February 8, 2014 | 129 Comments

What do Vioxx and homebirth have in common?

image

Both have executives who lie to preserve market share.

Author:Amy Tuteur, MD

View all posts by Amy Tuteur, MD →
  • Ripley_rules

    I know this is somewhat OT, but since The Feminist Breeder is mentioned on this blog occasionally, I thought Dr. Amy and those who comment regularly would find this interesting. According to the site Get Off My Internets, which tracks TFB blog:

    “(Gina) informed the internet a few days ago that her child has been diagnosed with ASD. Since then she has apparently become an expert on autism and its causes, posting stories she claims show “further proof that high intervention birth practices” are possibly “to blame for some of what we’re seeing”.
    “As people who actually have ASD began to comment on her proclamations, Gina immediately turned on the Gina and began telling them, in a nutshell, that they have no idea wtf they are talking about, and she won’t be listening to any of it.”

    “I’m not sure why anyone is bothering to debate with this woman. She has long made it clear that she knows everything about everything, and if you disagree you just don’t know what you’re talking about. They may as well go try to have a discussion with a pile of mud about what it’s like to be a human – at least a pile of mud wouldn’t tell you that they have seen human beings walk by, so they totally know what being human is all about.”

    I really feel for the TFB because I have a child on the spectrum. My sympathy for her ends when she uses her son’s diagnosis to ignore evidence-based medicine and promote dangerous psuedoscience because it makes her feel better and gives her a false sense of control. Of course, she’s also subjecting her son to the usual biomed quack treatments. I hope she’s not using alt med treatments at the expense of proven therapies that work. But i guess she’ll just have to learn the hard way.

  • Jocelyn

    Another OT thread, this one about someone planning a UC. The reason I’m shocked and am posting it is because in her first birth, at a birth center, the midwives messed up and gave her newborn son a shot meant for HER, not the newborn. http://www.mothering.com/community/t/1395929/help-unnassited-birth-of-2nd-child (The rest of the thread is just the usual UC craziness.)

    • LMS1953

      I wonder what the shot was. The candidates are: Pitocin, Methergine, Rhogam, Tdap (pertussis vax), Zofran, Phenergan…I can’t think of many others. Don’t nurses do the FIVE R’s anymore? They called the CDC so I am leaning toward Tdap. Others would go to poison control which is usually a state department.

      • Susan

        (snark) we don’t need to we have Pyxis and scan the meds at the bedside who needs to think? … seriously though we do still do them. Reading that post though made me think that no doctor I know would want to see that woman as part of their practice. As I said to one doc I work with recently… there are advantages in someone else being the nut magnet….

      • Young CC Prof

        Wouldn’t the baby die if it was Rhogam?

        Yeah, I have to think it was Tdap. And it’s a killed vaccine, so if you gave that to a newborn, probably not much would happen. (Of course, let’s not experiment. Wouldn’t the dose or needle gauge tell you you had the wrong person?)

        • LMS1953

          Rhogam is IgG anti-D antigen. It is given Antepartum at 28 weeks and again post partum if the baby is Rh positive and mom is Rh negative. It crosses the placenta at 28 weeks. A direct dose to the newborn would be negligent but never lethal.

          • The Compute Ate My Nym

            If they were giving Rhogam, that implies that the baby is or at least might be Rh+ and the shot might cause hemolysis, though I doubt enough to be fatal. Possibly enough to warrant a hospitalization for jaundice/hemolysis.

    • Trixie

      Oh look, more insights from Professor Spilde!

      Also, hospitals sell your placenta for $30,000? How does a rumor like that get started?

      • LMS1953

        There used to be the notion that hospitals sold placentas to shampoo makers. I think this was an urban legend. Then there was cord blood banking. Then there was placenta encapsulation. There is a reality show about Appalachians harvesting ginseng root for thousands of dollars. I think placentas have entered that realm.

        • Trixie

          Honestly, if I could’ve gotten $30,000 for each placenta, I’d have done it in a heartbeat! Put that in a 529 now, and it’d almost pay for college!

  • LMS1953

    https://olis.leg.state.or.us/liz/2013R1/Downloads/CommitteeMeetingDocument/22882

    “As a bit of history, I was the Governor for the State of Oregon when Senate Bill 1063 granting the title of Licensed Direct Entry Midwife was proposed, argued and voted upon in 1993. When I signed the bill in to law it was my understanding that low risk pregnancies and births would be the types of situations that a Licensed Direct Entry Midwife would attend and bill the Oregon Health Plan for. I never at any time considered, nor was I given information to the idea, that Licensed Midwives would attend to any situation that extended to a risk level higher than average LOW RISK pregnancy and birth. Further, I certainly never envisioned that higher risk births that included Vaginal Birth after a Cesarean section, breech or twins would be included in the scope of practice of a Licensed Direct Entry Midwife. At the time I fully understood the meaning of scope of practice and as I often had to address that issue with other health care professions.”

    This link is a great read regarding the battle over DEM licensure in Oregon back in 2012. I think the current studies will snowball in momentum. We can only hope.

  • Amy Tuteur, MD
    • Josephine

      And an excerpt from one of the comments:
      “Thank you so much for your story. I needed to hear that. My first birth
      was at a birth center and people have suggested home birth for my
      second. My gut was telling me not to do that; it made me nervous. You
      just helped me decide for sure. Better to be on the safe side. I am also
      more convinced to get an extra ultrasound before the birth.”

