Subject: Home Birth
Attached is an updated version of evidence based procedures and regulations.
This notice relates to obstetricians (hereinafter referred to as OB) and to midwifery practitioners (hereinafter referred to as midwives).
The Ministry of Health respects the rights and freedom of every woman to choose where to give birth. Nonetheless, with the responsibility for public health, the Ministry sees it as its professional and moral obligation to emphasize that births in recognized and authorized delivery rooms are safer for the birthing mother and the neonate.
In light of the fact that homebirths are carried out in Israel, directives are given for their implementation in a way that remains consistent with a balance between the freedom of choice of the mother and the need to preserve the safety of the mother and the neonate (who does not benefit from the freedom of choice).
Home birth = birth in the home of the mother after advanced planning and preparation, by choice of the mother.
Based on the midwifery directives of 1929 and the medical directives (the updated version), 1976, certified midwives and OBs are permitted to receive homebirths in the home of the birthing mother.
We wish to clarify that there is no prohibition against a mother giving birth in her home without the assistance of a professional. Nevertheless, there is a prohibition against someone who is not a midwife or doctor to receive the birth as a professional practice.
Prohibition falls on activating a specific place for birthing that the medical establishment does not authorize.
1.Specifications to carry out an authorized home birth:
- Only the following are authorized to practice home births
- A midwife who is registered with the association of midwives in Israel with a minimum of three years of experience in a delivery room that is recognized in Israel according to the public health regulations, only after doing 10 homebirths in the presence of an experienced homebirth midwife.
- A doctor who specializes in neonatal and womens’ health who has a certification of specialization and a license in Israel, who practices or practiced obstetrics in a recognized delivery room in Israel for the duration of three years.
- Whoever practices home births is obligated to pass a CPR course with a minimum level of BLS, including a neonatal CPR course (NRP- Resuscitation neonatal program) provided by the Israel Association of Neonatology. It is in his responsibility to keep the certificate attesting to attendance and performance in the course. Once all of the courses are completed there will be an annual refresher course.
- It is the responsibility of homebirth practitioners to continuously stay updated on the relevant guidelines and notices from the website of the Ministry of Health (health.gov.il)
- It is appropriate for every homebirth practitioner to be insured with professional liability insurance. If the practitioner receiving the birth is not insured as mentioned above it is their responsibility and obligation to inform the birthing mother at an appropriate time, to clarify the implications of the lack of insurance, and to ensure that the birthing mother understands and agrees to this – document this
- Conditions necessary for a homebirth
Below is a list of conditions that only with their existence is it permitted to plan and carry out a homebirth.
2.1 – Obstetrics and Physical conditions
2.1.1 Pregnancy with a single fetus in the head presentation
2.1.2 The birth takes place between weeks 37 and 42 of pregnancy. Staring from week 41 (40+6) weeks of pregnancy there is a need to ensure and attest to a normal biophysical score no later than three days before the birth
2.1.3 Estimated weight of the fetus must be between 2500 and 4000 grams
2.1.4 The birthing mother declares her health status. If the midwife has doubts about the birthing mothers physical competence to home birth (as is delineated further below), it is necessary to demand confirmation of this from the attending physician.
2.1.5 The birthing mother is over the age of 18 (between ages 17 and 18 she is allowed to homebirth only with written consent from her parents), legally qualified, and able to make a decision independently based on her own free will.
2.1.6 There is a written record of the medical and obstetric history of the birthing mother.
2.1.7 There is documentation from the doctor or midwife that monitors and follows through the current pregnancy in accordance with the Ministry of Health.
2.1.8 Examination of the relevant body systems is carried out throughout the pregnancy – and there is documentation attesting to that.
2.1.9 Gestational diabetes is ruled out – and there is documentation attesting to this.
2.2. Conditions for the environment of the birthing mother
2.2.1 It must be ensured in advance that the home of the birthing mother is suitable for a homebirth – that there is running hot water, electricity, heating, a telephone, and that it is clean.
2.2.2 It must be ensured that the room in the house of the birthing mother where the birth is being planned to take place is suitable in size to the activity requirements (no less than 10 meters).
2.2.3 There exists the possibility to get to a hospital with an authorized delivery room within 30 minutes of making the decision to switch over to a hospital
2.3 Informed Consent
A written document of informed consent must be obtained from the birthing mother on the form “Request and Consent of the Woman to a Home Birth” (Appendix A). This is only after a detailed explanation is given to her by the midwife or attending physician that includes at least all of the information delineated in the said form.
