When a mother who planned to give birth at home ends up in hospital, she is said to have 'transferred to hospital care'. Such transfers can occur before labour starts, during labour, or after labour. When booking a home birth, you might want to know what your chances of having to transfer are, and what are the most common reasons for transfer.
If you are planning a home birth, it makes sense to think about what would happen if you transferred. The chances are that you will indeed have your baby at home, and some mothers just do not want to think about the possibility that they might not stay at home. However, there are steps you can take to make things easier, in case you do transfer. For example, you could:
During pregnancy, some women are transferred to hospital care without even going into labour, for reasons such as:
Transfer during labour occurs most commonly because the labour is taking a long time, and not necessarily because of any immediate risk to the health of mother or baby. The mother may request transfer because she is exhausted, or her midwife may advise it because of her own worries or hospital guidelines. Transfer may also occur if there are concerns about the health of mother or baby.
It is relatively rare for an emergency situation to arise which requires immediate transfer and very urgent hospital treatment, although this is always a possibility. Usually the mother or midwife realise that things are not straightforward well before an emergency arises, so that by the time any action is needed, they have been in hospital for some time. The baby's heart rate might not be responding perfectly to contractions, for example.
There are many signs which inform a midwife that intervention might be needed later on. Consultant obstetrician Rick Porter of Wiltshire healthcare NHS trust stated in an interview about home births that 'The things that go wrong in the vast majority of cases, particularly with first babies, do so slowly or with plenty of warning so you have time to make your transfer' (2)
One common reason for transfer is that meconium is found in the waters. This means that the baby has had a bowel movement before or during labour, and it is a sign that the baby possibly is, or has been, in distress. The midwife can tell from the colour of the waters whether the meconium is fresh, which indicates that it might be in distress now or was recently, or old, which indicates that the baby may have been in distress at some point in the past. For a detailed discussion of when this is most significant, and the situations where transfer is most important, please see the separate page on meconium.
In many areas there is a blanket recommendation that the mother should always transfer to hospital if meconium has been passed. In other cases, midwives may be happy for the labour to continue at home if the baby appears to be coping well with the labour. For example, if the meconium is clearly old, and is well-diluted by amniotic fluid, all this tells us is that the baby might have been in distress at some point in the past. If the baby is postdates then it may just tell us that the baby's gut is mature. In these situations, if there are no signs of current problems, some mothers make an informed decision to continue with a home birth.
Transfer of mother or baby occasionally occurs after birth. The mother may have third stage problems, such as a retained placenta (ie the placenta has not been delivered within the time expected), or heavy blood loss. The baby's health may be in question and the midwife might suggest that it is taken into hospital for treatment or observation. In the rare event of a severe haemorrhage, or a baby with serious breathing problems, transfer is a genuine emergency and really can involve life-or-death situations. Fortunately this is rare, but it is something that no mother planning a home birth can fail to consider. Note that babies with breathing problems can receive oxygen at home and during transfer, usually using a bag and mask set-up which provides oxygen under pressure. Occasionally babies are intubated at home, which means that a tube is passed directly into the lungs to provide oxygen, but this procedure can be dangerous and is usually only carried out in hospital.
More on reasons for transfer can be found on the Studies on Transfers page. Among the topics covered are: whether mothers who transfer are as happy with their care as those who stayed at home, whether it is possible to predict which mothers will transfer because of slow progress, and how soon after transfer mothers needed medical attention.
First-time mothers, or primigravidas, are more likely to transfer than women who have had at least one child (multigravidas). Here are transfer figures from some studies which detail them:
| Study/Author | Overall transfer rate | Multigravidas | Primigravidas |
| National Birthday Trust | 16% | 10% | 40% |
| Howe, KA (1988) | 16% | not known | not known |
| Davies et al (1996) | 14% | not known | not known |
| Tyson (1991) | 17% | 8% | 32% |
| Pop (1995) | 23% (11% during pregnancy, 12% during labour) | not known | not known |
The studies referred to in this table are summarised on the studies of home birth transfers page.
You may go in an ambulance, or in your car if someone is available to drive it for you. Even if you have a non-emergency transfer in an ambulance, the sirens and flashing lights may be used to help you get to hospital more quickly.
The National Birthday Trust study provided some details of nearly 900 women who transferred from home to hospital birth in the UK in 1994. It found that:
No, you don't. As with any offer of medical treatment in pregnancy and childbirth care, it is the mother's decision to make. However, your midwife's recommendations certainly deserve very careful consideration. If you would rather not transfer and it is not an emergency situation, you could discuss things with her and ask what the alternatives are. Heather's birth story is a good example of a mother making an informed decision to stay at home after her midwives asked her to transfer for slow progress.
