Thoughts on Homebirth Transfer
by Mary Esther Malloy

[Editor’s note: The following article is a resource that midwives can adapt and pass out to their clients about homebirth transfers. This article first appeared in Midwifery Today, Issue 109, Spring 2014.]

I have given birth twice in a birth center and once at home. I have never transferred, but I have had to plan for transfers and as a doula I have supported a number of new parents through transfers. I have also followed the healing journey of many women in my talk groups who had planned to birth at home, but who ultimately gave birth in the hospital for a variety of reasons. I have put together the following notes on transfers for midwives and doulas in the hopes that some of the strategies and perspectives suggested might be of help to your clients if a transfer needs to happen.

I’ll begin with a perspective on homebirth offered by a woman I worked with a few years ago. She said, “I am hiring a birth professional for the care I want. I hope I give birth at home, but I understand that there is a continuum of where I might give birth—home or hospital. What matters to me is that I will have my midwife with me. I think of it more as hiring a person I trust than planning a birth in my home.” Her attitude struck me as a very open place from which to enter birth. She was passionate about what she wanted (a high level of individualized care from a birth professional she trusted), and there was an ease about the birth itself.

In the US, all too often home and hospital births get set up as antagonistic opposites (for some good reasons, I’ll add). There are, of course, parts of the world where we find a close and functional relationship between homebirth midwifery practices and hospital care. Based on my experience supporting non-US homebirthers, I’ll wager that, generally speaking, we find a more relaxed view of transfer in those parts than is typically the case here. And since most will agree that “relaxed” is a lovely state for birth, I vote for taking some time while preparing for a homebirth to imagine coping well with plan B. It is helpful to soften the edges of our thinking about the possibility of giving birth in a hospital even as we prepare to give birth at home.

Before I get to my notes, I will also remind us that birth really does work most of the time. When something bumps a woman from normal, run-of-the-mill status, it is worth remembering that the vast majority of transfers are non-emergency transfers. Usually, there is time enough for deliberation and a range of strategies to avoid an emergency situation and to keep the birth as low-intervention as possible. Additionally, it must be said that there are a few rare emergency situations that homebirth midwives are not equipped to deal with. Be sure to discuss aspects of risk with your midwife to get a sense of how and when she transfers. Make sure her approach feels right to you.

If the best and safest course for you and your baby is to give birth in a hospital…

1. Practice acceptance.

Keep in mind that birth is sacred. Period. There are no second-class births. A person is being born; a family is being born. This is of the highest order of sacred in my book. Draw on the strength, love, support and expertise of your team (partner, midwife, doula, hospital staff). Keep them in close.

Expect that you will feel many emotions as you continue to work to birth your baby in the hospital—feelings of upset, concern and grief may co-exist alongside your excitement to meet this baby. Even with these mixed feelings, commit to being truly present at your child’s birth. Your baby needs you now and deserves to be welcomed fully.

Every birth has its challenges, its darkest hour and its lessons. These lessons always seem to circle around to some version of surrender. Do your best to surrender and accept. Very wise teachers have told us that this is how suffering ends.

Work with fear. Breathe, meditate, pray, find a helpful word to repeat over and over, stay physically close to your partner, midwife or doula and get the reassurances you need to quiet unwarranted fears.

2. Make the experience go as well as possible (birth partners, take note).

Find who and what is positive. Advocate and get a supportive nurse, resident or attending physician.

Make friends with the hospital staff; learn names, thank staff for their care and be respectful even if you are in disagreement over some aspect of care.

Be an active participant in all decisions. Ask your questions and consider your options (remember that in the case of a true emergency, you can ask your questions afterwards). One way to remember helpful questions when a treatment or procedure is proposed is to memorize this simple mnemonic, BRAND:

B—Benefits: What are the benefits?
R—Risks: What are the risks?
A—Alternatives: Are there alternatives we can try?
N—Now: Is it medically necessary that we do this now or can we wait an hour/day/week?
D—Decision: Can we have a few minutes alone to make a decision?

Consider what matters most to you and do your best to make these things happen. For some, this might mean advocating to keep your baby with you in an uninterrupted way in the hours following the birth. For others, it might mean insisting on sleeping with your baby on your body during the hospital recovery stay. Following a transfer, many women experience an empowering sense of agency by doing whatever it takes to help breastfeeding go well. A doula friend of mine told me about a transfer she recently attended. The mother ended up using the tools of Pitocin and an epidural and gave birth to a beautiful boy. As the time of birth neared, she and her partner convinced the hospital staff to do something they had never done: lower the foot of the hospital bed and place the baby there as he was born. Others then helped the mother to sit up so that she could see, touch and be the first to pick up her son. Before the birth, the mother had really loved the idea of her midwife guiding her baby down at the moment of birth. The mother said afterwards that making that moment happen in the hospital was particularly powerful and healing, given the transfer.

3. Know your rights in the hospital.

Find out if your state has a “Hospital Patients Bill of Rights.” Frequently, states protect patients’ rights to informed consent, as well as the right to decline care from any hospital staff and the right to refuse a proposed procedure or treatment. These rights are as applicable to homebirth transfers as they are to individuals planning hospital births.

4. Prepare.

Be sure to talk with your midwife during your pregnancy about transfer plans and ask all your questions. I have found that some homebirthers feel more confident if they create a simple transfer plan that identifies certain things they would like to see in the event of a transfer (uninterrupted skin-to-skin contact with the baby after the birth, continuous support from the birth team, etc.).