2.4 Equipment and supplies necessary for a homebirth
2.4.1 A birth receiving kit (including at least four large pads)
2.4.2 A separation kit 2 , קלמים ,קוכר (scissors, bandages)
2.4.3 A sterile sewing kit
2.4.4 A sterile disposable gloves
2.4.5 An amniotome
2.4.6 A dopton
2.4.7 A mobile suction unit and accompanying equipment including catheters for the mother and the neonate or oral suction
2.4.8 An airway for the mother and the neonate
2.4.9 An ambu and mask for the mother and the neonate
2.4.10 oxygen and accompanying equipment
2.4.11 A blood pressure gauge
2.4.12 An adult bladder catheter
2.4. 13 An infusion set and accompanying equipment for the mother
2.4.14 Fluids and chemical solutions for the infusion
– Contracting uterus (such as: oxytocin and methargine)
– Cream or drops for the eyes (whichever are accepted at that time in Israel)
– VIT K
2.4.17 Sterile pads
2.4.18 Needles and syringes for injections
2.4.20 Blood test – tubes
2.4.21 A weight scale for the neonate
2.4.22 A thermometer
- Indicators against carrying out a homebirth
3.1 If in light of the medical information given by the birthing mother or information detailed in her medical chart, there is a doubt as to whether she meets the adequate health qualifications to do a homebirth, she is required to present confirmation from her attending physician. Only then is she allowed to do a homebirth
Below is a detailed list of conditions that always require confirmation from an attending physician:
3.1.1 Chronic illness and disability that are likely to influence the course of the birth or the neonate
3.1.2 An infectious disease that is active in the birthing mother
3.2 A homebirth cannot be conducted if the birthing mother is taking drugs or is on medication to withdrawal from drugs
3.3. Complications in the obstetrical past that constitute an indication against a homebirth
A homebirth cannot be received if in one of the following events occurred in a previous pregnancy
3.3.1 Fetal death in the womb or during the birth for known obstetric reasons that will likely influence the course of the current pregnancy or on the course of the birth
3.3.2 Separation of the placenta – not due to trauma
3.3.3 Birth with shoulder dystocia
3.3.4 A rupture in the perineum at the 3-4th degree or a rupture in the cervix
3.3.5 Unusual bleeding after birth (post partum hemorrhage)
3.3.6 Previous neonate who became ill with an early disease – from GBS
3.4 Defects in the uterus or the birth canal, congenital or acquired that constitute an indicator against a homebirth:
A homebirth cannot be accepted if one of the following situations exist:
3.4.1 unicornuate uterus, bicornuate uterus, septate uterus, uterus didelphys, double vagina, vaginal septum, uterus with a large myoma or fibroid which is a tumor previa in the current pregnancy. Everything is in accordance with the birthing mothers’ obstetric history and medical documentation
3.4.2 Surgical scars in the uterus (C section, removal of tumor, injury or perforation), after separation of intrauterine infection
3.4.3 Distortion of pelvis or spine – either congenital or acquired
3.5 Problems in the current pregnancy that constitute an indicator against a homebirth
A homebirth cannot be accepted if any of the following situations:
3.5.1 A pregnancy with more than one fetus
3.5.2 Any presentation that is not the head presentation
3.5.3 Systemic diseases that are chronic or acute that are diagnosed during pregnancy including heart disease, diabetes (including gestational diabetes), autoimmune diseases and thrombophilia
3.5.5 Inflammation of the kidneys or a urinary tract infection that is not responsive to antibiotic treatment through the pregnancy
3.5.6 GBS bacteriuria – in the course of the pregnancy, Deep Venus Thrombosis
3.5.7 Morbid obesity at time of the birth
3.5.8 Maternal anemia in the current pregnancy (less than 10 HGB per deciliter), Thrombocytopenia (less than 100,000 per microliter), according to the updated blood count – in the range of two weeks before the birth and/or other disturbances in the coagulation system, congenital or acquired, including treatment against coagulation in the current pregnancy.
