Cesarean section entails considerably higher risk of poor outcome to mother and baby than vaginal birth. This is due to an associated increase in the incidence of maternal mortality and morbidity, which is in turn due to increased incidence of infection, hemorrhage, blood clots, and damage to other organs. Having a baby through normal spontaneous vaginal birth incurs the least risk of mortality and morbidity for both mother and baby in the vast majority of cases. Cesarean section is a life saving operation in certain situations, such as placental abruption, or transverse lie. These medical indications for cesarean section have remained stable, but the cesarean section rate has shown a significant increase in recent years. One of the major reasons for this is that once a woman has a cesarean section, the scar on her uterus is seen as a significant risk factor for uterine rupture, which may result in fetal and maternal mortality and morbidity. To reduce the repeat cesarean section rate, appropriate women must be offered the option of vaginal birth after cesarean (VBAC). Recent studies have called into question the safety of VBAC under certain conditions. Many hospitals and physicians are reacting to this by making the choice for women to have a VBAC difficult, if not impossible. As a result, some women who might otherwise choose a hospital birth are opting for VBAC at home. Other VBAC women choose the home as their preferred birth place. Midwives who attend home birth VBACs need evidence based guidelines to ensure care practices that make the safety of mother and baby top priority, including guidelines to transfer a laboring woman to the hospital for cesarean section if risk factors develop. The conceptual framework guiding this study is a relationship between the following three concepts: 1. Home birth has been demonstrated to be a safe option for certain women. 2. VBAC has also been demonstrated to be a safe option for certain women. 3. Therefore, home VBAC may be considered a safe option for carefully selected women. A review of the literature reveals that home birth is as safe or safer than hospital birth under specific conditions, and that VBAC, although it does entail risk, is a reasonable option for many women. There are areas of debate over who should have a home birth, and who should attend home births. Little is known about VBAC home births at this time. The purpose of this paper is to review the current research to determine what the best care practices are for VBAC births at home.

Identification of the phenomenon of interest

Home birth is safe and satisfying for certain appropriately screened women, when a trained birth attendant is present (Jackson & Bailes, 1995). A subgroup of women seeking home birth, VBAC women, have been giving birth at home since the adage "once a cesarean always a cesarean" has been questioned by the medical establishment and supported through research findings. The increase in uterine rupture that has been reported when VBAC women are subjected to an induction of labor through pharmacologic means (Lydon-Rochelle, Holt, Easterling, & Martin, 2001) has produced a generalized fear about VBAC birth among physician practitioners in particular. The low intervention practice of most home birth midwives allows for VBAC to be as safe at home as it has been in the past (Olsen & Jewell, 2002). The medical interventions, induction of labor with prostaglandins, and Pitocin, and Pitocin augmentation, that increase the rate of uterine rupture do not happen at home births. The controversy over VBACs in the hospital should be focused on the data that demonstrates that certain interventions are increasing uterine rupture. This data is not applicable to home birth since these invasive and risky interventions are not being done at home. Current research evidence that demonstrates the added risk of uterine rupture when induction and augmentation are used is not applicable to the home setting. Given the current research evidence applicable to home birth, what are the best care practices for VBAC women planning a home birth?

In 2000, 22.9% of all births in the United States were cesarean sections. This is a 4% increase over the 1999 rate. For a point of reference, the cesarean section rate in 1970 was 5.5%. The VBAC rate in 2000 was 20.7% (Martin, 2001). Healthy People 2010 has set the goal of 18% cesarean section rate by 2010, (Healthy People 2010, November 2000). To achieve that goal, a majority of women who have had one or more cesarean must have successful VBAC deliveries for their subsequent births.

In 1980, the VBAC rate was 3.4%. In 1996, the VBAC rate peaked at 28.3%, (Martin, 2001) The increase in VBACs was achieved by encouraging and facilitating VBAC deliveries by maternity care providers. That trend has been reversed by the more restrictive guidelines that are being followed for VBAC deliveries (ACOG 1988, 1994, 1995, 1999). See the table below for a comparison of how ACOG practice quidelines have changed since 1988, and how they compare to the ACNM statement on VBAC, (ACNM, 2000).

	POSITION ON VBAC	POSITION ON VBAC WITH 2 or > PRIORS	CONTRA- INDICATION	MANAGE- MENT	EPIDURAL PITOCIN PROSTA- GLANDINS	WHO ATTENDS	WHERE
ACOG 1988	strongly supportive, safer than c/sec, repeat c/sec only for specific indications	should not be discouraged	classical incision only (not enough evidence on multiple gestation, breech or macrosomia to contraindicate	no specific restrictions (treat like other labors)	not restricted	physician capable of evaluating labor and performing c/sec should be readily available	where c/sec can be performed within 30 minutes, as is standard for any OB patient
ACOG 1994	same as above	same as above	non specifically listed, rate of rupture with a classical incision is noted at 12% and VBAC "should be strongly discouraged"	same as above	epidural OK. Pitocin OK unless there is a classical incision, no evidence to not use prostaglandin	same as above	in a hospital setting that can respond to OB emergencies
ACOG 1995	same as above	same as above	same as 1988	same as above with intermittent auscultation q15m in first stage, q5m in second stage, or EFM evaluation q15m first stage, q5m second stage,	epidurals ok Pitocin in question, conflicting evidence reported, high rates leads to increase rupture, prostaglandin not enough evidence	not addressed	should not be limited to large specialty hospitals, ok at any well- equipped hospital that can respond to IP emergencies
ACOG 1999	not supportive, makes conflicting statements "even though evidence suggests benefits outweigh risk, it is now apparent VBAC is associated with risk of uterine rupture and poor outcome, and these adverse events have led to malpractice suits"	may be considered but there is an increased risk of uterine rupture	classical or T incision, or other transfundal surgery, contracted pelvis, medical or OB complication that precludes vaginal birth, inability to perform emergency c/sec because of unavailability of surgeon, anesthesia, staff, or facility	not discussed	epidurals ok, Pitocin same as above, prostaglandin appears to be safe, but there are occasional reports of uterine rupture	physician immediately available	institutions equipped to respond to emergencies
ACNM 2000	strongly supportive	not discussed	"appropriate selection"	informed consent, heightened surveillance of FHR as in high risk labor	not discussed	midwives ok with arrangements for medical consult and emergency care	not discussed

These changes in guidelines and approach to VBAC delivery has come about primarily because of more recent research and editorial writings that encourage repeat cesarean section due to fear of uterine rupture, fetal and maternal mortality, and malpractice suits. (Lydon-Rochelle, et al, 2001; Phelan, 1996). ACOG admits in the 1999 guidelines that the evidence still suggests (as it did in the previous quidelines) that the benefits of VBAC outweigh the risk. But then they go on to say that what has changed or "become apparent" is that poor outcome from uterine rupture has lead to malpractice suits. They do not say that uterine rupture has increased, only that it has led to malpractice suits. In this one conflicting statement is the heart of the controversy. ACOG is suggesting in essence that we overlook the evidence based guidelines. They are admitting the studies continue to support VBAC ("benefits outweigh the risks"). They are changing the guidelines because it is "now apparent" that rupture leads to malpractice suits. What has changed is not the evidence. It has always been apparent that there is a risk of uterine rupture with VBAC. The change is due to the fact that now it is apparent that the cases of rupture have led to an increase in malpractice suits (ACOG, 1999).

Significance of the study to midwifery and women's health

Review of Literature

The literature is being reviewed to determine the factors that increase the risk of mortality and morbidity for VBAC women whatever their place of birth, and to determine the factors that make home birth a safe option for certain women.
The literature review supporting this research was conducted as a search of the World Wide Web using the search engines Pubmed, Medscape, and CINAHL. The search topics used were VBAC and Home Birth. Twenty-two full text documents were obtained through the medical library at Gundersen Lutheran Hospital, LaCrosse, Wisconsin.

