Creating a Backup Plan for Home Births

When Is a Transfer Necessary?

When you are interviewing a midwife, it's important to ask them about their methods if complications should occur. Many midwives may have different opinions on when a transfer to a hospital is absolutely necessary. Finding a midwife who meets your needs and desires and who will keep you and your baby as absolutely safe as possible is a crucial part of finding the right midwife for you.
Having a thorough discussion with your midwife can help alleviate your concerns about potential complications that could occur. It's important to understand what problems may happen and how your midwife will recommend handling them. Some of the potentially dangerous problems may include:
  • Blood loss after the birth (postpartum hemorrhaging): With virtually all hospital births (and with some home births), the third stage of labor (delivery of the placenta) is "actively managed" by giving the mother oxytocin and by gently pulling on the cord. Research overwhelmingly shows that these measures reduce the risk of postpartum hemorrhage. However, many midwives prefer a "hands-off" approach, letting the woman's body handle this stage of labor on its own. Many midwives believe that rushing the natural process is what leads to excessive bleeding.
Typically, each midwife will have their own preferences and methods. If the midwife's methods do not work and medications she can give you do not control the bleeding, it is probably time to call an ambulance and transfer you to the hospital.
  • Baby is slow to breathe or needs neonatal resuscitation: Your midwife will be able to manually resuscitate your baby if he or she is slow to breathe after birth. She may try manual suctioning of the mouth or nose or ventilating (giving oxygen) using a special bag and mask.
In hospitals, the assessment and resuscitation of newborns is usually done on a large table across the room from the mother. This means that the umbilical cord must be cut. However, there are many physiological advantages of leaving the cord intact. This cord provides oxygenation even after birth between the placenta and the baby until the newborn's lungs have transitioned to air. This process can take 30 to 90 seconds in an infant that is full term. If a newborn can't breathe on its own, the placenta is its life-support system, unless the cord is flat, limp, and nonpulsing -- then it is no longer working.
The World Health Organization (WHO) recommends that clamping the cord before beginning resuscitation is unnecessary and that the mother's bed is a warm and suitable place for resuscitating the newborn. If the baby continues to struggle with breathing, then a transfer to a hospital might be necessary.
  • Lack of progress in the second stage of labor: In midwifery training, labor is divided into three distinct stages. The first stage involves regular and coordinated uterine contractions, as well as dilation of the cervix. The second stage begins when the cervix is fully dilated and ends when the baby is fully delivered through the birth canal. The third stage is the period after the baby is born until the delivery of the placenta.
According to most hospitals, a cervical dilation rate of less than 1 cm per hour is considered "abnormal." However, less than 50 percent of women having their first baby will manage to meet the criteria set out for "normal progress," which can lead to unnecessary interventions like rupturing the membranes or giving drugs like Pitocin to speed things up. 
If the time limits on the second stage of labor are approaching, a midwife may recommend directed pushing. However, this does not significantly reduce the length of labor. It does, however, increase the risk for problems, such as damage to the perineum and fetal hypoxia. The mother holds her breath as she bears down to push, thus reducing oxygen levels in the baby. If directed pushing does not speed up the progress, or if the baby shows signs of distress, then the birth may need further assistance, such as using forceps.
Talk to your midwife about the possible situations that may call for a hospital transfer. In many cases, pure exhaustion by the mother calls for a transfer to the hospital.
  • Emergency C-section: In general, the need for a cesarean delivery is typically lower for women who choose home births. This is usually because women who choose out-of-hospital deliveries tend to be at a low risk for problems. However, if complications do come up or your baby shows signs of fetal distress and birth does not appear to be imminent, you may require hospital assistance, intervention, or a C-section.
  • Umbilical cord prolapse or other cord problems: Umbilical cord prolapse happens when the cord slips into the vagina after the membranes have ruptured but before the baby descends into the birth canal. This occurs in about 1 out of 300 births. The baby can put pressure on the cord as he or she passes through the cervix, which can cut off blood flow from the placenta to the baby. This can put the baby's oxygen supply in great danger. This is considered an emergency situation, as the pressure on the cord must be relieved immediately. You will likely need to transfer to a hospital for a C-section.
There are a number of problems that can happen with the umbilical cord, but it doesn't necessarily mean you will have to be transferred to a hospital. In some cases, the cord may get a knot in it (about 1 percent of babies are born with one or more knots in the umbilical cord) or be looped around the baby's neck. As long as the knot or loop remains loose, it will not usually cause harm to the baby. However, if the baby is showing heart-rate abnormalities, then a hospital transfer and C-section may be needed.
  • Meconium passed in utero: Approximately 15 percent to 20 percent of babies are born with what is commonly called "meconium-stained liquor." Meconium is the baby's first stool, and if it happens before the baby is born, it can present numerous risks. There are basically three reasons this happens:
    • The baby's digestive system has reached maturity and the bowels have begun to work (this is the most common reason, and 30 percent to 40 percent of post-term babies will pass meconium in utero)
    • The umbilical cord or head is compressed during labor
    • Fetal distress results in hypoxia (deprivation of adequate oxygen supply).
However, just because there is meconium present does not mean that there is fetal distress. If the baby's heart rate is abnormal, then there is a risk of fetal distress. Also, thick meconium rather than thin meconium is associated with complications.
Meconium-stained liquor (MSL) may lead to a more dangerous complication called meconium aspiration syndrome (MAS), which is when the baby breathes in the meconium, either in utero by intrauterine gasping or when the baby takes that first breath. Approximately 2 percent to 5 percent of the 15 percent to 20 percent of babies with MSL will develop MAS. Of that 2 percent to 5 percent, 3 percent to 5 percent of babies will die. So basically, MAS is quite rare, but it can be fatal.
Some midwives may have differing opinions on what to do if meconium is present. Talk to your midwife about the methods used to handle a situation like this. If the baby does show signs of fetal distress, a hospital transfer may be necessary.
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