Out-of-Hospital Deliveries

Out-of-hospital deliveries can be divided into planned and unplanned1. The former generally occur in a prepared setting and are attended by medical personnel; the latter generally occur when the woman is entering the active phase of labor rapidly and may take place en route to the hospital or at the home itself. In either event, unplanned out-of-hospital delivery can be a stressful and sometimes even hazardous experience. Unplanned out-of-hospital deliveries carry an increased risk for adverse maternal and perinatal outcomes, specifically hemorrhage and perinatal mortality2–14. Out-of-hospital deliveries are not confined to countries with low resources and where home deliveries are the rule rather than the exception. In countries with high resources, specific groups are more likely to experience out-of-hospital deliveries than the general population. For example, Bateman et al.3 reported that patients who delivered out-of-hospital in the USA were more likely to be African-American, multigravid and to have had little or no prenatal care. Similarly, other ethnic minorities such as Asians living a long way from the hospital in Europe are also at risk for out-of-hospital deliveries and for adverse pregnancy outcome4–6. In one often-quoted article, albeit written almost 50 years ago and not repeated to our knowledge, approximately 5% of all women who underwent vaginal delivery without complications lost more than 1000 ml of blood15. Assuming that this is correct, it has enormous implications for any woman who undergoes an out-of-hospital delivery because the objective evaluation of bleeding after delivery may be difficult in the absence of trained health care providers, especially if bleeding is slow and steady or in the presence of concomitant intra-abdominal bleeding16. Of equal importance, the clinical signs of blood loss, such as decrease in blood pressure and increased heart rate, tend to appear late, and only when the amount of blood loss reaches 1500 ml, mainly due to the high blood volume of pregnant women (see Chapters 9–11). Here again, a woman delivering out of hospital would appear to be at greater risk should this occur and not be noticed or monitored. Our group performed a large population-based study of risk factors for early postpartum hemorrhage (PPH)17. Although this was not the first such evaluation18–21, we were stimulated to characterize women at risk who warrant special attention after birth and, in particular, consultation about the advisability of outof-hospital delivery. Early PPH complicated 0.43% (n = 666) of all singleton deliveries included in this study (n = 154,311). Independent risk factors for early PPH, which can be of major importance during outof-hospital deliveries, are presented in Table 1. These risk factors were drawn from a multivariate analysis and included retained placenta, labor dystocia, placenta accreta, severe lacerations, large-forgestational-age newborn and hypertensive disorders16. One of the largest studies regarding out-of-hospital deliveries derives from our hospital, a tertiary medical center located in the Negev region, Israel12,13. In this area, most deliveries do occur in the hospital, and virtually all newborns and their mothers are brought to the hospital if delivered outside. This is done mainly because hospital deliveries are entitled to a birth payment from the government, which is also given to newborns who are brought to the hospital within 24 h of birth. The incidence of unplanned, accidental outof-hospital deliveries in this study was 2% (2328/ 114,938). These deliveries were described as unattended, as opposed to deliveries that were out-ofhospital but attended by skilled personnel. Perinatal mortality was significantly higher among out-ofhospital deliveries (odds ratio (OR) 2.01, 95% confidence interval (CI) 1.4–2.9), as compared with in-hospital deliveries. In addition, parturients who gave birth out-of-hospital had higher rates of perineal tears and retained placenta, as compared with patients delivered in hospital (Table 2). Finally, patients