Home Birth Article Reviews

This study describes the results of a national survey on the practices and outcomes of 11,788 intended home births attended by CNMs during 1987-1991 (Anderson & Murphy, 1995). Data forms were filled out by midwives using past birth logs. Ninety participating practices entered their information into a standard database, and descriptive statistics were generated.

The transfer to hospital rate was 8%. The IP/neonatal mortality rate was 2/1000. Excluding congenital anomalies, it was 0.9/1000. There were no maternal deaths. Nineteen deaths were due to congential anomalies and 8 intrapartum deaths were due to post dates (2), placental abruption (2), nuchal cord (1), true knot in cord (1), and unknown reasons (2). Two deaths were due to prematurity, and three due to birth asphyxia. Data on emergency and non-emergency transfer is closely examined and reported as well. The most common reason for transfer intrapartum was failure to progress in labor. This accounted for 55% (496) of the hospital transfers. The emergency transfers intraparum were for maternal hypertension (20), maternal sepsis (19), meconium stained fluid (116), fetal distress (60), cord prolapse (8), placenta previa (3), placental abrution (2). Emergency postpartum transfers were for severe postparum hemorrhage (41). Neonatal transfers were due to serious anomalies (17), meconium aspiration (12), neonatal sepsis (5), and low birth weight <2500 grams (5). The data supports the concept that Certified Nurse-Midwives can appropriately screen for risk in the antepartum, intrapartum and postpartum periods for women in the home setting. For example, there were 47 low birth weight babies born to women intending to have a home birth, and 40 of the mothers were transferred to a hospital before the babies were born. This ability to identify pregnancies at risk is also consistent with other research.

One of the strengths of this research is the large n value, over 11,000. The statistics arrived at through the gathered data closely corresponds to other studies on home birth, which helps to validate the accuracy of this study. For example, the neonatal mortality rate of 2/1000 is similar to the rate 1.3/1000 arrived at in the National Birth Center Study reported by Rooks , Weatherby, Stapelton, Rosen, and Rosenfeld, (1989).

One of the weaknesses of the study is its response rate of only 66%. It is inferred from anecdotal comments, that the response rate was this low because many of the home birth midwives do not have the time to fill out extra paper work. However, there is no way of knowing that for sure, and there is always the possibility that the non-responders had outcomes much worse or much better than the others, which would cause a significant change in the statistics generated from the responders, making the overall picture of the safety of home birth look different. Another weakness of the study is its retrospective nature, which allows for the possibility of adverse outcomes to go unreported. Also, data collection did not include information on demographics, or medical/obstetric history of the mothers. This limits the ability to compare this study to others in certain ways. Also the people most vested in having good outcomes are reporting the data.

The authors conclude with the midwifery perspective that home birth is an entrenched birth alternative in our country. Women choose home birth because home is most familiar and safe to them, and it provides security, comfort, and a sense of being in control of the powerful event of birth. Although the actual percentage of home births is low (1%), concerns about the risks of home birth must be addressed by birth attendants. Evidence of outcomes, such as shown in this study, provides important data that is useful in the debate over the relative risks and benefits of the choice of birth setting. This research article can reassure women with previous cesearan delivery and their care providers of the relative safety of home birth.

Declercq, Paine, & Winter, (1995) examined birth certificate data from the Natality Branch of the National Center for Health Statistics, and the national birth center data tapes from 1989-1992. The research was begun in the year 1989 because that was the year that a distinction was made between out-of-hospital births and home births on birth certificates. Before that, all out-of-hospital births were lumped together, so it is not possible to tell which ones are home births and which ones are birth center or clinic births.

The data from the National Center for Health Statistics provided information on demographics and geographical locations for 108, 829 home births during these years. More than 4 out of 5 home births were to white mothers, slightly higher than the national average of births to white mothers in general. CNMs attended only 12% of the home births in this study. Physicians attended about 20%, other midwives attended 30.5% of these births, and 37% were attended by someone "other" than a physician, CNM, or midwife. There is speculation that a large proportion of the 37% other attendants are actually midwives practicing illegally in various states that do not sign birth certificate.

White mothers who gave birth at home were more likely to be older than the average mother, and more likely to be married. Black and Hispanic mothers who gave birth at home were more likely to be younger and unmarried, and had a lower level of education. Geographically, more home births occur in the western and southwestern states, with the seven states having the most home births being Alaska, Montana, Vermont, Idaho, Oregon, Nevada, and Washington.

The data from birth certificates used to analyze various items was based on between 78,369 to 82,210 birth certificates from home births. The total number of births on which percentages of outcomes were based varies by item. The majority of women who gave birth at home had a parity > 3. Home birth mothers received less prenatal care in general. Black mothers had more low birth weight babies and more premature births than white and hispanic home birth mothers. There is no distinction on the birth certificate for planned or unplanned home birth, so it is possible that the higher percentage of premature low birth weight babies were born at home because of precipitous labor, not because of a planned home birth. Obstetric complications were lower for home births in all categories except precipitous labor, which again suggests that a proportion of these home births were not planned. Abnormal conditions of the newborn were lower at home births in all categories except anemia and low apgar score. There is no mention of the rate of neonatal mortality because later neonatal deaths would not be available from birth certificates data.

The authors conclude with the comments that the rate of home births is remaining stable at about 1%. The average mother having a home birth is older, higher parity, married, white, less educated, less likely to smoke or drink alcohol, less likely to have prenatal tests or to be diagnosed with a prenatal medical risk or obstetric complication. The health of her baby compares favorably with the average baby born in the United States. The authors give their opinion that home birth will continue to be an area of controversy, regardless of this and other research findings that attest to the safety of home birth. Nevertheless, such research is essential to shape policy based on evidence.

The major weakness of this research is the inability to determine which home births are planned and which are precipitous unplanned births. The statistics still attest to the relative safety of home birth, (compared to hospital birth) even with the unplanned home births included. Another weakness of the study was the lack of reporting on maternal or neonatal mortality. That omission makes it more difficult to compare the safety of home birth with hospital birth. Another weakness is the concern that some physicians do not allow midwives to sign birth cerificates, so there could be a higher number of midwife attended births than reported.

The major strength of this study is the large numbers of home births analyzed, and the validity of the data being from birth certificates and the National Center for Health Statistics. There is less likelihood of underreporting of adverse conditions when practitioners are not even included in the loop of gathering the data. My midwifery perspective is that this research provides more evidence that home birth is at least as safe as hospital birth, and a viable birthing option for certain women.

Murphy and Fullerton (1998), recruited 29 Certified Nurse-Midwife practices to participate in their study, and enrolled 1404 women who were intending to have home births from 1994-1995.

Of the 1404 original women, 6% miscarried, terminated the pregnancy, or changed their plans to have a home birth. Seven per cent were risked out of home birth for various perinatal complications antepartum, and were referred for hospital birth. Of women who began labor at home, 8.4% were transferred to a hospital during labor, 0.8% were transferred after delivery, and 1.1% of newborns were transferred to a hospital after birth. Neonatal mortality rate for babies born to mothers planning home birth and beginning labor at home was 2.5/1000. Neonatal mortality rate for babies actually born at home was 1.8/1000. According to the National Vital Statistics System, the neonatal death rate in 1997 in the US. was 7.5/1000 (National Center for Health Statistics 2001). The goal of Healthy People 2010 is to reduce this rate to 4.5/1000 (Healthy People 2010, 2000).

The weakness of this research study is that it is not a matched population study comparing a group of women planning home birth with a similar group of women planning hospital birth. This is a difficult type of study to undertake, but it would help eliminate the criticism of home birth studies that they include only very low risk women to begin with and therefore are not a good indicator of the general safety of home birth. Another weakness is that the prospective study allows for underreporting of adverse outcomes because the reporters (midwives) have a vested interest in the data favoring home birth and are aware of the study going on from the beginning, since it is prospective.

