considerations on choice of place of planned birth

Last edited 10/2023 and last reviewed 10/2023

Guidance on considerations on choice of place of planned birth

NICE have stated guidance as to considerations as to place of planned birth (1)

Medical conditions indicating increased risk and suggesting planned birth at an obstetric unit are stated as:

Disease area Medical condition
Cardiovascular

  • Confirmed cardiac disease

  • Hypertensive disorders
Respiratory

  • Asthma requiring an increase in treatment or hospital treatment

  • Cystic fibrosis

Haematological

  • Haemoglobinopathies, such as sickle-cell disease, beta-thalassaemia major

  • History of thromboembolic disorders

  • Immune thrombocytopenia purpura or other platelet disorder or platelet count below 100×109/litre

  • Von Willebrand's disease

  • Bleeding disorder in the woman or unborn baby

  • Atypical antibodies which carry a risk of haemolytic disease of the newborn
Endocrine

  • Hyperthyroidism

  • Diabetes needing medication
Infective

  • Hepatitis B or C with abnormal liver function tests

  • Toxoplasmosis - women receiving treatment

  • Current active infection of chicken pox, rubella or genital herpes in the woman or baby

  • Tuberculosis under treatment
Immune

  • Systemic lupus erythematosus

  • Scleroderma
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 inpatient care

Other factors indicating increased risk and suggesting planned birth at an obstetric unit are stated as:

Factor Additional information
Previous complications

  • Unexplained stillbirth or neonatal death, or previous death related to intrapartum difficulty

  • Previous baby with neonatal encephalopathy

  • Pre-eclampsia requiring preterm birth

  • Placental abruption with adverse outcome

  • Eclampsia

  • Uterine rupture

  • Primary postpartum haemorrhage requiring additional treatment or blood transfusion

  • Caesarean birth

  • Shoulder dystocia
Current pregnancy

  • Multiple birth

  • Placenta praevia

  • Pre-eclampsia or pregnancy-induced hypertension

  • Preterm labour or preterm prelabour rupture of membranes

  • Placental abruption

  • Anaemia – haemoglobin less than 85 g/litre at onset of labour

  • Confirmed intrauterine death

  • Substance misuse

  • Alcohol dependency requiring assessment or treatment

  • Gestational diabetes needing medication

  • Malpresentation – breech or transverse lie

  • Recurrent antepartum haemorrhage

  • Small for gestational age in this pregnancy (less than third centile or reduced growth velocity on ultrasound as defined in the NHS Saving babies lives version 3)

  • Abnormal fetal heart rate, umbilical or fetal doppler studies

  • Ultrasound diagnosis of oligo- or polyhydramnios
Previous gynaecological history

  • Myomectomy

  • Hysterotomy


Medical conditions indicating individual assessment is needed when planning place of birth are stated as:

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

  • Anaemia - haemoglobin 85 to 105 g/litre at onset of labour
Endocrine Unstable hypothyroidism such that a change in treatment is needed
Infective

  • Group B streptococcus where intrapartum intravenous antibiotics are recommended

  • Hepatitis B or C with normal liver function tests (as baby will need paediatric review after birth)

  • Carrier of or infected with HIV
Immune Non-specific connective tissue disorders
Skeletal/NeurologicaL

  • Spinal abnormalities

  • Previous fractured pelvis

  • Neurological deficits
Gastrointestinal

  • Liver disease without current abnormal liver function

  • Crohn's disease

  • Ulcerative colitis

Other factors to take into account when planning place of birth are stated as:

Factor Additional information
Previous complications

  • Stillbirth or 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

  • Retained placenta needing manual removal in theatre

  • Previous term baby with jaundice requiring exchange transfusion

  • Major gynaecological surgery
Current pregnancy

  • Antepartum bleeding of unknown origin (single episode after 24 weeks of pregnancy)

  • Body mass index (BMI) at booking
    • advise women that, in general, the higher their body mass index (BMI) at booking (and particularly with a BMI above 35 kg/m2), the greater the likelihood of complications, so this may be something they wish to think about when planning their place of birth. Discuss with them that:
      • these complications include unplanned caesarean birth, postpartum haemorrhage, transfer from home to an obstetric unit, stillbirth, neonatal death or the baby needing neonatal care
      • the risk of complications may depend on whether the woman is nulliparous or multiparous, but in general the risks of complications are higher for nulliparous women with an increased BMI compared with multiparous women with an increased BMI
      • in the event of complications arising, advanced care can generally be given more quickly in an obstetric unit or an alongside midwifery unit than at home or in a freestanding midwifery unit
  • Blood pressure of 140 mmHg systolic or 90 mmHg diastolic or more on 2 occasions
  • Clinical or ultrasound suspicion of macrosomia
  • Induction of labour
  • Grand multiparity (parity 4 or more)
  • Recreational drug use
  • Under current outpatient psychiatric care
  • Age 40 or over at booking

  • Fibroids

  • Fetal abnormality

for detailed guidance then see full guideline (1).

A review concluded that (2)

  • birthplace choice is informed by many factors
  • women may encounter fewer overt obstacles to exercising choice than in the past, but women do not consistently receive information about birthplace options from their midwife at a time and in a manner that they find helpful
  • introducing options early in pregnancy, but deferring decision-making about birthplace until a woman has had time to consider and explore options and discuss these with her midwife, might facilitate choice

Reference:

  • NICE (September 2023). Intrapartum care
  • Hinton L, Dumelow C, Rowe R, Hollowell J. Birthplace choices: what are the information needs of women when choosing where to give birth in England? A qualitative study using online and face to face focus groups. BMC Pregnancy Childbirth. 2018 Jan 8;18(1):12.

Related pages:

pregnancy