Home Birth

Home birth: A birth that occurs at home rather than in hospital or in a birth centre.

BGH: Borders General Hospital.

Significant meconium: This is defined as dark green or black amniotic fluid that is thick or tenacious, or any amniotic fluid that has lumps of meconium in it. Nice (2014)

All midwives must ensure competence at managing obstetric emergencies, fetal monitoring and neonatal resuscitation and have attended NHS Borders mandatory training in line with national guidance.

All midwives attending a homebirth must ensure they have all the equipment required as listed in midwives’ equipment for a homebirth. Appendix 1 this should be dated and signed by the midwives checking the kit. Quick release tamper tags can be used on parts of the kit not accessed routinely to ensure they remain complete in the event of an emergency.

It is the responsibility of the woman’s designated “team” to deliver the home birth equipment up to 1 week prior to on call commencing.

The midwifery staff are responsible for working within their scope of practice, recognising deviation from “normal”, identifying and escalating any concerns to senior midwife or medical staff.

All midwives must consider their own safety and that of their colleagues and work within the NHS Borders lone working policy. Any concerns relating to this risk assessment should be escalated to the line manager and prevention and management of aggression and violence (PMAV) team.

All midwives should have attended PMAV training in line with NHS Border policy.

The on call rota should be a live document on the shared drive and it is the midwives’ responsibility to ensure this is up to date and that labour ward, community midwifery team and senior charge midwife is aware of any changes that have been made.

It is the midwives’ responsibility to ensure they are fit to work, if the midwife feels patient safety may be compromised due to this, they are responsible for reporting this to the line manager or labour ward staff to arrange for another midwife to attend.

It is the midwives’ responsibility to keep the labour ward coordinator updated of the home birth situation every 4 hrs, this does not have to be a progress report but an opportunity to discuss any aspect of the woman’s care or joint decision making that is taking place.

It is the midwives’ responsibility to inform the line manager of the hours they spend attending the home birth to ensure they are paid correctly.

Home birth locality can be recorded using “what 3 words” and documented on woman’s Badgernet record and communicated to the wider community team. This method is more accurate than using postcodes particularly for more remote locations.

In the event of a car breakdown the midwife should contact her line manager within hours or labour ward co coordinator out of hours. The midwife should contact a breakdown company to attend.  The woman will then be informed and plan made.

The midwife should inform the line manager or labour ward coordinator when they arrive at the woman’s home and when they have returned home.

The on call rota should be a live document on the shared drive and it is the midwives’ responsibility to ensure this is up to date and that Labour Ward, Community Midwifery team and Senior Charge Midwife is aware of any changes that have been made.

The on call rota should be made up 6-8 weeks in advance with midwives able to make requests directly with the midwife responsible for the on call rota.

Current working time directives state no midwife should be working for more than:

48hrs a week. This is averaged out over a rolling 17-week period.

A midwife who has worked through the day should not be expected to work for more than 8 hrs at night (including the hrs between 0000-0500.)

Working time is from the time the midwife receives the phone call to attend the home birth until the time she returns home.

Advice given over the phone during an on-call period counts as working time.

After 6 hrs a midwife is entitled to a rest period/break of 20mins. This should be covered by a colleague whenever possible.

If a midwife is called out during the day between 08:30-16:30 she would be expected to be able to return to work the next day.

If a midwife is working during the day and called out overnight between 00:30-08:30 she would not be expected to work the next day.

If a midwife has worked through the day and is called out in the early evening 1630-0030 she would be able to return to work the following day with the option to start later. The line manager should be informed as soon as possible if the intention is to commence work later in the day to ensure the team know the midwife is safe and well and so any workload can be rearranged or redistributed appropriately.

In the event of severe weather conditions, the midwife on-call should be aware of NHS Borders updates and advice. Please adhere to NHS Border weather policy (2019) for guidance.

No on-call will be cancelled in advance but consideration of weather conditions and warnings will be taken into account and the woman would be advised to call the hospital in early labour if there are concerns relating to weather conditions and access to her address. 

A decision on safety will be made at the time the woman informs us of being in labour.

The on-call midwife in discussion with unit co-ordinator and hospital on-call manager will make the decision whether it is possible for them to travel to the homebirth safely. This may require provision of 4x4 transport support.

The woman will always be kept informed of the decision.

