Planning for Place of Birth

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Planning for Place of Birth

Your decision about where you will have your baby will be influenced by your feelings about each model of care, and also by where you live, your health and your baby's health and any previous experiences you may have had of pregnancy and birth. Although giving birth is generally very safe for both you and your baby, there is not a large quantity of quality research available about the relative safety of planned place of birth. The research that is available suggests that for women planning to give birth at home or in a midwife-led unit or program, there is a greater likelihood of experiencing a normal birth or less intervention.

Where you decide to give birth and with whom is a very personal decision. Whilst you are considering your decision you will probably take the following factors into consideration:

  • What options are available to me where I live?

  • Do I have any health issues which will affect the degree of risk to the baby?

  • What cultural or other life circumstances are going to impact on my choices?

  • How do any previous experiences of pregnancy or birth affect this decision?

  • What do I feel about each model of care?

Pre-existing health issues and the health of your baby or babies during pregnancy, will have an impact upon what options are available to you for your maternity care and place of birth.

The UK's National Institute of Health and Clinical Excellence recommends that all women should be offered the choice of planning birth at home, in a birth centre or 1:1 midwifery program (midwife led care) or in a hospital labour ward (obstetric care). It is important that you know the risks and benefits of each option so that you can decide what is right for you and your baby. Giving birth is generally very safe for both you and your baby. The information we have on planning place of birth is not of good quality or quantity, but it does suggest that for women who plan to give birth at home or in a midwife-led unit/ program the likelihood of a normal birth is greater and there is less risk of intervention. If you are considering this option, it might be helpful to find out what the likelihood of being transferred into the hospital labour ward might be and how long this might take.

A hosptial labour ward will provide you with direct access to obstetricians, anaesthetists, neonatologists and other specialist care including epidural analgesia. If something does go unexpectedly and seriously wrong during labour at home or in a midwife-led unit or program, the outcome for you and the baby could be worse than if you were in a hospital labour ward with access to specialised care.

If you have a pre-existing medical condition or you have had a previous complicated birth, that makes your risk of developing complications higher during this next birth, and you will be advised to give birth in a hospital labour ward.

Tables 1 and 2 show medical conditions or situations in which there is increased risk for the woman or baby during or shortly after labour, where care in a hospital labour ward would be expected to reduce this risk.

Table 1. Medical conditions indicating increased risk suggesting planned birth at an obstetric unit

Disease Area

Medical Condition

              

Cardiovascular
  • Confirmed cardiac disease
  • Hypertensive disorders
              

Respiratory
  • Asthma requiring an increase in treatment or hospital treatment
  • Cystic fibrosis
              

Haematological
  • Haemoglobinopathies – sickle-cell disease, beta-thalassaemia major
  • History of thromboembolic disorders
  • Immune thrombocytopenia purpura or other platelet disorder or platelet count below 100,000
  • Von Willebrand's disease
  • Bleeding disorder in the woman or unborn baby
  • Atypical antibodies which carry a risk of haemolytic disease of the newborn
              

Infective
  • Risk factors associated with group B streptococcus whereby antibiotics in labour would be recommended
  • Hepatitis B/C with abnormal liver function tests
  • Carrier of/infected with HIV
  • Toxoplasmosis – women receiving treatment
  • Current active infection of chicken pox/rubella/genital herpes in the woman or baby
  • Tuberculosis under treatment
              

Immune
  • Systemic lupus erythematosus
  • Scleroderma
              

Endocrine
  • Hyperthyroidism
  • Diabetes
              

Renal
  • Abnormal kidney function
  • Kidney disease requiring supervision by a renal specialist
              

Neurological
  • Epilepsy
  • Myasthenia gravis
  • Previous cerebrovascular accident
              

Gastrointestinal
  • Liver disease associated with current abnormal liver function tests
              

Psychiatric
  • Psychiatric disorder requiring current inpatient care
              

 Source: NICE (2014) Intrapartum care: Care of healthy women and their babies during childbirth. Pg.16 link

 

Table 2. Other factors indicating increased risk suggesting planned birth at an obstetric unit

Factor

Additional Information

              

Previous Complication
  • Unexplained stillbirth/neonatal death or previous death related to intrapartum difficulty
  • Previous baby with neonatal encephalopathy
  • Pre-eclampsia requiring preterm birth
  • Placental abruption with adverse outcome
  • Eclampsia
  • Uterine rupture
  • Primary postpartum haemorrhage requiring additional treatment or blood transfusion
  • Retained placenta requiring manual removal in theatre
  • Caesarean section
  • Shoulder dystocia
              

