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Transfer of Care - Transport

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These are easy to read and understand and are beautifully presented.

Subsections on this page:

How To Foster a Good Transport Situation

Best Practice Guidelines: Transfer from Planned Home Birth to Hospital

Here in N. Texas we have formed a liaison committee. We make appointments with various hospital where we meet with the administrator or assis. admin., chief of staff of O.B., and nursing administrator. We give them a copy of our laws and standards and let them know that by Texas law we have to come to their hospital if we have to transport in their area. We tell them that the purpose of the meeting is to find out from them what they expect from us during a transport and what we expect out of them also. We get phone numbers that we can call in case we get into a situation like yours. We are very tactful and courteous but let them know that it is very important to us that we resolve any issues in the office so we can all work together for the welfare of the mom and baby. Maybe something like this might help you all or anyone in any other state.

If you want to appear in the role of a primary care provider, it helps to wear a white lab coat with a copy of your license in the badge holder.  One of our local midwives uses an expired license with a passport photo.

Could you give some tips to those of us who never were nurses on how we might be able to foster good relationships with nurses assuming care during transport situations?

You raise a number of good questions--it's been some time since I worked L&D, but I'll give you my opinions, mostly from a midwife's standpoint.

First, when I take on a client for midwifery care, I stress to them that it is fine to be committed to home birth. This is different, however, than being attached to home birth. Sometimes a transport is necessary and then we need to open up to the mental/emotional shift that allows us to be accepting of and, yes, even grateful for the hospital. This being the case, when I have a transport I remind myself that:

  1. The situation has changed from being appropriate for home to appropriate to hospital. I am "asking a boon" when I come in to the labor and delivery area with a transport, so I get myself to a place of real gratitude and humility before I ever walk through the hospital doors.
  2. I make sure that I have complete charting throughout the birth so that, if we must transport and I am asked for information from the chart, it is quite complete. My chart has been developed over many years of practice so that it is very comprehensive. Midwives' charts can favorably or unfavorably impress the staff and I want everything to be in our favor. I don't want my client to be poorly treated and I don't want to be professionally discounted (or even investigated) because of poor or non-existent charting.
  3. I am very careful about what I wear. I keep a change of clothes in the car in case of transport, and this includes shoes (I carry running shoes). I will not wear my Birkenstocks into a hospital--it is an established professional turn-off, especially if I'm not wearing socks! I generally wear sweats in the winter and scrubs in the warmer months. I know that some would think the latter to be way too medical for homebirths, but they are incredibly practical and, if I have a transport, I blend in instantly. (I do prepare the ladies for this garb well before the birth, and most do not have a problem with it.) I guess a few nurses might be offended over my wearing the "official hospital uniform" as an OOH midwife; most, however, see the logic when they think about it. With our fundamentalist clients we usually wear a skirt and blouse and low heels or flats (and use a full apron to avoid staining)--sounds like a pain, I know, but these ladies very much appreciate the feeling this lends to our care. And if transport is necessary, we certainly do look professional! I used to wear home birth t-shirts, thinking these would carry an uplifting message for the client in labor at home. However, it's quite likely to offend the hospital staff if you have no time to change before a transport, the message often being interpreted as "Home birth is better than hospital birth", even if that's not what was intended. I avoid wearing jeans if at all possible. Though we did get called to attend a client on extremely short notice a few days ago--she and her anesthesiologist (yikes!!) husband desired a water birth. Baby was coming so quickly, I just waded into their pool, jeans and all. Great birth--and when it was done, the hubby gave me a pair of his scrubs to wear! They obviously had no heartburn over scrubs at all! :
  4. With regard to interaction with the L&D nurses, I give them a full report of all pertinent information and I use correct medical terminology when doing so. (I also take care not to sound condescending or "full of myself" with wording that might be interpreted as pretentious.) I "keep my eyes warm", smile whenever appropriate and greet nurses by name. With hostile nurses, I defer to their wishes unless doing so will compromise my client's care. I'm very careful to pick my battles--there's so much people can and will get backed up about. I offer to assist the nurses and acknowledge their stress and fatigue and the fact that they're overworked. As they see that I am absolutely willing to change disposable underpads and can safely get ladies up to the bathroom, etc., trust levels increase and everyone begins to relax.

