The hubris of homebirth midwives

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Obstetricians are inherently humble.

You can’t attend thousands of births and fail to be impressed with the unpredictability of life threatening complications. They can come out of nowhere. Within minutes a perfectly healthy baby can die from a cord prolapse, a shoulder dystocia or a ruptured uterus. Within minutes a perfectly healthy mother can die from a postpartum hemorrhage, an amniotic fluid embolus or a ruptured uterus.

As proud as obstetricians are of their hard won knowledge and skills, all of us respect the life and death power of childbirth. We are not foolish enough to believe that we can accurately predict the future, so we plan for all possibilities. After all, the lives of our patients and their babies depend on us being prepared.

Homebirth midwives, on the other hand, are rather prideful. They actually think that they can predict unexpected complications is advance. They show precious little respect for the awesome life and death power of childbirth, reassuring women (falsely) that there will be plenty of time to transfer to a hospital in case of an emergency, even though there is no transfer fast enough to save the life of a baby in the case of cord prolapse, shoulder dystocia, or the need for an expert resuscitation with intubation.

Obstetricians are humble enough to recognize that “normal childbirth” is a retrospective diagnosis. Homebirth midwives, on the other hand, presume to make that diagnosis in advance. Indeed, they presume to make that diagnosis even when a pregnancy is known in advance to be high risk. In their ignorance and hubris, they simply reclassify high risk situations, like breech, twins and VBAC, as “variations of normal.”

Moreover, they impute bizarre, impossible skills to themselves such as preventing and curing pre-eclampsia with diet, turning breech babies by shining lights at the vagina, or stopping postpartum hemorrhage by shoving a piece of placenta under the mother’s tongue.

Is it really surprising, then, that homebirth midwives have hideous perinatal death rates, so hideous that the Midwives Alliance of North America has spent nearly 5 years trying to hide their own death rates? Hardly.

Any woman contemplating homebirth needs to understand that when homebirth midwives say “trust birth,” what they really mean is “trust me; I can predict unpredictable complications in advance, and assure you before the fact that nothing will go wrong.” What they really mean is “don’t show respect to birth; show respect to me and my awesome ability to see the future.”

There’s an old saying, “pride goeth before the fall.” The extraordinarily high rate of preventable death at homebirth reflects the outsize pride of homebirth midwives.

Unfortunately, it is babies and mothers who take the fall.

  • batmom

    As I’ve said before, I’d trust birth, but it’s an asshole. Or, to quote McSweeney’s, if a C-section becomes necessary, please use Western medicine.

    OT: so, it’s common advice everywhere that when the cream has separated from the liquid in the breastmilk, one must gently swirl it instead of shaking it. This is to preserve… something?

    Q1: On the assumption that one is not putting it in a centrifuge, I can’t see how the method of mixing it makes a damned bit of difference. Am I wrong in this?

    Q2: Where the hell did this misinformation come from? It’s quoted everywhere. But where did it originate?

    • Lynnie

      I have never heard you aren’t supposed to shake separated breastmilk. I always shook my son’s when he was getting mama juice in a bottle. Maybe THAT’s why he has a stubborn streak now at 3 years old. Or being super stubborn is a normal 3 year old trait.

      • http://kumquatwriter.wordpress.com/ Kumquatwriter

        Normal or not, same stubborn shaking boat here. Oy.

    • Jocelyn

      I’ve never heard that before. Seems false to me. It’s not like shaking it with just the strength of your arm is going to denature the proteins or anything.

    • Jennifer2

      At one point I knew what it was supposed to do – prevent proteins from breaking down or something. But I think it is really to prevent damage to the sparkles from shaking around too vigorously and damaging the unicorn hair.

      • Jocelyn

        Speaking of unicorns, today I found out that they’re the national animal of Scotland. Go Scotland!

      • Jennifer2

        A quick Google search turned up some women on a babycenter board who seem to think it breaks the little antibodies that protect your baby. Also this article, which I am guessing is where the whole “swirled, not shaken” started since it’s copyrighted 1998.

        http://www.bflrc.com/ljs/breastfeeding/shakenot.htm

        I will just leave that there without comment.

        • Amy M

          Well, I can tell you that in the lab, we don’t usually vortex (vigorously shake) the purified RNA or DNA for fear of shearing, but we do vortex the antibodies which are stored in a thick buffer to protect them in the freezer, and this doesn’t affect them at all. And if they are bound to something, shaking the tube won’t shake them loose.

      • Petanque

        That’s why breastfeeding mama’s shouldn’t go jogging either!

        • batmom

          Oh, hell, I ran 4.4 miles yesterday. Should I pump and dump? ;-)

          • Petanque

            Yes, you don’t want to cause any damage to the natural development of your baby! ;)

          • Young CC Prof

            That depends. Were you wearing shoes? If you were wearing shoes with rubber soles, then you were grounded, and couldn’t be earthed. But if you were barefoot, or wearing shoes made from natural materials, then it should be fine.

    • Dr Kitty

      So your baby doesn’t grow up to be the next James Bond?

      • The Bofa on the Sofa

        Isn’t he “shaken, not stirred”? Sounds like this is the anti-James Bond.

    • Trixie

      Yeah, they claim it will denature the proteins or break down the fat or something.

      It’s kind of like in homeopathy where water remembers what molecules it used to touch if you beat it over a horsehair blanket a certain number of times.

    • http://shameonbetterbirth.wordpress.com/ Shameon Betterbirth

      I’m pretty sure that its just so you don’t get a bunch of air in the milk and cause your baby to be extra gassy.

  • ol

    I agree with this post.
    I think about the phrase “trust me” or “trust smth”. I can trust or not trust but you can make me trust (saying ‘you should trust’) or I can’t make myself trust – it’s my inner feeling towards the person or event, feeling withot any bad things or suspicion. If someone say “you should trust” it means I do not trust already but you think it would be better if I act as I trust.
    and I think the feeling of trust towards the person that not equal you in some sphere and competence imply a child-parent relation (“I don’t know, I trust you, you know more, you are good, you take care of me”)

  • Dreah Louis

    Great post!!!!

  • Dreah Louis

    There needs to be more talk about the things that can go wrong. The midwives that I had were not qualified enough and its sad to find out after the death of a child. Makes you see homebirth in a new light

  • Stacy21629

    ‘There’s an old saying, “pride goeth before the fall.” ‘
    Actually, it’s in the Bible. Proverbs 16:18 – Pride goeth before destruction, and an haughty spirit before a fall.

