Homebirth Policy at a British Hospital

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Home Confinements within S. Beds

Background

The area served by the Directorate of Obstetrics & Gynaecology of Luton & Dunstable Hospital NHS Trust (S. Bedfordshire) currently has a rate of planned home confinements above the national average. The current position of all three relevant Royal Colleges (RCOG/RCGP/RCM) appears to accept that for suitable (low-risk) cases, any risk to the mother and her child associated with planned home confinement (rather than in hospital) is small or non-existent, and if the women makes an informed choice in such a situation then professionals should support her in her decision and facilitate her choice.

Such a view is likely to encourage more requests for home confinement. Even among those women who do not wish a home confinement for themselves in their current pregnancy, the supportive attitude of local health professionals to the concept of home confinement is likely to be viewed positively.

Many GPs feel that they do not have the necessary skills and/or on-call cover arrangements to allow them to accept responsibility for planned home confinements of women registered under their care. They are nevertheless able to continue to offer antenatal care and other family doctor services.

Arrangements

Deliveries which are appropriate for home confinement must be by definition be suitable for midwife only care. Direct medical input is therefore not necessary.

Where problems develop in labour then those problems need obstetric skills, which may not be within the scope of the GP. In such cases transfer to a hospital maternity unit is appropriate. Other than initial maternal and/or paediatric resuscitation only straightforward midwifery care should be given in the home.

Paramedic trained ambulance personnel should be regarded as the appropriate back up to midwives engaged in a complication arising in a planned home confinement. After any initial resuscitation the woman (and her child) should be promptly evacuated to the nearest hospital maternity unit - where personnel will have been warned to expect her. At no stage during a planned home confinement or during any ensuing complications will the GP be expected to be asked to attend. Midwives should not ask the GP for advice or assistance in intrapartum care. Her support is via her supervisor and the hospital-based obstetric team. GPs who wish to be involved in such intrapartum care may opt to do soon a general or individual case basis.

Women who wish to be considered for a planned home confinement should be screened according to locally agreed guidelines before being accepted. Difficult cases should be reviewed by the GP and/or consultant obstetrician.

Ambulances responding to an emergency call to a midwife supervising a home confinement carry at least one paramedic trained crew member. The neonatal check is routinely performed on babies born in hospital at a variable time between delivery and discharge home. Provided that the baby has been found to be grossly normal and without evidence of respiratory compromise by the attending midwife, it would seem reasonable for the neonatal check to be performed by the mother's GP on the next normal working day following delivery and according to their practice arrangements (this may be in the surgery).

All women will continue to be free to choose hospital delivery. Home confinement will not be promoted, but rather be available as an option to those women who desire it.

Future Plans

For the future the following improvements might be anticipated: Training in IV canulation for community midwives. IV canulae, IV fluids and airways should routinely be available to such midwives conducting home confinements. Leaflets need to be produced to detail the choices in patterns of antenatal and intrapartum care available (consultant care/shared care/community care & consultant booking/midwife care in labour/Domino/home birth).

Approval

A draft of this policy has been seen and agreed by: Directorate of Obstetrics & Gynaecology, L&D Hospital NHS Trust; The local GPs, through their representatives (LMC & GP Advisory group the Beds Health); Bedfordshire Health; Local Ambulance Trust; Maternity Services Liaison Committee.

I am grateful for the comments of very many professionals in the drafting of this document.

M.Griffiths 3/4/97