Home Birth Risk Assessment in Austin, TX
Abundance Midwifery Service Home Birth Risk Assessment Criteria
How do I know if I'm a candidate for a home birth?
In order to have a successful home birth, you must be at low risk for certain medical complications. That's why we use the criteria below to help assess your risk level. Complications like these in pregnancy, labor, or postpartum call for consultation and case review. They may also require additional surveillance to determine if you need special approval for a home birth.
Conditions for ineligibility, referral, or transfer
The complications below in bold text indicate ineligibility for home birth registration with Abundance Midwifery Service. If you're a client and one develops during pregnancy, labor, or postpartum, we may immediately refer or transfer your care.
Managing multiple risk factors
When several unbolded risk factors accumulate during care, we require a case review by practice midwives for home birth suitability.
If you believe anything that follows applies to your medical history or pregnancy, please discuss it with your midwife.
Medical & Obstetric History
1. One or more previous premature labors or history of low-birth-weight infants (<2500 grams/5.5 lbs.) [delivery at less than 37 weeks or less than 5.5 lbs. birth weight]. Requires consultation with maternal fetal medicine physician during prenatal care.
2. Previous shoulder dystocia [difficulty delivering shoulders following birth of head]. Requires payment for additional staff to be present at birth.
3. Previous stillbirth or neonatal loss [infant death before birth or within first month of life].
4. History of incompetent cervix [a cervix which opens without labor contractions from the weight of advancing pregnancy].
5. Previously diagnosed abnormalities of the genital tract or bony pelvis [malformation or obstruction of the vagina, uterus, or pelvis].
6. Previous severe psychiatric conditions or illness.
7. Primary previous cesarean section or other uterine surgery involving the myometrium. Not eligible if more than one cesarean or if prior cesarean was not low transverse. Clients will need to provide an operative report to show indication for surgery and type of incision.
8. Previous placental abruption, postpartum hemorrhage, or retained placenta [problems at the placental implantation site which result in abnormal bleeding.] Must have had a normal birth subsequently.
9. Morbid obesity in primigravida (35 BMI, or 30 BMI with multiple risk factors). If BMI 40 or greater, not eligible for home birth [body mass index (proportion of height/weight); primigravida is first pregnancy].
10. Epilepsy or other seizure disorder.
11. Any minor non-life-threatening chronic medical problem [such as asthma or hypothyroidism], unless in remission, or well controlled and does not pose additional risk during pregnancy or birth. Client must provide documentation of care of physician who will co-manage condition during pregnancy, and/or stating client in remission and now healthy and low risk.
12. Prior pregnancies that were complicated by another confirmed medical disease (e.g. insulin dependent gestational diabetes, severe preeclampsia).
13. Auto-immune disorders such as systemic lupus, antiphospholipid syndrome, hyperthyroidism, rheumatoid arthritis.
14. Thrombophilias [clotting disorders resulting in increased risk of blood clotting] such as sickle cell anemia, Factor V Leiden.
15. Any other life-threatening disease such as cardiac disease, chronic renal or liver disease, cancer, etc.
16. History of prior infant with a genetic disorder.
17. Client is more than 20 minutes away from hospital with NICU and on-site OB physician (Neonatal Intensive Care Unit).
18. Client is more than 45 minutes from midwife.
19. IVF (In Vitro Fertilization).
Pregnancy
1. Early onset gestational diabetes/prediabetes in the first or second trimester (before 28 weeks). Prediabetes requires special visits/labs or referral at midwife discretion.
2. Overt/chronic diabetes (Hgb A1C 6.5) requires transfer of care to OB.
3. Untreated eating disorder or intractable hyperemesis gravidarum [prolonged vomiting in pregnancy] or lack of adequate nutrition.
4. Significant alcohol or drug use in pregnancy.
5. Tobacco smoking >1/2 pack per day.
6. Exposure to known teratogens (e.g. radiation, medication, chemicals).
7. Certain medications required to treat bi-polar, depressive or other psychiatric disorders (will be considered on a case-by-case basis and if the client stays in care, must be co-managed by maternal fetal medicine).
8. Grand multiparity with other risk factors [5 births or more after 20 wks].
9. Abnormal cervico-vaginal cytology [pap smear lab result indicating abnormal cervical cells] requiring treatment during pregnancy.
10. Current active communicable disease ie HIV, Syphilis. Hepatitis B or C positive with confirmatory testing. Requires reports to the Health Department and follow up to prevent transmission to baby.
11. Rh or other blood group iso-immunization (mother produces antibodies which destroy fetal red blood cells).
12. Intractable anemia/thrombocytopenia (< 30% hematocrit; <9.0 hemoglobin; platelets <100,000 at term) not responding to treatment; [low iron levels or genetic anemias that are unresolved by term].
