How babies’ brains get injured during childbirth

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Childbirth is inherently dangerous for babies.

Why? During labor contractions, blood flow to the uterus (and therefore the placenta and baby) is cut off. During each contraction, the baby is, in essence, holding its breath. Most babies tolerate this pretty well, because between contractions the placenta is providing so much oxygen that the baby has a reserve to draw upon during the contractions.

But what happens if the placenta is not functioning optimally? In that case, the baby develops fetal distress. Otherwise healthy babies can tolerate a fair amount of fetal distress. That’s why C-sections done in the early phases of fetal distress produce very healthy, apparently undistressed babies.

It can take a long time for a baby to die of oxygen deprivation in labor, because the baby is usually getting some oxygen, albeit not enough. During that time, if the oxygen deprivation is severe enough, the baby’s brain cells will begin to die because brain cells are extremely sensitive to injury from lack of oxygen. Babies who survive may bear permanent brain injuries. The technical term for this type of brain injury is hypoxic ischemic encephalopathy (HIE).

HIE is often preventable. A new paper by American College of Obstetricians and Gynecologists’ Task Force on Neonatal Encephalopathy, published in this month’s edition of Obstetrics and Gynecology, describes the causes of and treatments for HIE. The paper, Executive Summary: Neonatal Encephalopathy and Neurologic Outcome, Second Edition, is available for free.

This paper should be of particular interest to anyone contemplating homebirth, because the existing scientific evidence shows that in addition to a 3-9X higher increased risk of death at homebirth, there is also an increased risk of injury to the baby during labor (Homebirth increases the risk of a 5 minute Apgar score of zero by nearly 1000%) and an increased risk of HIE (Risk of anoxic brain injury is more than 18 times higher at homebirth).

The paper starts by defining the problem:

Neonatal encephalopathy is a clinically defined syndrome of disturbed neurologic function in the earliest days of life in an infant born at or beyond 35 weeks of gestation, manifested by a subnormal level of consciousness or seizures, and often accompanied by difficulty with initiating and maintaining respiration and depression of tone and reflexes…

How do we know if a specific case of encephalopathy is caused by and event that occurred during labor?

Neonatal Signs Consistent With an Acute Peripartum or Intrapartum Event

A. Apgar Score of Less Than 5 at 5 Minutes and 10 Minutes

1. Low Apgar scores at 5 minutes and 10 minutes clearly confer an increased relative risk of cerebral palsy. The degree of Apgar abnormality at 5 minutes and 10 minutes correlates with the risk of cerebral palsy. However, most infants with low Apgar scores will not develop cerebral palsy.

2. There are many potential causes for low Apgar scores. If the Apgar score at 5 minutes is greater than or equal to 7, it is unlikely that peripartum hypoxia–ischemia played a major role in causing neonatal encephalopathy.

In other words, HIE is often first manifested by a low Apgar score a 5 minutes. Oxygen deprivation can be confirmed by a low pH of blood taken from the umblical cord, and brain injury can be confirmed by damage seen on MRI scans. Oxygen deprivation often causes damages to other organs, too, and these babies can suffer from kidney, liver, heart and intestinal problems due to lack of oxygen during labor.

Sometimes there is an obvious and dramatic cause for fetal oxygen deprivation during labor:

1. A ruptured uterus

2. Severe abruptio placentae

3. Umbilical cord prolapse

4. Amniotic fluid embolus with coincident severe and prolonged maternal hypotension and hypoxemia

5. Maternal cardiovascular collapse

6. Fetal exsanguination from either vasa previa or massive fetomaternal hemorrhage

Anyone planning a homebirth needs to take these possibilities into account. If one of these events occurs, the baby may likely die or be profoundly brain damaged if the event takes place in a hospital. If it happens at homebirth, the risk of brain injury and/or death rises dramatically.

In the absence of a dramatic event, how can we tell that a baby is suffering from oxygen deprivation during labor? Electronic fetal heart rate monitoring.

The patient who presents with a Category I fetal heart rate pattern that converts to Category III as defined by the Eunice Kennedy Shriver National Institute of Child Health and Human Development guidelines is suggestive of a hypoxic–ischemic event.

