Aust NZ J Obstet Gynaecol
1992; 32: 4: 291
THE AUSTRALIAN & NEW ZEALAND JOURNAL OF November, 1992
OBSTETRICS & GYNAECBLOGY Vol. 32 - NO.4
The Royal Women’s Hospital Family Birth Centre: The First 10 Years Reviewed C. Stern’, MBBS, M. Permezel*,MD, FRACOG, C. Petterson’, FRACOG, J. Lawsod, RN, T. Eggers’, FRACOG and M. Kloss’, FRACOG Royal Women’s Hospital and Department of Obstetrics and Gynaecologj University of Melbourne, Victoria
EDITORIAL COMMENT: Results of obstetricpractice are conventionally assessed by consideration of perinatal and maternal mortality rates, rates of intervention in labour (induction, epidural analgesia), rates of operative proceduresfor delivery (episiotomy, forceps, Caesarean section) and rates of postpartum complications (retained placenta, postpartum haemorrhage). Other important considerationsare physical and emotional morbidity and whether or not the woman and her partner are pleased with the birthing experience and their birth attendants. The editorial committee wishes to request readers to provide information concerning the long-term emotional results of the malepartner’s decision to be present at the birth of his child since such data is not available and yet is relevant to the advice given to women regarding the partner’s role during parturition. Thispaper reports a marvellousperinatal mortality ratefor births in a birth centre. Indeed the editor makes the prediction that this figure of less than I death per 1,000 births for women acceptedfor delivery in a Birth Centre, including those with intrauterine death diagnosed when the woman was admitted in labour, will stand as a record, since this rate is less than 10% of that for the state of Victoria as a whole (9.7per 1,000 births in 1990). The results according to the method of delivery are also exemplary. It should be noted however, that 19fetal deaths in utero occurred in the 889 women excludedfrom the group because of antenatal complications, and the authors do not provide information regarding neonatal deaths in this group or the number, i f a n j of these women admitted in labour with an intrauterine death. The data provided indicates that the perinatal mortality rate in the 5,365 women initially booked for delivery in the Birth Centre was at least 4.3 per 1,000 (23 in 5,365). Authors’ Response: In addition to the 4 perinatal deaths in patients who presented to the Birth Centre in labour, and the 17 intrauterine deaths listed in table 4, there were 15 other deaths (9 stillbirths, 6 neonatal deaths) in the patients excluded antenatally i.e. theperinatal mortality ratefor the original series of 5,365 women was 6.7per 1,000 births.
~
~
~~
1. Registrar.
2. Senior Lecturer. 3. Consultant Obstetrician. 4. Charge Midwife. Address for correspondence: Dr Michael Permezel, University Department of Obstetrics and Gynaecology, Royal Women’s Hospital, Carlton, Victoria, 3053, Australia.
292
AUST.AND N.Z. JOURNAL OF OBSTETRICS AND GYNAECOLOGY
Summary: In reviewing the first 10 years experience of the Royal Women’s Hospital Family Birth Centre (FBC), we examined the outcomes of pregnancy and labour in a group of women who requested alternative birthing care and who were identified antenatally as being a ‘low-risk’ population. This study is a retrospective analysis of 5,365 women booked with the birth centre between 1980 and 1989. Over 16% of women developed antenatal complications precluding further care there, while a further 16% developed complications in labour requiring transfer out to conventional labour wards. Thus 67% of those originally booked delivered in the FBC. The instrumental delivery rate was 11070,and the Caesarean section rate was 4%. Of the women who delivered in the FBC, 3.1% had a postpartum haemorrhage and 1.8% required manual removal of placenta. Approximately 4% of babies born in the FBC required some resuscitation, and 0.8% needed admission to the neonatal nursery. Two perinatal deaths occurred in women admitted in labour to the FBC with a live baby, whilst 2 other women presented in labour with a fetal death in utero (perinatal mortality 0.89 per 1,000). The Royal Women’s Hospital Family Birth Centre (FBC) was established in October, 1979, in response to a demand by the community for birthing centres to provide an alternative to the conventional hospitalbased facilities. The FBC aims to satisfy these needs, providing a service which offers a high standard of care in a pleasant, home-like environment using minimal intervention but with the back-up to deal with complications if they develop. The alternative facilities available in the community include home birth and free-standing birth centres, both of which, by their very nature, require patient transport to hospital facilities if and when emergency situations develop. Birthing services in Victoria are currently under review and thus it is timely to review the first 10 years experience of the Royal Women’s Hospital FBC. Data from 1980 (1) and 1981-1984 (2) has previously been presented and is included in this report. The underlying philosophy of the Family Birth Centre is that birth is a natural, physiological process, which should take place in a familiar environment with the support of nominated ‘support people’ and caregivers. One of the major criticisms levelled at standard obstetric services is that women giving birth in these institutions surrender all control over the birthing experience to the obstetrician/midwifery team. Sheila Kitzinger has said of birth ‘Only when basic human experiences like these have significance, can we feel that we are the ‘creators’instead of merely being at the mercy of fate, or of doctors, the ‘them’ who do things to us, and helpless in the cat’s paws of larger hierarchical organizations. This is why we need to demedicalize birth’ (3). While most obstetricians would feel this criticism is unjustified, the issue of control over delivery is a recurrring theme central to discussions of birth worldwide. The Ministerial Review of Birthing Services in Victoria 1990 stated: ‘The responsibility for birth is a shared one. It does not lie solely with care-givers, individual women and their families, or service providers. All participants share responsibility for the experience and its outcomes and all have particular and important roles to play’ (4).
With regard to safety, most proponents of alternative birthing would agree that women with high risk pregnancies should still be managed in specialist obstetric centres, and all registered alternative facilities apply selection criteria to their prospective patients. However, this fails to deal with the problem of complications arising intrapartum or in the early postpartum/neonatal period when intervention becomes necessary for maternal or fetal well-being.
METHODS The Royal Women’s Hospital FBC contains 4 birthing rooms and accepts women as either public or private patients. It is run by a team of 2 obstetricians and midwives overseeing care of public patients, while several obstetricians and general practitioners utilize the service for their private patients. Women must satisfy entry requirements in terms of being free of foreseeable complications, must book for antenatal care before 24 weeks, and are required to attend regularly. Routine antenatal screening tests are performed and most women have an ultrasound examination at 18 weeks. Patients and their support persons attend special antenatal classes run by birth centre staff, encouraging them to become informed and educated about what to expect in pregnancy, childbirth and the puerperium. For the period of confinement the couple room-in at the birth centre and are looked after by a midwife. There is a 24-hour discharge policy after delivery but provisions are made for women who wish to extend their stay further by transfer to a postnatal ward. Obviously in keeping with the philosophy of minimal intervention, only women with low risk pregnancies are eligible for care in the FBC. The exclusion criteria for the RWH family birthing centre are listed in table 1. Preexisting maternal disease, past obstetric complications such as Caesarean section, intrauterine growth retardation, severe preeclampsia or postpartum haemorrhage and complications in the current pregnancy are all contraindications to care in the FBC.
c.
