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Sunday
Feb062011

Did You Transfer/Transport to the Hospital?

Some of the Navelgazing Midwife Facebook I ask are more profound than others; this was one of those. My comments and thoughts are in bolded italics. I’ll also edit for clarification.

You’ll see no initials in this post as there usually are. Women have come to me and said that even the initials sometimes are too much for them to share their private thoughts, so no more initials. I’m also having women email me privately if they want to respond, but don’t want it on the FB page. Feel free to do so with either the FB or NgM questions.

One more thing. This post offered a great opportunity to show different complications, so there are graphic (sometimes, very graphic) photos below. You are forewarned.

So, here’s the question I asked:

Did you intend to have a homebirth, but were transferred/transported (non-emergent/emergent) to the hospital? What was the reasoning? And if you're comfortable sharing, what was the resolution?

- I was transferred with my 4th. I never imagined I would be. When my water broke, my fluid was stained with blood and she (the midwife?) panicked and thought I was having an abruption. I had no other signs of that though. She wasn’t quite experienced enough, I found later, so she made a call she felt comfortable with. Turns out after I went to the hospital and was treated like a dog and accused of having NO prenatal care because she was a lay midwife, all it was was a vessel on my cervix. I had an all natural, healthy baby born a few hours later, but was left with PPD (Postpartum Depression) and a lot of trauma.

- I was (transferred). Three days after SROM (Spontaneous Rupture of Membranes) at almost 44 weeks I spiked a fever, contractions never picked up past 10-15 minutes apart. Resolution ended up being c-section a day later. Failure to Progress.

- My midwife could not continue care due to my being 43w, so I ended up at the hospital and had a section for failure to progress due to being effaced but not dilated. In my state, midwives have to transfer care to an OB at 42.5w.

42 weeks and 5 days pregnant according to the Last Menstrual Period. In many, if not most, states, the transfer protocol is at the end of 41 weeks, or another way of looking is 41 weeks and 6 days, plus one more day. The woman above says the rules in her state were to transfer at 42 weeks and 5 days.  Many things can affect a woman’s due date from longer ovulation cycles to hormonal issues creating havoc with ovulation, so being married to a Due Date is typically a medical operative. Those more natural birth inclined, including homebirth midwives, have a belief that each mother and baby should be treated individually and as long as the baby continues doing well, it’s okay to keep going. My own belief is observational testing should be done a Bio-Physical Profile starting at 41-41.3 weeks and every 2-3 days thereafter to closely monitor the baby and change plans if signs show the baby’s declining. Its important to know that my beliefs are also often challenged and, in your own pregnancy, learn all the options and then make the decision that you feel is the safest for you and your baby your doctors or midwifes viewpoint notwithstanding.

-  I intended a UC VBAC (Unassisted Childbirth, Vaginal Birth After Cesarean), and transferred after 18 hour hours of active labour, the last 12 with hard contractions consistently 3 minutes apart. I was 16 days post-dates, it was 4AM, I hadn't slept for two days, and I was worn out and frightened and had no support or caregiver other than my inexperienced husband.

Upon reaching the hospital they told me I had almost no dilation and the baby had not dropped. I was offered a repeat c-section and told that I could either accept immediately and have a spinal (thus being awake for the birth) or wait a few hours and be given a general anaesthetic when the baby went into real distress. I accepted the immediate c/s.

I was told afterwards that my cervix was scarred closed due to my prior c-section being botched (now I know it was likely caused by infection after the first c/s, not by an actual cut to the cervix).

-  I was (transferred) a few hours after my third birth for a cervical/uterine prolapse.

I had been sitting on my bed with the baby, thought I had to use the restroom, and when I was bearing down, my cervix came down. When my midwife came back over it was pretty swollen and she could see the uterus. We went to the ER. The OB on-call refused to come in for a couple hours, finally did, almost refused to look at what was going on (the RN insisted because she saw how swollen it was when I came in), and flippantly told me that it didn't matter because when I stood up, everything was just going to fall back out. (It didn't. And hasn't since, even after another birth.)

Interestingly, I learned to leave all but the most overt (complete) uterine prolapses alone – if the woman was not symptomatic. Three times in midwifery school, I saw different degrees of uterine prolapse, the most serious was similar to what the woman describes above, seeing the cervix on the outside of the woman's body. It looked similar to this, but the mom was postpartum, so there was blood in and around the area.