  • Sue

    “You can’t attend thousands of births and fail to be impressed with the unpredictability of life threatening complications.”"

    I can relate to that – most clinicians get LESS cynical about complications with increasing exposure. Once you’ve seen it, you can’t deny it.

  • Lizz

    I haven’t really had an issue with my doctor being full of themselves I guess I get to choose my doctor(I realize that not everybody get’s that luxury). But has anybody else had a problem with the nurses being a bit full of themselves?

    I won’t go back to my local hospital because the nurses kept being assholes. They’ll refuse to give pain medicine they don’t deem necessary or will put it in your IV and not flush the line. They kick you out of bed or decide that you’ve been on the monitor long enough and need to move. They roll their eyes when you say that your not VBACing and then try to shame you into it even as they are supposed to be prepping you for surgery. They flipping went over my doctor’s head because of 1/2cm since I was preterm.
    But maybe I just got the nurses from hell with both children.

    • Bombshellrisa

      I am a nurse and felt like the NCB nurses from hell found me during my stay. I am hoping for the best with my baby due in February, but judging from the clientele the hospital wants to attract, I see I am going to be up against some really woo filled nurses (the OB has already announced that nobody gets awards for giving birth without pain relief or breastfeeding, and she should know, she did both).

      • Mishimoo

        Hope you get the nice ones this time around.

        • Bombshellrisa

          Hope so-different hospital, different doctor!

          • anion

            If it helps, I had a hellish experience (maternity, not L&D) nurses at the hospital where my first was born. With my second I went to a different hospital in the same system (kept my OB, though, since I adored him) and it was *completely* different. The nurses were amazing: kind, gentle, friendly, eager to help in any way they could.

            I didn’t want to leave, I loved them so much.

            So it definitely can happen, and I hope it does for you!

          • Bombshellrisa

            Thank you!
            My last was 7 years ago, and I was terrified. I was also a closet woo believer and the L&D nurse fed into some of my idiocy, which didn’t help when no amount of breathing or support relieved my pain or stopped me from being triggered. I have a doctor who talks about birth plans at the 36 week appointment. Mine will be a couple sentences with “epidural” underlined

      • amazonmom

        I felt the same way as you and I got the real A team this time around. I really felt well taken care of with no woo. They asked early in the stay what bothered me about the first birth and NONE of that crap happened again!

    • Mishimoo

      I’ve had a few problems with nurses over the years. The ones during my miscarriage were terrible, a triage nurse made us wait for hours due to disapproval over following the doctor’s orders, and a child health nurse was angry that our daughters are thin due to genetics even though they eat all the time. (Our doctor rolled his eyes and pointed out that they’re perfectly healthy)

      Luckily, those nurses are in the minority. Most of the ones I have interacted with are incredibly sweet, wonderful people,

      • Sullivan ThePoop

        An L&D nurse told my SIL her C-section was unnecessary.

        • Anj Fabian

          Wow. That nurse needs to start med school, stat! Her brilliance is wasted in nursing.

    • Lynnie

      OMFG, the nurses at my son’s birth were horrible. Well, there were a few that were ok, but the nurses. Ugh. They practically ruined breastfeeding for me. I was having a harder time than usual trying to get my son to feed and they made me feel like I wasn’t trying hard enough. The doctors and midwives were the ones who realized I was having extra issues with breastfeeding and my son was having issues. The nurses were to busy chewing me out for little “mistakes” that I was making with my son. Ugh. They made the birth of my son a very stressful time for me and made me dread breastfeeding. (The hospital lactation consultant was at a conference or something out of town.)

    • FormerPhysicist

      I got a mix. With my third, I was scheduled for repeat c/s on a Thursday. Monday night, after getting my bloodwork back from the lab, my OB called me at 11:30 pm, told me to go check in at maternity and she was doing a c/s in the first available slot Tuesday morning.

      One nurse was very disapproving, took me off the monitor when my back was hurting, said it was from lying on the uncomfortable bed. At about 4 am, I finally realized – that’s not a muscle ache, that’s back labor. I paged a nurse, got a different nurse (a little young) and she paged the charge nurse and suddenly my room was full of awesome nurses, they determined I was at 5 cm dilation and called my OB immediately. The c/s was at 6 or 7 am. I’m honestly not sure.

      I didn’t have to complain about the first nurse – my OB did. She got reprimanded for taking me off the monitor. And deserved it, frankly. I was in there for signs of pre-E and, yep, that’s what happened.

    • Young CC Prof

      I’m about half-convinced that in the recovery room after my hernia repair, I was given saline and told it was hydromorphone.

      I came out of the anesthesia in massive pain. Like, before I could speak or move or knew where I was, I knew it HURT. First thing I managed to say was to ask for pain relief. Got an injection, but it did NOTHING. Two hours later, finally got an injection that worked.

      Of course, by then the pain was so massively out of control that it wore off in an hour and a half, and the nurse told me I could only have one dose every 4 hours. Which turned into five and a half, because the nurses were busy… Yeah, that went on all evening and night.

      I’m still a bit pissed at them, although the pissed is mostly cancelled out by the fact that the surgery was performed flawlessly and I had a great outcome. (I did not, however, choose to deliver my baby there. I don’t need L&D nurses with that kind of attitude towards pain relief.)

    • Maria

      I have had really good luck with doctors. Even the ones who weren’t very warm and fuzzy were very competent, answered my questions and let me ask as many as I had. My L&D nurses were amazing. The Maternity nurses were less so, but they were also busier and didn’t have the time to focus on just one patient. I think my worst experience was with the NP I saw after my first miscarriage. She was trying so hard to sympathize with me that she didn’t see that she was just upsetting me more. I guess I am not a good candidate for a MW as I tend to chafe at too much warm and fuzzy.

  • guesty

    “Obstetricians are inherently humble” HAHAHAHAHAHAhahahahahahaha!!!

    • Carolina

      Yeah, this isn’t a great point. Doctor’s generally aren’t known for their humility.

      • http://kumquatwriter.wordpress.com/ Kumquatwriter

        Even I winced. Most of my family works in the medical field in one way or another, and all attest to the massive MD egoes. Sure, there are plenty of humble doctors, but it isn’t a word that I think of when I think physician.