Table 1. Exclusion Criteria ~
~~
293
STERN ET AL
Table 3. Mode of Delivery of Patients Commencing Labour in FBC
~
1. Preexisting maternal disease Heart disease Moderate or severe renal disease Drug addiction including alcohol Bleeding disorder Past history of fractured pelvis 2. Past obstetric history Caesarean section Eclampsia/severe preeclampsia Poor outcome (maternal or fetal) 3. Other Age >36 years in primigravida Booking after 24 weeks Primigravida height less than 150 4. Current pregnancy P reec1ampsia Oligo- or polyhydramnios Malpresentation Rhesus isoimmunization Genital herpes
Thrombosis or embolism Epilepsy Diabetes mellitus or thyroid disease Hepatitis carrier state Uterine scar from previous surgery Intrauterine growth retardation Postpartum haemorrhage on 2 occasions Age >41 years in multigravida In vitro fertilization pregnancy cm Multiple pregnancy Placenta praevia Other significant obstetric complications
Table 2. Outcomes of FBC Bookings Commencinn labour in FBE (qo)
Outcome
n
Antenatal transfers Intrapartum transfers Postpartum transfers Antenatal care labour delivery and postpartum care in FBC
889 862 84
16.6% 16.1% 1.6%
19.3% 1.9%
3,530
65.8%
78.9%
Total bookings
5,365
Bookings
Normal vaginal delivery in FBC Normal vaginal delivery after transfer Instrumental vaginal delivery after transfer Instrumental vaginal delivery in FBC Caesarean section after transfer
3,463 340 345 151 177
Total commencing labour in FBC
4,476
(77.4%) (7.6%) (7.7%) (3.3%) (4.0%)
FBC = Family Birth Centre
Table 4. Antenatal Exclusions ~
~
Reason for exclusion Hypertension, preeclampsia Ruptured membranes not in labour Breech presentation Prolonged pregnancy Intrauterine growth retardation Premature labour Preterm rupture of the membranes Antepartum haemorrhage Herpes simplex virus infection Fetal death in utero Congenital abnormality Gestational diabetes Small pelvis Multiple pregnancy Unstable lie Moved interstate Planned home delivery Miscellaneous Total
222 132 92 84 70 70 52 42 27 17 14 10 9 8
3 14 8 15
(25.0%) (14.9%) ( 10.4 700) (9.5To) (7.9 % ) (7.9 Yo) (5.9%) (4.7 Yo) (3.0%) (1.9%) (1.6%) (1.1%) (1.0%) (0.9%) (0.3%) (1.6%) (0.9%) (I .7%)
889
Table 5. Intrapartum Transfers
FBC = Family Birth Centre
This study is a retrospective analysis of the course and outcome of pregnancy of all women booked for confinement at the Royal Women’s Hospital Family Birthing Centre from January 1, 1980 to December 31, 1989. Data was extracted from both individual patient histories and the hospital obstetric data base.
RESULTS In the 10 years 1980-1989 a total of 5,365 women were accepted as suitable for confinement in the FBC (table 2). Of these, 63% were primigravidas. A total of 889 women were excluded during their antenatal course (16.6%). The most common reasons for antenatal exclusion were hypertension or preeclampsia (25%), breech presentation (10.4%), prolonged pregnancy (9.5%), or spontaneous rupture of the membranes > 37 weeks with no labour within 24 hours (14.9%) (table 4). Thus a total of 4,476 women (83.4% of bookings) were admitted in labour to the FBC. Of these women a further 862 were transferred out to a conventional labour ward intrapartum (16.1% of total bookings and 19.3% of those admitted in labour to the FBC). Primigravidas accounted for 72% of these women. The most common indications for transfer out were failure to progress in labour (43.4%), or meconium-stained liquor
Failure to progress in labour Meconium-contaminated liquor Fetal distress Preeclampsia Epidural analgesia Ketonuria Intrapartum haemorrhage Malpresentation Sepsis Fetal death in utero
377 227 69 69 64 18 14
Total
862
13 8 3
(43.4%) (26.4%)
(8.0%) (8.0%) (7.4%) (2.1%) (1.6%) (1.5%) (0.9%) (0.4%)
requiring continuous fetal heart monitoring (26.3 070) (table 5 ) . A total of 496 women required forceps or ventouse delivery (11.1070),while 177 underwent Caesarean section (4%) (table 3). Eighty percent of the 4,476 women admitted in labour to the FBC gave birth in the centre. This represents 67% of all women booked there. This includes a small number of low forceps deliveries performed in the birth centre (149) and delivery of 2 undiagnosed breech presentations. A further 84 women (2.3%) were transferred out postpartum for either postpartum haemorrhage (PPH) or retained placenta requiring manual removal. A total of 112 women had a P P H greater than 600 ml(3.1%), while 63 required manual removal of placenta (1.8%). Twenty women required blood transfusions. Sixty percent of women with a P P H did not receive a prophylactic injection of an oxytocic drug.
