What is "high risk"? - Mothering Forums
Homebirth > What is "high risk"?
erin23kate's Avatar erin23kate 12:07 PM 04-22-2011

Spinning off the footling/breach conversation further, does your midwife have a definition of "high risk"?  As in, should not deliver at home?

 

Most home birth proponents (me included) say that home birth is often right for "low-risk" pregnancies, but there doesn't seem to be a gold standard for the definition of it.  Should there be?  Or should it be up to the individual provider and parents to determine?

 

Thanks for the feedback - this isn't wholly theoretical; I have personally been called high risk by some providers and low risk by others.



~~Sarah~~'s Avatar ~~Sarah~~ 07:39 AM 04-25-2011

Sorry to answer your question with another question but... High risk for what? Different pregnancies are at different risks for different things. Some are at high risk for miscarriage or pre-term birth, which wouldn't make a homebirth unsafe provided the pregnancy lasted until term... right? Some pregnancies are at high risk for hemorrhage which, would generally risk someone out of homebirth.

 


erin23kate's Avatar erin23kate 03:25 PM 04-25-2011

I see what you mean.   I guess I was looking for more of a "set" list, like, um....(making this stuff up, if I knew the answer I wouldn't ask)

 

~less than 36 weeks gestation

~mom has pre-e, or BP over ###

~mom has gestational diabetes, or sugar over ###

~transverse lie, footling breech

~twins/triplets/quads/quints

~VBA6C?

 

That sort of thing.  Is there a list somewhere that MANA or another organization agrees on?  ACOG's list is simple, Pregnant = Hospital, but I was curious if there is an industry standard for certain medical conditions which contraindicate home birth.


PunkElmo's Avatar PunkElmo 03:55 PM 04-25-2011

certain states have definite regulations...

 

premature (before 36 or 37 weeks)

advanced maternal age

VBAC

pre-E or high BP

multiples

breech

placental issues 

 

those can all be "risk out" factors...

 

but a lot of it is a gray area in a lot of states... and some midwives choose NOT to follow laws (based on their experience, etc., they feel X, Y or Z is safe or not a risk)

 

Most of the midwives I interviewed had experience in 3rd world countries, where they delivered breech, multiples, and tons of other "high risk" stuff that nobody wants to touch in our litigious country (but, of course, they have no CHOICE in those countries).  Some were willing to do those kinds of deliveries here, but have to be very underground and cautious about it, due to licensure and politics.

 

so yes, what IS high risk?

 

(I'm curious too, as I was just risked out by a midwife after a single high BP reading that wasn't all THAT high [pre-e was ruled out too as a precaution] - another midwife found my reading to be a. much lower [probably because she wasn't stressing me out like the first midwife] and b. acceptable for homebirth)


AlexisT's Avatar AlexisT 04:14 PM 04-25-2011

Not a homebirther, but the question of risk interests me a great deal.

 

"Low" and "high" risk aren't well defined terms in either obstetrics or midwifery. There's a good deal of grey area.

 

However, in a safety context, we do have a starting point--the exclusion criteria used in studies. These tend to be on the strict side, because any complication can be a confounder--however, when we say that homebirth has been validated as a safe choice for low risk women, this is what they mean by low risk. Unfortunately, even these aren't consistent, but here are some typical ones:

 

- Multiple births

- Any position other than vertex

- Term pregnancy only (usually 37-42 weeks, sometimes 38-42)

- Preexisting major health conditions (including all hypertension and diabetes)

- Frequently, VBACs - though the Canadian study last year permitted VBA1C (single LSCS)

- Complications of pregnancy: hypertensive disorders, IDGDM, cholestasis

- Previous obstetrical complications, such as history of stillbirth, PPH over a certain point, early-onset preeclampsia

 

Here's the list of criteria used by the hospital where I gave birth last time (this applies to all midwifery services in the trust, including birth centres and home birth): http://www.bcf.nhs.uk/our_services/maternity_services/ridgeway_mlu/midwifery_led_acceptance_criteria?display=original


konayossie's Avatar konayossie 06:50 PM 04-25-2011
IUGR -- just know this one bc of my own experience.
erin23kate's Avatar erin23kate 06:55 PM 04-25-2011

I gave birth to my son in a hospital birth center, one 45 min from my home,  because I risked out of the first one.  The first CNMs labeled me high risk because of my BMI - I wear a size 18, and I'm 5'8".  Oddly enough, I became "high risk" during pregnancy because of a severe Crohn's flare, but I was still able to stay in my midwife's care because of her relationship with her backup OB. I went into labor at 37w on the day; one day earlier, literally, and I would have had to deliver at an entirely different hospital, one I hate, without either of them.  And, to add to the fun, I had a retained placenta and PPH. 

