Memorandum of Understanding between SECMs and the HSE for the provision of home birth services under the National Home Birth Service in Ireland.
Appendix 1.
MEDICAL CONDITIONS AND OTHER FACTORS REQUIRING PLANNED BIRTH IN AN OBSTETRIC UNIT
Table 1: Medical conditions requiring planned birth at an obstetric unit
| Disease area | Medical condition |
| Cardiovascular | Confirmed cardiac disease |
| Hypertensive disorders | |
| Respiratory | Asthma requiring an increase in treatment or hospital treatment or requiring steroid treatment in last year |
| Cystic fibrosis | |
| Haematological | Haemoglobinopathies – sickle-cell disease, beta-thalassaemia major |
| History of thromboembolic disorders | |
| Immune thrombocytopenia purpura or other platelet disorder or platelet count below 100 000 | |
| Von Willebrand’s disease | |
| Bleeding disorder in the woman or unborn baby | |
| Atypical antibodies which carry a risk of haemolytic disease of the newborn | |
| Infective | Risk factors associated with group B streptococcus whereby antibiotics in labour would be recommended |
| Infective Hepatitis B or Hepatitis C | |
| Carrier of/infected with HIV | |
| Toxoplasmosis – women receiving treatment | |
| Current active infection of chicken pox/rubella/genital herpes in the woman or baby | |
| Tuberculosis under treatment | |
| Immune | Scleroderma |
| Systemic lupus erythematosus | |
| Endocrine | Diabetes |
| Maternal thyrotoxicosis | |
| Renal | Abnormal renal function |
| Renal disease requiring supervision by a renal specialist | |
| Neurological | Epilepsy |
| Myasthenia gravis | |
| Previous cerebrovascular accident | |
| Gastrointestinal | Liver disease associated with current abnormal liver function tests |
| Psychiatric | Psychiatric disorder requiring current in-hospital care and / or requiring specialist care. |
Table 2: Other factors requiring planned birth at an obstetric unit
| Factor | Additional information |
| Previous pregnancy complications | Unexplained stillbirth/neonatal death or previous death related to intrapartum difficulty [to be discussed with neonataologists] |
| Previous baby with neonatal encephalopathy | |
| Pre-eclampsia requiring preterm birth | |
| Placental abruption with adverse outcome | |
| Eclampsia | |
| Uterine rupture | |
| Primary postpartum haemorrhage requiring additional pharmacological treatment or blood transfusion | |
| Caesarean section | |
| Shoulder dystocia | |
| Current pregnancy | Multiple birth |
| Placenta praevia | |
| Pre-eclampsia or pregnancy-induced hypertension | |
| Post-term pregnancy [ For medical review by 42 weeks] | |
| Preterm labour< 37 +0 | |
| Preterm pre-labour rupture of membranes | |
| Term pregnancy (37+0 to 42+0) pre-labour rupture of membranes for more than 24hrs | |
| Placental abruption | |
| Anaemia – haemoglobin less than 10g/dl at onset of labour | |
| Confirmed intrauterine death | |
| Induction of labour | |
| Substance misuse | |
| Alcohol dependency requiring assessment or treatment | |
| Onset of gestational diabetes | |
| Malpresentation – breech or transverse lie | |
| Recurrent antepartum haemorrhage | |
| Fetal indications | Small for gestational age in this pregnancy (less than 5th centile or reduced growth velocity on ultrasound) |
| Abnormal fetal heart rate (FHR)/Doppler studies | |
| Ultrasound diagnosis of oligo/polyhydramnios | |
| Previous gynaecological history | Myomectomy |
| Hysterotomy |
OTHER NON-CLINICAL FACTORS TO BE CONSIDERED IN THE ASSESSMENT OF THE HOME BIRTH APPLICATION BY THE DESIGNATED OFFICER IN CONSULTATION WITH THE SELF EMPLOYED COMMUNITY MIDWIFE
These may include, for example:
- lack of a family / peer support network;
- inadequate facilities at home;
- distance from the midwife or nearest hospital maternity unit
