Hindawi Publishing Corporation
Obstetrics and Gynecology International
Volume 2013, Article ID 196709, 4 pages
Unattended Home Labor until Complete Cervical Dilatation
Ending with Hospital Delivery: Analysis of 238 Pregnancies
Ozlem Gun Eryilmaz, Nasuh Utku Dogan, Cavidan Gulerman,
Leyla Mollamahmutoglu, Nedim Cicek, and Ruya Deveer
Zekai Tahir Burak Women’s Education and Research Hospital, 62000 Ankara, Turkey
Correspondence should be addressed to Ozlem Gun Eryilmaz; firstname.lastname@example.org
Received 1 September 2012; Revised 21 December 2012; Accepted 29 January 2013
Academic Editor: Gian Carlo Di Renzo
Copyright © 2013 Ozlem Gun Eryilmaz et al. This is an open access article distributed under the Creative Commons Attribution
License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly
Objectives. Hospital fear and avoidance of the routine hospital obstetrical interventions cause some women with low-risk
pregnancies to spend most of the active labor period at home, and subsequently they present to the hospital for delivery. Our
aim was to analyze the maternal and neonatal outcomes of pregnancies with a planned hospital birth, yet spending the first stage of
labor at home without a health provider and completing the delivery in the hospital setting.Methods. We retrospectively compared
238 pregnancies having home labor plus hospital delivery (study group) with 476 pregnancies that had spent the whole labor
in the hospital setting, considering various maternal and neonatal outcomes. Results. Cesarean and episiotomy rates were lower
(푃 < 0.0001 and 푃 < 0.001, resp.), but neonatal intensive care unit admissions of the infants were more prevalent (푃 < 0.01) in
implications of current data warrant further prospective trials.
the study group. Other maternal and neonatal outcomes including neonatal mortality were comparable. Conclusion. Although our
preliminary data generally do support the safety of home active labor plus hospital delivery for low-risk pregnancies, the clinical
Hospital setting is generally considered the safest place for
labor and delivery due to the presence of qualified birth
attendants, specialized personnel, and modern technological
equipment. There are several studies focusing on the safety
of a planned home birth, in which the maternal and neonatal
the fact is the decreasing home birth rate around the world
despite relatively favorable results following home birth .
The woman’s decision about the place of labor is
affected by many factors. Feelings of being safe, comfort-
able home environment, and the assistance of the relatives
may provide some women with more physiological support
in a home than a hospital birth. Additionally, the geo-
graphical distance between home and emergency services
could be a distressing factor in the presence of possible
Turkish maternity care system generally favors hospital
rates. In urban regions, most of the births take place in
hospitals with the attendance of an obstetrician. However in
certain rural districts, home births with or without the atten-
dance of healthcare personnel are still the leading category of
birth. There is another group of women, who belong to none
of the previously-mentioned groups. They plan a hospital
birth, but spend most of the labor period at home outside
the followup of any healthcare personnel and subsequently
complete the delivery in the hospital setting. Latent and
active labor periods in the first stage are completed at home,
and they would eventually present to the hospital labor
ward with complete or near-complete cervical dilatation
and effacement. Therefore, the active labor period that is
spent at home is considered “alone.” This implies absence of
was alone regarding any professional healthcare support
or obstetrical intervention. However, the laboring woman’s
partner, relatives, or neighbors are the only attendants in
this scenario. Consequently, the delivery takes place in the
hospital setting mostly with an attending obstetrician.
2 Obstetrics and Gynecology International
The implications of home labor followed by hospital
delivery have not been adequately studied, and data on these
pregnancies are scarce. In the current study, our aim was to
analyze the maternal and neonatal outcomes of pregnancies
with home labor plus delivery in our hospital.
2. Materials and Methods
We conducted a retrospective case control study between
January 2008 and September 2009 in Zekai Tahir Burak
Women’s Education and Research Hospital, Ankara, Turkey.
This hospital is a tertiary center specialized in women’s
health. Using hospital admission data, 279 women were
found to present to the labor ward with full dilatation, and
of these 238 were singleton and low-risk pregnancies (≥37
weeks’ gestation) that comprised the study group. Exclusion
criteria were (i) multiple pregnancies, (ii) previous caesarean
section, (iii) preterm deliveries (<37 weeks), and (iv) high
Women in the study group had spent the first stage at
cal dilatation at the end of the active first stage, and delivery
was performed in the hospital. A total of 476 gestational-
age matched pregnancies whose active labor period and
the delivery were spent in the hospital setting set up the
control group. Relevant data were extracted from maternal
and neonatal files.
