What happens if there’s an emergency during a homebirth?

According to the growing body of homebirth studies available, the majority of transfers to the hospital from a planned homebirth are not emergent, but due to when a laboring parent nears clinical exhaustion and would benefit from hospital pain medication to save their strength before pushing.  An appropriate level of transfer out of homebirth midwifery to obstetric care throughout pregnancy and birth is 11 to 15%, depending on the region.

Part of what makes the need for hospital transfer low is that licensed homebirth midwives are required to care only for low-risk pregnancies, meaning no presence of illness or complications that would make need for hospital-grade intervention more likely.  A large part of our job is continual risk assessment throughout pregnancy in addition to preventative, holistic care.

So what about actual emergencies? Though they are not frequent, part of responsible midwifery care is planning for them and carrying the necessary supplies, medications, and up to date skillset to manage them.

The most “common” emergencies in homebirth are hemorrhage, meaning too much bleeding after the birth of the baby, shoulder dystocia, meaning the baby’s head emerges but the shoulders get stuck in the pelvis and need assistance, and a baby that needs help breathing.  These situations are not actually common, just the most likely emergencies to happen in a low-risk birth.  Licensed homebirth midwives are trained to manage these scenarios in the home, and have protocol in place with clear indication of when backup may be called. The majority of the time that these three scenarios happen, EMS is never called because it is resolved in the home with the tools and skills we have.

The scope and medications assigned to homebirth midwives vary a little state by state. As a Nashville homebirth midwife in Tennessee, I can share what we carry in my practice, which is similar to what other practices here do:

• For excessive bleeding, we carry a handful of medications including Pitocin, misoprostol, methergine, and some of us also carry TXA. The first of these three are meant to help the uterus contract and prevent more bleeding from the placental wound, and the last works more broadly on clotting factors to stop bleeding.

• For shoulder dystocia, there is a cycle of position changes we help moms/birthers get in and out of, and hands-on maneuvers we utilize to make space in the pelvis and manipulate the baby’s shoulders to allow them to be born. I talk through these with families during our home visit at 36 weeks so that everyone is prepared should we need to resolve one together.

• For a baby that is having trouble breathing, we maintain our neonatal resuscitation certification and carry the needed supplies. This includes oxygen, face masks, laryngeal masks, suction, a pulse ox, and prioritizes involvement of parents’ physical warmth and keeping the cord intact while the midwife and assistant work through the algorithm. The majority of babies having trouble breathing after birth only need stimulation and a couple breaths. It’s rare to need oxygen and rarer to need compressions, but we carry the necessary equipment and are prepared should they be needed.

On the rare occasion that EMS has to be called, the midwife continues care through their arrival, sees them off with mom/birther and/or baby, and then calls the hospital to inform them of their upcoming arrival, the situation, and the midwife’s assessment. Depending on the situation, we follow to the hospital either right away or later during the labor or postpartum time.

I recommend you ask midwives you interview what medications they carry, if they have an assistant for needed hands in an emergency, and what can be expected with hospital transfers in your area. Relationships between hospitals and out of hospital providers are an important piece of keeping community birth safe.

I am always happy to answer questions and talk through risk assessment with families as they search for a homebirth midwife. If you are interested in getting into care with Maypop, please fill out our contact form and we’ll reach out to schedule a call!