 

As I contemplate our next baby, I am weighing home birth, but since I do ride the line of high risk, especially if I flare again, it's more than theoretical.  If I am truly high-risk, I would like to know, independent of a single person's opinion.

 

Interesting lists, for sure.  Maybe the next question would be.... what do YOU think is too high a risk for YOU to deliver at home?


erin23kate's Avatar erin23kate 07:03 PM 04-25-2011



 

And there's my Crohns (though they spelled it wrong)!  Plus the BMI @ 36...and the PPH....and the retained placenta....yeah, that's quite a list.  Hmmm.... Food for thought.


Midwife Scottie's Avatar Midwife Scottie 07:42 PM 04-25-2011

The reason that high/ low risk is so high to define is because just because a mama has a extremely high BP (using an extreme cause to illustrate a point)- say 190/115 doesnt mean that she is going to have a seizure; just means she is more likely too. It is true that different states have different laws and many will actually dictate how a midwife is to act in certain case. But there are still grey areas- VBACs and vaginal breeches in nonfirst time mamas. This is where informed choice comes in. This is a central component of homebirth and if your midwife isnt participating in it then you should find another. The midwife should give you all the benefits and risks of a certain situation and mamas should seek out their own information and then make the decision that feels right to them. For me, personally, these are some of the items that are clear cut risk out items:

-BP over 140/90 on two different occasions

-Preeclampsia

-Placenta Previa

-Poor fetal heart tones that dont resolve

-Gestational diabetes that is not controled by diet

- Certain genetic abnormalities (such as heart defects)

-nonlongitudinal lie

-abnormal bleeding (any sign of a possible abruption)

-and certain health conditions in the mother

 

These are just what I could think of off the top of my head. There are probably many more that I am forgetting....

What it comes down to is that women are responsible for their own healthcare- seek out providers who will educate you not just treat you and seek out information for yourself. This empowers you to make decisions for yourself and your baby. In the end you and your baby will be happier and healthier.


Midwife Scottie's Avatar Midwife Scottie 07:52 PM 04-25-2011

Just so you know-

Just because you had a retained placenta or a PPH does not mean that you will next time. That does NOT make you high risk. It also makes me mad when women get labeled as high risk just for their BMI- that is just one component of health. What is her diet like? Is she exercising? How much (or little) weight is she gaining in this pregnancy? Again, I dont think that makes you high risk. As far as the Crohn's- I dont know enough about it to say- i would have to look it up.

Getting labeled as "high risk" can really mess with mama's heads and how they think about their bodies and their ability to birth. I hate how easily people use that label and even apply it to themselves! If someone tells you that you are high risk- ask for actual statistics on birth outcomes in patients with similar situations. Good luck ladies!


Cutie Patootie's Avatar Cutie Patootie 01:18 PM 05-03-2011

I was "risked out" of my homebirth because my diastolic bp number isn't staying below 90.


cinderella08's Avatar cinderella08 10:29 PM 05-08-2011

In South Carolina, midwives are fairly heavily regulated.

 

This is our list of what needs a referral or consultation.  Please note, I have upset many people by looking at this list.  These things do NOT mean you have to transfer care from the CPM/LM.  It simply means a consult is needed with an OB or CNM.  What generally happens is the CPM and CNM will confer and decide what, if any, course of action needs to be taken.  Like hyperemesis.  CPMs can't write a script for medications, so the CNM would see the client and write a script for Zofran and return the client back to the CPM.