AUST.AND N.Z. JOURNAL OF OBSTETRICS AND GYNAECOLOCY
294
Table 6. Complications of FBC Deliveries Maternal complications Postpartum haemorrhage Retained placenta Blood transfusion Neonatal complications Apgar score
1992; 32: 4: 291
THE AUSTRALIAN & NEW ZEALAND JOURNAL OF November, 1992
OBSTETRICS & GYNAECBLOGY Vol. 32 - NO.4
The Royal Women’s Hospital Family Birth Centre: The First 10 Years Reviewed C. Stern’, MBBS, M. Permezel*,MD, FRACOG, C. Petterson’, FRACOG, J. Lawsod, RN, T. Eggers’, FRACOG and M. Kloss’, FRACOG Royal Women’s Hospital and Department of Obstetrics and Gynaecologj University of Melbourne, Victoria
EDITORIAL COMMENT: Results of obstetricpractice are conventionally assessed by consideration of perinatal and maternal mortality rates, rates of intervention in labour (induction, epidural analgesia), rates of operative proceduresfor delivery (episiotomy, forceps, Caesarean section) and rates of postpartum complications (retained placenta, postpartum haemorrhage). Other important considerationsare physical and emotional morbidity and whether or not the woman and her partner are pleased with the birthing experience and their birth attendants. The editorial committee wishes to request readers to provide information concerning the long-term emotional results of the malepartner’s decision to be present at the birth of his child since such data is not available and yet is relevant to the advice given to women regarding the partner’s role during parturition. Thispaper reports a marvellousperinatal mortality ratefor births in a birth centre. Indeed the editor makes the prediction that this figure of less than I death per 1,000 births for women acceptedfor delivery in a Birth Centre, including those with intrauterine death diagnosed when the woman was admitted in labour, will stand as a record, since this rate is less than 10% of that for the state of Victoria as a whole (9.7per 1,000 births in 1990). The results according to the method of delivery are also exemplary. It should be noted however, that 19fetal deaths in utero occurred in the 889 women excludedfrom the group because of antenatal complications, and the authors do not provide information regarding neonatal deaths in this group or the number, i f a n j of these women admitted in labour with an intrauterine death. The data provided indicates that the perinatal mortality rate in the 5,365 women initially booked for delivery in the Birth Centre was at least 4.3 per 1,000 (23 in 5,365). Authors’ Response: In addition to the 4 perinatal deaths in patients who presented to the Birth Centre in labour, and the 17 intrauterine deaths listed in table 4, there were 15 other deaths (9 stillbirths, 6 neonatal deaths) in the patients excluded antenatally i.e. theperinatal mortality ratefor the original series of 5,365 women was 6.7per 1,000 births.
~
~
~~
1. Registrar.
2. Senior Lecturer. 3. Consultant Obstetrician. 4. Charge Midwife. Address for correspondence: Dr Michael Permezel, University Department of Obstetrics and Gynaecology, Royal Women’s Hospital, Carlton, Victoria, 3053, Australia.
292
AUST.AND N.Z. JOURNAL OF OBSTETRICS AND GYNAECOLOGY
Summary: In reviewing the first 10 years experience of the Royal Women’s Hospital Family Birth Centre (FBC), we examined the outcomes of pregnancy and labour in a group of women who requested alternative birthing care and who were identified antenatally as being a ‘low-risk’ population. This study is a retrospective analysis of 5,365 women booked with the birth centre between 1980 and 1989. Over 16% of women developed antenatal complications precluding further care there, while a further 16% developed complications in labour requiring transfer out to conventional labour wards. Thus 67% of those originally booked delivered in the FBC. The instrumental delivery rate was 11070,and the Caesarean section rate was 4%. Of the women who delivered in the FBC, 3.1% had a postpartum haemorrhage and 1.8% required manual removal of placenta. Approximately 4% of babies born in the FBC required some resuscitation, and 0.8% needed admission to the neonatal nursery. Two perinatal deaths occurred in women admitted in labour to the FBC with a live baby, whilst 2 other women presented in labour with a fetal