One of the cases was before the woman left the center, but the others were women who came back once they found their cervices just inside or after they saw it out of their vaginas. The two times the women were sent to the hospital, the doctors did nothing either time, saying that if the cervix was still on the outside of the body at six weeks postpartum, then they would consider other treatments (pessary, hysterectomy).

pessary over the os of the cervix

 The other time, we counseled the woman the same as the doctors did and all three of them saw their uteri back in place by six weeks postpartum. This doesn't mean the commenter above shouldn't have been transferred; each midwife evaluates each case and makes a decision that's right for their client. I can't say I wouldn't transfer if I saw it again, but probably more for antibiotics than anything else. I would be very wary of sending a mom directly into an ER; a friendly OB would be my first, second and third choice.

Most agree that Kegels can help prevent later-in-life pelvic floor prolapses, but when the uterus has already fallen, it can take up to six months post-prolapse before any progress is seen with Kegels... if there is going to be any at all. Many women choose not to wait that long and seek treatment much earlier. I can hear you all out there hollering, "Alternative treatments!Acupuncture, chiropractic, homeopathy!" Certainly, if you're so inclined, helping the body right itself this way can't hurt. 

And the commenter above is correct… just because you have had a prolapse once does not mean you will have another with each child.

I have only seen a complete prolapse in the hospital during (what I would consider) third stage mis-management. The doctor replaced the uterus with his hand/fist and mom did well afterwards. (As well as can be had after having a fist inside the uterus.)

One more note. I am of the school that believes if mom's cervix is presenting outside the vagina, or if anyone has had to replace/visit the uterus manually... sterile gloves or not... mom should be on prophylactic antibiotics to stave off infection. And, of course, the usual recommendations that are made with rupture of membranes... wipe front to back, no intercourse, take your temperature every four hours, etc. are in effect. Not that we say this with ROM, but I'd also strongly discourage baths.

- I was transferred with my first as I was exhausted. Ended up with a C Section almost 3 days after labour started. I wish the midwife had been more proactive about getting me to walk and be active in early labour.

This can be a tricky thing, walking in early labor. I’ve seen it cause more exhaustion than dilation, so tend to encourage early laborers to chill more than run around. Once things start picking up, however, walking can be one of the nudges to use to keep it going; that and nipple stimulation, cuddling, etc. But, it is very difficult to tell, right in the beginning, if a labor is going to move forward or peter out, waiting for another day. That doesn’t mean, at all, that the commenter above might not have had a feeling of what could have helped her labor to progress. I bring it up because there is the push/pull of care providers and clients about what to do when labor begins.

- These transfers-of-care for being "past due" make me really sad. (Anyone know what the cut off point is in Tennessee?

After some serious digging (geez, Tennessee do you think you could make it any harder to find your midwifery regulations?), the best I could come up with was Tennessee Midwives’ Association Practice Guidelines. It says physician consultation and referral is to be made when there is a post-maturity pregnancy (>42 completed weeks). This is where things get sticky for some people, but technically, this means the woman would be 42 weeks, 6 days, 23 hours and 59 minutes before she would need to be handed over in one more minute. (Does this make sense?) This homebirth protocol >42 completed weeks is rare to see today.

- (My comment in the thread) The general gist is 42 weeks everywhere. After that, it depends on your philosophy, comfort level and (please, oh please) how the baby's doing with post-dates testing (BPPs).

While it isn't popular to talk about, babies do die from being post-dates. The placenta
does have a "shelf life" (if you will). Some women really don't go into labor on their own.

Until you've been with a woman who’s lost her baby due to post-dates without induction, it seems absurd; the body always works, right? If we just wait long enough, the body will eventually have the baby, right? Incorrect.

Women with hormonal issues... PCOS, thyroid stuff, Insulin Resistance, women who needed help getting pregnant, women who've had a history of irregular cycles (and there’s my own thoughts that Vitamin D deficiency might play a significant role)... these women (and more) might really, truly need help getting un-pregnant. And then there are the women for whom we can never pinpoint why she didn't go into labor, but it does happen.


(me again) This transfer/transport topic is a hard one to talk about, but I feel it's vital for homebirthing mamas to know it is, absolutely, a possibility in every birth (as you see from above). It is vital to discuss the possibility... not obsess about it... but to have a plan to execute, a plan that includes informed consent during the pregnancy... so mom and baby can be kept safe.