      Just in case people think sharing these tragic stories isn’t important or is done to be cruel. No, it really does help people make a more informed decision. Of course a birth center isn’t much better, but I’m hoping it’s at the least one of those birth centers adjacent to a hospital.

    • Trixie

      Omg. Some of the other stories on that board are awful too.

      • R T

        The unplanned precipitous home birth with paramedics leading to death from HIE is horrifying! I can’t even imagine how awful it must have been!

        • LMS1953

          Do you have a link? I could not find it.

          • Trixie

            It’s in a comment in the same thread, as of right now it’s the last comment.

    • LMS1953

      The one I was linked to – she says the baby died in the hospital due to a congenital anomaly and that she was glad she delivered in the hospital because the baby would have died immediately at home. The baby lived for two weeks in the NICU. She was grateful.

    • Sue

      Two very poignant comments:

      ” I just never ever thought it would happen to me.” and then

      ”We ended up having two pieces of really shitty luck – she had a random, unpredictable complication that requires immediate access to hospital facilities to have any hope of a good outcome, and I had a precipitous birth. So she was born half-dead in my kitchen into the hands of waiting paramedics, rushed to the hospital, and died of birth injuries after 4 days in NICU. I also never thought it could happen to us.”

      Such a terrible way to acquire this insight. Such as waste.

      • Amy M

        That second one is jenny I think, she posts here all the time.

        • jenny

          Indeed, it is me.

      • Marguerita

        I just found out recently that the baby I’m carrying has a congenital anomaly – transposition of the great arteries. It used to be 100% fatal but is now 98% survivable thanks to modern medicine. Of course, you would have to be in the hospital to have such a good chance at life. The risk of getting it is 5 in 10,000. I never thought it would happen to me. I never even knew this could happen, actually. Now I’m terrified of having a precipitous birth.

        The thing is, it’s not detected prenatally 9 out of 10 times. I do hope this is giving my homebirthing relatives second thoughts.

        • jenny

          Best wishes for you and your baby!

          I hope your OB has some way to allay your fears about precipitous birth. Because of our history, I’m probably going to have a planned induction with my son, but everyone’s situation is different.

          • Marguerita

            Thank you 🙂 Best wishes to you too 🙂
            My first birth (this one will be my second) was a very quick and painless induction. 2-3 hours from start to finish and I asked for pain meds when it was too late because I didn’t think labor could be so fast and I didn’t feel like I was in labor. I’ll probably have a maternal request cesarean at 38 weeks or so for this one.

        • Young CC Prof

          I’m sorry to hear that, but I’m glad it was diagnosed, so you can start planning treatment now!

          When my friend found out that her baby had a serious congenital defect, she was actually induced at 38 weeks, in part because her local hospital was not equipped to treat the baby and the best hospital to manage it was 2-3 hours from her home.

        • Awesomemom

          I hope that everything goes well with your baby. My son also has TGA along with a few other additional heart defects. It was rough when he was little and going through his surgeries but he has been doing really well since they were completed.

          • Marguerita

            That’s good to hear! Everyone is so optimistic about TGA babies. The cardiologists treat it like it’s good news, which was quite strange to me at first.

        • Medwife

          I trained at a big Level III NICU hospital and got to meet quite a few babies after TGA surgeries. I know it’s a scary condition, but they do GREAT and heal so quickly!

        • rh1985

          My brother was born with that before the days of routine ultrasounds. Total shock for my parents at birth. His surgery was successful and he is now in his late 30s. Because of this I was given a very detailed ultrasound of my baby’s heart at 22 weeks and the MFM doctor seemed confident she does not have it. Is it just hard to find on less detailed scans or if it is not specifically being looked for?

          • Marguerita

            Good luck with your little one 🙂

            I’m not an expert, but what my MFM told me was that he treats every 20 week ultrasound as though it’s a complete cardiological scan. Many sonographers just overlook it because they don’t look at the heart in as much detail. Needless to say, I’m really glad I’m going tot his MFM and he’s awesome.

            How did it affect your brother’s life (only if you don’t mind answering)?

          • Captain Obvious

            In all fairness, most OB/GYN and sonographers only perform a 76805 ($300-400) fetal screening for malformation ultrasound. You really can’t perform a 76811 (~$550) full fetal anatomic survey at the 20 weeks visit. Insurance will usually deny a 76811 done for every 20 week scan. MFM get referrals for abnormal 20 week scans or patients with hereditary risks, so they can perform an in depth survey of everything and get paid more for doing that. That MFM is doing what every MFM does. A true fetal echocardiogram is usually performed by a pediatric cardiologist.

  • Jocelyn

    OT: A home birth with at 42 weeks 6 days, 11 lbs 12 oz, with shoulder dystocia: “-Wonderful!!!” : http://www.mothering.com/community/t/1396755/homebirth-shoulder-dystocia-11lbs-12oz-42-6-weeks-7-hr-labor-wonderful-zephyrs-birth-story

    • Jocelyn

      “So Zephyr’s out and is blue. By the time I look at him Brenda is already
      pumping room air into his mouth and nose and is calmly but still
      assertively telling me to talk to my baby.” Riiiiiight. Because talking to the baby helps them breath.

