Guidance on considerations on choice of place of planned birth
NICE have stated guidance as to considerations as to place of planned birth (1)
Medical conditions indicating increased risk and suggesting planned birth at an obstetric unit are stated as:
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| - Confirmed cardiac disease
- Hypertensive disorders
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| - Asthma requiring an increase in treatment or hospital treatment
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| - Haemoglobinopathies, such as sickle-cell disease, beta-thalassaemia major
- History of thromboembolic disorders
- Immune thrombocytopenia purpura or other platelet disorder or platelet count below 100×109/litre
- Von Willebrand's disease
- Bleeding disorder in the woman or unborn baby
- Atypical antibodies which carry a risk of haemolytic disease of the newborn
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| - Hyperthyroidism
- Diabetes needing medication
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| - Hepatitis B or C with abnormal liver function tests
- Toxoplasmosis - women receiving treatment
- Current active infection of chicken pox, rubella or genital herpes in the woman or baby
- Tuberculosis under treatment
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| - Systemic lupus erythematosus
- Scleroderma
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| - Abnormal renal function
- Renal disease requiring supervision by a renal specialist
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| - Epilepsy
- Myasthenia gravis
- Previous cerebrovascular accident
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| Liver disease associated with current abnormal liver function tests |
| Psychiatric disorder requiring current inpatient care |
Other factors indicating increased risk and suggesting planned birth at an obstetric unit are stated as:
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| - Unexplained stillbirth or 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
- Caesarean birth
- Shoulder dystocia
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| - Multiple birth
- Placenta praevia
- Pre-eclampsia or pregnancy-induced hypertension
- Preterm labour or preterm prelabour rupture of membranes
- Placental abruption
- Anaemia – haemoglobin less than 85 g/litre at onset of labour
- Confirmed intrauterine death
- Substance misuse
- Alcohol dependency requiring assessment or treatment
- Gestational diabetes needing medication
- Malpresentation – breech or transverse lie
- Recurrent antepartum haemorrhage
- Small for gestational age in this pregnancy (less than third centile or reduced growth velocity on ultrasound as defined in the NHS Saving babies lives version 3)
- Abnormal fetal heart rate, umbilical or fetal doppler studies
- Ultrasound diagnosis of oligo- or polyhydramnios
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Previous gynaecological history | |
Medical conditions indicating individual assessment is needed when planning place of birth are stated as:
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| Cardiac disease without intrapartum implications |
| - Atypical antibodies not putting the baby at risk of haemolytic disease
- Sickle-cell trait
- Thalassaemia trait
- Anaemia - haemoglobin 85 to 105 g/litre at onset of labour
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| Unstable hypothyroidism such that a change in treatment is needed |
| - Group B streptococcus where intrapartum intravenous antibiotics are recommended
- Hepatitis B or C with normal liver function tests (as baby will need paediatric review after birth)
- Carrier of or infected with HIV
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| Non-specific connective tissue disorders |
| - Spinal abnormalities
- Previous fractured pelvis
- Neurological deficits
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| - Liver disease without current abnormal liver function
- Crohn's disease
- Ulcerative colitis
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Other factors to take into account when planning place of birth are stated as:
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| - Stillbirth or 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
- Retained placenta needing manual removal in theatre
- Previous term baby with jaundice requiring exchange transfusion
- Major gynaecological surgery
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| - Antepartum bleeding of unknown origin (single episode after 24 weeks of pregnancy)
- Body mass index (BMI) at booking
- advise women that, in general, the higher their body mass index (BMI) at booking (and particularly with a BMI above 35 kg/m2), the greater the likelihood of complications, so this may be something they wish to think about when planning their place of birth. Discuss with them that:
- these complications include unplanned caesarean birth, postpartum haemorrhage, transfer from home to an obstetric unit, stillbirth, neonatal death or the baby needing neonatal care
- the risk of complications may depend on whether the woman is nulliparous or multiparous, but in general the risks of complications are higher for nulliparous women with an increased BMI compared with multiparous women with an increased BMI
- in the event of complications arising, advanced care can generally be given more quickly in an obstetric unit or an alongside midwifery unit than at home or in a freestanding midwifery unit
- Blood pressure of 140 mmHg systolic or 90 mmHg diastolic or more on 2 occasions
- Clinical or ultrasound suspicion of macrosomia
- Grand multiparity (parity 4 or more)
- Under current outpatient psychiatric care
- Age 40 or over at booking
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for detailed guidance then see full guideline (1).
A review concluded that (2)
- birthplace choice is informed by many factors
- women may encounter fewer overt obstacles to exercising choice than in the past, but women do not consistently receive information about birthplace options from their midwife at a time and in a manner that they find helpful
- introducing options early in pregnancy, but deferring decision-making about birthplace until a woman has had time to consider and explore options and discuss these with her midwife, might facilitate choice
Reference:
- NICE (September 2023). Intrapartum care
- Hinton L, Dumelow C, Rowe R, Hollowell J. Birthplace choices: what are the information needs of women when choosing where to give birth in England? A qualitative study using online and face to face focus groups. BMC Pregnancy Childbirth. 2018 Jan 8;18(1):12.