One of the things that annoys me (and crushes moms) is when someone was transported because the MW wasn't experienced enough to decipher a complication. (This, regarding the comment made above about a woman’s midwife not having enough experience to know the difference between a placental abruption and a normal amount of blood during the birth.) Worse yet, of course, is
not transporting for not recognizing the seriousness of a complication. I’ve mentioned before I don’t think most (imo!) CPMs don’t get enough experience before they get their licenses. Much of the skittish-ness of new midwives comes from lack of experience. (And I’m the first to stand up and say, “Me, too.”) The comments here by women are but a minute few of the times I've heard women say, "My midwife got scared/didn't know what it was/wasn't sure what to do/etc."

Solo on-the-job training shouldn’t be a part of a midwife's learning curve. 

Case in point:
-  I was transported by EMS after my fourth, for a retained placenta and hemorrhage. My midwife later said that she wishes she'd donned a shoulder-length glove and gone in after it, but I think she was a little panicked. I was morbidly obese at the time (before the pregnancy) and did not have any prenatal care at all. I'm sure I was anemic.

The worst part is that my state says my baby was born at the hospital, because that's where the placenta was delivered. I hate that my baby's birth certificate says that! It took years to process that birth.

I just had my fifth on Christmas day, at home, and everything went perfectly. In between these pregnancies I had a biliopancreatic diversion with a duodenal switch (weight loss surgery) and lost 130 lbs. During the pregnancy, I was much more vigilant about my prenatal care as well. When my hematocrit got really low, I went to a hematologist and received iron infusions for a month to get it back up to 11.

It isn’t every state that marks the birth as the birth of the placenta.

-  Thanks, Barbara! I was induced at 42w by a hospital CNM, but I truly feel that she wasn't quite ready to come out and that I should have refused to go in because it took 36 hours for her to come out and I was only at 1cm to start.

I had this fantasy that with the next one I would be able to wait longer, but I would rather do just about anything than go through medical induction again. It was pure hell!

- Went to bed late, woke up at 6 a.m. when water broke, contractions started within 15 mins. 21 hours later, hadn't slept, had been at 7-8 cm & in transition for 10-12 hours, & baby hadn't descended. Not my call to transfer, midwife + husband + mom decided & I was told. Went to hospital, epidural, nap, woke up fully dilated, baby born vaginally. There were other factors at play with my transfer, including that the midwives had just come from another birth (a surprise breech) & were exhausted. The sad fact is, I was treated better at the hospital than at home!

- I planned a HBAC (Home Birth After Cesarean), but a while after my water broke, I started seeing thick chunks of fresh meconium (aka mec) and in my province the college guidelines for midwives is to transfer to hospital for mec. My labour started fast and hard and my midwife didn't think she was going to make it to our house in time. My husband didn't even know what mec was and texted our doula asking her because my labour was too intense at that point to explain anything to him and my midwife's phone died. She asked us to meet her at the hospital. My son was born four hours after we got there and we left six hours later.

Although it was slightly disappointing to be in the hospital and not in my nice birth pool - the tub in the hospital sucked and I was too uncomfortable to birth in it, the birth was gentle, hands off and wonderful.

(Her birth story, Victorious, can be read here.)

- I think it's a fine, and sometimes invisible, line between a mom who naturally "cooks" a baby longer and a true "never going to go into labor" mom. My 42.5w baby showed NO signs of post dates and my placenta was fine. I don't think that is going to be the case for every woman, but some of us do cook longer (my first was 10 days post dates also). For this reason, I do think stress testing after 41w is advisable. 

I absolutely agree some women gestate longer than others.

- Planned homebirth with midwives, 4th baby. Water broke 38 weeks 1 day, no labor for 32 hours, GBS status unknown. We were discussing options and they suggested castor oil, which I was adamantly opposed to. They were very supportive of my decision to go to the hospital. Baby was persistent ROT (Right Occiput Transverse).

I had tried to get him to turn and he wouldn't. I asked him to tell me why and in a dream he said he was stuck, so I really thought we might be going in for a cesearan. Relaxed drive to hospital, long check in, still no labor. My RN started IV, OB ordered an ultrasound and after that RN checked I think I was 4 cm. Mild contractions began after that exam and I quickly went into active labor during shift change. New RN came in to start antibiotics and pitocin, but I refused the pit. Told her if the contractions stopped, she could start it then. Very hard fast, painful labor (back hurt terribly) I shook uncontrollably. Hooked up to IV, bp (blood pressure cuff), EFM (external fetal heart monitor), and O2 (oxygen, the baby had decels). Asked for epidural (after 3 successful natural births!). 