… Additional fetal heart rate patterns that develop after a Category I fetal heart rate pattern on presentation, which may suggest intrapartum timing of a hypoxic–ischemic event, include tachycardia with recurrent decelerations and persistent minimal variability with recurrent decelerations.

This is critically important. Contrary to the belief of many homebirth advocates, a baby does not need to have a period of prolonged slow heart rate (bradycardia) in order for profound oxygen deprivation to be happening. A bradycardia is often a terminal event; it doesn’t happen until the baby is nearly dead. This is almost certainly what has happened when a mother reports that her baby fell into the homebirth midwife’s hands dead or nearly so even though the heart rate was “normal” throughout labor. Just because the baby’s heart rate is not abnormally slow does not mean that the baby is fine. The signs of fetal distress are often too subtle to be detected by simply listening to the heart rate though it would be glaringly obvious on an electronic fetal monitoring tracing.

Is fetal heart rate monitoring perfect? Hardly, but the problem with monitoring is that it may indicate fetal distress when the baby is not distressed. In contrast, it is extremely reliable when a baby is experiencing oxygen deprivation. In other words, electronic fetal monitoring may lead to unnecessary C-sections, but if your baby is really in distress, it won’t miss it. So when a woman chooses homebirth “to avoid a C-section,” she is making a tradeoff. By avoiding electronic fetal monitoring, she is reducing the chance that she will will have an unnecessary C-section, but she is increasing the chance that her baby will suffocate to death without her midwife having any idea it is happening.

Moreover, the damage to the baby’s brain does not end when the baby is born, even if the baby is then getting enough oxygen, but with head cooling therapy, some of that additional damage can be prevented:

The implementation of hypothermia for the treatment of neonatal encephalopathy is a milestone in neonatal medicine and represents the culmination of research spanning decades that has proved the potential for neural rescue after “perinatal asphyxia.” The recognition that this therapy improves early childhood outcomes has accelerated the pace of investigations to find other brain-oriented treatments. The fact that greater than 40% of neonates undergoing hypothermia treatment still develop adverse neurologic outcomes underscores the need to further understand the underlying processes in neonatal encephalopathy…

Lately, there’s been a lot of discussion in the mainstream media about the increased risk of death at American homebirth. Unfortunately, there has been little or no research on brain injuries resulting from homebirth because, amazingly enough, homebirth midwives don’t bother to track brain injuries. They boast about breastfeeding rates, and ignore brain damage, which gives insight to their priorities.

Brain damage to your baby is a very real consequence of homebirth, and American homebirth midwives can’t be bothered to assess the scale of the problem, let alone prevent or treat it.

Women who choose homebirth are putting their babies brains at risk. How does the baby experience this? Elizabeth Heineman provides a vivid description of what she believes her baby suffered before dying during homebirth:

[The] brain, deprived of oxygen, each cell suffocating, withering into itself, crumpling, collapsing, but still struggling, alerting the nerves that something was terribly wrong. The nerves suddenly plunged into burning acid, receiving the frantic message, send­ing that information in a useless loop back to the very brain that was under siege. The brain screaming in increasing des­peration to the lungs that they should try something, anything. The lungs naively expanding, opening, to pull in relief, to pull in the cool air whose oxygen molecules it will quickly trans­mit to the bluish blood, re-reddening it, re-energizing it, so the blood can rush to the brain, restore it. The lungs instead getting meconium-filled amniotic fluid, choking the blood by transmitting precisely nothing, the blood by now dead but still pumped by the heart that hasn’t yet learned that it is all over, the heart sending the useless blood to the brain cells now wrung dry as they complete the act of withering, crumpling, collaps­ing …

Thinking about homebirth? Think again.

  • Johannes Lawen

    concern mentioned in article is valid but she forgets to mention vbac risk and reduced post cesarean fertility. if its your last or second last baby, then do a c-sec… but for the first if you wanna have five? they also forget the social impact on mothers from cultures were limited offspring due to high c-section rates is perceive a detriment to a vital family interest. amy tuteur needs to broaden her view, comprehensively educate, and leave the choice to the parents.

