Birth Safety
Assessing Safety for Out-of-Hospital Birth
Women who are low-risk throughout pregnancy are good candidates for out-of-hospital birth.
In 2023, 5% of women were referred during pregnancy for a higher level of care. Pregnancy referral reasons included: fetal anomalies, maternal cardiac issue, high risk blood clot, and high blood pressure.
In 2023, 5% of women were referred at the end of pregnancy for induction or cesarean because of: postdates induction, breech, high blood pressure, intrauterine growth restriction.
In 2023, 9% of women in labor were transferred for preterm rupture of membranes, high blood pressure, preeclampsia with severe features, high blood pressure, desire for pain medicine, arrest of descent/significant meconium.
We use the following criteria to make sure the women birthing out of hospital with us continue to be low risk.*
The following serious conditions that may exist prior to pregnancy would likely necessitate referral to a physician for prenatal care and delivery:
- high blood pressure
- cardiac disease
- pre-existing diabetes
- kidney disease (albuminuria, hematuria, casts)
- Asthma or bronchitis with daily treatments
- epilepsy or other seizure disorder
- drug addiction (including alcohol & marijuana)
- tuberculosis
- previous Rh sensitization
- previous cesarean section**
- HIV/AIDS
- vaginal plastic surgery
- adrenal disease
- collagen disease
- acute or chronic liver disease
- hematologic disease(like Von Willebrand, leukemia, hemophilia, etc)
- neurological disorder
- hyperthyroidism
The following conditions that may develop during your current pregnancy might necessitate referral to a physician for the remainder of your pregnancy and for your birth:
- severe anemia (hemoglobin less than 10) uncorrected by iron or ther therapy
- uterine bleeding in the second or third trimesters
- baby not laying vertex (head down) after 37 weeks
- preeclampsia
- multiple gestation (twins, triplets)
- labor before 37 weeks 0 days
- absence of labor by 42 weeks 0 days
- gestational diabetes requiring medication
- inappropriate uterine size for gestational age
- unresolved mental health problems compromising mother’s ability to care for herself or her baby
The following conditions that may arise in the immediate postpartum period would necessitate transfer to the hospital:
- severe hemorrhage
- retained placenta
- third or fourth degree perineal laceration
- an infant with persistent respiratory distress, cardiac irregularities, congenital anomalies, a fever, a five-minute Apgar score of less than 7, or any problem requiring immediate care or medical assessment
*Many of these guidelines are state or CABC guidelines.
**For women who are considering VBAC, we would be glad to discuss birth options with you.
The following pre-existing conditions might necessitate consultation with a physician during your pregnancy.
Consultation is done to make a plan for safe care in pregnancy, labor and birth. Frequently these women birth out of hospital with us:
- maternal height less than 60 inches
- prepregnancy weight under 100 pounds or over 200 pounds
- age under 16 or over 40
- having birthed 4 babies already
- GI disorders like ileitis or ulcerative colitis
- asthma that does not require daily treatment
- mental illness
- thrombophlebitis
- smoking
- urinary tract surgery
- scarred uterus
- gestational diabetes
- Past history of:
– More than 2 consecutive miscarriages
– Preeclampsia
– Postpartum hemorrhage
– Third stage of labor problems like retained placenta, inverted uterus, severe lacerations
– Pushing more than 2 hours with previous baby
– Previous baby weighing less than 5 lb 8 oz
– Previous baby weighing more than 9 lb 14 oz
– Previous baby with respiratory distress
– Previous baby with congenital abnormality or genetic disorder
– Previous baby who has passed away
– Previous baby with injury from birth
The following conditions that may develop during labor would necessitate transfer to a hospital:
- maternal fever of more than 100.5 degrees
- signs or symptoms of preeclampsia
- abnormal presentation of baby
- umbilical cord prolapse
- rupture of membranes (broken water) for 18 hours without regular contractions
- rupture of membranes (broken water ) for 24 hours with contractions but birth is not close
- signs of fetal distress by abnormal heart rates that don’t improve with simple measures (e.g. maternal repositioning)
- thick or fresh meconium staining of amniotic fluid when birth is not imminent
- abnormal bleeding
- extremely prolonged or arrested labor after natural means of labor stimulation have failed
- severe maternal exhaustion
- the desire of the mother for pain medication
- the desire of the mother for hospital transfer for any reason
Vaginal Birth After Cesarean (VBAC)
Whether or not to pursue a VBAC with a subsequent pregnancy is a very sensitive decision and families deserve full information about the benefits and risks of all their options, so that they can make the decision that is best for their family. VBAC is considered a good option for most people who have a scar in their uterus. There are a small number things that make a VBAC much less safe or more unsafe (contraindications). You can find good information from: evidencebasedbirth.com/ebb-113-the-evidence-on-vbac/ and vbacfacts.com/blog
The Association of Ontario Midwives has their clinical guidelines statement on VBAC freely available on their website as well as a really great document that’s called, for clients, Thinking about VBAC: Deciding what’s right for me. It’s a decision-making tool for people considering VBAC, and this resource is available for free in English, French, Spanish, Farsi, Arabic and simplified Chinese.