re et al. Gigue
31 Levine RJ, Maynard SE, Qian C, Lim KH, England LJ, Yu KF, et al. Circulating angiogenic factors and the risk of preeclampsia. N Engl J Med 2004;350:672–83. 32 Sibai BM, Koch MA, Freire S, Pinto e Silva JL, Rudge MV, Martins-Costa S, et al. Serum inhibin A and angiogenic factor levels in pregnancies with previous preeclampsia and/or chronic hypertension: are they useful markers for prediction of subsequent preeclampsia? Am J Obstet Gynecol 2008;199:268 e1–9. 33 Yu J, Shixia CZ, Wu Y, Duan T. Inhibin A, activin A, placental growth factor and uterine artery Doppler pulsatility index in the prediction of pre-eclampsia. Ultrasound Obstet Gynecol 2011;37:528–33. 34 Poon LC, Maiz N, Valencia C, Plasencia W, Nicolaides KH. First-trimester maternal serum pregnancy-associated plasma protein-A and pre-eclampsia. Ultrasound Obstet Gynecol 2009;33: 23–33. 35 Steyerberg EW, Eijkemans MJ, Harrell FE Jr, Habbema JD. Prognostic modeling with logistic regression analysis: in search of a sensible strategy in small data sets. Med Decis Making 2001;21:45–56.
36 Powers RW, Roberts JM, Plymire DA, Pucci D, Datwyler SA, Laird DM, et al. Low placental growth factor across pregnancy identifies a subset of women with preterm preeclampsia: type 1 versus type 2 preeclampsia? Hypertension 2012;60:239–46. 37 Vandenberghe G, Mensink I, Twisk JW, Blankenstein MA, Heijboer AC, van Vugt JM. First trimester screening for intra-uterine growth restriction and early-onset pre-eclampsia. Prenat Diagn 2011;31: 955–61. 38 Akolekar R, Syngelaki A, Sarquis R, Zvanca M, Nicolaides KH. Prediction of early, intermediate and late pre-eclampsia from maternal factors, biophysical and biochemical markers at 11– 13 weeks. Prenat Diagn 2011;31:66–74. 39 Mikat B, Zeller A, Scherag A, Drommelschmidt K, Kimmig R, Schmidt M. betahCG and PAPP-A in first trimester: predictive factors for preeclampsia? Hypertens Pregnancy 2012;31:261–7. 40 Carbillon L. First trimester uterine artery Doppler for the prediction of preeclampsia and foetal growth restriction. J Matern Fetal Neonatal Med 2012;25:877–83.
Homebirth after caesarean section: a choice too far? STEPHANIE BOND, OBSTETRICS & GYNAECOLOGY REGISTRAR, ROYAL HOBART HOSPITAL, AUSTRALIA BOON H LIM, DIRECTOR, ROYAL HOBART HOSPITAL, AUSTRALIA
.................................................................................................................................................................. In 2013, the Australian media reported the Coroner’s findings on a fresh stillborn baby involving a mother who engaged a private midwife to support the homebirth of her son, despite a history of two previous caesarean sections. The cause of death was severe peripartum asphyxia from uterine rupture following transfer of the mother to hospital with fetal distress and second stage delay. The Coroner found that the death was preventable “if the labour and delivery had been undertaken in a hospital setting” and recommended that the Minister for Health gave consideration to the appropriateness of regulating the practice of providing home birth services (COR 20104851, Coroners Court of Victoria 2013). Homebirth rates in Australia remain low at 0.9% of all births (Perinatal Statistics 2010) compared with 26% in the Netherlands (Netherlands Perinatal Registry 2013). The perinatal mortality rate of normally formed babies in publicly funded homebirths 2005– 2010 was also low, at 1.7 per 1000 births, with no maternal deaths (Med J Aus 2013; 198, issue 11). However, no conclusion could be drawn about the safety of homebirth due to the small sample size (n = 1521). At such
410
