Home Birth Reference Site

“But What If.....?”

We all wonder what would happen if a problem occurred at a home birth. On this page you will find responses to some frequently asked questions.

See also "You can't have a home birth, because...." which looks at reasons why individual women might be told they are unsuitable for home birth, eg expecting your first baby, a large baby, previous bad tear, previous caesarean, previous assisted delivery, previous heavy blood loss, diabetes, grand multiparity, anaemia, platelet levels, and others...

  1. What if you want pain relief?
  2. What if you had a postpartum haemorrhage?
  3. What if you needed an assisted delivery - forceps or ventouse?
  4. What if you need a caesarean?
  5. What if the cord is around the baby's neck?
  6. What if there was a cord prolapse?
  7. What if there is a shoulder dystocia?
  8. What if your baby needs resuscitation?
  9. What if your baby dies? How will you feel then?

What if you want pain relief?

There are various forms of pain relief which are available at a home birth. Many pain-management techniques that you can control yourself can be very helpful, but in addition, there are drugs which can be used at a home birth to help the mother with pain management. In the UK, midwives normally bring the gas Entonox (Nitrous Oxide and Oxygen, often called "gas and air") to home births, and injected opiates such as Pethidine can be arranged too if that is your choice.

You can't have an epidural at home - if you find during labour that you really want an epidural, you would transfer to hospital to have one. You might find the wait difficult, but bear in mind that women who have planned a hospital birth often have to wait some time for an epidural, too. Epidurals have to be administered by an anaesthetist and it is hard to predict when one will be available, as these doctors normally cover all areas of a hospital and not just the maternity wards. They might be called upon to provide emergency anaesthesia for someone who has been involved in an accident, for instance. Your midwife could phone ahead as soon as you decide to transfer, to try to arrange for an epidural as soon as possible after your arrival.

For more discussion of pain relief options at home - whether involving drugs or alternatives - see "Pain Relief at Home Births". For instance, there is research finding that women generally describe labour pain as more manageable at home than in hospital.

What if you had a postpartum haemorrhage?

Midwives at home births carry the same drugs which are used to expel the placenta and contract the uterus as would be used in hospital. These include synthetic Oxytocin and Ergometrine, often given in combination as Syntometrine. If these do not control the haemorrhage, the midwife would call an ambulance to transfer you to hospital, and undertake other emergency measures in the meantime, such as giving intravenous fluids and manually compressing your womb.

However, it is significantly less likely that you would have a post-partum haemorrhage after a home birth than after a hospital birth, because the risk of PPH rises with interventions such as assisted delivery and induction of labour, which are only carried out in hospital.

There is more discussion of these issues, references, and links, on the page about postpartum haemorrhage on this site.

What if you needed an assisted delivery - forceps or ventouse?

In the past, family doctors would sometimes perform assisted deliveries at home births. However, assisted deliveries involve increased risks to the baby (eg injuries such as head trauma, or complications like shoulder dystocia) and the mother (severe tearing and/or bleeding). For these reasons, assisted deliveries are not performed at home in the UK nowadays.

If you needed an assisted delivery, eg for lack of progress in the second stage, you would have to transfer to hospital. Sometimes women transfer in this situation and then go on to give birth spontaneously in hospital, while others do go on to have an assisted delivery. It is not usually an emergency situation, but transfer for slow progress in second stage can of course be uncomfortable and disappointing for the mother.

Here are some birth stories from women who transferred for assisted deliveries: Sarah (forceps), Nikki (ventouse), Karen (forceps), Sam (forceps).

What if you need a caesarean?

If you needed a caesarean, you would tranfer to hospital to have one. The majority of unplanned caesarean sections are performed for slow progress in labour, where neither mother nor baby are in immediate danger. Such a caesarean might occur after the mother has transferred to hospital for slow progress, perhaps tried an epidural to get some rest, and a syntocinon (pitocin) drip to speed up her labour. Sometimes it happens after a failed attempt to deliver the baby by forceps or ventouse.

