By Hayley Oakes LM, CPM ~
Photographs by Shoots & Giggles Photography
The majority of the clients who choose to give birth at the birth center do so because they either don’t feel comfortable in a hospital setting or are afraid of medical interventions that could lead to an ‘unnecessarian’ (unnecessary cesarean birth). I find most families are nervous of this possibility of transferring as they think this option is only reserved for emergency situations or a need for a c-section, when that is rarely the case (cesarean rates for planned out-of-hospital births are 5% compared to the national average of 31%). (1) However, in preparation for a healthy, natural birth outside of the hospital, this includes understanding when transfer is indicated, so if it happens the process is that much smoother.
How often does transfer happen?
For low-risk, first time mothers planning an out-of-hospital birth, 22% will transfer to the hospital (7.5% for mothers who have previously given birth) according to US survey. Of those transfers for first time mothers, about 90% are due to non-urgent reasons i.e. maternal exhaustion, need for pain relief, or augmentation of the labor and birth. (1) In these scenarios, the health of both mother and baby are not in danger. The need to go to the hospital arises out of needing medical interventions that are not offered in an out-of-hospital setting (i.e. epidural, Pitocin, vacuum extraction, etc.) in order to still achieve a vaginal birth.
What is the process of transferring to a hospital?
The back-up physician is contacted as well as the labor and delivery unit at the hospital of choice. Medical records are either faxed to the hospital or printed and given in hand to the family. Thus, the hospital and its care team are aware of your arrival and ready to care for you.
Mothers are transported in their personal automobiles accompanied by their partners and/or family members. The midwife follows the family to the hospital in her personal car to continue support in the hospital (albeit another woman in labor needing her services at the birth center). Once you transfer settings, so will the care of your medical provider. This means your midwife will no longer be managing your labor (unless she has medical privileges at that hospital to do so) and will act more in the role of an advocate and support person.
Below is a list of some of the more ‘common’ reasons to transfer. However, this is not an all-inclusive list. There may be situations that arise that are not included here. What are the non-urgent reasons to transfer to the hospital?
As mentioned above, maternal exhaustion is the most common reason to go to the hospital. This can be due to a long early labor (inconsistent but strong contractions that are difficult to rest or sleep through), the baby is in a non-optimal position causing back pain and frequent contractions that don’t lead to cervical dilation, and/or stalled progress in the pushing phase.
When the mother’s body is working hard for many hours with potentially little sleep, food and hydration (as many women don’t have an appetite and/or the labor hormones can make a woman feel nauseous and even throw up), its efforts at producing strong contractions diminishes leading to less contractions overall and stalled progress and/or descent. Despite the midwife’s natural remedies of increasing the mother’s energy, the frequency and intensity of contractions, and/or encouraging a more optimal fetal this is an indication to go to the hospital for rest and augmentation of the labor (i.e. an epidural, Pitocin and/or vacuum extraction, if indicated).
“I feel like I was able to have two birth experiences and both are very special to me. Laboring at Del Mar Birth Center was really the best you could hope for. The room was private, cozy and calming and laboring in the tub helped me progress through the harder parts quickly. However, after a couple hours pushing I seemed to be stalling out from exhaustion and my mind and body just didn’t want to work anymore. After trying a few things, Hayley suggested we go to my back up, California Hospital. My heart sank in that moment, but she explained that with an epidural I might be able to get some rest so that I would have more energy to continue with the delivery.
The drive downtown to California Hospital was rough for both me and my husband, and the wait to be admitted felt like forever although looking back I’m actually surprised how quickly they got me in and settled. Midwife Hayley and my doula arrived shortly after we did and having their support did make the transition much easier. There was a lot going on in the maternity ward, but I felt I was given just as much care and attention. I never felt that my wishes weren’t being honored or I was forced into any procedures or interventions that I did not agree to. I did not know the midwife or nurses who delivered my son prior to our arrival, but they made me feel very comfortable and calm, despite the circumstances. My midwife at the hospital was sweet enough to even make sure my husband and sister had a comfortable place to rest while I slept and regained my energy for pushing. When my son finally arrived around 6am, he was placed on me immediately and only taken away for a brief cleaning and cord-cutting by my husband. He then stayed by my side the remainder of our time at the hospital.
At first, I was sad and disappointed that things didn’t go as I had planned, but now I actually enjoy thinking back on my birth experience and realizing that all the things I was concerned about melted away once I was in labor. I enjoyed things I didn’t expect–like being cheered on by a room full of hospital staff while I pushed!”