        I think, though, that Dr. Amy was using the term not as a personality descriptor, but as a reference to OBs (and Drs in general) being aware of how little they can control nature. Similar to me saying “Birth is awesome,” meaning that I was awestruck, not that it was also totally bodacious and most excellent.

        • me

          Agreed.

          I took it in the sense that the better educated you are (truly educated, not Google-educated) the more you realize you don’t know, and can’t control for. Not that they are humble in the sense of having a modest/low estimate of themselves, or being meek/not proud. Just understanding that there is *always* more to learn and even very well educated and experienced doctors are, at times, totally powerless to stop the inevitable (not that they can’t act quickly and adeptly to intercede and save lives, just that even they cannot prevent *all* complications/problems, IYKWIM).

        • Squillo

          Pilots, politicians, and attorneys are often also accused of having enormous egos. I almost think you have to have a pretty good-sized ego to do something that is inherently audacious day-in, day-out, like assuming responsibility for the lives of strangers.

          Which is not to say that a big ego can’t also be problematic, if it leads to overconfidence or treating others badly.

    • Amy Tuteur, MD

      I didn’t mean that they were always humble toward laypeople. I meant that they are humble in regards to childbirth.

  • http://www.mycupcakemafia.blogspot.com cupcakemafia

    I’ve met quite a few OBs that weren’t humble and acted like they were gods. You can’t make a generalized statement that they’re all humble just like you can’t say that all homebirth midwives are prideful.

  • Ennis Demeter

    The mark of a true professional in many professions is humility. A good lawyer, for example, never promises a certain outcome and admits ignorance when asked about something about the law she isn’t expert on.

    • Carolina

      Well, yes. But most lawyers are pretty arrogant about their skills. I admit my limitations, but I’m far from modest.

  • Guest

    Great article. I can only comment on UK homebirth, but I know that it is easy to convince yourself that homebirth is safe, because most of the time things go ok and there are wonderful birth stories out there. However, ‘most of the time’ isn’t enough. You only have to read the stories of the women who lost their babies due to homebirth to understand that you don’t want that to be you. You are never close enough to the hospital unless you are actually there.

    • The Bofa on the Sofa

      I gotta say, when it comes to my baby, things going ok “most of the time” isn’t NEAR enough. I don’t understand how people can be so cavalier about their babies. I was fretting over every little thing, scared to death that something would go wrong.

      I would lie in bed in a cold sweat while my wife went to the bathroom during the middle of the night, fearing that she would come back and tell me something was wrong.

      Trust birth? I didn’t trust anything!

      • BeatlesFan

        My husband was the same; he was about 1000x more paranoid during my pregnancies and labors than I was. With our son, I chalked it up to the fact it was our first child, and he was new to the whole thing. Then we had an early miscarriage 3 weeks before conceiving our daughter, so his fears during that pregnancy/labor were actually worse. Every time I’d gasp from a hard baby kick, or I’d groan while trying to roll over in bed, I thought the poor guy was going to have a heart attack,

        • The Bofa on the Sofa

          No, it didn’t get any better the second time around for me, either, and we didn’t have near the experience you did.

          My wife did have some bleeding early on with our first, and I say, when you see the imaging prescription with the box “Abortion – threatened” checked on it, it can hit you pretty hard. I never wanted to see that again.

      • http://shameonbetterbirth.wordpress.com/ Shameon Betterbirth

        I know for me a lot of complex psychological factors combined with the fact that it was my very first baby made me choose midwives, despite knowing there was some increase in risk. I thought the absolute risk was small enough to justify my choice. ugh.

  • Courtney84

    This is OT, but I’m no doctor and something has been on my mind. It seems like we often read in home birth and birth center stories about babies who presented breech when that hadn’t been expected. Often there is a claim that the baby turned at the “last minute” which seems highly unlikely. I had assumed in the past the only way to know baby’s position was with U/S. However, I asked my OB several weeks ago about baby’s position. She said since we always find heart tones on Doppler well below my belly button it was very unlikely he was breech, and she’d have a better answer in a couple weeks. Last week I had my first internal exam and she told me he was definitely head down since his he could feel his head with her finger, pointing out the head is firm and a bottom is soft (…duh?). So are these things true head down babies have heart tones detected well below the belly button, and you can feel there boney head with a finger with a routine cervix check, or is my doctor some sort of goofball? If that is all it takes to know head up from head down why do midwives get it wrong?

    • Mer

      My provider has been doing external exams where she feels for baby’s head externally on my abdomen, it involves pressing with both hands on my uterus and got mildly uncomfortable the bigger we got. I believe it’s called Leopold maneuver, someone please correct me if I’m mistaken. Anyways from what I’ve seen they locate baby’s bottom, back and head and with those landmarks you can tell pretty accurately the fetus’ orientation.

    • Trixie

      It does happen occasionally that they flip during labor.

      • Siri Dennis

        Very rarely though. I’ve never seen it. It’s more likely that someone’s got the presentation wrong…

        • sarahh.rosanne@gmail.com

          My first baby allegedly flipped from breech the day before I went into active labor (I was approx 38w3d), but I think the CNM mistook the presentation because I did not feel that type of dramatic movement and I hadn’t had an ultrasound in several months. My second baby was in a transverse lie until about 35 weeks and I definitely felt the pressure of him turning head downward. The sensation was intense enough that I wouldn’t have mistaken it for any of his normal normal movements.

          • sarahh.rosanne@gmail.com

            This is an OT question as well- does anyone know if it is unusual for a baby’s head to be engaged in the transverse position (only the head, not the entire baby, to clarify) and for nobody to notice this over the course of labor until pushing? This has happened to me twice (both labors in hospital with CNM care) and I have been curious how, after 28 and 31 hour labors, it was only in the last 10 minutes that anyone made that observation. I now know that I have a classic platypelloid pelvis- after two emergency rotational mid forceps deliveries.

          • Wren

            Oh, when mine flipped I sure felt it. I packed up and swore I was going into labour, then nothing for another few days. No way can you miss a baby that late turning.

          • Amy M

            Yeah, one of my twins turned about two days before they were born (he was semi-transverse facing my right, and managed to get around pretty much head down with his head on the left side.) I sure felt it. That was 35wk and change

          • Trixie

            Mine turned between 36-37 weeks and I never felt it happen. I could have been asleep, I guess.