3.5.9 Infection during pregnancy – fetal infection (or founded suspicion), positive test for TORCH, or a carrier for infectious diseases such as genital herpes, HIV, GBS, Jaundice C and B
3.5.10 Suspicious signs of pregnancy toxicosis
3.5.11 Cervical sutures that have not been removed
3.5.12 Known status of sensitivity against RH factor
3.5.13 Uterine bleeding in the second or third trimester
3.5.14 Pregnancy where a review of the systems was not carried out and gestational diabetes was not ruled out
3.5.15 Suspicion of a defect that is likely to cause an immediate functional interference of the neonate
3.5.16 Disturbance in the fetal rhythm or other pathological pattern in the pulse/heartbeat of the fetus close to birth,
3.5.17 Intrauterine growth retardation (IUGR)
3.5.18 When on evaluation the weight of the fetus close to birth is over 4000 grams or less than 2500 grams
3.5.19 Partial or complete placental previa or low placenta
3.5.20 Deficiency or excess of amniotic fluid
3.5.21 Low fetal movement
3.5. 22 Maternal fever 37.8 degrees and above, immediately prior to birth.
- Rules for treatment, registration and reporting of the birthing mother and the neonate
The treatment of the birthing mother and the neonate before, during and after the birth will be carried out in accordance with the guidelines of the Ministry of Health and provisions of the law.
4.1 The midwife/OB will guide the birthing mother at the time when the signs of active labor begin
4.2 The midwife/OB will arrive at the place of the birthing mother within an hour of her when she notified them that active labor has begun.
4.3 The midwife/OB will remain with the laboring mother from the beginning of active labor until at least two hours after the birth
4.4 Follow up must be performed to check on the vital signs with the birthing mother at least once an hour
4.5 The fetal heart rhythm should be listened to at least once every half hour in the first stage of labor and every 5-10 minutes in the second stage of labor.
4.6 A check and evaluation of the condition of the neonate should be performed immediately with the birth
4.7 The midwife/OB will closely supervise and monitor the neonate for a period of time of at least two hours after the birth
4.8 It is the responsibility of the midwife/OB to conduct a follow up visit to evaluate the mother and neonate twenty four hours after the birth
4.9 The midwife/OB will provide the birthing mother with information on ways of connecting with them in the postpartum period
4.10 Registration and Summary of the course of labor
4.10.1 The midwife/OB will document homebirths that were done by them and conduct organized archives according to the laws and regulations
4.10.2 The information given over to the birthing mother must be documented in an organized fashion, as must be the vital signs, the fetal heart rate, the findings of the neonatal checkups and the course of labor- throughout the birth management and immediately afterwards, as it accepted and required with every medical record
4.10.3 The records should include:
– Notes on the process of the birth including facts of the monitoring that was done
throughout the birth process of the birthing mother and neonate.
– Summary of the course of the birth (appendix b)
– Written physical assessment of the neonate (appendix c)
4.10.4 A copy of every note and report as mentioned above must be submitted to the birthing mother and the original should be kept by the midwife/OB
4.10.5 The minimum amount of time to keep the files and forms that are kept by the midwives is 25 years (at least).
4.10.6 The documents must be available for examination by the Ministry of Health at their will.
4.11 Upon completion of the homebirth without complications, the birthing mother should be informed that within twenty four hours of the birth the neonate must be examined by a pediatrician. The birthing mother should be encouraged to turn to a hospital for examination, to have the neonate examined and to register him in an orderly manner within twenty four hours after the birth.
- Rules for transferring the birthing mother and neonate from the homebirth to the hospital
Any situation that deviates from the normal course of childbirth and/or when the midwife/OB are not convinced of their ability or capability to care for the situation in a way that is fitting according to the health needs of the birthing mother and neonate, is required to be transferred to the hospital.
The midwife/OB have an obligation to honor any request of the birthing mother to be transferred to a hospital, at any stage of labor, immediately.
At the onset of any of these cases or any of the following complications that can be medical indications, the birthing mother should be transferred to a hospital. It is the responsibility of the midwife/OB to clarify to the birthing mother that it is her responsibility to be vacated to the hospital speedily/urgently as applicable.
5.1 Medical indications to transfer the birthing mother from the homebirth to the hospital during the course of labor
5.1.1. An unusually large amount of bleeding
5.1.2 Signs indicating placental abruption: Continual pain in the lower stomach, heightened uterine tone, changes in the heartbeat/pulse of the fetus that indicate distress, bleeding, decrease in blood pressure without external bleeding,
5.1.3. Umbilical cord prolapsed, preceding umbilical cord, or occult
5.1.4 Significant changes in the birthing mothers vital signs. Examples:
Rising temperature during labor (over 38 degrees Celsius)
Heartbeat/pulse over 120/minute for fifteen minutes or longer.
