Although evidence is limited, what data there are suggest that one significant outcome—neonatal death—occurs with higher frequency among home births than among hospital births, even after correcting for anomalies (odds ratio, 2.9 [95% confidence interval, 1.3–6.2]).2 Although women who delivered at home did have fewer episiotomies, fewer third- and fourth-degree perineal lacerations, fewer operative deliveries (vaginal and cesarean) and a lower rate of infection, those reductions seem inconsequential compared to the death of a newborn….
WHAT THIS EVIDENCE MEANS FOR PRACTICE
Bottom line? Home birth is legal; home birth may be appropriate for some women who are at low risk and willing to accept a legitimate amount of personal risk; and you, as an OB, are in no way required to participate in or endorse the practice.
Many institutions have addressed this matter by developing a family-centered health care model for obstetrics—so-called hospitals within hospitals—that allow for a less interventionist approach to childbirth within the safety net of a hospital facility, should unforeseeable complications arise. Consider your interest in affiliating with such a facility, based on your acceptance of the practice of home birth and your comfort with being part of this approach.
Formal, systematic planning is key to managing
postpartum hemorrhage
A question for mothers-to-be: What could be worse than having a cesarean delivery in your home?
Answer: Having an associated postpartum bleed.
Perhaps that isn’t the most elegant segue, but postpartum hemorrhage is a significant problem that remains a major contributor to maternal mortality in the United States. And, in fact, a prolonged and unsuccessful labor—the kind that could present to your hospital from an outside birthing facility or home—necessitating a cesarean delivery is a set-up for postpartum hemorrhage.
One of the tenets of emergency management in obstetrics is the three-pronged preparedness of 1) risk identification, 2) foreseeability, and 3) having a plan for taking action. Of late, many institutions have begun to develop a formal plan for managing OB emergencies—in particular, postpartum hemorrhage.
(A note about the potential role of interventional radiology in the management of postpartum hemorrhage: Our experience is limited, but we conjecture that, in most US hospitals that provide OB services, mobilizing an interventional radiology group in an emergency isn’t feasible. That makes it essential to have established medical and surgical management guidelines for such cases.)
WHAT THIS EVIDENCE MEANS FOR PRACTICE
To establish a plan on labor and delivery for managing postpartum bleeds, we recommend the following steps and direct you to ACOG’s “Practice Bulletin#76” for more specific information3:
- Establish a list of conditions that predispose a woman to postpartum hemorrhage and post that list throughout labor and delivery to heighten the awareness of team members
- Establish protocols for pharmacotherapeutic intervention—including oxytocin, methylergonovine, misoprostol, and prostaglandin F2a, with dosage and frequency guidelines and algorithms for use—and have those protocols readily available on labor and delivery, either on-line or posted
- Establish an “all-hands-on-deck” protocol for surgical emergencies—actual or potential—that includes what personnel to call and in what order to call them
- Use simulation to practice the all-hands-on-deck protocol and evaluate team and individual performance in managing hemorrhage
- Establish blood product replacement protocols, including order sets for products that are linked to particular diagnoses (e.g., typing and cross-matching for patients coming in to deliver who have a diagnosis of placenta previa; adding products such as fresh frozen plasma and platelets for patients who have complicating diagnoses, such as suspected placenta accreta or severe preeclampsia).
To prevent preterm birth: Cervical length screening
and progesterone
Preterm birth accounts for almost 13% of births in the United States, with spontaneous preterm labor and preterm rupture of membranes accounting for approximately 80% of those cases.4 Once preterm labor has begun, little in the way of successful intervention is possible, beyond short-term prolongation of pregnancy with tocolytic agents to allow for corticosteroid administration. Studies in recent years have, therefore, moved the focus back on prevention, using the same treatments that were used 60 years ago—progesterone supplementation and cerclage—with the addition of transvaginal ultrasonography (US) screening for cervical length.
Several large, randomized trials have examined the use of intramuscular injection or vaginal delivery of progesterone to prevent preterm birth in patients who are at high risk of preterm birth based on their obstetric history.5,6 Both 17a-hydroxyprogesterone caproate and vaginal progesterone suppositories are associated with a significant reduction in the risk of preterm birth in singleton pregnancies. ACOG reconfirmed the value of this finding in a 2011 Committee Opinion, which recommended the use of progesterone supplementation in singleton pregnancies in which there is a history of preterm labor or preterm rupture of membranes.7