  • Layla Forndez

    Hi, I’m Akbar from UAE. I had a hemorrhagic stroke for 6 years on the right side. This was so tough for me because i never imagined myself in this way. I lost my speech and i was obviously useless because i could not perform any activity without any support, i could not walk, i used to enjoy driving but none of this i could do again. I was totally paralyzed. The worst part was the emotional aspect of it. I cry very easily and have no control over it because all the doctors or physiotherapist i met were not helpful at all. I am, however, very lucky that i was able to find a very effective alternative natural treatment to stroke that cured me completely. It has been two years now and i still can drive, i actually thought the cure was not permanent but now i am fully convinced and that is why i decided to write this. If you have stroke or any paralysis just contact Dr Joseph on (josephalberteo @ gmail. com) for more information or advise and i am sure his medicine can help you too. I hope this helps someone out there.ey

  • sdsures

    Has anyone read the book “Midwives” by Chris Bohjalian? Fictional. It tells the story of a lay midwife, Sybil, who is arrested and charged with causing a mother’s death at homebirth. The baby survived because Sybil, believing the mother to be dead, performed a c-section. I don’t want to spoil the plot in case anyone wants to read it.

    The book mentions the use of both Doppler and something called a Fetalscope.

    From reading this blog for a number of years, I get the same that hese contraptions are nowhere near as accurate as continuous electronic fetal heart rate monitoring.

    Can someone please tell my exactly what a Doppler and a Fetalscope do?

    • Dr Kitty

      Doppler is the little probe that picks up the baby’s heart rate as an audible “galloping horse” sound. It is pretty low tech, most midwives and family doctors will have one. You can even buy them on Amazon for about £60. The are based on ultrasound waves and the Doppler effect. Most will calculate heart rate automatically for you.
      If you don’t know what you are doing though, you can mistake maternal aortic pulse or placental blood flow for foetal heart sounds.

      A fetoscope or foetal stethoscope is basically a cone shaped piece of metal or plastic, which works at picking up foetal heart sounds on the same principle as holding a glass to a wall if you try to eavesdrop on a conversation. You place on side on the pregnant belly over the baby’s anterior shoulder and your ear on the other. You have to manually count and multiply to get a rate.
      It is used in very resource poor places, and Jeevan Kuruvilla thinks they are too old fashioned and unreliable to be used in his clinic in rural India, so that gives you an idea.

      CPMs seem to like fetoscopes.
      They don’t cost much, there are no ultrasonic waves being emitted, they are “natural” oh yes, and no-one else can hear or record what you hear…which cynical me says may come in handy if you have difficulty hearing a foetal heart or want to bodge the rate to make a tachy or brady or decel seem less bad than it really is…

      • sdsures

        And have nothing to prove at court testimony what the fetus’s heart rate was before it died. No paper readout. Oopsies.

      • sdsures

        Logic fail: Why are some mothers gung-ho for HB that might include the CPM monitoring with a Doppler, but OH NOES! Prenatal ultrasounds are EBIL! ?

        • Young CC Prof

          I think it’s partly because some people associate ultrasound with either preemptive interventions or termination for defects.

          As for the first one, it’s true, but most people consider interventions to PREVENT problems a good thing. As for the second, yes, that happens, but the majority of problems detected by ultrasound are treatable, and knowing in advance increases the probability that treatment will be successful.

  • Harold Lee

    True. Most women consider C section surgery as an alternative to childbirth. But I would say that this is not fair. C section surgery is meant for critical situations where chances of risks is higher. I don’t know whether C section surgery is good for Erythroblastosis Fetails. Similarly, there is a great chance for risks in the case of assisted birth. Doctors often use vacuum cups to assist the childbirth. One of my cousin had experienced the negative side of assisted birth. Her elder son has still health problems due to the assisted delivery. In such cases we can sue a case against the doctor if the mistake was happened by them. Initially she was not interested in suing the doctor. But later we had to consult with https://www.campisilaw.ca in Toronto. They attended the case for free and we paid them after she got settlement on this case.