The term 'emergency caesarean' can be confusing, because in fact an 'emergency' caesarean just means one which was not planned at the start of labour, regardless of whether mother or baby was in immediate danger. What most people worry about is a 'crash' or 'true emergency' caesarean, where the baby needs to be delivered urgently. This is rare in a low-risk pregnancy which ends in a physiological (natural, spontaneous) labour. Nonetheless, it can happen. The baby's heart rate might indicate to the midwife that the baby is in severe distress. Perhaps the cord is around its neck - this happens in about a third of all births and does not usually cause a major problem, but in some cases the baby does get severely deprived of oxygen. Perhaps the cord has become compressed inside the womb. The mother could be bleeding from a partial placental separation or, very rarely, a ruptured uterus.

In a dire emergency situation like this, the midwife would call an ambulance immediately, and would telephone ahead to the hospital and ask them to have the operating theatre made ready and the surgical team assembled. The ambulance team would take the mother straight to the operating theatre. While waiting for the ambulance and during transfer, the midwife might insert an intravenous drip or a Venflon needle, which would allow a drip to be put up straight away in the ambulance or in hospital.

In the past, obstetric 'flying squads' have sometimes been used to take emergency assistance to a home birth. However, these have been phased out in the UK as they were found to be, overall, less safe and effective than transferring people to hospital.

So how much time would you lose by having to transfer from home? Obviously it depends on your distance from the hospital, and traffic conditions, but even if you started off in hospital, the operating theatre would have to be prepared and a surgical team assembled. There is an interesting table in the paper by Tuffnell et al (see refs, below) listing steps from decision to delivery in a caesarean section. If you were labouring in hospital when your baby went into distress, you might be surprised at how long it could take from 'call to cut', ie the time it took the surgeon to actually begin operating.

The UK target for delivery by emergency caesarean is 30 minutes from decision to delivery, but research suggests that this target is not usually achieved. For example, MacKenzie and Cooke (2001) found that the average time from decision to delivery in emergency caesareans where there was fetal distress was 42.9 minutes in their large Oxford teaching hospital. Tuffnell et al (2001) found that:

"66.3% women were delivered in 30 minutes and 88.3% within 40 minutes; 29 (4.0%) were undelivered at 50 minutes. If the woman was taken to theatre in 10 minutes, 409 of 500 (81.8%) were delivered in 30 minutes and 495 (97%) in 40 minutes."

An interesting read on this subject is the National Sentinel audit of Caesarean Sections in the UK, published by the Royal College of Obstetricians and Gynaecologists (www.rcog.org.uk). To be reviewed for this article at a later date.

It seems inevitable that transferring from home for a crash caesarean will usually result in some time being lost, compared to a planned hospital birth. However, depending on your transfer times, the difference might not be as large as you would expect. If you could be in the operating theatre within 20 minutes, for instance, the difference is likely to be very small indeed.

The issue for most women is how likely it really is that they would require a 'crash' caesarean section. If you do not fall into a high-risk group, and you have not had interventions in your labour which increase risk (eg induction, augmentation of labour), the chances are very small indeed. Only you can decide which combination of risks is acceptable for your family.

Here are some birth stories from women who transferred from a home birth for caesarean sections: Kiara, Laura, Mel .

I have not had any birth stories submitted from women who transferred in a serious emergency situation, but would be happy to publish yours if you send it. I (eventually!) publish all birth stories which are sent to me. Please contact me on
angela @ abcde.homebirth.org.uk
Antispam provision: remove 'abcde.' to get the real email address.

What if the cord is around the baby's neck? (Nuchal cord)

Around 1 in 3 babies are born with the cord around their necks. It might be looped around once, twice, three times or more. Although it can be frightening at the time, it is not usually a major problem; some babies need some resuscitation such as rubbing the skin, giving air by bag and mask, or oxygen, but most are fine. Occasionally it can be more serious, no matter where the baby is born. It would be dealt with at home in the same way as in hospital, in nearly all cases.

