Home births gone wrong

[MNNICU, RN]

Do you see this often in your facility? In 2.5 years we have had 2 babies die and 2 be severely disabled from home birth. I have a really hard time with this. I understand my role is to care for babies and families without judgement to the best of my ability (which I DO!) but I come home and just stew on these situations. Recently we had a mom who was told she needed a C section by two different physicians at two different facilities for a breech baby and low fluid and she refused, signed out AMA and attempted a home birth with midwives. The baby of course became stuck with the body born and required a 13 minute code. We cooled her immediately for 72 hours and she spent two weeks on a vent. She just now is extubated but will require a trach because she can't cough or swallow or gag so secretions just build up. She is more or less vegetative and on a slew of anti seizure meds. This stuff just really makes it hard for me to sleep! I feel like these poor innocent babies end up paying for their parents risky stupid decisions. Does anyone else see these situations? How do you handle it? I am not looking to hear about how my job isn't to judge, I get that. But I am human too and this job is very emotional sometimes!

[cayenne06, MSN, CNM]

Umm ... No.

"Protecting the baby" is not a reason to criminalize any part of childbearing. Especially since many of the issues raised in this thread can be directly traced to the behavior of the healthcare system and individual practitioners. Criminalizing decisions made by pregnant or laboring women does nothing to address those issues.

I can't say this enough. Adults have the right to decline any and all medical care, and they have the right to use any "alternative" methods of care that they deem appropriate, even if it is a bunch of hooey. Pregnant women do not lose any of their rights when they become pregnant. They have the right to refuse care, even care that could harm or cause the death of their fetus.

The issue here (and the issue with things like homeopathy, naturopathy, etc) is not what grown adults chose to do with their own health care. The issue is the ethical and moral responsibility of health care providers to be giving their patients the safest, most effective care they can. I think it is unethical for a midwife to practice with substandard training, and I think it is unethical for a midwife to present home birth as a viable option for women who are not in the lowest risk category. I think it is unethical for NARM to certify midwives that don't meet the minimum standards set by ICM. That's just crazy.

Some midwives argue that if they don't attend that twin HBAC, then the mother will just give birth unassisted. I do understand that argument, but I also believe that while patients have the right to choose their care, I have the right to decline to participate in care that I do not believe is appropriate. Of course, if I have agreed to take on the care of a patient and she refuses my recommendation for transfer of care (either prenatally or during labor), I am going to protect that patient to the best of my abilities, even if that means continuing to care for her at home if her labor turns high risk and she won't transfer. But I will be calling 911 and alerting my back up physician and doing everthing else I possibly can to safeguard you, because that is my professional responsibility.

Pregnant women retain complete autonomy of their bodies. Laws and regulations that try to interfere with this right are something we should all care deeply about. Pregnant women are free to make as many dumb decisions as any random 25 year old dude. Fetus notwithstanding.

Direct entry midwives (and naturopaths, and chiropractors) lobby for licensure under the guise of protecting patient choice. But granting licensure confers a patina of legitimacy which can mislead patients. I believe strongly in science based medicine and in a unified standard of care that all of us are beholden to. I do not believe patient choice is served in ANY WAY by legitimizing pseudoscience and substandard care.

Let patients choose whatever snake oil they want. Let pregnant women choose their place of birth. But we, as providers, have an ethical responsibility to provide science based care, and to police our own profession to ensure that patients can reliably expect a certain level of care and expertise from our providers. As a midwife, I am disturbed by the state of the direct-entry certification. It reflects poorly on American midwives as a profession, and does a disservice to US, as a profession, and more profoundly for our patients. THIS is where we need regulation- on us, as professionals. Not on patients.

ETA- I've been a CPM since 2006 and a CNM since 2015. It is profoundly humbling to acknowledge the deficiencies in my training and to admit that I have provided substandard care to women who trusted me and my expertise. I foolishly thought my CPM education prepared me for the autonomous care of pregnant women and their newborns, when in fact I was dangerously underprepared. I am thankful that I realized this before I inadvertently caused harm to a patient. Women who choose home birth in the U.S. (myself included) deserve a midwife who is trained to the standard of ICM, full stop. We need to shore up the training of all midwives to meet this standard, and we need to work to integrate home birth into mainstream health care, because right now home birth in the U.S. is decidedly NOT as safe as it should be.