 

1. Has a history of serious problems not discovered at the initial visit with a health
care provider;
2. Develops a blood pressure of 141/89 or more, or a persistent increase of
30 systolic or 15 diastolic over her usual blood pressure;
3. Develops marked edema of face and hands;
4. Develops severe persistent headaches, epigastric pain, or visual
disturbances;
5. Develops proteinuria or glycosuria;
6. Has convulsions of any kind;
7. Does not gain at least 14 pounds by 30 weeks gestation or at least four
pounds per month in the last trimester, or gains more than six pounds in any twoweek
period;
8. Has vaginal bleeding before the onset of labor;
9. Has symptoms of kidney or urinary tract infection;
10. Has symptoms of vaginitis;
11. Has symptoms of gonorrhea, syphilis or genital herpes;
12. Smokes more than 10 cigarettes per day and does not decrease usage;
13. Appears to abuse alcohol or drugs;
14. Does not improve nutrition within satisfactory limits;
15. Is anemic (Hematocrit under 32; Hemoglobin under 11.5);
16. Develops symptoms of diabetes;
18
17. Has excessive vomiting;
18. Has "morning sickness" (nausea) continuing past 24 weeks gestation;
19. Develops symptoms of pulmonary disease;
20. Has polyhydramnios or oligohydramnios;
21. Is Rh negative for periodic blood testing;
22. Has severe varicosities of the vulva or extremities;
23. Has inappropriate gestational size;
24. Has suspected multiple gestation;
25. Has suspected malpresentation;
26. Has marked decrease in or cessation of fetal movements;
27. Has rupture of membranes or other signs of labor before completion of 37
weeks gestation;
28. Is past 42 weeks gestation by estimated date of confinement and/or
examination;
29. Has a fever of 100.4 for 24 hours;
30. Demonstrates serious psychiatric illness or severe psychological
problems;
31. Demonstrates unresolved fearfulness regarding home birth or midwife care,
or otherwise desires consultation or transfer;
32. Develops respiratory distress in labor;
33. Has ruptured membranes without onset of labor within 12 hours;
34. Has meconium-stained amniotic fluid;
35. Has more than capillary bleeding in labor prior to delivery;
36. Has persistent or recurrent fetal heart tones significantly above or below
the baseline, or late or irregular decelerations which do not disappear permanently
with change in maternal position, or abnormally slow return to baseline after
contractions;
19
37. Has excessive fetal movements during labor;
38. Develops ketonuria or other signs of exhaustion;
39. Develops pathological retraction ring;
40. Does not progress in dilation, effacement or station in any two-hour period in
active labor;
41. Does not show continued progress to delivery after two hours in second
stage (primigravida); one hour for multigravida;
42. Has a partially separated placenta or atonic uterus;
43. Has bleeding of over three cups before or after delivery of placenta;
44. Has firm uterus with no bleeding but retained placenta more than one hour;
45. Has significant change in blood pressure, pulse over 100, or is pale, cyanotic,
weak or dizzy;
46. Retains placental or membrane fragments;
47. Has laceration requiring repair;
48. Has a greater than normal lochial flow;
49. Does not void urine within six hours of birth;
50. Develops a fever greater than 100.4 on any two of the first ten days
postpartum excluding the first day;
51. Develops a foul-smelling or otherwise abnormal lochial flow;
52. Develops a breast infection;
53. Has signs of serious postpartum depression;
54. Develops any other condition about which the midwife feels concern


starling&diesel's Avatar starling&diesel 07:56 AM 05-11-2011

This is SUPER LONG, but very comprehensive.  It shows the guidelines and transfer of care for our provincial college of midwives here in BC:

 

COLLEGE OF MIDWIVES OF BRITISH COLUMBIA
 
INDICATIONS FOR DISCUSSION, CONSULTATION 
AND TRANSFER OF CARE

 
As a primary caregiver, the midwife is fully responsible for decision-making, together with the
client. The midwife is responsible for writing orders and carrying them out or delegating them
in accordance with the standards of the College of Midwives.
 
The midwife discusses care of a client, consults, and/or transfers primary care responsibility
according to the Indications For Discussion, Consultation And Transfer Of Care. The
responsibility to consult with a family physician/general practitioner, obstetrician and/or
specialist physician lies with the midwife. It is also the midwife’s responsibility to initiate a
consultation within an appropriate time period after detecting an indication for consultation.
The severity of the condition and the availability of a physician will influence these decisions.
 
The College of Midwives expects members to use their professional judgement in making
decisions to consult or transfer care. The following list is not exhaustive. Other circumstances
may arise where the midwife believes consultation or transfer of care is necessary.
 