MEDICAL CONDITIONS AND OTHER FACTORS REQUIRING REFERRAL TO CONSULTANT OBSTETRICIAN BY THE MIDWIFE FOR FINAL ASSESSMENT WHEN PLANNING PLACE OF BIRTH
Table 3: Medical conditions requiring assessment by consultant obstetrician when planning place of birth
| Disease area | Medical condition |
| Cardiovascular | Cardiac disease without intrapartum implications |
| Haematological | Atypical antibodies not putting the baby at risk of haemolytic disease |
| Sickle-cell trait | |
| Thalassaemia trait | |
| Immune | Nonspecific connective tissue disorders |
| Endocrine |
|
| Skeletal/neurological | Spinal abnormalities |
| Previous fractured pelvis | |
| Neurological deficits | |
| Gastrointestinal | Liver disease without current abnormal liver function |
| Crohn’s disease | |
| Ulcerative colitis |
Table 4: Other factors requiring assessment by consultant obstetrician when planning place of birth
| Factor | Additional information |
| Previous complications | Stillbirth/neonatal death with a known non-recurrent cause |
| Pre-eclampsia developing at term | |
| Placental abruption with good outcome | |
| History of previous baby more than 4.5 kg | |
| Extensive vaginal, cervical, or third- or fourth-degree perineal trauma | |
| Previous term baby with jaundice requiring exchange transfusion | |
| Retained placenta requiring manual removal in theatre | |
| Current pregnancy | Antepartum bleeding of unknown origin (single episode after 24 weeks of gestation) |
| Body mass index at booking of ≥ 35 or < 18 kg/m² | |
| Blood pressure of 140 mmHg systolic or 90 mmHg diastolic on two occasions | |
| Clinical or ultrasound suspicion of macrosomia | |
| Para 6 or more | |
| Recreational drug use | |
| Under current outpatient psychiatric care | |
| Age over 40 at booking | |
| Fetal indications | Fetal abnormality |
| Previous gynaecological history | Major gynaecological surgery |
| Cone biopsy or large loop excision of the transformation zone | |
| FibroidsFemale circumcision |
Table 5 Indications for intrapartum transfer
| Spontaneous rupture of membranes > 24 hours |
| Indications for electronic fetal monitoring (EFM) including abnormalities of the fetal heart rate (FHR) on intermittent auscultation |
| Delay in the first or second stages of labour |
| Meconium stained liquor |
| Maternal request for epidural pain relief |
| Obstetric emergency – antepartum haemorrhage, cord presentation/prolapse, postpartum haemorrhage, maternal collapse or a need for advanced neonatal resuscitation |
| Retained placenta |
| Maternal pyrexia in labour (38.0 °C on one occasions or 37.5 °C on two occasions 2 hours apart) |
| Malpresentation or breech presentation diagnosed for the first time at the onset of labour, taking into account imminence of birth |
| Either raised diastolic blood pressure (over 90 mmHg) or raised systolic blood pressure (over 140 mmHg) on two consecutive readings taken 30 minutes apart |
| Uncertainty about the presence of a fetal heartbeat |
| Third or fourth degree tear or other complicated perineal trauma requiring suturing |
Table 6 Indications for Postpartum transfer
| Mother: | Postpartum haemorrhage (>500mls) or any amount that causes the mothers condition to deteriorate |
| Pyrexia(38.0 °C on one occasions or 37.5 °C on two occasions 2 hours apart) | |
| Concerns for psychological wellbeing | |
| Signs of thromboembolic disease | |
| Infant | Congenital or genetic abnormality |
| Respiratory symptoms – tachypnoea (RR>60/minute), grunting, recession | |
| Cyanosis, plethora, pallor | |
| Bile-stained vomiting, persistent vomiting or abdominal distensionDelay in passing urine or meconium >24 hours | |
| Fits, jitteriness, abnormal lethargy, floppiness, high pitched cry | |
| Jaundice <24 hours |