Home Birth Risks and Reduction Program

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Table of Contents

Introduction
Literature review
Methodology
Implementation
Attachments
How to transfer a mother from home to a hospital using ambulatory services
Conclusion
References

Introduction

The following report is a group project done by three members. All members of the group were responsible for creation of the purpose of the project. They decided that the main objective of the project was to develop a homebirth toolkit to be implemented at hospitals and clinics that handle expectant mothers. Each member of the group was in charge of a particular segment of the report. Some people handled the literature review; others handled policy formulation, implementation of the tool and evaluation procedures. Another member covered the conclusion. Since all sections of the report were dependent on the previous sections, then a group member dealing with a preceding section had to tell another group member about the completion of his part in order to facilitate coverage of the next aspect. It was difficult to coordinate all the group’s activities because none of us met in person. We communicated online or via telephone. Nonetheless, the group completed the project successfully.

Literature review

Health bodies around the world acknowledge a woman’s right to give birth at home if her choice is informed. They also add that adequate support services ought to be presented. Sacks and Donnenfeld (1984) explain that some women may choose a home birth because they want to feel in control of their situation. These mothers can select the individuals that will be present during delivery. Others may want to avoid separation from their children. Some women may do it in order to evade extreme obstetrical management.

Within the hospital setting, a mother’s role is reduced to that of a child bearer. No consideration is given to her other roles as a sister, wife, or aunt as the case is in a home birth. What’s more, the birth process is driven by objective scientific forces in the hospital environment, yet midwives tend to use a more natural approach at home. Many authors such as Sacks and Donnenfeld (1984) tend to focus on the motivations behind home births. They do not focus on the health policies that may make them safe, which is the centre of this report.

A number of researches have also focused on the dangers of home births versus hospital births (Mehl-Madrona & Mehl-Madrona, 1997). Corren (2002) found that home births compromise the Apgar score of newborns. It was found that chances of death at delivery are higher among children born at home than those born in a hospital. Postpartum risks such as bleeding and prolonged labour are much higher at home than in the hospital. Janssen (2002) carried out the same research among women with the same socioeconomic background and demographic status. They found that the number of perinatal deaths was just as high as the rate in hospital deliveries. In these studies, it has been highlighted that carrying out home deliveries may present additional challenges when complications arise because of the lack of resources to deal with them.

The problem with such studies is the possibility of confounding factors that emanate from self selection of the mothers. Additionally, because home births are much fewer in number than hospital births, especially in developed countries where the studies are done, it is inaccurate to compare outcomes. The complications that are the focus of these researches must occur several times (in hospitals and home births) in order to make strong conclusions about them.

Midwives and doctors have varied practices and attitudes towards home births thus complicating the issue further. Unplanned home births yield significantly different results from planned ones, so they should not be treated ambiguously. Some researchers do not make these distinctions in their papers. Furthermore, all the studies done on the danger of home births rarely focus on all the healthcare precautions that could have been taken to avoid the dangers. Consequently, this study will attempt to fill that gap.

Some case studies also illustrate the preference for home births. One such instance was the case of Maria; a mother of three who had her third born at home. She opted for this approach because her home environment provided her with the psychological and emotional support that a hospital could not. This expectant mother had a child with the assistance of a midwife from a health centre. She also had a visit from the doctor during labour and committed to taking her child to the hospital after 6 hours of delivery. Therefore, this home birth was a success because the health centre and the mother were protected by some rigorous conditions.

Other analyses sometimes focus on the rate of satisfaction between mothers who had home births and those who delivered in hospital. Davis (1996) found that approximately 85% of all mothers who chose homebirths were satisfied with their experience and 91% claimed they would do it again. The latter analysis entailed persons who had done both home and hospital deliveries. While understanding a mother’s perception of child birth is important, it is necessary to know about the safety and health risks of the decision; this will be tackled in the report.

Most of the researches that talk about the risks associated with home deliveries tend to dwell on post birth outcomes. They will consider the health complications of mothers and children without necessarily thinking about the preventive safety measures that could have been administered. Additionally, measuring satisfaction levels between these two categories of women has minimal implications on safety, so this necessitates a new perspective in research.