The strength of the study is that it is prospective, which allows for more careful investigation for the variables that are being examined from the beginning. The fairly large number of participants (1404) is also a strength. The study is clearly written and understandable, and the results are succinct and straight forward. The authors conclude that home birth can have good outcomes when there are qualified birth attendants, and a system of hospital transfer in place and used as needed.

A midwifery perspective on this research is that it is another strong and useful piece of data to add to the list of articles that show home birth to be as safe or safer than hospital birth when it is planned and attended by qualified personnel, and there is appropriate hospital back-up. There is no mention of VBAC attended home birth in this research.

Schramm, Barnes, and Bakewell (1987), gathered data from home birth attendants using their birth logs. Information on 4,054 home births was analyzed. Data is reported comparing observed outcome versus expected outcome according to national statistics, and compared with physician attended hospital births. Among the 3,067 recognized planned home births, there were 17 neonatal deaths. This is a neonatal mortality rate of 5.5/1000. The excessive mortality occurring at planned home births was in association with lesser trained attendants (12 of the 17). The neonatal mortality rate at planned home births with trained attendants (physician, certified-nurse midwives, or Missouri Midwife Association recognized midwives) was 1.6/1000.

Weakness of this study is in confusing reporting of data and unclear application of comparison. It was not made clear what the definition was of expected outcome versus observed outcome and how the outcome compared to hospital births. Also, it was not explained why only 3,067 of the 4.054 births were counted as planned births. Explaining how this determination was made would give the study more validity.

A strength of the study is in the general original intent to be one of the first to demonstrate the safety of home birth when there is a trained attendant (originality). Seeing a lack of such data at this time, I believe the authors did the best they could to set in motion more professionally done home birth studies to follow.

A midwifery perspective on this study is that if you look simply at the neonatal mortality rate at planned home births with trained attendants the rate is very impressive compared to the national neonatal mortality rate at that time according to the Office of Vital Statistics, 10.1/1000, during 1984 when this study was completed (National Center for Health Statistics 2001). This study again provides further evidence for the safety of home birth with trained attendants.

Pang, Heffelfinger, Huang, Benedetti, and Weiss (2002) designed a retrospective analysis of birth registry information comparing planned home births to planned hospital births during 1989-1996 with regard to specific adverse neonatal outcomes of neonatal death, low Apgar scores, and ventilator support, and maternal outcomes of prolonged labor and postpartum hemorrhage.

The results were that infants of planned home births were at increased risk of neonatal death and low Apgar scores. Out of 6,133 planned home births there were 20 neonatal deaths, a mortality rate of 3.3/1000. The causes of these deaths were; brain injury (2), congenital heart disease (5), respiratory distress (5), infant sepsis (2), congenital anomalies (3), and other (3). Out of 10,593 planned hospital births there were 18 neonatal deaths, a mortality rate of 1.7/1000. These deaths were caused by brain injury (1), congenital heart disease (5), infant sepsis (3), congenital anomalies (6), and other (3).

One of the weaknesses of the study is that the infants that were part of the intended home birth population but were transferred before delivery were lumped together with all the planned home birth babies. The distinction needs to be made between planned home birth babies that are actually born at home, and planned home birth babies that are not born at home because some complication led the birth attendant to transfer the mother to the hospital. If the transfers are counted as home births then of course the risk of home birth is going to appear higher. However, when a transfer is made to the hospital, it is important to remember that the cause of the transfer does not necessarily have any correlation with the planned birth site. For example, if there is a cord problem and fetal distress, and the mom is transfered to the hospital in a timely fashion and has a cesarean section, there is no way of knowing if the outcome would have been any different if she had been in the hospital to begin with. The cord problem and fetal distress would still have occurred and depending on the effectiveness of the monitoring and the decision making of the attendants the mother would have had the cesarean earlier, at the same time, or later than the home birth mom. To draw the conclusion that planning a home birth led to a higher incidence of neonatal mortality from this study, is to assume that the transfer complications would not have happened if those women had planned hospital births. That assumption can not be made.

Another weakness of the study was lumping together all the neonatal deaths as if the place of birth had an effect on them. The 3 babies that died of congenital anomalies in the home birth cohort would most likely have died whereever they were born. Subtracting these 3, the mortality rate would be 2.7/1000. The five babies that died of congenital heart defects may have died in the hospital as well, unless they were born in a level 3 hospital with an in house pediatric cardiologist. If these 5 babies are subtracted from the 20, along with the 3 with congenital anomales, the neonatal mortality rate for this cohort would be reduced to 0.19/1000. It is important to keep in mind while looking at these numbers, that the United States neonatal mortality rate overall for 1996 was 7/1000 and in Washington state it was 5.3/1000 (National Center for Health Statistics, 2002).

The strength of the study is the large numbers analyzed (6133 planned home births and 10, 593 planned hospital births). Another strength is the clearly defined parameters being investigated, that is, particular neonatal and maternal adverse outcomes.

A midwifery perspective is that this research article is a good example of how research can be flawed in design and ultimately contradict most other research on the same subject. The authors include in their discussion a review of the Missouri home birth study reviewed above, and they came to a different conclusion about the study then the authors of that study did. The Washington authors state, "In one population based cohort study of 3067 home deliveries in Missouri, there was a two-fold increase in the overall incidence of neonatal death in babies delivered at home compared with hospital deliveries attended by physicians". They focused on one fact in the study and took it out of context. However, they fail to explain that in the home birth group there were 17 neonatal deaths, and 12 of them occurred in deliveries where the attendant was untrained. The Missouri authors concluded that there was little difference in neonatal mortality rate in the home vs. hospital groups when the distinction was made between trained attendants (physicians, Missouri Midwife Association recognized midwives, and certified nurse-midwives), and untrained attendants (Schramm, Barnes, & Bakewell 1987).

The references listed in this article include several excellent studies on home birth that came to the conclusion that there is no significant difference in the safety of home birth versus hospital birth. One of the articles is the meta-analysis on home versus hospital birth from the Cochrane Library (Olsen, 2002). The referenced studies with conclusions in oppostion to this study are not mentioned in the text of this study.

The statistics in this study were derived in a legitimate way, but not making the distinction mentioned above, between planned home births and planned completed home births, skewed the outcome results enough to make home birth in general look risky. A better analysis would be to have listed what the outcome was for the planned and completed home births, and what the outcome was for the planned home births that ended in hospital transfer before delivery which indicates that there was some complication making home birth inappropriate. Then those two distinct groups could be compared in a more realistic way with planned hospital births.

VBAC Article Review

This retrospective study by Lydon-Rochelle, Holt, Easterling, & Martin, (2001) was to assess the risk of uterine rupture in certain groups of pregnant women with one previous cesarean section, and no previous vaginal births. The risk of uterine rupture was assessed for three groups: deliveries after spontaneous onset of labor, deliveries after labor induced with prostaglandins, and deliveries after induction by other means. The rate of uterine rupture in these three groups was then compared with uterine rupture rates in repeat cesarean deliveries without labor. The hypothesis was that inducining labor would increase the rate of uterine rupture. Another purpose of the study was to demonstrate that uterine rupture is lowest in women who have repeat cesarean without labor.

The conclusion drawn by the authors is that induction of labor increases the risk of uterine rupture in VBAC deliveries, and induction with prostaglandins increases the risk to an even greater extent.
One of the strengths of this study is the large number of subjects. Using subjects having a second child after a cesarean delivery with the first baby eliminates the variables of parity, multiple gestation, and more than one cesarean. It was very interesting and useful to note the many variables examined that did not affect the rate of uterine rupture. Another strength is the clear result of increased risk of uterine rupture with induced labor, especially using prostaglandins. Precise definitions based on birth certificates and medical records using ICD-9-CM procedure codes and diagnosis codes is another strength.

