A 37-year-old woman, gravida 2 para 1, at 8 weeks gestation comes to the clinic to establish prenatal care. The patient has had mild nausea, but no vomiting or vaginal bleeding. She has no chronic medical conditions and has had no surgeries. Her only medication is a prenatal vitamin. The patient's prior pregnancy ended in a spontaneous vaginal delivery at 38 weeks gestation. BMI is 32 kg/m2. Physical examination is unremarkable. Ultrasound confirms an 8-week intrauterine pregnancy with normal cardiac activity. Although the patient's last delivery was at a hospital, she is now considering a planned home birth. Which of the following is the most appropriate statement to this patient?
Although most births in the United States occur in a hospital, the number of planned home births has steadily increased. Common reasons for choosing home birth include desires to avoid labor interventions (eg, artificial rupture of membranes), have greater personal control in the birth process, and deliver in a familiar home environment.
Notably, most patients who have a planned home birth are multiparous and have had a prior in-hospital delivery. In some cases, desiring a planned home birth for the current pregnancy may reflect low satisfaction or negative experience with the prior in-hospital delivery. Therefore, providers should seek to understand what, if any, aspects of the prior in-hospital birth experience were concerning to the patient. This is also an opportunity to review the risks (eg, increased neonatal mortality, lack of access to emergency medical interventions) and benefits (eg, higher vaginal delivery rate, fewer obstetric interventions) of home birth. Patients determined to proceed with a home birth require counseling on the indications for transfer to a hospital (eg, abnormal fetal heart rate, arrest of labor).
(Choice A) Although home births are associated with increased neonatal mortality, stating that home birth is risky (ie, "I don't think we should consider this option") does not allow the patient to express her concerns and is paternalistic.
(Choice B) Safe home births require more than a good support system (eg, partner, family, doula). Ideally, an experienced home birth provider with appropriate resources (eg, neonatal resuscitation kit) is present, and there is a backup plan for transfer to a hospital if needed. In addition, this statement shifts responsibility for this patient's care to another (nonmedical) provider, which is inappropriate.
(Choice D) This patient's prior vaginal delivery and absence of chronic medical conditions are favorable for home birth. However, the caveat "as long as your pregnancy remains uncomplicated" may set the patient up for disappointment if obstetric complications arise. In addition, it may discourage her from disclosing symptoms (eg, vaginal bleeding, persistent headache) of serious obstetric complications.
(Choice E) Delaying the conversation about home birth dismisses the patient's concerns, which will likely harm the physician-patient relationship. Exploring her reasons for wanting a planned home birth is a more patient-centered approach.
Educational objective:
Desiring a planned home birth may reflect low satisfaction or negative experiences with a prior in-hospital delivery. Therefore, providers should assess what, if any, aspects of the prior in-hospital delivery were concerning to the patient.