Methodology

Reduction of risk factors for home births through health centre collaboration

The main objective of this study is to reduce the risks associated with home births through implementation of a home birth tool in a hospital or health centre. Although home births do not take place in health facilities, members of these institutions should still be involved in the process as they can substantially reduce the risks associated with the birth.

The following is the policy statement for this study: “To reduce health and safety risks associated with home births through effective training and preparation of midwives and other health practitioners, effective monitoring of the birth process, and education of mothers prior to decision making”.

In order to ensure effective implementation of the policy, it is necessary to define some of the terms of the study as follows:

Midwife

A legally recognised and certified individual who provides care during pregnancy, at labour, at birth and after birth. The person may perform these functions within the hospital setting or outside.

Conception

The point at which an egg and sperm unite to form a foetus. This is when pregnancy begins.

Obstetrician

An expert who specialises in the care and management of women during pregnancy, labour, and birth. He or she may also handle gynaecology and must be trained and certified by a professional medical body in his or her country.

Homebirth

A situation in which a woman chooses and plans to give birth at home with the help of a midwife.

Infant mortality

Frequency of death that occurs among newborns.

Perineal suturing

Sewing the flesh between the birth canal and anus of a birth mother in order to facilitate healing.

Post natal

The period after birth; most doctors start counting four weeks after delivery.

Multiple pregnancy

A person who has been pregnant more than once.

Postpartum Haemorrhage

Excessive bleeding after the birth of a baby. If a mother exceeds 500ml, then her bleeding may be classified as excessive.

Foetal abnormalities

Complications that exist in the baby before birth

Maternal Hypertension

A condition in which a mother experiences high blood pressure at birth.

Pre labour membrane rapture

When the foetal membrane ruptures earlier than predicted or prior to the due date.

Apgar score

A system that birth attendants use to assess the physiological well being of a newborn. 2 points are awarded for 5 categories: colour, muscle tone, breathing effort, reflexes and heart rate.

Birth weight

A newborn’s weight just after delivery.

Neonatologist

A paediatrician who focuses on medicine administered to newborns

Implementation

The policy will be implemented within a period of 10 months and will be managed by a group of five members called the clinical consultative group. It is assumed that the members will emanate from the health facility (clinic, hospital, maternal centre) that aims at reducing risks in homebirths. This group will comprise of a midwife, a mother who intends on giving birth at home, a general practitioner, a neonatologist, and an obstetrician. Some mothers may not require certain experts in their program such as neonatologists if no complications arise.

The first 1-9 months will entail adequate monitoring of the pregnant mother by the concerned general practitioner. If it assumed that a mother conceived on 4^th August 2012, then monitoring should begin as soon as 4^th September 2012. The general practitioner will be in charge of monitoring the pregnant mother for possible health complications. He or she will also inform her about the possible health implications of doing a homebirth if she desires one.

By the 4^th of January, a mother who wants a home delivery should already know whether she qualifies or not. If she is pregnant with twins, then she cannot access the service. Furthermore, if the person had a caesarean section before, then she will be excluded from a homebirth. If her general practitioner or obstetrician detects hypertension or diabetes, then she cannot deliver from home. If the person is less than 18 years or obese (body max index of 40), then she will also be excluded from home birth. Persons with a history of medical complications during child birth or those who are drug dependent should forget about this option.

At this time, other activities will also take place concurrently. By the 4^th of March 2013, which is 28 weeks after conception, the expectant mother should have selected the concerned institution as her backup hospital. The concerned doctor and midwife will provide her with a document in which the expectant mother will learn about the terms of care. She will be expected to sign the form and include her name, date and witness’s signature. In the form, the concerned hospital will declare support for the expectant mother in the event of a complication.

