Death of infant born at freestanding birth center deemed a homicide

[queenanneslace, ADN, MSN, APRN, CNM]

Jury: Death of baby at Fort Mill birthing center was homicide | The State The State

It Could Have Been Me - honest midwifeA newborn died after birth at a freestanding birth center. The coroner held a jury hearing to determine the nature of the death. The midwives were licensed to practice midwifery and were legally providing services at their birth center.

When does the death of a patient under the care of a licensed provider become homicide instead of negligence or malpractice?

It will be interesting to see if the midwives can be/will be charged with homicide.

Or, is the case that the midwives had no malpractice insurance - (it is no secret that many midwives practice without carrying malpractice insurance) - and so alternative avenues were pursued to investigate the death of the baby?

It sounds like this birth center had multiple problems - including multiple newborn deaths - so there is likely more to the story.

It makes me uneasy when licensed providers are accused of being homicidal. Unless, of course, they are truly homicidal - but that's a pretty slim segment of the population.

Negligent and incompetent might be more appropriate.

[Qteapi]

Saw this yesterday and was really interested to see what would come of it....will be looking for more info in the coming weeks and how it will affect practice going forward....thanks for sharing!

[RiskManager]

Generally speaking, when a medical examiner or a coroner does an inquest in a death, they can choose one of several options to describe the cause of death: natural, accidental, homicide, suspicious, suicide or undetermined. The options available depend on the jurisdiction. The finding of 'homicide' only means that none of the other categories apply, and the cause of death appears to be caused by someone or at the hands of someone known or unknown. It is not a criminal finding. A prosecuting attorney would have to make a separate determination on whether to bring criminal charges against someone.

In most cases like this involving medical treatment, the finding of 'homicide' only means that the medical providers did, or failed to do something, that resulted in the death of the patient. They were not necessarily negligent or criminal in causing the death of the patient.

Most states have explicit laws/regulations mandating that deaths be investigated depending on the circumstances. In my experience, it is not uncommon for a free-standing birthing center maternal or neonatal death to have such an investigation. The same applies for a patient death in a free-standing surgery center as well.

The providers in this case likely will not face any criminal sanctions, but a licensure investigation or a malpractice claim would not surprise me.

[biggolp]

I am confused.

The article states:

Fisher said it's possible to recover a child from meconium aspiration, but that it requires the right transition, the right technical support.” He added that there's no tell tale” signs of meconium aspiration, and that it's usually not evident until after the water breaks.

Read more here: Jury: Death of baby at Fort Mill birthing center was homicide | The State The State

My question is - does meconium in the fluid always indicate meconium ASPIRATION?

Also, NRP gives clear guidelines for babies born with meconium and everything they recommend should be available at a FSBC. What does a hospital have for immediate use that the Birthing Center doesn't have?

I do understand that had they seen meconium earlier they would have transferred. But I've been at many births where meconium isn't detected until the baby is actually born (because there was no SROM or AROM).

Read more here: Jury: Death of baby at Fort Mill birthing center was homicide | The State The State

[queenanneslace, ADN, MSN, APRN, CNM]

My question is - does meconium in the fluid always indicate meconium ASPIRATION?

This source states that approximately 10% of infants born with meconium stained fluid develop meconium aspiration syndrome.

Medscape: Medscape Access

ACOG reports similar numbers:

"Meconium-stained amniotic fluid is a common obstetric situation, occurring in 12–22% of women in labor (1, 2). Meconium aspiration syndrome is a major complication in the neonate. This syndrome occurs in up to 10% of infants who have been exposed to meconium-stained amniotic fluid, with significant morbidity and mortality."

Amnioinfusion Does Not Prevent Meconium Aspiration Syndrome - ACOG

Anecdotally - I've seen lots of babies born with meconium - thick meconium - and no meconium aspiration. So I agree - presence of meconium does not equal meconium aspiration syndrome. I do, however, appreciate the presence of skilled NICU staff at these births who can properly support a newborn with this complication, should it arise.

What does a hospital have for immediate use that the Birthing Center doesn't have?

Neonatologists, NNPs, NICU nurses, respiratory therapists, staff trained and skilled at neonatal intubation and advanced neonatal life support.

