Learning Objectives
By the end of this section, you will be able to:
- Explain considerations when choosing an in-hospital birth
- Explain considerations when choosing an out-of-hospital birth
- Analyze considerations when choosing a birthing place
When a person becomes pregnant, the birthing place is most often based on their choice of prenatal care provider or their health care insurance carrier. Other pregnant persons choose the birthing place based on personal preference first and then choose a health care provider who provides care in the choice of birthing place. In the United States the various birthing place choices can be divided into in-hospital and out-of-hospital birthing places.
In-Hospital Birthing Place Choices
In the United States more than 98 percent of births take place within hospitals (Scrimshaw & Backes, 2020). There are four levels of regionalized perinatal care provided by hospitals (ACOG, 2019). Each level is based on the resources, staff, equipment, and processes in place for a perinatal patient’s specific needs and risk level (The Joint Commission, n.d.).
Level I hospitals are capable of providing care for low-risk and moderate-risk pregnancies and newborns at term. A Level I hospital has the capability to perform cesarean births and initiate complex antepartum and intrapartum care as well as neonatal support measures until transfer to a higher-level facility. Level II hospitals are capable of providing Level I care plus care for moderate-risk to high-risk pregnancies and newborns at 32 weeks’ gestation or later. Level III hospitals provide Level II care plus have the capability to care for high-risk pregnancies with complex preexisting medical and pregnancy-related conditions, obstetric complications, and fetal and newborn conditions. Level III hospitals are capable of providing care for preterm and critically ill infants regardless of gestation. Level IV hospitals provide Level III care plus on-site availability for the most comprehensive and intensive perinatal care required for complex preexisting medical and pregnancy-related conditions, critically ill obstetric patients, and fetuses and newborns (ACOG, 2019).
Labor and Birth Suites
In-hospital birthing places include units composed of labor and birth rooms or suites. A labor and birth suite is designed to provide care to the person during the entire labor and birth process, immediate care to the newborn, and care in the first hours of recovery for the birthing person and transition for the newborn. The labor and birth suites are designed to provide care to the birthing person and newborn for vaginal births. The suites include a birthing bed, a fetal monitoring system, an infant warmer, and an ensuite bathroom. The suites are equipped to provide oxygen and suction to both the birthing person and newborn, as well as equipment and supplies for the labor, birth, and first hours after the birth for both the newborn and postpartum person. The suites are large enough to provide sufficient room for support persons, health care providers, and nursing and ancillary staff to move freely throughout the labor and birth process and the first 1 to 2 hours after birth.
One to 2 hours after birth, the birthing person and newborn are transferred to mother/baby units as a couplet or the birthing person to a postpartum unit and the newborn to a newborn nursery. When the birth is uncomplicated, a baby-friendly hospital promotes and supports breast-feeding and does not separate the birthing person from their newborn during the entire hospital stay. The birthing person and their newborn are transferred to a mother/baby unit, and a nurse is assigned to provide care to the couplet. Some hospitals that are not designated as baby friendly transfer the birthing person to the postpartum unit, and the newborn is transferred to the newborn nursery. Once the initial newborn assessment is completed by the nurse, the newborn is allowed to be in the room with the birthing parent as much as possible. A nurse is assigned to care for the postpartum person, and a different nurse is assigned to care for the infant.
Labor, Delivery, Recovery, and Postpartum Suites
A suite in an in-hospital birthing place where the patient labors, gives birth, and remains for the entire hospital stay is known as a labor, delivery, recovery, postpartum (LDRP) suite. Similar to the labor and birth suites, the LDRP suites are designed to provide care to the person during the entire labor and birth process and immediate care to the newborn, but also provide postpartum care to the birthing person who had a vaginal birth. The LDRP suites are set up like and contain the same equipment as the labor and birth suites. The difference is there is no need to transfer the birthing person to a postpartum or mother/baby unit. When the LDRP suites are within a baby-friendly hospital, the newborn stays in the suite with the birthing parent until discharge, and one nurse cares for the couplet. If there is a newborn nursery, the newborn is with the birthing parent as much as possible.
In-Hospital Birthing Centers
An in-hospital birthing center is a unit within a hospital staffed and equipped to provide intrapartum, postpartum, and normal newborn services to pregnant persons who are designated as low risk, have an uncomplicated pregnancy, and carry a single fetus in a vertex presentation. The unit is separate from the labor and birth unit in the hospital and is designed with a home-like physical environment. There are fewer restrictions on the presence and number of support persons and family members in the birthing rooms within a birthing center.