When a woman’s water breaks in labor or it is manually broken for her by her midwife, the fluid should be clear, like water. When there is discoloration like yellow, green or brown to the fluid, this is a sign that a baby has had a bowel movement, called meconium. Sometimes this is a physiological response of a more mature baby (50% of babies past 42 weeks have meconium in the amniotic fluid) or it can be a sign of distress in labor. This happens in 12-16% of all births. (2)
The risk with meconium in the amniotic fluid is not always in the moment of observing it (unless the baby’s heart rate is also showing signs of stress); it’s at the time of birth. Meconium is a very sticky substance that when swallowed can make it difficult for the baby to take a breath and can potentially make a baby sick. 10% of babies in meconium stained water will develop meconium aspiration syndrome, which carries a 4-19% mortality rate. (3)
Midwives carry tools to help suction meconium and normal secretions after the birth, but if the meconium is thick and/or there is a sign of distress in the heart rate, it’s best to give birth in a hospital setting with a Neonatal Intensive Care Unit (NICU) where deeper suctioning can be performed and treatment given, if need be. Depending on the thickness of the meconium, imminence of birth and the baby’s heart rate, this is a conversation that is had between you and your midwife about the risks and options of care.
“As we prepared to welcome our second child into the world, nothing could quite prepare us for what was to come…a hospital transfer. I am absolutely terrified of hospitals not to mention my fear of needles and being poked and prodded. As I lay in the tranquil birthing tub at Del Mar Birth Center, trying to get through each of my contractions, suddenly my midwife noticed a strange tinge in the water. She asked me to get out of the tub and have a contraction on the bed. Waiting in anticipation, the contraction came and out came more amniotic fluid which unfortunately also contained signs of meconium. My heart sank deep into the depths of my stomach as I knew this would mean my profound desire to birth in the tub would come to an end. Sure enough we packed up our bags and headed to the hospital.
Meanwhile, Hayley, my midwife, prepped me for what I was about to experience. I remember her telling me just to stay focused and keep doing what I was doing and to not let fear or anxiety take over. I closed my eyes and prepared for the change. To my surprise, and with the incredible love and support from my husband and Hayley, I welcomed my sweet boy into the world. Reece came into the world in an all natural, unmedicated, vaginal birth. The nurses and staff who cared for me in the hospital were wonderful, though I did have to do quite a bit of kissing up and begging to get them to really take my side and help me. All in all, it ended up being a lovely experience and all that mattered was that I brought a healthy baby into the world.”
Fetal heart rate variability
Even without the presence of meconium, if the baby’s heart rate is not reassuring (prolonged accelerations or decelerations) this can be a sign of distress. At the birth center, we perform intermittent auscultation (vs. continuous monitoring), which means we listen to the baby’s heart rate with a Doppler ultrasound every 30 minutes during active labor and every 5 minutes during the pushing phase. This helps the midwife identify any issues of oxygenation to the baby and tolerance of the labor process that she can intervene, if necessary. This is a discussion your midwife will have with you depending on the imminence of birth or pattern of the baby’s heart rate and transfer may be necessary in an ambulance. (4)
When would an ambulance ride be necessary?
This is defined as the lack of expulsion of the placenta after 30 minutes. Typically, the placenta follows the birth of your baby within 5-15 minutes. After the birth, your uterus continues to contract, which helps release the placenta off the uterine wall. In 1.4% of women giving birth, the placenta won’t do that. This is called a retained placenta. (5) Of these cases, 80-90% are due to the uterus being too tired after birth and not willing to contract as frequently as it had been doing during labor. As a result, the placenta can either remain attached or become partially attached with an increase in maternal bleeding.
At 30 minutes post-birth, your midwife will start to intervene with medications and natural remedies to encourage placenta delivery. At 1 hour post-birth, if your placenta has not delivered, it is the time to go to the hospital. There, they have the ability to manually remove it and give you a blood transfusion afterwards if blood loss requires it. While your bleeding may be minimal and you feel stable, it’s recommended to transport to the hospital via ambulance. The risk is that while the placenta is not completely off the uterine wall, there could be partial separation and thus concealed bleeding behind it. If the placenta spontaneously delivers on the way to the hospital, there can be a large amount of blood loss that follows the placenta and thus the mother is at risk for losing too much blood and going into shock. Therefore, riding in an ambulance with the ability of starting an IV, giving oxygen and transporting her to a hospital in a quicker fashion is the safest way.