Bear in mind also that many transfers occur at the mother's request - when she is tired and would like labour to be accelerated, and/or she has had enough pain and wants to have an epidural. So it is possible that you would be asking the midwife to transfer, rather than the other way around.
If your midwife is generally supportive of home birth then she is unlikely to suggest that you transfer unless either she thinks you or the baby might need medical attention at some point in the future, or if her employer (eg the Health Authority in the UK) has protocols which mean that she must ask you to transfer in certain situations.
Of course, employers' protocols are not laws - they are negotiable and will always be arbitrary. For example, there might be a protocol which states that all women who have been in labour longer than 12 hours should transfer to hospital. However, if the baby is in good condition and you are happy to continue labouring at home, then it would be entirely reasonable for you to refuse to transfer. It all depends on the individual circumstances, and on how well you understand the suggested reason for transfer, and whether you agree with it. Another example might be a policy that midwives should transfer clients if meconium is found in the waters, but if the baby's heart rate shows that it is coping with labour well, and the meconium is not thick, then you might decide to stay at home anyway.
Some women worry that their midwife is not supportive of home births, feels underconfident out of a hospital environment, and that she might encourage them to transfer unnecessarily - that she would be looking for an excuse to get them into the hospital. It is not uncommon to hear reports of births where this seems to have happened, and it is quite possible that a midwife who was not happy attending home births could have a higher transfer rate than her colleagues who were more confident.
This is probably not something you want to have to think about while you are actually in labour, so if you have doubts about a particular midwife's commitment to home birth, you could change your midwife or inform the supervisor of midwives that you do not wish to have that person attending you in labour. A discussion and a sample letter on changing your midwife is available.
You could also consider hiring an independent midwife who specialises in home births, so that you know she will only suggest transfer if she really does think it necessary. More details about hiring independent midwives in the UK are available online.
Newest stories at the top of the list:
Inger is from Holland where homebirth is common, and she planned a homebirth for her first baby. It was not to be, though; although prelabour started at home, she developed pre-eclampsia and transferred to hospital for induction. Baby Nathan was back-to-back and was turned by forceps after a tough labour, but Inger still managed to push him out herself. However, problems developed after his birth. Inger cautions to consider the possibility of transfer when writing your birth plan.
Gemma was all set for a homebirth with her second baby, when she developed Obstetric Cholestasis, and had an induction in hospital. She had great support from a midwife who respected her birth plan, and even though Caleb was persistently OP (back-to-back), Gemma still managed to push him out all by herself.
Louise L's first baby was huge, and in the Occiput posterior position. And that was only the start of it... cord round the neck twice, baby passing meconium, emergency caesarean...but, as Louise says, hers is a very good example of how what happens when a homebirth starts to get complicated. A positive birth story, and one which helps to place complications in the context of a good labour.
Nicola H transferred to hospital and had an emergency caesarean when baby Isabelle passed meconium and showed other signs of distress. It's clear that, although this is not the birth Nicola had hoped for, it is the one she needed, and she was very pleased with the care she received both at home, and in hospital.
Kelly G had a bad tear stitched in hospital after the home birth of her first baby, but was back home just a couple of hours later.
Hayley had an active labour at home for twelve hours with her first baby, managing some difficult situations along the way. She transferred to hospital for help when her labour slowed and she was exhausted, but still managed to deliver her baby by her own efforts.
Chris C gave birth to her second baby at home, on a lovely home-made birthing nest, and the birth itself went very well. However, she had a serious postpartum haemorrhage and transferred to hospital afterwards. The ambulancemen had trouble maneouvring a stretcher in her house, and Chris reminds us to consider emergency access to the room chosen for birth.
Emma Laing was advised to transfer to hospital when she bled heavily after her third baby's birth, but she chose to be observed at home instead.
Hannah transferred to hospital for slow progress and her first baby was delivered by caesarean section. She suspects that the outcome might have been different, had her midwives been more supportive.Rachael K transferred to hospital when her baby showed signs of distress, had an emergency c-section. Rachael stood her ground at every stage, agreeing to interventions when she was confident that they were necessary, but declining others.
Emma had a very long, but positive, labour and homebirth, followed by a transfer to hospital to have baby Cameron checked over when he coughed up lots of mucus. Cameron was found to have a serious congenital abnormality, and spent the next three weeks in hospital.
Emma Taylor transferred after the birth of her first baby, to have an episiotomy stitched up as the attending midwife did not have her kit with her.
Gemma planned a homebirth for her first baby, but her painful, back-ache labour didn't ever really establish. Gemma transferred to hospital - but they sent her home again! This continued for two days until an exhausted Gemma was eventually admitted and given some help to deliver her baby.