  5. I often preface my caretaking activities with, "Do you mind if..." (I get her some ice chips, get her an extra pillow, a warm blanket, etc.). The nurses are usually grateful to have someone competent to assist them in their work. I know as a former L&D nurse there is SO much to do. I do whatever I can for the staff because they are doing me and my client a great service by giving us their assistance and expertise.
  6. If I notice a problem that requires staff intervention and they haven't yet noted it (late decels on the monitor, full bladder preventing descent, etc.) I do point it out, usually phrased around a question. "I was just noticing a few late decels starting on the monitor; do you think we should try some O2 and see if that improves things a bit?" "I was just noticing that her bladder seems rather full since she's had her epidural. Do you think cathing her might help get some descent?" Perhaps this approach seems manipulative but I prefer to think of it as being respectful and politic. Of course, if there were a full-blown emergency I would ring for the nurse and begin action myself, then allow them to take over as soon as they were able. Or if the baby were suddenly coming . . . and that's happened a few times, too. They usually let me catch. If the doc walks in while it's occurring, I ask him if he wants to take over. I would not set that situation up, though-- a set-up is way too transparent.

Avoiding Abandonment

It is my understanding that one can avoid abandonment by helping the client to find another provider. This can be difficult, especially if you are not legally practicing, but perhaps a third party could explore options for you.

I do not believe the intent of the abandonment laws was to force any provider to continue to care for a particular client, but rather to make sure that appropriate arrangements are made. I don't think it is a requirement that the client agree to this choice, but that you have found an appropriately trained, willing provider. For example, you could not transfer to a surgeon or a radiologist, but to another midwife, a family physician or an obstetrician.

I am not an attorney, but I was taught in residency that a certified letter informing the patient of your unwillingness to continue to care for them with 30 days notice met abandonment criteria, as did a direct referral.

I have learned the hard way to ALWAYS offer consult or referral to anyone that was disagreeing with my recommendations. This does not have to be punitive, but can offer a family a way out of a relationship that has become conflictual.

I know that Dr. Harless is very hard on situations he considers abandonment. I do not really know his definition. What I do know is that we MUST be very careful. If there is a need to release a client for non-payment you really need to send a registered letter with names and phone numbers of several alternate caregivers for the client to choose from. The problem for us is that we are independent caregivers with little or no backup. If a doctor's patient does not pay and is released from care, all they have to do is show up at the hospital and someone will care for them. If we release a client for non-payment, our sister midwives are not going to want to do a freebee at the last minute. It gets REAL TOUCHY!!

Mother's Response to Transport

What if Your Homebirth Doesn't Happen at Home?

How to Transport

EMS Transfers - An excellent transport form put together by Barbara E. Herrera

1. get to know the doctor who would deliver if we had to transport to a hospital, and let him know that we are choosing a home birth because it is SAFER based on our research. if your doctor is unsupportive get another.

2. develop a birthplan detailing the type of management of care we want when we transfer to a hospital as an emergency case. the docs and nurses tend to respect parents with birthplans more, esp if you can sit down and talk to them about everyone's concerned BEFORE the problem arises...then an agreed upon focus for the problem exists :)

3. interview the paramedics who would be transporting and test their knowledge. Special Delivery by Rahima Baldwin has an excellent section on management of emergencies...get to know it like the back of your hand, or better. and let the paramedics know you intend to have a homebirth, so they are a little prepared should they have to come to the house.

4. learn how to palpate the position of the baby...this way you can tell if the baby is breech, posterior, anterior, etc....once again Special Delivery has a great section on that, and it also tells you where you can find the heartbeat of the baby depending on what position the baby is in and visa versa (INVALUABLE!!)

