Models of intrapartum care

She is 36 weeks, well, and this is her first baby. She hands you a birth plan that says "home birth, water pool, no obstetric review." The temptation is to say yes or no. The consultants who handle this well do neither first — they give her the numbers for a nulliparous woman, and they let the numbers change the conversation. This whole topic turns on whether you counsel on planned place of birth with her parity in mind, or whether you quote the pooled average and miss the risk that is concentrated exactly where she sits.^[1]

Overview and definition

Four planned birth settings are the frame, and the words matter because they decide what is and is not available in the room.^[1][7]

• Obstetric unit (OU) — midwives, obstetricians, anaesthetists, theatre, blood, neonatal team, continuous monitoring: the full capability on site.
• Alongside midwifery unit (AMU) — midwifery-led, on the same site as an OU, so transfer is a corridor rather than an ambulance.
• Freestanding midwifery unit (FMU) — midwifery-led, geographically separate; transfer is by ambulance.^[4]
• Home — midwifery-led, in the woman's home; transfer is by ambulance.

Midwifery continuity of carer means the same midwife (or small team) provides care through pregnancy, birth and the postnatal period — distinct from caseload midwifery (a named midwife with backups), team midwifery (a shared team), and standard fragmented care.^[3]

Water immersion in labour (first stage in the pool) and waterbirth (birth in the pool) are different questions with different evidence — keep them separate in the counselling.^[2]

References9ShowHide

1. [1]Brocklehurst P, Hardy P, Hollowell J, et al. Perinatal and maternal outcomes by planned place of birth for healthy women with low risk pregnancies: the Birthplace in England national prospective cohort study. BMJ, 2011.PMID 22117057
2. [2]Cluett ER, Burns E, Cuthbert A Immersion in water during labour and birth. Cochrane Database Syst Rev, 2018.PMID 29768662
3. [3]Sandall J, Soltani H, Gates S, Shennan A, Devane D Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database Syst Rev, 2016.PMID 27121907
4. [4]Overgaard C, Møller AM, Fenger-Grøn M, Knudsen LB, Sandall J Freestanding midwifery unit versus obstetric unit: a matched cohort study of outcomes in low-risk women. BMJ Open, 2011.PMID 22021892
5. [5]Wax JR, Lucas FL, Lamont M, Pinette MG, Cartin A, Blackstone J Maternal and newborn outcomes in planned home birth vs planned hospital births: a metaanalysis. Am J Obstet Gynecol, 2010.PMID 20598284
6. [6]Bovbjerg ML, Cheyney M, Caughey AB Maternal and neonatal outcomes following waterbirth: a cohort study of 17 530 waterbirths and 17 530 propensity-matched landbirths. BJOG, 2022.PMID 34773367
7. [7]American College of Obstetricians and Gynecologists Committee Opinion No. 697: Planned Home Birth. Obstet Gynecol, 2017.PMID 28333824
8. [8]de Jonge A, Geerts CC, van der Goes BY, Mol BW, Buitendijk SE, Nijhuis JG Perinatal mortality and morbidity up to 28 days after birth among 743 070 low-risk planned home and hospital births: a cohort study based on three merged population-based datasets in the Netherlands. BJOG, 2015.PMID 25204886
9. [9]Royal Australian and New Zealand College of Obstetricians and Gynaecologists Water immersion during labour and birth (C-Obs 24) RANZCOG, 2021.Source