Postpartum hemorrhage is defined as blood loss greater than 500 mL (or more than 2 cups of blood). This occurs in 1.6% of healthy women in a low risk setting. (6) 80-90% of these care are due to a long labor that leads to the uterus not wanting to contract down and stop the bleeding. Other reasons include retained placenta fragments, blood clots, and/or a full bladder inhibiting the uterus from contracting down. While all these things can be remedied at a birth center as we carry all the same anti-hemorrhagic medications, if our efforts have not resolved your bleeding, then that is a reason to go to the hospital for further management. (7) In this scenario, as well as for a retained placenta, your partner and baby will follow behind in your personal auto and meet you at the hospital.
Midwives are prepared to support a baby needing extra stimulation to take his or her first breath after birth. However, if after only moments that the supportive measures (stimulation, suctioning, positive pressure ventilation with oxygen tank) to encourage spontaneous breathing are not effective, a baby needs to go to the hospital. 911 is called to quickly transport baby to the closest hospital while also continuing to give baby oxygen. It’s important to note, that while a baby who is has not taken his or her first spontaneous breath is still receiving oxygen to vital organs and the brain from the Ambu-bag (ventilation device) and oxygen tank. Depending on the mother’s state, amount of blood loss and whether or not the placenta has delivered, she will either stay to recover at the birth center while her partner accompanies the baby in the ambulance or go with the baby to the hospital.
What can I do to prepare for a transfer?
I encourage clients to do a hospital tour or a test run of the drive from the birth center to the hospital to be familiar with where the hospital is, where to park, etc. It can be stressful for a partner who is also most likely sleep deprived to try and figure that all out in the moment when the plan has changed.
Also, making a preferences sheet for the birth, newborn and a cesarean, if need be. Most of the things you might see on the Internet regarding making a birth plan in a hospital setting will include things like dim lights, intermittent fetal monitoring, no IVs, etc. When you are transferring from an out-of-hospital setting to the hospital, it means your labor is considered outside of the normal pattern and those interventions are actually medically necessary.
However, what you can still ask for (as long as the baby is healthy and crying at birth) are preferences for the immediate postpartum. This includes skin-to-skin, delayed cord clamping, support with breastfeeding, and your preferences of the newborn procedures i.e. vitamin K, erythromycin, Hepatitis B vaccine to be delayed an hour or so to give you and the baby time to recover and bond. Lastly, if the medical need for a cesarean came up and it wasn’t an emergency (meaning you were not put under general anesthesia), you still have some choices for how it will go. See Penny Simkin’s ideas for having an empowered and gentle surgical birth.
I find that the more prepared one is for the back up plan, the less heightened fear and anxiety there is around the concept of your birth not unfolding how you envisioned (and perhaps the less likely you will the back up plan). Information and knowledge can be a powerful tool. In the situation of an unintended transfer to the hospital during labor, birth or immediate postpartum, it can be used to help seamlessly integrate the experience both emotionally and physically.
See past blog posts “Optimal Preparation for the Out-of-Hospital Birth You Planned” and “Right Sided Babies” to control what you can in the pregnancy to have the birth center birth you want in order to surrender and trust how it all unfolds in the moment.
1. Cheyney, Melissa, et al. “Outcomes of Care for 16,924 Planned Home Births in the United States: The Midwives Alliance of North America Statistics Project, 2004 to 2009.” Journal of Midwifery & Women’s Health, vol. 59, no. 1, 30 Jan. 2014, pp. 17–27., doi:10.1111/jmwh.12172.
2. Mundhra, Rajlaxmi. “Fetal Outcome in Meconium Stained Deliveries.” Journal Of Clinical And Diagnostic Research, 7 Dec. 2013, doi:10.7860/jcdr/2013/6509.3781.
3. Gruenberg, Bonnie Urquhart. Birth Emergency Skills Training: Manual For Out-of-Hospital Midwives. Birth Guru Publications, 2008.
4. Dekker, Rebecca. “Evidence-Based Electronic Fetal Monitoring.” Evidence Based Birth®, 20 Jan. 2017, evidencebasedbirth.com/evidence-based-fetal-monitoring/.
5. Ashwal, Eran, et al. “The Incidence and Risk Factors for Retained Placenta after Vaginal Delivery – A Single Center Experience.” The Journal of Maternal-Fetal & Neonatal Medicine, vol. 27, no. 18, Apr. 2014, pp. 1897–1900., doi:10.3109/14767058.2014.883374.
6. Ngwenya, Solwayo. “Postpartum Hemorrhage: Incidence, Risk Factors, and Outcomes in a Low-Resource Setting.” International Journal of Women’s Health, vol. 8, 2016, pp. 647–650., doi:10.2147/ijwh.s119232.
7. Davis, Elizabeth. Heart & Hands a Midwife’s Guide to Pregnancy and Birth. 4th ed., Ten Speed Press, 2004.