INFORMATION FOR CANDIDATE:

Your next patient in general practice is a 25 y old

Mrs. Julie Grant who is 34 weeks pregnant and would
like to get your advice about home birth. She had read
an article in the womens weekly where quite a few
women talked about their positive experiences with
home birth and she is quite keen on the idea and so
his her husband.
YOUR TASK IS TO:
Take a history
Perform an examination
Explain home birth
Answer the patients and examiners questions

HOPC: Mrs. Julie Gran is 34 weeks pregnant and would like to get your advice about
home birth. She had read an article in the womens weekly where quite a few women
talked about their positive experiences with home birth and she is quite keen on the idea
and so his her husband. It is her first pregnancy and has been uncomplicated with normal
antenatal visits including an U/S at 18 weeks and a normal GCT. Julie would like to know
if home delivery is safe, what you, the GP think about it, if there are any risks and what
needs to be done if anything goes wrong and if she then might need a caesarean section.
Gyn. Hx.: menarche age 14, regular periods, has been on OCP for 4 years until 8 months
ago, no STDs, no problems.
PHx. + FHx.: unremarkable
SHx: married shop assistant, no stresses, non smoker, no alcohol, NKA, no medication.
EXAMINATION: well looking woman, P 72, regular, BP 120/60, RR 167, SaO2 98% on
RA, afebrile.
No pathological findings on physical examination, obstetric examination normal (normal
fundal height and fetal heart rate, cephalic presentation, left lateral position) .
INVESTIGATIONS:
Urine ward test NAD
DIAGNOSIS: request for home delivery
The Royal Australian and New Zealand College of Obstetricians and Gynaecologists
(RANZCOG) does not endorse planned homebirth due to its inherent risks and the ready
availability of safer options for labour and delivery in Australia and New Zealand. Where
a woman chooses to pursue planned homebirth, it is important that reasons for this are
explored and that her decision represents an informed choice, considering all the possible
benefits and potential adverse maternal and perinatal outcomes.
Australia is a geographically diverse country and has a poorly developed infrastructure for
planned homebirth. The geography does not suit itself to obstetric flying squads that
are readily available to retrieve mothers from home when problems have arisen during
labour and birth. Australia has the dual problems of vast distances in rural settings, and
heavy city traffic in Melbourne and Sydney. Evidence is that approximately 12 to 43% of
those identified as low risk in pregnancy will develop a complication necessitating
transfer to care in a conventional birth suite setting. In many locations in Australia this
cannot be accomplished expeditiously.
Therefore in Australia the patient should be advised that home delivery is not
recommended due to the risk to mother and baby before, during and after delivery,
especially in a primagravida.
However there seems to an increasing debate and many midwives claim that available
evidence confirms that for low-risk women, a planned home birth with trained
attendants is a safe and viable option.

Unpredictable complications are:

Foetal distress
Intra-partum or post-partum haemorrhage
shoulder dystocia
obstructed labour
meconium aspiration
abruption
cord prolapsed
Such complications can require the immediate resources in the hospital setting with all
medical staff and appropriate equipment available.
Most hospitals offer reasonable alternatives to home birth and a patient should be
encouraged to visit such a centre, ideally with her partner:
Collaborative Model of Care
Collaborative care between midwives and obstetricians (specialist or GP) in a hospital
setting is considered the best model of maternity care. This model provides the
opportunity for close surveillance of mother and baby during labour and the
implementation of appropriate and timely interventions if problems arise. In the absence
of complications, minimal intervention is required.
Alternative Birth Centres and Low Intervention Models of Care
It seems likely that birth in a home-like / family birthing suite setting with close
proximity to hospital care can achieve some of the aesthetic appeal of planned homebirth
but with reduced exposure to risk.
If a patient decides on a home birth, the following points need to be considered:
distance to the next maternity hospital
availability of transport
a back-up plan for the patient
there should be a singleton cephalic fetus at term
abscence of co-existing potentially serious medical conditions like cardiac or renal
diseases, coagulopathy, diabetes etc.
Abscence of serious obstetrical conditions like preeclampsia or antepartum
bleeding
No previous caesarean section
Abscence of contraindications to vaginal birth like placenta praevia, active genital
herpes
Spontaneous labour