Memorandum of Understanding for Home Birth Midwives working with the National Home Birth Scheme

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:

  1. lack of a family / peer support network;
  2. inadequate facilities at home;
  3. 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
  • Hyperthyroidism
  • Unstable hypothyroidism such that a change in treatment is required
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