CASE Failed home birth after CS twice
A 32-year-old woman, G3P2, two prior C-sections, is brought to the emergency department (ED) in labor after a failed home birth. The nursing administrator asks if you (on the labor and delivery unit caring for your patients) will assume her care.
You ascertain that the patient’s two prior C-sections were performed for failure to progress. With this pregnancy, she desired to attempt home birth and searched the Web to find a midwife who was enthusiastic about participating in her birth plan.
At term, the patient went into labor at home, but the cervix remained at 6 cm dilation for 4 hours in the setting of regular, strong contractions. The midwife then told the patient’s husband to take her to the ED.
You confirm dilation at 6 cm, –2 station, and fetal weight of approximately 8 lb. Variable decelerations with contractions are noted. Based on the physical exam, uterine contractions are adequate and occurring every 2 minutes.
Do you assume her care?
During the 19th century, most births still occurred at home—many in the presence of an experienced birth attendant. Boston’s Lying-In Hospital, for example, was largely utilized at the time as a staging area, where physicians, nurses, and medical students resided until summoned to attend laboring women in their homes. A woman in labor sent a message to the hospital and a pair of clinicians—a physician and either a nurse or a medical student—would travel to the home and perform the delivery, typically in the kitchen.
In the 20th century, the development of blood banking, anesthetic, and antiseptic techniques and advancing obstetric and surgical technology prompted a shift in births from home to hospital. The movement was remarkably successful: In that period, maternal mortality was reduced 98%; infant mortality, 97%.
A continuing controversy in developed countries
About 0.6% of births in the United States are recorded as planned home births—a rate that has been stable over the past few years.1 The rate is similar to what is seen in most developed countries—except The Netherlands (30%) and England (2%).2,3 A curiosity of European medical practice is that home birth is favored in The Netherlands but not in neighboring Belgium or France.
Both the American College of Nurse Midwives and the American Public Health Association support the practice of out-of-hospital birth, both at home and in non-hospital birth centers. ACOG opposes home birth because complications for both the mother and newborn can arise with little or no warning, even in a low-risk pregnancy. ACOG has consistently supported birth in a hospital; in a birthing center within a hospital complex that meets the standards of the American Academy of Pediatrics and ACOG; or in a free-standing birthing center that meets standards of the Accreditation Association for Ambulatory Health Care, the Joint Commission, or the American Association of Birth Centers.
Home birth advocates paint a rosy picture
Search for “home birth” on the Web and you’ll find millions of pages that extol the virtues of home birth and whose authors are, directly or indirectly, uncomplimentary to such in-hospital birth practices as oxytocin, induction, episiotomy, and operative delivery.
No large-scale, randomized clinical trials comparing planned home birth and planned hospital birth have been conducted.4 Consequently, all available data are from observational studies.
Looking at some of those studies, it appears that home birth is associated with reasonably good results—but only in carefully selected women whose risk of complications is low. With the caution that many of these studies have significant design flaws, it’s notable that they report that maternal and neonatal death rates are generally comparable in planned home and planned hospital births.5
From Washington State. In one study here, home delivery was associated with an increase in neonatal mortality (adjusted relative risk [RR], 1.99; 95% confidence interval [CI], 1.06–3.73) and an increased risk of an Apgar score of <4 at 5 min (RR, 2.31; 95% CI, 1.29–4.16). Among nulliparous women, home birth was associated with an increased risk of postpartum hemorrhage (RR, 2.76; 95% CI, 1.74–4.36).6
From Australia. An increased risk of neonatal death after intended home birth has also been reported in an Australian study.7 Investigators concluded that home birth attendants’ and pregnant women’s failure to recognize the obstetrical and neonatal risks of post-term pregnancy, twin pregnancy, and breech presentation contributed to the observed increase in neonatal mortality.