If the cord is very tight, the baby's head may not descend and its heart rate would almost certainly show signs of distress as the cord tightened during contractions, as the head was pushed down. Midwives at home would be regularly monitoring the baby's heart rate, and if this showed signs of distress then you would transfer to hospital. If fetal distress continued then you would normally have a caesarean section.

However, in most cases, the cord is loose enough to allow the baby to be born vaginally. If the baby does not show distress earlier in labour and its head descends, then the situation would be managed in the same way, wherever you gave birth - after all, there would not be time for a caesarean in hospital if your baby showed signs of distress only in the last 10 minutes of labour. When the head is born, if the cord is loose enough, the midwife may loop it over the baby's head, or she might support the baby's head close to your perineum while its body is born, and 'somersault' it so that it is born through the loop of cord. Rebecca's story is one example of untangling a baby without cutting the cord, while Willow's baby was also born with the cord round her neck. If the cord is very tight then she might clamp and cut the cord as soon as the head is born - for example, see Nicola's story, Suzanne's, Rosie Taylor's or Doris's story. However, many experienced midwives feel that it is almost never necessary to cut the cord in this situation because as the uterus contracts and the baby's belly moves down, so the cord will loosen. As one midwife said, the worst-case scenario is that the cord snaps as the baby is born; how is that different from cutting it? Christy's story is one example of a cord which was too tight to unloop, but which still allowed the baby to be born.

Early cord cutting is best avoided for two main reasons. Firstly, if the baby's shoulders get stuck after the cord has been cut then it has no oxygen supply until it is born. Secondly, early cord cutting deprives the baby of a significant amount of its blood which would normally be transfused from the placenta and cord in the few minutes after the birth, and there is nowadays much research linking this with an increased risk of anaemia in infancy, amongst other problems (see The Third Stage of Labour).

If the baby is not in good condition at birth then the midwife will give it resuscitation, and the steps taken at home, at least in the first instance, are the same as those in hospital. See "What if your baby needs resuscitation?", below.

There are discussions about nuchal cords on the UK Midwifery Archive pages (www.radmid.demon.co.uk/cord.htm)

What if there was a cord prolapse?

Cord prolapse is one of the emergency situations which give midwives nightmares. Cord presentation occurs when the umbilical cord presents in front of the baby's presenting part (usually its head, unless it is breech). As the head descends, the cord is compressed and this can restrict the baby's oxygen supply. Cord prolapse is the next stage - when the cord protrudes from the uterus in front of the baby, and can be felt in the vagina.

Sometimes a midwife or doctor can push the cord up and out of the way, holding the baby's head up while they do it. However, often an emergency caesarean is needed. If a cord prolapse occurred at home, your midwife would probably ask you to go on all fours, with your head lower than your body and your bottom stuck in the air. This would take the pressure off your cervix and hopefully off the cord. The midwife might keep a hand inside you, holding the baby's head up and off the cord, while waiting for the ambulance to arrive. She may well remain in this position while the ambulance crew transported you to hospital. An interesting sight for the neighbours - but potentially life-saving for your baby. However, there is no denying that this is one complication where any delay could prove fatal; there is little doubt that hospital is the best place to have a cord prolapse. The issue is, how likely is it that cord prolapse will occur?

Cord prolapse is a complication which could be fatal in home or hospital. The National Birthday Trust Fund study of planned home births in the UK reported on the incidence of cord prolapse. In the home and hospital groups totalling 10,695 women, only one cord prolapse occurred, in the home birth group - but no fetal death was reported*. The authors point out that cord prolapse occurs on average once in every 900 deliveries (cord presentation once in every 300), but is much more likely in certain high-risk categories: breech or transverse lie, small babies, polyhydramnios (excessive amniotic fluid). Very few women planning a home birth have pregnancies which fall into these categories.