The discussion on place of birth should commence from the initial booking appointment and be revisited throughout your routine antenatal care appointments to continually risk assess the place of birth as factors may change throughout.

NICE (2014) suggest Midwives:

• Advise low risk multiparous women that planning to give birth at home is particularly suitable for them because the rate of intervention is lower and the outcome for baby is no different compared with an obstetric unit. NICE (2014)
• Advise low risk nulliparous women that if they plan a home birth there is a small increase in the risk of adverse outcome for baby. 9.3 adverse perinatal outcome events per 1000 planned home births compared with 5.3 per 1000 birth planned for obstetric units. NICE (2014)

Conditions and factors where a hospital birth is recommended.

Table 1

Other factors where a hospital birth is recommended

Table 2

Medical conditions to discuss with Consultant Obstetrician

Table 3

Other Factors to discuss with Consultant Obstetrician

Table 4

In the presence of identified risks that may affect the woman’s choice for a home birth the midwife should give evidence based balanced advice without offering judgement or personal opinion to influence the decision making.

Sign post women to patient information leaflets on Badgernet and useful links to appropriate websites.

Give time to answer questions and expand on any explanations required.

It is recommended that the woman be referred to attend birth choice clinic/ obstetric clinic where a fuller discussion with regards to benefits and risks can be discussed and documented on Badgernet.

If a woman rejects referral and advice, then this must be documented and escalated to the line manager or in her absence a deputy or clinical midwifery manager.

Offer to facilitate a visit to obstetric unit and an opportunity to meet some of the staff.

Ensure a clear plan of care is agreed and documented before on call commences and ensure that the risk assessment and care planning is a continuous process and that all discussions and revisions of the plan for care are recorded, in the Pregnancy Record and communicated to the rest of the midwifery team.

It would be appropriate that any woman who wishes a home birth out with guidelines should be visited by 2 midwives, the named midwife and a senior midwife, team lead or supervisor.

The decision about place of birth should be made jointly by the woman, their primary midwife, and obstetrician in the case of women with more complex needs. If there is a possibility that the baby may be at increased risk of complications, consider early referral to paediatric staff through a neonatal alert on Badgernet or direct contact via email to paediatric lead consultant and on call ANNP. For some women, decision-making will need to be revisited during the pregnancy as circumstances change, but the emphasis should be on joint decision-making. Best Start (2017)

On Call should commence between 38-42 weeks’ gestation although in some circumstances it may be appropriate to consider on call from 37 weeks’ gestation. This can be done following discussion with the woman and line manager.

Ensure that home birth is recorded on planned location of birth on Badgernet. This can be updated and changed during any antenatal assessment and ensure the woman’s name automatically is added or removed from the home birth list.

Home Assessment

A home visit should be conducted between 32-36 weeks’ gestation (or as soon as possible in the case of a late request)

The purpose of this visit is to review the home environment, discuss birth plans and expectations of the woman, her family and they midwife providing care.

Complete the home assessment check list on Badgernet as this is a useful guide during this visit to aid identification of any risks. The list is not exhaustive and any additional risks should still be identified and documented clearly on the front summary page.

Key points include:

Mobile phone signal strength and access to an alternative such as a different mobile network or landline.

Size of room

The area should be sufficiently free from clutter with clear access to exits in an emergency.

Access to the birthing pool should be from at least 3 sides, should the woman choose one.

Consider the weight of the filled pool if it is not located on the ground floor.

Check for hazards such as electrical sockets near the water source and route for the hose to fill the pool.

Advise against using candles or naked flames particularly if gases are being used. (Entonox or O2)

Document both hazards and suggestions made for removal of these prior to on call commencing. If appropriate arrange a revisit to ensure these tasks have been done prior to on call commencing.

It is best practice that the woman’s partner or birth partner is present to ask any questions they too may have.

Any woman who wishes a home birth out with guidelines should be visited by 2 midwives, the named midwife and a senior midwife, team lead or supervisor.

Women who choose to give birth at home need to be informed that:

• Giving birth is generally safe for both women and their baby
• Pharmacological pain relief options at home are limited.

• There is a possibility of transfer into hospital during labour or soon after and this is more likely if this is a first baby.

