Hospital Transfers

Midwifery Today E-News, July 15, 2017 • Volume 19, Issue 15
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“Giving birth was the most amazing thing I’ve ever done. I’d been living in a Third World country, and I said, “I’m going to just squat behind a tree.” I basically did that but in a chair in my living room. I didn’t want a sterile hospital room. I didn’t want doctors.”
—Carolyn Murphy, Supermodel

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At our conference in Helsinki, Finland, this October, Tine Greve will offer a session entitled “Birth, Breastfeeding and Bonding: Does It Matter How We Are Born?” During this Thursday, October 5 pre-conference session, Tine will cover how physiological birth is an involuntary process orchestrated by neurochemicals and hormones that unfurl in a woman’s body. These processes prime the mother/baby dyad for breastfeeding and bonding after birth. What happens to motherbaby when these fine-tuned mechanisms are disturbed by interventions such as induction, augmentation or epidural anesthesia? These interventions are everyday events in hospitals all over the world. Are midwives, doctors, doulas and mothers aware of the direct and indirect consequences of these procedures?

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Hospital Transfer Q&A

What has your experience been with hospital staff when you have to transfer a homebirth client to the hospital? Has it gotten better over the years?

I had a necessary, but non-emergent, HBC with my first: Treatment to my face was fine; discussion behind my back was not. I heard from a student (I teach there) that a nurse said, “That homebirth worked out really well for her, huh?”
—Samantha Whiteaker

I have had great reception in the last 10 years. I have worked hard to establish good relationships with staff and the hospital OBs. My receiving physician helped this along. There will always be staff who will scoff at the homebirth clients, but if you can identify nurses who understand and thank them for their work in a transfer, they will become advocates for safe transport. You need to have thick skin for the staff who see homebirth as a negative comment on their service.
—MaryAnn Griffin

Sometimes that connotation comes from jealousy in that HB midwives act as many labor nurses were trained. Bedside, 1:1 care of a laboring family isn’t the norm anymore. It’s more juggling several labors, maybe, and an antepartum or two and the relentless documentation that seems to have more value in the hospital world than actual patient care.
—Roxi Augustine

Had three transfers past 30 days. The only time I had any unkindness was when I tried to call report for a woman for prolonged rupture of membranes (past 48 hours). The on-call OB called back and said he strongly suggested I take my client to where my collaborative MD had privileges. He didn’t want her at his hospital and said he wasn’t sure what I was doing was even legal. (I’m a CNM … he knows it’s legal.) Went to hospital where I used to work L&D. Patient was well-received.
—Rachel Harris

I used to sit in a background capacity when I transferred and didn’t interrupt the nurses when they said, “Well at least your baby is all right” when my client expressed her disappointment that she was in the hospital. I finally became much more proactive with the nurses and started pulling them aside and saying, “Yes, my client is glad for what you have to offer in terms of the health of herself and the baby, but she is allowed to be disappointed that this didn’t go the way she planned.” The nurses started treating my clients with much more empathy after that.
—Louana George

The hospital we transfer to is amazing, caring and professional. I planted my birth center four blocks away specifically because of this hospital.
—Kristine Tawater

I have seen wonderful and horrible to parents and midwife. And all ranges in between. There seems to be no way to predict it.
—Gail Hart

I am very lucky … I have always had easy transfers of care.
—Dina Fraize

I tell mamas and students when going to a hospital there are three ways you can approach it: Passively “Oh, you can do whatever you want Dr; I’ll follow whatever you say” or aggressively “You can’t do anything I don’t tell you to. I’m in control; you’re my adversary” or assertively “Thank you for your help and advice. My partner and I will take what you say into consideration and make a decision on how we want to go forward.” The assertive approach gets the transition they need at a very vulnerable and a scary time. If the couple go in with dignity and respect they will get it back.
—Celesta Rannisi

We had to transfer at the homebirth I was attending as a doula this past Friday. Even though mom and baby were both doing well, we were greeted with, “You need to go straight to the back for a c-section.” When the mom didn’t consent to this plan we were threatened relentlessly with scare tactics of “You and your baby are going to die!” and other horrific things that a woman in active labor doesn’t want to hear. It was one of the worst hospital experiences I have ever encountered…. I pray that this is not the norm.
—Nubia-Earth Martin