low rates, the general public may have lost an appreciation of the factors which increase risk associated with childbirth. In COR 20104851, the mother stated to the Coroner that she considered “the risks [of attempting a natural birth after caesarean] are so minimal as to be not something [she] considered a risk”. This was despite the concerns expressed to her by several obstetricians. The Coroner’s view was that a diminishing appreciation of the inherent risks of childbirth has led to perhaps inappropriate denial of risks by some care providers and community members. In Australia, homebirths remain a contentious issue, even more so in the setting of increased risk such as previous caesarean section. The Royal Australian and New Zealand College of Obstetricians & Gynaecologists (RANZCOG) “does not endorse planned homebirth”. The Australian College of Midwives position statement declares that “Women have a right to decide where they wish to give birth to their baby”. Women undergoing trial of labour after multiple caesarean sections have a significantly increased risk of blood transfusion and hysterectomy, and a higher perinatal mortality rate (Smith GC
et al., PLoS Med 2005; 2:e252, Landon MB et al., N Engl J Med 2004;351:2581–9), although the reported difference in the uterine rupture rate (0.9% versus 0.7%) is not statistically significant due to small numbers. There is no evidence that homebirth is associated with a different rupture risk than hospital birth. Any adverse outcome would be expected to be worse if experienced outside the hospital setting due to the lack of rapid access to specialist care if urgently required. Home births in women at higher risk continue to be an ethical and medico-legal challenge. When promoting patient empowerment and autonomy, we must also consider safety. Obstetric and midwifery experts need to continue to work collaboratively to develop an evidence-based resource to enable prospective parents to be fully informed of the issues associated with the various birthing options. Birth plans should include an agreed pathway for seeking specialist advice and help, and transfer to a hospital in the event of deviation from normality at any stage of the antenatal, intrapartum or postnatal course. Disclosure of interests The authors have no conflicts of interest or financial ties to disclose. &
ª 2014 Royal College of Obstetricians and Gynaecologists
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
31 Levine RJ, Maynard SE, Qian C, Lim KH, England LJ, Yu KF, et al. Circulating angiogenic factors and the risk of preeclampsia. N Engl J Med 2004;350:672–83. 32 Sibai BM, Koch MA, Freire S, Pinto e Silva JL, Rudge MV, Martins-Costa S, et al. Serum inhibin A and angiogenic factor levels in pregnancies with previous preeclampsia and/or chronic hypertension: are they useful markers for prediction of subsequent preeclampsia? Am J Obstet Gynecol 2008;199:268 e1–9. 33 Yu J, Shixia CZ, Wu Y, Duan T. Inhibin A, activin A, placental growth factor and uterine artery Doppler pulsatility index in the prediction of pre-eclampsia. Ultrasound Obstet Gynecol 2011;37:528–33. 34 Poon LC, Maiz N, Valencia C, Plasencia W, Nicolaides KH. First-trimester maternal serum pregnancy-associated plasma protein-A and pre-eclampsia. Ultrasound Obstet Gynecol 2009;33: 23–33. 35 Steyerberg EW, Eijkemans MJ, Harrell FE Jr, Habbema JD. Prognostic modeling with logistic regression analysis: in search of a sensible strategy in small data sets. Med Decis Making 2001;21:45–56.
36 Powers RW, Roberts JM, Plymire DA, Pucci D, Datwyler SA, Laird DM, et al. Low placental growth factor across pregnancy identifies a subset of women with preterm preeclampsia: type 1 versus type 2 preeclampsia? Hypertension 2012;60:239–46. 37 Vandenberghe G, Mensink I, Twisk JW, Blankenstein MA, Heijboer AC, van Vugt JM. First trimester screening for intra-uterine growth restriction and early-onset pre-eclampsia. Prenat Diagn 2011;31: 955–61. 38 Akolekar R, Syngelaki A, Sarquis R, Zvanca M, Nicolaides KH. Prediction of early, intermediate and late pre-eclampsia from maternal factors, biophysical and biochemical markers at 11– 13 weeks. Prenat Diagn 2011;31:66–74. 39 Mikat B, Zeller A, Scherag A, Drommelschmidt K, Kimmig R, Schmidt M. betahCG and PAPP-A in first trimester: predictive factors for preeclampsia? Hypertens Pregnancy 2012;31:261–7. 40 Carbillon L. First trimester uterine artery Doppler for the prediction of preeclampsia and foetal growth restriction. J Matern Fetal Neonatal Med 2012;25:877–83.