The informed choice agreement between the midwife and client should outline the extent of
midwifery care, so that the client is aware of the scope and limitations of midwifery care. The
midwife should review the Indications For Discussion, Consultation And Transfer Of Care with
the client.
 
DEFINITIONS
 
Discussion with Another Midwife or a Physician1 
It is the midwife’s responsibility to initiate a discussion with, or provide information to, another
midwife or a physician in order to plan care appropriately. It is also expected that the midwife
will conduct regularly scheduled reviews of client charts to assist in planning care. Discussion
should be documented by the midwife in her records.
 
Consultation with a Physician2
It is the midwife’s responsibility to initiate a consultation and to communicate clearly to the
consultant that she is seeking a consultation. A consultation refers to the situation where a
midwife, using her professional knowledge of the client and in accordance with the standards
of the College of Midwives, requests the opinion of a physician competent to give advice in
the relevant field. A midwife may also seek a consultation when another opinion is requested
by the client. Consultation must be documented by the midwife in her records in accordance
with the standards of the College of Midwives.
                                                     
1
 Discussion should occur with a physician, or with another primary care provider such as a nurse practitioner, where another
midwife is not available.
2
 In this document, consultation with a physican means consultation with a physician licensed by the College of Physicians
and Surgeons of BC unless otherwise specifically indicated.
 
Refer Standard 2 Indications for Discussion, Consultation and Transfer of Care
CMBC Standards of Practice 
Current Revision: March 15, 2010
page 2 of 7
 
The midwife should expect that the consultant will address the problem that led to the referral,
conduct an in-person assessment(s) of the client, and promptly communicate findings and
recommendations to the client and to the referring midwife. Discussion may then occur
between the midwife and the consultant regarding the future care of the client.
 
Where urgency, distance or climatic conditions do not allow an in-person consultation with a
physician, the midwife should seek advice from the physician by phone or other similar
means. The midwife should document this request for advice in her records, in accordance
with the standards of the College of Midwives, and discuss the advice received with the client.
 
A consultation can involve the physician providing advice and information, and/or providing
therapy to the woman/newborn, or prescribing therapy to the midwife for the woman/newborn.
 
After consultation with a physician, primary care of the client and responsibility for decision-
making,  with the informed consent of the client, either:
 
a) continues with the midwife, or
b) is transferred to physician.
 
If care is transferred to a physician, the midwife may continue to provide supportive care and
whatever care is within her scope of practice and is agreed to by the physician who is in the
role of most responsible care provider.
 
Once a consultation has taken place and the consultant’s findings, opinions and
recommendations have been communicated to the client and the midwife, the midwife must
discuss the consultant’s recommendations with the client and ensure that the client
understands which health professional will have responsibility for primary care.
 
The consultant may be involved in, and responsible for, a discrete area of the client’s care,
with the midwife maintaining overall responsibility within her scope of practice. Areas of
involvement in client care must be clearly agreed upon and documented by the midwife and
the consultant.
 
Only one health professional has overall responsibility for a client at any one time, and the
client’s care should be co-ordinated by that person. The identity of the primary caregiver
should be clearly known to all of those involved and documented in the records of the
referring health professional and the consultant. Responsibility could be transferred
temporarily to another health professional, or be shared between health professionals,
according to the client’s best interests and optimal care; however, transfer or sharing of care
should occur only after discussion and agreement among the client, the referring health
professional, and the consultant(s).
 
Transfer to a physician for primary care
When primary care is transferred permanently or temporarily from the midwife to a physician,
the physician assumes full responsibility for subsequent decision-making, together with the
client. When primary care is transferred to a physician, the midwife may provide supportive
care within her scope of practice, in collaboration with the physician and the client.
Refer Standard 2 Indications for Discussion, Consultation and Transfer of Care
CMBC Standards of Practice 
Current Revision: March 15, 2010
page 3 of 7
INDICATIONS: Initial History and Physical Examination
Discussion:

 adverse socio-economic conditions

 age less than 17 years or over 40 years

 cigarette smoking

 grand multipara (5 or more previous births)