• If something goes unexpectedly wrong or in the event of an emergency at home only basic life support is able to be administered to either mother or baby and may lead to a worse outcome than if the emergency occurred in a hospital with advanced life support staff and access to equipment and facilities for mother and baby.
• Transfer times to the hospital can be affected by road conditions, weather conditions, distance to the hospital and availability of emergency services.
• In the presence of certain risk factors there is a higher chance of developing complications and in those circumstances they would be advised to give birth in a hospital.
• The home birth team within NHS Borders is integrated with the community midwifery service and therefore an on call system is operated. This on call service means we are limited to covering only 1 home birth at any one time. You may not have your named midwife in attendance but there is a higher chance you may have met one of the midwives within the team before you give birth.
• All community midwives carry mobile phones and are able to access advice from medical staff within the BGH.
• In the event of adverse weather conditions, the midwives may advise you to call the hospital earlier than planned so a decision can be made to ensure the safety of you and your baby as well as that of the midwifery staff.
• Explain the on call rota start/end times for day and night shifts
• Explain on call will commence from 38 weeks-42 weeks. If labour commences pre term (before 37 weeks) we would advise transfer of care to obstetric unit.
• Ensure the woman has the contact details for labour ward and knows to call them directly when she believes her labour has started.
• Discuss that we will do our best to arrive in a timely manner, however due to the large geographical area we cover it may take us longer than anticipated for us to arrive. We will try to give an estimated time for our arrival as soon as we are called by Labour Ward.
• Explain the use of “what 3 words” documented on woman’s Badgernet record as a means for the community team to find addresses in a safe and efficient manner.
• Offer early labour advice and coping strategies.
• Inform woman that initially there may be only 1 midwife in attendance to assess labour and progress before calling out a 2^nd midwife.
• Home assessment should take place between 34-36 weeks and documented on Badgernet including full risk assessment of the home (follow check list on Badgernet).
• Discuss reasons for transfer of care. (statistics in table below)
• If a late request is submitted, the named midwife needs to ensure that the woman’s details (Name, CHI, EDD, parity, risk factors, on call dates and “what 3 Words”) are circulated to all community midwives and labour ward by email and update the home birth list on the on call rota on the shared drive.

Transfer of care refers to the transfer between midwifery led home environment and the obstetric unit for consultant led care.

Primary reasons for transfer to an obstetric unit birthplace (2011) & local Data NHS Borders (2022)

NB: some mothers may have been transferred to hospital for more than 1 reason.

Antenatal/ early 1^st stage Intrapartum transfer to hospital may be by private means if the assessing midwife is confident there are no maternal or fetal risks. Document reasons for choice.

Intrapartum 2^nd and 3^rd stage of labour transfers to hospital must be by ambulance and one attending midwife in the ambulance. An ambulance must always be called even if you believe the woman will decline transfer.

Postpartum transfer for either woman or baby must be via ambulance.

An ambulance should be called using 999 stating you are at a home birth and you require paramedic support. Document the incident number.

All women should have access to the BGH Labour Ward telephone number and be asked to call this in the first instance if they believe labour has started.

It is the responsibility of the midwife taking the triage call to advise the woman appropriately and make the decision to call out the community midwife on call for that shift.

On arrival at the home during labour the midwife should:

Treat all women with respect. Ensure that the woman is in control of and involved in what is happening to her and recognise that the way in which care is given is key to this. To facilitate this, establish a rapport with the woman, ask her about her wants and expectations for labour, and be aware of the importance of tone and demeanour, and of the actual words used. Use this information to support and guide her through her labour.

Review the management plan with the woman and her partner.

Taking time to go over the birth plan with the woman and her choice of birth partner.

Assess onset of labour through methods agreed with the women relating to her birth plan and using clinical judgement.

Inform labour ward of your arrival at the woman’s home and perform initial assessment (as seen below)

If labour is established the 1^st on call midwife must make the decision when to call out the 2^nd on call via labour ward if this has not already been done. Ensure clear documentation or arrival time of 2^nd midwife.

A midwife must call labour ward every 4 hrs to update the team on the wellbeing of staff and ongoing situation. Any concerns should be escalated and labour ward called sooner.

Ensure the labour ward coordinator is aware if attending a woman who is having care out with guidelines.