13. Multiple gestation [twins require MD co-management, both head down, separate sacs]
14. Incompetent cervix requiring cerclage [stitch placed in cervix to keep closed] (requires co-mangment with MFM).
15. Late registration for prenatal care:
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20 weeks or more without prenatal care
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If 28 weeks or more with previous prenatal care, requires review of prenatal records before acceptance.
16. Insufficient prenatal care (lapsed prenatal care missing prenatal care visits that are recommended).
17. Abnormal vaginal bleeding.
18. Medication-dependent gestational diabetes [unable to control blood sugar with diet and exercise].
19. Hypertension before 20 weeks [chronic high blood pressure].
20. Preeclampsia or gestational hypertensive disorder [high blood pressure disorder in pregnancy].
21. Persistent polyhydramnios [too much amniotic fluid] requires follow up with MD.
22. Oligohydramnios [too little amniotic fluid].
23. Intrauterine fetal death [stillbirth].
24. Unresolved placenta previa [placenta is over the cervix or low-lying placenta, diagnosed by ultrasound that does not resolve by 28 wks (placenta within 2 cm or closer to cervix) which increases chances of bleeding].
25. Postdates pregnancy (14 days past final due date) from sure last menstrual period/date of conception or ultrasound.
26. Unstable social situation making a home birth inappropriate [client or family severe anxiety/unstable home environment/domestic violence].
27. Large fibroids or tumor or other obstruction of the birth canal [a tissue or bony blockage].
28. Any known fetal malformation requiring immediate postnatal hospital care [birth defect detected during pregnancy which could severely affect the infant’s chance of survival].
29. Non-compliance with prenatal care and education. Refusal to have required testing or preparation according to home birth checklist.
30. Abnormal weight gain during pregnancy [<10 pounds or >50 pounds].
31. Persistent or severe abnormal estimated fetal weight <2.5 kg or 5.5 lbs at full term and/or IUGR estimated fetal weight <10% (intrauterine growth restriction diagnosed by sonogram).
32. Abnormal findings on fetal surveillance such as biophysical profile, non-stress test, sonograms and fetal monitoring in pregnancy.
33. Maternal age is less than 15 or greater than 40 at EDD (Estimated Due Date).
34. Need for pharmacologic induction of labor (Misoprostol/Pitocin).
Intrapartum & Postpartum (during & after birth)
1. Preterm premature rupture of membranes and/or preterm labor [<37 weeks].
2. Rupture of membranes [bag of water is broken] for more than 36 hours without active labor. GBS-positive client with PROM and no labor within 24 hours. Refusal to have GBS prophylactic antibiotics and PROM.
3. Suspicion or evidence of fetal distress in labor [abnormal fetal heart rate or rhythm or thick meconium].
4. Development of pre-eclampsia or any hypertensive disorder [high blood pressure with liver or renal dysfunction related to being pregnant].
5. Prolapsed cord [umbilical cord is below the baby in the birth canal and subject to excessive compression].
6. Intrapartum bleeding or uncontrolled postpartum hemorrhage [too much blood loss during labor or after birth].
7. Evidence of infection (such as visible lesions suspicious of herpes or symptoms of chorioamnionitis).
8. Non-cephalic presentation, transverse lie or breech [baby is sideways in the uterus; feet or bottom are in or above the pelvis; and birth not imminent].
9. Development of other severe medical or surgical problems such as placenta abruption, maternal shock.
10. Failure to progress in labor:
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First stage: lack of progress in active labor after 5-6 centimeters and complete effacement (effacement = thinning of the cervix which allows dilation). Lack of adequate contractions or change in cervix for several hours.
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Second stage: more than two hours without measurable progress in descent [10 cm dilation and pushing].
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Third stage: more than 45 minutes [after birth of baby and delivery of placenta] retained placenta.
11. Persistent abnormal uterine activity in labor, when birth is not imminent.
12. Any condition requiring more than 12 hours postpartum observation.
13. Lacerations requiring extensive repairs beyond the scope of the midwife.
14. Client desires to transfer to the hospital.
High-risk Factors Requiring Neonatal Transfer
1. Apgar score <7 at 5 minutes [assessment scale which assigns values to heart rate, breathing, color, muscle tone, and reflex at 1 and 5 minutes after birth].
2. Signs of respiratory distress. Rapid or labored breathing, low oxygen levels with oximeter testing/need for prolonged oxygen administration.
3. Immediate jaundice [yellowing of the skin], anemia, or polycythemia [excessive red blood cells].
4. Unstable temperature; persistent hyper or hypothermia [<97 or >100 degrees F after 2 hours of age].
5. Exaggerated tremors, irritability [persistent shaking].
6. Congenital anomaly requiring immediate physician intervention [birth defect].
7. Any condition requiring >12 hours observation.
8. Signs of infection: lesions, unstable temperature, central cyanosis [bluish color occurring with poor oxygenation], hypo or hypertonia [poor or exaggerated muscle tone].
9. Unresolved low blood sugar.