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!

[heron, ASN, RN]

An interesting read: For Her Own Good: 150 years of experts' advice for women, by Barbara Ehrenreich and Diedre English.

It's a history of, among other things, the growth of modern obstetrics from a feminist/sociological point of view. It's by no means gospel, but it can provide some insight into how non-medical women might be less than impressed by conventional health care

As previous posters have pointed out, there is misinformation, fear-mongering and frank malpractice on both sides of this equation.

Lay people have no idea of just how very wrong pregnancy and childbirth can go. So, they happily follow poorly informed, credulous or self-serving alternative providers right off the cliff, leaving the NICU, Ob/Gyn and psych nurses to pick up the pieces when the worst happens.

Medical people have no idea how biased we are in pathologising perfectly normal processes. Which can be just as self-serving as any snake-oil sale. We are trained to foresee/prevent the potential or treat the actual complications of pregnancy and childbirth. It's easy to over-treat, over-medicate and over-control our patients out of an over-abundance of caution. And when the worst happens, you guys have to pick up those pieces, too.

I've worked on both sides of this divide and the deeper tragedy, to me, is that there is a divide in the first place.

[24gaDalek]

Lay people have no idea of just how very wrong pregnancy and childbirth can go. So, they happily follow poorly informed, credulous or self-serving alternative providers right off the cliff, leaving the NICU, Ob/Gyn and psych nurses to pick up the pieces when the worst happens.

Medical people have no idea how biased we are in pathologising perfectly normal processes. Which can be just as self-serving as any snake-oil sale. We are trained to foresee/prevent the potential or treat the actual complications of pregnancy and childbirth. It's easy to over-treat, over-medicate and over-control our patients out of an over-abundance of caution. And when the worst happens, you guys have to pick up those pieces, too

Agreed. This is the crux of the issue. There is a disconnect somewhere and the end result can be poor outcomes for infants. The sweet little infants are the ones that suffer the decisions of others.

[annabanana2]

It's interesting to hear how different midwifery regulation in the US is versus other countries. In Canada, in my province specifically, midwives must be registered with a college exactly like nurses, physicians and other regulated health care providers are. Midwives have a baccalaureate degree in midwifery and midwives here aren't nurses (I guess nothing would stop a nurse from going to university to get a baccalaureate degree in midwifery but I bet it's pretty rare, especially considering the BSN is the requirement for entry to nursing in the first place). Research done in my province on outcomes of planned home birth vs. planned hospital birth indicates that planned home birth results in lower or comparable rates of perinatal mortality and adverse outcomes for mom or baby as compared to planned hospital birth with EITHER physician or midwife. Interestingly, planned hospital birth with a physician resulted in the highest rate of perinatal mortality between the three groups (home birth vs hospital vs hospital with physician). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician

[sadiemae1123]

It seems the crux of the matter in the US is the almost complete absence of regulation among lay midwives and Certified Professional Midwives.

Certified Nurse Midwives are RNs who have completed a graduate program, are licensed and regulated by the state, and are expected to carry malpractice insurance. If something goes wrong, families are able to sue for damages and the CNM can be reported to the state. Any disciplinary action is available to the public.

None of this exists for lay midwives or CPMs. In many states midwife is not considered a protected term, meaning someone who has never even seen a birth can call themselves a midwife, and legally charge for the service. There is no one to report negligence or malpractice to. No governing body ensuring the quality of the school's curriculum (or if they even went to any school), practical training, and continuing education. No checks and balances to make sure appropriate prenatal care and screenings are done to risk out people who should never be delivering at home. No one to stop them from falsifying records.

These people can continue delivering babies with bad outcomes and then move on with the next family having no way to even know what quality of midwife they are hiring. Unless a family tries to pursue criminal charges, it can all be swept under the rug.

And most of the lay midwives and CPMs fight the idea of regulation tooth and nail, turning it into a "feminist issue" of the government interfering with a woman's right to choose. In reality it's an issue of patient safety, and providing those who want a home birth informed consent of what qualifies someone to be a women's health provider, the need for prenatal screening to assess risk, and what an appropriate candidate for home birth is.

