This case is somewhat local for me and I work postpartum, so I have been following the story with more than a casual interest.
Seems like that parents wanted the VBAC so much that they were willing to overlook some serious red flags.
For instance, any practitioner who says they will hightail it out of a troubled scenario and wants no mention made of their name is saying that they have something to hide and do not intend to accept responsibility for their actions.
I remember when this case broke a year ago being stunned at the many irregularites and questionable circumstances in the first article I read about it.
The older article quotes Dentice as saying that she has been performing "midwife services" for more than 22 years. In the more recent account (linked in the OP's post), she claims to have participated in more than 100 home births. That doesn't add up to even one a month and could be as little as half of that. Not an impressive amount of experience for someone stepping into a situation where people with much greater skill refused to tread.
I am also disturbed by the thought of trying a home delivery after 3 c-sections. A primary VBAC is usually entered into as a trial
of labor with no guarantees that an additional section will not be needed. The only way to accurately monitor a high risk mom and baby is in a setting where, a) there is equipment available to continuously evaluate the status of the child and the progress of the descent, and, b) there are facilities and staff people immediately available to switch to a surgical intervention should this become necessary.
Other midwives turned this couple down for home birth because they felt it was too risky. For a patient with a history of THREE previous sections, the OBs I know would look long and hard at the conditions of those deliveries and be very cautious about considering a VBAC, even in a hospital. And with good reason.
The problem described in the article is shoulder dystocia, a presentation in which the baby becomes "stuck" in the birth canal. This is a true obstetrical emergency which requires immediate action. There are a number of "maneuvers" which involve changing the mother's position to expand pelvic diameter or external interventions which manipulate the baby's orientation in the hope of compressing shoulder diameter. The most drastic of these involves pushing the baby back up into the vagina and performing a crash c-section.
During this emergent kind of delivery, the baby is at obvious risk for clavicle fracture, Erb's palsy (temporary or permanent paralysis of the arm and shoulder), hypoxic brain injury, and, as is all too apparent, death.
The mother, especially one with three previous sections, is at risk for uterine rupture and hemorrhage.
Shoulder dystocia is not entirely predictable, HOWEVER, the patient's previous history may have suggested it was a possibility. If the reason for intervention with the c-section babies was "failure to progress" or "failure to descend," then it's well within the realm of possibility that a vag delivery with any of them might have led to a similar predicament.
Other unsettling information is Dentice's refusal to arrange transport when the parents requested it. Although the mother (in another article) said that Dentice didn't forbid her to go to the hospital, she certainly strongly encouraged the couple to continue with the home birth and assured them that the delivery was going well. I'm guessing her reluctance to call for help was influenced by her "consciousness of guilt," ie. an awareness that such a call could expose her activities and place her in legal hot water. Putting her own self-interests ahead of the needs of the delivering child caused her to make the decisions that led to a tragic outcome.
As I understand it, if Dentice had been a licensed
practitioner, she could have been charged with malpractice and possibly negligence. As an unlicensed person, she could have been charged with manslaughter, but the circumstances probably would not have met the legal standards required to get a conviction. At one point she was charged with second-degree reckless endangerment, but it appears that was dropped as part of the plea agreement. By agreeing to plead guilty to practicing medicine and delivering a prescription drug without a license Dentice spared everyone an emotionally wrenching and possibly lengthy trial. It also seems, from other local news accounts, that she is extremely remorseful and has no intention of appealing the six-month sentence. (She could have gotten almost seven years.)
I am familiar with the judge in the case. She is known for being tough but fair, and I believe she demonstrated those attributes in this case. No one, not even the parents, believes that Dentice is a bad person or that she intentionally harmed anyone. The concensus is that she is an otherwise law-abiding person who willfully chose to greatly exceed both her capabilities and the scope of her training by participating in a high risk home birth that she was in no way equipped to handle. Making one bad decision after another, she proceeded until the tragic outcome was inevitable.
That the parents bear a responsibility is also clear. They didn't research Ms. Dentice well enough. Nor did they heed the advice of the practitioners who assessed home delivery as too dangerous given the mother's history. They will have to live with the loss of their daughter for the rest of their lives.
But in accepting the role of a "practitioner," Ms. Dentice assumed a greater responsibility by virtue of putting herself in the role of caregiver and advisor.
The one good thing to come out of all of this is increased support for legislation (already in the works prior to this sad event) that will set legal guidelines for midwives in the state of Wisconsin.
A new law expected to be signed today [April of 2005] would license Wisconsin midwives who are nationally accredited.
The law will spell out medications that midwives can dispense and prohibit non-licensed midwives from referring to themselves as midwives.
The law will require licensed midwives to provide clients with detailed information about their skills, experience, education and training, as well as their current malpractice insurance
The new law prohibits people who are not licensed midwives from referring to themselves as midwives. Licenses will be granted to those with a certified professional midwife credential from the North American Registry of Midwives or a certified nurse-midwife credential from the American College of Nurse Midwives.
Members of both of these groups support the legislation.
Such a sad event for all concerned. The parents have lost a child. Ms. Dentice has lost her reputation and her "practice." She will spend time in jail and be closely supervised during three years of probation. Nobody won.
Except, perhaps, the mothers and babies who will be protected by the new legislation.