The study is limited by the number of variables that were made available for examination. There are thousands of variables that could be considered in the complex scenario of birth. For example, we know nothing of the interventions used in management of these 20,095 hospital VBAC attempts. Common interventions such as routine IV, no oral intake, IUPM, and continuous EFM may or may not have an influence on the rate of uterine rupture. A significant limitation is that there is no data on augmented labors. Since (Pitocin) induced labors had a greater rate of uterine rupture, it would be important to know if Pitocin augmented VBAC labors also produced a greater number of uterine rupture. Also, it would be helpful to have more information about outcomes besides just the rate of uterine rupture, like how the rate of uterine rupture relates to the rate of infant morbidity and mortality.

This research chooses a few variables and attempts to examine and rule out the effects of a number of other variables to present a precise and useful study design. However, the data can later be skewed to suggest conclusions that the authors did not intend. This study has been used in editorials by other authors to suggest that the policy of "once a cesarean, always a cesarean'' is the safest policy and should be again followed. New protocols have been written because of these editorial comments, and media reviews of them, which have made it progressively harder for women to have VBACs. Consequently, the cesarean section rate has gone up to the level it was at before the VBAC movement began in the 1980's.

In a personal communication with first author Dr. Lydon-Rochelle, on August 16, 2002, she expressed dismay that this article was being criticized by other midwives for making trial of labor more difficult to obtain in hospitals. The research is not about VBACs, but about how certain interventions (induction) makes trial of labor higher risk. When asked what she would say to a woman who wanted a VBAC home birth, she said she would not rule that option out, but would look at each woman on an individual basis for risk status.

Smith, Pell, Cameron, & Dobbie, (2002) analyzed research on a population-based retrospective cohort study of data from the Scottish Morbidity Record including births in Scotland between January 1, 1992 and December 31, 1997.

The populations studied were women with uncomplicated pregnancies who had a trial of labor after a previous cesarean, women having a planned repeat cesarean, and multiparous and nulliparous women at term not delivered by planned cesarean. 313,238 singleton births between 37 and 43 weeks were examined, and delivery related death defined as intrapartum stillbirth or neonatal death unrelated to congenital anomalies were compared in the 4 groups.

Women who had a trial of labor after a cesarean delivery had perinatal mortality rate of 1.29/1000. This was 11X greater risk than the risk associated with planned repeat cesarean, 2X the risk of multiparous women with no scar, and similar to the risk of nulliparous women. Maternal mortality of woman who had a trial of labor was 0.45/1000. This rate was 6X greater than other multiparous women. The authors conclude that although the risk of death is low, it is still significantly greater than the risk of death associated with planned repeat cesarean delivery.

One weakness of this study is the definition of "trial of labor" as any vaginal birth or emergency cesarean after 37 weeks. Any woman who had a uterine rupture or placental abruption and came to the hospital in that condition and underwent emergency cesarean would be classified as "trial of labor" subgroup even if she did not labor at all. A woman with a previous cesarean was put in the planned cesarean group only if she actually had a cesarean birth planned. All other women with previous cesarean history were put in the "trial of labor" category. This would include any catastrophic event that led to emergency cesarean, so would increase the rate of neonatal mortality, not because of any trial of labor, but because of the event that led to the emergency cesarean.

Another weakness of this study was that it did not take into consideration the effects of induction and augmentation of labor with Pitocin and prostaglandins, even though other studies have associated these inductions with a higher incidence of uterine rupture.

A strength of the study is the very large population examined, and the comparison made between the 4 groups. However even disregarding the flaws in the study, the actual numbers for neonatal and maternal mortality are very low. Considering the neonatal mortality rate nationwide in the US in 1999 was 7.1/1000, the neonatal mortality rate from "trial of labor' births of 1.3/1000 appears very low.

A midwifery perspective of this article is that it is confusing and misleading to use these numbers to make VBAC birth appear so much riskier than planned repeat cesarean that it should not be considered an option. The article does not address the fact that there is risk involved in all births, and removing the element of trial of labor after cesarean does not take away the other risks. The article also does not address the issue of the increased risk to future pregnancies of placental abruption and placenta previa when a cesarean section is performed. Although the authors admit that the risk is "low" they do not go far enough to explain that there is the concept of acceptable risk. If there was not, no babies would be born vaginally or otherwise.

Authors Yap, Kim, & Laros, (2001) did a retrospective chart review of uterine rupture between 1976 and 1998. Thirty eight thousand and twenty seven births were considered in the data base. There were 21 uterine ruptures identified, giving a rate of uterine rupture of 1.8/1000 or 0.18%. Seventeen of these were in women with prior cesarean deliveries. Three uterine ruptures occurred in women with no increased risk, and one occurred in a woman with a bicornuate uterus. Sixteen of the women presented symptoms of increased abdominal pain, vaginal bleeding, or altered hemodynamic status. Two women required hysterectomies and 2 required blood transfusions. There were no maternal deaths. In 13 of the cases fetal heart rate patterns showed bradycardia, repetitive variables, or late decelerations. Two babies died, one at 23 weeks, and one with Potter's Syndrome at 25 weeks. All other 19 infants had no evidence of neurological abnormality before discharge.

These authors conclude that there is relatively small risk of uterine rupture with vaginal birth after cesarean. The rate of uterine rupture in women with previous cesarean was 0.22% and the rate in unscarred uteri was 0.095%. When close fetal and maternal monitoring is done, VBAC does not result in major maternal or neonatal mortality.

A weakness of this study is the lack of information given for the actual ruptured uteri. It would be helpful to know how many, if any, were associated with labor induction or augmentation, or other obstetric complications. A strength of the study is the large population studied and the clearly written outcomes.

A midwifery perspective is that a neonatal mortality rate caused apparently by uterine rupture of 0.05/1000 (two babies out of 38,027) is very low. When you take into consideration both of these deaths were of premature babies, and one had congenital anomalies, one could question whether even this low rate had an association with uterine rupture at all. Perhaps the one normal baby would have survived, as did the other babies delivered after uterine rupture, if it had been full term. This perspective brings into question what the conclusions of this research actually mean. Looked at in another way, the results could be interpreted as meaning that even uterine rupture entails no greater risk to the baby than normal vaginal delivery (since no neonatal death can be clearly attributed to uterine rupture alone).


Appleton, Targett, Rasmussen, Readman, Sale, and Permezel (2000) underwent a retrospective analysis of medical records from 1992-1997 of 234,015 deliveries in Australia. Of these deliveries, 21,452 (9.2%) were VBACs. Of this group, 5419 (25.3%) delivered vaginally. There were 62 cases of uterine rupture, a rate of 0.28%, and no maternal deaths. Twenty-five per cent of the 62 women underwent hysterectomies. Perinatal mortality within the 62 cases was 25%. That means the actual perinatal mortality of the 5419 successful VBAC deliveries was 15.5/5419 or 2.8/1000. Again when comparing this rate to the neonatal mortality rate in the US for a given year, say 2000, of 6.9/1000, this rate appears very low (National Center for Health Statistics 2001).

The authors conclude that VBAC rates are increasing, and the incidence of uterine rupture is low, and is associated with better outcome than rupture of an unscarred uterus.

A weakness of this study was, similar to some of the other studies reviewed, no information on obstetric management of the VBAC subgroup. Information on induction, augmentation, and any other obstetric interventions could throw a different slant onto the whole picture of what is the safest way to care for VBAC women to reduce the number of uterine ruptures. Another weakness is that there is no information about the infants that died after uterine rupture. It is important to know if any of them died of other causes unassociated with uterine rupture, related to prematurity or congenital anomalies. This would lower the neonatal mortality rate actually associated with uterine rupture.

A strength of the study is the large number of births reviewed, and the simplicity of looking at only a few variables. The variables examined were VBAC birth vs. non-VBAC, uterine rupture, uterine rupture with hysterectomy, and perinatal mortality.