Care provided in an in-hospital birthing center includes:
- Intermittent fetal and uterine contraction monitoring, allowing more freedom to move about the birthing center
- IV access for intermittent fluids for dehydration or antibiotics if the pregnant person is positive for group B Streptococcus (GBS) infection
- Comfort measures, breathing and relaxation techniques, and emotional support for the discomfort of labor
- No narcotic analgesia, inhalation anesthesia, and epidural anesthesia
- Local anesthesia for perineal repair
- Medications and intravenous solutions for management of postpartum hemorrhage
- Neonatal and birthing person resuscitation equipment
- A length of stay that is 24 hours from the time of the birth for the postpartum person and newborn
Reasons for transferring the patient to the labor and birth or postpartum unit include:
- Request for epidural
- Temperature above 100.4° F two times, 4 hours apart
- Tachycardia or hypertension
- Labor augmentation
- Prolonged active phase or second stage
- Failure to progress or descend
- Presentation other than vertex or multiple gestation
- Meconium-stained, bloody, or malodorous amniotic fluid
- Fetal stress or need for continuous fetal and uterine contraction monitoring
- Need for cesarean birth
- Prolapsed cord
- Excessive vaginal bleeding, abruption, retained placenta, or postpartum hemorrhage
- Resuscitation
Reasons for transferring the newborn to the nursery include:
- Resuscitation
- Transient tachypnea of the newborn
- Sepsis
- Persistent hypothermia or hypoglycemia
- Signs of prematurity
- Weight less than 2,500 g
- Jaundice
- Failure to breast-feed or bottle-feed
- Failure to void or have a bowel movement within the first 24 hours after birth
Out-of-Hospital Birthing Place Choices
In the United States less than 2 percent of births take place outside hospitals (Scrimshaw & Backes, 2020). Low-risk pregnant persons at term with uncomplicated single-fetus pregnancies and without expected labor and birth complications fit the criteria to deliver outside the hospital. Two out-of-hospital birthing choices are free-standing birthing centers and home births.
Free-Standing Birthing Centers
Approximately 28 percent of pregnant persons who choose an out-of-hospital birth in the United States deliver in free-standing birthing centers (Scrimshaw & Backes, 2020). A free-standing birthing center provides intrapartum, postpartum, and normal newborn care to low-risk persons whose pregnancy is uncomplicated and only one fetus in a vertex presentation is present (ACOG, 2019). The care provided in a free-standing hospital birthing center and reasons for transfer are the same as for the in-hospital birthing center. The major difference is the distance from the closest hospital with perinatal services, so transfer to the hospital is via medical transport (ambulance). Free-standing birthing centers are often located within 30 minutes of a hospital with perinatal services.
Birthing at Home
Approximately 67 percent of out-of-hospital births in the United States occur in the home (Scrimshaw & Backes, 2020). The majority of home births are planned. Like birthing centers, home births are recommended for low-risk persons whose pregnancy is uncomplicated and there is only one fetus in a vertex presentation.
Exclusion criteria for home birth include:
- People who smoke
- People who use or abuse substances
- Less than 16 and over 40 years of age
- Height less than 5 feet
- Weight less than 100 pounds or greater than 220 pounds at conception
- History of previous perinatal complication
- Preexisting medical conditions
- Previous cesarean birth or uterine surgery
- Known congenital or genetic anomaly
- Preterm labor or rupture of membranes
The care provided when birthing at home and reasons for transfer are similar to those for birthing centers. One major difference is home births may occur more than 30 minutes from a hospital if an obstetric emergency occurs. Home births also differ from birthing-center births in the attendants. Physicians rarely provide home birth services, and most home births are attended by midwives with various levels of education. The birth attendants bring all the birthing equipment with them, and newborn and postpartum supplies are provided by the birthing person.
Choosing a Birthing Place
Choosing a birthing place involves more than talking with a family member or friend and financial and health insurance factors. It is important to understand the care capabilities provided by the birthing place; feel comfortable with the actions required when a complication of the labor, birth, postpartum, or newborn develops; and realize that transfer from the original birthing place location is sometimes required. Previous birth experiences also influence the choice of birthing place.
Nurses can assist the pregnant person with making a choice by being knowledgeable about all factors to consider and being aware of the level of the in-hospital birthing place and capabilities of the out-of-hospital birthing places available in the community. The factors to consider include the capabilities of the level of care provided within the birthing place; the absence or presence of antepartum, intrapartum, and postpartum risk factors for the pregnant person, as well as newborn risk factors; what is involved when a transfer of birthing place is required; and the training and qualifications of the health care providers and staff associated with each birthing place.
Link to Learning
Understanding the outcomes and choice of the various birth settings available to pregnant persons in the United States can help the nurse guide them when selecting a birthing place.