    • sdsures

      “C section surgery is meant for critical situations where chances of risks is higher.”

      Not in all cases. Some C-sections are planned well in advance, given certain medical conditions of the mother.

      • SporkParade

        I’m assuming this guy is here pretending to be a real person when he’s really an advertiser for the law firm.

        • MaineJen

          Oh no, I’m sure you’re wrong. Real people TOTALLY always include the link to the law firm they used to get their settlement after a birth injury. They also routinely get almost every medical term wrong or use it in the wrong context. In fact, I know for a fact that most real people compose their comments to make it sound like English is not their native language, and they are in fact being outsourced by the law firm to conduct shady online marketing. In such cases, we have no cause for concern, am I right?

  • cwmom

    When they went in for the c-section they discovered that my uterus had ruptured also.

    • sdsures

      Yikes.

  • cwmom

    Are you saying that the tachycardia is indication of oxygen deprivation or brain damage? My son was born via c-section 3 months ago and his heart rate was high before they got him out. His apgar scores were 8 and 9 and his umbilical cord blood gases were all normal, but I am so worried that he was deprived of oxygen.

  • Ebee

    I just want to add to this. My child has HIE. Her injury occurred in a hospital. She had continuous electronic fetal monitoring. While fetal monitoring can pick up on the distress and signal that a c-section needs to happen ASAP, more importantly is that the practitioners and nurses involved know how to recognize a problem on the strip. This did not happen for us even though now we know that the strip did show problems (or they just didn’t take it seriously enough) and now our child is left suffering the consequences of their inaction. When you choose a birth practitioner and hospital to deliver at, please make sure they employ nurses on the L&D floor that KNOW what they are doing in reading these fetal monitoring strips. Some places (which we didn’t know before we experienced it) will sometimes place fill-in or travel nurses on an L&D floor who don’t have enough experience reading the strips or who just haven’t had to do it for a while so they aren’t up on what they should be. Remember to check everything and everyone’s experience when you are in the hospital! If you find that they’ve for some reason assigned you to someone who doesn’t consistently work L&D, don’t be afraid to insist on a nurse who works it regularly. The strip isn’t going to prevent anything if the people assigned to you don’t know what to do with it. We found this out the hard way. Sorry for the bummer post. I just don’t want anyone else to find themselves in the situation we did. We had never heard of this happening before it happened to us. 🙁

    • Deborah

      The thing that SOMETIMES helps with this (although unfortunately not for you) at a hospital birth (but NEVER at a homebirth) – is that the fetal monitor is running out at the nursing station for everyone to see. So it’s usually not just your nurse watching — all the nurses and doctors who are around the unit can look at all of the strips, all the time. So even if you have a new or unobservant nurse, usually SOMEBODY will say, “Uh, isn’t there a problem in room 3?” and interventions will happen.

      • Rosalind Dalefield

        I wish it had been running in the nurse’s station rather than by my bedside with my first baby! He was showing fetal distress for two hours before the nurse-midwife finally called the doctor, and he was surviving on a partially abrupted placenta. It is my view merely good luck that he suffered no brain damage.

      • Taysha

        Yeah, mine was running in the nursing station. 3 doctors and two nurses rushed in just while another nurse disconnected me so I could pee.
        She ended up having to call my OB so they would let me pee. You don’t restrain a 35w7d twin mom without peeing. It’s cruel. I think the Geneva convention says something about that.

  • KT

    Thank you for posting this. I have often wondered the source of my now 2 year old daughter’s fetal distress after I experienced PROM (the distress was managed via c-section at the hospital by my wonderful OB). My daughter came out with great APGARs and is today a happy and healthy toddler, as I had hoped.

    This post brings me a lot of good questions to ask my OB, such as how the baby I’m currently handling is going to deal with the fact that my contractions seem to be of an abnormally long duration according to the nurses in L&D.