 history of infant over 4,500 g

 history of one late miscarriage (after 14 weeks) or pre-term birth

 history of one low-birth-weight infant

 history of serious psychological problems

 less than 12 months from last delivery to present due date

 obesity

 poor nutrition

 previous antepartum haemorrhage

 previous postpartum haemorrhage

 one documented previous low-segment caesarean section

 history of essential or pregnancy-induced hypertension

 known uterine malformations or fibroids

 
Consultation
 current medical conditions, for example: cardiovascular disease, pulmonary
disease, endocrine disorders, hepatic disease, neurologic disorders, severe
gastrointestinal disease
 family history of genetic disorders, hereditary disease or significant congenital
anomalies
 history of cervical cerclage or incompetent cervix
 history of repeated spontaneous abortions
 history of more than one late miscarriage or pre-term birth
 history of more than one low-birth-weight infant
 history of eclampsia
 history of significant medical illness
 previous myomectomy, hysterotomy or caesarean section other than one
documented previous low-segment caesarean section
 previous neonatal mortality or stillbirth
 rubella during first trimester of pregnancy
 significant use of drugs, alcohol or other toxic substances
 age less than 14 years
 history of postpartum haemorrhage requiring transfusion
 
Transfer:
 any serious medical condition, for example: cardiac or renal disease with failure,
or insulin-dependent diabetes mellitus
 
Refer Standard 2 Indications for Discussion, Consultation and Transfer of Care
CMBC Standards of Practice 
Current Revision: March 15, 2010
page 4 of 7
INDICATIONS: Prenatal Care
Discussion:
 presentation other than cephalic at 4 weeks prior to due date
 no prenatal care before 28 weeks gestation
 uncertain expected date of delivery
 
Consultation:
 anaemia (unresponsive to therapy)3
 documented post-term pregnancy (42 completed weeks)
 suspected or diagnosed foetal anomaly that may require physician
management during or immediately after delivery
 inappropriate uterine growth
 medical conditions arising during prenatal care, for example: endocrine
disorders, hypertension, renal disease, suspected or confirmed significant
infection, including H1N14, hyperemesis
 placenta previa without bleeding
 polyhydramnios or oligohydramnios
 gestational hypertension
 isoimmunization, haemoglobinopathies, blood dyscrasia
 serious psychological  problems5
 sexually transmitted disease6
 twins7
 repeated vaginal bleeding other than transient spotting
 presentation other than cephalic at 37 weeks
 
Transfer:
 cardiac or renal disease with failure 
 insulin-dependent diabetes
 multiple pregnancy (other than twins)
 pre-eclampsia or eclampsia
 symptomatic placental abruption
 
 
                                                     
3
 Consultation may be with a physician or a nurse-practitioner
4
 Consultation with a physician is required for all cases of H1N1infection; co-management or transfer of care may be
necessary based on the physician’s assessment
5
 Consultation may be with a physician, clinical psychologist, mental health worker, or nurse practitioner.
6
 Consultation may be with a physician, or a nurse-practitioner.
7
 In many settings the management of a twin pregnancy will involve transfer of care to an obstretrician. The midwife may
continue to provide supportive care and whatever care is within her scope of practice and is agreed to by the physician who is
in the role of most responsible care provider.
 
Refer Standard 2 Indications for Discussion, Consultation and Transfer of Care
CMBC Standards of Practice 
Current Revision: March 15, 2010
page 5 of 7
INDICATIONS: During Labour and Delivery
Discussion:

 no prenatal care
 thin, non-particulate meconium8
 
Consultation:
 breech presentation9
 pre-term labour (34-37 completed weeks)
 prolonged active phase
 prolonged rupture of membranes
 prolonged second stage
 suspected placenta abruption and/or previa
 retained placenta
 third or fourth degree tear
 twins10
 unengaged head in active labour in primipara
 thick or particulate meconium11
 
Transfer:
 temperature over 38°C on more than one occasion
 active genital herpes at time of labour
 pre-term labour (less than 34 weeks)
 abnormal presentation (other than breech)
 multiple pregnancy (other than twins)
 pre-eclampsia or eclampsia
 prolapsed cord
 placenta abruption and/or previa
 severe hypertension
 abnormal foetal heart rate patterns unresponsive to therapy
 uterine rupture
 uterine inversion
 haemorrhage unresponsive to therapy
 obstetric shock
                                                     