        • Trixie

          I’m not denying it’s rare. A friend had her baby’s position confirmed by ultrasound when she got to the hospital in labor (I think they were checking for something else), and after several hours he flipped transverse.

      • Captain Obvious

        I have never had a baby flip in labor, in 21 years. Yet babies seem to flip every month with these Homebirth Internet posts. Maybe if polyhydramnios was present, I might see it happen. It just doesn’t happen often at all. Usually just a midwife not performing ultrasound, not performing pelvic exams, then ending up with a breech and they cover it up by saying the baby flipped.

        • Sullivan ThePoop

          My cousin’s baby changed positions after her water broke during labor, but didn’t completely turn around. Although it was enough that she required her first C-section after 3 vaginal births.

        • Josephine

          I requested an induction at 40 weeks (and my midwife agreed) because my unstable lie baby had finally settled head down for more than a week and I wanted him out vaginally if possible. He turned breech despite my strong contractions. They scheduled me for c-section when I said I was sick of this unstable lie drama and believed the section was the best option (it had gone on for 10 weeks and I was emotionally exhausted, to be honest, along with having the world’s longest and most stubborn cervix).

          He turned head down again in between the ultrasound 5 minutes before start of surgery and the time that they got to him in my uterus. I only say all this to say that all the nurses and doctors were surprised and kept saying how unusual it was. And this at the hospital with the largest/best NICU in the state, so they’ve seen just about everything. So yeah, I’m unconvinced that it happens all the time.

        • ersmom

          Once, in residency, I have seen it. Once. I’ve got 11+ years of experience. So between us, I’d guess it is very rare.

        • Jtmo

          Once, in residency, we were inducing a woman who sadly had a fetal demise at 34 weeks. She also had polyhydramnios. Baby was breech at the start of the induction by ultrasound (and she had 2 ultrasounds done in the course of confirming the demise) and yet baby came out head first. She had an extremely large amount of fluid, though, and our guess was that the heavier head flipped down during the torrent of fluid that came when her membranes ruptured.
          It is sometimes obvious and easy to tell presentation, and sometimes not so easy. Frank breech with the legs extended can make the butt feel like head from the outside, and since you feel feet in the upper uterus, you think it must be head down. If you do OB long enough, you accidentally labor a breech.
          But I agree, babies rarely turn in late pregnancy, and even rarer in labor. Thankfully!

    • Young CC Prof

      I am 100% sure my baby is breech because he kicks me below the navel, near the bikini line. ALL DAY LONG. (And I now get ultrasounds every week.)

      If you’re getting kicked in the ribs, that’s head-down. Yes, it usually is easy to identify baby position once they get big.

      • Courtney84

        I am confident the little boy is had down – a because my doctor said she felt up his head with her finger, and b I swear he puts both his feet in my diagram and tries with all his might to stretch out (at least that is how it feels). I was asking more because these two things my doctor did first to say likely head down, and then definitely head down seem simple enough. I mean I get midwives don’t have a lot of training… But it does seem like an internal exam should be quite telling of whether the head or bottom is down.

        • Bombshellrisa

          Well there you go-homebirth midwives always say that they don’t do cervical exams until labor starts and even then they try to avoid them!

        • Montserrat Blanco

          I learned to determine baby´s position during my medical training. It was very easy near term. In any case we always always always performed an ultrasound to double check. We would never trust only our hands with something that important.

          One week ago one of my patients complained of an unusual headache. I performed a complete neurological exam that was absolutely normal. I sent him to the ER to get a brain CT scan. It was normal. Only at that point I was confident there was not a subarachnoidal bleeding or another intracranial complication. Physical exam is the basis of the job, but if your life depends on it, get an imaging test to be sure.

          • Dr Kitty

            Yup.
            The mainstay of my job is going “I’m 99% sure you have X. But there is a 1% chance you have Y. If we leave Y untreated it can be dangerous….let’s run some tests for Y”.

            I am open to being proved wrong.
            I try to take steps to ensure that if I AM wrong my patient is as safe as possible.

            I don’t think I am infallible, and I try to remember my mistakes and try to learn from them so I don’t repeat them.

            Medicine is often the art of hedging your bets.

      • Trixie

        Actually, no. They can be frank breech with their legs folded straight up by the head and be kicking you in the ribs. I thought that too, until my CNM did an exam and thought she felt a butt. I said, “but I’m getting kicked in the ribs!” and we did an ultrasound, and there she was, breech. This was at 36ish weeks.

        Luckily, she flipped on her own by the next week.

        Actually, my head-down, but persistently posterior baby, kicked both above and below the navel. I know because you could see his feet.

      • Ainsley Nicholson

        That matches my experience with my recent singleton. I was getting all sorts of kicks to the bladder until he went head-down; then finally I got kicks in the ribs. I was so relieved! Those bladder-kicks hurt!

    • Siri Dennis

      A properly trained midwife will know how to ‘palpate’ (feel) your abdomen and work out your baby’s lie (ie straight up and down, sideways), presentation (head up or down), position (back to front, back to back). She will then know where to listen for baby’s heartbeat. A breech baby’s heartbeat will typically be higher up than a cephalic baby’s, and baby’s head is easily felt as a hard, round object up by mum’s ribs. Vaginally it’s easy to tell if it’s a head or a bottom.

      • Karen in SC

        There was a mother on MDC awhile back that was UP/UCing. So she was palpating her own uterus and convinced she was carrying twins. Totally convinced, even though she had an earlier u/s before she decided to go it on her own. I checked up on her and she did have a singleton and in her words, “a huge placenta.” Expert on her own body, NOT.

    • Wren

      My son turned quite late (head down to footling breech) and I think it was partially the expectation that a baby who was head down at 40 weeks would stay that way that led to the turn being overlooked until I was actually in labour. Also, I don’t know how true it is, but apparently being feet first rather than bum all the way in my pelvis made a difference.

    • Dr Kitty

      If you have a fluffy lady or polyhydramnios then it can be very, very hard to get presentation right. Or, in my case if you have a thin lady and a foetus with a bony little bum that does a good head impression. My OB though she was breech at 34 weeks, I thought not based on position of kicks. He’s had almost 40 years experience, but I was right (because we checked with USS).