* Note: I have been contacted by a mother who participated in this study. She was originally booked for home birth, but decided at the end of pregnancy to have a hospital birth instead. On arrival at hospital in labour, she was found to have a prolapsed cord and her baby died. It is not clear whether her case is the one mentioned above. As she was originally booked for home birth, her baby's death will have been counted as a death in the planned home birth group. Note that she was not at home or in transit when this occurred - she was in a hospital. Babies sometimes die from this condition, wherever the mother is labouring - but the worry is that if it happens when she was at home, somebody, somewhere will blame the fact that it was a home birth. If it happens in hospital, it will be "just one of those things".

Cord prolapse is an example a risk affecting a relatively small proportion of births, which skews the safety statistics overall. One cord presentation in 300 average births sounds quite terrifying when you consider that this is a life-threatening complication, but for healthy women with low-risk pregnancies, the risk is many, many times lower.

Here is one tragic case report of a cord prolapse occurring at home. After the midwife detected the prolapse, the mother transferred to hospital with the midwife manually holding the baby's head up off the cord. It took 56 minutes from the detection of the prolapse to the caesarean delivery of the baby, who died three days later. The mother, Traci Relph, is a midwife herself and in this Daily Telegraph article she explains why she still supports home births. She feels that the outcome would still have been bad if she had been in hospital when the prolapse was detected, as her son might have still died, or might have lived but been severely disabled. She would certainly have had the c-section much faster if she had been in hospital; in a case this urgent, most hospitals would be able to deliver the baby within 30 minutes.

See also World Health Organization guidelines on emergency management of cord prolapse (www.who.int/reproductive-health/impac/Symptoms/Prolapsed_cord_S97_S98.html)

What if there is a shoulder dystocia?

'Shoulder Dystocia' means that the baby's head has been born, but its shoulders are still stuck inside the mother and are not spontaneously born with the next contraction. It is life-threatening for the baby as the baby cannot breathe until its body is delivered - there is no room for it to inflate its lungs - but the cord may be compressed once its head has been born. It is a scenario which can be terrifying for birth attendants as well as the mother, wherever it happens.

All midwives in the UK should be trained in emergency management of shoulder dystocia, and these maneouvres to free the trapped shoulder can be carried out at home as well as in hospital. They include changing the mother's position to one which allows more space for the baby to move through her pelvis, the McRoberts maneouvre where the woman is pushed onto her back and her knees are pushed up high under her armpits, and the midwife using a hand to free the baby's trapped shoulder.

There is only one maneouvre which can be carried out in hospital but not at home, and that is virtually unheard of in the UK - the Zavanelli maneouvre, where the baby's head is pushed back up into the mother's body and the baby is delivered by caesarean section. Because of the time it would take to do this, circumstances where it might save the baby's life are vanishingly rare.

For more discussion, see:-

What if your baby needs resuscitation?

Midwives in the UK normally bring resuscitation equipment to home births, and all are required to be trained in newborn resuscitation. Most resuscitation methods which are used in hospitals are also available at home, and certainly all those which are most likely to be needed after a spontaneous vaginal birth.

'Resuscitation' is a term used for several different measures to encourage or enable a newborn to breathe for itself. The most common forms include:-

Suctioning, administering Naloxone, giving oxygen and ventilating with a bag and mask can all be done at home. Intubation can also be done at home if the midwife is trained, but as this procedure can itself be dangerous for the baby and can trigger or worsen respiratory distress, it is normally only carried out in hospital, and then only in serious situations. If prolonged resuscitation is needed, midwives will usually ventilate by bag and mask until the baby is transferred to hospital. The World Health Organization guidelines on newborn resuscitation include diagrams for ventilating a newborn using a bag and mask. Note that this is the recommended way of ventilating in the first instance, wherever the baby is born.

There are usually two midwives in attendance at a home birth in the UK, so that in the unlikely event of both the mother and baby needing help after birth, one professional will be available for each.

