PRACTICE GUIDELINES
The items listed in this document comprise those that raise concerns regarding a woman’s plan to give birth at home or her plan to remain at home with her baby after her baby has been born.
Every item listed in this document is an item that raises concern. That, however, doesn’t mean every item raises equal measures of concern. Some items will demand immediate transference out of homebirth midwifery care while other items simply require a measure of extra information, extra discussion, extra thought, and extra thoughtful decision-making. Many of the items represent issues that may be remedied adequately enough to proceed with at-home planning. A few of the items represent issues we consider important to remedy from a quality-of-life perspective.
We’d like to make it clear that three of the items listed in this document—namely VBAC birth, breech birth, twin birth, and Group B Streptococcus carriage—are variations from the norm we will consider taking on depending on location (legality), the availability (or lack thereof) of adequate in-hospital options, and the results of careful and continuing case-by-case assessments. Though VBAC, breech, twin, and Group B Streptococcus carriage births may indeed be accomplished safely at home, they do carry a higher burden of risk than do the births homebirth midwives generally attend, and that realization is never far from our minds. In an ideal world, truly adequate in-hospital options would be available for such births, as would respectful and cooperative support between out-of-hospital and in-hospital birthing staff and systems be ideal for homebirthers over all. As it yet is, however, homebirth is often the only alternative to highly medicalized and/or surgical birthing options for those with scarred uteri or for those carrying breech and/or multiple babies or those carrying Group B Streptococcus. Therefore, where we’re legally able to do so and where we deem the mom and babe low-risk enough, we remain willing to serve.
VBAC, breech, twin, and Group B Streptococcus carriage births will be explained in more detail in documents specific to them, and will require signed acknowledgements of the risks unique to each.
We serve primarily in the state of Colorado, but we also serve periodically in the state of Michigan. If an item in this document is listed in black ink, it’s an item reflecting restrictions we’ve placed upon our personal practice of homebirth midwifery, regardless actual legality per state. Many if not most of the items listed in black ink reflect restrictions homebirth midwives and homebirth midwifery regulatory bodies agree to universally. If an item is listed in red ink then, though the issue is sure to be of a measure of concern wherever it arises, the specificity of the guideline pertains to our practice in the state of Colorado. Likewise, if an item is listed in blue ink, the specificity of the guideline pertains to our practice in the state of Michigan.
To view the laws regulating the practice of midwifery in Colorado, visit:
dpo.colorado.gov/Midwives/Laws
To view the laws regulating the practice of midwifery in Michigan, visit:
legislature.mi.gov/Laws/MCL?objectName=MCL-368-1978-15-171.
CONCERNS INCONGRUOUS WITH PLANS TO GIVE BIRTH AT HOME
health history issues incongruous with plans to give birth at home:
history of thrombophlebitis
history of pulmonary embolism
history of uterine rupture
history of placental abruption with abruption risk factors
history of retained placental fragments with retained placenta risk factors
history of placental attachment disorders with placental attachment disorder risk factors
history of myomectomy
previous premature births, stillbirths, or neonatal deaths associated with maternal health or genetic anomaly without an intervening normal pregnancy and birth
diseases processes incongruous with plans to give birth at homebirth:
diabetes mellitus
hematological or coagulation disorders
hypothyroidism uncontrolled by medication
seizures controlled by medication if the woman has seized within the last year
seizures controlled by medication
chronic significant pulmonary disease and/or cardiac disease
chronic significant hepatic and/or renal disease
cushing’s disease
systematic lupus erythematosus
antiphospholipid syndrome
polyarteritis nodosa
hepatitis B, syphilis, HIV, or AIDS
primary genital herpes infection in pregnancy
active herpes outbreak at the onset of labor
current conditions incongruous with plans to give birth at home:
illegal use of drugs, medications, or alcohol
use of psychotropic medications without monitoring of a physician during pregnancy