Homebirth after caesarean section: a choice too far? STEPHANIE BOND, OBSTETRICS & GYNAECOLOGY REGISTRAR, ROYAL HOBART HOSPITAL, AUSTRALIA BOON H LIM, DIRECTOR, ROYAL HOBART HOSPITAL, AUSTRALIA
.................................................................................................................................................................. In 2013, the Australian media reported the Coroner’s findings on a fresh stillborn baby involving a mother who engaged a private midwife to support the homebirth of her son, despite a history of two previous caesarean sections. The cause of death was severe peripartum asphyxia from uterine rupture following transfer of the mother to hospital with fetal distress and second stage delay. The Coroner found that the death was preventable “if the labour and delivery had been undertaken in a hospital setting” and recommended that the Minister for Health gave consideration to the appropriateness of regulating the practice of providing home birth services (COR 20104851, Coroners Court of Victoria 2013). Homebirth rates in Australia remain low at 0.9% of all births (Perinatal Statistics 2010) compared with 26% in the Netherlands (Netherlands Perinatal Registry 2013). The perinatal mortality rate of normally formed babies in publicly funded homebirths 2005– 2010 was also low, at 1.7 per 1000 births, with no maternal deaths (Med J Aus 2013; 198, issue 11). However, no conclusion could be drawn about the safety of homebirth due to the small sample size (n = 1521). At such
410
low rates, the general public may have lost an appreciation of the factors which increase risk associated with childbirth. In COR 20104851, the mother stated to the Coroner that she considered “the risks [of attempting a natural birth after caesarean] are so minimal as to be not something [she] considered a risk”. This was despite the concerns expressed to her by several obstetricians. The Coroner’s view was that a diminishing appreciation of the inherent risks of childbirth has led to perhaps inappropriate denial of risks by some care providers and community members. In Australia, homebirths remain a contentious issue, even more so in the setting of increased risk such as previous caesarean section. The Royal Australian and New Zealand College of Obstetricians & Gynaecologists (RANZCOG) “does not endorse planned homebirth”. The Australian College of Midwives position statement declares that “Women have a right to decide where they wish to give birth to their baby”. Women undergoing trial of labour after multiple caesarean sections have a significantly increased risk of blood transfusion and hysterectomy, and a higher perinatal mortality rate (Smith GC
et al., PLoS Med 2005; 2:e252, Landon MB et al., N Engl J Med 2004;351:2581–9), although the reported difference in the uterine rupture rate (0.9% versus 0.7%) is not statistically significant due to small numbers. There is no evidence that homebirth is associated with a different rupture risk than hospital birth. Any adverse outcome would be expected to be worse if experienced outside the hospital setting due to the lack of rapid access to specialist care if urgently required. Home births in women at higher risk continue to be an ethical and medico-legal challenge. When promoting patient empowerment and autonomy, we must also consider safety. Obstetric and midwifery experts need to continue to work collaboratively to develop an evidence-based resource to enable prospective parents to be fully informed of the issues associated with the various birthing options. Birth plans should include an agreed pathway for seeking specialist advice and help, and transfer to a hospital in the event of deviation from normality at any stage of the antenatal, intrapartum or postnatal course. Disclosure of interests The authors have no conflicts of interest or financial ties to disclose. &
ª 2014 Royal College of Obstetricians and Gynaecologists
Copyright of BJOG: An International Journal of Obstetrics & Gynaecology is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
