when to transfer to hospital

[medmom7]

Can any midwives or other experts weigh in on their opinion on when it is time to transfer from a homebirth to hospital? Here is a list of my thoughts:

-Persistant vital sign abnormalities on part of mom (fever, hypotension)

-Fetal heart tone abnormalities (normal for variation of fetal heart tones in labor, how do you tell what is normal variation and what is concerning?)

-Bleeding (more than expected/usual)

-Intractable pain (labor pain admittedly being very severe but does seem like there is at least some predictability of it)

-Not progressing (at what point would you call it quits?)

Thanks!

[Jen286]

Not a midwife, but I attend quite a few homebirths on a regular basis. The most common transfer I see is mom deciding she wants anesthesia. Second most common involves really poor fetal heart tones early in labor that don't seem to be improving (heart rate under 120 and not improving, or under 100). It seems like when this happens near delivery, more effort is generally made to handle it at home. A baby turning breech with a midwife who isn't trained or comfortable with breech delivery is another fairly common one. I don't see transfer for bleeding/hemorrhage very often. At least the local homebirth midwives here seem to all be pretty well equipped to handle that event. I have seen more for stitches (after delivery) when a midwife felt like something needed repair beyond her skill level than I have for bleeding. I've heard of transfers for failure to progress, but have not personally been attending any where that happened unless mom decided she wanted to for anesthesia, fetal heart tones weren't looking good, or fever or other issues with maternal vitals had appeared.

[loveneverfails]

If the hair sticks up on the back of anyone's neck, I transfer now, as a HB mom (not a MW.)  People at my births know me well enough and I trust them if they have a bad feeling.  If anyone gets the feeling that something is off and concerning, I will transfer, even if signs are otherwise reassuring.

Emergency situations with a newborn.  Not every transfer happens during labor.  

[rumi79]

My transfer was due to running a fever after 20 hrs of ROM and history of GBS+ with previous birth. I was also a HBAC and had really hard time dilating, baby's head was tilted, overall there was this feeling that something is not quite right.

[Tumble Bumbles]

I agree a transfer is indicated if mama feels something is wrong. Often intuition is the best early indicator, before even physical symptoms develop. I've considered this and since we are having a UC (unassisted childbirth) I've considered the reasons I would transfer. A deep feeling something is not right would be big. Second to that, I would transfer if I had prolonged ROM coupled with indicators of an active GBS infection since my status will be unknown. I would transfer if baby had a lower 5 minute apgar score than I felt comfortable with. I would transfer if I had any symptoms of placental abruption (fever, bleeding before baby is born, contractions on top of each other without a break unlike what I've felt in my previous labor). I would likely transfer for retained placenta, if it weren't out within an hour or so and/or I wasn't feeling too hot. If I was feeling great after an hour I would give it a wait and see approach every 10 minutes. Um... I probably wouldn't transfer for "prolonged labor" provided I still felt okay and nothing seemed amiss. I would transfer for prolapsed cord (God forbid!). It goes without saying I would call 911 if babe was in distress.

Those are all I can think of at the moment but praying none of them happen of course!

[Full Heart]

I transferred last time before labor began because baby was not moving.  I had a hospital birth after induction and everything was fine.  For heart tones if the heart rate does not change thats a concern.  If you listen and its just 140 140 140 140...thats a problem.  You want it to go up and down.  Thats what was happening with my baby that didn't move.  I also transferred with my 2nd after being stuck at 7 cm for a very long time.  By the time we went I was in labor for more than 24 hours and at 7 for more than 12.  I could no long sit up straight, and was obviously not progressing so we went in.  If the baby was not in the correct position, like if it was transverse.  After birth if you had an unusual tear like on your cervix.  You can transfer for lots of reasons, they just don't happen very often. 

[jksmith]

if the water breaks and there is meconium in it, you need to transfer so the baby can be intubated for deep suctioning of the larynx, if needed. so they don't inhale the mec particles.

[Tumble Bumbles]

Originally Posted by jksmith 

if the water breaks and there is meconium in it, you need to transfer so the baby can be intubated for deep suctioning of the larynx, if needed. so they don't inhale the mec particles.

I disagree. There was meconium in my amniotic fluid and babe was just fine. She didn't take her first breath until she was well out and the meconium was able to be removed before she breathed. We were fine at home :)

 In some cases meconium in amniotic fluid requires a transfer, but definitely not in all.

[mommato5]

http://www.medscape.com/viewarticle/437101_4

[CBEmomma]

* High blood pressure

* Fever which may indicate an infection

* Low decels in baby

* Mom not managing well

* Blood loss

* Signs indicating complications such as pre-e, etc.

* Any time you felt it is needed

Hmmm, that is what I can think of off the top of my head. Your gut feeling can also be a sign. You might not have a physical sign, but something might just feel off to you. You can also go get checked and then go back home if it's nothing.

[jksmith]

Originally Posted by Tumble Bumbles 

I disagree. There was meconium in my amniotic fluid and babe was just fine. She didn't take her first breath until she was well out and the meconium was able to be removed before she breathed. We were fine at home :)

 In some cases meconium in amniotic fluid requires a transfer, but definitely not in all.

Yes, you're right. It's more complex than what I originally said. There is a big difference between thin meconium and thick particulate mecomium. As a student I have seen plenty of births with mec where the baby came out and breathed fine. But we are required to transfer if the water breaks early enough before delivery (in Ontario). But often at home births the water breaks with mec just before the baby is born and theres no time to transfer, but it doesnt matter.

[RosieL]

Originally Posted by mommato5 

http://www.medscape.com/viewarticle/437101_4

Thanks for the reference, I always appreciate a citation. :)