A midwifery perspective of this research article is that it is another piece of strong evidence that VBAC birth is as safe as birth in general, if you are just simply comparing neonatal mortality rates from VBAC births, to births overall.

Authors Gardeil, Daly, and Turner (1994) conducted a study that took place in Ireland in one particular hospital, Coombe's Women's Hospital in Dublin. Uterine rupture data was reviewed between the years of 1982-1991. This is a retrospective descriptive study of 65,488 deliveries with a finding of 15 cases of uterine rupture, giving an overall incidence of 1/4366. Of the 15 cases of uterine rupture, 2 occurred in unscarred mutligravidas, and 13 occurred in VBAC deliveries following the previous delivery by cesarean section. There were no maternal deaths, but 5 of the 15 required hysterectomies. There were 5 perinatal deaths, but only 3 of them were attributed to uterine rupture. That gives a neonatal mortality rate of 3/3961 VBAC births or 0.75/1000. Of the 15 cases, 13 had Pitocin administered either to induce or augment labor.

The authors conclude that risk of uterine rupture is low, but is related to previous cesarean section associated with Pitocin administration.

A weakness of this study is that it is a retrospective study and important data on adverse outcomes could possibly have been underreported. Strengths of the study are its large population, its clearly written results, its inclusion of data on the use of Pitocin, and its distinction between neonatal mortality resulting from uterine rupture or from other causes.

A midwifery perspective of this research article is that it presents a powerful case for the relative low risk of VBAC delivery in general, and especially in the home setting where pitocin induction or augmentation is not done.

Conceptual Framework

The conceptual framework of a study helps the readers understand what the underlying concepts of the study are. The research problem and hypotheses should flow naturally from the framework. The conceptual framework guides the study methods used. The findings of the study are interpreted within the framework and should support the framework (Polit, Beck, & Hungler, 2001). A theory is comprised of at least 2 concepts related in some way. The theory attempts to explain how these concepts are related.

The conceptual framework presented here is that environment influences practice and outcomes. Environment is defined as the "circumstances, objects or conditions by which one is surrounded" and also " the aggregate of social and cultural conditions that influence the life of an individual or community" (Merriam, 1977). Practice means what health care providers actually do and don't do. Practice is defined as "the usual way of doing something" (Merriam, 1977). And outcomes can cover a broad spectrum, from whether a client lives or dies, to whether a client is happy or sad. Outcome is defined as "something that follows as a result or consequence" (Merriam, 1977).

The theory presented here is that home birth and VBAC are both relatively safe under specific conditions, and therefore home VBAC is also relatively safe under certain conditions. The environment of the home, and the condition of VBAC influence the way the birth is managed, which can increase the safety.

There are many advantages to the home environment for birth. The mother has increased authority over her experience, increased privacy, unfettered contact with family members, undisturbed bonding, and more energy to deal with labor and allow it to unfold in its unique way. Her increased level of privacy allows her to reach a deeper level of being uninhibited, which in turn allows for more options of coping techniques. A woman birthing at home is the central figure by which all intrapartum plans and decisions are made. The ACNM Statement of Philosophy (1987), acknowledges how a woman's belief system can affect her childbearing process. In her own environment, a woman can unselfconsciously express her own spiritual and cultural identity. A thorough review of the literature demonstrates that home birth is a valid and safe option for certain women under specific conditions (Jackson & Bailes, 1995).

In 1974, the ACNM published a position statement that declared the hospital the officially recognized site for childbirth. Over the next few years considerable protest and debate led to this statement being revised. The 1980 ACNM Statement of Practice Settings was adopted, and it acknowledges the home as an acceptable birth site.

Conceptual Map

Home is defined as "a family's place of residence" and "at home" is defined as "relaxed and comfortable, at ease, on familiar ground" (Merriam, 1977). Home birth does not necessarily mean the birth takes place at the mother's place of residence, but it does mean that she is on familiar ground where she can be relaxed and comfortable. Out-of-hospital birth is an all encompassing term that means any birth that takes place somewhere besides a hospital. This can be in the home of the mother, in someone else's home, in a birth center, in a motel room, or even in a teepee. For the purpose of this pape,r home birth is best described as birth out of hospital in the place that the mother feels most comfortable.

This broad concept of "home" demonstrates how environment can influence outcome. If the mother's environment is where she is most comfortable, she will be able to relax more, and that will affect the outcome of the birth. Grantly Dick-Read wrote in his famous book Childbirth Without Fear about the fear, tension pain cycle. The more fear a woman has in labor, the more tense she is, and the more painful her labor is (Dick-Read, 1987). This simple concept initiated the childbirth education movement in 1944 with the belief that fear could be reduced by knowledge of what happens in labor. Fear can also be reduced when women give birth where they are most comfortable, and for some women, that is at home.

More recent research on catecholamines supports this idea. It has been shown that fear increases the level of catecholamines, which then can interfere with the labor process, slowing it down and hence making it more painful (Farley, 1995). It has also been shown that a certain amount of catecholamine release is normal at birth. Labor is naturally a stressful event, causing the release of catecholamines. The stress of labor causes the catecholamine norepinephrine to be released into the bloodstream which slows the fetal heart, reducing the oxygen needs of the heart and shunting more blood to the brain. Catecholamines also promote absorption of amniotic fluid in the lungs, and assist the newborn in temperature regulation. These physiological responses to the stress of labor occur to some degree in all normal births. The question remains, how much stress is too much? The research suggests that a certain amount of stress which produces catecholamine release is a positive adaptive process for the fetus. However, research and experience has also shown that, as Dick-Read theorized, an excessive level of stress leads to higher levels of catecholamines which may negatively impact the fetus and the mother (Farley, 1995).

Women choose home birth for many reasons. One of the most common reasons is the belief that the comfort of her familiar environment will help her relax (Rooks, 1997). When a laboring women is able to relax more because she is at home, she is facilitating a normal birth, and a normal physiological level of catecholamines. In contrast, when a woman is in a hospital and given drugs to help her relax, the drugs themselves may interfere with the release of catecholamines (Farley, 1995). In most home births, pain management is accomplished by means other than medication. This is an example of how the environment in which a woman births influences the practice and outcome. A mother given drugs results in the baby's normal level of catecholamines being affected.

Pitocin or misoprostol induction of labor and Pitocin augmentation of labor are not home birth practices. Induction of labor has doubled in the past decade at hospital births (Rayburn & Zhang, 2002). Induction and augmentation of labor have become acceptable practice with VBAC clients in the hospital setting (ACOG, 1994,1995,1999). Recent research has shown that induction and augmentation increase the risk of uterine rupture (Lydon-Rochelle, 1999). Since Pitocin and prostaglandin induction is not done at home births the statistics that show an increase risk of uterine rupture with VBAC are not applicable to the home birth setting. This is another example of how environment influences practice and outcome.

To summarize, the conceptual framework is that the environment influences practice and outcome. The specific theory is that the environment of home influences practice in such a way that the outcome is a safe birth. This also applies to a woman having a VBAC under specific conditions.

My literature review has demonstrated that home birth is as safe or safer than hospital birth when the mother is carefully screened and remains low risk throughout her antepartum, intrapartum and postpartum care. A trained birth attendant must provide antepartum, intrapartum and postpartum care for home birth to be a safe option. The literature also has demonstrated that VBAC is a relatively safe option for certain women with low transverse scars, no other obstetric risk factors, careful monitoring during pregnancy and labor, no labor induction or augmentation, and plans to refer to an obstetrician if risk factors develop which would require a cesarean section. Safety is a relative concept and refers to the fact that statistically there is a low incidence of neonatal or maternal mortality and morbidity. It does not imply that there is no chance of death or injury, only that the chance is low enough to be acceptable. This concept of safety is inherent in childbirth because all birth presents a risk of neonatal and/or maternal mortality and morbidity. When we look at the various childbirth options and procedures available, we are not looking for what is the only safe option, we are looking at what options have been shown to have a demonstrated low incidence of adverse outcomes and therefore provide evidenc of relative safety.

