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Tuesday, October 12, 2010

Home birth death: are pieces of the puzzle missing?

I recently read the article about a Missouri baby who died after a troubling home birth in October 2009. I felt that, based on what I read, surely there are pieces of this puzzle that are missing.

I've read two separate articles - one who's tone was anything but unbiased and felt very negative towards midwifery and home birth in general. The other was filled with several inconsistencies, and left me scratching my head at the statements made by doctors: "The doctor told the investigator that the baby likely would have been born safely by cesarean section if the mother had come to the hospital soon after her water broke."

It seems like some form of cord compression happened as a result of the baby's cord being wrapped around his neck, which the doctor described as a "common condition that is easily corrected at hospitals." (emphasis mine)

Wow. Where to even begin here?

The whole issue of nuchal cord and their response to it makes me laugh, because women are often made to think this is always a life-threatening issue that can only be avoided by cesarean. Or that it makes it impossible to birth a baby vaginally. I'd be willing to bet that a good midwife will know how to fix it in a way that doesn't end in surgery more often than an OB would, but that's just a guess. And now suddenly it's "common" and can be fixed only in a hospital? Are you kidding me?

The response about wanting the mother to come in several hours after her water broke seems typical: the general rule is that usually if contractions don't begin within 24 hours, a cesarean is recommended. Some are speculating whether they're really necessary even then, as long as the baby is doing okay and if few vaginal exams are done in order to prevent infection. Some doctors wait less than the typical 24 hours, and a few I've read about give only eight hours. Where's the continuity of care in that?

The comments the doctor made to investigators, though, got me thinking. What, really, does this investigator know about childbirth? About current birth politics? About the reasons women want to avoid a hospital birth? All this comes into play when considering the death of this baby. You can't just take a doctor's admission of the baby "likely" being born safely, because even that is not a given. Since the obstetrical crystal ball technology hasn't really been perfected yet, the best you can do is speculate. Unless the jury is remarkably packed with pro-home birth advocates, or at the very least, people who really know something about birth - and why some women feel boxed into a corner when it comes to hospital birth - what do you really think the jury is going to say? Since most of the country naively perceives all midwives as incompetent, and home birth to always produce disastrous results, why even bother going before a jury? Why not just engage in a massive witch hunt and dispense with the formalities already?

What's to stop any doctor who just happens to be anti-home birth from making this into a situation that clearly damns the midwife, no matter what? How is any investigator going to know the difference?

This raises more questions than answers for me, some of which don't have anything to do with the safety of home birth in and of itself. It's not just a question of poor judgment on the midwife's part; there's so much more going on here.

Apparently, the midwife insisted she had everything under control when the parents were asking about transferring to the hospital. However, "minutes later," she decided to dispatch them to the hospital anyway.

As birth advocates, we preach endlessly about trusting your care provider. Sure, that's very important. But I'm not sure it means that you still don't question them sometimes and do everything they say. I don't know - if the parents are asking to transfer, what do you say? Who's to say you're right, and they're not? Or vice versa?

If I reached a point in a home birth where I thought my instincts were telling me to ignore the advice of my very trusted midwife, I don't know if anyone could hold me back from the doorway and take the keys out of my hand as I prepared to leave for the hospital. It makes me wonder about this thing called "patient compliance," where we as patients find ourselves agreeing with things, doing and saying things while at the same time, in our heads, we're wondering, "Why did I just say that? I don't believe that. I don't want to do it this way, and yet I'm agreeing to it anyway."

I can't really blame the parents, though, because if you don't get that "intuition" that tells you that something might be wrong, then what?

It does make me question, though, how in-depth they researched her qualifications. The midwife apparently produced records after the baby's death that said she was some type of "medicine woman and traditional spiritual leader." Umm.... not exactly sure what that means or how it even remotely makes you appropriately qualified.

