Breathing in excrement is just a variation of normal!


Sometimes I really fear for the future of midwifery.

It has gone from being a noble profession, saving countless lives and always struggling to save more, to a bunch of clowns drumming up business and always struggling to drum up more.

The amount of stupidity and wishful thinking spewed by these fools is epic. Case in point: a post from the hilariously misnamed blog Midwife Thinking entitled The Curse of Meconium Stained Liquor.

Now you or I might think that the curse is that when excrement is inhaled into a baby’s lungs, it can result in severe respiratory illness and death. But for this midwifery clown, the “curse” is the potential loss of business. But never fear; the all purpose tool wielded by people who profit from homebirth is always available: it’s just a variation of normal!

Letting me repeat that: rather than lose business, Rachel Reed, Midwife (Not) Thinking, simply announces that breathing in excrement is just another variation of normal.

The motivation of the midwife is apparent from the very first paragraph:

Dear unborn baby,

Please consider holding your poo in until after you are born. The big people on the outside get very stressed about your poo and will want to change the way you are birthed if they find any evidence that you have failed to keep it in. Your mother will be told that you are in danger, and will be strapped to a CTG monitor. This will: reduce her ability to help you through her pelvis by moving; prevent her from using water to relax; and increase your chance of being born by c-section. Your mother will also have her time limits for labour tightened up. This may lead to labour being induced or augmented which will put both of you at risk of further interventions. You will be expected to get through your mother’s vagina quickly and if you take too long you will be pulled out with medical instruments…

Imagine that, those evil obstetricians will compromise the birth process for no better reason than to maximize the birth outcome: a healthy, live baby.

But Rachel Reed knows better. She has her priorities in order: it’s more important to have an intervention free labor than for a baby to be able to breathe or even survive.

Rachel is all over this:

MAS is the major concern when meconium is floating about in the amniotic fluid. It is an extremely rare complication – around 2-5% of the 15-20% of babies with meconium stained liquor will develop MAS (Unsworth & Vause 2010). Of the 2-5% of the 15-20%, 3-5% of babies will die. OK enough %s of %s – basically it is very rare but can be fatal.

Apparently both math and logical thinking are hard for Rachel, so let me make it easy for her. One in 5 babies will have meconium in the amniotic fluid. Of those 1 in 20 will become seriously ill (respiratory distress, mechanical ventilation, prolonged NICU stay, risk of death). Of those, nearly 1 in 20 will die. In other words, 1% of babies will have end up with a life threatening illness. That’s not rare. And that illness will kill 5% of those ill babies. That’s not rare, either.

Or, put another way, once a mother learns there is meconium in her baby’s amniotic fluid, there is a 1 in 20 chance of serious complications. And if her baby does experience severe complications, there’s a very real chance that he or she will die. In the US, that means that there are 25,000-35,000 cases of meconium aspiration syndrome (MAS) per year, and approximately 1500 deaths.

I would have thought that anyone with more than two functioning brain cells would recognize that excrement in the lungs is a bad thing, but not Rachel Reed. As far as she’s concerned, it’s not a big deal because:

Meconium is a mixture of mostly water (70-80%) and a number of other interesting ingredients (amniotic fluid, intestinal epithelial cells, lanugo, etc.).

You know what else is 70% water? Battery acid, and I suspect that even Rachel Reed would recognize that battery acid is very harmful.

It’s the other stuff in meconium (intestinal cells, hair, etc.) that makes it dangerous when it ends up in the lungs. What does it do?

This lecture for medical students explains how meconium damages a baby’s lungs:

Decreased alveolar ventilation related to lung injury, ventilation-perfusion mismatch and air-trapping.
• Pneumothorax or pneumomediastinum in 15-30% of cases
• Persistent pulmonary hypertension (PPHN) in severe MAS(increased pulmonary vascular resistance with right-to-left shunting)
• Fetal acidemia
• Chemical pneumonitis
• Surfactant inactivation caused by meconium’s disruption of surface tension

So meconium makes it much for difficult for a baby to expand his lungs, to absorb oxygen and can even lead to a hole in the lung causing it to collapse.

But meconium is not merely an irritant, it is a symptom of another serious problem, lack of oxygen getting to the baby during labor. The baby responds to the severe stress of lack of oxygen with a response similar to “fight or flight”: it defecates.

So there are two reasons to deliver a baby expeditiously once it has defecated in the amniotic fluid. First, the meconium itself is harmful to the baby’s lungs and the more meconium is sucked into the lungs, the worse the harm is likely to be. Second, a baby who has passed meconium is often a baby in distress, and the longer that oxygen deprivation lasts, the more severe the consequences are likely to be. Hence the desire to use whatever interventions are necessary to deliver the baby expeditiously.

This is not rocket science, but apparently it is too hard for Rachel to understand. She offers her bizarre take on meconium aspiration:

So you would think that the sensible thing to do if a baby has passed meconium (for whatever reason) is to create conditions that are least likely to result in hypoxia and MAS. This is where I get confused because common practice is to do things that are known to cause hypoxia, for example:

Inducing labour if the waters have broken (with meconium present) and there are no contractions or if labour is ‘slow’ in an attempt to get the baby out of the uterus quickly.
Performing an ARM (breaking the waters) to see if there is meconium in the waters when there are concerns about the fetal heart rate.
Creating concern and stress in the mother which can reduce the blood flow to the placenta.
Directed pushing to speed up the birth.
Having extra people in the room (paediatricians), bright lights and medical resus equipment which may stress the mother and reduce oxytocin release.
Cutting the umbilical cord before the placenta has finished supporting the transition to breathing in order to hand the baby to the paediatrician.”

The stupid, it burns. It’s the equivalent of approaching the situation of a child drowning in a lake by claiming that the best response is to avoid interventions like rescuing the child and, instead, wait patiently for its body to float to shore. It’s the equivalent of claiming that the “stress” of a frantic rescue with bright lights (oh, the horror!) is more damaging than the lack of oxygen in the child’s lungs.

Rachel’s entire piece is a monument to the stupidity and venality of homebirth midwives, but some parts are more idiotic than others. My personal favorite:

Avoid an ARM during labour so that any meconium present is not known about until the membranes rupture spontaneously …

That statement is a perfect illustration for a new motto for homebirth midwives:

Ignorance is power!

If that’s the case then midwife Rachel Reed is very powerful indeed.