Some homebirthers will prepare hospital bags in advance, others won’t. Some will visit a potential back-up OB and hospital, others won’t. I, myself, did not feel it necessary to do either of these things. However, when I drove to my back-up hospital and drew up simple maps for my husband and midwife, I could feel myself relax at a deeper level about my upcoming homebirth. Having maps in the hands of my team helped me feel safer. Do whatever helps you feel safe, and this may mean doing nothing other than trusting your midwife to manage a transfer should the need arise.

5. Work through the experience afterwards.

Your baby and birth deserve to be celebrated and announced just as any other birth would be. Celebrate your baby and this birth with photos, announcements and stories that include the heroic shifting to plan B required of this baby’s parents. In other words, don’t hide your story. Tell it with pride, even if you are still struggling with how you feel about the birth. Honor your efforts and your baby’s birth.

Allow for the mixed feelings both during and after the birth. Many well-meaning individuals, including hospital staff and family, will tell you, “How can you be upset now? You have this beautiful baby in your arms!” However, it is possible to simultaneously cherish your baby and mourn aspects of your birth. Grief and gratitude can exist side-by-side, and this will likely be the emotional tacking that defines your recovery. It is fully normal. Expect it. Work with it. Do not fear the difficult or dark emotions that may come up. Cry and move through them. You will heal. Get support by going to a mothers’ talk group or therapist. We heal by telling our stories; we heal through our laughter and tears.

A woman from my moms talk group who had transferred from a planned homebirth described a recent night with her 6-week-old son. Her son had been crying and crying that evening and she simply reached a breaking point and burst into tears herself. She described how she and her son clung to each other and cried together for what seemed like ages. She said she felt like they were both working through the challenging birth they had shared six weeks earlier. After their good cry, she described feeling much lighter and reported that her son’s crying was no longer so persistent. She felt they had really connected and shifted something through that memorable cry.

6. Help your baby.

If the birth or the period following the birth was challenging for your baby, you might consider trying a few things to help your child integrate what may have been difficult.

If you and your newborn missed the first “golden hour” for any reason, you can create this special hour at any point hours, days or even weeks following the birth. Repair is always possible. Simply set aside an hour or so to focus your full attention on your child. Let this be a special time where you observe, listen to, welcome and reassure your child. Allow everything to be slow. It might be nice to place your baby skin-to-skin on your chest or take a bath together for this reclaimed golden hour. If your child cries, this is fine. Just listen. If your child sleeps or nurses, lovingly pay attention and talk to your child.

If you feel there was a degree of trauma involved before, during or after your child’s birth, try talking to your child as she sleeps. (We now know that babies—and bigger people, too—listen in their sleep.) This can be an effective strategy to help your child process what might have been a challenging experience. Check out the wonderful booklet by Marcy Axness on this practice or set up a coaching session with her (marcyaxness.com). You might also want to get to know the impressive work of Patty Wipfler, found at handinhandparenting.org.

Common Reasons for Transfer

I include this list of common reasons for transfer simply because I am frequently asked this question by parents planning a homebirth. In no way do I include this list to give expectant parents additional reasons to worry. Some of you will not want to read through this list of complications. You will say to yourselves, “I trust my midwife to let me know if there is a risk factor at play that means the hospital will be the best and safest place to birth my baby. I know worrying now will not be helpful.” This is a fine and excellent decision. Pregnant women are vulnerable and are smart to be cautious about the information they take in. A woman entering birth wants to be in the head space of a birthing woman, not in the head space of a medical professional.

If reading through this list will help you be less fearful, please keep in mind that homebirth midwives are skilled medical professionals and have a host of tools to deal with the list of challenging situations below. Eat well, exercise and prepare in positive ways for the birth of your child. Address fears as they come up now. Stay hydrated, eat and rest or sleep when you can in your labor.

Prior to labor, common reasons for transfer include:
  • Persistent malposition of baby (e.g., breech)
  • Maternal health issue (e.g., hypertension)
  • Baby health issue (e.g., intrauterine growth restriction)
  • Postdate with complicating factor (e.g., very low fluid, non-reassuring fetal heart rate)

During labor, common reasons for transfer include:

  • Signs of stress on baby (e.g., non-reassuring heart rate)
  • Very long or abnormally progressing labor
  • Long pushing phase, usually with some sign that baby is not tolerating it well
  • Sign of infection (e.g., maternal fever, rising fetal heart rate)

Postpartum, common reasons for transfer include:

  • Excessive bleeding post-birth
  • Issues with baby

Conclusion

I’ll close by sharing a brief story. Recently I was sitting with a woman who had given birth by cesarean the previous week. Parenting was going well, she was clearly in love with her baby, and she was openly weeping as we spoke about her birth. As we sat together on her couch with her mother, she shared an experience she had had as the surgery started. She told us that when she was lying on the table in the operating room, she had a clear image of herself at a lake in Canada with her baby in her arms. Years ago, she explained, she had visited this lake and had felt the loving presence of her late father. As her baby’s cesarean birth began, she had a flash of the lake and again felt her father’s presence. She heard the words, “You and your baby are safe.” She experienced a deep sense of peace as she went on to birth her baby with the help of technology. Now, in her living room a week later, she turned to me with tears running down her face and said, “This is what I had wanted from my birth. I wanted it to be spiritual and it was.”

Her mother moved closer to her daughter on the couch. This woman had birthed both her daughters naturally in India and had recently attended her other daughter’s natural births. She laughed and said, “If you had birthed your baby the other way, I doubt you would have had this same spiritual experience!”

Mary Esther Malloy is a New York City-based doula, birth counselor and Bradley childbirth educator who has the pleasure of parenting three children ages 3, 9 and 11. For more about Mary Esther, please visit mindfulbirthny.com.


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