrs for nullip and multip or “slowing in the progress of labour” for multips First stage delay is <2 cm in 4 hrs for nullip and multip or “slowing in the progress of labour” for multips Delay is >3 hrs active 2 nd stage in nullips and 2 hrs in multips Delay is >3 hrs active 2 nd stage in nullips and 2 hrs in multips Failure of the head to descend or rotate over 30 min active pushing Failure of the head to descend or rotate over 30 min active pushing

Transfer to an Obstetric Unit Discuss and explain to patient & others Discuss and explain to patient & others Arrange transport, alert obstetric unit Arrange transport, alert obstetric unit Midwife who cared for her to accompany her if possible Midwife who cared for her to accompany her if possible Make her as comfortable as possible & allow her to move as she wishes Make her as comfortable as possible & allow her to move as she wishes Companions to travel with her if possible Companions to travel with her if possible Keep mother and baby together if possible Keep mother and baby together if possible Records to accompany them Records to accompany them

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