[rnkaytee]

"I am going to protect that patient to the best of my abilities, even if that means continuing to care for her at home if her labor turns high risk and she won't transfer."

^^ Do you feel like this happens often? I know mothers who are very invested in "home birth above all else" but I'd like to think that if their midwife (who they ostensibly trust) said it's time to go, they'd go.

Edit: formatting issues.

[RiskManager]

[quote=cayenne06;9073361

Of course, if I have agreed to take on the care of a patient and she refuses my recommendation for transfer of care (either prenatally or during labor), I am going to protect that patient to the best of my abilities, even if that means continuing to care for her at home if her labor turns high risk and she won't transfer. But I will be calling 911 and alerting my back up physician and doing everthing else I possibly can to safeguard you, because that is my professional responsibility.

This gives RiskManager the vapors and causes me to clutch my pearls in terms of watching out for your best interests and the safety of the patients (both mom and baby). If you knowingly take on a high risk case that has a reasonable chance of exceeding your ability to safely manage the delivery, especially out of the hospital, because you were trying to accommodate the wishes of the mom, you will likely be held up to criticism if things go south. Plaintiff counsel would argue that as the trained and experienced midwife, you had an obligation to set limits on what you felt competent and safe to perform, and you should not have exceeded those limits just to support the mom.

This is a different situation than things going south rapidly during the delivery at home. Emergency situations are viewed somewhat differently in court.

You might want to chat with your friendly local risk manager, or the risk or claims manager at your malpractice insurer about the concept of if you should knowingly take on or continue with a case that you think is clinically contraindicated to accede to the mom's wishes when she is refusing your advice. I can tell you that most physicians will refuse to do a delivery that they think is unsafe just because this is what the mom wants.

[cayenne06, MSN, CNM]

This gives RiskManager the vapors and causes me to clutch my pearls in terms of watching out for your best interests and the safety of the patients (both mom and baby). If you knowingly take on a high risk case that has a reasonable chance of exceeding your ability to safely manage the delivery, especially out of the hospital, because you were trying to accommodate the wishes of the mom, you will likely be held up to criticism if things go south. Plaintiff counsel would argue that as the trained and experienced midwife, you had an obligation to set limits on what you felt competent and safe to perform, and you should not have exceeded those limits just to support the mom.

This is a different situation than things going south rapidly during the delivery at home. Emergency situations are viewed somewhat differently in court.

You might want to chat with your friendly local risk manager, or the risk or claims manager at your malpractice insurer about the concept of if you should knowingly take on or continue with a case that you think is clinically contraindicated to accede to the mom's wishes when she is refusing your advice. I can tell you that most physicians will refuse to do a delivery that they think is unsafe just because this is what the mom wants.

Sorry, I thought I made it clear in my post that I think it is unethical and immoral for HB midwives to knowingly take on women who are not healthy and low risk. That was like, the entire point of my post :) It is a reflection on NARM midwives as a whole, that this kind of thing is tolerated. And it saddens me.

The statement you quoted was about not abandoning a patient in the midst of an acute event, which no health care provider of any stripe would ever do, no matter how egregiously bad the patient's choices may be or how dangerous the situation is.

ETA- if I had a prenatal patient who I deemed to fall outside of the healthy, low risk category (not even necessarily "high risk"), I would decline to continue to care for that patient, and would arrange for appropriate transfer of care. I wouldn't, like, continue to care for a hypertensive mom because she doesn't want a hospital birth. But if my previously low risk patient develops hypertension or whatever in labor and she refused a transfer, obviously I would safeguard her to the best of my abilities while I arranged for appropriate care, including calling 911 no matter what the wishes of the patient. She can decline EMS when they get there, but I am still going to call them.

I know too many HB midwives who are quick to dismiss potential risk factors in their patient, citing the "normalcy" of birth and respecting their patient's autonomy. When in fact, this kind of attitude interferes with a patient's autonomy by preventing her from having access to accurate medical information with which to make her choices.

[cayenne06, MSN, CNM]

"I am going to protect that patient to the best of my abilities, even if that means continuing to care for her at home if her labor turns high risk and she won't transfer."

^^ Do you feel like this happens often? I know mothers who are very invested in "home birth above all else" but I'd like to think that if their midwife (who they ostensibly trust) said it's time to go, they'd go.

Edit: formatting issues.

Yes, it is thankfully rare. Most women want what is best for their fetus, and trust their providers enough to follow their recommendations. Unfortunately, there are too many midwives who abuse their position of trust and steer their patients towards less than ideal choices.