I have an extremely positive relationship with my hospital. I can call at any time for anything and have moms admitted, skipping triage entirely. They trust my care, decision-making and long record of safe practice. They are extremely slow to intervene, always respectful, always ask consent and for my parents’ input in the plan. Discharge is generally early because they know I will follow up with my parents.
—Kate Aseron

It depends on which hospital I transfer to and who is there to meet us. I’ve had clients treated like crap and others accepted with compassion and respect. But transfers always make me nervous.
—Pamela Brott

I’ve been fortunate to have always (in 24 years) had multiple great collaborating docs in four different states (five different cities) to help maneuver through L&Ds. I think it makes a world of difference to go into transports prepared with printed and faxed charts, and give thorough triage information in a professional, respectful manner. Wear scrubs (or a lab coat over your civilian clothes). In 24 years of out-of-hospital (birth center and homebirth) practice, I can count on one hand the “not so great” transports I’ve done due to disrespectful providers.
—Kim R. Lane

When the professionals greeting us in the hospital see/saw that we appreciate their expertise and have the documentation to chart vital info, doors truly open and parents and baby are center in a very cooperative, caring team.
—Gail Tully

Our local, very small hospital has been dominated by an OB for the past 30 years who came from a very patriarchal country. Any time a new doc came with woman-centered goals, he or she was gone within a year. His c-section and induction rates are out of sight. This is a rural/economically depressed area.
—Susan Rusk

It depends on the hospital in my area. One hospital is wonderful and another just down the highway is awful.
—Jessica Tilderman

I had a client last year who had her baby boy—after a homebirth transfer—urine-tested for drugs. Every other client I’ve had that was a planned hospital birth in the same hospital did not have that done with their babies.
—Angie Porter

Hospitals have different cultures and personalities. Here in the Dallas metroplex we have many hospitals. There are two hospitals that most midwives transfer to because our clients are welcomed there by a staff person who understands that the family has had to let their birth preferences go—they are doing the best they can to embrace a plan B. The midwife is welcomed at these hospitals and often continues to be a part of the team. Other hospitals even a few miles away are hostile. We are very intentional about networking with doctors and communicating our deep appreciation for the nurses.
—Margie Wallis

I’ve run into a few biases, but have never had a bad experience. I have much worse experiences from midwives than from the hospitals.
—Katie O’Day

I believe it has improved over the years. When I first started, homebirth was basically an unknown. There was no CPM certification so we were all treated badly. Now that homebirth is more popular they’re more used to transports, we have initials after our names and I built up a reputation so most doctors I transport to respect me. It is important to transport in a timely manner. They don’t want to see trainwrecks, and I don’t blame them! Besides coming in before it’s an emergency, also coming in with a humble spirit goes a long way. You’re coming to ask for help. You need to make some concessions: don’t come in with a chip on your shoulder demanding stuff that they’re not comfortable doing. Never contradict the doctor or nurse in front of the family; wait till they leave the room and then give your opinion.
—Marlene Waechter

Greatly improved! We have worked hard. We have had meetings, made handouts and tried to adhere to the Summit Guidelines and share those with the hospital staff. We always call ahead and usually have direct-admit. With the number of homebirths rising, hospitals will see us more frequently. For the most part, hospital staff are respectful of our clients and midwives. I still feel anxious when it happens and pray all the way there! We go to the least busy hospital so I think they appreciate the “business” when it happens.
—Deidre DeGrado

Some are great. Some awful. We had one in Emporia that was fabulous. The ER doc was very pro-midwife and one of the nurses and the RT had homebirthed themselves. They only person confused was the admissions clerk.
—Susannah Hines Reed

It depends on the hospital and the docs. I’ve had experiences where I was treated like a colleague with valuable knowledge and insight. But I’ve also been screamed at and told I am irresponsible and putting women in danger. I transferred one woman with a serious pp hemorrhage, BP that kept bottoming out and a loose uterus that I had to hold the entire trip to the ER (the EMT didn’t know how to compress the uterus and they don’t carry antihemorrhagics) When we got to the hospital they immediately gave her IM pit and that slowed the bleed and with a bag and slow drip of more pit they were able to get tone to the uterus and everything under control. I was screamed at (38 wks pregnant myself) by the OB department head. He told me I shouldn’t have brought her in, that I “made the mess” and “should clean it up.” When I asked if he seriously thought I should not transfer a woman with a hemorrhage he said, “If they want to practice their informed consent, then they can deal with the consequences.”
—Camarell Anderson