Heather's birth story is a good example of a mother making an informed decision to stay at home after her midwives asked her to transfer for slow progress.
Laura got to fully dilated at home with her first baby, and pushed for five hours, but he just wouldn't budge. She transferred to hospital and, with a huge effort, managed to give birth to him by her own efforts, avoiding the episiotomy and forceps that she was offered.
Terri Eaton planned a homebirth for her second baby, but after problems with a racing heart rate in pregnancy, she had very high blood pressure in labour and transferred to hospital. There were some other complications and Terri was persuaded to stay in hospital after she gave birth for observation, but the care she received was very sketchy and in retrospect she feels she would have been better cared for at home.
Charlie Paris had a great homebirth with her first baby, but her blood pressure rose in labour and she went to hospital overnight when it remained high afterwards.
Claire got to 10cm dilated at home and her labour was progressing rapidly, but the baby's head was high and the membranes were bulging. Her midwives were nervous about the possibility of cord prolapse when the waters went, so she transferred to hospital to have a controlled artificial rupture of membranes.
Sue planned a homebirth for her third baby after two straightforward hospital births. However, she changed her plans to a hospital birth when she found she had a low-lying placenta and it was not clear whether a caesarean would be necessary.
Peta transferred to hospital after the birth because of concerns about her baby's breathing.
Lorna's midwife advised transfer because there was meconium in the waters, but Lorna asked her to monitor the baby's heart, and when that was fine, decided to stay at home. Then she decided to transfer to hospital anyway for an epidural... an ambulance arrived ... but they didn't have time to go anywhere...
Katherine planned a homebirth for her first baby, but accepted a hospital induction at nearly 3 weeks past her estimated due date. Unfortunately her induction did not progress and ended in a caesarean. This is the story of her second labour, for which she planned a home VBAC (vaginal birth after caesarean). However, this baby was in there for the duration too, so Katherine again accepted an induction in hospital when she reached 14 days past her EDD - this time with much happier results. A very positive experience of hospital induction - and for all of us planning homebirth, it's good to know that if Plan A doesn't work out, Plan B can still be a triumph.
Diana planned a home birth for her first baby, but developed symptoms of pre-eclampsia and was hospitalised for twelve days at the end of her pregnancy, undergoing five doses of Prostin in an attempt to induce her labour. When all that was unsuccessful, Diana agreed to an elective caesarean. This story was written 11 days after baby Maia was born, and Diana was still having difficulty coming to terms with what had happened, so be prepared for some raw, but honest, feelings.
Becky wanted a home waterbirth for her first baby, and she prepared thoroughly, with hypnobirthing, active birth classes, and having homeopathic remedies and aromatherapy oils available. She transferred to hospital because there was meconium in her waters, but was still able to put all of her forward planning into use. An excellent example of negotiating the best birth you can, in difficult circumstances. I particularly liked Becky's idea of taking her baby in the birth pool and letting go of her sadness at not getting the birth she'd hoped for, while celebrating her daughter's arrival. Lots of suggestions for others who transfer.
Alex gave birth to first baby Nathan in hospital after transferring because meconium was found in the waters. Although Nathan weighed 10lb 3oz and had some trouble with the birth of his shoulders, Alex still managed without needing forceps or ventouse, and using only gas and air. Some positive thoughts for women facing transfer. Alex writes "it's the most precious memory I have and I know it's a cliché but as long as the baby is ok.. I think you have to extract the good bits, remember them, and try to forget the bad bits if you can."
Cassy transferred after four nights and three days of irregular contractions and had a caesarean. Her labour at home, and the caesarean operation, were both positive experiences, but she found labouring in hospital before the surgery difficult.
Anna planned a homebirth for her first baby, but after a long labour which did not seem to be progressing, she transferred to hospital hoping to have an epidural. At hospital she was told that she could not have an epidural as her labour was too advanced, and she had an horrific forceps delivery.
Jillian's second baby was born at home after a very positive labour, but she bled heavily after the birth and transferred to hospital.
Rachel laboured at home for nearly two days before transferring to hospital for a ventouse delivery. Includes positive and constructive comments on transferring to hospital.
Lucy gave birth to her first baby at home, after a three hour second stage. She transferred to hospital for observation because of heavy bleeding afterwards.
Clair had her first baby by caesarean section, and planned a homebirth for her second. She transferred for unexplained bleeding, and after a ventouse attempt, she had a second caesarean. She felt that the birth was still a positive experience, and was glad that she had planned a homebirth. She went on to have a home waterbirth for her third baby, on 31 January 2006 - birth story eagerly awaited!