multiple gestation
monoamniotic twin gestation
gestational diabetes
hypertension, primary or pregnancy induced: regular blood pressure greater than 140/90 at rest
preeclampsia
eclampsia
HELLP (Hemolysis, Elevated Liver enzymes, Low Platelet count) syndrome in current pregnancy
hemoglobin of less than 9 resistant to supplemental therapy
hemoglobin of less than 11 and/or hematocrit less than 34% resistant to supplemental therapy
maternal/fetal blood type sensitizations reflected via positive antibody titres
persistent placenta previa
placenta overlying site of previous uterine scar
incompetent cervix
abnormality of pelvis
intrauterine growth restriction
fetus with congenital abnormalities requiring immediate medical intervention at birth
commencement of labor prior to 37 completed weeks of pregnancy
commencement of labor prior to 36 completed weeks of pregnancy
rupture of membranes prior to 36 6 weeks of pregnancy without active labor
breech presentation at the commencement of labor
unsatisfactory biophysical profile score
STATES-OF-BEING THAT MUST BE WELL-ADDRESSED AND/OR ADEQUATELY RESOLVED
IN ORDER TO PROCEED WITH PLANS TO GIVE BIRTH AT HOME
The following states-of-being require that bit of extra information, extra discussion, extra thought, and extra thoughtful decision-making already mentioned in order to proceed with plans to give birth at home, as well as medical corroboration of qualifiers.
Any woman desiring to give birth at home after having birthed a baby with a major genetic anomaly likely to recur.
Any woman desiring to give birth at home after having birthed previously by cesarean section must provide medical records identifying the necessity of her cesarean birth.
Any woman desiring to give birth at home after having birthed previously by cesarean section must provide medical records confirming she was delivered of her baby via horizontal incision.
Any woman desiring to give birth at home after having birthed previously by cesarean section must provide medical records confirming her uterus was repaired via at least two distinct layers.
Any woman desiring to give birth at home after having birthed previously by cesarean section must provide medical records confirming the date of her previous cesarean birth is 18 months distant from her current estimated due date.
Any woman desiring to give birth at home after having birthed two or more times previously by cesarean section must provide medical records confirming she’s already given vaginal birth without incident since her last cesarean section.
Any woman desiring to give birth at home after having birthed previously by cesarean section must live within 30 minutes of a facility equipped to perform cesarean sections.
Any woman desiring to give birth at home after having birthed previously by cesarean section must be fully apprised of the risks and benefits of birthing vaginally after cesarean section at home and she must sign a document indicating she accepts full responsibility for assuming those risks.
Any woman desiring to give birth to twins at home must be carrying diamniotic twins with medical record corroboration.
Any woman desiring to give birth to diamniotic twins at home must be fully apprised of the risks and benefits of birthing twins at home and she must sign a document indicating she accepts full responsibility for assuming those risks.
Any woman desiring to give birth to a breech baby at home must be fully apprised of the risks and benefits of birthing breech babies at home, specifically pertaining to the sort of breech baby she is carrying and how it relates to the particulars of her medical history and current condition, and she must sign a document indicating she accepts full responsibility for assuming those risks.
Any woman desiring to give birth to a baby at home while carrying Group B Streptococcus must understand that, while the American standard of care for women carrying Group B Streptococcus is the prophylactic administration of antibiotics by IV and, though I’m legally sanctioned to provide prophylactic antibiotics by IV in the home setting, I’m not comfortable doing so and, therefore, I do not offer prophylactic antibiotics in the home setting.
Any woman desiring to give birth to a baby at home while carrying Group B Streptococcus must be fully apprised of the risks associated with maternal Group B Streptococcus carriage and the potential for the newborn to become infected through the process of vaginal birth, and she must sign a document indicating she accepts full responsibility for assuming those risks.