  • Trixie

    Semi-OT, but relevant considering how the Healthy Home Economist post blew up the other day: USA Today quotes Sarah Pope about how she let all her kids get pertussis back in 2006. http://www.usatoday.com/story/news/nation/2014/04/06/anti-vaccine-movement-is-giving-diseases-a-2nd-life/7007955/?csp=fbfanpage

    • Siri

      I had whooping cough as a baby, and again at 42; I was so ill the second time, I really thought I was dying. Took me ages to feel better, and I was emaciated and exhausted for months afterwards. I now encourage all adults to have a booster vaccine! It’s a horrible illness.

      • Trixie

        I’m glad you’re okay!

        • Siri

          Thank you, Trixie! 🙂

      • The Bofa on the Sofa

        Jeez, what good is getting whooping cough if you can’t have lifelong immunity?

        • Young CC Prof

          Exactly. The disease gets you full immunity for (on average) ten years and partial for a while longer. The old vaccine conferred immunity almost as long as natural infection, the new one, 5 years.

        • Siri

          I know, right? Life is just SO unfair. I was vacciminated against pertussis before contracting it as a baby too, so that was doubly unfair. I want a refund. And an apology. And a £20 supermarket gift voucher.

    • moto_librarian

      If you willfully expose your children to a potentially life-threatening disease, you should be charged with neglect. I hate seeing my children in pain, and I would do damned near everything to spare them from normal illnesses. What kind of a monster thinks this is a good thing?

  • LMS1953

    How babies get injured during circumnavigation:

    http://www.foxnews.com/us/2014/04/06/navy-ship-sent-to-pick-up-sick-toddler-on-sailboat/

    I will bet:
    1. The children were waterbirthed at home.
    2. The children have not been vaccinated.
    3. Mom is still breast feeding both of them.
    4. The family is primarily vegetarian except for maybe fish and they brought aboard a substantial store of kale.
    5. Their medicine kit contained encapsulated placenta, herbal teas, some color of cohosh and primrose of some time of day.
    6. Both of them voted for Obama both times

    • Young CC Prof

      Actually, I know someone who sailed around the world with her husband and young daughter. Crunchy, but in a very pro-medicine reality-based way. Her younger son was born by 37-week c-section because her uterus was weak from prior myomectomy, for example.

      Didn’t bring a whole lot of kale. Did bring MREs, because, “They’re really useful when it’s storming so bad you can’t stand up to use the stove.”

      She was a really interesting person.

    • Amy Tuteur, MD

      Why do you keep acting like a Fox News clown?

      Political conservatism is a failed philosophy. The Tea Party nuts would have been Tories during the Revolutionary War, slave holders during the Civil War, Klan members during Jim Crow (some still are), isolationists during the run up to WWII, and are currently deniers of both evolution and climate change.

      Just about everything that makes this country great, our commitment to justice, our commitment to equality, and the many freedoms we hold dear, were initially opposed by conservatives.

      I know you are proud of your conservatism, but, really, you should be embarrassed.

      • LMS1953

        The failed political philosophy is socialism, clown.

        • Amy Tuteur, MD

          I notice that you couldn’t rebut my claims.

          Since the US has never contemplated being a socialist country, your comment is irrelevant.

        • Dr Kitty

          Seems to be working out OK in Scandinavia and Germany…

          • The Computer Ate My Nym

            And the Netherlands and Canada. Among others. “Pure” socialism as attempted in the Soviet Union didn’t go so well, but then again, “pure” capitalism is an utter failure as well. No working society even tries it. It’s a complete disaster. But components of capitalism in a mixed system can work very well.

          • Renee Martin

            We ARE trying pure, crony capitalism, and that is why we are going the way of Brazil and Mexico.

            I just wish all these tea bagging idiots would travel a bit and get a clue. Every advanced nation OTHER THAN THE US has solved these problems.

          • Hannah

            As an Australian living in the US, it saddens me to know the new Aussie PM sees the US as the ideal model, rather than a cautionary tale.

      • LMS1953

        Look, clown, when is it going to dawn on you that the vast majority of legislators on both the Federal and state levels who support home birth and seek to legalize and legitimize CPMs are liberal/progressive Democrats? Just check out the situation in Vermont and Oregon. And they are chomping at the bit to use Obamacare to facilitate that. Thankfully, come November, the Libtards will get kicked to the curb and some sanity will be restored to Congress.