Here is a comment from a midwife who is experienced in attending home and hospital births:

A Midwife's View on Resus at Homebirths

What I have at a home birth for neonatal resus is:

What I don't have, which is in the room in hospital:

However, if I ever was at a homebirth where the baby didn't breathe within the first minute, I would ask someone to call paramedics, who have mechanical suction, laryngyscopes & ET tubes, probably drugs too. And they know how to use them and are up to date.

Viv (midwife)

There are more discussions from midwives about resuscitation at home and in hospital on the UK Midwifery archive page on Newborn Resuscitation.

See also the World Health Organization's guidelines for management of immediate newborn problems (www.who.int/reproductive-health/impac/Symptoms/newbornr_conditions_problems_S141_S150.html)

Midwife Lisa Barrett has an article on resuscitation at home, together with a sequence of photos showing a non-breathing baby being resuscitated while still attached to the mother, on her blog.

The National Birthday Trust Fund study of home birth in the UK found that babies planned for home birth were less likely to have any form of resuscitation than babies who had planned hospital birth, but were of similar risk levels. Babies who were born in hospital after transfer from a planned home birth were more likely to need resuscitation, but many of these will have transferred to hospital because of complications which emerged in labour. And of course, as these babies were born in hospital, the fact that their mothers had originally planned home births did not affect the availability of resuscitation facilities for them.

  Planned home Planned hospital
Suctioned 11.3% 18.0%
Bag and mask 5.6% 9.1%
Intubation 0.6% 0.8%

Birth stories involving resuscitation

Here are some birth stories where babies have needed some resuscitation or been born in poor condition at birth. The standard definition of 'poor condition' is having an APGAR score of below 7 at birth, out of a possible 10.

What if your baby dies? How will you feel then?

Sometimes babies do die after or during a homebirth. Sometimes babies die after or during a hospital birth. The death may be due to congenital deformities, or to things which would have happened wherever the birth took place.

Rarely, a baby may die after a homebirth, when he or she might have survived after a hospital birth. Perhaps a crash caesarean is needed, and transfer to hospital is delayed. And the converse is true - sometimes babies die after hospital births, when they might have survived after a homebirth. This could happen because of breathing difficulties after caesarean section, hospital-acquired infection, birth injuries from assisted delivery, severe reactions to drugs given to the labouring mother, or stress or injury resulting from labour being induced or augmented.

Sometimes it is not possible to tell from any one case whether the outcome would have been different elsewhere. People can always speculate, but in individual cases, often we will never know. What we can do, however, is look at the outcomes over large numbers of planned homebirths, and ask whether more babies are likely to die or be injured at home or in hospital. Much of this website is dedicated to that question, and overwhelmingly the expert consensus is that babies are no more likely to die, and babies and mothers are less likely to be injured, when a homebirth is planned. Have a look at the pages on research for summaries of all the recent research on homebirth that I am aware of.

There are two birth stories on this site from families who have had a baby die after a homebirth. In both cases the baby could not breathe alone, and despite immediate resuscitation measures and rapid transfer to hospital, both died. In both cases, the parents went on to have their next baby at home. Please read the birth stories from Nicky and Megan, in memory of the children they lost, and in celebration of the babies who stayed.


Mackenzie and Cooke, 2001:
BMJ 2001;322:1334-1335 ( 2 June )
Prospective 12 month study of 30 minute decision to delivery intervals for "emergency" caesarean section
I Z MacKenzie, clinical reader in obstetrics and gynaecology, Inez Cooke, clinical lecturer in obstetrics and gynaecology.
Nuffield Department of Obstetrics and Gynaecology, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU

Tuffnell et al, 2001
BMJ 2001;322:1330-1333 ( 2 June )
Interval between decision and delivery by caesarean sectionare current standards achievable? Observational case series
Derek J Tuffnell, consultant, Kath Wilkinson, clinical governance support officer, Nicola Beresford, senior house officer.
Maternity Unit, Bradford NHS Trust, Bradford BD9 6RJ

You can read these papers in full in the British Medical Journal online (http://bmj.bmjjournals.com/)


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