Let's Talk about Transfer
You’ve done your research. You decided you want a homebirth. You interviewed midwives and feel like you found a good fit. Now you’ve been taking good care of yourself and your baby for these last few months. Your plan is in place. But what it things don’t go as planned? What if you have to transport?
A lot of us don’t want to think about transport or the need for more medical intervention and assistance when we are planning our natural and physiologic birth, but it’s an important topic and every midwife and every family should discuss the possibility of transport to a hospital during labor.
The chances are really good that you will have the homebirth of your dreams. Sarah and Erin started going to births together in May of 2013 and today is the last day May of 2018. Our transport rate during labor over this time period is 8%. That’s right, the overwhelming majority of families planning a homebirth WILL have a homebirth.
We Talk about Transfer During the Prenatal Period
We usually first talk about transport during the interview or consultation visit. Even before you have decided to work with us, we think it’s important that transport and emergencies that may be managed at home are topics that are out in the open. Birth is unpredictable. Sometimes it’s smooth. One of my midwife friend calls those butter births. Sometimes it’s a little rocky, but it’s still safe, possible and desirable to stay home to complete the birthing process. Sometimes it slowly or abruptly becomes clear that the hospital is the right place to be.
We welcome questions about transport at any time during the course of prenatal care. We usually have an extended discussion about transport at one of the 3rd trimester visits. Late in pregnancy is the usual time that the birth begins to occupy more space in a women’s mind and spirit. It’s time to reckon with the big task of giving birth.
One of the things we talk about is which hospital would we transfer to if needed. We usually determine which is the closest hospital and what is the preferred hospital. In the case of a true emergency, we would go to the closest hospital under almost all circumstances. In the case of a non-emergent transport, where travel time is not the most important factor, we can take lots of things into consideration including if a hospital is in or out of network with your insurance, what the facilities are like, your experiences with a certain hospital or what have you heard from your friends. We can also share our experiences as midwives at a given hospital, what kind of treatment do clients and midwives get at a certain hospital. If you live in the cities of Minneapolis and St. Paul, there are many excellent choices. When transferring to a metro hospital, it’s pretty likely that your receiving providers have had experience with a homebirth transport. They know that neither the family nor the homebirth midwives are a bunch of crazy people! Sometimes in tiny rural or exurban hospitals, staff may not have met a homebirth midwife before or had a homebirth transport in recent memory. We do everything we can to make those experiences smooth and collegial. Sometimes, however, rural and exurban clients may choose to drive further for a non-emergent transport to a hospital that is more familiar and receptive to homebirth transfers.
Midwife to Midwife Transfer
Back when we were training taking a mom into the hospital during labor meant you got provider potluck. Now, however, thanks to the hard work of some of our Minnesota midwives, there are formal processes in place for transferring care from a homebirth midwifery practice to a some CNM midwifery practices that deliver in hospitals. This is a wonderful development for the birthing community! Hospital based CNM care can utilize more technological tools at birth, while maintaining the midwifery model of care, which respects women’s choices and autonomy and values physiologic birth. Whenever possible Geneabirth midwives try to help our clients transfer to a midwifery practice when a hospital transfer is necessary or desirable
What does transport usually look like?
Hands down the most common scenario for a homebirth to hospital transfer in labor is first time mom experiencing a long, long labor with little to no progress and exhaustion and discouragement. In fact, looking over our stats from the last 5 years, I would place about 70% of our transports into that category. Homebirth mamas are some tough women and homebirth midwives are known for their patience with the birthing process! By the time we get to transfer we have done ALL THE THINGS. This mama may be 24, 36, 48, 72(!!!) hours into this process. She’s been in the birthtub, she’s lunged, and walked the stairs, she’s rested and tried to sleep between contractions, she drank the labor aide and ate the eggs, she’s had lots of loving support from her partner, midwives, doula and mom. The chiropractor or the cranial sacral therapist has come to do a home consult. All the spinning babies tricks have been used. Maybe herbs have been used or homeopathic remedies or essential oils. These women are so brave! At some point though maybe contractions have started to space out, they aren’t long enough, strong enough or close enough to effect change and make this birth happen. Or maybe the mom just can’t keep any food or drink down, which contributes to a vicious cycle where the body is not nourished and hydrated enough to keep a good, strong active labor pattern going. Or maybe a woman just feels done.
This is not a unilateral decision made by Sarah and Erin. We don’t decide that a woman has run out of time. As long as baby has good heart tones and mama has healthy vitals and there are no other concerning symptoms we can stay home and keep trying. Slow can be normal. But sometimes over a period of hours and usually with lots of conversation and trying or re-trying a few more things, a woman and her partner decide it’s time to go in. It’s not a rush. It’s not an emergency. The mom gets into the clothes she wants to wear and with help packs a bag. A midwife calls the hospital and let’s them know that we want to come in, make sure there’s room for the birthing woman, appraise them of the details of the labor so far. We fax over the records. We listen to the baby one last time. We get in our own cars and drivel to the hospital. Typically, one of the midwives stays behind to clean up your home and even take down the birth tub. She will join us later.