CONCERNS THAT MUST BE WELL-ADDRESSED AND/OR ADEQUATELY RESOLVED
IN ORDER TO PROCEED WITH PLANS TO GIVE BIRTH AT HOME
suspected mood disorder or uncontrolled psychiatric illness
suspected substance abuse
urine glucose of 2+ or greater on two sequential visits, or if other signs or symptoms of gestational diabetes occur with the 2+ urine glucose
abnormally elevated blood glucose levels unresponsive to dietary management
marked weight gain at multiple prenatal visits
hyperemesis beyond the 24th week of gestation
severe malnutrition; severe, persistent dehydration; protracted weight loss
blood pressure greater than 140/90, or an increase from baseline greater than 30mm Hg systolic or 15mm Hg diastolic
proteinuria with increased blood pressure and/or persistent pitting edema and/or persistent edema of face and/or hands and/or persistent headaches and/or hyperreflexia and/or epigastric pain and/or visual disturbances
proteinuria
significant proteinuria
persistent edema
hyperreflexia
clonus
persistent headaches
epigastric pain
visual disturbances
seizures
abnormal liver function panel
abnormal metabolic panel
hypothyroidism requiring medication
persistent symptoms of urinary tract infection
persistent vaginal tract infection
vaginal bleeding after 20 weeks
significant vaginal bleeding prior to the onset of labor not associated with uncomplicated spontaneous abortion
suspected hydatidiform mole
TORCH infection: Toxoplasmosis, Other, Rubella, Cytomegalovirus, Herpes
suspected coagulation disorder
thrombocytopenia with platelet counts of less than 100,000 platelets per microliter
any abnormal laboratory results indicating necessity of medical attention
suspected uterine abnormalities
suspected abnormality of pelvis
symptoms of deep vein thrombosis/thrombophlebitis
temperature of or greater than 101° (with intact membranes) which does not resolve within 72 hours or for more than 24 hours when accompanied by other signs/symptoms of clinically significant infection
temperature of or greater than 100.4° (with intact membranes) for more than 24 hours
suspected polyhydramnios or oligohydramnios
marked or severe polyhydramnios or oligohydramnios
inflammatory bowel disease
rheumatoid arthritis
addison’s disease
scleroderma
GBS carriage: rupture of membranes exceeding 12 hours without labor
rupture of membranes exceeding 18 hours without labor
rupture of membranes exceeding 24 hours without labor
commencement of labor between 36 and 37 completed weeks of pregnancy
gestation exceeding 42 weeks
marked abnormal fetal heart tones
suspected intrauterine growth restriction
decreased fetal movements, lack of fetal movement, inability to auscultate fetal heart tones, suspected fetal demise
CONCERNS THAT MUST BE WELL-ADDRESSED AND/OR ADEQUATELY RESOLVED
nausea
heartburn
diminished appetite
constipation
watery stools
insomnia
IN-LABOR CONCERNS REQUIRING TRANSFER FROM HOME TO HOSPITAL
bleeding other than capillary bleeding/show prior to delivery
signs of uterine rupture/placental abruption, including continuous lower abdominal pain and tenderness
prolapse of the cord
any meconium staining without reassuring fetal heart tones, moderate or greater meconium staining regardless status of fetal heart tones
maternal temperature greater than 100.4°
maternal pulse over 100 with decrease in blood pressure
blood pressure greater than 140/90, or an increase from baseline greater than 30mm Hg systolic or 15mm Hg diastolic
proteinuria with increased blood pressure and/or persistent pitting edema and/or persistent edema of face and/or hands and/or persistent headaches and/or hyperreflexia and/or epigastric pain and/or visual disturbances
proteinuria
significant proteinuria
persistent edema
hyperreflexia
clonus
persistent headaches
epigastric pain
visual disturbances
seizures
glucose in the urine
lack of steady progress in dilation and descent after 24 hours of labor in the primipara or 18 hours in the multipara