      • Maybe a boy named Zephyr is better off not breathing. No, that’s not very nice, and I am joking [bad joke]

        • R T

          That’s not even a little bit funny! Yuck! I know a couple little boys named Zephyr and I actually like it! It’s better than another Jaxon!

      • R T

        Poor big, little guy. I hope he doesn’t have any issues, like learning disabilities, they don’t know about yet from his oxygen deprivation.

        • Medwife

          Or blood sugar issues. What are the odds they tested him even once after he was born?

          • R T

            Oh yeah, totally!

          • OBPI Mama

            Slim

      • OBPI Mama

        My midwife had me talk to my son as well when she was pumping air into his lungs and trying to get him breathing again. Even then, it felt like a very strange thing to do.

        • AlisonCummins

          I think the logic is that his soul hasn’t decided whether or not to stay in his body or not, so by talking to him you’re encouraging the soul to stick around.

          • Susan

            It’s so common that someone MUST be teaching it to the homebirth midwives. I may try to track that one down. I’ve heard it off and on for many years. If you look at the Karen Strange(sp?) homebirth NRP site it almost looks like they are alluding to it. I wonder if that’s the source?

          • Susan

            I looked at her site and I don’t see a direct reference to this. When I googled
            “talking to newborn resuscitation” though this gem not surprisingly came up.

            http://www.homebirth.net.au/2008/04/resuscitation-of-newborn.html

        • Susan

          That’s a super common homebirth midwife thing. I have heard it more than once… the talk to the baby thing. I frankly think it’s scary nonsense. Though I do pray sometimes…..silently…. as I am working on things that matter.

          • OBPI Mama

            I believe in prayer too and, frankly, that would have been easier to manage than the whole talking thing. I remember thinking, “I don’t want to talk to the baby. I don’t know what to say.” when she was yelling at me to talk to him. It felt very awkward just saying things (I was bleeding a lot so I was feeling very shakey and odd). I just kept eerily squeaking to my mom, “Look at my baby. I have a baby. It’s a baby.” while my mom prayed! Fun homebirthin’ times…

        • Sue

          If the baby understands being spoken to during resuscitation at birth, how is it that they then take two or three years to re-learn language?

          • Young CC Prof

            Newborns generally DO respond to their mother’s voice. (Obviously not the specific words!) Whether it would somehow motivate them to breathe, though, that’s a bit of a stretch.

      • Houston Mom

        It also gives the mother some busy work to occupy her so she isn’t panicking and dialing 911.

    • Medwife

      “At the hospital they would have cut an episiotomy and used forceps” to resolve shoulder dystocia. Huh. Guess I’ve been doing it wrong then.

      • Gene

        Correct me if I’m wrong, but forceps would be of no use in a case of shoulder dystocia. Because the forceps grab the head and the head is already out. It’s the shoulders that are stuck.

        • Irène Delse

          That’s what I thought too. I can see the episiotomy in that case, but forceps? Uh?

          • Medwife

            Episiotomy if you need more space to get your hand in for internal maneuvers. Forceps… No. Just no. This is a lady who thinks she knows how things work in obstetrics, and clearly does not. Now she thinks her midwife saved her from forceps. Pff

          • Young CC Prof

            That’s part and parcel of the deep NCB cult. Even when things go wrong, the mother is left convinced that it would have gone worse in the hospital.

        • Susan

          You are right.

      • Lionessong

        That part made me snarl, I had my baby 2 months ago and he was 10 lbs and we had a SD at his birth, there were no forceps involved in freeing him. Just a well practiced team of nurses, my midwife and my OB doing the drill and getting him out in less than two minutes with no injuries and an apgar of 8 (he was howling as soon as he was out). No freaking episiotomy or drugs either, and I would have preferred the drugs or an epidural for the internal maneuvers they had to do to deliver his posterior arm!

    • Young CC Prof

      I like the part where she got into a car accident at 40 weeks, started contraction, and just let that go on for 3 weeks. Because, you knw, trust placentas. And trauma.

      The midwife, though, “confirmed that he wasn’t a GD baby, just big.” How could she possibly know by looking at him?

      • Trixie

        If I got in a car accident at 40 weeks, assuming there wasn’t a medical reason for me not to have the operation, I think I’d want a c section right there and then, just to make sure nothing bad had happened or was about to happen.

        • Young CC Prof

          That’s a darned good idea. It’s tough to directly injure a fetus by trauma from the outside, but it’s quite a bit easier to damage the placenta.

          • OBPI Mama

            Oh gosh, do you think she even thought of that? I didn’t until you wrote that reply.

          • Medwife

            I’d sure as hell get an ultrasound at the bare minimum. NST too of course. Lord.

          • FormerPhysicist

            I was in a car accident at about 6 months pregnant. Maybe 30 weeks? I called my OB immediately, and she said protocol was 3 hours monitoring (NST?) and an ultrasound. She called the hospital for me, but didn’t insist the ambulance take me there immediately. So, I took my older daughter to a friend’s house and then went to the hospital.