5. you can also get a doula (professional labor assistant) to attend the birth...usually by the time they are certified they have a pretty good idea of what to notice re: emergencies, and the emotional support alone can alleviate many fears and ease the progress of labor

First [the midwife] made an appointment with the hospital administrator, the Chief of Obstetrics, and the Nurse Manager of Maternal services. She laid it on the line.....she is a licensed health care provider, she will be in practice in the area whether they like it or not, she brings them patients like any other health care provider, her clients deserve the same consideration that any other provider's patients get, life would be easier for all involved if they could cooperate. In return she would bring records on all clients, transport in a timely manner, call with a full report on the expected transport before arrival, prepare her clients emotionally for transport to avoid hostility between patients and staff, and accompany all transports to the hospital and stay for labor support. These efforts all get rid of the "dump" syndrome.

Because of her efforts we now have hospitals that don't exactly LOVE transports, but put aside their philosophical differences about home birth and collaborate FOR THE GOOD OF THE PATIENT/CLIENT.

I do have a transport sheet on which I record what-I-think-is-pertinent info to give a sort of summary to the receiving medical personnel.  I also have provided the prenatal sheet for copying if they want it.  I have never provided the labor history.  The transport sheet contains info like name, DOB, LMP, GP, ABO/Rh, EDD, line for notes of "special circumstances", partner's name, baseline BP, baseline FHR, basic lab values (and they often get hung up on her not having had a GTT), total wt gain, summary of labor (when active, ROM hx, ctx hx, fetal position, VE results at last VE, and postpartum summary if delivered incl DOD, placenta time and completeness, total EBL, lacerations noted, apgars, baby vitals, reason for transport.

We used to have a brief Transport Summary Sheet with what we thought was pertinent information.  Now, we take the whole notebook and let them look over all the records.  We found that if the receiving staff was not friendly, they didn't want to see any paperwork of "ours", but with good back-up we have usually talked once or twice on the phone during labor and they know the situation already, and they appreciate seeing the full record.  In fact, they're usually pretty impressed with the records we keep.  We have a pretty good relationship with the CNMs and OBs who do our backup, but the support staff (nurses) may have never dealt with a home birth woman before.  Seeing the records helps to dispel the misconception that we are a bunch of home birth hippies who chant and burn incense at home (of course, we might do that too but it isn't recorded in the birth notes!).

I thought this info might be interesting to many on the list. Here in San Antonio the midwives have an excellent working relationship with the local county hospital. It is where most of us transport unless we have private back up plans. I have to admit that I personally prefer to transport to the county hosp (University Hospital) because they are best prepared for all kinds of emergencies and are used to walk ins.

The way we developed our relationship with them is that we approached the director of nurses and explained that the midwives would like to have smooth transports and make our and their jobs easier when this would be the case. This opened up the way for meetings and we even have luncheons periodically where the nurses, some docs, and the midwives all bring food and we get together and talk. They like the fact that we practice safe midwifery and will transport when necessary, and we like the fact that if they are "nice" to us and our clients, transport will be easier and we are less likely to stay home "just a little bit longer" when we really shouldn't just to avoid a nasty hospital scene. The results have been that when a mw does transport, she stays with her client, the whole time, and one midwife a while back even was allowed to "finish the birth" and caught the baby in the hospital. (we are not talking about CNMs here, this is DIRECT ENTRY MIDWIVES!!!) The hospital staff learned about midwives (yes, we do prenatal care, we monitor labor closely, we keep written charts!) and have seen the benefit of having the midwife be there for the client in what can be a scary situation (especially if had to transport) all of this frees up the nursing staff a little and we really can work together as a team.