      Sometimes it is very obvious as to lie and presentation, sometimes because of flukes of anatomy or position or fluid levels it isn’t. Which is why ultrasounds are an excellent idea.

      There are plenty of anecdotes of MWs and OBs who THOUGHT they had a face presentation and were feeling a mouth on vaginal exam, when it actually turned out to be breech and an anus. Human beings are not infallible.

      • me

        Not to mention many midwives (particularly lay midwives) don’t routinely check the cervix late in pregnancy. Seems like the margin for ‘oops, it’s a breech’ would be a lot higher when relying solely on where the heart tones are found and external palpation. Especially if your last u/s was the 20 week anatomy scan….

      • Mel

        OT: Cattle rarely cause that mistake since they are born with teeth. Ofc, a common outcome of turning a fetal calf is skin-abrasions from those teeth. Plus, if you are feeling the butt, your can generally feel the tail. Figuring out which legs you are seeing is a little trickier, but the hind legs have a groove on the leg.

        Also, a normal way of trying to deliver a large piglet that is facing head-first is to try and get the piglet to clamp on to your finger using their cute, sharp little teeth then levering them into the right position.

    • Therese

      Unexpected breeches do happen in hospitals too. I have a friend who they didn’t know her baby was breech until the saw a foot poking out and then they had to do a crash c section. But hey, at least they were in a hospital where a crash c section was a possibility.

    • Ainsley Nicholson

      My second son turned breech during labor- I think he flipped shortly after his twin was born, and he suddenly had all sorts of room. They were going to do an emergency C-section when his breech position was discovered…the docs were scrubbing when the nurse yelled out “I see feet!”. Doc decided to give him a chance, since I was on the operating room table anyway, and they were ready if things went south….one push and he was out.

  • http://Www.awaitingjuno.blogspot.com/ Mrs. W

    There’s a reason why obstetricians are far more likely to choose planned cesareans for themselves or their partners – they know birth is a total crap shoot.

    • Siri Dennis

      Although funnily enough, hardly any UK midwives opt for elective c/s (apart from breech or placenta praevia)! And they see ALL births, from the easiest to the absolute worst.

      • Dr Kitty

        BUT, this is the thing, in the UK it is rare to be JUST an OB, almost every OB does Gynaecology too.

        The midwives aren’t seeing the TVTs, pelvic floor repairs, hysterectomies or ring pessaries for prolapse or the sexual dysfunction after childbirth that the OBs are dealing with.

        Not all complications of vaginal childbirth occur in the immediate puerperium and the midwives walk away 28 days after delivery…

  • Lynnie

    Reminds me of the saying, “The more I know, the more I realize how much I do not know.” It is easy to pretend to be knowledgeable about something in theory, but it’s in practice that’s what matters and where the proverbial excrement hits the fan.

    I don’t know very much about childbirth, but I do know enough to know that I want to put my trust in trained medical professionals for the safest possible birth.

    • Sullivan ThePoop

      So true! I heard or read once that you can always tell someone is ignorant on a topic if they don’t even understand what they don’t know.

    • Bombshellrisa

      http://www.highlandmidwife.com/BabyCounter.html
      Lorri Carr has no idea what she doesn’t know. This is her “baby counter”-how much do you think you can learn from attending 43 births in a year?

      • amazonmom

        What is the nearest hospital with level 3 NICU and OB to Goldendale? None of the hospitals I am familiar with are anywhere near where Lori Carr practices. We are talking hour long transports or more AFTER the wait for help to arrive.

        • Bombshellrisa

          The hospital in Goldendale is seven bed, level four. Closest level 1 ER is Legacy Emmanual in Portland, which is where they transport anything serious. It’s like Sherry Dress CPM and her “hospital is ten minutes away” speech in La Grande Oregon. Yeah, I can fly down my super long dirt drive way there, down the two gravel roads it takes to get to the main road and be at the hospital faster than the ambulance can BUT anything more complicated than a broken bone and whoever is hurt is going to be transferred hours away to St Luke’s in Boise Idaho.

          • amazonmom

            Just what I thought. I’m kinda glad I live where I can spit and hit a few hospitals that can do just about everything.

          • Bombshellrisa

            Even the new Swedish at Issaquah can take 32 week babies and it’s not that big a hospital. Too bad it’s wooish but I guess it could be a lot worse.

      • Mel

        I LOVE her pre-conception consultations. My GP and OB/GYN’s preconception consultations were apparently terribly lacking. I mean, my medical doctors walked me through getting off an SSRI that should be avoided during pregnancy, expressed excitement/joy/happiness, asked if we felt we needed more information on how to conceive a baby, laughed with me as I said “Um… don’t use birth control and have sex regularly? It seems to work for cows and we’re mammals too.”
        They recommended a prenatal vitamin.

        They didn’t do a nutritional analysis – oh, wait, they did. That was the prenatal vitamin and discussed changes I’ve made over the last 6 months. But they didn’t do food allergy testing….oh, wait. They wouldn’t need to since I know what I’m allergic to.

        BUT they didn’t try to sell me nutritional/herbal supplements to boost my fertility. Drat.

    • Tracey

      I was horrified to find out that a homebirth midwife I had considered had only attended 50 births in the last 9 years. In my ignorance it was a question I never thought to ask. So glad I changed my mind!!

  • Mel

    I agree – the level of hubris surrounding midwifery is an excellent example of why pride was counted as a cardinal sin rather than a cardinal virtue.

    I can’t get my head around it. I’m not an OB, but I hear lots about being a cattle midwife.

    *Anyone who tells you that they can predict a healthy birth before the birth is over is lying through their teeth or criminally stupid. Certain characteristics may give you a higher probability of an uncomplicated birth, BUT probability means very little on a small sample size (ie, your baby’s birth)

    *Anyone who believes they can fix catastrophic problems outside of a hospital with no real medical training is either lying through their teeth or criminally stupid. If you don’t believe me, come to my farm. We have 500+ births a year and you can watch – in real time – deaths of calves during labor due to asphyxia and entrapment. It sucks, but it’s a whole lot less painful to see a dead calf than a dead baby. (Actually, my husband has more training than the average midwife, so we’ll keep count of calves that would have died if no trained attendant was there.

    *Treating labor complications requires training and caution to minimize damage to the mother. Mal-presentations are a bit easier to fix in cattle than in humans, but only if you know what you are doing. Fetal hooves can rip holes in the uterus. Pull too hard on a calf in the wrong position and the calf breaks legs and the mom’s pelvis breaks. Both generally end with euthanasia.

