Having read this chapter, the reader should be able to:
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.
Homebirth is surrounded internationally by lots of debate and ‘politics’ within the different professional groups (Dahlen 2012, McNutt et al 2013). In 2012 in England and Wales, 2.3% of births took place at home (ONS 2012). There is however, considerable regional variation with rates of nearly 10% for some areas (BirthChoiceUK 2011), and individualized midwifery providers managing much higher rates (e.g. Collins & Kingdon 2014, 31%).
Safety is always the uppermost in everyone’s mind. The Birthplace Study (BIECG 2011) examined the outcomes for 65 000 low-risk women in the UK between 2007 and 2010. Its findings cannot be ignored: birth is generally very safe, for multiparous women home birth is safe also, but for primiparous women a planned home birth increases the risk for the baby. This blanket statement covers the statistic that for 1000 planned primiparous homebirths there were 9.3 adverse perinatal outcomes. These were classified as birth-related injuries, stillbirth, early neonatal death, encephalopathy, and meconium aspiration syndrome. This compared to 5.3 per 1000 in obstetric units. However, while the aim of care is to achieve 0 per 1000 births (highly unrealistic), 9.3 per 1000 births remains a low figure, i.e. 0.93%. Supporters of home birth would argue that birthing at home also offers so much in the qualitative experience for women who choose it, as well as safety (Dahlen 2012). The joint RCOG/RCM work indicated lower intervention rates and higher maternal satisfaction when birthing at home compared to hospital (RCOG/RCM 2007). NICE (2014) are clear in their updated labour guideline that four birth venues are open to all women: adjoining and free-standing midwifery-led units, home and obstetric units. Women should be given the information to decide which is right for them.
The distinction is made here between planned births at home (often with low risk factors) and unexpected (for whatever reason) delivery at home.
While NICE (2014) are clear that women should be given a choice about where to give birth, they also propose medical and obstetric conditions that would affect the choice of birthing venue. It is generally considered that low-risk women can be booked for home birth, whilst those with the risk factors listed in Box 35.1 should either be booked for, or individually reviewed for, obstetric unit care. Primiparity is not included in the list; this continues to suggest that the real risk is low.
If women are encouraged to book for the venue of their choice, midwives should be alert to the women for whom home is chosen, but for whom risk factors are present. NICE (2014) identify that midwives should not disclose their personal views about the woman’s choice. In the UK, Supervisors of Midwives work to support all women in their choices and to support all midwives as they care for all women. Supervisors help midwives to maintain a high standard of clinical practice; if the midwife feels less than confident with regard to any aspect of home birth or caring for a particular woman at home, the Supervisor of Midwives is able to facilitate appropriate professional development.
If the midwife feels concerned at the woman’s choice, various steps can be taken:
• Additional midwifery team members who also get to know the woman and are updated clinically with their own skills and knowledge of the woman’s situation. Likely attendance of two midwives to the delivery with direct support from a Supervisor of Midwives.
For all women, there should be ongoing assessment throughout the pregnancy and labour to ensure that the booked place of birth is appropriate.
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 (Collins & Kingdon 2014, Cook 2003, Dahlen 2012, Jones 2003, Kitzinger 2001). While many midwives may have limited experiences of home birth, those that do often regard it as a professionally enhancing experience. Some additional skills are helpful:
• Needing a full understanding and confidence in labour physiology and a woman’s ability to give birth naturally. Gwillim & Charles (2013) suggest there is a danger of providing a hospital birth at home for those midwives who are not truly confident in home birth. Floyd (1995) suggests that a woman has greater ‘success’ if the midwife has a positive attitude, confidence, competence and willingness.
• Fundamental midwifery skills using limited equipment, e.g. Pinard stethoscope or fetal 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. Dahlen (2012) takes her knitting! She recognizes that this helps the woman to know that the midwife feels that all is well, while as a midwife she tunes in to the woman’s verbal cues better.
• 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.
• Management of unexpected situations or emergencies for mothers or babies when assistance may be some miles or minutes away. As mentioned earlier, the midwife should maintain all skills, particularly the emergency drills that include resuscitation, management of haemorrhage, shoulder dystocia, and breech delivery. In the home setting these situations may have to be managed alone (Magill-Curden 2012).