[SoldierNurse22, BSN, RN]

As an L&D nurse, I can tell you a few stories about home births gone wrong. However, I could probably tell you even more stories about hospital births gone wrong.

For all the concerns that people have about giving birth at home, people tend to forget that many of the emergencies that we see in a hospital setting are of our own making: aggressive induction, unnecessary induction, elective induction of an unripe cervix, jumping to start epidurals only to have mom's BP crash and baby circle the drain, excessively rough cervical exams, unnecessary episiotomies, impatient providers that can create traumatic birth situations, patients being bullied into c/s for the convenience of the doctor, postpartum hemorrhage from inadequate/poorly thought-out treatment plans, and a slew of other issues.

What really amazes me is how many women these days (even in 2016!) blindly do whatever their OBGYNs tell them to do. One of our docs likes to induce primips the second they go past 39 and 6. Another one is an extremely aggressive cervical checker. Several prefer c/s cases to natural births, and another likes to scare her patients into "medical" inductions with her "11-lb baby" stories.

Of course, on the opposite end of the spectrum, you've got the super-granola moms who want to deliver breech at home with a CPM, refuse Vitamin K, and absolutely will not hear the nurse/doc/midwife on why a c/s might actually be a really good idea. I've found there are very few women who fall in between these categories.

Personally, I'm all for natural childbirth and home and/or birth center births with qualified, competent providers and a pre-determined, well-practiced emergency plan. However, I also wouldn't be sitting here writing this right now were it not for a very compassionate OBGYN who saved my life a few years ago, so I have no problem giving credit where credit is due when it comes to the vital, life-saving surgical skills unique to the practice of OBGYNs.

[sadiemae1123]

It's interesting to hear how different midwifery regulation in the US is versus other countries. In Canada, in my province specifically, midwives must be registered with a college exactly like nurses, physicians and other regulated health care providers are. Midwives have a baccalaureate degree in midwifery and midwives here aren't nurses (I guess nothing would stop a nurse from going to university to get a baccalaureate degree in midwifery but I bet it's pretty rare, especially considering the BSN is the requirement for entry to nursing in the first place). Research done in my province on outcomes of planned home birth vs. planned hospital birth indicates that planned home birth results in lower or comparable rates of perinatal mortality and adverse outcomes for mom or baby as compared to planned hospital birth with EITHER physician or midwife. Interestingly, planned hospital birth with a physician resulted in the highest rate of perinatal mortality between the three groups (home birth vs hospital vs hospital with physician). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician

I would certainly hope the physicians have a higher rate of perinatal mortality. Remember, they are caring for the women at highest risk for adverse events.

If the perinatal mortality was no better with the midwives, who should only be delivering women with the lowest risk of adverse events, then I would be extremely concerned with the level of care the midwives were providing.

[NICUNurseEliz]

None of this exists for lay midwives or CPMs. In many states midwife is not considered a protected term, meaning someone who has never even seen a birth can call themselves a midwife, and legally charge for the service. There is no one to report negligence or malpractice to. No governing body ensuring the quality of the school's curriculum (or if they even went to any school), practical training, and continuing education. No checks and balances to make sure appropriate prenatal care and screenings are done to risk out people who should never be delivering at home. No one to stop them from falsifying records.

These people can continue delivering babies with bad outcomes and then move on with the next family having no way to even know what quality of midwife they are hiring. Unless a family tries to pursue criminal charges, it can all be swept under the rug.

And this is the issue with the horrible group of midwives in my area that we run into. Almost 50% of our unit's cooling babies were patients of these midwives and we have seen some absolutely clear cut negligence from them, yet they keep on practicing and consistently producing poor outcomes.

[heron, ASN, RN]

I would certainly hope the physicians have a higher rate of perinatal mortality. Remember, they are caring for the women at highest risk for adverse events.