Decrease in systolic blood pressure of 20milimeters mercury from the base value for fifteen minutes or longer
Blood pressure above 140/90 at two different times measured within the same hour
5.1.5 Amniotic fluid that is meconium or bloody during the first stage of labor
5.1.6 A pathological course of birth such as:
184.108.40.206 Arrest of dilation in the first stage of labor for over two hours with the presence of regular contractions
220.127.116.11 Second stage of labor that is continuing for more than three hours primipara, or two hours with a repeat birth on the condition that there is no arrest of descent
5.1.7 Pathological changes in the fetal heart rate including: base heart rate less than 110 or above 160 per minute
5.1.8 Delay in the development of active labor, 12 hours after the water breaks, on the condition of maintaining proper hygiene and monitoring Chorioamnionitis
5.1.9 Signs of hypovolemia in the birthing mother
5.2 Indications to transfer the birthing mother to the hospital after the birth
5.2.1 Placenta has not come out by an hour after the fetus has been born
5.2.2 Increased bleeding before or after the placenta has separated
5.2.3 Incomplete placenta or suspicion of incomplete placenta
5.2.4 Pathological changes in the blood pressure of the mother including:
Decrease in LD systolic – 20 mm mercury or more from the base value for fifteen
minutes or more, or blood pressure above 140/90
5.2.5 Respiratory distress
5.2.6 Confusion, stillness/silence, and/or changes in the level of consciousness of the birthing mother
5.2.7 Difficulty in sewing up tears or the episiotomy
5.2.8 The appearance of a hematoma in the birth canal or vulva after birth
5.2.9 Three or four degree tears in the barrier or vagina or suspicion of a tear in the cervix
5.2.10 Pathological psychological signs in the birthing mother
5.3 Indicators to transfer the neonate immediately to the hospital
5.3.1 A baby who weighs less than 2500 grams or larger than 4000 grams
5.3.2 Signs of respiratory distress
– More than 60 breaths per minute
– Recoiling in the chest
– Nasal flaring and grunting
– Cyanosis or pallor
5.3.3 Blue or grey skin color that improves when oxygen is provided and stops when it is removed (Hypoxia). Transfer to the hospital will be done with an ambulance that will give the neonate oxygen.
5.3.4 Improper skin color- pale, yellow or red
5.3.5 Body temperature that is less than 35.5 degrees Celsius on two measurements that are not after an attempt to warm the neonate
5.3.6 Apgar of 7 or less, five minutes after the birth
5.3.7 Tremors, unusual movements, seizures
5.3.8 Signs of trauma including paralysis, sub-cutaneous hemorrhages
5.3.9 Congenital defects
5.4 Transferring the birthing mother and the neonate to the hospital
5.4.1 The method of transferring the birthing mother (by ambulance or another car) will be determined by the midwife/OB
5.4.2 The transferring of the birthing mother and the neonate will always be done through the accompaniment of the midwife/OB
5.4.3 It is the responsibility of the midwife/OB to inform the midwife on duty at the hospital or the designated doctor about the transfer to the delivery room and all other relevant medical information
5.4.4 A completed form of “Transferring the birthing mother from the homebirth to the hospital” (Appendix D)
5.4.5 The midwife/OB will give over to the hospital verbally or in writing all the details connected to the birthing mother, the pregnancy, the course of labor, and the neonate, including appendixes B, C, and D
- Guidelines for treating the birthing mother and the neonate after the birth (if the birthing mother chooses not to go to the hospital within twenty four hours after the birth).
It is the responsibility of the midwife/OB to:
6.1 To give preventative eye treatment to the neonate, according to the guidelines of the Ministry of Health
6.2 To inject the neonate with vitamin K – with a dose of 0.5 m.g. as is possible to the birth.
If the parents refuse the injection in the manner in which it is offered, vitamin K can be offered orally according to the following protocol:
– First dose – 2 mg within six hours after the birth, as soon as the neonate is able to nurse
– Continuation of the treatment – a dose of 2 mg at one week and two weeks of age
– For the neonate that spits up the vitamin within an hour of receiving it – the dose has to be given again
6.3 When the birthing mothers’ blood is RH negative, or in the event that in the blood serum of the mother is antibodies immune to antigens to the blood group, a blood test of the neonate must be taken checking the blood type, hemoglobin, and bilirubin in the blood.