    • Karen in SC

      BUT probability means very little on a small sample size (ie, your baby’s birth)

      Excellent point – when it’s you vs. a serious life-threatening complication, the probability is either 0% or 100%.

  • Bobbi

    I am currently planning for the home birth of my second child in Canada. My daughter was born with a midwife attending in a hospital setting. After giving birth in the hospital once, I will not go back.
    I requested an epidural and ended up with 2 epidurals that didn’t work. The anesthesiologist was unable to inject the medication. She offered a spinal that would numb me from the waist down, but unfortunately was unable to find the correct spot in my spine to insert the needle. I screamed in pain at my husband to make her stop as she wiggled the needle back and forth, sending searing nerve pain shooting down my leg.
    After all of this, I pushed for quite some time, but was too tired to push my daughter out. My midwife suggested we ask the OBGYN on call to use the vacuum, as then it would only take one more push. He told me I needed a C-Section, hooked up the pitocin drip (which I didn’t need as my contractions were still coming fast and hard) and left for an hour, leaving me terrified he was transferring me to surgery and still vainly trying to push my daughter out for an hour before he came back. When he did come back, the resident, not him, used the vacuum and my daughter was out in 1/2 a push.
    I was frustrated and upset with his short and rude manner and the fact that he pumped me full of induction drugs I didn’t need at that point in my labor. It was a very traumatic experience, one that I hope to never go through again. I found that the doctors that I dealt with didn’t listen to me, even when I was screaming for them to stop doing what they were doing. In fact, they talked over me as if I wasn’t even there.
    Our midwives in my province work very closely with an OBGYN, are sanctioned and paid by the health region and only take on cases of women who have no serious medical issues that could risk the baby or mother. If so, they will insist on a hospital birth or even recommend that you use an OBGYN.
    I’m very much looking forward to a home birth. It is the right choice for my family. It’s not for everyone, but it is for me.

    • Anj Fabian

      Did you file a complaint with the hospital? Those are your tax dollars they are spending!

      • Bobbi

        Didn’t really get a chance to. We just got out of there as soon as we could. That’s why I was a little upset with this post of Dr. Tetuer. In my experience here in my city, it’s the anesthesiologists and the OBGYNs that have the hubris. They’re the ones who say at prenatal classes held at the hospital that, “Women you will love me more than your husband when I take all your pain away with an epidural.” THAT’S arrogance, especially when mine didn’t work and I wasn’t told any of the side effects or complications that could happen.

        • Sullivan ThePoop

          Didn’t get a chance to? Did you just leave the hospital a second ago?

          • Bobbi

            This was 3 years ago with the birth of my daughter. We really just wanted to get out of there as fast as possible. Thankfully our midwives provide at home, post-natal care, so we were able to go home 4 hours after the birth and she checked on us there. I probably should’ve complained, but we were just happy to have our daughter and be home, so…

          • DaisyGrrl

            So you decided to leave future women to their own fates as far as their births. Nice.
            What province do you live in that the anesthesiologist doesn’t explain the risks of an epidural? I’m in Ontario and they’re required to provide informed consent here.

          • http://Www.awaitingjuno.blogspot.com/ Mrs. W

            Cut Bobbi some slack – she had a traumatic experience. I didn’t complain formally for more than a year after the birth of my daughter.

          • Sullivan ThePoop

            If she really had such a traumatic experience then I do feel for her. It is just that so much of her story is almost verbatim what NCB says about hospital birth. I know that doesn’t mean it isn’t true.

          • Bobbi

            Sorry, what does NCB stand for?

          • CherryDarling

            Natural Child Birth(ers)

          • DaisyGrrl

            I cut her slack up thread. I would have cut her more slack here if she had done something other than shrug her shoulders and say “oh well”. I don’t see a problem with filing a formal complaint months or years later, but when her response to several people encouraging her to file a complaint is “it’s too late, what’s done is done. Boo hospitals!” then I have every right to take issue with it. She has every right to ignore me. You are doing something positive to ensure that women have a better experience than the one you had and I commend you for it.
            Bobbi, if you’re reading, please consider filing a complaint. Even if it’s just a letter to the hospital explaining why you won’t give birth there again, they can’t change if they don’t know what happened.

          • Bobbi

            Actually, I wasn’t even aware of being able to file complaints about our hospitals. I’m not a naive person, but I really thought that we didn’t really have that option. We did complain about a nurse who was incredibly annoying (she finally toned it down, nice, just waaaay to energetic for us), but I just chalked it up to an anesthesiologist who was maybe new or had trouble with me. I was more upset that she didn’t tell me about the horrible headaches I would have for a week after (a friend who’s a paramedic told me why I was having those) and that she didn’t listen when I screamed for her to stop. When the 2nd epidural didn’t work, she offered to try again (4th needle in my spine). I replied, “No you can’t. Get all the needles out of me and don’t touch me again.” She finally left after that. Even if we were going back to the hospital, there’s no way I would get another epidural. I just suffered way too much from it. I’m not specifically against them, but they’re not at all for me.

          • DaisyGrrl

            Sorry you had the headaches! My mom had those after both me and my sister. With her, the headache persisted for a month and I understand it was terrible. Epidurals can be awesome, but as you unfortunately learned, they’re not for everyone.
            As for complaining, here’s the Saskatchewan gov’t website explaining how to raise concerns:
            http://www.health.gov.sk.ca/patient-service-received

            You’ll notice there’s a link to the self regulating professions:
            http://www.health.gov.sk.ca/professional-associations
            Doctors are on the list, as are midwives. If you have problems with any health care provider, please consider filing a complaint. I’d also suggest having a plan in place for what you’d want to do in the event you need to transfer to hospital during your home birth. If you need a c-section, is the epidural off the table for you and are you okay with the alternatives? What about other types of pain relief? You probably won’t need to enact the plan, but if anything happens, you’ll at least know ahead of time what the plan will be and your midwife will be in a better position to advocate for you.

          • KarenJJ

            My Mum took a few years before she made her complaint against her obgyn. Some perspective, time and coming to terms with it needed to happen first.

        • Young CC Prof

          You probably still can file a complaint. It doesn’t necessarily have to be done the minute something happens.