VBAC= vaginal birth after cesarean
EBCPG= evidenced based clinical practice guidelines
HB= home birth
+HO= positive health outcomes

VBAC with EBCPG in HB ----(+)---> HO Health outcomes

CHAPTER 3

The problem addressed by the EBG-CP for VBAC home births

STUDY	GRADE OF EVIDENCE	STUDY DESIGN	STATISTICS REPORTED	CONCLUSIONS/ OPINIONS
Outcomes of 11,788 Planned Home Births by Certified Nurse Midwives (Anderson, 1995)	D	Retrospective cohort survey	N=11,788 home births intrapartum/neonatal mortality =2/1000 (0.9/1000 excluding congenital anomalies) transfer=7.4%	Planned home birth with qualified care providers can be a safe alternative for healthy lower risk women.
The Cost-Effectiveness of Home Birth (Anderson, 1999)	D	Retrospective cohort survey	N=11,592 hospital births and 11,788 home births mean hospital birth cost in 1991= $5382 mean home birth cost in 1991=$1844 overall neonatal mortality for home birth= 1.3/1000 overall neonatal mortality for hospital births=2.2/1000	Home births offer lower rates of neonatal mortality and cesarean section, and a savings of up to 76% over hospital births
Home birth in the United States, 1989-1992 (Declercq, 1995)	D	Retrospective longitudinal study	N=82,210 home births CNM attended=12% physician attended=20% other midwives attended=30.5% other attended=37%	Outcomes of newborns born at home compared favorably to the national average dring the same period. Several findings varied considerably by race or ethnicity of the mother.
The Safety of Home Birth, The Farm Study, (Durand, 1992)	D	Retrospective comparative study	N=1707 home births N=14,033 hospital births overall home birth mortality rate (intrapartum and neonatal)=8.8/1000	The mortality rate is higher than home birth rates from other studies. It includes a very different population; breech, twins, high parity, hospital transfers,and other complicated deliveries not normally attempted at home. The rate compares with the overall rate for the U.S.
Home birth with Certified Nurse Midwives, (Jackson, 1995)	D	Meta-analysis retrospective overview		International literature documents the saftey of home birth.
Outcomes of elective home births, (Mehl,1977)	D	Retrospective matched population comparative study	N=1,046 home births N=1,046 hospital births neonatal and perinatal mortality rates for home and hospital were statistically the same	Incidence of all interventions studied was lower in the home birth cohort. Home birth is as safe or safer than hospital birth.
Meta-analysis of the safety of home birth, (Olsen, 1997)	D	Meta-analysis retrospective	N=24,092 perinatal mortality was not significantly different between the two groups (OR= 0.87, 95%CI 0.54-1.4)	Home birth is an acceptable alternative to hospital birth for selected women, and leads to reduced medical interventions.
Outcome of planned home births in Washington State: 1989-1996, (Pang, 2002)	D	Retrospective analysis of birth registry	N=6133 home births, neonatal mortality= 3.3/1000 N=10,543 hospital births, neonatal mortality=1.7/1000	Planned home birth had greater infant and maternal risks than hospital births.
Neonatal mortality in Missouri home births, (Schramm, 1987)	D	Retrospective analysis of birth attendants' charts	N=4,054 neonatal mortality=5.5/1000, neonatal mortality with trained attendants= 1.6/1000	Shows that skilled attendants at planned home birth improves outcome.
Place of birth and perinatal mortality, (Tew, 1985)	D	Retrospective analysis of Bristish sample surveys of births	N=4,394 hospital low risk N=3,094 clinic and home low risk perinatal mortality for hospital births=8/1000 perinatal mortality for home/clinic births=3.9/1000 (p<0.05)	Obstetrical practices in hospitals make birth less safe than home births with no intervention.

______1. The client’s operative report from previous cesarean section must indicate low-transverse uterine
incision. If possible, obtain information on closure type.

______2. Consider 3rd trimester US to determine placental placement
.
______3. The client must have had an uncomplicated post-op course
.
______4. The client ideally should be within 30 minutes of a hospital with 24 hour availability of
OR/Anesthesia

______5. Arrangements for consultation and transport for emergency care in place.

______6. If induction or augmentation becomes necessary home birth is no longer an option.

______7. Evidence of informed consent.







Appendix B
VBAC Informed Consent form


INFORMATION AND CONSENT FOR WOMEN WITH PRIOR CESAREAN SECTION(S)

Developed by Bruce Flamm, MD, reprinted with permission


The purpose of this form is to provide information regarding vaginal birth after cesarean (VBAC) to mothers who have previously had a cesarean and to provide an opportunity for the mother to choose VBAC after discussion with her health care provider (HCP). Please read the following information carefully, discuss your concerns with your HCP, initial your choice, and sign this form in the area indicated below.

All mothers who have had one previous low transverse cesarean section are encouraged to attempt a vaginal delivery unless the physician indicates otherwise. VBAC is also a reasonable option if your previous records cannot be obtained and it is unlikely that you had a classical uterine incision. Successful, uncomplicated vaginal birth after cesarean section carries the lowest risk to both mother and baby as compared to repeat cesarean section. However, I understand that if I choose a VBAC and end up having cesarean during labor, I have a slightly greater risk of problems than if I had had a cesarean without labor. Not all women will be able to have a VBAC. the success rate for those attempting VBAC is about 75%.

The most serious complication of attempting a VBAC is uterine rupture, which occurs in about 1% of cases. In the case of uterine rupture, internal and /or external bleeding may occur and may require blood transfusions and/or hysterectomy. Rarely, fetal injury or death may also occur.

Elective repeat cesarean (the alternative to VBAC) also has some risks. Cesarean section is a major operation and in some case there can be injuries to the mother's bladder or bowel or other serious complications.

Patients who have had more than one cesarean will not be discouraged from attempting vaginal birth if they request. However, there may be a slightly increased risk of uterine rupture in this group.

I have read the above information and I understand it. I have discussed the alternatives with my HCP and I have received all the information I want.

___I want to attempt a VBAC ____I want a repeat cesarean

______________________ ________________________

Patient's signature Print patient's name

___________________ _________________________

Date Witnessed by

Appendix C Home Birth Criteria


HOME BIRTH SELECTION CRITERIA
Selection Criteria of Clients

Home birth clients are selected carefully according to specific criteria. The criteria, which are outlined below, have been established not only for initial acceptance but also for the entire prenatal period, labor, birth, and postpartum. If any of the criteria are not met appropriate consultation, plans, and referrals are made. When criteria for the birth in the home are not met the nurse-midwife will transfer the client for hospital delivery, or the consulting physician assumes direct responsibility for her care.

Potential clients must initially be self-selected. They must expressly request birth at home and give evidence of sufficient commitment. The risks and benefits of an out-of-hospital birth will be thoroughly discussed. If the client continues to desire out-of-hospital birth, this criterion of self-selection is met.

Clients must meet several medical and non-medical criteria in order to be accepted.

These include but are not limited to:


· Attend early pregnancy, prepared childbirth, classes or receive private instructions (unless classes have previously been taken by the pregnant woman and her birth partner).
· Agree to make required preparations at home including the selection of a responsible support person for any siblings that may be present at the birth, maps to the home and nearest hospital, and supplies ready.
· The mother will breast feed the newborn baby.
· The mother will work to achieve suitable nutritional requirements during the pregnancy.
· Be a non-smoker
· Locate a physician who will agree to see the newborn within 24 hours of a birth if necessary, otherwise within 2 weeks of the birth
· Agree to transfer of self and/or infant to a hospital if determined necessary by the attending midwife or the consulting physician..
· Assume financial responsibility for services rendered.

