help! good reasons for transfer/NO transfer

[corban's mum]

Im planning a hbac and have been told i need to meet the senior midwife of the local hospital to get a plan in place

by plan they mean "set conditions" cuz basically i've been told "if the midwife isnt happy you have to transfer"
so i would really like to have a structured list of reasons that i am happy to transfer - such as life or death situations etc and a list of reasons that i COULD be tranferred (such as stall in labor) but would like to try natural methods/coping at home first, and get them to agree to it at this meeting on friday.

i would love some help in compiling this list


i'll start with the easy one- things i dont want to immediately transfer for:

stall in labour (would rather just sleep and try natural stimuli)
"poor" fetal positioning (if babe is OP then im going to get in pool and use lateral positions etc etc)
cervical lip (would prefer to give it time and maybe poke it back over babys head etc)
"slow" labour (patience is a virtue)
pain - i would rather try hypnosis/encouragement first, then tens machine then gas and air, pethidine as a last resort before transfer

ALL of these are assuming baby is happy etc


so far i would be willing to transfer for:
heavy bleeding/Uterine Rupture
fetal distress (meconium or a sustained raise/dip in HR not just a slightly raised one due to that being normal at times throughout labors)
placental issues
baby does some kinda flip and tries to come out butt first etc
PPH etc

can anyone think of any other special circumstances to add to either list? and ways to home-manage them?

really grateful for any help

[vtamanda]

cord prolapse

[corban's mum]

ah good one thanks, kinda obviously *facepalm* lol

[corban's mum]

need more reasons for NOT transferring and ideas of natural solutions i think, just realised i'll probably freak myself out too much if i list too many bad situations lol

[lunarlady]

I'd add Transfer for: maternal/newborn fever

You might also want to give some timelines. How long are you willing to wait before you transfer due to: ROM, stalled labor, hours of pushing, retained placenta? These can all be judgement calls, and good to consider in advance.

[Sijae]

Sounds like dancing with the devil. Can you simply let them know that you will be happy to transfer if you are convinced it is the right thing for your and your baby? It's not up to the midwife, it's up to you.

Bargaining and negotiating to gain rights you already have is going backwards.

Laura

[Comtessa]

Welll... except in the UK, I think the MW's have to be pretty conservative about when they call for a transfer. So it might be good to say, "I really don't want to transfer if baby and I are doing fine and there are minor complications that are slowing my labor." A list, though, is overdoing it, IMO. There's just too many things that can happen in labor, and it's hard to know what to expect. You could have something serious like PPH that can, nevertheless, be managed at home... and then again, you could end up having to transfer (like I did) because you can't keep liquids down and you're getting dehydrated. I think if you come in with a list, you're going to sound a little too controlling (and trust me, I write ten-page-long birth plans, I know about controlling). It's just not possible to know ahead of time what will be necessary or not. Better just to ask them to consult with you about any suggestion to transfer, and let them know that you're not comfortable considering a transfer unless all options at home to deal with a complication have already been exhausted. Then trust their professional judgment to get the baby here safely -- that's why you're having them show up at all!

[turnquia]

I'd also put on there that if there is something not your list that you will discuss with midwives and trust their expertise provided there is proof of an issue with mother or baby. Realistically everyone knows you will transfer for the big things. PPH/Cord Prolapse/Abruption/Uterine Rupture... But that you'll be more than happy to discuss transfering with the midwives in attendance provided their clinical experience suggests it and there is documented proof of it. (Such as meconioum, fever etc).

I'd also maybe write that at any time in labor your natural gut instinct calls for a transfer, no matter what the reason is.. you will transfer, even if maybe at that moment in time there are no signs of something being wrong. Sometimes that gut instinct can be so strong that you wouldn't be comfortable staying home.

I maybe wouldn't list specific things just keep it vague. When vital signs of both mother and baby are well and within normal limits for the patients that you'd like to stay home. Even if it means a stalled labor, and again you'll use the clinical judgement of your midwives at home as well as gut instinct on how you and your family feel with the situation.

[ShwarmaQueen]

UR wasn't one of my worries either. I think it's so far down, statistically, of things that could happen I hardly thought of it. Besides, that's the MW's job, right?

Do MWs in the UK carry Pitocin?

[MegBoz]

Originally Posted by Sijae

Sounds like dancing with the devil. Can you simply let them know that you will be happy to transfer if you are convinced it is the right thing for your and your baby? It's not up to the midwife, it's up to you.

This makes sense to me - however, is there a case here of liability issues? Here in the US, CPMs (direct-entry/ non-nurse midwives) are licensed in only about half the states. (The others have either no legislation regarding them, or they are outright illegal.)

I believe in some of the states with licensing, there are some restrictions, such as they're not legally able to attend HBAC, breech, or beyond 42Weeks or they could lose their license.