When performing an initial assessment of a woman in labour, listen to her story and take into account her preferences and her emotional and psychological needs. NICE (2014)

Carry out an initial assessment to determine if midwifery‑led care in any setting is suitable for the woman, irrespective of any previous plan. The assessment should comprise the following:

• Observations of the woman:
• Review the antenatal notes (including all antenatal screening results) and discuss these with the woman.
• Ask her about the length, strength and frequency of her contractions.
• Ask her about any pain she is experiencing and discuss her options for pain relief.
• Record her pulse, blood pressure and temperature, and carry out urinalysis.
• Record if she has had any vaginal loss.
• Observations of the unborn baby:
• Ask the woman about the baby's movements in the last 24 hours.
• Palpate the woman's abdomen to determine the fundal height, the baby's lie, presentation, position, engagement of the presenting part, and frequency and duration of contractions.
• Auscultate the fetal heart rate for a minimum of 1 minute immediately after a contraction. Palpate the woman's pulse to differentiate between the heartbeats of the woman and the baby.
  
  In addition:
• If there is uncertainty about whether the woman is in established labour, a vaginal examination may be helpful after a period of assessment but is not always necessary.
• If the woman appears to be in established labour, offer a vaginal examination. NICE (2014)

Transfer the woman to obstetric‑led care if any of the following are observed on initial assessment:

• Observations of the woman:
• pulse over 120 beats/minute on 2 occasions 30 minutes apart
• a single reading of either raised diastolic blood pressure of 110 mmHg or more or raised systolic blood pressure of 160 mmHg or more
• either raised diastolic blood pressure of 90 mmHg or more or raised systolic blood pressure of 140 mmHg or more on 2 consecutive readings taken 30 minutes apart
• a reading of 2+ of protein on urinalysis
• temperature of 38°C or above on a single reading, or 37.5°C or above on 2 consecutive readings 1 hour apart
• any vaginal blood loss other than a show
• rupture of membranes more than 24 hours before the onset of established labour
• the presence of significant meconium
• pain reported by the woman that differs from the pain normally associated with contractions
• any risk factors recorded in the woman's notes that indicate the need for obstetric led care.
• Observations of the unborn baby:
• any abnormal presentation, including cord presentation
• transverse or oblique lie
• high (4/5 to 5/5 palpable) or free‑floating head in a nulliparous woman
• suspected fetal growth restriction or macrosomia
• suspected anhydramnios or polyhydramnios
• fetal heart rate below 110 or above 160 beats/minute
• a deceleration in fetal heart rate heard on intermittent auscultation
• reduced fetal movements in the last 24 hours reported by the woman.
  
  If none of these are observed, continue with midwifery-led care unless the woman requests transfer NICE(2014)

If any of the factors in recommendation are observed but birth is imminent, assess whether birth in the current location is preferable to transferring the woman to an obstetric unit and discuss this with the coordinating midwife. NICE (2014)

When conducting a vaginal examination:

• be sure that the examination is necessary and will add important information to the decision‑making process
• recognise that a vaginal examination can be very distressing for a woman, especially if she is already in pain, highly anxious and in an unfamiliar environment
• explain the reason for the examination and what will be involved
• ensure the woman's informed consent, privacy, dignity and comfort
• explain sensitively the findings of the examination and any impact on the birth plan to the woman and her birth companion(s)

If it is thought that labour has not established yet ensure findings are communicated clearly and documented. Following discussion with the family and information sharing on early labour advice, it is up to the individual midwife and the woman to decide if it is appropriate to leave the home.

Considerations must include maternal risks, travelling time for midwife, road conditions, weather conditions and any other concerns relayed by the woman and her partner.

Reasons for decision should be clearly documented and labour ward informed that you are leaving.

The woman and her birth partner must be informed they should contact labour ward should they need a midwife to return

Follow the plans for management if appropriate.

If appropriate (particularly where risk has been identified) have the second on-call midwife may be present during the first stage of labour for support.

Encourage the woman to have support from birth companion(s) of her choice.

