35. Principles of intrapartum skills
management of birth at home
CHAPTER CONTENTS
Safety253
Midwifery skills254
Principles of managing birth at home256
Born before arrival (BBA)258
Role and responsibilities of the midwife258
Summary258
Self-assessment exercises258
References258
LEARNING OUTCOMES
Having read this chapter the reader should be able to:
• highlight the research-based evidence that relates to safe delivery at home
• discuss the differences in skills and attitudes that the midwife utilises when managing birth at home
• discuss the value and principles of good preparation for all the parties concerned
• list the equipment and information that the midwife needs available
• discuss the overall role and responsibilities of the midwife when caring for labouring women at home
• Discuss the initial assessment necessary if attending a birth that has already happened without medical assistance (born before arrival (BBA)).
This chapter focuses on the midwife’s role and management of labour and delivery in the home setting. It highlights the considerations for care at home that are different from care in hospital; the reader may find it helpful to refer to other relevant chapters (e.g. Chapters 31, 32 and 33). Safe homebirth is very much a team effort, the woman and her family are at the centre of the care, but it can only be facilitated with midwifery skills, the communication and planning of obstetric services as a whole, effective working with the ambulance service and in some instances active involvement of the general practitioner (GP). Some women will prefer to give birth in a hospital setting; this is as much their choice as home is for other women.
Safety
According to the Office of National Statistics (ONS 2008), in 2006 in England and Wales, 2.7% of births took place at home. This is an upward trend; regional variations show that some areas have a much higher figure (BirthChoiceUK 2008). It is also considered that if women were given a truer choice the rate would be nearer 8–10% (DH 2003). It is necessary to make the distinction between planned births at home (often with low risk factors) and unexpected (for whatever reason) delivery at home. For planned home births there is little in the way of randomised controlled trials but meta-analysis of smaller (often observational) studies suggests a greater chance of a normal birth, with lower intervention rates and higher maternal satisfaction when birthing at home compared to hospital (RCOG/RCM 2007).
NICE (2007) are clear that women should be given a choice about where to give birth. This is clarified however by the need for a low risk criterion, with an extensive list for medical or childbirth related disorders that warrant care in an obstetric unit (Box 35.1). Ongoing assessment throughout the pregnancy and labour will be necessary to ensure that the woman remains within the low risk criteria. The emphasis, however, remains on communication and choice. The woman who is fully informed regarding, the likelihood, method, length of time and possible reasons for transfer in labour to an obstetric unit, is more likely to make a ‘realistic’ plan for her labour.
Box 35.1 Risk factors suggesting a planned birth at an obstetric unit
• Medical disorders: cardiac disease, hypertension, asthma that requires additional treatment, cystic fibrosis, haemoglobinopathy disease, thromboembolic disease or history, platelet disorders, atypical antibodies, known Group B Streptococcus (GBS) needing antibiotics in labour, immune, endocrine and renal disorder, abnormal liver function tests, epilepsy or previous cerebrovascular accident, psychiatric disorder requiring current inpatient care, myomectomy/hysterotomy
• Pregnancy/labour related issues: pre-eclampsia/eclampsia, now or previously, small for gestational age, fetal death, poly-/oligohydramnios, abnormal fetal heart (FH), multiple birth, malpresentation, antepartum haemorrhage, substance misuse, preterm labour or spontaneous rupture of membranes (SROM), haemoglobin <8.5 g/dL, BMI >35 kg/m 2 at booking
• Other factors warranting individual assessment: haemoglobinopathy traits, haemoglobin 8.5–10.5 g/dL, spinal abnormalities, previous fractured pelvis, history of previous baby >4.5 kg, history of extensive perineal trauma, >40 years, parity 6 or more, cone biopsy or fibroids
Adapted and summarised from NICE (2007)
Midwifery skills
There are many articles of opinion that share highly positive experiences for midwives and their practice as well as the women and families in their care (Cook, 2003, Jones, 2003 and Kitzinger, 2001). While midwives may have limited experiences of home birth, those that do often regard it as a professionally enhancing experience. Different skills are needed than when caring for women in hospital including issues such as:
• Needing a full understanding and confidence in labour physiology and a woman’s ability to give birth naturally.
• Fundamental midwifery skills using limited equipment, e.g. Pinard stethoscope or Doppler sonicaid use rather than cardiotocography monitor, delivery in alternative positions, management of pain with limited availability of pharmacological preparations.
• ‘Active inactivity’: women who have planned their birth at home often assume a greater level of control. A midwife may feel a little superfluous but has in fact to remain ‘with woman’, to keep alert, being active in, for example, observing for signs of the labour progressing, while appearing to be relatively inactive. As a guest in the woman’s home, the midwife is obliged to be relaxed, tactful, blending in to the circumstances and events, while still exercising the full range of professional labour care and support. Mood and temperament of the environment affect the finely tuned hormonal interplays that are needed physiologically for labour (Russell 2008). Odent (1996) describes the midwife’s role as watching, waiting and trusting the woman’s own ability to give birth.
• Flexibility and adaptability are required, e.g. continuing to maintain standard precautions, following aseptic guidelines or maintaining health and safety protocols while working in an unfamiliar environment. Midwives also find that their decision-making skills and professional autonomy are increased.
It is clear, however, that as well as being professionally well prepared for birth at home, the midwife’s personal feelings are significant in the woman’s success. Floyd (1995) suggests that a woman has greater success if the midwife has a positive attitude, confidence, competence and willingness. Supervisors of midwives can assist midwives who feel that they are lacking the experience to gain this as part of their annual professional development review.
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