death in utero (perinatal mortality 0.89 per 1,000). The Royal Women’s Hospital Family Birth Centre (FBC) was established in October, 1979, in response to a demand by the community for birthing centres to provide an alternative to the conventional hospitalbased facilities. The FBC aims to satisfy these needs, providing a service which offers a high standard of care in a pleasant, home-like environment using minimal intervention but with the back-up to deal with complications if they develop. The alternative facilities available in the community include home birth and free-standing birth centres, both of which, by their very nature, require patient transport to hospital facilities if and when emergency situations develop. Birthing services in Victoria are currently under review and thus it is timely to review the first 10 years experience of the Royal Women’s Hospital FBC. Data from 1980 (1) and 1981-1984 (2) has previously been presented and is included in this report. The underlying philosophy of the Family Birth Centre is that birth is a natural, physiological process, which should take place in a familiar environment with the support of nominated ‘support people’ and caregivers. One of the major criticisms levelled at standard obstetric services is that women giving birth in these institutions surrender all control over the birthing experience to the obstetrician/midwifery team. Sheila Kitzinger has said of birth ‘Only when basic human experiences like these have significance, can we feel that we are the ‘creators’instead of merely being at the mercy of fate, or of doctors, the ‘them’ who do things to us, and helpless in the cat’s paws of larger hierarchical organizations. This is why we need to demedicalize birth’ (3). While most obstetricians would feel this criticism is unjustified, the issue of control over delivery is a recurrring theme central to discussions of birth worldwide. The Ministerial Review of Birthing Services in Victoria 1990 stated: ‘The responsibility for birth is a shared one. It does not lie solely with care-givers, individual women and their families, or service providers. All participants share responsibility for the experience and its outcomes and all have particular and important roles to play’ (4).
With regard to safety, most proponents of alternative birthing would agree that women with high risk pregnancies should still be managed in specialist obstetric centres, and all registered alternative facilities apply selection criteria to their prospective patients. However, this fails to deal with the problem of complications arising intrapartum or in the early postpartum/neonatal period when intervention becomes necessary for maternal or fetal well-being.
METHODS The Royal Women’s Hospital FBC contains 4 birthing rooms and accepts women as either public or private patients. It is run by a team of 2 obstetricians and midwives overseeing care of public patients, while several obstetricians and general practitioners utilize the service for their private patients. Women must satisfy entry requirements in terms of being free of foreseeable complications, must book for antenatal care before 24 weeks, and are required to attend regularly. Routine antenatal screening tests are performed and most women have an ultrasound examination at 18 weeks. Patients and their support persons attend special antenatal classes run by birth centre staff, encouraging them to become informed and educated about what to expect in pregnancy, childbirth and the puerperium. For the period of confinement the couple room-in at the birth centre and are looked after by a midwife. There is a 24-hour discharge policy after delivery but provisions are made for women who wish to extend their stay further by transfer to a postnatal ward. Obviously in keeping with the philosophy of minimal intervention, only women with low risk pregnancies are eligible for care in the FBC. The exclusion criteria for the RWH family birthing centre are listed in table 1. Preexisting maternal disease, past obstetric complications such as Caesarean section, intrauterine growth retardation, severe preeclampsia or postpartum haemorrhage and complications in the current pregnancy are all contraindications to care in the FBC.
c.