Anesthesiologist came in to administer the epidural and while he was readying his stuff, we decided RN should check again. When I turned from kneeling over the head of the bed the baby came out. All at once, face up and I caught him and laid him on the bed. He was completely wrapped in one of the longest cords any of them have ever seen (he was "stuck" lol). Baby had some breathing difficulties (retractions, a couple of episodes of choking where he stopped breathing) but other than that was fine.

retractions - note the sucking in of the chest 

They did put him through a lot (IVs, heel sticks, etc) that I know wasn't really necessary, but I don't regret my decision to transfer. (More than willing to answer questions if you have them, I'm only 8 weeks postpartum and still working through the birth).

- I labored for 26 hours, and actively pushed for 6 hours... 10cm dilated, 2 IV infusions and every position know to womankind and my posterior daughter wouldn't budge past -1 station. So, deeply fatigued, I transferred to the hospital.  Had a really kind OB say it was time for a c-section. I ended up with a 9lb 5oz 22inch girl- with a ridge on her head where she got lodged on my pelvic bone trying to come out face first. Great team and very supportive & understanding transfer. The OB told me my next would surely be a VBAC and he praised my midwife. Very happy overall.

- Free-standing birth center, led to transfer for c section. Baby was footling breech and wouldn’t descend. Short cord and it was wrapped around him 3x.

- Thanks for this discussion! I'm planning my first home birth (third baby, second VBAC) for later this September, and I agree that part of my planning should involve knowing the full range of experiences of home birth mamas.

-  I planned a homebirth with my first child, I was a midwifery student at the time. I love and completely trust my midwife. My baby was posterior and acynclitic. My labor was not progressing. I was 3 cm after 18 hours of hard labor. When my water broke, there was meconium staining and the baby's heart rate dropped into the 80s. My midwife listened to fetal heart tones for half an hour straight, as she was willing to give it some time. The heart rate did recover, but the meconium got worse. I knew it was time to go and my midwife called the hospital. We drove ourselves and arrived at the hospital. 

We were seen by a wonderful CNM who was incredibly respectful to all of us, my husband, my midwife and me. We did an amnioinfusion.

The heart rate was steady, but I was still not making progress. I tried some Demerol to take the "edge" off because I was really trying to avoid the epidural. After more hours of labor, and still hardly any progress, both midwives suggested that now was the time for an epidural and pitocin. So, that is what we did. My BP dropped, then the baby's heart rate dropped again. The nurses and my husband helped me get on my left side. The heart rate recovered, but the CNM warned us that if that happened again, we would really need to consider a C-section. Luckily, it did not happen again. We did decide to place an internal fetal monitor at that point.

 The electrode that screws into the baby's scalp.

I finally started feeling some pressure, and I was complete. I pushed for about an hour, and my son's heart rate was not doing well at the end. As soon as he was born, he was suctioned an intubated for a short period of time due to suspected meconium aspiration. His first Apgar was 2.

 He was in pretty rough shape. So, even though it was disappointing for me, I absolutely think that it was an appropriate transfer.

- I planned a homebirth with a wonderful midwife! I went past 42 weeks and was forced into an induction I didn't want by her consulting physician and it ended up with my daughter being still born. Never again! I will catch my baby by myself before I go back to a hospital (barring any real complications).

- Much to dear Barbwife's (Me, NgM) sobbing dismay, we transferred with Spring. Barbwife was certain they'd cut me again. Oddly, it never crossed my mind as a possibility. Turns out spring had a very short cord, which is why she bungeed through (evidently) a REALLY long pushing phase. Amazing OB used mid-forceps to guide her down to a point where I could VBAC my babe. Everyone was in awe of the OB's artistry and skill with the salad spoons. Spring only had two small red spots on her temples, which never bruised!

As much as we had wanted a homebirth, the transfer did wonders to heal a very BAD hospital birth experience with my first.

-  And the only reason you didn't have a CBAC is because it was right after Katrina (in New Orleans) and there was one operating room in action in the hospital and someone was already in there. I've never seen mid-forceps used ever... before or since; they are simply not done anymore. Your doctor was amazing. She was a gift of obstetric talent and kindness that she believed in you and Spring. Your birth was one of those transforming ones for me. Thank you for inviting me in.