          I don’t know the appropriate channels in Canada, but it’s worth looking into when you have a moment. If no one complains, how can things get better?

        • DaisyGrrl

          You should request a review with midwife to better understand what happened. If, after discussion with your midwife, you feel your treatment was outside the boundaries of medical ethics, then please please please file a complaint with the appropriate medical board as well as the hospital where you gave birth.
          Women who give birth in hospital deserve respectful care. Problems can’t be fixed if no one comes forward when this goal is not met.

        • Wren

          You really were not given any of the potential complications or side effects? That is a normal part of obtaining informed consent.

        • Karen in SC

          Bobbi, sorry you had a bad experience. You might be interested in a few posts by an anesthesiologist “The Adequate Mother.”

          http://theadequatemother.wordpress.com/2013/05/14/the-connection-between-poor-labour-analgesia-and-ptsd/

          http://theadequatemother.wordpress.com/2013/02/04/2-cm-810/

          If you use the tags, you may be able to find more info. Even if you are planning a homebirth, there is always that small chance that you will be facing the need to transfer and receive an epidural so it would be good to learn more and try to find out what could be done better.

        • theadequatemother

          you had a bad experience and that’s terrible and I wish it hadn’t happened. but midwifery and homebirth in Canada is very different than in the US. Canadian midwives have more training and oversight, they are inte=grated into the hospital system. Dr. Amy mainly blogs about the untrained fools in the US that attend homebirth. Although what she says about catastrophic compl;ications at home is still true in Canada – I doubt that our midwives would treat pph with placenta tho!

          • Bobbi

            Yeah…my first midwife certainly didn’t recommend placenta as a cure-all for everything!

        • Bethany Barry

          “Women you will love me more than your husband when I take all your pain away with an epidural” isn’t just arrogance, it’s inappropriate, sexist, and inaccurate (as 100% pain relief for the duration of labor with an epidural is pretty rare, I believe). There are certainly inappropriate, sexist, dishonest OBs out there, particularly in markets without much competition. That won’t change unless you complain, even months or years later. Because here’s the thing–misconduct on the part of a licensed medical professional has consequences. Misconduct on the part of a CPM here in the states so often does not.

          I support your choice to attempt a home birth with a fully licensed midwife (Oh Canada!) provided you fully grasp the risks. What if you become too tired to push again?

          I worry you might be jumping from the frying pan into the fire…

          • Bobbi

            I’m not really worried about playing out so fast this time. I plan to be more active during labor this time, knowing what I know now. Being attached to 2 separate monitors, an IV pole and having 3 needles in my back made it pretty hard to do the things I wanted to, like sit on the ball or go in the tub, even though we have the “walking epidural” here in Saskatchewan. I have friends who had great epidurals, I was just unlucky I guess. Plus I was told that the midwives are now trained on using the forceps at home, as well as bringing an oxygen tank in case baby needs it. After attending at a friend’s home birth, I’m really excited to experience it myself. It really was a beautiful part of life, which is what I believe it is, rather than a medical procedure, which is what it felt like in hospital.

          • mtbakergirl

            I am sorry to hear that you had such a distressing time with your last birth, have you sat down to talk to a trained counsellor about what happened? Talking to someone could be very helpful regardless of the setting you choose, as having a home birth is not a guarantee that everything will go smoothly with this birth.
            In the interests of accuracy, I would like point out that to the best of my knowledge, using forceps is not permitted for any midwife, particularly not in a home birth situation. Hopefully, things go well and this information is never needed, but it is vitally important to have a clear picture of what emergency or semi-emergency procedures are available in the home birth setting. More information on what midwives are permitted to do is here: http://www.qp.gov.sk.ca/documents/English/Regulations/Regulations/M14-1R1.pdf.

          • Poogles

            “Plus I was told that the midwives are now trained on using the forceps at home,”

            OMG, I sincerely hope that’s not true. I can’t see how using forceps is safe at home, especially in the hands of a midwife. Are midwives in Canada usually trained and have adequate experience in forceps??

    • Lizz

      I’m not really familiar with the Canadian system but can you go to a different hospital?
      I mean personally I would rather chew my leg off then go back to the hospital closest to me so I found a way to go to a hospital slightly farther away.

  • Mom2Many

    Dr. Amy, another great piece. Just FYI, there is a typo in the first sentence of the paragraph that reads, “Obstetricians are humble enough to recognize that THEIR normal” etc.
    By the way, for me, that sentence is the best sentence of this whole article. Hind sight is 20/20 as they say, and fortunately, most times things do go well. But it is those times when they don’t that can be catastrophic….and nobody can predict whether or not this time it is all going to go south.

  • Amy M

    “Wait
    a minute – I don’t have the skills to prevent a complication from
    resulting in a death? Then what the hell are my clients paying me for,
    anyway? I beg to differ, since I have done so many times
    already…because the worst complications can’t wait for 911. Are you
    saying that a midwife cannot correct a nutritional deficiency that could
    result in a critical complication if ignored? Can’t manage a shoulder
    dystocia? I cannot agree, we do both of those (for example) better than
    the MDs. If I did not have those skills, I would just be a doula.”–Lorri Carr

    The above quote is from another thread on the Elder Midwives FB page. I think it illustrates Dr. Amy’s point nicely.

    • Karen in SC

      That is exactly what I say! That she can’t really prevent complications nor handle the serious ones. I’d ask for statistics but who could believe a self report?

      • Bombshellrisa

        Lorri Carr attends births in a rural area of WA state. The closest hospital that could handle a serious emergency is not a couple of minutes away and it might take some doing for the ambulance to get to you. She also believes that if the mother is following her plan of care down to taking the herbs she suggests that complications simply won’t happen.

        • Amy M

          Check out the rest of that thread if you can find it. One of the more sane women there made a comment about many DEMs weren’t trained enough, sparking the above comment by Lorri Carr, and similar by several other of the “Elder Midwives” who couldn’t understand why anyone would think they weren’t trained enough.