Another irony is the criminal investigation of the midwife, and others like her - whether they're trained or not - when a baby dies. Conversely, babies die in hospitals every day. Sure, doctors can be investigated, sued, even. No one denies that. But where is the outrage over that? Given the rise of things like the "Pit to Distress" phenomenon and iatrogenic prematurity, it's amazing more babies don't die. What's even sadder is that people seem completely unaware that this stuff happens, simply because babies don't die more frequently. Depending on the situation and state laws, many times an autopsy is never performed - which grieving parents often, understandably, might not think about or want to deal with at the time, meaning negligence is unlikely to be proven.

Interestingly enough, I do remember during my brief employment at a hospital one OB nurse talking to me at length about a doctor who waited too long to do a cesarean. She said nurses were urging him to do so, but he waited. The baby died. As far as I know, he is still practicing medicine, still delivering babies.

One must wonder if perhaps the midwife's obvious reluctance to head to the hospital sooner meant that she would be met with scrutiny and a couple of policemen on each arm. I would hope the mother, when hiring this woman in the first place, would understand that - as well as midwifery laws and their tumultuous history in her home state of Missouri. The often (well-documented) harsh, judgmental behavior of both doctors and nurses during a home birth transfer is, sadly, probably enough to make many only want to head there as a last resort, which could possibly have dire consequences. Couple that with the all-too-common naive assumption that any home birth transfer is likely because of impending disaster, and it's a recipe that leaves a very bad taste in one's mouth.

Edit: Reader Lauren has recently posted this link about the death of a labor and delivery nurse's baby and her hospital transfer when things went wrong. Apparently, you can never get to the hospital soon enough, so it's always your fault, right?


Anonymous said...

To be honest you don't know when this baby started having problems. We assume it's because of ROM but, this could have been brewing for a couple of days prior to ROM.

She had already been taking antibiotics for GBS prophalaxis and avoiding SVE so the sepsis was out of the ordinary.

We can't know what the chain of events that led to this traggic outcome.

I was actually surprised that an emergency cesarean section wasn't performed immediately upon her arrival to the unit, regardless of bringing the heartrate back up. I can't imagine that it was a Category I tracing after bradycardic baseline for an unknown period of time.

How truly awful it must have been for this mother.

The Deranged Housewife said...

I know. It's really no different than fetal demise in someone who is not approaching labor - it happens, and sometimes we just can't pinpoint when. To try to do so would mean what - strapping a monitor around our bellies 24 hours a day from the moment we get the first BFP? Come to the hospital at the first twinge of labor so you can cut me open "just in case"?

There is no neat little answer.

fuzzy said...

bull....the reason behind monitoring is so you have a prayer of knowing when something is going wrong. Had I been at home with my first child, this might have been my story...Instead, the tracing showed trouble, they took the baby with forceps, and she is happy and healthy 29 years later. All for a corpsman who wanted to try out his new gadget.....otherwise, she would have died. 3x nuchal cord, failure to descend....

Anonymous said...

What was this nurse attempting to prove, other than to make anyone with any sense question why the hospital didn't perform a caesarean as soon as the Mum arrived? If the FH was in its boots at home, and still in its boots when they arrived at the hospital then what were they doing leaving baby in there? Plus, if the Mums waters had gone then thick meconium must have been draining as that was what they found when they, eventually, performed the section.
If there is any finger wagging it should be about poor practice at the hospital, not at a woman wanting a homebirth and then transferring in when problems became evident.
P.S I am more alert to potential cord problems when there have been reports of baby being encouraged, or helped to flip from breech to cephalic.

The Deranged Housewife said...

That's understandable and a case where electronic fetal monitoring is doing it's job. On the other hand, there are more sections done today because of 'bad' tracings or false readouts that lead the doctor to believe there is something wrong, when there isn't. Diagnostic tools have come a long way since then (I'm not much older than your daughter, really) but for all they're worth, doctors put way too much faith in them.

So it's not entirely "bull."