It completely depends where we transfer. The last two were actually ridiculously good—except for one nurse in each case—and when I calmly brought their behavior to their attention they backed off.
—Courtenay E. Grabowski

Although I have a low transport rate, I’ve experienced a difference for the better, mostly. In some Idaho hospitals they’ve practically rolled out the red carpet during transfers of care and even asked what I thought was the woman’s condition and what might work best. When in other states too, for the most part, doctors and nurses would work to create a more welcoming situation than some of the other practitioners on duty.
—Julie Swart

They have always been super friendly to me, but the city is growing and hospital is expanding and a lot of new people have come from big cities. They don’t know me and don’t seem as supportive, although none have been rude yet. … Being kind goes very far. We don’t have to agree on everything to still be friends for the good of our clients who go there. My experiences with other midwives have been far worse.
—Elizabeth Wyson Smith

Overall better, but I just had one of the worst transport experiences ever last month. I felt like we were back in the Dark Ages.
—Helen Stockton

The last time I took someone to the hospital closest to my birth center, I got a five-minute-long rant from the doctor who was on call. He told me never to come there again and that all my clients would have immediate c-sections on arrival, because he would not “labor” my patients. I recorded the call [and] filed a complaint with the Texas Medical Board, but they said the Dr was well within his rights. The staff hid their faces and acted like they couldn’t hear anything, blind to his threatening behavior. The same sort of behavior has happened many times over the years at this hospital. I don’t take anyone there unless absolutely necessary. I try to avoid waiting till the last minute, call ahead, take records, act civil and respect their territory.
—Jackie Griggs

They have to want to participate and help. I have called ahead for years and years even when unlicensed. Although there was some improvement for a short time, the newer docs have read the CDC info and judged this to be a stupid thing to do.
—Sharon Hodges-rust

It has greatly improved over the years … it has also cost me countless cookies, candy and pizzas to thank the staff. At this point, in a true emergency, they will even meet me at the door to the ER or the ambulance bay.
—Jeni Rector

The hospital experience after a transport varies from time to time. I assume it’s because the staff changes. Some nurses are great, some are horrible. Much of the time there seems to be a disconnect between the hospital staff understanding that the transfer is about keeping mother and/or baby safe, and a good thing, and the staff’s personal dislike of homebirth and midwives. The weak link in the vast majority of emergency transports is the EMS.
—Margie Dacko

We had one who was hemorrhaging and I told [the paramedics] they had to hold on to her uterus the whole way. They didn’t, not even fundal massage, nothing. Just drove and she lost an extra liter on the way. When we got to the hospital that was then my fault in the eyes of the doctor.
—Susannah Hines Reed

When we go in I always try to get in a friendly, short talk about how we so appreciate the hospital, and please understand the couple is not anti-hospital, they just wanted a birth in the comfort of their own home. I also try to remind them—in a light-hearted way—that every time they see us there are probably almost a hundred births that they never see because they happened just fine at home.
—Gail Hart

It’s improved tremendously in the 40 years since I started. In 1981, when I opened my birth center, we had a small community hospital five minutes away. The OBs took call for emergencies during the night. One doc truly hated us and was rude to our clients. We tried to avoid this hospital just in case he was on call. Now we have a variety of hospitals and doctors and CNMs we can call and we are recognized and respected.
—Helen Jolly Nelson

I was transferred at the end of my pregnancy because of fissures in membranes. I was treated like an outcast. The doctor … was rude and condescending. [She did] an internal (while I’m leaking fluid) without sterile protocol—just used a pair of gloves from the box everyone stuffs gloves back into when too many fall out. She made fun of my age, my decision to have a midwife and kept ranting about my not having any prenatal care. (I had my huge file with me.) Her actions were likely responsible for the infection that took my daughter’s life. Neonatal tests showed my baby was perfectly healthy—but when signs of infection set in, I was ignored even though I repeatedly asked for help for eight hours. My daughter died. Never once did the Ob/Gyn step in to check.
—Debbie Brown

It’s been a while since I had to transport, but I have had complaints filed against me almost every time I did. Not for reason, just because my clients dared to try a homebirth. One doctor screamed at me right in the middle of the ward, and walked out refusing care. Even the nurses were shocked and tried to apologize. This was a transfer that was supposedly planned with her OB, who didn’t show up.
—Pamela Golliet


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