          • Bombshellrisa

            I am Lorri Carr, a Washington Licensed Midwife, Certified Professional Midwife, and Oregon Licensed Direct-Entry Midwife with experience that includes hospital births and clinical OB/GYN care. I am the only Licensed Midwife in Klickitat county, Washington, the only obstetrical care available in Goldendale, and as of 2013 I am the only licensed maternity care provider delivering babies in all of Klickitat county. In addition to complete prenatal care, home birth, and postpartum follow-up, I offer gentle and thorough gynecological care, nutritional analysis, and herbal remedies for my clients. I serve mothers from the Yakima Valley to the Columbia River Gorge into Oregon, with office appointments in The Dalles and Yakima.” This makes her sound SOOO impressive. Whatever you have to tell yourself, but I promise there are other, more qualified people to deliver a baby in Klickitat county.

          • Bombshellrisa
  • Amy M

    You’d think they’d always win the lottery, if they were that good at predicting the future.

  • http://shameonbetterbirth.wordpress.com/ Shameon Betterbirth

    Hey dr amy did you see this?

    http://www.betterbirth.com/negative-review

    The Arrogance, seriously……….

    • auntbea

      “we have discovered too late that a client is mentally ill, and her
      illness did not allow her to accurately perceive the events of labor.”

      This is so gross. It is certainly true that they have patients who are mentally ill, but so do all businesses, because people who are mentally ill are a non-negligible part of the business-needing population. But most businesses do not go around pointing this out, as it is both unnecessary and potentially insulting to their clientele. Unless you are a psychiatrist, the number of reviews written by mentally ill people for your business is no higher than those written by mentally ill people for any business, so that is just not going to be an explanation for why your reviews are so much worse than theirs.

      • Anj Fabian

        I went and read that
        “we have discovered too late..”

        Leaving aside the issue of a lay person making such a diagnosis, exactly how much interaction do they have with someone that only AFTER the event do they decide their patient was mentally ill?

        If they did recognize their patient had mental health issues that needed to be treated, why didn’t they refer their patient to a qualified professional?

        • moto_librarian

          You know, posting something like that online is certainly grounds for libel…

          • Sullivan ThePoop

            I agree! There has got to be someone we could report that to. I mean an organization for the rights of people with mental illness or something. I am usually not for reporting people, but that is really bad.

          • auntbea

            I believe she is already suing for this, among many other things. Is that right, Shameon?

        • Bombshellrisa

          My OB has asked from the start about any anxiety or depression and once I answered yes, it’s as normal to be asked about it as it is that they check my BP during an appointment. Since these homebirth midwives claim to be so much more caring and concerned about their patients, you would think that all the talking they do during those hour long prenatal appointments might give them a clue if their patient is struggling with mental health issues.

        • auntbea

          Were they unhappy with your services? Must have been a closet case.

        • anion

          That was exactly what I thought. Isn’t it their job to know those things? And isn’t it supposedly one of the big benefits of going with a midwife instead of one of those evil OBs, that they will listen and treat you according to your individual needs, and be mindful of your personal traumas or issues? That they’ll get to know you as a person and treat you that way?

      • amazonmom

        Hmm, got a mental illness but my bullshit detector works just fine. What a bitch.

      • DaisyGrrl

        Two things I don’t like about that sentence:
        1) you know what else interferes with your ability to accurately perceive the events of labour? PAIN! So I would expect that many women who have an unmedicated labour may have perceived their experience differently than others present (and there’s nothing wrong with that).
        2) This smacks of discrimination against the mentally ill. Aside from not being qualified to diagnose mental illnesses, it appears to me that they are implying they wouldn’t take on mentally ill patients if they are aware of their condition. Besides, if they take a proper medical history, they should be aware of the condition and ensure any special care measures are provided accordingly. So either they didn’t know about a mental illness because they didn’t do their job (or the patient lied – not saying that’s the case here) or they “diagnosed” a mental illness because they don’t like what the patient is saying. Either possibility is disgusting.

      • Young CC Prof

        Indeed. If I’m looking up reviews of a business, and I see 99 reviews that are positive or mostly positive, and one glaringly negative review that involves a really weird implausible story, I can figure out for myself that the problem might be the 100th reviewer, not the business. (If there are 10 completely different totally negative reviews with similar themes, then I get suspicious.)

        A business should NOT generally respond to negative reviews unless it involves fixing specific problems. “We are sorry your order was delayed, we’re rushing it to you as soon as possible.”

    • Sullivan ThePoop

      What?!?! Sometimes a patient is mentally ill?? Are they serious?

      • Amy Tuteur, MD

        Maybe they’re just warning prospective clients that if you complain about their service they will publicly label you as mentally ill. Good to know!

        • slandy09

          Oh, and if you’re mentally ill, they’ll recommend a supplement that you have to pay at least $50 for because it supposedly cures everything from ADHD to schizophrenia! I know this because one of my friends is going to them and she has serious depression and anxiety issues, and this is what they recommended.

    • slandy09

      My SIL used them for two of her children and I have a friend using them now who thinks her birth is going to be just awesome because she’s going to the birthing center. She has serious anxiety and depression problems and they keep recommending this supplement that costs upwards of $50!!!! I told her that my antidepressant costs me $10 for a three-month supply–so much for Big Pharma. I worry for her.

    • Lizz

      “We never do anything illegal,immoral, or unprofessional. Ever.” I don’t even know people who can say that about their driving let alone their job. Claiming to be morally infallible is generally not a good idea for human beings and honestly the whole thing was unprofessional to write.

    • AlisonCummins

      “Our goal is to give every client the very best birth possible.”
      I thought the mother gave birth, not the midwife.

    • Dr Kitty

      That page is not an appropriate, professional response by a HCP.

      “Some of our clients have been unhappy about the care they have received. We are sorry that their experiences have not been as positive as we had hoped and we are taking steps to learn from this and ensure a better experience for our clients in the future”. THAT is the kind of response I would expect.

      You don’t disrespect former clients or reveal personal information about them. You don’t suggest that any problems are all in their heads. You don’t get into specifics about individual cases.

      That page is a HUGE flashing red light, and for that reason alone I hope they don’t replace it with something more appropriate. Anyone who can read that and STILL decide to trust them…wow.

    • Mel

      Did you read their packages? You can save $700 if you are willing to be a guinea pig for training new midwives! You also should plan to shell out $900 dollars for other luxuries like antibiotic eye drops and Vitamin K shots for your newborn. I don’t know why they included kitchenettes in each room at Bella Natal – even the Midwife package kicks you out 8 hours postpartum

      • Bombshellrisa

        You have got to be kidding me-what home birth midwife doesn’t have students around anyway? The midwives I learned with didn’t give a discount for having me there.