Best Practice Guidelines: Transfer From Planned Home Birth To Hospital

I am excited to announce that the Collaboration Task Force of the Home Birth Consensus Summit drafted best practice guidelines for transferring from home or birth centers to hospital. The guidelines are free and open source, meaning you can adapt part or all to your local setting.

Having clear guidelines for both the transferring midwife/physician and for the receiving hospital staff will facilitate a respectful, seamless transfer of care. This is especially important when the mother/baby pair has transferred for an urgent or emergency situation.

The Collaboration Task Force explains how they created the guidelines:

To create the Best Practice Transfer Guidelines, the Collaboration Task Force researched existing standards for universal intrapartum transport, transfer, consultation, and collaboration guidelines for all professionals who are involved when a woman or baby is transferred to a hospital from a planned home birth, as well as the evidence on practices that lead to improved interprofessional coordination. The result is a set of guidelines designed to serve as a blueprint for all of the providers involved in a transfer, including the midwife transferring care and the receiving hospital.

The Best Practice Transfer Guidelines are open source and providers are welcome to use or adapt any part of the document as desired.

The Collaboration Task Force is accepting endorsements of the guidelines from organizations, institutions, health care providers, and other stakeholders. We are pleased to advise that the American College of Nurse-Midwives (ACNM), the Midwives Alliance of North America (MANA), and the National Association of Certified Professional Midwives (NACPM) are early endorsers.

We are asking you to show your support of respectful, collaborative care for women and families who experience transfer from a planned home birth or birth center by endorsing the guidelines and encouraging the leadership of any maternity care organization that you are affiliated with to do so also.

To obtain the guidelines and provide your endorsement, please click visit www.homebirthsummit.org/best-practice-transfer-guidelines.

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Interview with Melissa Cheyney

Several weeks ago I posted about collaborations, transfers, and attitudes towards home birth, including the research of OSU professor and CPM Melissa Cheyney into physician's perceptions of home birth. Cheyney and co-researcher Courtney Evans have published their findings in the March 2009 issue of Anthropology News. The article, "Narratives of Risk: Speaking Across the Hospital/Homebirth Divide," is available here as a PDF. In addition, RH Reality Check featured an interview with Melissa Cheyney about her research.

I am especially interested in reading the protocol she is helping create for collaboration between OBs and home birth midwives. It's the first of its kind and will hopefully pave the way for better collaboration and communication between the two groups of birth attendants.

Some excerpts from the interview:

Newman: How can providers who are already open and amenable to working with midwives help foster a more supportive culture among colleagues, as you suggest in the proposal?

Cheyney: One of the mechanisms for maintaining distrust between midwives and obstetricians is what my colleagues and I have termed “birth story telephone.” This is very similar to the childhood game of telephone where as the story spreads from one individual to another, it grows in nature and the details change substantially. As home and hospital birth stories are told and retold, and filtered through the lens of the teller, details shift to match the preconceived worldview of the teller. For example, a non-emergent transport for a slow, uncomplicated and non-progressive labor can turn into a mother laboring at home for days with poor heart tones and a uterine infection before the midwife reluctantly brings her in. By the time the story has been passed along, mother and baby who were actually never in danger were saved from a near death experience by the hospital staff.

Conversely, hospital births where a woman feels too many interventions were used can be constructed as abusive or traumatizing to the woman after numerous retellings. These stories effectively maintain the home/hospital divide. Physicians and midwives can work to overturn that divide by refusing to participate in “telephone,” by being committed to accuracy and professionalism; sharing only the stories they have first-hand knowledge of. Midwives and physicians who have positive experiences working with one another also need to speak up regarding those positive interactions.

Newman: What are some of the stereotypes or judgements held by midwives about OBs/physicians?

Cheyney: Let me begin with this caveat, midwives often hold fewer misconceptions about obstetricians because we actually get to see hospital deliveries when we transport. We have first-hand knowledge of the model of care that we often critique. However, very few physicians ever attend a home delivery, and yet feel very comfortable critiquing that option.

That said, because midwives often hear stories of hospital births from clients who are unhappy with the experience and are now seeking an alternative, many maintain an outdated view of hospital deliveries as inhumane and impersonal. The vast majority of women, about 70% in the United States, leave the hospital feeling it was a positive experience. Only about 30% leave with regrets or frustrations about their experience and treatment. We as midwives disproportionately serve that 30%. This can prevent us from seeing the work that obstetricians are doing to humanize and individualize birth in the hospital.

Finally, while obstetricians can envision a world without midwives, midwives cannot envision a world without obstetricians. Thus, midwives have a larger incentive to work towards positive relationships with back-up physicians.

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Collaboration, transfers, and attitudes towards home birth

One of the blogs I follow, Midwife with a Knife, has a new post about her views on home births. She's a high-risk OB training to be a perinatologist. I enjoy hearing from physicians who can talk rationally and sensibly about home birth. I don't agree with her on every point. For example, I do think that HBAC is a reasonable choice. And in many places, it's one of the only ways to have a vaginal birth. It's refreshing to hear from someone within the obstetrical system who understands why some women make this choice and who doesn't resort to the typical scare tactics or accusations of maternal selfishness. Perhaps there is hope in bringing together obstetricians and home birth midwives in collaborative, respectful relationships. After all, better communication, respectful treatment during hospital transfers, and open, collaborative relationships would only enhance safety for home birth families.