-  Er... kind of (a transfer). Freestanding birth center birth planned, but I foolishly thought I knew all about birthin’ babies since this would be my 4th birth ( and 3rd was twins) and was caught totally unprepared for a bigger boy staying stubbornly OP (Occiput Posterior). I didn't know he was OP, I just knew that this labor was taking more than twice as long as my previous. I was fully dilated, he was still high up and I had ZERO urge to push and amazingly intense back pain. I was pretty sure there was something wrong, so asked ( demanded, screamed, take your pick) to be transferred. Was, and had an awesome OB that supported my initial desire for an intervention/drug free birth even though by that time I was begging for some drugs. No drugs, super healthy vigorous boy born with no intervention other than a (needed) military demand that I PUSH. 

I can't thank all of you enough for sharing. And if anyone wants to add to this, we can make it a new entry... either comment here or send me an email and we'll keep the discussion going. Really, thank you women so very much. 

References (2)

References allow you to track sources for this article, as well as articles that were written in response to this article.
  • Response
    - Navelgazing Midwife Blog - Did You Transfer/Transport to the Hospital?
  • Response
    - Navelgazing Midwife Blog - Did You Transfer/Transport to the Hospital?

Reader Comments (4)

I transferred to the hospital from a planned home birth after 6 nights of prodromal labor that alternated manageable contractions with agonizing back spasms (my daughter was ROA the whole time). My home birth MW had never seen anything like it in her 20+ years of practice. During the day, I saw an osteopath who tried to help and several OBs at the hospital, none of whom could really explain what was going on. All they had on offer was an induction (which I declined) and/or Demorol, which scared the crap out of me (although I know now that Demorol can actually have a role in nudging prodromal labor into active labor). Finally, I was so exhausted that I transferred and got an epidural without being in active labor. I had dilated 3cm in the course of the week, and was 'augmented' with pit after an AROM, although I'd say it was really an induction. The hospital follows a high-dose pit protocol, and they ended up cranking it up all the way. I dilated to 10 in 6-7 hours but my daughter's FHR became non-reassuring toward the end. I had zero sensation and couldn't push effectively during the two practice pushes they gave me. She was delivered by forceps and suffered a moderate to severe shoulder dystocia that resulted in a birth APGAR of 3, a collapsed lung, and a 36-hour-NICU stay.

As you can tell from my need to share all the details, I still grieve the circumstances of her birth almost 2 years later. I do feel that I ran out of options and had no other realistic choice than the hospital transfer, but after suffering pretty much every complication that is associated with the interventions I received, I also feel robbed by the universe. The hospital itself was fine, I didn't like it much, but I also didn't hate it. I hated the things that happened in the hospital. I pretty much shut down emotionally for the delivery to match my number physical state, and I grieve not having been an active participant in her emergence into the world.

I'm pregnant again, and have been advised to birth in hospital this time due to the SD and complications. I know I have a lot of emotional work to do to enter this birth with an open mind and without prejudice for the hospital as a place where bad things happen.

February 9, 2011 | Unregistered CommenterVW

VW, can you touch more on the Demerol and active labor connection? That's not anything I've ever heard of before.

I had Demerol during my induction/augmentation with Tristan; epidurals weren't an option back in 1982 where I was, so I had two shots of Demerol during the 17 hours... one at 2cm and one at 3cm. I *hated* it. I felt like I was screaming inside my head, but was absolutely immobilized on the outside. I remember the nurses saying things like, "Oh, look how peaceful she is. I'm glad she's finally getting some rest." Inside I was screaming, "THIS FUCKING HURTS!" It was like a horror movie. To this day, I hate how Demerol makes me feel and ask for anything but that if I need pain meds.

Your birth sounds so, so... difficult? Painful? I don't have the words to tell you how sorry I am your birth unfolded the way it did.

I do hope you're able to find some peace as you approach this next birth.

(I keep typing and erasing ideas that might help, but you haven't asked, so I'll just keep my mouth shut for now. You know where I am if you find yourself wanting a stranger's opinion/ideas.)

Thank you so much for sharing your words, your story. Really.

February 9, 2011 | Registered CommenterNavelgazing Midwife

We planned a home birth for baby #9. My water broke and with the gush out came the umbilical cord. I stuffed it back up, then my husband called 911 and held it up during the ambulance ride and entire emergency c-section. My son, Apollo, was born healthy and strong with an agar of 8 at birth. You can read his story here:

http://bakersdozen.typepad.com/a_bakerss_dozen_daily_lif/2010/06/the-birth-of-apollo-xiv.html

February 14, 2011 | Unregistered CommenterRenee

That's flippin' amazing, Renee! Wow!

And thanks for the link to the story. I'll post it on FB this morning.

Wow.

February 14, 2011 | Registered CommenterNavelgazing Midwife

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