Current Pregnancy:

Fetal Indications

  • Multiple birth
  • Placenta praevia
  • Pre-eclampsia or pregnancy-induced hypertension
  • Preterm labour or preterm prelabour rupture of membranes
  • Placental abruption
  • Anaemia – haemoglobin less than 8.5 g/dl at onset of labour
  • Confirmed intrauterine death
  • Induction of labour
  • Substance misuse
  • Alcohol dependency requiring assessment or treatment
  • Onset of gestational diabetes
  • Baby in a breech or transverse lie
  • Body mass index at booking of greater than 35 kg/m2
  • Recurrent haemorrhage during pregnancy
  • Small for gestational age in this pregnancy
  • Abnormal fetal heart rate (FHR)/Doppler studies
  • Ultrasound diagnosis of oligo-/polyhydramnios
              

Gynaecological History
  • Myomectomy
  • Hysterotomy
              

 Source: NICE (2014) Intrapartum care: Care of healthy women and their babies during childbirth. Pg.17 link

 
The factors listed in Tables 3 and 4 are not reasons in themselves for advising birth in a hospital labour ward, but indicate that further consideration of birth setting may be required.

Table 3. Medical conditions indicating individual assessment when planning place of birth.

Disease Area

Medical Condition

              

Cardiovascular
  • Cardiac disease without labour implications
              

Haematological
  • Atypical antibodies not putting the baby at risk of haemolytic disease
  • Sickle-cell trait
  • Thalassaemia trait
  • Anaemia – haemoglobin 8.5–10.5 g/dl at onset of labour
              

Infective
  • Hepatitis B/C with normal liver function tests
              

Immune
  • Non-specific connective tissue disorders
              

Endocrine
  • Unstable hypothyroidism such that a change in treatment is required
              

Skeletal/Neurological
  • Spinal abnormalities
  • Previous fractured pelvis
  • Neurological deficits
              

Gastrointestinal
  • Liver disease without current abnormal liver function
  • Crohn's disease
  • Ulcerative colitis
              

Source: NICE (2014) Intrapartum care: Care of healthy women and their babies during childbirth. Pg.17 link

Table 4. Other factors indicating individual assessment when planning place of birth.

Factor

Additional Information

              

Previous Complications
  • Stillbirth/neonatal death with a known non-recurrent cause
  • Pre-eclampsia developing at term
  • Placental abruption with good outcome
  • History of previous baby more than 4.5 kg
  • Extensive vaginal, cervical, or third- or fourth-degree perineal trauma
  • Previous term baby with jaundice requiring exchange transfusion
              

Current Pregnancy
  • Bleeding during pregnancy of unknown origin (single episode after 24 weeks of gestation)
  • Body mass index at booking of 30–34 kg/m2
  • Blood pressure of 140 mmHg systolic or 90 mmHg diastolic on two occasions
  • Clinical or ultrasound suspicion of the baby weighing more than 4.5 kg
  • 6 previous pregnancies or more
  • Recreational drug use
  • Under current outpatient psychiatric care
  • Age over 40 at booking
              

Fetal Indications
  • Fetal abnormality
              

Previous gynaecological history
  • Major gynaecological surgery
  • Cone biopsy or large loop excision of the cervix or lower part of the uterus
  • Fibroids
              

Source: NICE (2014) Intrapartum care: Care of healthy women and their babies during childbirth. Pg.18 link

 

QUICK FACTS

 

 

The UK's National Institute of Clinical Excellence's new draft guidelines for the care of healthy women and their babies, recommends that women should be advised to give birth in the following venues:

 

 

 

Home

 

For all 'low risk' women having a second or subsequent baby, because the rate of intervention is lower and the outcome for the baby is no different compared with an obstetric unit (hospital). For women having their first baby at home, there is a small increase in the risk of an adverse outcome for the baby (NICE 2014:170).

 

 

 

 

 

Birth Centre

 

For all 'low-risk' women, because the rate of intervention is lower and the outcome for the baby is no different compared with an obstetric unit (hospital) (NICE 2014:170).

 

 

 

 

 

1:1 midwifery

 

For all 'low-risk' women, because the rate of intervention is lower and the outcome for the baby is no different compared with an obstetric unit (hospital) (NICE 2014:170).