          • realityycheque

            Really? I was also in a car accident in the third trimester, got t-boned by a Chevrolet truck, which was was a total write-off for my little car. I felt alright afterwards, albeit somewhat shaken. Suffered a headache and felt a bit achy the following day. I was under the “care” of a midwife and wasn’t recommended/offered an ultrasound or NST, just told to take it easy and to call through if I experienced any abdominal pain or bleeding. I do recall thinking at the time that some fetal monitoring wouldn’t have gone astray, but didn’t think to question the person I saw as the expert in the situation… thankfully all was okay, but it’s interesting to hear how her standard of care differed from what you would experience in the hospital.

          • FormerPhysicist

            FYI, mine was 2009. Also T-boned, but only about 10-20 mph, if that. My van was drivable, but the sliding door was busted.
            I was 41, though I don’t think AMA mattered in that case.

          • Young CC Prof

            No, I don’t think so it had to do with AMA. Several women on my birth month club suffered car accidents or hard falls and all were sent to the hospital for fetal monitoring.

          • attitude devant

            Standard of care with a viable fetus is to monitor after an MVA, no matter what the mother’s age. Just saying. It’s all about compression/decompression injuries to the placenta. The uterus is flexible and stretchy, like a water balloon, and changes shape. The placenta does not stretch with it, and can shear off the wall of the uterus. You won’t see the damage unless you are looking for it,.

          • LMS1953

            Board Question I Was Asked: What is the FIRST thing to do when a pregnant woman presents with a history of trauma?

            Answer: Evaluate the mother.

          • Sue

            In Emergency Medicine training we learn that resuscitating the mother is the priority – and the best way to maximise the chances for the baby.

          • prolifefeminist

            I was involved in a MVA at 40 wks – a guy pulled out from behind a bus to make a left turn across my lane and I slammed into him going about 25 mph. I was ok – just very shaken up. Cops came right away, saw that I was pregnant, and called for an ambulance. I called my CNMs on the spot and they told me to come in.

            I got to the hospital, was put on the EFM, and almost right away the nurse noticed a smooth, wavelike pattern to his heartbeat. I was also having a very, very mild (easily ignored if not for the accident) cramping feeling at the top of my uterus. CNM called the OB into the room and he took one look at the monitor and recommended we get to the OR immediately because the placenta might be abrupting. His advice: sure, we could “wait and see” if it was really an abruption, but by then it might be too late and did we really want to take that chance. (Of COURSE not! I was planning an unmedicated birth with CNMs but after hearing that, I wanted him out that second). Worst feeling in the world to know that your baby might be dying.

            They rushed me to the OR and my son was born within minutes. He didn’t cry right away and those thirty seconds or so while I held my breath and waited to hear that cry and know he was alive felt like hours – never been so scared in my entire life. But finally he DID cry. 🙂 OB said there was no evidence of a large abruption during the surgery, but I guess the pathology report indicated that there were areas where it was beginning to peel off. I don’t know what would have happened had we not gone to the hospital – maybe nothing, or maybe I would have had a massive abruption and lost my sweet boy. It’s hard to fathom how someone could be in an accident, start having contractions, and not even get checked out to see if their baby is in danger.

            I will be forever grateful for that cesarean and to the doctor who was quick to act when seconds mattered.

          • Trixie

            Wow. Chills. So glad you were both okay!

          • Susan

            They did it right! So glad you are ok!

          • Medwife

            I don’t know what they actually saw on the monitor, but there’s something called a “sinusoidal pattern” that they may have thought was developing, and its very ominous. It can indicate fetal-maternal hemorrhage, among other things. By the way, this is one of those things that can NOT detected by auscultation! I am so glad your story ended the way it did!

          • Susan

            Me too! and yes I would bet that’s what they were seeing from the story. And so true, and sad in some cases when people don’t know better, that auscultation is completely inappropriate fetal surveillance after MVA.

          • Susan

            Here you would have been monitored at least a couple hours if not for 24.

          • LMS1953

            What really ticks me off with MVAs in pregnancy is the “Nobidy knows nothin’ ’bout no babies” in the ER. The ACOG Bulletin on trauma in pregnancy says mom MUST BE evaluated in the ER first before transfer to L&D. Seldom does that happen – the 20 week rule trumps it in the minds of ER personnel. I had a patient trip on her stoop of stairs at her mobile home and fracture her ankle at 37 weeks. There were literally skid marks on the linoleum from the wheel chair tires as she was rushed to L&D. It looks like a scene from Hot Shots! as she was wheelchaired from L&D to X-Ray back to L&D back to X-Ray back to ER to see the Ortho – each time over several carpet/linoleum bump/bump interfaces. What has been y’all’s experience – have you been appropriately evaluated in the ER after an accident prior to monitoring in L&D?

          • Susan

            LMS1953–be careful what you wish there. I know of cases when pt was kept in an ED post trauma where any OB person with a brain would have picked up on impending disaster but it was missed in ED. What’s obvious to us isn’t obvious to them and I am sure vice-versa. I know it’s different in every hospital. So that’s my experience… I want them to remember to CALL US to at least see the patient.

          • Medwife

            Totally. There could be a nail sticking out of a woman’s hand but if she’s 20+1, to L&D she goes.

          • Sue

            Hey – less of this ED (ER) bashing!

            We all have our stories – in my ED, we have trouble getting OB to take ruptured ectopics to the OT (OR).

            We see pregnant women with all kinds of injuries and illnesses, generally do our own basic ultrasounds, Kleinhauer tests AND consult OB.