I can understand if your MWs have such 'rules' that tie their hands. But I would think those rules already exist & everything else, such as stalled labor or PPH is an individual judgment call made by MW & Mama together. So I guess I'm still not clear on why YOU need to be the one to come up with this list.

[HappyMommy2]

My very-experienced mw told me that in her experience, the most common reason for transferring was maternal exhaustion. She also said that for (most or all) the major things, you can get to the hospital in time, because she can see it coming.

In order to satisfy your own comfort level, you might discuss each situation with your homebirth midwife and exactly what she would recommend at that time. For example, in a stalled labor, maybe you walk the stairs a couple times, roll your hips around, eat/drink something, etc.

She and I were on the same page. We would both do everything in our power to keep me at home.

A vague threat like your "if the midwife isnt happy you have to transfer" is totally bogus. Who is saying that? The midwife or the hospital?

A frank discussion with your HB midwife will allay your fears.

I don't think the hospital is demanding a plan from you, but I think your natural inclination to do so means that YOU want to know which situations will require transfer. As well you should! I personally, would not provide that much info to the hospital senior midwife. Your detailed plan should be with the homebirth mw.

The "plan" with the hospital should be ... "in case of a necessary transfer, where do I enter the building?" They will want to have you and your insurance info on file to make it easier if you arrive late in labor. They may want to give you a quick tour of labor and delivery. I would definitely not go into details with them. It sounds like they are satisfied that if your hb mw isn't "happy" then you will transfer. Leave it at that.

Don't discuss details with the hospital, you would be asking for a fight and stress. And THAT is the reason most of us homebirthers birth at home! We don't want to deal with all of the hospital drama!

Congrats on your upcoming homebirth mama!!

[corban's mum]

thanks mamas these are all really great points to consider.

the MW's i've seen at doctors clinics have all said that i need to see the senior midwife and the vbac team to come up with "a plan" before theyd be "professionally able to/happy to attend" to me. it was only yesterday that i actually asked exactly what they meant when they kept saying "set up a plan" because i had said did they mean my birth plan and she said no, they need to "inform me of all the risks, talk about circumstances upon which they'll transfer me and that i may not refuse otherwise im putting the MW in attendance in a career-comprimising situation"

which lead me to think maybe i should state a list of things that i wouldnt want to transfer straight away for. just so i don't get bullied two hours in with "ur progressing too slowly u need to go in" etc etc because theyre afraid of HBAC

but yeah - i think maybe saying "unless there isn't time and i need ambulance STAT i would like to have the reasons for suggesting transfer discussed with myself/doula/dh and natural methods be used at home wherever possible" may be a good route to take. but I also do think i need a few examples to give so i don't just get the patronising pat-on-the-head "we'll see" reply from them that i usually do. just so i can be clear that 1. im relatively clued up on birth and natural methods and 2. thati'm serious about this being my desire and that i'm willing to take responsibility for my own choices-as long as im given them

that isnt to say i wouldnt be peeved if the MW was blatently negligent or something, but im willing to understand that as i want a hands off, natural birth with a MW there to basically do newborn checks and be backup if anything happens, i need to be realistic in the share of responsibilty for outcomes

i'm not stubborn or "anti intervention" and i would be straight in the back of an ambulance on the way to L+D in the blink of an eye at any serious complication, i just want to be given a chance to labour at home, and if all goes well-deliver there too. but im being made to feel like i have to go and "ask permission" from the head of MW's and be "risk assessed" and stuff like it's some huge deal. to me it's not - im pregnant, i have a scar so i have in increase of less than 1% of UR, i live so close to hospital that if the mw called ahead i'd STILL be in the pre-op room b4 the theatre was even set up and i'm willing to be held accountable for any bad judgement calls on my part.

gah i know im ranting, but i've seriously been passed from pillar to post this whole pregnancy with them hoping i'll "get over it" and decide to hosp birth, lots of times being told "you wont be allowed" or "that's a silly idea isnt it" by mw's and doctors. one even said "we all love our aroma-therapy dear, but this is serious" (when i mentioned wanting hypno-HB), for no reason other than a 6 yr old low horizontal cut from a cs for fetal distress *sigh* i've got no other medical problems and baby and i are fit n well so i just wish theyd take me seriously and maybe, just maybe tell me, just once "u can do it mama"..... garghh

[JamieCatheryn]

I've read this and your other thread, it really sounds like your particular midwives are incredibly disrespectful and condescending. I'm sure they fear you'll minimize a serious problem they want you to transfer for, but to throw their weight around, threaten you with legal action, and LIE to you is not the best policy. You've tried to speak with them about how with minor issues you'd rather wait it out and they lectured and told you they'd have the police haul you in for a cesarean for goodness sake. This is how they respond to a concern about medical overpractice? I'm sure not every midwife in your area is so unprofessional as that. Aren't you allowed to switch?