Monitoring during labour

The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals and practitioners are expected to take the NICE (2017, amended 2022) guideline fully into account, alongside the individual needs, preferences and values of their patients or the people using their service. It is not mandatory to apply the recommendations, and the guideline does not override the responsibility to make decisions appropriate to the circumstances of the individual, in consultation with them and their families and carers or guardian. Any woman who wishes a home birth out with guidelines should be visited by 2 midwives, the named midwife and a senior midwife, team lead or supervisor. NICE (2014)

Throughout labour, provide women with information on the fetal monitoring method being advised and the reasons for this advice. NICE (2017, amended 2022)

Support the woman's decision about fetal monitoring during labour. Include birthing companion(s) in these discussions if appropriate, and if that is what the woman wants. Document these discussions and decisions in the woman's notes. (2022)

Keep women and their birthing companion(s) informed about what is happening if additional advice or review is being sought by the care team, for example from a senior midwife or obstetrician. NICE (2014)

Perform and document a systematic assessment of the condition of the woman and unborn baby every hour, or more frequently if there are concerns.

Discuss the results of each hourly assessment with the woman and base recommendations about care in labour on her preferences and:

• her reports of the frequency, length and strength of her contractions
• any antenatal and intrapartum risk factors for fetal compromise
• the current wellbeing of the woman and unborn baby
• how labour is progressing
  
  Include birthing companion(s) in these discussions if appropriate, and if that is what the woman wants. NICE (2017, amended 2022)

Remember that:

• fetal heart rate monitoring is a tool to provide guidance on fetal condition, and not a standalone diagnostic tool
• the findings from monitoring need to be looked at together with the developing clinical picture for both woman and baby. NICE (2022)

Ensure one-to-one support is maintained by having a midwife remain with the woman throughout labour. If the midwife needs to leave the room or there needs to be a change in staff, ensure the woman knows this is happening. NICE(2017, amended 2022)

1^st stage of Labour

• use either a Pinard stethoscope or Doppler ultrasound
• carry out intermittent auscultation immediately after a palpated contraction for at least 1 minute, repeated at least once every 15 minutes, and record it as a single rate on a partogram and in the woman's notes
• record accelerations and decelerations, if heard
• palpate (and record on the partogram) the maternal pulse hourly, or more often if there are any concerns, to ensure differentiation between the maternal and fetal heartbeats
• 4hrly Temp and BP in line with MEWS pathway.
• Frequency of passing urine
• Offer vaginal examination 4hrly or sooner if there is concern about progress or in response to the woman’s wishes. (after abdominal palpation and assessment of vaginal loss)
• Do not routinely offer amniotomy. Consider consultation with medical staff first.

2^nd Stage of labour

Once the woman has signs of, or is in confirmed second stage of labour:

• perform intermittent auscultation immediately after a palpated contraction for at least 1 minute, repeated at least once every 5 minutes and record it as a single rate on a partogram and in the woman's notes
• palpate the woman's pulse simultaneously to differentiate between the maternal and fetal heart rates
• if there are concerns about differentiating between the 2 heart rates, seek help and consider changing the method of fetal heart rate monitoring. NICE (2007, amended 2022)

If, on intermittent auscultation, there is an increase in the fetal heart rate (as plotted on the partogram) of 20 beats a minute or more from the start of labour, or a deceleration is heard:

• carry out intermittent auscultation more frequently (for example, after 3 consecutive contractions)
• carry out a full review, taking into account the whole clinical picture including antenatal and existing or new intrapartum risk factors, maternal observations, contraction frequency (including hypertonus) and the progress of labour. NICE (2017, amended 2022)

If fetal heart rate concerns are confirmed:

• summon help
• advise continuous CTG monitoring, and explain to the woman and her birth companion(s) why it is recommended, and the implications for her choices of type and place of care
• transfer the woman from midwifery-led to obstetric-led care, providing that it is safe and appropriate to do so 

 Transfer the woman to obstetric‑led care if any of the following are observed at any point, or additional concerns identified using MEWS chart unless the risks of transfer outweigh the benefits:

• Observations of the woman:
• pulse over 120 beats/minute on 2 occasions 30 minutes apart
• a single reading of either raised diastolic blood pressure of 110 mmHg or more or raised systolic blood pressure of 160 mmHg or more
• either raised diastolic blood pressure of 90 mmHg or more or raised systolic blood pressure of 140 mmHg or more on 2 consecutive readings taken 30 minutes apart
• a reading of 2+ of protein on urinalysis
• temperature of 38°C or above on a single reading, or 37.5°C or above on 2 consecutive occasions 1 hour apart
• any vaginal blood loss other than a show
• the presence of significant meconium

As part of ongoing assessment, document the presence or absence of significant meconium. This is defined as dark green or black amniotic fluid that is thick or tenacious, or any meconium‑stained amniotic fluid containing lumps of meconium

If significant meconium is present, transfer the woman to obstetric‑led care provided that it is safe to do so and the birth is unlikely to occur before transfer is completed.