            My anecdote vs your anecdote!

          • Susan

            I’ve definitely seen the turfing or avoidance go both ways. I always think the ED is so anxious to get rid of pregnant women because EVERYTHING else is theirs. It’s the only thing they are allowed to be afraid of.

          • FormerPhysicist

            Good point. In my particular case, I wouldn’t have even considered medical attention if I had not been pregnant. I did not get medical attention for my 7-year-old who was in the car (on the opposite side).

          • Elaine

            I had an occupational needle stick at around 26 weeks (so TOTALLY unrelated to pregnancy, TOTALLY not requiring EFM) and I went to the ER. Nobody even *asked me why I was there* before they tried to turf me to L&D, and I only got to stay on the ER side after a lot of protesting. Also one attendant got fairly visibly irritated with me when I refused to sit in a wheelchair. I ended up in L&D anyway because it was the only way to talk to an OB about the specific risks of the needle stick vis a vis pregnancy, but at least I chose to go there.

          • Elaine

            Oh yeah, and when I got up to L&D, they didn’t get why the ER had sent me up there instead of just consulting them via phone, in re the pregnancy-specific risks of the needle stick.

      • LMS1953

        She got in a car accident taking her son to get his cast off. She might want to hire an astrologer to re-align her ill-fated star chart. Trust osteoblasts. How did we ever get here as a species if we couldn’t trust our bodies to heal our broken bones.

    • rh1985

      Ouch!!!

    • Jen

      Oh dear. I read a birth story recently – hospital VBAC after 40 weeks (first baby was emergency c-section and 10 pounds plus). She was thrilled about getting her VBAC – never mind the shoulder dystocia and nerve damage to one of her daughter’s arms. I was gobsmacked.

      • OBPI Mama

        My son also has a brachial plexus injury from a shoulder dystocia. As her daughter ages and undergoes years of therapy and surgeries (if needed) and she sees how much it will affect her darling’s life, she may change her mind about her vbac. I certainly changed my tune about how thankful I was to have a homebirth after a few years of processing and learning and realizing how lucky my son was.

        • Siri

          I have a lot of respect for you, OBPI Mama. You have so much love for your children; clearly they are as lucky to have you as you are to have them.

      • Amazed

        There is something I really can’t understand with all these “I must get my VBAC to prove that my body isn’t broken!” Well, of course a c-section doesn’t mean a woman’s body is broken but let’s for a moment, just a moment, assume that it does. So what?

        I’ve broken both my feet and I can certainly say I sometimes do feel like I am broken… because I am. I cannot raise my foot to my knee and bend it… well, I can but it’s so not worth it to risk hearing a crack and then have the whole, “hello, dear doc, hi, beloved hospital, it’s your faithful Amazed. I liked it so much here last time that I decided it was no biggie to break this foot again” thing. I cannot run downstairs to catch the tub… well, I can but I prefer not to do it. So what? It’s just a part of me, not my entire life.

        Why is it so different with c-sections? Why is it so important to not be broken? Our bodies get broken quite regularly in one way or another and guess what? It isn’t the end of the world. We can dance around it and go on our merry way. And the stakes are so high with VBAC.

        Let’s be clear: I fully respect the decision to have one. Women do have heads on their shoulders and they can consider all aspects. But this is just one reason I cannot understand.

    • OBPI Mama

      Of course, the midwife would not suggest going to the hospital to get an xray of his clavicle… Maybe it’s broke and that’s why he’s crying a lot. Ugh…

      • Mishimoo

        That was my first thought too! Poor baby.
        Granted, all of our babies cried a lot during the first night after being born. My husband slept through most of the labours and woke up for the important part, so that he was rested enough to rock and soothe them while I rest.

    • Elizabeth A

      I wonder if Brenda the midwife in that story is Brenda Capp.

    • sleuther

      So much crazy in one story. Here’s a gem:

      “I lost my mucus plug at 3am (finally got to see a mucus plug! Always wondered what they looked like but didn’t want to Google it). ”

      Wow, alert the media….I can see how this would be extremely important, said no one, ever.

    • LMS1953

      The limits of patient autonomy. This is what is so hard to deal with “these people” as an OB. I can see at least five opportunities for a successful malpractice lawsuit: 1) failure to do fetal surveillance at 41 weeks 2) failure to induce by 42+ weeks, 3) failure to do adequate intrapartum monitoring, 4) failure to properly manage shoulder dystocia, 5) failure to make prompt diagnosis of brachial plexus injury. I think Dr Amy had a blog about a $140 million (?) lawsuit judgment in Michigan from this same scenario. The malpractice triad is 1) the plaintiff suffered an injury, 2) you were responsible for the care rendered that caused the injury AND 3) your care fell below the standard of care.

      Now, you would think a mother’s refusal to permit certain interventions would trump 2 & 3. As long as everything comes out alright – no harm, no foul. Still, if substandard care was rendered, there are 20 years of liability window for the baby to sue and mom has 2 years. But, if there is a major problem, the plaintiff can claim lack of informed consent/informed refusal. “It was not explained to me that my refusal to permit X would have resulted in Y. If I had only known I would have consented to it”. Or, “I know I wrote a 15 page birth plan, but I rescinded it when I screamed out – I can’t do this anymore and my mother begged you to do a C-section.