And hence, I want to reiterate that this is NOT about a woman's choices in childbirth. It is about the ethical and moral responsibility of midwives to ensure that, as a profession, we are ensuring a safe level of basic competence and a science-based standard of care. Non nurse midwives are not meeting this ethical responsibility and it is not okay. I know there are many wonderful direct entry midwives, but the credential itself in NO WAY guarantees that, and women deserve better than that.

[floridanurse1983]

I don't get the anti c-section movement. If it's needed, it's needed. Just suck it up and do it!

[floridanurse1983]

My mom wanted to have me at home. Completely uncomplicated pregnancy and assumed birth would be too. Had arraignments made and everything. Then her friend panicked when she started contracting and talked my mom into the hospital. I ended up being a severely prolapsed cord delivery. So much that I almost died with an emergency c-section done pronto. If she had stayed home, I'd be dead. I don't get crying and hand wringing over a c-section and deviation from a "birth plan". You can't plan a birth. That's like trying to plan an accident. Things come up and you change, adapt, and deal.

[Elvish, BSN, DNP, RN, NP]

The reason there's such an anti-section sentiment is that C-sections are way overused. Some facilities have a 50% c-section rate, which is appalling. It's 3-5x higher than the WHO ideal of about 10-15% (below which you're likely not sectioning people who genuinely do need one), and about twice the US national average of 25-30%.

I don't blame people for being angry for being bullied or threatened into a section. Sometimes they genuinely need one and sometimes it's all the stuff we've done to them, or a doctor who calls it 'failure to progress' or 'fetal macrosomia' when s/he really just wants to be out of there by 5pm. Even cord prolapses are occasionally manmade, unfortunately.

[babyNP., APRN]

I don't get the anti c-section movement. If it's needed, it's needed. Just suck it up and do it!

C-sections are not a benign procedure; it's a major abdominal surgery. If the ideal is 10-20% and your population is now looking upwards of 30-50%, then there are thousands of unnecessary surgeries. Some of those are going to have complications that were preventable through lady partsl birth.

Furthermore once you have a c-section, you're almost always going to have a subsequent c-section for future births. More c-sections, more surgeries, more complications- more risks of needing a hysterectomy.

Unnecessary c-sections are also not great for the baby. They don't get exposed to the lady partsl flora that helps prime their immune system (some studies linking less chance of asthma & allergies). If a mother has a planned c-section (for those subsequent deliveries after a primary c-section), not going into labor doesn't have the benefit of contractions, which squeeze out fetal lung fluid. Without that benefit, babies can develop transient tachypnea of the newborn (TTN) and end up in a NICU admission with oxygen, antibiotics, and separation of the mother...

Nobody is arguing against c-sections in needed situations (a prolapsed cord in your case is an example of one). But there are too many unnecessary c-sections and they are hurting babies and mothers.

[RiskManager]

In working on the defense of L&D malpractice claims, one of the most common allegations by plaintiff medmal counsel is that a C-section was not done, or was not done quickly enough, and this would have prevented the poor neonatal outcome.

[Elvish, BSN, DNP, RN, NP]

In working on the defense of L&D malpractice claims, one of the most common allegations by plaintiff medmal counsel is that a C-section was not done, or was not done quickly enough, and this would have prevented the poor neonatal outcome.

Yet, birth outcomes in countries with c/section rates in line with WHO guidelines are not significantly worse than those with higher rates.

http://www.who.int/healthsystems/topics/financing/healthreport/30C-sectioncosts.pdf

There are times when sections are necessary, but so many US facilities do them almost willy-nilly. There is absolutely no reason that half of babies born have to come out of an abdominal incision. The fact that so many are done probably speaks to - as you alluded in your post - a high incidence of OB-related litigation and the huge resultant payouts. Not because outcomes are improved on a wide scale.

[babyNP., APRN]

Reminds me of the continuous fetal monitoring large scale studies that have been done- even if it makes us all feel better, continuous fetal monitoring does not improve outcomes, but does increase one's risk for having a c-section.

I agree that our litigious culture goes overboard at times, but that doesn't mean that we should do things we know aren't in the best interest of our patients, putting their health at risk.

Change in the culture is coming, but slowly. At least ACOG has now explicitly stated that full term is really 39 weeks and elective sections before then are not good practice.