What are the most common reasons that women transfer to hospitals?

The most common reason a woman transfers into a hospital after a planned homebirth is because her labour goes on and on and she becomes exhausted. Lots of strategies can be tried at home to help facilitate labour and combat exhaustion, however even with the best tools, sometimes a trip to the hospital is required.

Women expecting their first baby are more likely to transfer to a hospital than women who’ve given birth vaginally before.

Other common reasons that may require a transfer to the hospital include:

• Concerns with blood pressure
• Changes in the baby’s heart rate patterns
• Meconium in the waters
• Bleeding during labour
• Significant bleeding after the birth
• Problems with the birth of the placenta
• Problems with the baby after birth

What percentage of your clients transfer?

The percentage of my clients that transfer from a home birth fluctuates. Because a private midwife sees low numbers of women, a couple of transfers close together to increase the transfer rate significantly and conversely a run of homebirths lowers it significantly. Over the years my transfer rate has fluctuated between 10 to 18 per cent.

Do women have to transfer? What is the private midwife’s role in this?

Women have the choice of whether or not to transfer into the hospital. It is important for women to be as informed as possible before making the decision about whether or not to transfer to the hospital.

Some situations are an emergency so time may be of the essence. As a result, in an emergency, it can be more difficult to be well informed. A private midwife’s role is to provide the woman and her family information about what is occurring and the options open to her.

A private midwife provides guidance in situations that require a transfer and may provide her informed opinion on which course of action she feels is most appropriate. All expected Private midwives to follow the Australian College of Midwives Guidelines for Consultation and Referral.

What is the journey to the hospital like? (ambulance, car etc…)

The experience of the journey to the hospital depends on the situation at hand. If something has occurred early in labour that isn’t an emergency, the trip is in a car and there isn’t a need to rush the trip making it a less stressful experience.

However a trip to the hospital either by car or ambulance late in labour can range from being very uncomfortable to distressing. If there is an emergency, an ambulance is required. One of the main advantages of an ambulance is the ability to move through heavy traffic much more easily, a particular plus if you need to go through peak hour traffic.

How quickly does help arrive at the hospital?

When a woman transfers to the hospital the midwife will call ahead and speak with the hospital so they are aware that a transfer is occurring. A phone call enables hospital staff to get things ready at their end and ensure they are aware of what is occurring ahead of time.

My experience is that if there is a real emergency the staff are ready and waiting when we arrive. If the situation is not an emergency, it can take time for the hospital staff to come and see the woman. Wait times depend on how busy the particular birth unit is at the time of the transfer. Sometimes there is a significant delay in being seen but this is uncommon.

What is the role of a private midwife in NSW when she goes with a homebirth client to the hospital?

Does there have to be a ‘shared care’ arrangement in place?
The role of a private midwife in the hospital setting when a homebirth client transfers in is a controversial area. Midwives are required by their registration to be covered by professional indemnity insurance. Currently, midwives cannot get professional indemnity insurance for homebirths. An exemption is in place until the end of 2016 enabling midwives to attend homebirths without professional indemnity insurance.

However once a woman transfers to a public hospital as a public patient midwives are no longer covered by professional indemnity insurance, and the exemption no longer stands. As such, if a midwife continues to attend as a midwife they are in breach of their registration.

The sanctioned role is that we hand over to midwifery and/or medical staff at the hospital and cease to provide care. This is an untenable situation for both the women and the midwife. Ways around this include:

• Getting visiting rights. No one in NSW currently has visiting rights, but this is hopefully changing very soon. Some midwives, however, may have an agreement with the local hospital to continue care as an employed hospital midwife
• Having a private obstetrician provide back- up so that if the woman transfers into the hospital as a private patient the midwife can continue providing midwifery care. This option is only valid if the midwife has MIGA professional indemnity insurance (the only insurance that provides professional indemnity insurance for birth in a hospital)
• Having a relationship with the hospital that permits the midwife to be put on staff to continue caring for the woman after the transfer

That said, these conditions are not easily achieved. In most circumstances, the midwife must give up her official role as a midwife and if she stays she becomes a ‘support person’.

What are the challenges women face when they transfer (e.g. making decisions, facing ‘attitude’)?

Thankfully many transfers are met with welcoming staff and a positive experience ensues. However, this is not always the case and a homebirth transfer can be met with hostility from hospital staff who does not welcome it when a woman and her team make decisions contrary to their advice.

The midwife and the woman’s support team are critical in protecting the woman and supporting her wishes. To make the hospital transfer smoother ask for information from the hospital staff about what they see as the best way forward. Then ask them to give some time so a decision can be made by the woman and her support team without pressure being applied.

A BRAIN analysis can help when trying to reach a decision: Think about the Benefits and the Risks attached to the intervention being suggested. Explore if there are there any Alternatives to the suggested intervention that is acceptable. Explore what your Instinct is telling you. Think about what will happen if you do Nothing. – Benefits, Risks, Alternatives, Instinct, Nothing.

How do women cope with the unexpected outcome of their birth? From your perspective, does having their own private midwife make a difference in this?

I find most women cope well with an unexpected outcome of their labour and birth if they have been involved in the decision-making process throughout the whole experience.

If a woman feels rushed, pushed, or not respected or listened to, her perception of the birth will usually be very negative. Post-traumatic stress syndrome can occur following a traumatic birth.

Having a private midwife enables women to have access to continuous support, lots of information to make informed decisions and someone who knows the woman’s wishes intimately. A private midwife can help to facilitate the best birth outcome given the circumstances at hand and lessen the chance of the birth being traumatic.

Once the birth has occurred the private midwife has a very important role, that of birth debriefing. The private midwife can help the woman explore her birth experience, including the positives and negatives, work out what could have been done differently and be there simply to listen. A private midwife can also help to work through an unexpected outcome and assist the woman feel at peace with her birth.

Written 28th June 2015