      I think it is completely unethical of a medical-legal system to expect me to provide substandard care to the “maternal-fetal unit” while I am speared on the horn of absolute maternal autonomy and then get tossed on the horn of improper informed consent when mom does not like the outcome of her (stupid) decisions. Juries don’t like to see dead or permanently maimed babies brought before them and they expect doctors to rise to the occasion and do the right thing. Sorry, when it comes to intrapartum management I think that mom and baby should have an equal voice. And since the baby can’t speak, I will speak for the baby. I will give mom wide latitude and broad discretion, but I will NOT intentionally condone substandard care that will likely permanently maim a baby. And I have gone to the lengths of obtaining an emergency court order to prevent it.

    • lol my blog is locked down right now (hopefully temporarily), but better birth’s ‘happy customer’ stories were totally horrifying and a lot like that lady’s. I am about 90% sure the first one was a shoulder dystocia, and she was in so much pain she was blacking out. wtf. Is it stockholm to thank the person who put you through that?

    • Irène Delse

      Let’s see: postdate, shoulder dystocia, big baby, born blue and with what looks like shoulder injury… Makes me cringe, because it’s so close to what my mother told me about my birth. Except, she was followed by an OB/GYN who convicted her that she needed an induction, and delivered in the hospital with two nurse midwives in attendance, and an OB on call if necessary. As it happened, his assistance was needed indeed: the midwives recognized SD and lost no time to call for help, and the OB managed to get the baby (me) out by cutting a quick, clean episiotomy, which probably avoided some bad tearing to my mother as well. Still, as quick and efficient as it was, there was an anxious moment when the midwives and doctor saw I was blue in the face, and they had to give me oxygen. But in the end, no lasting damage, either to me or my mother. (She was not so happy about her second birth, which was so precipitate that she barely had time to get to the L&D room before the baby was out, as big as the first one, causing some bad tearing that needed painstaking repair.) Non medicated birth sounds nice unless you’ve never had something go wrong!

      • LMS1953

        B-b-but EVIDENCE BASED MEDICINE sez episiotomies are always bad. Bad episiotomies, bad. Vaginal hand grenade lacerations are soooo much better..

        • Irène Delse

          Ha! Wishful-thinking based medicine, maybe! 😉

        • OBPI Mama

          What about if you had both? Do they cancel each other out?

        • Susan

          LOL yeah, seen that. Is that when the OB says they feel like they are stitching hamburger? It’s a great time to be the NURSE.

    • LMS1953

      http://www.skepticalob.com/2012/04/oregon-homebirth-midwives-sued-for-50.html

      Here is a lawsuit described in a previous post by Dr Amy in 2012 about a lawsuit against an Oregon birth center and CPMs basically for lack of informed consent. I wonder how it turned out? Paging Attorney, Paging Really Attorney.

      • LMS1953

        http://www.skepticalob.com/2011/11/jury-awards-144-million-for-failure-to.html

        Link to the $144 million law suit for a shoulder dystocia with very bad outcome. Gee, Doc, this baby would have been just fine if you had just done a C-section. But there was no way to know there was going to be a shoulder dystocia until there was a shoulder dystocia. We did all the appropriate maneuvers. There was no breach of standard of care. Oh posh, anybody could tell she needed a C-section. Her MOTHER told you she needed a C-section because ahe knew all of them thar Smith’s needed a C-section if they was carrying the baby high that way and she tried to tell the Doctor and he just would not listen (At this point cue John Edwards (former Democrat presidential aspirant, OB malpractice billionaire, and adulterer) to do his famous “Let me out, let me out, routine – after checking his hair in the mirror first, of course).

        • Susan

          Just for arguments sake though, Dr. Amy ended her post with “defensive medicine works”. I have seen you post about tort reform before and I am genuinely interested in what your opinion of what good law would look like in the US. We talk here a lot about how wrong it is for midwives not to carry malpractice. People do make mistakes, we are human, certainly there is a legitimate reason for malpractice insurance. But, I think, like you, that what it really has turned into is if there is a damaged baby– we will invent a mistake, or find a twisted logical explanation to allow a jury to do what they obviously will want to see whey they see that damaged baby, which is find a way to give them money, because the insurance policy is there with the money. I do think the system is nuts. We see med/mal attorneys as vultures. They see themselves as the protector of the little guy … heroes. They really do. The subject is intensely disturbing yet fascinating because there is such a divergence of how people see these things. Doctors get personally devastated in the process. But if we argue that midwives should too are we being hypocritical? Also, I always think it’s just telling that if the OB/hospital makes glaring errors that result in the death of a baby it is likely harder for that patient to find an attorney to take her case than a damaged baby where there is no evidence there was any deviation from standard of care at all. It’s so much more about what’s the case worth than did someone actually screw up. Best evidence, how hard it is for the victims of insane levels of negligence at homebirth to get anyone to take their case. No insurance? No assets? Is that the best protection of all? What a screwed up system!