Groups were compared considering maternal age, parity,
antenatal follow-up characteristics, fetal presentation, signs
of labor, presence of meconium-stained amniotic fluid, route
requirement. The analyzed neonatal outcomes comprised
of birth weight, Apgar scores at minutes 1 and 5, and the
Additionally, data on the causes of prolonged home
period of the labor were also specifically retrieved if acces-
sible. Preference for this conduct was grouped as (1) desire
for a relaxed environment during labor, (2) hospital fear, (3)
logistic problems, that is, transportation to the hospital, and
(4) woman’s preference for her partner’s attendance during
transfer to the hospital.
were used to evaluate the normality of the continuous vari-
risk pregnancies including (but not limited to) hypertension,
diabetes, other endocrinological problems, and abnormal
ables within groups. Mann-Whitney 푈 test and independent
categorical data, Pearson’s chi-square or Fisher’s exact test
was utilized for comparisons. A 푃 value less than 0.05 was
The incidence of home labor plus hospital delivery was
0.7% within all the deliveries during the study period.
Demographic data and the maternal outcomes of the study
and control groups are presented in Table 1. The parity was
home labor were more likely to have received no antenatal
followup compared to controls (Table 1). The labor signs
were also different between the two groups. Both groups had
abdominal pain as the mostly pronounced complaint. The
thatofthehomelaborgroup(18.3%versus0.8%,푃 = 0.0001),
The mean gestational ages at presentation were similar
across the groups. The requirement for episiotomy and
cesarean delivery was significantly lower in the study
group (Table 1). Other perinatal complications including
meconium-stained amniotic fluid were comparable with no
significant differences (Table 1). There was a single postpar-
tum uterine atony case (0.4%) in the home labor group
versus two women with postpartum hypotonic uterus and
one placental bed bleeding (0.4%).
Mean birth weights and Apgar scores did not differ among
the groups. Analyses of neonatal intensive care unit (NICU)
requirements for the newborns are summarized in Table 3.
to NICU (Table 2). Respiratory depression was the most
pronounced neonatal problem (44%) in the NICU in the
study group. There were no neonatal mortalities in the home
labor group versus one in the hospital labor group due to
probable birth asphyxia (not significant).
The motives for spending the first stage of labor out
of the hospital environment are summarized in Table 4.
Most common explanations were hospital fear caused by the
negative birth experiences (46%) and desire to stay longer in
the so-called comfortable home conditions (44%).
and 71.4% for the hospital labor groups (푃 < 0.01). Rupture
and bleeding was more prevalent in the hospital labor group
(3.8% versus 11.3%, 푃 = 0.0001).
Various investigations [1–6, 8, 10] on the feasibility of home
birth have reported relative safety and convenience of home
labor and delivery if attended by a certified healthcare
home birth rates except the Netherlands, the leading country
system encourages planned hospital births. In urban regions
of the country, hospital birth attended by an obstetrician is
generally the standard. However, the study population in the
current series was apparently diverse in that the first stage of
labor period was outside the hospital, despite the location of
the hospital in an urban residential area.
Our data revealed that home labor was not a decision
of a specific age group in the defined population. Both
adolescent and middle-aged pregnant women had similar
intentions for choosing to spend most of the time for active
labor period at home. Close social contacts such as the elder
pregnant women. The older women’s orientations possibly
Obstetrics and Gynecology International3
Table 1: Comparisons of demographic data and pregnancy outcomes of pregnancies with home and hospital labor.
(푛 = 238)
38.7 ± 1.2
Meconium in amniotic fluid (%)
Episiotomy rate (%)
Cesarean delivery rate (%)
Composite morbidity (%)
Home labor group
26 ± 5.4
Hospital labor group
25.4 ± 5.1
(푛 = 476)
38.9 ± 1.0
Prenatal care (%)
Gestational age (weeks)
Fetal presentation (head) %
1.2 ± 1.00.7 ± 0.9
96.2 (228/238)99.4 (473/476)
Values are expressed as mean ± standard deviations. NS: not significant.
Table2:Comparisonsof certainneonataloutcomesof pregnancies
with home and hospital labor.