If the perinatal mortality was no better with the midwives, who should only be delivering women with the lowest risk of adverse events, then I would be extremely concerned with the level of care the midwives were providing.

I think you and soldier nurse are both spot on.

So - has anyone figured out what proportion of the badness is iatrogenic?

[MNNICU, RN]

It's interesting to hear how different midwifery regulation in the US is versus other countries. In Canada, in my province specifically, midwives must be registered with a college exactly like nurses, physicians and other regulated health care providers are. Midwives have a baccalaureate degree in midwifery and midwives here aren't nurses (I guess nothing would stop a nurse from going to university to get a baccalaureate degree in midwifery but I bet it's pretty rare, especially considering the BSN is the requirement for entry to nursing in the first place). Research done in my province on outcomes of planned home birth vs. planned hospital birth indicates that planned home birth results in lower or comparable rates of perinatal mortality and adverse outcomes for mom or baby as compared to planned hospital birth with EITHER physician or midwife. Interestingly, planned hospital birth with a physician resulted in the highest rate of perinatal mortality between the three groups (home birth vs hospital vs hospital with physician). Outcomes of planned home birth with registered midwife versus planned hospital birth with midwife or physician

agreed just about every other country that regulates home birth closely has way better outcomes. The us just doesn't regulate it at all. Also one thing I wanted to point out about that study: for the people delivering in hospitals with physicians it makes sense to me that the neonatal mortality rate would be highest as those would be the moms/babies with complications that require a hospital delivery with an OB and not fit for home birth or midwives. If they are working with more complex or at risk groups of course their mortality rate would be the highest

[MNNICU, RN]

Oh my never mind I see I was the third person to point that out. Didn't even see the other comments on the issue. Well apparently that was abundantly obvious to everyone

[annabanana2]

I would certainly hope the physicians have a higher rate of perinatal mortality. Remember, they are caring for the women at highest risk for adverse events.

If the perinatal mortality was no better with the midwives, who should only be delivering women with the lowest risk of adverse events, then I would be extremely concerned with the level of care the midwives were providing.

Actually in this study ALL the moms met the criteria for home birth, so they were all low risk:

Eligibility requirements for home birth mandated by the College of Midwives of British Columbia

• Absence of significant pre-existing disease, including heart disease, hypertensive chronic renal disease or type 1 diabetes
  
• Absence of significant disease arising during pregnancy, including pregnancy-induced hypertension with proteinuria (> 0.3 g/L by urine dipstick), antepartum hemorrhage after 20 weeks' gestation, gestational diabetes requiring insulin, active genital herpes, placenta previa or placental abruption
  
• Singleton fetus
  
• Cephalic presentation
  
• Gestational age greater than 36 and less than 41 completed weeks of pregnancy
  
• Mother has had no more than 1 previous cesarean section
  
• Labour is spontaneous or induced on an outpatient basis
  
• Mother has not been transferred to the delivery hospital from a referring hospital
  

And, I mean, really. You all think experienced researchers wouldn't have taken risk status into account? It's not these guys' first rodeo. This study had to get past peer review.

[MrNurse(x2), ADN]

My second child was a planned home birth. There is a lot I want to say to those of you who say I'm "selfish" but it would get me banned. I might return to this thread when I'm feeling more rational and not about to blow up at the ignorance demonstrated in this thread.

That is fair, given your experience, both professional and personal. The overwhelming truth that goes through my head reading this thread is that we are an arrogant society, thinking that the reason our infant mortality is low is because we are so advanced. It is low because we have overwhelming majority acute setting births! Home setting births will maintain third world mortality rates because, although the homes don't have dirt floors, the emergency support is identical. I have no experience with these practitioners, but I doubt that that figure is brought up when selling their services. I am sure it is very difficult to work in an area where these tragedies could be averted and have to see the result of a choice they may not have made, but that is what must be kept in perspective, these women, families, made the best choice that they believed at the time. Just like someone can not fathom the logic behind someone who has opposing political views.