8
 Whenever meconium, is present the midwife in attendance must be prepared to intubate any non-vigorous newborn.
9
 While many of these deliveries may become transfers of care, breech presentation and twins are listed as indications for
consultation to allow an obstetrical consultant discretion in deciding if a midwife may manage such a delivery, where a spontaneous
birth is reasonably anticipated. Usually a midwife would conduct the delivery under t he direct supervision of an obstetrician. In a
remote area, the availability of an experienced midwife who has the confidence of her obstetrical colleagues can prevent a woman
from having to leave her family and community. Midwives may also gain important hands-on experience under obstetrical
supervision.
10
 See footnote #8 above
11
 Where thick or particulate meconium is identified, delivery in hospital is indicated unless the membranes rupture so close to the
time of birth that transport to hospital would be unsafe. The midwife should initiate appropriate surveillance of fetal well-being
(see Guideline for Fetal Health Surveillance in Labour) and consult with a physician in hospital. In hospitals where pediatricians
are available on-call, it is recommended that a pediatrician be consulted and in attendance at the birth. Indicators such as a
reassuring or non-reassuring fetal heart rate pattern will affect whether or not transfer of care during labour is indicated. With thick
or particulate meconium, it is important to have a midwife or physician in attendance who is both skilled and prepared to intubate
any non-vigorous newborn. 
 

INDICATIONS: Postpartum (Maternal)
Consultation:

 breast infection unresponsive to therapy12
 wound infection13
 uterine infection14
 signs of urinary tract infection unresponsive to therapy15
 temperature over 38°C on more than one occasion16
 persistent hypertension
 serious psychological problems17
 
Transfer:
 haemorrhage unresponsive to therapy
 eclampsia
 thrombophlebitis or thromboembolism
 uterine prolapse
 
INDICATIONS: Postpartum (Infant)
Discussion:
 feeding problems18
 
Consultation:
 suspicion of or significant risk of neonatal infection
 34 to 37 weeks gestational age19
 infant less than 2,500 g
 less than 3 vessels in umbilical cord
 excessive moulding and cephalohaematoma
 abnormal findings on physical exam
 excessive bruising, abrasions, unusual pigmentation and/or lesions
 birth injury requiring investigation
 congenital abnormalities, for example: cleft lip or palate, congenital dislocation
of hip, ambiguous genitalia
 abnormal heart rate or pattern
 persistent poor suck, hypotonia or abnormal cry
 persistent abnormal respiratory rate and/or pattern
 persistent cyanosis, pallor or jitteriness
 jaundice in first 24 hours
 failure to pass urine or meconium within 24 hours of birth
 suspected pathological jaundice after 24 hours
 temperature less than 36°C unresponsive to therapy
 temperature more than 37.9°C unresponsive to therapy
                                                   
 vomiting or diarrhoea20
 infection of umbilical stump site21
 significant weight loss (more than 10% of body weight)
 failure to regain birth weight in 3 weeks
 failure to thrive
 
Transfer:
 Apgar score lower than 7 at 10 minutes
 suspected seizure activity
 significant congenital anomaly requiring immediate medical intervention, for
example: omphalocele, myelomeningocele
 temperature instability
                                                     
 


starling&diesel's Avatar starling&diesel 08:03 AM 05-11-2011

I debated whether or not to include the previous info in the main body of my message, but then decided yes.   It's helpful info.  I like that it separates the issue into categories of history, pre-labour, labour, and post-delivery for mama and baby.

I was risked out for pre-eclampsia last time.  And now that I understand when the midwives will transfer care or require that I deliver in hospital, it has taken a lot of pressure off of myself and my partner knowing that we don't need to be making those decisions on our own, inside a bubble. 

My signs and symptoms were not obvious or extreme (no blurred vision, no dizziness) but my normally very low bp was high for me (we're talking 120/104, which is not alarming in itself, but I'm normally 95/65, even while pregnant), but more worrying was that I was spilling protein in my urine and my kidneys were not working properly, according to the blood work.

 

We're aiming for a homebirth again this time, but I am way less attached to where I birth, and far more attached to how I birth.  Last time I had a natural induction and med-free/intervention-free labour and delivery, and I'm aiming for that again, and hopefully at home!  The nice thing about BC is that your midwives go with you to the hospital where they consult the powers that be regarding your situation, but I actually NEVER saw a doc.  Just my midwives and the required L&D nurses, who I studiously ignored while bellowing like a cow. 


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