The individual will only sign this form if she lives in a geographical area that is less than 15 minutes from the supporting hospital. By this date, the concerned midwife should have paid a visit to the consumer’s home in order to determine whether it can support safe birth. The professional ought to check on the cleanliness and hygiene in the home. It should also have electricity and running water. The home should have no signs of drugs used for recreational purposes, as well. If these factors have been analysed, then the institution and mother can proceed to the next phase.

On 4^th April all transport arrangements to the clinic should be made by the mother in consultation with her supporting midwife and GP. Ambulatory services ought to be examined and paid for at this time.

By the 4^th of May 2013, the concerned general practitioner and midwife should be preparing for birth. At this time, one of the two individuals (midwife) will first visit the expectant mother as soon as signs of labour manifest. Once the professional has arrived at the patient’s home, she ought to offer her support throughout the birth process. This will entail measurement of dilation levels of the mother. She will also check on the position of the baby to ascertain that it is alright.

If the midwife finds that the baby is in the breech position, or a position in which a part of the body other than the head faces the vaginal exit, then the midwife should immediately transfer the mother to the supporting institution. However, if this is not true, then the midwife should keep caring for the mother until a birth occurs. All procedures that take place during labour, birth and after ought to be documented. If labour is prolonged or goes on for longer than 12 hours, then a backup midwife should be called to step in.

During labour, the midwife should keep monitoring the foetus in order to ensure that it is in good condition. This should entail heart rate monitoring as well as engagement of the foetal head. The mother’s health should also be monitored in order to ascertain that she is in a good condition for delivery. Her temperature should not exceed 37.6 ^oC more than once.

Haemorrhaging should not occur at this juncture. The midwife should also ensure that the three stages of labour follow one another as required. The first stage of labour should not exceed 18 hours while the second stage should last for one hour and result in manifestation of the baby’s head. The third stage should not have a retained placenta. If any of the above issues take place, then the midwife should make arrangements for transfer to the supporting institution.

Transfer from the home to the hospital using an ambulance should be done in an orderly fashion. The midwife should accompany the labouring mother in the ambulance and continue to offer her support. She should notify her obstetrician and other medical personal about their possible time of arrival. The midwife should ensure that all accompanying documentation is in the ambulance together with the patient. The same procedures should be followed if the patient opts to use private transport. However, the midwife must not drive the expectant mother to hospital as this will detract her from her obstetrical duties.

In the event that none of the complications associated with labour arise, then the midwife should continue supporting the mother until she gives birth. Immediately after birth, administration of oxytocic injections must be done in order to minimise haemorrhage. The midwife must also monitor postpartum haemorrhaging in order to ensure that it is not excessive. She must transfer the patient to a hospital if she looses 600 ml of blood or more. The professional must also perform perineal suturing so as to facilitate healing. If tears have reached the third or fourth degree, then she should consider transfer.

The midwife should check on the apgar score of the baby; this should be less than 7. The baby’s temperature should fall below 36.5^oC or exceed 37.4^oC. No convulsions should be manifested. Documentation of the baby’s temperature, colour, reflexivity, respiratory and apex beat should take place. The midwife should report these findings to the mother, as well. If any complications exist, then immediate transfer to the supporting hospital should occur. A midwife should facilitate breastfeeding before departing from the home. The latter should occur two hours after removal of the placenta. At the same time, she can administer Vitamin K.

After the above checks, the supporting doctor should visit the home. Normally, this ought to be 6 hours after birth. The GP should check on the respiratory system of the baby and other vitals. The mother’s conditions should also be assessed and treated immediately.

Assuming that the birth took place on the 5^th of May 2013 at 11am, then the supporting midwife should visit the mother on 6^th May at 11am. This should be followed by a number of other meetings which will ensure that the mother and her baby are in good health. The doctor should also give a Hepatitis B vaccine and all other immunisations with the permission of the mother.

Evaluation of the policy should occur one month after the birth. In this case, it would take place on 6^th June 2013. The five member team in charge of the policy implementation process should be responsible for this. They should look at the case and ascertain that all the risk factors were minimised. Evaluation should start with prenatal care. The team should ensure that the expectant mother was duly informed about the homebirth. An analysis of the prenatal phase should be done to ascertain that all the respective checks were done. An examination of foetal position, condition and the mother’s health condition should be assessed. The hospital should also look at the documentation process.