        • Trixie

          Classy use of the “tard” suffix there.

        • prolifefeminist

          There are complete idiots on both sides of the aisle, LMS. What’s your point?

        • Amy Tuteur, MD

          The victim mentality is deeply ingrained in conservatives. Even when they controlled the Presidency, Congress and the Supreme Court, they whined that they were being victimized.

          Conservatives need to stop with the paralyzing self-pity and get back to American values; you remember those, don’t you? The ones where Republicans put the safety and well being of the whole country ahead of their political party. Ahhh, for the old days when Republicans had both ethics and principles.

          • LMS1953

            Victim mentality? Victim mentality? Your comments are as idiotic as MANA. A CEO gets axed for a $1000 donation to support California Prop 8 – in the SAME YEAR Obama expounded that marriage is the union of one man and one woman. Clown, if you seriously believe that the Democrat Party is not the party of victimhood and the taking-of-offense and rule by judicial and executive fiat, then you, ma’am are a complete and utter imbecile.

          • Amy Tuteur, MD

            Yes, victim mentality, and you share it. You are constantly whining and injecting your feelings of victimization into blog posts on this blog, which has nothing to do with politics.

            We get it. You moved to Vermont where everyone thinks you are a wingnut and you are angry about that. But, you know what, we really don’t care about your desire to wail and moan that things aren’t going the way you think they should.

            Your philosophy is POISON and is destroying the country. The Tea Party will go down in history with the slave owners, isolationists, racists and assorted other wackos. The Civil War ended; you lost. Get over it.

          • The Computer Ate My Nym

            Wait, LMS lives in VERMONT? Why? He (or she) is an OB and can get work anywhere! So why not move to Mississippi or Texas or some other “right to work” state? Probably some excuse about the poor schools or low life expectancy…

          • Trixie

            I thought he used to live in Vermont but now lives in the south somewhere.

          • fiftyfifty1

            He already worked in the South. It bugged him when The Illegals needed his services. It especially bugged him when multips with “hispanic last names” asked for epidurals because he knew they didn’t really need them because their sisters back in Mexico sure weren’t getting them. Somebody called him a racist for that, and then for some reason Dr. T got on that person’s case for name calling. Remember that episode? Not a highlight.

          • The Computer Ate My Nym

            It bugged him when The Illegals needed his services.

            Yeah, well, I can see his point: I’m from Texas originally and Texas history is full of problems with immigrants with attitudes. Sure, when the Anglos first showed up they said they’d respect the laws of Mexico and not make a fuss, but what did they do a few years later? Rebel. And over what? They were annoyed at Mexico’s government abolishing slavery. Nothing but trouble has come from letting Anglos into Texas. Beware the immigrants from the north!

            …Oh, wait. That’s not what he meant, is it?

          • attitude devant

            Ok, Computer, I really did LOL! Nicely done!

          • Hannah

            I was like ‘wut?’ at first, and then I laughed so hard I spat my tea on the computer.

          • Renee Martin

            The hate for illegals is galling.
            ANd LOL on them not getting epidurals. Mexicans in cities actually have access to epidurals and CS on demand. The medical care isn’t bad unless you are very rural, but hat is also improving. Those that can, will travel back and forth often go back to Mexico for treatment.
            But what do I know, I just lived there.

          • Trixie

            Wait, wasn’t that CEO fired as the result of the free market making a financial decision based on the company’s own economic best interest? Seems like the sort of thing a conservative would celebrate?

          • Dr Kitty

            I think the Mozilla thing is a result of consumers showing a company what values they wish it to espouse.

            Free market economics, supply and demand, no?

            The values that young, urban, tech savvy professionals want the companies they do business to espouse are not necessarily the same values that win votes in the Bible Belt. Tough. That’s business-know your brand, know your consumer.

          • Eater of Worlds

            Well, it was well known that he supported it years ago when he was CTO. Now that he’s CEO, he needed to step up and say “yes, this is how I feel because of my religious beliefs, but I’m committed to making sure everyone at Mozilla and everywhere is treated fairly under under the law, and this is what I’m going to do about it”. He also needed to apologize not for “causing people pain” but for contributing to a cause that created real discrimination to his employees and contributors.

