Drills for Community Birth: Safety First

I have been a birth center midwife for well over a decade. During this time, I have developed a passion for leading and creating drills for community birth. It takes time, dedication and patience to organize these drills but they are critical to providing safe care to our families. In the community setting, with good eligibility requirements and robust policies emergencies will be rare. However, they will still happen and because they are rare, we must drill for them often. Essentially, there are 3 types of transfers that can happen:

Loading up in the ambulance during the drill.
  • Intrapartum (IP): these are transfers that happen before the birth of the baby and can be related to the pregnant person or the baby.
  • Postpartum (PP): this is a transfer after the birth of the baby and involves the birthing person.
  • Newborn (NB): this is a transfer after the birth that involves the baby.

For each of these categories, the transfer can be emergent or non-emergent. Emergent transfers from the community setting to a hospital are rare and happen in only about 1-2% of transfers overall. Here are some examples of reasons why emergent transfers may be necessary:

  • Fetal Intolerance of Labor: this happens before the birth when a baby, for various reasons, does not tolerate the process of labor and contractions. This is why we monitor the baby’s heart rate during the labor process
  • Umbilical cord prolapse: once the waters have released, this can happen if the umbilical cord comes down through the cervix and vagina before the baby is born.
  • Postpartum hemorrhage: After the birth, when the birthing person looses too much blood this is called a postpartum hemorrhage (PPH).
  • Retained Placenta: this happens if the placenta is not delivered in a timely manner after the birth of the baby and may require additional interventions.
  • Newborn respiratory distress: this may happen as a result of various causes but is rare in healthy, full term babies and the midwife may need to give the baby assistance with the first breaths.
  • Unknown newborn anomalies: a baby can be born and can have a structural issue not known before the birth that can cause the baby to have distress
Going over equipment with our EMS partners

This list is not exhaustive, it is simply to give some descriptions of common reasons that may require a transport from the community setting to a hospital. Your birth team should be prepared educationally and with appropriate equipment to respond to these situations. (When you are choosing your community birth team, be sure to ask their plans and procedures for handling emergencies.) For more information all about the safety of community birth in a birth center, please check out the American Association of Birth Centers page on the National Birth Center Study II. Homebirth is also another safe community birth option for low risk families, here is a quick read published by the Lancet medical journal with more information.

Our birth center team and EMS working together

At my center, we do monthly “in house” drills with our midwives, nurses and support staff. These will alternate between maternal and newborn emergencies. Typically, I will not alert the staff ahead of time to the type of drill that will happen. In real world situations, you need to be prepared for all emergencies at all times. I think of it this way, in a physiologic birth at the end of a healthy pregnancy, I as a midwife, will likely not do too much in the way of medical interventions or procedures. I will be at your side, offering support and guidance, giving you food and water, squeezing your hips, monitoring you and the baby to be sure you are both safe but I will not utilize most of my “fancy” skills and education. However, like a lifeguard who sits in the high chair at the public pool, when you do need me to jump down and intervene you really need me to, and so I will without hesitation. This is why you have hired me, for the rare times when you and/or the baby will need help. You can read about some of the tools I have ready at each birth in one of my previous posts all about the Tools of My Trade.

The birth center team starting a drill

At least two times each year, I organize and execute massive interfacility Drills for Community Birth between my birth center, our local EMS service and our partner hospital. The drills are split into two components, a didactic presentation and a hands on drill. The didactic presentation will be related to the type of emergency we will be practicing. For example, our last drill was all about babies, so the presentation was all about the fetal to neonatal respiratory and circulatory transitions that happen at birth. This portion is attended by our staff, staff from the hospital and members of the EMS teams such as EMT’s and paramedics.

The birth center team and our hospital partners working together in the emergency room after the mock transport

Next, in the hands on drills, we start at the birth center responding with our tools and training then we “notify” our 911 system of the need for transport and they “dispatch” a crew to the center. We then give report to the EMS crew, load the transferring person (pregnant person, postpartum person or baby) into the ambulance accompanied by one of our midwives and we travel to the hospital. The hospital is then alerted of our situation and estimated arrival time. When we arrive to the hospital, our midwife gives report to the hospital team and we continue the drill through the hospital process to completion. As you may imagine, these drills take a lot of effort to plan, coordinate and manage. I usually start the process about 3 months in advance. In the end, these Drills for Community Birth are well worth all the work, time and effort. They are crucial for our families as well as our staff, our local EMC crews and our partner hospital.

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