[AlexisT]

This is the NHS. The guidelines for transfer are pretty much set at trust level based on guidance from NICE. The midwife does not set her own policies.

VBAC is normally consultant (OB) led and is outside the normal criteria for home birth. That's why she has to meet with the OB and the supervisor of midwives.

And yes, UK midwives carry drugs for PPH--pitocin and methergine (some carry syntometrine which is a combination).

[corban's mum]

Originally Posted by JamieCatheryn

I've read this and your other thread, it really sounds like your particular midwives are incredibly disrespectful and condescending. I'm sure they fear you'll minimize a serious problem they want you to transfer for, but to throw their weight around, threaten you with legal action, and LIE to you is not the best policy. You've tried to speak with them about how with minor issues you'd rather wait it out and they lectured and told you they'd have the police haul you in for a cesarean for goodness sake. This is how they respond to a concern about medical overpractice? I'm sure not every midwife in your area is so unprofessional as that. Aren't you allowed to switch?

it wasn't me they threatened with police/sectioning etc but i have been lied to and had the odd lecture, but meh i can't pick the midwife who turns up on the day, hopefully she'll be great but it just need to get them to agree to sending one in the first place, i know they can't legally refuse but there are other ways they can find around it

[corban's mum]

Originally Posted by AlexisT

This is the NHS. The guidelines for transfer are pretty much set at trust level based on guidance from NICE. The midwife does not set her own policies.

VBAC is normally consultant (OB) led and is outside the normal criteria for home birth. That's why she has to meet with the OB and the supervisor of midwives.

And yes, UK midwives carry drugs for PPH--pitocin and methergine (some carry syntometrine which is a combination).

cool ok. the guidlines also say that a VBAC mother has to be "in a place where she can be delivered in 30 minutes should and emergency arise" which i am, as i'm 7 mins away from hospital. also just read that guidliones state that vbac mum's shouldn't be treated any differently during labour than primip mum's, so i have a bit more of a leg to stand on when i say that i don't want CFM and an IV/labour in bed should i have to go to hospital. which is what they told me would happen if i go in (what a way to tempt me in eh? lol)

[GoBecGo]

Hey corbansmum - i'm in the UK, i had an NHS HB in 2006 and as a 1st-time mum with NO problems it was hard to get them on board for it, though they did eventually (literally at 38 weeks) become supportive. I did fine, i'm sure you will too.

You are within your rights to ask to be assigned a supportive midwife. Tell them you understand that HBAC's are rare but you want to have one and you want a midwife who is supportive of your choice. I know it's hard to speak up but i got a medically-minded terrified midwife i'd never met before in labour and had i not laboured so fast i'm sure i would have ended up in a no-real-reason transfer.

Can you afford to pay for care? There may well be an independent midwife in your area who would be able to support you, but they charge a fee. I had an IM HB in June, the full cost of care, birth, postnatal was £2700 i think, but it was worth every penny a hundred times over for the one-to-one care, the REAL belief in normal birth and the support she gave us all through the pregnancy. I know it's expensive, we did our savings and annual bonus in getting it, but it really was worth it.

[corban's mum]

heyy congrats on your two HB's

unfortuntely an IM is not an option for us, we literally just moved into a new house, first time buyers/hefty mortgage etc

or i would have soooo paid for an IM from the start. i have however managed to pay for hypnobirthing classes and the practitioner is also my doula so i know i'll have SOMEONE on my side to support me and be my advocate during the birth

[coraljean]

I would also find out where they stand on transferring for a long pushing phase. This is why I got transferred, and ended up with a c-section. I'm planning on not having any cervical checks in labor this time since I don't want to be encouraged to push before I feel an urge. If you are worried about them transferring you out because of a stall in labor, I feel like they might use the cervical checks against you like "Well you have been stuck at 7cm for x hours." If you don't let them check you, they won't know that! Just something you might want to think about. Good luck!

Coral Jean
Mama to Dylan c/s 12/08 & expecting another boy in December, planning HBAC!

[corban's mum]

i agree about the cervical checks, im going to request that they dont ask me, that i will ask them if and when i want to be checked, like maybe when i get a pushing urge/help with cervical lip if that becomes an issue etc etc

but routine exploration of my private parts to see if im matching up with the 1cm/1 hour "guide"- no fankoo LOL

basically if baby is doing well HR wise etc about labour is taking 30 hours what does it matter (apart from the fact i'd be knackered lol) im sure i'll dilate just fine. i made it to like 9 cms last time before he started to flood mec

im not going to say anything about not wanting internals until im actually in labour though - i have a feeling theyd use that to jump on me "how can we know what's going on if you dont let us monitor you properly" etc etc