          • LMS1953

            Susan, you make superb points. It think it is unconscionable that the ACA has the hubris to take over 1/6th of the economy with over 2200 pages and not have a single page/paragraph/sentence/word on tort reform. OBs pay about $60,000 to $200,000 for malpractice premiums – about half of that goes to pay attorneys both plaintiff and defense and the insurance companies overhead and stockholders. The system is utterly hopeless and beyond repair. The only tort reform will derive from fact that OBs net worth will be so low that there will be no incentive to sue them (ie, killing the goose that laid the golden egg). Frankly, I am getting to the point of saying to hell with the crunchies. They only make up 1% to 2% and if they want to endanger their babies, fine, go right ahead. Just have them spare me and the hospital grief when they are brought in for emergent care and still want the woo. I believe most women these days don’t want to deliver like farm animals and liberal use of epidurals, inductions and C-sections will find a very receptive audience for at least 95% to 98% of the population.

          • LMS1953

            Susan, I read your link. The paper was written in 2005 back when BHO was casting a string of “present” votes as a senator from Illinois. The truth (then) was somewhere in between. Now, the entire playing field has changed. We have gone from a baseball diamond to a cricket pitch with an umpire who rewrites the rule book according to which bench bitches the most or which team slips him the most money or whose fans cheer for him the loudest. Until we return to the rule of law and representative democracy it will be impossible to get a handle on tort reform/defensive medicine/appropriate mechanisms to compensate for medical mishaps. For example, if the shoulder dystocia CP baby (whose management was textbook perfect without an inkling of breach of standard of care) is on a lifetime of Medicaid, why should medical expenses be figured in? If there is a huge disincentive to work so as not to diminish government subsidy – will this be adjusted with future earning potential? If there was no breach of standard of care, why should there be punitive damages?

          • Susan

            I have more questions than answers. I don’t know that much in depth about it though I do have some unique and unfortunate life experience that gives me insight into how differently the different professions see themselves and the problems.

          • Young CC Prof

            One part of the problem, I think, is the USA’s poor overall safety net. If you get hurt and can sue someone with insurance, you get good care and lost wages. If there’s no one to sue, you might wind up treated by whatever doctors take Medicaid (or the broke and uninsured) as you fall behind on your mortgage.

            Sometimes people sue out of greed or anger, but a lot of times people sue out of desperation.

          • Susan

            I am sure. I don’t begin to believe I can comprehend what it would be like to raise a child with a catastrophic birth injury. I can’t imagine any amount of money would ever make it better. Our system is set up that the only way they can get the help they need is to spread the pain; I am sure sometimes they want to but more often it’s as you say, desperation.

          • LMS1953

            CC, there are basically two types of doctors: self-employed in a solo or partnership practice and a hospital employed physician. If you are hospital employed, you get a salary and take whatever patients the hospital takes per their insurance panels. I have never worked in a hospital that refuses Medicaid or Medicare. On the private side there is more discretion. But OB docs have to take call and if you don’t take Medicaid, you won’t get paid for those. You can limit the number of Medicaid patients you take but I have not worked on a hospital staff where any OB doc refused to take Medicaid OB patients although I am sure there are concierge practices which are restrictive. I think about 50% of all deliveries in the US are covered by Medicaid and in states like Mississippi it is 75%+.

            To be on staff at the vast majority of hospitals, you have to carry malpractice insurance.

    • Josephine

      I like how she keeps saying she wouldn’t induce for postdates alone. Uh, okay, so how the HELL would you know anything else was wrong that justifies induction?! You’re being monitored by a homebirth midwife, no NSTs or BPPs, no way to find out if anything is going wrong with your aging placenta…eyeroll.

    • Melissa

      Well, she doesn’t believe in inducing (even with castor oil) with post-dates! And we know Mamma instinct>science. Post dates are just a variation of normal.

      I wonder if it has more to do with the fact that once the pregnancy ends the attention on her is over and it shifts to people paying attention to the baby, so of course she wants to delay. I know that sounds cruel, but her entire story is dripping with such narcissism (the birth center didn’t make me feel SPECIAL enough, I love my midwife because she lets me do what I want, My husband is just a prop to hold me and take care of the baby until I’m ready for my close up) that it seems possible.

      • LMS1953

        Question on the castor oil induction. Does EVIDENCE BASED MEDICINE prove that it is both efficacious and safe? Does it work in a controlled double blind study? Does it cross the placenta and cause the fetus to defecate and increase the risk of meconium aspiration. Isn’t castor oil made from castor beans – the source of ricin – a deadly POISON? We can’t use Pitocin because if it ain’t natural, it will pop unicorn fart bubbles and cause autism and prevent bonding and cascade to a C-section. But a poisonous seed oil – well, shit, what could possibly go wrong with that besides taking a shit? But it is NATURAL – it grows on trees. Well, so does hemlock.

        • LMS1953

          Ricin
          The castor seed contains ricin, a toxic protein. Heating during the oil extraction process denatures and inactivates the protein. However, harvesting castor beans may not be without risk.[8] Allergenic compounds found on the plant surface can cause permanent nerve damage, making the harvest of castor beans a human health risk. India, Brazil, and China are the major crop producers, and the workers suffer harmful side effects from working with these plants.[9] These health issues, in addition to concerns about the toxic byproduct (ricin) from castor oil production, have encouraged the quest for alternative sources for hydroxy fatty acids.[10][11] Alternatively, some researchers are trying to genetically modify the castor plant to prevent the synthesis of ricin.[12]

          Awesome, crunchies get to take advantage of Third World sweat shops and child labor, causing these workers to sustain permanent neurological damage so they can avoid the hideous cascade of pitocin.

