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Joan Doglio Smith of Abundance Midwifery assisting a client with their newborn in Austin, TX

Home Birth Risk Assessment in Austin, TX

     Our Home Birth Risk Assessment Tool for a Safer Birth



How do I know if I'm a candidate for a home or birth center birth?

Determining risk status for out-of-hospital birth

The health and wellness of you and your baby are of primary importance to us. That's why it's essential to identify medical conditions affecting your risk level for an out-of-hospital birth. If a client has or develops any of the conditions below during pregnancy, labor, or postpartum, special midwife approval is required to remain with AMS. Complications like these indicate the need for consultation, case review, and potentially more surveillance to determine risk status.

Conditions for ineligibility, referral, or transfer

Please note: The complications or risk factors listed in bold type below indicate ineligibility for registration at Abundance Midwifery Service. If you're a current client and develop any in pregnancy, labor, or postpartum, we'll facilitate referral or transfer of care for you.

Managing multiple risk indicators

Sometimes several un-bolded risk factors accumulate with a client over time. When this occurs a case review by our practice midwives is required to determine suitability for out-of-hospital birth.

Please review and discuss these conditions with your midwife if you believe any of them apply to your medical history or pregnancy.


Medical and 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].


3. Previous stillbirth or neonatal loss [infant death before birth or within first month of life].


4. History of an incompetent cervix [a cervix which opens without labor contractions from

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. Previous cesarean section or other uterine surgery involving myometrium. Not eligible for care if there has been more than one cesarean or if a prior cesarean was not low transverse. The client must provide an operative report to show indication for surgery and the type of incision.


8. Previous placental abruption, postpartum hemorrhage, or retained placenta. [Problems at the placental implantation site which result in abnormal bleeding].


9. Morbid obesity (35 BMI, or 30 BMI with multiple risk factors). If BMI is 40 or greater, client is not eligible for care [body mass index (proportion of height/weight)].


10. Epilepsy or other seizure disorder.

11. Any minor, not life-threatening chronic medical problem like asthma or hypothyroidism unless in remission or well controlled and posing no increased risk during pregnancy or birth. The client must provide documentation of care and of the physician who will co-manage the condition during pregnancy. Or documents stating the patient is presently in remission, healthy and at low risk.


12. Prior pregnancies that may have been complicated by other confirmed medical diseases (e.g., insulin dependent gestational diabetes, severe preeclampsia).

13. Auto-immune disorders such as systemic lupus, antiphospholipid syndrome, hyperthyroidism, rheumatoid arthritis.


14. Thrombophilia [clotting disorders resulting in increased risk of blood clotting] such as sickle cell anemia or thalassemia, Factor V Leiden.


15. Any other life-threatening conditions such as cardiac, chronic renal, or liver disease, cancer, etc.

16. History of having a prior infant with a genetic disorder.


17. The client is more than 20 minutes away from a hospital (ineligible for home birth).


18. The client is more than 45 minutes from the birthing center.


Pregnancy conditions

1. Early onset gestational diabetes/prediabetes in the first or second trimester (before 26 weeks). Prediabetes requires special visits or referral at the midwife’s discretion.


2. Overt diabetes (Hgb A1C 6.5) requires transfer of care to an OB.


3. Untreated eating disorder or intractable hyperemesis gravidarum [prolonged vomiting in pregnancy] or lack of adequate nutrition.


4. Significant alcohol or recreational drug use in pregnancy.


5. Smoking >1/2 pack per day.


6. Exposure to known teratogens (e.g., radiation, medication, chemicals).


7. Certain medications that are required to treat bi-polar, depressive, or other psychiatric disorders (this will be considered on a case-by-case basis. If the client stays in our care, they must be co-managed by a maternal fetal medicine specialist.).


8. Malignancy requiring chemotherapy or active cancer.


9. Grand multiparity with other risk factors [5 births or more after 20 weeks].


10. Abnormal cervico-vaginal cytology [lab result indicating abnormal cervical cells] requiring treatment during pregnancy.


11. Current active communicable disease i.e., HIV, Syphilis. Hepatitis B or C positive with confirmatory testing.


12. Rh or other blood group iso-immunization (mother produces antibodies which destroy fetal red blood cells).


13. Intractable anemia/thrombocytopenia (< 30% hematocrit; <9.5 hemoglobin; platelets <100,000 at term) not responding to treatment [low iron levels or genetic anemias].


14. Congenital anomaly requiring intensive monitoring or immediate physician intervention after birth [birth defect].


15. Multiple gestation [twins, triplets].


16. Incompetent cervix requiring cerclage [stitch placed in cervix to keep closed].


17. Late registration for prenatal care:


a. 20 weeks or more without prenatal care.


b. If 28 weeks or more with previous prenatal care, requires review of prenatal records before acceptance. Known last menstrual period or ultrasound dating consistent with uterine growth and complete records of prenatal care.


18. Abnormal vaginal bleeding.


19. Medication dependent gestational diabetes [unable to control blood sugar with diet and exercise].


20. Hypertension before 20 weeks [chronic high blood pressure].


21. Preeclampsia or Gestational Hypertensive Disorder [high blood pressure disordering pregnancy].


22. Persistent polyhydramnios [too much amniotic fluid] requires follow up with MD.


23. Oligohydramnios [too little amniotic fluid].


24. Intrauterine fetal death [stillbirth].


25. Unresolved placenta previa [placenta is over the cervix or low-lying placenta, diagnosed by ultrasound that does not resolve by 28 weeks (placenta within 2 cm or closer to cervix) which increases chances of bleeding].


26. Postdates pregnancy (14 days past final due date) from sure last menstrual period/date of conception or ultrasound.


27. Unstable social events making an out of hospital birth inappropriate [client of family severe anxiety/unstable home environment/domestic violence].


28. Large fibroids or tumor or other obstruction of the birth canal [a tissue or bony blockage].


29. Any known fetal malformation requiring immediate postnatal hospital care [birth defect detected during pregnancy which could severely affect the infant’s chance of survival].


30. Non-compliance with prenatal care and education. Refusal to have required testing or preparation for out of hospital birth.


31. Abnormal weight gain during pregnancy [<10 pounds or >50 pounds].


32. 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). EFW > 5 kg requires MD consultation.


33. Abnormal findings on fetal surveillance such as biophysical profile, non-stress test (fetal movement counts, sonograms, and fetal monitoring in pregnancy).


34. Maternal age less than 15 or greater than 40 at EDD.


35. Need for pharmacologic induction of labor.


Intrapartum & postpartum conditions (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, unless birth].


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; or no discernable presenting part in the pelvis at the beginning of labor].


9. Development of other severe medical or surgical problems such as placenta abruption, maternal shock.


10. Failure to progress in labor:


a. 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.


b. Second Stage: more than two hours without measurable progress in descent [10 cm dilation and pushing].


c. Third Stage: more than 45 minutes [after birth of baby and delivery of placenta] retained placenta.


11. Abnormal uterine activity in labor, such uterine tachysystole [greater than 6 strong contractions in 10 minutes].


12. Any condition requiring more than 12 hours postpartum observation.


13. Lacerations requiring extensive repairs beyond the scope of the midwife.


14. Client desires 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, anemia, or polycythemia [jaundice - yellowing of the skin; 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.

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