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Decision-Making About Birth Setting Should Reflect Current Evidence, Including Contraindications, Say ACOG Guidelines

July 25, 2016

Washington, DC – Women considering a planned home birth for their delivery should be medically informed about the risks and benefits associated with their decisions, says a newly revised Committee Opinion from the American College of Obstetricians and Gynecologists (ACOG). Specifically, women and their health care providers should know that although planned home birth is associated with fewer maternal interventions, it is also associated with a more than twofold increased perinatal death and a threefold increased risk of neonatal seizures or serious neurologic dysfunction.

Because of this, ACOG continues to believe that although each woman has the right to make a medically informed decision about her delivery, hospitals and accredited birth centers are the safest setting for each birth. The new revision also presents an expanded list of absolute contraindications for home birth, which now include fetal malpresentation, multiple gestation, and prior cesarean delivery.

In the Committee Opinion, ACOG also reemphasizes its position from its 2015 Obstetric Care Consensus on Levels of Maternal Care that trial of labor after cesarean delivery should be undertaken in facilities with appropriate staff and the ability to begin an emergency cesarean delivery within a time interval that best incorporates maternal and fetal risks and benefits with the provision of emergency care.

While ACOG has noted since 2011 that planned home birth offers carries increased risk, the new Committee Opinion reflects updated evidence. For example, a recent U.S. study found that although the absolute risk associated with childbirth in the hospital, birth center, and home setting remains low, the rate of perinatal death was higher in the planned home setting.

“Obstetrician-gynecologists recognize that women are seeking home births for a variety of reasons. Our goal is to help them understand and balance the benefits with the risks by providing information to help them come to a medically informed decision,” said Joseph R. Wax, MD, a primary author of the opinion.

Moreover, ob-gyns should be prepared to counsel women regarding the potential risks associated with planned home birth, even for uncomplicated pregnancies. For example, safe and timely transfer of the laboring patient is a key factor that influences the safety of planned home birth, with up to 23 to 37 percent of women delivering their first child needing transport to an obstetric facility because of lack of progress in labor, nonreassuring fetal status, need for pain relief, hypertension, bleeding, and fetal malposition.

The Committee Opinion also addresses studies that have reported relatively low perinatal and newborn mortality rates for planned home birth. Ob-gyns can help their patients to understand that many of these data are from areas outside the United States with highly integrated health care systems and established criteria and provisions for emergency intrapartum transport. While ACOG and other peer organizations are working to better integrate and regionalize maternal care, these data may not be generalizable to the United States.

“Although serious complications are rare, they may be serious and unpredictable,” said Dr. Wax. “It’s important for women to be able to choose the birth setting that is right for them. As part of this decision making, women should be aware of the contraindications to home birth as well as factors associated with reduced perinatal mortality.”

Specifically, women should have ready access to consultation throughout prenatal care and should be informed that provider type is important: women who desire home birth should seek a certified nurse-midwife, certified midwife, or a midwife whose education and licensure meet International Confederation of Midwives Global Standards, or a physician practicing obstetrics within an integrated and regulated health system.

Committee Opinion Number 669, “Planned Home Birth,” replaces Committee Opinion Number 476.

For more information, visit www.acog.org/More-Info/Planned HomeBirth.

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Other recommendations issued in the August Obstetrics & Gynecology:

 

Committee Opinion #668, Menstrual Manipulation for Adolescents With Physical and Developmental Disabilities

For an adolescent with physical disabilities, intellectual disabilities, or both, and for her caregivers, menstruation can present significant challenges. If, after an evaluation, the adolescent, her family, and the obstetrician–gynecologist have decided that menstrual intervention is warranted, advantages and disadvantages of hormonal methods should be reviewed and individualized to each patient’s specific needs. Complete amenorrhea may be difficult to achieve, and realistic expectations should be addressed with the patient and her caregivers. The goal in menstrual manipulation should be optimal suppression, which means a reduction in the amount and total days of menstrual flow. Menstrual suppression before menarche and endometrial ablation are not recommended as treatments. Optimal gynecologic health care for adolescents with disabilities is comprehensive; maintains confidentiality; is an act of dignity and respect toward the patient; maximizes the patient’s autonomy; avoids harm; and assesses and addresses the patient’s knowledge of puberty, menstruation, sexuality, safety, and consent.

Committee Opinion #670, Immediate Postpartum Long-Acting Reversible Contraception

Immediate postpartum long-acting reversible contraception (LARC) has the potential to reduce

unintended and short-interval pregnancy. Women should be counseled about all forms of postpartum contraception in a context that allows informed decision making. Immediate postpartum LARC should be offered as an effective option for postpartum contraception; there are few contraindications to postpartum intrauterine devices and implants. Obstetrician–gynecologists and other obstetric care providers should discuss LARC during the antepartum period and counsel all pregnant women about options for immediate postpartum initiation. Education and institutional protocols are needed to raise clinician awareness and to improve access to immediate postpartum LARC insertion. Obstetrician–gynecologists and other obstetric care providers should incorporate immediate postpartum LARC into their practices, counsel women appropriately about advantages and risks, and advocate for institutional and payment policy changes to support provision.

Technology Assessment #12, Sonohysterography

The primary goal of sonohysterography is to visualize the endometrial cavity in more detail than is possible with routine transvaginal ultrasonography. Sonohysterography also can be used to assess tubal patency. The indications for sonohysterography include, but are not limited to, evaluation of the following: abnormal uterine bleeding; uterine cavity, especially with regard to uterine leiomyomata, polyps, and synechiae; abnormalities detected on transvaginal ultrasonography, including focal or diffuse endometrial or intracavitary abnormalities; congenital abnormalities of the uterus; infertility; recurrent pregnancy loss; and suboptimal visualization of the endometrium on transvaginal ultrasonography. Sonohysterography should not be performed in a woman who is pregnant or who could be pregnant. Credentialing obstetrician–gynecologists to perform or supervise diagnostic sonohysterography should be based on education, training, experience, and demonstrated competence in performing and interpreting transvaginal ultrasonography and sonohysterography. The obstetrician–gynecologist should be skilled in the transcervical placement of catheters. The sonohysterography procedure, including benefits and risks, should be explained fully to the patient before the procedure is performed.

The American College of Obstetricians and Gynecologists (The College), a 501(c)(3) organization, is the nation’s leading group of physicians providing health care for women. As a private, voluntary, nonprofit membership organization of more than 57,000 members, The College strongly advocates for quality health care for women, maintains the highest standards of clinical practice and continuing education of its members, promotes patient education, and increases awareness among its members and the public of the changing issues facing women’s health care. The American Congress of Obstetricians and Gynecologists (ACOG), a 501(c)(6) organization, is its companion organization. www.acog.org

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