The history and physical examination, and laboratory results of clients requesting home birth must be within the normal limits which is defined as no evidence of the following:
Chronic hypertension

Epilepsy or seizure disorder

Evidence of sero-conversion to HIV

Severe psychiatric disease

Persistent anemia (Hgb <10.0 or Hct < 32) or blood dyscrasia

Diabetes

Heart disease

Kidney disease

Endocrinopathy

Multiple gestation

Substance abuse

Additionally, clients should be no younger than 18. Clients accepted for home birth should appear emotionally mature and stable. The physical and emotional environment of the client’s home or chosen birthplace should be conducive to having a home delivery as well.

Client and partner must both be comfortable with home birth. If either party is uncomfortable eligibility for home birth must be reconsidered. The midwife reserves the right to refuse home birth if there are medical, emotional, or social factors that she feels makes the family inappropriate for home birth.

Clients are encouraged to initiate care as early as possible. Clients transferring care from another provider must enter the practice before the 36th week. They must have documentation of care from a previous care provider immediately available and meet client selection criteria.

Appendix D Home Birth Informed Consent

I. The following conditions existing prior to the present pregnancy may necessitate referral to a physician for prenatal care and delivery.

high blood pressure

renal disease

emphysema

epilepsy or other seizure disorders

alcoholism or abuse

drug addiction or abuse

psychiatric disease

tuberculosis

previous Rh sensitization

chronic hypertensive disease

sickle cell anemia

uterine fibroids

obesity (more than 30% above normal weight)

history of severe pre-eclampsia or eclampsia

HIV

II. The following conditions developing during the present pregnancy may necessitate referral to a physician.

active genital herpes at time of labor

onset of labor less than 37 weeks, or more than 42 weeks, as determined by LMP and other supportive data

presentation other than cephalic at 37 weeks on

multiple gestation

bleeding in the third trimester

gestational diabetes demonstrated by abnormal GTT

preeclampsia

hypertension which persists

severe anemia (hemoglobin less than 10)

inappropriate uterine size for gestation

major emotional problems

III. The following conditions developing during labor may necessitate transfer to a hospital, and/or referral to a physician.

temperature > 100.4

symptoms of preeclampsia

cord prolapse

fetal distress as evidenced by abnormal heart rate pattern

thick meconium stained fluid

abnormal bleeding

abnormal labor pattern

altered hemodynamic status (signs of shock)

abnormal abdominal pain

IV. The following conditions developing during the immediate postpartum period may necessitate transfer to a hospital and/or referral to a physician.

uncontrolled hemorrhage

retained placenta

lacerations > second degree

infant with:

cardiac irregularities

weight less than 2500 grams (5 & 1/2 pounds)

congenital abnormalities

Apgar <7 at 5 minutes

prematurity, dysmaturity, or postmaturity

rectal temperature > 101 degrees Farenheit

any other problems requiring hospital care in the opinion of the attendants

I/We have read, discussed, and understand the above:

signed__________________________________________________________________________________________________

signed__________________________________________________________________________________________________

date ------------------------------------------------------

Appendix F Practice guidelines

To provide safe, holistic health care options for essentially healthy women and their newborns.

Choice of birth location (home, birth center, hospital) along with the choice of provider and type of care.

The woman seeking health care from the midwife. The client is further defined within the context of her immediate family (housemates), extended family, social, cultural, and spiritual community.

Also known as co-management. The process by which the midwife and physician design a mutually agreed upon plan of care. This plan may be implemented by the midwife. This does not necessarily imply the physical presence of the physician during caregiving.

The process by which the midwife seeks an opinion from the physician or other members of the health care system. The midwife retains independent management of the client.

The woman and / or newborn without an identifiable chronic or life-threatening pathological process.

Practice guidelines are based on the meta-analysis of scientific research, along with traditional time-honored (>50 years of use) alternative practices. Time-honored alternative practices must be consistently reported in the literature to show no known harmful effect.

The complete human experience including biological, emotional, psychological, social, and spiritual factors.

The process by which the client accepts or declines a test, treatment, alternative therapy, pharmaceutical, or surgical procedure. This process includes a thorough review of the community standards of practice, research evidence, alternative options, benefits, risks, and potential outcomes.

Cooperation and mutual respect between members of different health care disciplines, where each practitioner contributes his or her distinct area of expertise.

Midwife refers to certified nurse-midwives (CNM), as recognized by the state of Wisconsin. CNMs are educated in the two disciplines of nursing and midwifery, and have passed a national exam verifying expertise. The midwife is licensed to provide preconception counseling, care during pregnancy and childbirth, normal gynecological services, care of the peri/post-menopausal woman, and wellness education. CNMs in Wisconsin also hold full prescriptive authority.

The absence of chronic or life-threatening health conditions.

Practice guidelines outline the most likely course of action utilized in given circumstances. Each guideline is based on scientific research and time-tested modalities, individual client applicability, and informed consent. These practice guidelines are presented with the understanding that it is impossible to predict variability of client responses, as each pregnancy and birth are unique. Therefore, the midwife will apply practice guidelines based on suitability to the situation.

Physician refers to a licensed provider of medical care and may include medical doctors (MD), osteopaths (DO), general practitioners (GP), family practioners (FP), obstetricians (OB), gynecologists (GYN), perinatologists, and any other person legally recognized as a doctor by the state of Wisconsin.

The process by which the midwife sends a client to another provider for the assessment, evaluation and / or specialized care of a specific concern. The midwife may or may not continue to provide primary care of the client.

The process by which the midwife ceases her role as provider of a client’s health care, while assisting the client to obtain health care with another provider. The midwife will maintain continuity of care by providing a copy of the client records (contingent on client written consent), and by offering continued support and education to the client.

Any woman who begins care in the first trimester and meets screening criteria.

A woman who begins care in the second trimester and meets screening criteria. After 22 weeks, the woman seeking home birth must also provide records of at least one prenatal visit with another care provider. These records must include baseline weight, vital signs, and standard labwork.

A woman, no further in pregnancy than 36 weeks, will be accepted in the third trimester only if she has received regular prenatal care with a licensed care provider. Copies of the original prenatal records must be available. Ideally, the woman will meet with the midwife at least four times prior to the birth.

The home birth location will be no further than a thirty minute drive from a hospital that includes obstetrical services AND cesarean capability. Upon onset of active labor, the hospital and consulting physician will be notified of the impending birth.

E. Selection Criteria of Clients

Potential clients are initially self-selected. Home birth clients are screened carefully according to the criteria outlined below, which have been established not only for initial acceptance but also for the entire prenatal period, labor, birth, and postpartum.

Clients must expressly request birth at home and give evidence of sufficient commitment. The risks and benefits of an out-of-hospital birth will be thoroughly discussed initially (and during the course of care as preparation for a potential transport). If the client continues to desire out-of-hospital birth, this criterion of self-selection is met .

Clients must meet several medical and non-medical criterion in order to be accepted.

These include but are not limited to:

· Attend early pregnancy, prepared childbirth classes or receive private instructions (unless the pregnant woman and her birth partner have previously taken classes).
· Agree to make required preparations at home including the selection of a responsible support person for any siblings that may be present at the birth and has made maps to the home and nearest hospital.
· The mother will breast feed the newborn baby.
· The mother will work to achieve suitable nutritional requirements during the pregnancy.
· Be a non-smoker
· Locate a physician who will agree to see the newborn within 24 hours of a birth if necessary, otherwise within 2 weeks of the birth
· Agree to transfer of self and/or infant to a hospital if determined necessary by the attending midwife or the consulting physician.
· Assume financial responsibility for services rendered.