Sarah Ockwell-Smith planned a homebirth for her first baby, Sebastian, but after a long prelabour which progressed slowly, she transferred to hospital for an epidural. She hoped to have another go with her next baby, Flynn, but pre-eclampsia intervened. Finally, with Rafferty, she gave birth at home - and her baby weighed over 11lbs!
Megan Oxberry transferred for hospital induction when her waters broke and her labour didn't establish in a timeframe she and her obstetrician were comfortable with.
Jo Burberry gave birth to her first baby, Alex, at home, and transferred to hospital for removal of a retained placenta.
Sara Patterson planned a home birth after two previous caesareans, but transferred in labour and had a third caesarean which was a very positive birth.
Juliet had a very positive, gentle home birth for her first baby, Florence, but later transferred to hospital for manual removal of the placenta.
Jo Robertson planned a home birth for her first baby, Ellen, but transferred to hospital because of slow progress, prolonged rupture of membranes, and meconium in the waters. Despite this, she had a very positive birth in hospital with supportive midwives.
Kate Wood planned a home birth for her third baby, but transferred to hospital because her midwives were worried about the progress of her labour. Kate still managed a natural birth in hospital, but writes that "I learnt from this labour that it's very important to leave the labouring woman to herself as much as possible, to allow her to go within and dig deep and find the resources she needs to carry her through this amazing journey; that often the biggest help to a woman is no help, just a strong, comforting positive physical presence around her. "
Claire had a straightforward, good hospital birth for her first baby, and planned a homebirth for her second. In the event, her labour was induced in hospital for reduced amniotic fluid levels and suspected small size.
Amy Driver's first baby, Ella Hope, was born at home after a straightforward labour, but Amy transferred to hospital after the birth because of heavy bleeding.
H planned a home birth for her third baby, but transferred to hospital care because she was told that her community midwives would not attend a home birth at more than 10 days post-dates (an absolutely outrageous and unjustified policy in my opinion - if you come across anything like this, please do contact AIMS for advice).
Ruth planned a home birth for her first baby. She achieved a natural birth in hospital after deciding to transfer to have the option of more pain relief, and that her NHS midwives were not able to provide the support she needed to have the best chance of giving birth at home.
Kiara planned a home birth for her first baby but ended up with an emergency caesarean because Ben was not only facing the wrong way (posterior), but his head was deflexed and asynclitic - tilted up and to the side. The journey to hospital was more 'eventful' than you might wish for, and consequently took a lot longer than it should have.
Lucy Banwell's first baby, Adan, was born in hospital after she transferred because of prolonged rupture of membranes and worries about infection, because her temperature was raised. Her wishes were not respected and Lucy finds the memory of the birth traumatic. She says "I feel that I have had a taste of both hospital and home birth, and under no circumstances would I ever chose to give birth anywhere but home in the future. "
Sarah Sadler's first baby, Kirsty, was born in hospital after transferring from home because of a long second stage. Kirsty decided to start labour in the posterior position...
Sunrise Jade transferred to hospital for the birth of her sixth child, Laurie, after her fifth was born at home. She went on to have her seventh, eighth, ninth and tenth children at home!
Helen Gardner transferred to hospital after a home birth to have some stitching, but her triumphant story makes it clear that this has not marred her memories of the birth.
Sophie S planned a home waterbirth for her second baby, but when he turned out to be a surprise breech, she chose a hospital birth instead - and had a completely natural breech birth.
Helen Ollerenshaw was persuaded to change her plans for a home birth by unsupportive health professionals; she ended up with a traumatic forceps delivery in hospital after a classic 'cascade of interventions'.
Karen Fairweather transferred in labour with a baby in the Occiput Posterior position.
Genesis Dove transferred to hospital for induction after her labour never really got going...
Nikki Murphy's baby was born with the assistance of a Ventouse after a long second stage.
Jennifer Vaudin agreed to induction in hospital because of pre-eclampsia.
Clare K transferred to have a complicated tear stitched in hospital after the home birth of her first baby.
Anna planned a home birth for her first baby, but was persuaded to transfer to a hospital booking by a midwife and GP, because her baby was expected to be large. She had a planned caesarean instead, which ended in an emergency hysterectomy.
Childbirth.org birth stories - some transfers included.
http://www.childbirth.org/articles/stories/categories/homebirthstories.html
(1) National
Birthday Trust - Report of the Confidential Enquiry into Home
Births, 1994
Chamberlain, G, Wraight, A & Crowley, P (eds).
(2) Pregnancy and Birth magazine, September 1998, p77
[3] 'Meconium-stained amniotic fluid' by McNiven, Roch and Wall, a review published in 'Modern Midwife', July 1994.
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