• pain reported by the woman that differs from the pain normally associated with contractions
• confirmed delay in the first or second stage of labour
• request by the woman for additional pain relief using regional analgesia
• obstetric emergency – including antepartum haemorrhage, cord prolapse, postpartum haemorrhage, maternal seizure or collapse, or a need for advanced neonatal resuscitation
• retained placenta
• third‑degree or fourth‑degree tear or other complicated perineal trauma that needs suturing.
• Observations of the unborn baby:
• any abnormal presentation, including cord presentation
• transverse or oblique lie
• high (4/5 to 5/5 palpable) or free‑floating head in a nulliparous woman
• suspected fetal growth restriction or macrosomia
• suspected anhydramnios or polyhydramnios
• fetal heart rate below 110 or above 160 beats/minute
• a deceleration in fetal heart rate heard on intermittent auscultation

 Nice (2017, amended 2022)

3^rd stage

The time immediately after the birth is when the woman and her partner are meeting and getting to know their new baby.

Whenever possible ensure uninterrupted skin to skin for at least 1hr and delayed cord clamping of at least 1 minute. This may be longer if requested and both woman and baby are both well.

Ensure any care interventions are sensitive to this special time and minimise separation or any disruption of the mother and baby.

Women should be informed of the options for;

Active management;

• routine uterotonic drugs (Oxytocin)
• delayed cord clamping
• controlled cord traction

Physiological management;

• no routine uterotonic drugs
• no clamping of the cord until pulsation has stopped
• delivery of placenta by maternal effort. NICE (2014)

Prolonged 3^rd stage is diagnosed when the 3^rd stage of labour is not completed within 30 mins following active management or 60 mins following physiological management.

Observations recorded should include:

Vaginal blood loss

Condition of mother, skin tone, respiratory rate and verbal report on how she is feeling.

Inform labour ward of delivery of new born and placenta and report on condition of woman and baby.

Retained Placenta

In the event that the placenta has not delivered within the expected time frame; explain the situation to the woman and her birth partner and explain increased risk of PPH if placenta remains in situ.

Offer Oxytocin if not already given

Advise woman to spontaneously empty her bladder. Offer in out catheter only if woman is unable to do this or if there is active bleeding, then use an indwelling foley catheter.

Call an ambulance

Inform labour ward/ medical staff

Secure IV access and explain to woman why this is necessary. Only midwives trained in cannulation should attempt this otherwise await arrival of ambulance.

Do not use IV Oxytocin routinely to deliver a retained placenta NICE (2014)

If actively bleeding use IV Oxytocin to deliver placenta. NICE (2014) This can be done by a midwife trained in cannulation and IV therapy or a paramedic.

Provided baby is well at time of delivery they should be placed immediately onto the mother’s chest for skin to skin contact.

According to Unicef (2022)

• all mothers have skin-to-skin contact with their baby after birth, at least until after the first feed and for as long as they wish
• all mothers are encouraged to offer the first feed in skin contact when the baby shows signs of readiness to feed
• mothers and babies who are unable to have skin contact immediately after birth are encouraged to commence skin contact as soon as they are able, whenever or wherever that may be.

• Vigilance of the baby’s well-being is a fundamental part of postnatal care immediately following and in the first few hours after birth. For this reason, normal observations of the baby’s temperature, breathing, colour and tone should continue throughout the period of skin-to-skin contact in the same way as would occur if the baby were in a cot (this includes calculation of the Apgar score at 1, 5 and 10 minutes following birth). Care should always be taken to ensure that the baby is kept warm. Observations should also be made of the mother, with prompt removal of the baby if the health of either gives rise to concern.
• Staff should have a conversation with the mother and her companion about the importance of recognising changes in the baby’s colour or tone and the need to alert staff immediately if they are concerned.
• It is important to ensure that the baby cannot fall on to the floor or become trapped in bedding or by the mother’s body. Mothers should be encouraged to be in a semi-recumbent position to hold and feed their baby. Particular care should be taken with the position of the baby, ensuring the head is supported so the infant’s airway does not become obstructed.