3284.9 ± 427.9
(푛 = 238)
3303.1 ± 432.3
(푛 = 476)
Birth weight (g)
Apgar score at minute 1
Apgar score at minute 5
NICU admission (%)
6.9 ± 0.3
6.9 ± 0.1
8.9 ± 0.38.9 ± 0.0
Values are expressed as mean ± standard deviations. NICU: neonatal
intensive care unit. NS: not significant.
Table3:Detailsof outcomesof theinfantsadmittedtotheneonatal
intensive care unit in the study and control groups.
(푛 = 18)
(푛 = 17)
Respiratory morbidity (%)
Meconium aspiration syndrome (%) 16.6 (3/18)
Major congenital abnormality (%)
Caput succedaneum (%)
Neonatal mortality (%)
44.4 (8/18) 58.8 (10/17)
For all comparisons, 푃 > 0.05.
Table 4: Grounds for late hospital admissions in the study group.
(푛 = 238)
Hospital fear (%)
Remain at home during labor (%)
Woman waiting for her partner (%)
Logistic problems: home far from hospital (%)
nant women with uncomplicated previous birth experiences
could be courageous about the home labor. This subset of
women probably do not have “hospital fear,” but prefer the
more comfortable home environment, as reported in other
studies on home births [13–15]. The more experienced the
pregnant woman about birth, the higher the home labor rate
was reported. For instance, home birth frequency was found
to be two times much more common among multiparous
women with a low-risk previous pregnancy .
Previous negative birth experiences of the pregnant
delayed presentation at the labor ward. These findings were
parallel to previous information on home birth [13–16]. A
hospital birth experience in the current study; in fact most
of the time in labor had been bypassed at home so as to
not experience the negative hospital practices. These women
obvious that further investigations are needed to figure out
the social and medical motivations of such behavior in those
Women preferring home labor were also more likely
to fail to comply with a regular antenatal followup. It is
possible that supposedly low-risk pregnancy profile led these
women not to attend regular antenatal followup. Alterna-
tively, women vigilant about the antenatal visits also prefer
the complete hospital labor and delivery attended by an
obstetrician. This might be related to a proposal that medical
interventions and routine hospital procedures are necessary
and medical interventions worth to have a healthy birth
Signs of labor, such as vaginal bleeding, amnion leakage,
or abdominal pain, seemed influential for the women in
the study to remain at home. Rupture of the membranes
was almost absent in the home labor women. On the other
hand, vaginal bleeding was the leading sign in the hospital
labor group. Probably, vaginal bleeding was considered as
an emergency sign to reach the physician. Vaginal bleeding
or amnion leakage is apparently a more objective symptom
4 Obstetrics and Gynecology International
that most women and their partners would regard as an
emergency during birth. Women free of these signs can
be proposed to feel more stress-free and safe at home,
formulating home a more logical environment for them.
Decreased caesarean section rate in the study group
can partially be explained by the lack of labor induction
and augmentation. Pregnancies with an unattended first
stage of labor would receive less medical interventions.
This might account for lower cesarean rates in this subset
of women. Meconium-stained amniotic fluid risk was not
increased in the home labor group. It is possible that lack
of labor induction also prevented unnecessary episiotomies
in our population. It can be hypothesized that physiological
relaxation capacity of the pelvic floor muscles was more
pronounced in women with home labor.
Interestingly, assistance by healthcare personnel during
the active first stage did not negatively affect most maternal
and neonatal complications in our data. Despite medically
nonsupervised labor, infants of the study group had similar
Apgar scores at 1 and 5 minutes compared with controls.
However, increased NICU admissions of the home labor
group were mostly related to respiratory problems with no
significant effect on neonatal mortality. These could indicate
that the respiratory problems of infants from those low-risk
pregnancies were not associated with increased mortality,
probably indicating relative safety of absence of professional
labor followup at least in some women. Nevertheless, this
information should be evaluated with caution, as we do
not have data on medium- to long-term neonatal outcomes.
The number of the pregnancies we included might also be
undersized to draw straightforwardconclusionsforrelatively
uncommon outcomes such as various neonatal problems.
In conclusion, our preliminary analyses on the maternal
and neonatal outcomes of low-risk pregnancies with the out-
of-hospital first stage of labor in the absence of any health
personnel revealed that such approach might be relatively
safe. However, requirement for NICU following delivery is a
concern in infants of these pregnancies.
Conflict of Interests
The authors confirm that they have no conflict of interests to
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