Table 1. Exclusion Criteria ~
~~
293
STERN ET AL
Table 3. Mode of Delivery of Patients Commencing Labour in FBC
~
1. Preexisting maternal disease Heart disease Moderate or severe renal disease Drug addiction including alcohol Bleeding disorder Past history of fractured pelvis 2. Past obstetric history Caesarean section Eclampsia/severe preeclampsia Poor outcome (maternal or fetal) 3. Other Age >36 years in primigravida Booking after 24 weeks Primigravida height less than 150 4. Current pregnancy P reec1ampsia Oligo- or polyhydramnios Malpresentation Rhesus isoimmunization Genital herpes
Thrombosis or embolism Epilepsy Diabetes mellitus or thyroid disease Hepatitis carrier state Uterine scar from previous surgery Intrauterine growth retardation Postpartum haemorrhage on 2 occasions Age >41 years in multigravida In vitro fertilization pregnancy cm Multiple pregnancy Placenta praevia Other significant obstetric complications
Table 2. Outcomes of FBC Bookings Commencinn labour in FBE (qo)
Outcome
n
Antenatal transfers Intrapartum transfers Postpartum transfers Antenatal care labour delivery and postpartum care in FBC
889 862 84
16.6% 16.1% 1.6%
19.3% 1.9%
3,530
65.8%
78.9%
Total bookings
5,365
Bookings
Normal vaginal delivery in FBC Normal vaginal delivery after transfer Instrumental vaginal delivery after transfer Instrumental vaginal delivery in FBC Caesarean section after transfer
3,463 340 345 151 177
Total commencing labour in FBC
4,476
(77.4%) (7.6%) (7.7%) (3.3%) (4.0%)
FBC = Family Birth Centre
Table 4. Antenatal Exclusions ~
~
Reason for exclusion Hypertension, preeclampsia Ruptured membranes not in labour Breech presentation Prolonged pregnancy Intrauterine growth retardation Premature labour Preterm rupture of the membranes Antepartum haemorrhage Herpes simplex virus infection Fetal death in utero Congenital abnormality Gestational diabetes Small pelvis Multiple pregnancy Unstable lie Moved interstate Planned home delivery Miscellaneous Total
222 132 92 84 70 70 52 42 27 17 14 10 9 8
3 14 8 15
(25.0%) (14.9%) ( 10.4 700) (9.5To) (7.9 % ) (7.9 Yo) (5.9%) (4.7 Yo) (3.0%) (1.9%) (1.6%) (1.1%) (1.0%) (0.9%) (0.3%) (1.6%) (0.9%) (I .7%)
889
Table 5. Intrapartum Transfers
FBC = Family Birth Centre
This study is a retrospective analysis of the course and outcome of pregnancy of all women booked for confinement at the Royal Women’s Hospital Family Birthing Centre from January 1, 1980 to December 31, 1989. Data was extracted from both individual patient histories and the hospital obstetric data base.
RESULTS In the 10 years 1980-1989 a total of 5,365 women were accepted as suitable for confinement in the FBC (table 2). Of these, 63% were primigravidas. A total of 889 women were excluded during their antenatal course (16.6%). The most common reasons for antenatal exclusion were hypertension or preeclampsia (25%), breech presentation (10.4%), prolonged pregnancy (9.5%), or spontaneous rupture of the membranes > 37 weeks with no labour within 24 hours (14.9%) (table 4). Thus a total of 4,476 women (83.4% of bookings) were admitted in labour to the FBC. Of these women a further 862 were transferred out to a conventional labour ward intrapartum (16.1% of total bookings and 19.3% of those admitted in labour to the FBC). Primigravidas accounted for 72% of these women. The most common indications for transfer out were failure to progress in labour (43.4%), or meconium-stained liquor
Failure to progress in labour Meconium-contaminated liquor Fetal distress Preeclampsia Epidural analgesia Ketonuria Intrapartum haemorrhage Malpresentation Sepsis Fetal death in utero
377 227 69 69 64 18 14
Total
862
13 8 3
(43.4%) (26.4%)
(8.0%) (8.0%) (7.4%) (2.1%) (1.6%) (1.5%) (0.9%) (0.4%)
requiring continuous fetal heart monitoring (26.3 070) (table 5 ) . A total of 496 women required forceps or ventouse delivery (11.1070),while 177 underwent Caesarean section (4%) (table 3). Eighty percent of the 4,476 women admitted in labour to the FBC gave birth in the centre. This represents 67% of all women booked there. This includes a small number of low forceps deliveries performed in the birth centre (149) and delivery of 2 undiagnosed breech presentations. A further 84 women (2.3%) were transferred out postpartum for either postpartum haemorrhage (PPH) or retained placenta requiring manual removal. A total of 112 women had a P P H greater than 600 ml(3.1%), while 63 required manual removal of placenta (1.8%). Twenty women required blood transfusions. Sixty percent of women with a P P H did not receive a prophylactic injection of an oxytocic drug.
AUST.AND N.Z. JOURNAL OF OBSTETRICS AND GYNAECOLOCY
294
Table 6. Complications of FBC Deliveries Maternal complications Postpartum haemorrhage Retained placenta Blood transfusion Neonatal complications Apgar score