The most vital aspect of the evaluation phase will be the assessment of the labour and prenatal handling of the patient. Evidence of communication between the midwife and hospital personnel concerning transfer must be indicated. There should also be evidence of measurement of all vitals prior to birth. Care procedures carried out need to be indicated. If any of them were not performed, then the team should find ways of preventing this occurrence again. Negligence on the part of any of the professionals should be penalized. If the team finds that the concerned midwife or general practitioner lacked skills in handling home births, then they should undergo training aspects concerning items such as perineal suturing, water birth and resuscitation after birth ought to be considered.

All the evaluation activities should be done within the same day. An overall evaluation of all homebirths ought to occur annually. The team should carry out satisfaction surveys among mothers in order to ensure that they received all anticipated results. Special emphasis should be given to the communication processes that took place as well as proper documentation.

Attachments

Terms of Care document

Hospital XXXXX will provide you with a comprehensive midwifery service throughout your pregnancy in order to minimise risks during homebirth. Homebirths will not be available to you if: You expect twins, have a foetus in a breech position at the end of your term or had children with neonatal risks before. You will not have a home birth if you had a caesarean section before or if your body mass is greater than 40 or are less than 18 years. A home located more than 15 minutes from the hospital will not allow you to access homebirth.

Declaration

I agree to work with a midwife, a backup midwife and a consulting doctor throughout the delivery of my child at home.
I agree to the use of medical support services in this institution if my supporting midwife detects any complications during delivery at home.
I have been duly informed about the risks involved in a home birth and consciously choose to pursue it.

Signature:

Full name:

Witness name: Signature:

Date:

Equipment needed for a home birth

The attending midwife must possess a tool kit with the following items

Thermometer
Stethoscope
Pregnancy wheel
Obstetric cream
Speculum
Amnicators,
penlight torch
Suturing material
Dissecting forceps
Weighing scales

Information for women at birth

Learn about a home birth
Learn about birth and delivery of the placenta
Learn how to deal with an overdue pregnancy
Learn about risk factors that necessitate hospital delivery
Learn about infections and diseases that emanate from delivery

How to transfer a mother from home to a hospital using ambulatory services

Call the emergency services at the hospital and provide information about the patient’s location, such as street number and land marks.
Tell the emergency correspondent that you are a midwife linked to the patient.
When the paramedics arrive, wear your badge so as to facilitate easy identification
Document all the events that led to the decision and the time of call
Unlock the door in the house and turn on front lights so as to facilitate easy entrance of paramedics.
Accompany the patient in the ambulance and continue to liaise with the paramedics in order to ensure continued care.
Notify the concerned hospital that you are on the way and provide an estimated time of arrival
Carry all accompanying documentation and complete a form upon arrival.

Conclusion

Homebirths should not present any danger to mothers who choose this system if a healthcare facility implements the above policy tool. It needs to follow deadlines for every aspect of birth with special emphasis on coordinating and communication between the health practitioners involved. Once adequate preparation has been done and the patient duly informed, then homebirths can be just as safe as hospital deliveries.

References

Corren, C. (2002). Health of mothers, babies, may be compromised in planned home births. Perspectives on Sexual and Reproductive Health, 34(6), 320-321.

Davis, J. (1996). Prospective regional study of planned home births. British Medical Journal, 313, 1302-1306.

Janssen, P. (2002). Outcomes of planned home births versus planned hospital births after regulation of midwifery in British Columbia. Canadian Medical Association Journal, 166(3), 315-323.

Mehl-Madrona, L. & Mehl-Madrona, M. (1997). Physical and midwife-attended homebirths: Effects of breech, twin and post dates outcome data on mortality. Journal of Nurse Midwifery, 42(2), 91-97.

Sacks, S. & Donnenfeld, P. (1984). Parental choice of alternative birth environments and attitudes toward childbearing philosophy. Journal of Marriage and the Family, 46(2), 469-475.

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