6.4 When the birthing mother is blood type RH negative and the neonate is blood type RH positive, the birthing mother should receive an Anti D vaccine
6.5 To perform a blood sample on the neonate for metabolic diseases. Neonates are examined in the hospital for these diseases including Phenylketonuria and thyroid function, at the earliest forty eight hours after the birth and no later than seven days old. Afterwards a hearing test should be performed.
6.6 To give guidance for caring for the neonate on issues including: nursing, feeding, laying down (including positions), diapering, bathing, wiping, treating the belly button (umbilical area), dressing, temperature regulation in the bedroom in accordance with the different seasons, the importance of proper and secure seating and belting of the baby in the car, in accordance with the guidelines of the Ministry of Health and the law.
6.7 To inform the birthing mother that a checkup with a pediatrician is obligatory within 24 hours after the birth. Later on there will need to be regularly scheduled follow up for the neonate in a medical framework at a Center for the Mother and Child or for monitoring by a pediatrician.
6.8 To inform the birthing mother that according to the recommendations of the Ministry of Health she should turn to the Center for the Mother and Child to vaccinate the neonate against viral hepatitis B within twenty four hours after the birth.
6.9 To refer the birthing mother to register the neonate at the Ministry of Interior with an attached certification from the physicians declaration in accordance with Amendment #9 of the Population Registration Act as is detailed in the notice of the Ministry of Health 3/2006 Paragraph 2.
7 Guidelines for receiving the birthing mother and neonate from a homebirth into the hospital:
7.1 In receiving the birthing mother and neonate from the homebirth to the hospital a process of hospitalization that is usual for reception to the delivery room, will be performed. A complete medical and nursing registration must be performed. A copy of the registration form of the birth process will be attached to the medical file.
7.2 The birthing mother and the neonate will go through a checkup and a follow up of treatment in accordance with the processes and procedures of the Ministry of Health and the hospital, including a thorough examination for neonatal metabolic diseases and a hearing test.
7.3 Upon completion of the registration/reception process, the birthing mother enters hospitalization. If she refuses, she can be released by the senior obstetrician on duty.
7.4 In general, the mother and the neonate will be released simultaneously. This excludes medical situations that indicate the need to keep the neonate in the hospital after the mother has been released home. (Notice from Medical Administration #43/99)
7.5 If the mother refuses to allow the provision of treatment to the neonate, this should be documented in the Refusal of Treatment form, as is accepted in the hospital, with the signature of the nurse, the pediatrician, and the mother.
7.6 If the birthing mother requests to be released an early release, the nurse should:
7.6.1 Ensure that the neonate has been checked by a pediatrician before he has been released
7.6.2 Ensure that they have received a vaccination chart
7.6.3 Instruct the mother/parents about additional examinations that need to be performed on the neonate including examination for metabolic diseases, monitoring for bilirubin as needed, and a hearing test. The obligation for performance of these tests falls to the parents.
7.6.4 If the birthing mother is RH negative, blood tests should be taken from the mother and the neonate and the mother should be prompted to wait for the tests results in order to receive Anti D as needed.
This information should be passed to anyone who is dealing with this in their organizations.
Professor Arnon Afek
Head of Administration, Ministry of Health
Appendix A: Request and Agreement of the Woman to a Homebirth
A homebirth is intended for healthy birthing mothers that are not at risk according to medical classifications and who request to give birth at home with the assistance of a licensed midwife or the assistance of a physician who is a specialist in obstetrics and gynecology (From here on to be referred to as “midwife” or “OB”) without medical intervention as is accepted in regular births that take place in a delivery room, on the conditions and the environment that the birthing mother chooses.
It has been clarified to me that a homebirth is managed through a midwife or OB who are qualified in accordance with the law and professional practice.
Mothers Name ___________________________ I.D. ____________________________
Fathers Name ____________________________ I.D. ____________________________
I the undersigned request to give birth at home with the assistance of a qualified midwife or OB and I declare and confirm that a detailed verbal explanation from the midwife or OB _________________ Family name ____________________ License number __________________________ on the process of a homebirth and on its advantages and dangers including that which is detailed below, and I agree to act in accordance with them.
