Transfers in Out of Hospital Birth

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A common concern for expecting mothers and for those who care about them, is what happens if a home-birth-in-progress needs to become a hospital birth.  The reported risk of needing an intrapartum (during labor/delivery) transport to a hospital is 23–37% for nulliparous women (first delivery) and 4–9% for multiparous women (have delivered a baby before).  This page summarizes the available data and ongoing initiatives surrounding OOH birth transfers.

It’s important for a mother who is considering a home birth, as well as her partner, to know the circumstances that require emergency transfer.  The following are the situations during, and after birth that would require emergency transfer to a hospital for you or your baby.  The original list is part of the TDLR Midwives Administrative rules, Section 115.

If you’re not familiar with any of these conditions or symptoms, you can look them up in the the US National Library of Medicine Health Topics database to get reliable information.

 During Labor

Your midwife must provide emergency care and initiate emergency transfer by ambulance or personal vehicle if she notices any of the following during labor or delivery:

  1. prolapsed cord;
  2. chorio-amnionitis;
  3. uncontrolled hemorrhage;
  4. gestational hypertension/preeclampsia/eclampsia;
  5. severe abdominal pain inconsistent with normal labor;
  6. a non-reassuring fetal heart rate pattern;
  7. seizure;
  8. thick meconium unless the birth is imminent;
  9. visible genital lesions suspicious of herpes virus infection;
  10. evidence of maternal shock;
  11. preterm labor (less than 37 weeks);
  12. presentation(s) not compatible with spontaneous vaginal delivery;
  13. laceration(s) requiring repair beyond the scope of practice of the midwife;
  14. failure to progress in labor;
  15. retained placenta; or
  16. any other condition or symptom which could threaten the life of the mother or fetus, as assessed by a midwife exercising reasonable skill and knowledge

Postpartum: for mother

Your midwife must provide emergency care and initiate immediate emergency transfer if she notices:

  1. uncontrolled hemorrhage;
  2. maternal shock;
  3. any hypertensive disorder, including preeclampsia/eclampsia;
  4. signs of thrombophlebitis or pulmonary embolism; or
  5. any other condition or symptom which could threaten the life of the mother, as assessed by a midwife exercising reasonable skill and knowledge

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Postpartum: for baby

Your midwife must provide emergency care and initiate immediate emergency transfer of your baby if she notices any of the following within the first 6 hours after birth (the immediate postpartum period).

  1. non-transient respiratory distress
  2. non-transient pallor or central cyanosis
  3. jaundice
  4. apgar at 5 minutes less than or equal to 6
  5. prolonged apnea (lack of breathing)
  6. hemorrhage
  7. signs of infection
  8. seizure
  9. major congenital anomaly not diagnosed prenatally
  10. unstable vital signs
  11. prolonged:
    1. lethargy
    2. flaccidity
    3. or irritability
  12. inability to suck
  13. persistent jitteriness
  14. hyperthermia
  15. hypothermia; or
  16. other abnormal newborn behavior or appearance which could threaten the life of the newborn, as assessed by a midwife exercising reasonable skill and knowledge

Your midwife must provide emergency care and initiate immediate emergency transfer of your baby if she notices any of the following during any assessment after the immediate postpartum period.

  1. respiratory distress
  2. pallor or central cyanosis
  3. pathological jaundice
  4. hemorrhage
  5. seizure
  6. inability to urinate or pass meconium within 24 hours of birth
  7. unstable vital signs
  8. lethargy
  9. flaccidity
  10. irritability
  11. inability to feed
  12. persistent jitteriness, or
  13. any other abnormal newborn behavior or appearance which could threaten the life of the newborn, as assessed by a midwife exercising reasonable skill and knowledge

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Transfer Guidelines

Several times in the past decade, a national Home Birth Summit has convened, involving professionals in maternity care and hospital administration from all over the United States.  The focus of the organization is to bring different types of professionals together, to collaborate and achieve the best possible outcomes for mothers and babies.

One objective of this gathering in 2014 was to develop guidelines for transferring care of a mother and her baby from a planned home birth to the hospital.  They produced the Best Practice Guidelines: Transfer from Planned Home Birth to Hospital.  The Guidelines describe best practices for midwives, hospital providers, and policy makers to achieve the safest, smoothest possible transition to hospital care.

These guidelines are endorsed by the North American Registry of Midwives, the Midwives Alliance of North America, and the American College of Nurse Midwives, among others.  While the American College of Obstetrician Gynecologists has not yet endorsed the Guidelines, individual doctors and practice groups that have endorsed them are listed here.

These practices have been shown to result in better outcomes for mothers and babies.  These guidelines may help you, your midwife, and your chosen hospital to get on the same page about your transfer long before it becomes necessary.  As the patient/client, you can take the initiative to make sure everyone caring for you and your baby understands these guidelines and how to use them in the event of your transfer.