The history and physical examination, and laboratory results of clients requesting home birth must be within the normal limits which is defined as no evidence of the following:
Chronic hypertension

Epilepsy or seizure disorder

Evidence of sero-conversion to HIV

Severe psychiatric disease

Persistent anemia (Hgb <10.0 or Hct < 32) or blood dyscrasia

Diabetes

Heart disease

Kidney disease

Endocrinopathy

Multiple gestation

Substance abuse

Additionally, clients should be no younger than 18. Clients accepted for home birth should appear emotionally mature and stable. The physical and emotional environment of the client’s home or chosen birthplace should be conducive to having a home delivery as well.

Client and partner must both be comfortable with home birth. If either party is uncomfortable eligibility for home birth must be reconsidered. The midwife reserves the right to refuse home birth if there are medical, emotional, or social factors that she feels makes the family inappropriate for home birth.

Clients are encouraged to initiate care as early as possible. Clients transferring care from another provider must enter the practice before the 36th week. They must have documentation of care from a previous care provider immediately available and meet client selection criteria.

At the first prenatal visit, the midwife completes the following:

Discusses the following with client:

a. Alternative option: Fasting BS and one-hour postprandial screen.

Policies and Guidelines

Midwifery management

Midwifery management of clients includes observation, assessment and treatment of clients according to standard practices. Implementation of selected approaches as deemed appropriate by the midwife is used to establish a diagnosis and a treatment plan when a deviation from normal occurs. Should deviations occur, the designated physician shall be consulted as necessary. The patient may remain under midwifery care, co-managed by midwife and physician or transferred to medical management as deemed appropriate by the midwife and physician.

Care by the midwife includes normal gynecologic care, primary care, pre-conceptual counseling, pregnancy and childbirth, and care of the newborn.

Episodic Medical Management

During the course of pregnancy situations may arise that require medical care and/or hospitalization of the client. If the condition requiring this care is limited and subsequently resolves the midwife may resume care of the client.

Physician/Midwife Co-management

Consultation should occur with patients that have or develop the following conditions during the course of their pregnancy and co-management considered:

I. Hypertension
a) pregnancy induced
b) chronic
II. Vaginal bleeding
a) placenta previa
b) unknown etiology
III. Chronic Systemic Disease
a) Hyper/hypothyroid
b) gestational diabetes
c) unstable asthma
IV. Conditions Related to Pregnancy
a) preterm labor prior to 36 weeks gestation
b) gestational diabetes requiring insulin
The above list is an adjunct to good clinical judgment and is not an inclusive list.

I. Antepartum
A. Clients are encouraged to initiate care as early as possible. Clients transferring care from another provider must enter the practice before the 36th week. They must have documentation of care from a previous care provider immediately available and meet client selection criteria.

1. Initial evaluation offered include:

a. Complete health history

b. Complete physical exam
c. Nutritional evaluation
d. Laboratory tests as appropriate
e. Routine antepartum visits are every 4 weeks to 28 weeks, then every 2 weeks until 36 weeks, then every week thereafter or more often at the discretion of the midwife. B/P, weight, dipstick UA, abdominal inspection, palpation (Leopolds), measurement of fundal height, and auscultation of FHT’s will be accomplished at every visit as well as careful screening of interim history, additional lab evaluation when necessary, and follow-up of presenting problems as indicated.

B. VBAC
The American College of Nurse-Midwives strongly supports the concept of vaginal birth after a previous cesarean delivery for appropriately selected women. Research demonstrates that VBAC results in significantly fewer risks for women and infants than repeat cesarean delivery. With appropriate arrangements for medical consultation and emergency care in place, midwives are qualified to manage care during labor and vaginal birth for a woman planning a VBAC.

Eligibility Criteria for Vaginal Birth After Cesarean

1. The client meets all previously stated home birth criteria.
2. The client’s operative report from previous cesarean section must indicate low-transverse uterine incision. If possible obtain documentation of closure type.
3. Consider 3rd trimester US to determine placental placement.
4. The client must have had an uncomplicated post-op course.
5. The client ideally should be within 30 minutes of a hospital with 24 hour availability of OR/anesthesia.
6. Arrangements for consultation and transport for emergency care in place.
7. If induction or augmentation becomes necessary, home birth is no longer an option.
8. Evidence of signed informed consent for VBAC.
II. Intrapartum
As agreed upon when accepted as a client for home birth, the client assumed several specific responsibilities to prepare for the birth of her baby outside of the hospital. This include having all necessary supplies available, has selected a care provider for the baby, has made maps to the home and nearest hospital and has taken approved childbirth preparation classes. The midwife team makes a home visit at 36 weeks to assess the arrangements made by the client and the preparedness of the physical environment for the birth.

Once labor begins, the midwife will only consult with the physician as deemed necessary.


A. Initial evaluation upon arrival
1. Review prenatal course and history as needed
2. Evaluate labor by performing vaginal exams as needed.
3. Perform physical assessment as needed.
B. Labor - First Stage
1. FHT auscultation as follows:
a. first stage every 15 - 30 minutes or more often if indicated

b. second stage every 5 - 15 minutes or more often if indicated

2. Client may eat or drink as desires. Electrolyte fluids will be encouraged.
3. Monitoring of labor status:
1. abdominal palpation of contractions for strength, length, and frequency as needed.
2. observation of client response to contractions.
3. sterile vaginal exams as needed.
4. Vital signs
5. amniotomy as indicated.
Risk criteria will continue to be applied. The physician will be consulted and transfer to the hospital considered for any of the following conditions but not limited to:
Abnormal bleeding during labor

Dysfunctional labor

Abnormal abdominal pain (sign of placental asbruption and/or uterine rupture)

Altered hemodynamic status (signs of impending shock)

Fetal heart irregularities

Elevation of temperature > 101. F

Thick, particulate meconium in amniotic fluid

Evidence of severe pre-eclampsia

Prolapsed cord

Abnormal lie

Wishes of the client
C. Labor - Second stage
1. The following may be performed as indicted:
a. assist vaginal birth

b. midline or mediolateral episiotomy and repair

c. repair of first and second degree perineal and vaginal lacerations and episiotomy

d. infiltration of perineum with local anesthetic (see treatment guidelines)

D. Labor - Third Stage
1. Delivery of the placenta
a. manual removal of the placenta (only in the presence of hemorrhage)

b. manual exploration of the uterus (only in the presence of hemorrhage)

2. medications: see treatment guidelines
3. catheterization as indicated
4. vital signs
5. If any of the following should occur, medical consultation is required and/or transfer of mother to a hospital:
a. uncontrolled hemorrhage

b. retained products of conception

c. extensive lacerations:
· third or fourth degree
· cervical

III. The Newborn Management

A.Immediate Newborn Procedures
1. thermoregulation
2. vital signs
3. apgar score
4. obtain cord blood sample in the case of RH (-) mother.
5. opthalmic ointment administered
6. aquamephyton
7. resuscitative measures as indicated

IV. Postpartum - Newborn
A. Continue management of stable thermoregulation and vital signs
B. Facilitate infant - family bonding
C. Facilitate initiation of breast feeding
D. Complete newborn exam
1. Neonatal factors requiring consult or transfer in the immediate postpartum period include but are not limited to:
a) persistent hypothermia
b) temperature >101.0 rectally
c) respiratory difficulties
d) cardiac irregularities
e) congenital abnormalities
f) apgar score less than 7 at 5 minutes
g) weight less than 2500 gm
V. Postpartum
In the immediate postpartum period, the midwife or designated assistant stays with the mother and infant until vital signs are normal and the baby demonstrates normal adaptation--a minimum of two hours. The mother and newborn must have a family member or friend in constant attendance for the first 24 hours

Postpartum instructions including newborn assessment are given to each client. Home visits or phone calls on any or all days 1 through 12 may be made as deemed necessary by the midwife or her assistants. The infant should be seen by the designated care-provider according to prior arrangement or within 24 hours if deemed necessary by the midwife or by 2 weeks of life. The midwife sees the mother and baby at 6 weeks postpartum. Family planning services are available at that time. The midwife will complete and sign the birth certificate and insurance forms in the week following the birth.