          • Sue

            Even without the toxic ricin, what makes these people think that swallowing an oil that irritates the gut would be a good thing, or would have anything to do with labor and delivery?

        • LMS1953

          http://www.instituteofmidwifery.org/MSFinalProj.nsf/a9ee58d7a82396768525684f0056be8d/e28ea481990d98da85257708004c24b6?OpenDocument

          Versus

          http://www.guideline.gov/syntheses/printView.aspx?id=24079

          CLASSIC
          if midwives do it – it is good
          If doctors do it and midwives can’t – it is BAD.

          EVIDENCED BASED MEDICINE says natural methods of labor induction are NOT RECOMMENDED

          • Susan

            I remember years ago reading the Mothering boards about there being homebirth midwives using Cytotec. Sometimes without even TELLING the patient. Incredibly arrogant, incredibly stupid, just unbelievable what how some of these people see anything THEY do is by definition right.

          • Josephine

            You have got to be kidding me! At least, I wish you were kidding me. Cytotec is a great induction tool but not without constant monitoring and sufficient medical knowledge. The audacity, good god…

            My induction was started off with Cytotec and within an hour I was having two minutes long contractions two minutes apart. Of course they were monitoring me constantly so they laid off of it after that and employed other options…I cannot imagine just giving it to someone with zero monitoring. That makes me ill to think about.

            Every time I think homebirth midwives can’t get any more loathsome, they surprise me all over again.

          • LMS1953

            There was a DEM midwife in Utah recently who had a pharmacist son from whom she would get things like Cytotec – that she killed a baby with. There was a son of an OB who forged an RX for Cytotec and he gave it to his pregnant girlfriend (calling it an antibiotic) so she would abort her first trimester pregnancy. He will be imprisoned for many years: Why isn’t the midwife imprisoned as long or longer for killing a term baby with it?

        • The Computer Ate My Nym

          No. I looked it up a while ago and it doesn’t work. I’ll find the refs from pubmed again, if you’d like.

          • LMS1953

            Check my links below. The midwives want to use it along with evening primrose oil mainly because they want “natural methods” of induction and ..:. the Egyptians used it. Government guidelines from the penocracy say that “natural methods” are not recommended. Look at it this way. If they DON’T work you have to suspend believe in the woo and not use them. If they DO work, then the standard of care is that the Bishop’s score should be documented along with an assessment of pelvic adequacy, fetal size and presentation. Then do a 20 minute EFM strip. Only THEN can you do Cytotec, prostin, pitocin, foley balloon, etc. Do you really think DEMs or CPMs or even most CNMs do all that before Miss Kitty serves up a shot of castor oil?

        • Many women experience a bout of diarrhea as labor begins. There IS some nervous connection between the bowel and the uterus. So, logically, inducing diarrhea might induce labor, right? That was one of the old rationales for giving an enema, btw, along with clearing the lower bowel of feces that could contaminate during the actual birth.
          The only problem is that there isn’t any evidence that it works as a means of induction, and, as my tutor said in the UK, pushing out solid stool rather than liquid, is more easily dealt with at delivery.
          Another “natural” means of induction, having sex, is at least more pleasant [ostensibly; the rationale being that the uterus contracts with orgasm]. Also not effective, alas.

        • Therese

          The evidence for castor oil being effective seems to be mixed. There are studies that show it does work to induce and studies that show no effect. To my knowledge, none of the studies show any risk to the baby though, including showing no increased risk of the baby passing meconium. So with that in mind I really don’t understand why people get so bent out of shape about NCBers using castor oil. If a women who is not willing to consider a hospital induction is willing to take the risk of feeling sick to avoid the risks that come with post dates pregnancy, that doesn’t seem like something we should be outraged about. I’d rather they do that than go to 43 weeks and have a stillbirth.

          • Young CC Prof

            I think the issue is that midwives are being hypocritical for rejecting pitocin and other drugs, which work much better with fewer side effects, when they promote castor oil, which is not exactly natural or harmless.

            Walking and sex (before rupture of membranes) are pretty harmless, whether they work or not.

          • The Bofa on the Sofa

            I haven’t taken the castor oil thing seriously since we heard the comment that someone was sure to clarify that they should be using _castor_ oil and not “Castrol” oil.

            Castrol oil is car oil (recall the line in American Graffiti, where Steve (Opie Cunningham) tells Terri the Toad that his car uses only “40 weight – castrol – R)

            When HB people have to be told not to drink motor oil, I have a had time seeing it as anything but a joke

      • Trixie

        Like how she just casually mentions that she has a photographer there. Yeah, totally normal.

      • rh1985

        I am almost 38 weeks and miserable and I can’t think of anything in this world that would make me go to 43 weeks. I will never understand wanting to avoid induction that badly not to mention the risks to the baby from waiting!

        • Karen in SC

          My second baby went to 41 weeks. I was content to wait as I knew it would be my last and there is something special about feeling your baby inside. But I understand being miserable at times.

          • rh1985

            Unfortunately my pregnancy-induced acid reflux has gotten really, really bad. that is the main reason I feel done.

  • KarenJJ

    MANA is just the gift that keeps on giving.

    • Mishimoo

      I thought that was STDs?

      • KarenJJ

        True, it’s difficult to tell the difference.