This is something that two Oregon State University researchers have been examining, in fact: conflict between obstetricians and home birth midwives and possible ways to create collaborative relationships. Assistant professor Melissa Cheyney (who had a baby at home a few weeks ago) and doctoral student Courtney Everson found that in Jackson County, Oregon:

assisted homebirths did not appear to be contributing to the lower-than-average health outcomes and, in fact, that the homebirths documented all had successful outcomes. But even more importantly to Cheyney, discussions with doctors and midwives uncovered a deep mistrust between the two groups of birthing providers, with doctors expressing the firm belief that only hospital births are safe, while midwives felt marginalized, mocked and put on the defensive when in contact with physicians....

One of the biggest problems Cheyney sees is that physicians only come into contact with midwives when something has gone wrong with the homebirth, and the patient has been transported to the hospital for care. There are a number of reasons why this interaction often is tension-filled and unpleasant for both sides, she says.

First is the assumption that homebirth must be dangerous, because the patient they’re seeing has had to be transported to the hospital. Secondly, the physician is now taking on the risk of caring for a patient who is unknown to them, and who has a medical chart provided by a midwife which may not include the kind of information the physician is used to receiving.

And because the midwife is often feeling defensive and upset, Cheyney said, the contact between her and the physician can often be tense and unproductive. Meanwhile, the patient, whose intention was not to have a hospital birth, is already feeling upset at the change in birth plan, and is now watching her care provider come into conflict with the stranger who is about to deliver her baby.

“It’s an extremely tension-fraught encounter,” Cheyney said, “and something needs to be done to address it.” As homebirths increase in popularity, she added, these encounters are bound to increase and a plan needs to be in place so that doctors and midwives know what protocol to follow.

“We’re having a meeting in early May to propose a draft for a model of collaborative care that might be the first of its kind,” in the United States, Cheyney said.

Physician blogger KevinMD agrees that physicians and midwives need to cooperate more. He writes:

From the doctor’s side, the only times they interact with midwives is when trouble arises....Doctors should also see things from the midwife’s perspective, and collaborative programs where they can experience successful midwife cases can help resolve the conflict between the two camps.

Make sure you read the comments as well as KevinMD's original post.

Unfortunately, not all physicians or nurses are respectful or rational when working with homebirth transports, as the L& D nurse blogger at Stork Stories illustrates. In OB Docs and Nurses Scoff at Homebirth, she writes about the attitudes her OB and nurse colleagues have displayed when they encountered transports.

Often the OB’s didn’t handle themselves well...certainly not professionally. We had this one OB who would call for the OR to be opened before he even examined the patient or evaluated the situation...regardless of why they came in. And he often actually yelled at the mother, in the middle of her scary situation. “Your baby will die if we don’t do an emergency C/S right now, why did you let this happen!”

Most often the backlash was directed at the midwife who cowered in the hallway- uninvited by the staff, left alone detached from her patient. She never left the unit though until she was afforded the opportunity to visit and speak to her patient...

I feel that instead of the midwife or mother receiving hostility (or even the mother being whisked away to the OR without a trial of something if the baby was deemed stable...) the staff should have behaved in a compassionate professional manner, acting on any urgent situation with consideration that this mother is now experiencing not only labor but fear and grief over the loss of her beautiful planned birth.

I have written earlier about my issues with the ACOG's and AMA's official positions against home birth. Probably the most significant repercussion of these official position statements is that they strongly discourage physician-midwife collaboration. For example, the CNM who attended Dio's birth needs to have a signed collaboration agreement with a physician in order to administer certain emergency medications in our state (IV abx for GBS+, anti-hemorrhagic meds, lidocaine for suturing, etc). The agreement does not require the physician to take on a supervisory role, nor does physician assume any liability for the midwife's clients. She has contacted over 150 physicians in our state, and not one was willing or able to sign the agreement--including some of her own physician clients! This was often due to the physicians' malpractice insurance policies or hospital regulations, which of course are strongly influenced by ACOG and AMA recommendations.

Wouldn't it be fabulous if all medical students, especially those going into family practice or OB/GYN, did rotations with out-of-hospital providers? And if all home birth midwives were able to do hospital internships as part of their training? And if we had some kind of forum for OBs and nurses and midwives to meet and talk about how to improve maternity care, a dialogue where they really learned from each other. Imagine midwives sharing how they are able to achieve such low cesarean rates. Imagine physicians giving suggestions for how to make transports smoother (what kind of charting would be helpful for the hospital staff or having the midwife call the local L&D when a client is in labor so the staff is prepared in case a transport is needed).

What suggestions would you have--as a physician, a nurse, a midwife, a doula, or a birthing woman--to improve collaboration and communication and to make home birth transfers smoother and safer?

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