What are the best‑practice steps to initiate care for an adult low‑risk pregnant client seeking home‑birth midwifery services?

Best Practice for Initiation into Care for Home Birth Midwifery Practice

For low-risk pregnant clients seeking home birth midwifery services, initiate care with a comprehensive reproductive and medical history, confirm pregnancy with urine testing, establish gestational age, assess risk factors that would preclude home birth, and provide immediate prenatal counseling including folic acid supplementation, lifestyle modifications, and STD/HIV screening if prenatal care will be delayed. 1

Initial Visit Components

Confirm Pregnancy and Establish Gestational Age

• Perform a qualitative urine pregnancy test at the initial visit 1
• Estimate gestational age based on last normal menstrual period 1
• If uncertain about last menstrual period dates, a pelvic examination may be needed to assess gestational age 1
• Rule out ectopic pregnancy or other pregnancy abnormalities through history and examination 1

Comprehensive History Taking

Document the following specific elements:

Reproductive History:

• Duration of pregnancy attempts and timing of conception 2, 3
• Previous pregnancies and their outcomes (including complications like preeclampsia, gestational diabetes, preterm birth, or fetal growth restriction) 1, 2, 3
• Menstrual history including cycle regularity 2, 3
• History of infertility or pregnancy loss 2, 3

Medical History:

• Chronic medical conditions (hypertension, diabetes, cardiac disease, psychiatric illness, physical disabilities) that may increase maternal morbidity and mortality 1, 4
• Current medications and allergies, as some medications are contraindicated in pregnancy 1
• Family history of reproductive complications 2, 3

Risk Assessment for Home Birth Eligibility:

• Identify conditions that would classify the client as high-risk and inappropriate for home birth (Level I basic care facilities provide care only to low-risk women expected to have uncomplicated births) 1
• Women with cardiac disease, chronic hypertension, previous preeclampsia, or other complications require specialty or subspecialty care (Level II or III facilities) 1, 4

Physical Examination

Perform a targeted physical examination including:

• Height, weight, and BMI calculation 1, 2, 3
• Blood pressure measurement (baseline for future comparison) 5
• Thyroid examination 2, 3
• Clinical breast examination 2, 3
• Pelvic examination to assess for vaginal or cervical abnormalities, uterine size and shape, and adnexal masses or tenderness 2, 3

Immediate Prenatal Counseling

Nutritional and Lifestyle Guidance:

• Prescribe or provide daily prenatal vitamin containing folic acid 1
• Counsel to avoid smoking, alcohol, and recreational drugs 1, 2
• Advise against consuming fish with high mercury levels 1
• Discuss impact of extreme body weight and high caffeine intake (more than five cups per day) on pregnancy outcomes 1, 2

Medication Review:

• Review all current medications for safety in pregnancy and advise that any medications need ongoing review by the prenatal care provider 1

Early Pregnancy Education:

• Provide information about normal signs and symptoms of early pregnancy 1
• Instruct client to report any concerning symptoms immediately for evaluation 1

Laboratory and Screening Services

If Delays in Ongoing Prenatal Care Are Anticipated:

• Provide or refer for STD screening including HIV testing 1
• Ensure appropriate vaccinations are up to date 1

Note on Unnecessary Testing: The following are NOT routinely needed at the initial visit for contraceptive purposes but may be appropriate for prenatal care planning: cervical cytology, routine laboratory tests for lipids, glucose, liver enzymes, hemoglobin, or thrombogenic mutations 1

Psychosocial Assessment

• Evaluate mental health status (depression, anxiety) that could affect pregnancy outcomes 2
• Screen for intimate partner violence and sexual violence, with referral for appropriate care if identified 2
• Assess social support systems and refer to counseling or supportive services as needed 1
• Assess substance use behaviors including alcohol, prescription medication abuse, and illicit drugs 2

Establish Care Plan and Follow-Up

Referral Coordination:

• For clients choosing to continue pregnancy with home birth, establish clear protocols for transfer to hospital care if complications arise (home birth requires backing by a modern hospital system) 6
• Provide resource listing or directory of backup obstetric providers and hospitals 1
• Make specific appointments or contact referral sites directly when needed 1

Partner Communication:

• Encourage client to include partner in discussions if desired, while maintaining confidentiality if client chooses not to involve partner 1, 2

Documentation:

• Confirm client understanding of the information provided using teach-back method 1
• Document client's understanding in the medical record 1

Critical Pitfalls to Avoid

• Do not proceed with home birth planning for high-risk clients: Women with cardiac disease, chronic hypertension, previous severe preeclampsia, or other medical complications require Level II or III facility care and are not appropriate candidates for home birth 1, 4
• Do not delay STD/HIV screening: If there will be delays in establishing ongoing prenatal care, provide screening at the initial visit 1
• Do not assume all medications are safe: Every medication must be reviewed for pregnancy safety 1
• Do not overlook intimate partner violence screening: This can significantly impact pregnancy outcomes and treatment adherence 2
• Ensure hospital backup is established: Home birth must be supported by a modern hospital system for emergency transfers 6

Ongoing Care Considerations

Women who experienced pregnancy complications in previous pregnancies (preeclampsia, gestational diabetes, preterm birth) should receive counseling about recurrence risk and mitigation strategies, as these conditions increase future cardiovascular disease risk 1, 7. This counseling should begin in the initial prenatal period and continue postpartum 1.

Home birth is appropriate only for selected low-risk pregnant women, and the International Federation of Gynecology and Obstetrics and International Confederation of Midwives conclude that out-of-hospital birth supported by a registered midwife is safe when properly backed by hospital systems 6. However, continuous risk reassessment throughout pregnancy is essential to identify any developing complications that would necessitate transfer to hospital-based care 1.