second stage of labor without steady progress of descent through the mid-pelvis and/or pelvic outlet longer than two hours in the primipara or one hour in the multipara
third stage of labor lasting longer than one hour
third stage of labor lasting longer than two hours
fetal heart rate below 110 or above 160 between contractions
fetal heart rate abnormalities including severe bradycardia and/or tachycardia
late or variable fetal heart rate decelerations
lack of fetal heart rate variability
client requests transport
IN-LABOR CONCERNS THAT MUST BE WELL-ADDRESSED AND/OR ADEQUATELY RESOLVED
IN ORDER TO REMAIN AT HOME
excessive vomiting, dehydration, acidosis, or exhaustion
bladder distension
posteriorly positioned baby
baby presenting military or brow
baby presenting face
IMMEDIATE POST-BIRTH CONCERNS REQUIRING TRANSFER FROM HOME TO HOSPITAL
per mother:
blood loss greater than 500cc unless bleeding is controlled and vital signs are stable
shock unresponsive to treatment
uterine atony
retained placental fragments
uterine inversion
third or fourth degree vaginal/perineal lacerations or cervical lacerations
inability of mother to empty her bladder within 6 hours after birth
loss of consciousness
respiratory distress or arrest
symptomatic cardiac arrhythmias or chest pain
signs of stroke
seizures
signs of pulmonary or amniotic fluid embolism
signs of anaphylaxis
per baby:
APGAR of 7 or less at ten minutes
newborn respiratory distress exhibited by respirations greater than 60 per minute, grunting, retractions, nasal flaring at one hour of age not showing consistent improvement
inability of newborn to maintain body temperature
medically significant anomaly in newborn
seizures in the newborn
fontanelle full and bulging
suspected birth injuries in the newborn
cardiac irregularities in the newborn
pale, cyanotic, gray newborn
lethargy or poor muscle tone in the newborn
baby appears to be less than 37 completed weeks gestation
singleton newborn weight below 5lb, 8oz
IMMEDIATE POST-BIRTH CONCERNS THAT MUST BE WELL-ADDRESSED AND/OR ADEQUATELY RESOLVED
IN ORDER TO REMAIN AT HOME
excessive vomiting, dehydration, acidosis, or exhaustion
first or second degree vaginal/perineal lacerations
bladder distension
excessive afterpains
POST-BIRTH CONCERNS REQUIRING TRANSFER FROM HOME TO HOSPITAL
per mother:
excessive, foul smelling, or otherwise abnormal lochia
significant tenderness of the uterus and/or adnexa
fever greater than 101°
blood pressure persistently greater than 140/90
seizures
signs of deep vein thrombosis/thrombophlebitis
signs of pulmonary or amniotic fluid embolism
signs of clinically significant depression and/or psychosis
loss of consciousness
respiratory distress or arrest
symptomatic cardiac arrhythmias or chest pain
signs of stroke
per baby:
signs of hypoglycemia, including jitteriness
abnormal cry
inability to pass urine and/or meconium within 24 hours
projectile or bilious vomiting
inability to suck
respirations greater than 60 per minute and/or grunting, retractions, or nasal flaring
pulse greater than 180 or less than 80 at rest
temperature below 96°or above 100.4°
jaundice within 24 hours of birth
severe jaundice after 24 hours of age
suspected infection of umbilicus
suspected infection of circumcised penis
any pulse oximetry readings other than 95% or greater at the right hand or either foot
any pulse oximetry readings greater than 3-percentage points difference between the right hand and either foot
positive antibody screen
abnormal newborn screen
abnormal hearing screen
POST-BIRTH CONCERNS THAT MUST BE WELL-ADDRESSED AND/OR ADEQUATELY RESOLVED
IN ORDER TO REMAIN AT HOME
per mother:
excessive afterpains
subinvolution of the uterus
insufficient diet and/or hydration
insufficient sleep
insufficient milk supply
constipation and/or hemorrhoids
urinary tract issues
irritation at site of vaginal/perineal tear
vaginal infection
per baby:
inadequate suck
inadequate weight gain
signs of dehydration
insufficient passage of urine and/or stool
jaundice after 24 hours of age
irritated umbilicus
irritation of circumcised penis
