Friday, May 18, 2012

Ask a Midwife: "Risk Out" Criteria

What are some "risk out" criteria for home birth? In other words, what are some things that might make a woman (and her midwife) change her mind about pursuing an out-of-hospital birth? -- Grand Rapids mom

As a provider (nurse-midwife) attending home births, one of the biggest challenges I am presented with is informing a woman that she is not (or is no longer) a candidate for a home birth. Why is this a challenge? Because it will disappoint her. One of the “myths” surrounding the natural childbirth community is the idea that having a labor/birth at home is a choice for all healthy women. However, there is often a difference between being “healthy” and meeting a medical criteria for a home birth that will optimize outcome for both mom and fetus/ baby.

A woman can be “healthy” (or have a self-perception of health) and still have a medical/ emotional diagnosis that risks her out of having a home birth. An example would be a woman with a history of seizures, even if the history were a remote one. She would still risk out of having a home birth. Another example would be a mom with a history of having insulin-dependant gestational diabetes with her previous pregnancy. She may be “diabetes-free” currently but her HISTORY of having the insulin-dependent GDM risks her out. Other factors are fetal-related as opposed to maternal-related issues. Malpresentation is the most common fetal related risk factor for a home birth, with breech presentation being the most prevalent at a rate of 2-3% of pregnancies.

The following is a list of common risk factors that "risk out" a woman from having a home birth in a responsible home birth practice. It is not an exhaustive list but includes many of the issues we have come across while interviewing clients and managing pregnancies within our practice. Many times we will co-manage gals that “risk out” of a home birth with their physician(s) and will provide continuity of care for them in the postpartum period as well as be present for them during the hospital labor/birth. Here is the list:

Noncompliance with visits, scheduled screenings, testing during pregnancy
History of previous cesarean section
Current/History of seizure disorder
Current diabetes (and history of Insulin Dependent Gestational Diabetes)
Current fetal malpresentation (breech, transverse lie)
Placenta Previa or Marginal Previa
Current drug and tobacco use
Current alcohol dependence
Current mental illness that involves thoughts of harming self or others
Home that is greater than 30 minutes from a hospital or paramedic station
Home that does not have running water, heat and electricity
Pre-eclampsia during pregnancy
Insulin-Dependent diabetes during pregnancy
Fetal anomaly detected during pregnancy that may compromise neonate if born at home (cardiac anomaly, cleft palate, gastroschisis, ect).
Pregnancy before 37 weeks
Pregnancy after 43 weeks (we require antenatal testing at 41 weeks weekly and if, at 42 weeks, mom wishes to continue plans for a homebirth, she is counseled on increased risk of meconium and the fact that we will no longer manage birth at home once meconium in noted.)
Poor support system in place for days after the birth
History of postpartum psychosis
Multiple gestations (twins, etc.)
Fetal demise during pregnancy

The article links below are pertinent to this topic. Please keep in mind that the Committee Opinion from ACOG (American Congress of Obstetricians and Gynecologists) does not reflect the difference between planned home births attended by CNMs and “other midwives”. Unfortunately we are all lumped in together, which is very disappointing since it is clear that Certified Nurse Midwives (CNMs) have the LOWEST neonatal mortality and morbidity rates of ALL providers both in the planned home birth and planned hospital birth settings.

Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician. CMAJ (Canadian Medical Association Journal) September 15, 2009 vol. 181 no. 6-7.  

Planned home birth. Committee Opinion No. 476. American College of Obstetricians and Gynecologists. Obstet Gynecol 2011;117:425–8 

"Ask a midwife" is a write-in series here on the blog. If you have a question for our Certified Nurse Midwife, please share it with us here.


  1. Curious as to your opinion about a woman who has one c-section scar, one successful subsequent hospital vbac, and then wants a homebirth for her third baby. Would she always be risked out because of that prior c-section?

  2. Yes Laura, she would. Infact, I just recently had this conversation with a client recently. A scar is a scar is a scar and every time that scar is stressed - be it with a VBAC or C/S, the risk for rupture is there (and is higher than if she had never had a c/s. She would risk out of having a Homebirth with our practice because of her history of having a uterine scar. Just not worth what "could" happen.

    1. i believe that is incorrect, ruptures are most likely to occur within the first 2 years after the original c/section

  3. Would maternal heart defects risk a mother out of home birth? Specifically something like a VSD or mitral valve prolapse with regurgitation?

  4. Dear Fluffy,
    Sorry for the delayed response. Deb hasn't been feeling well this week. She asked me to send you a quick reply for now to answer your question. Yes, maternal heart defects like those you described would risk a mother out of home birth for her practice. If you have more questions about this, please leave another comment for us or use the "contact" tab. Thank you for your post.