[RiskManager]

I see from the article that at autopsy, meconium was found in the infant's stomach and airway. Of note, one of my areas of specialty in malpractice claims management is OB cases. I have done a few cases involving free-standing birth centers. The usual allegations of malpractice in those claims include:

1. If the mom was an appropriate candidate (low risk) for a free-standing birth center

2. The qualifications of the midwife

3. The arrangements for physician backup (if any, or if required by the state) and emergent hospital transfer

4. The emergency response training and equipment capabilities of the free-standing birth center

5. When did the midwife recognize that things were going bad and what did s/he do at that time?

6. What monitoring technology (if any) was being used?

In my experience, despite whatever you do in terms of informed consent, disclaimers, liability waivers (if allowed in your jurisdiction) or the like, the 12 people in the civil jury box often hold the free-standing birth center to a similar standard of care as a hospital. It can be difficult for the non-hospital affiliated free-standing centers and their midwives to get affordable malpractice insurance or any insurance at all, since the major malpractice carriers don't like the business due to the risk.

[biggolp]

This source states that approximately 10% of infants born with meconium stained fluid develop meconium aspiration syndrome.

Medscape: Medscape Access

ACOG reports similar numbers:

"Meconium-stained amniotic fluid is a common obstetric situation, occurring in 12–22% of women in labor (1, 2). Meconium aspiration syndrome is a major complication in the neonate. This syndrome occurs in up to 10% of infants who have been exposed to meconium-stained amniotic fluid, with significant morbidity and mortality."

Amnioinfusion Does Not Prevent Meconium Aspiration Syndrome - ACOG

Anecdotally - I've seen lots of babies born with meconium - thick meconium - and no meconium aspiration. So I agree - presence of meconium does not equal meconium aspiration syndrome. I do, however, appreciate the presence of skilled NICU staff at these births who can properly support a newborn with this complication, should it arise.

Neonatologists, NNPs, NICU nurses, respiratory therapists, staff trained and skilled at neonatal intubation and advanced neonatal life support.

Thanks, queenanneslace, for your explanation and quotes.

I have also seen many babies born with mec in the fluid and no issues, hence my question.

I have another question - - the midwife in the case stated that the fluid had been clear when she first saw it (SROM?) and she was only able to see the meconium AFTER the shoulders were born. What does that mean?

[queenanneslace, ADN, MSN, APRN, CNM]

the midwife in the case stated that the fluid had been clear when she first saw it (SROM?) and she was only able to see the meconium AFTER the shoulders were born. What does that mean?

At the time of spontaneous rupture of membranes, the fluid was clear, but at birth, when baby was halfway out (after the shoulders) a larger gush of fluid revealed meconium in the amniotic fluid.

The insinuation is that the midwives were ignoring other signs that the baby was not tolerating labor well - the fact that they'd administered O2 to the mother makes others suspicious that the fetal heart rate was not perfect as they had indicated.

It is true that many babies can be born with meconium in the amniotic fluid and have "no issues" but we cannot rely on that happening 100% of the time.

The baby was very depressed at time of birth - whether or not that was caused by the meconium, exacerbated by the meconium, or if the meconium was only a sign that the baby was suffering from oxygen deprivation is kind of up for contention. But those reviewing this case believe that the midwives were ignoring signs of fetal hypoxemia, or perhaps not being completely honest about their assessments during labor.

[queenanneslace, ADN, MSN, APRN, CNM]

There also appears to have been multiple problems with this birth center.

Here's a news story from late 2013 where a baby died at this same birth center.

You know, as much as I want to support OOH birth, I become very tentative about recommending it when I read things like this.

SC DHEC details baby's death at Fort Mill birth center | The State The State

[biggolp]

Thank you for your clarifications!

I also looked into that birth center and read a lot from the other midwife you provided a link for.

It's really scary!

But, the FSBC I worked at was NOTHING like that!

It's run by CNM's who have worked for many years in and out of hospitals.

They follow protocols and risk patients out all the time.

That birthing center is owned and overseen by doctors.

The midwives also have privileges at the local hospital and can continue care in case of transport.

[Red Kryptonite]

I have another question - - the midwife in the case stated that the fluid had been clear when she first saw it (SROM?) and she was only able to see the meconium AFTER the shoulders were born. What does that mean?

My fifth child was an unintentional home birth. I planned to go to the hospital I had used for my fourth, but she was in too big a hurry.

I was alone when my water broke and I started pushing. The fluid was clear. My husband got home and assisted with the birth. Once he had me and baby lying safely in bed (I was standing in our bathroom) he told me that the fluid that came after the baby was green. I asked him if he had seen anything that color before her head was out and he said no.

I decided to have him call EMS because, even though I was 99% sure she had not aspirated any meconium, it seemed to me like the precipitous birth had stressed her and I should be more cautious than might otherwise be. We transferred and everything was fine, and she had not aspirated.

So, like with my daughter, it could be that baby got a little stressed, just later in the birth process.

[biggolp]

Thank you, Red Krytonite, for that info.

It was helpful.