The key to this particular hospital was working with the nursing staff, because it is a teaching hosp. The docs move in and out, but the nursing staff stays. When we do have to transport, we call the charge nurse and let her know we're coming and with what situation. We all have a "transport record" which has a brief overview of the labor and what her vitals have been, etc. This is turned over immediately into the hands of the charge nurse upon arrival, it helps to show us as the professionals that we are. I fill out my transport record as much as possible during the birth on every birth and then if I have to go, it's mostly done, usually I get to throw it away though! :) Above all else, be nice and friendly, even in the face of hostility. It may not make much of an impression on them this go around, but you can be sure it will make a dent somewhere down the line. You can bet they will remember the "bitchy" midwife for a long time however. It's hard because transport is the breaking of someone's dream, but life isn't perfect and neither is birth. But I really like the T-shirt slogan of "Birth is as safe as life gets".

When we transport, we never leave our client's side till after birth/surgery etc. We bring our records. A staff member takes them for a few minutes to the copy machine, we get them right back.. The docs discuss everything with us AND the client/patient -- none of this behind the door stuff. They do the best they can to help the mom have a non- interventive birth -- as much as possible.

There are some rare exceptions and occasionally we hear of rude treatment, but there is usually good and friendly transfer of care.

We might owe it a lot of our good access to a meeting we held years ago with a committee of docs at the local med school. We made the point that we NEEDED friendly and easy transfer because if the parents/midwives expected difficult or punitive treatment then they would be reluctant to transfer and "might' stay home when in-appropriate, or might wait so long that a minor complication became a major complication. FOR THE SAFETY OF THE CLIENTS -- the hospital should do what it could to make the transfer easy. AND, of course, we could always go to a hospital where we expected better treatment[Grin]. Must have been a staff meeting because we've been well and respectfully treated since then (though I'm certain there are individual resentments, they are remain private; as they should be).

I think if you can get one hospital to be more approachable, then the others will usually follow suit.

We have a less than friendly situation here all the way around but most hospitals are familiar with homebirth and we rarely see real hostility.

In my practice I have a number of physicians who will provide back up for the clients and meet them at the hospital if needed. Unfortunately there is only a handful of them and the clients are spread out over a large geographical area so the back-up may not be the nearest hospital. To create a smooth transition if needed I send every client home from their 28 week visit with an Emergency Back Up Worksheet. On this sheet they record all of their personal information including insurance policies and a copy of the insurance card. They also record who their back-up physician and hospital is and their lab work. They call the local fire department and record the name of the fireman they spoke with, the ambulance response time and what hospital they would be taken too.

If that hospital is not their nearest hospital they call that hospital and talk to the OB or charge nurse in L&D and ask basic question about where we should go on admittance, whether or not they would prefer a call and if there is anything we can do ahead of time to make it easier for them should we need their services. We record the name of the person we spoke with and then we do the things they suggest. The most common things I have had suggested are to bring copies of the lab work, for the midwife to stay for the birth to consult with the attending on the reason for transport, and on occasion ladies are asked to preregister and to have an open line in place when they arrive. We always follow these suggestions. Because of this practice the few transports we have had have generally gone smoothly. The initial hostility fades when it is realized that the mother is registered, and copies of her records are available. This system has worked well for me in this alegal state. But just last week a woman came in for her visit very upset that she had called her local hospital and the doctor she spoke to said that he didn't care how life threatening her emergency might be she should go where her back up is. They don't want her there.

This was very upsetting for her and for me. We are trying to create a collaborative situation and not just surprise the staff should we need them. It seems awfully cruel to say that if this woman had a prolapsed cord or an abruption she should make a 45 minute care ride to her back up hospital if there is a perfectly competent hospital 5 minutes away. This could be a life or death difference here. What else can we do?

When to Transport

Protecting your license or your relationship with your backup may require transports that you don't think are necessary.  Collaborating physicians or backup hospitals are not going to criticize you for erring on the side of caution.

Some things to consider - the reception you expect when transporting. So it might make sense to take transports in sooner if labor is prolonged in a primip. Protecting your license so you can continue to offer care to women in the future is definitely something to consider."

Well, actually, in areas that don't have good backup situations, you DO get criticized for bringing the client to the hospital.  Some of our local hospitals (in Silicon Valley) report all midwives who end up at a hospital for any reason, regardless of how responsible the care provided was.