It has been clarified to me that if there is a change in my situation or the situation of the fetus/neonate in the course of labor or afterwards, a transfer to the hospital is required as soon as possible, at the discretion of the midwife or OB.
It has been clarified to me that in a homebirth monitoring of the fetus will be carried out intermittently in accordance with the stages of labor.
It has been explained to me that in a homebirth, like in a birth that takes place in a delivery room, unexpected difficulties and complications can occur that may require medical intervention such as for example, bleeding (as a result of separation of the placenta or a tear in the uterus), difficulty with extrication of the fetus, and in rare situations blood clotting disorders or amniotic fluid embolism, which are life threatening conditions.
It has been clarified to me that in the situations detailed above it is significant to perform medical intervention quickly, in a hospital setting, and therefore the transfer time to the hospital can be significant for me or the fetus/neonate.
I am aware that a delay in medical intervention as mentioned above, can cause severe and irreversible damage to me or the fetus/neonate.
It has been clarified to me that in situations where my situation has changed and/or a there is a change in the situation of the fetus/neonate, during the course of the labor or afterwards there will be a need for providing medical/pharmaceutical care to me or to the neonate that is outside the framework of a natural birth agreement. This is to the discretion of the midwife or OB.
It has been explained to me that with a homebirth blood tests will be taken from me and the neonate and drug treatments will be given to me and the neonate that are given routinely in the hospital, excluding vaccinations.
It is agreed that the midwife or doctor will arrive at my house within an hour of being informed that the appearance of signs of active labor and will stay with me during the course of the entire labor and for at least two hours afterwards.
Signature of the woman ________________________
I confirm that I have verbally explained everything that is said above in necessary detail and that she signed this agreement in front of me after I was convinced that she understood my explanation completely.
Name of midwife/doctor ______________________
Signature of midwife/doctor _________________________
License number _____________________________
Appendix B: Homebirth Documentation Form
I hereby declare that I delivered Mrs.:
Place of Birth:
Neonate: Boy or Girl
Healthy/Other: Detail ___________
5 minute Apgar score:
Weight of the neonate:
Pregnancy week number:
Hour of break of amniotic fluid: _______________________ Spontaneous: Yes or No
Characterization of amniotic fluid: clear, murky or meconium
Duration of first stage:
Duration of second stage:
Time of birth:
Duration of third stage:
Way in which placenta left the body:
Neonatal suction: yes or no
Drug treatment that was given during the birth or immediately afterwards:
To the birthing mother:
To the neonate:
Mothers blood pressure at the end of the birth:
Evaluation of the amount of maternal bleeding during the labor: ___ cc
Mothers blood type ______________ RH______________
Lab tests were taken from the mother: Yes or No. Details ______________
Lab tests were taken from the neonate: Yes or No. Details ________________
Date of birth:
Time of birth:
Name of midwife/doctor:
Appendix C: Neonatal physical assessment form
|1||Skin color||Blue, yellow, red, pale, other finding|
|2||Breathing||Rhythm, nasal, groaning, recoiling, other finding|
|4||Muscle tone||Limp, heightened|
|5||Bellybutton||Bleeding, open קלם, other finding|
|6||Rectum||Closed, other finding|
|7||Head||Edema, wounds, birthmarks, fontanel, other findings|
|9||ENT||Cleft lip/palate, variation in the shape or location|
|10||Cry/Response||None, weak, increased|
|11||Stomach||Swollen, other finding|
|12||Back||Malformation, measure, hemangioma, pilonidal sinus, other finding|
|13||Limbs||Deformation, other finding|
|14||Skin||Birth marks, wounds, blisters, other findings|
|15||Genitals||Hydrocele, hypospadius, enlarged clitoris, other findings|
Mark with a V to describe a normal situation
Mark with a circle around the word that describes the abnormal situation or describe the finding.
Name of midwife or doctor:
Appendix D: Form for the transfer of the birthing mother and neonate from the homebirth to the hospital
To the delivery room in the hospital:
Name of the birthing mother:
Obstetrical and Gynecological history:
Mothers blood type:
Reason for transferring the birthing mother and the neonate to the hospital:
Pregnancy monitoring card: Attached or not attached
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