When we arrive at the hospital, a midwife will talk to your nurse and receiving midwife or doctor. We’ll help explain the situation and share any relevant information about your health, pregnancy or labor thus far. After which, our primary role is as support person. The hospital staff will be providing your care, but a midwife stays by your side, with hands-on physical support and suggestions, emotional support and encouragement helping you formulate questions or advocate for your self and your baby.
Interventions as help
People planning homebirths are trying to avoid interventions. Physiologic birth means letting your body do what it’s meant to do and letting the process unfold. In the case of transfer to the hospital during labor, we are going in for interventions. All the low-tech things like hydration, calories, position changes, fetal positioning techniques and natural therapies have already been tried and they just haven’t been enough. Medical interventions, whether it’s an IV, Pitocin augmentation, pain relief in the form of nitric oxide, other medications or an epidural can be viewed not as things to necessarily be avoided but as tools and as a way to help the baby be born. The majority of transports for a long labor result in a vaginal birth, it’s just that sometimes a mom needs some rest or some stronger contractions to make it possible for her to birth her baby.
C-sections and other operative deliveries
Over the past five years we have only had two transports in labor that have resulted in a cesarean section. Going to the hospital does not mean a surgical birth is inevitable! As mentioned above those interventions that can be helpful in the case of a long labor, can actually help you have a vaginal birth. We have also had one client have a forceps delivery and one client have a birth assisted by vacuum.
What about Urgent or Emergency Transports?
Not all transports are for long labors and maternal exhaustion. Sometimes the midwives have real concerns about the health of mom or baby or rarely, it’s a legit emergency. The most common urgent reasons we have transported are related to fetal heart tones. We transported 1x for tachycardia (rapid heartbeat) which, along with other symptoms was a result of a maternal uterine infection. We transported 1x for a highly unusual fetal heart rate patterns with incredible highs and lows. In that scenario it turned out there was an occult cord prolapse, meaning the cord was coming down with the head of the baby and getting pinched. It is times like that every midwife, no matter how naturally minded, is grateful for life saving technologically sophisticated medical care. In another case, we transported for decelerations of the fetal heart tones occurring regularly fairly early in the birthing process. In one case, we transported by ambulance for suspected abruption. In other words, the placenta was shearing away from the wall during labor, rather than after the birth of the baby. Excessive amounts of bleeding was present well before birth was imminent. That third time mom birthed her baby vaginally in the hospital! We are just one small practice. For a comprehensive list of reasons that a family might transfer from home to hospital during labor, consult the Minnesota Midwives Guild Standards of Care, appendix E. In more urgent transport scenarios, we try to keep things calm and smooth, but there is less time for talking and planning. Your midwives are moving swiftly and may need the birthing family and their support team to move swiftly as well.
In the event of transports we continue doing midwifery style postpartum care. We’ll see you five times (or more if needed) during your six week postpartum period and we are available by phone or text to help with nursing, making sure your baby is gaining well, assessing jaundice, cord and belly button care, looking after your emotional and psychological well-being, diet, bleeding, healing, anything you are concerned about. We are always available to process the birth with you. Women’s reactions and feelings about homebirth to hospital transfer are really varied. Many people have a mix of emotions which may be positive like relief and overall satisfaction, but sometimes people feel disappointment or grief. The door is always open to discuss your birth at any point during the postpartum or beyond.
How much should you plan for a transfer prenatally?
Considering how unlikely that you will have transfer, you don’t have to give a ton of mental and emotional space and energy to the possibility transfer. But DO have the conversation about hospitals, transfer scenarios and reasons with us or your midwives during your prenatal period. It’s important! For first-time families at least some reading or education about hospital birth is helpful. You can get this from the internet or a good book. If you are taking comprehensive childbirth ed like Bradley Method or Hypnobabies, they will cover this in class. The Childbirth Collective has a free parent topic night called Medications and Interventions that is part of their regular rotation of meeting topics. (Also a great place to meet a doula!)
Should you write a hospital birth plan? Most homebirth families don’t write a birth plan. There’s so much time at appointments and you get to know your midwives so well that by the time the birth comes around we know all about your dreams, wishes, fears, who will be at your birth, what you are doing with your placenta and all the other big and small details. Some families, especially families birthing for the first time or for the first time at home will write a hospital birth plan. Remember if we are going to the hospital in labor it’s because we need help. It is counter productive to write a birth plan for the hospital that says no IV, no Pitocin, etc. We need what they have to offer. It may really helpful in making your wishes about you newborn know to the staff. Do you plan to decline eye ointment or vitamin K or the hepatitis B vaccine? Are you planning to breastfeed or room-in or bathe the baby yourself for the first time? Your hospital plan should communicate those things.