Apgars should be assessed at 1 and 5 mins

Take cord blood samples in rhesus negative women for babies’ blood group and rhesus factor. (x1 large and x1 small red blood tube)

• Following skin to skin:
• Check babies’ temperature
• Weigh baby, OFC, Length
• Perform 1^st newborn examination with parents’ consent and with at least one if not both parents present.
• Administer Vitamin K as per parents’ consent.
• Record 1^st feed.
• If O2 saturation monitor available perform neonatal saturation levels before leaving the home. If unable to do this perform at routine new born examination within 24 hrs.

In the instance of significant meconium and the baby is healthy it is advised that the mother and baby are transferred to a consultant unit with access to a neonatologist for observations at 1hr, 2hrs and 2hrly until 12hrs of age.

If there has been non-significant meconium, observe baby at 1 and 2hrs of age in all birth settings and advise parents of signs of concern requiring transfer to hospital NICE (2017)

Carry out maternal observations: Temp, pulse, BP, RR and O2 Sats.

Uterine contractions and lochia.

Examine placenta and membranes noting their condition, structure, vessels and completeness.

Perform perineal inspection of woman with consent. If the woman needs to be sutured and the midwife feels she can confidently perform this at home then suture according to NHS Borders suturing guidelines. (See perineal care)

Assess woman’s emotional and psychological condition in response to labour and birth and document. 

Successful voiding of the bladder within the first 6 hrs.

Take Kleihauer test with consent in Rhesus negative mothers including FBC as per NHS Borders guideline.  (x 1 large red tube, x 1 small red tube)

Perineal Care

Define and record perineal or genital trauma.

Explain to the woman what is planned and why.

Offer Entonox

Ensure good lighting.

Perform examination sensitively, if genital trauma seen perform rectal examination.

Ensure the timing of this assessment does not interfere with bonding unless the woman has bleeding that requires immediate attention.

Assist woman to adopt a position that allows adequate visual assessment. Only maintain for as long as necessary.

If it is not possible to adequately assess the trauma or if there is uncertainty about the extent of the trauma, transfer the woman to hospital for further assessment and suturing with trained medical staff, adequate lighting and analgesia.

All midwives should have undertaken training in perineal/genital assessment and repair and ensure they maintain these skills.

Ensure effective analgesia is in place prior to suturing. Up to 20mls of 1% Lidocaine.

If skin requires suturing use continuous subcuticular technique.

Perineal repair should be undertaken using a continuous non-locked suturing with synthetic absorbable suture material.

Routinely offer non-steroidal anti-inflammatory drugs following repair unless contraindicated. This may include oral ibuprofen which can be bought in preparation for home birth by the family.

Complete all written documentation and information recording on Badgernet.

Obtain CHI number from Scottish Birth Record.

Documentation should be contemporaneous in the 1^st incidence but in the event of a rapid second stage of labour or an obstetric emergency it is acceptable to record documentation on paper and then scan this into the mothers’ notes as soon as possible on arrival in the hospital.

Ensure baby has fed. If breast feeding, ensure woman is confident with holding baby and position at breast as well as good latch.  If formula feeding, ensure woman has sterilising equipment and can make up feeds safely according to department of health guidelines. In both instances woman should understand how to feed responsively and how to seek advice for feeding support until her next midwife appointment.

Save labour and birth reports.

Open a postnatal record.

Transfer care to community midwife.

Ensure mother has emptied her bladder. If she has not done so by 6 hrs explain to her to contact labour ward for further advice.

Advise the mother how to contact a midwife if she has concerns.

Ensure parents are aware of the signs of an unwell baby and have contact details of who to call if they are concerned.

Advise the family of their routine midwife appointments and add this to Badgernet as a reminder for the woman.

Ensure family have registration documentation and leaflet “reducing the risks of cot death”, Care opinion form for feedback.

1. Home birth equipment, home birth drugs & gases
2. Fire Safety
3. Transfer to community care
4. Initial PPH Management
5. Cord Prolapse
6. Breech Presentation
7. VBAC
8. PPH discussion
9. Shoulder dystocia
10. Raised BMI
11. B Strep carrier
12. Low haemoglobin