I found that the longer I practiced the more conservative I became. My transport rate increased as the years went by. The reasons for this were several.

The first being the hospitals were pretty horrible in the early 1970’s when I started practicing and we were treated badly. When our client's treatment improved we were more likely to transport.

In the births of my own children I stayed home despite significant risk factors, it was not until my third when I had a total placenta previa and had a c-section myself, that I realized I could still have a positive family-centered birth in the hospital.

As I saw more complications, had more close calls, and realized that it was not about having a home birth; it was about having a healthy baby.  I realized that when I stayed home with significant risk factors, even though we may have successfully resuscitated that low APGAR baby, it still cost brain cells. And kids need all they can get. I had to lose my ego attachment as home birth as a goal. I stopped doing breeches and twins at home, not so much because I believe that can't be done at home safely, it is just the risks are greater. After you have been around the block a few times, the risks no longer seem worth it. Losing a baby is a terrible thing under any circumstances; the worse in situation where it was clearly preventable though timely hospital transport.

I told all my clients that I believe home birth is a philosophy and not a place. If they were looking for someone to stay home no matter what, they needed to find another midwife. My goal was a healthy baby and positive experience, and I believe home was the best place to achieve this. But sometimes things come up, and if something did we would bring all our values and beliefs to the hospital and have a healthy baby there.

For some clients, I stayed home despite established protocols, going on the wishes of clients, intuition and faith, those were the exceptions. One thing I tried not to do is transport someone I felt should be home because of my license or my backup; although I can't deny those things influenced my decision. The other thing I never did was not transport someone because of financial reasons. When I was practicing Medicaid paid very little for hospital transports, it was an understandable concern among some midwives, and we often wondered if it affected transport rates.

After retiring from clinical practice after 27 years and about 1000 births, my transport rate is not what I am proudest of - it was the low mortality and morbidity rate.

Talking to the Family about Transport

It is always so difficult to tell a mom and her partner that you think you need to go to the hospital for safety reasons.  Especially for first-time parents, they just have no conception of how vulnerable their baby is and how births can start to stray into dangerous territory that needs medical attention to stay safe.

One of my midwife friends tries to focus on the baby by saying something like, "Your baby is trying to tell us that you need to go to the hospital.  I'm going to go with you and stay with you.  This is going to be the best choice for you and your baby."

OB Comments that Transport Moms Are Mistreated

Regarding his statement: "Unfortunately, I've known doctors who think that anyone stupid enough to attempt a homebirth deserves whatever happens to them,".

I believe this was meant as an indictment of fellow practitioners. Stanford is such a hostile/adversarial place in general, local homebirth midwives avoid it like the plague. However, if such a transport ended up in Creevy's care, I think it's very unlikely he would be punitive.

And I think it's very likely that most caregivers there would be.

I am hoping to get an agreement from our local ICAN chapter to use this indictment as the basis for a survey of Stanford OBs on their behalf.

I think many of the problems associated with transport are related to a perceived absence of accountability on the part of the OBs and other hospital staff. I have sometimes thought that we should start a nationwide "study'" about transport. I'm pretty sure that the care we receive would be different if we came in with a videocamera, audiocamera or some obvious recording mechanism (even a special research study form).

Anyway, I'd like to get to a point where we have an official hospital policy from Stanford that homebirth transports are to be received with kid gloves.

Thanks for Good Transport Reception

Ways to thank a doc who provides good transport reception:

Don't forget to thank the nurses, even if they weren't truly that helpful.  You can always thank them for "respecting the client's right to informed consent about procedures"

Bottles of (good!) wine, gift certificates for nice restaurants or spas (females), Starbucks cards, boxes of bagels or sweets for office to name a few with cards containing lots of appreciative verbiage.  If you don't know wine, then stick with the Veuve Clicquot Ponsardin yellow label (since there is always something to celebrate!)

Response to Transport Problem

Response to Transport Problem

How to Respond to Bad Hospital Treatment


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