            But he didn’t do any of that. He avoided the issues in interviews, said some weird shit about how it’s important that they not be pro-gay marriage because of their foothold in Indonesia. I don’t know what he meant, maybe because Indonesia has a large Muslim population but it’s a secular country. He either handled interviews terribly, or he got terrible PR advice from Mozilla on how to handle it because the PR group misunderstood the issue. He fucked it up and failed, and THAT is what he couldn’t be seen doing as a CEO.

            He resigned because he couldn’t handle the job position, not because of his support of Prop 8.

          • This has what to do with saving babies and mothers?

          • birthbuddy

            As a non-US observer I find the passion in this banter interesting (and just a teensy bit disturbing).
            It dose deflect the conversation about babies a tad.

          • Renee Martin

            Nothing, LMS OUGHT to be BANNED. Not for his utterly idiotic beliefs, but because he cannot quit derailing every thread by ranting.

          • NoLongerCrunching

            I actually don’t want to see him banned, even though I am a proud liberal and agree with Dr Amy about the destructiveness of the Republican party. I think he is occasionally off topic, but we all are sometimes (e.g., recent thread about professional work attire :)). He often posts very useful comments too.

          • Amy

            Dude, the Mozilla thing is the sacred conservative free market at work. He didn’t get axed for his donation; he got axed because CONSUMERS decided they didn’t want to support a company with a guy like that at its head. Isn’t that what the libertarians are always telling us– that discriminatory behavior will not prevail because rational consumers will take their dollars elsewhere?

          • anion

            Hey, some of us lean conservative and deeply believe in all of those American values. Can we not paint all conservatives with the whiny crazy selfishbrush?

          • The Bofa on the Sofa

            Bofa’s Law

        • LibrarianSarah

          Yeah, fuck you for that “tard” portmanteau.

          • LMS1953

            Sorry, I thought Dr Amy said that Libtards were NOT the party of victimhood and self-pity. Libtard is a very common term. It encompasses the idea that progressive liberalism is irrational and idiotic – and it is very apt.

          • LibrarianSarah

            So your defense is “a lot of conservatives are ablest dicks” and then you decided to double down on dickishness. Okay then, continue on. You make your party look awesome.

          • Trixie

            Not common, LMS. Common on right wing talk radio, and actually common, are two different things. The fact that you can’t see why calling someone a “tard” might be offensive is very frightening.

          • Box of Salt

            I am compelled to take this apart: “Libtard is a very common term. It encompasses the idea that progressive liberalism is irrational and idiotic – and it is very apt.”

            Common term? OK, I don’t hang around political forums because I prefer paying attention to science, but the only usage I’ve seen of the term “Libtard” is from you, LMS1953.

            “irrational and idiotic”
            It seems to me that description also applies to the political rants you’ve been posting recently.

            “Libtard”
            I don’t particularly endorse PC philosophy because I can accept that sometime reality just sucks, and should not be sugar-coated. However, throwing in the “tard” suffix is needlessly offensive to the intellectually disabled. The fact that you keep using the term says more about you than the folks you are trying to criticize.

        • Renee Martin

          Oregon is actually using the ACA to QUASH Hb MWs, regulate them, and limit their ability to get any payments. HB MWs were NEVER allowed to get OR state payment, but used a loophole put there to protect patients and to ensure docs get paid.
          I know you wouldn’t know this if you weren’t here, and actually working on legislation.
          Try again.
          Also-
          BOTH extremes LOVE their HB- conservative xtians, anti government homesteaders on the right, and hippies, wealthy crunchy idiots on the left. It truly is a problem that is non partisan.

      • LMS1953

        Look clown, the Tea Party got its name from the Boston Tea Party – hardly a Tory supported event. Our freedoms are best expressed by the Bill of Rights. Each of these 10 Amendments has come under assault by Obama and Holder, except of course, the 5th which they assiduously use to get the IRS to intimidate and harass. The KKK? Surely you jest, clown. Harry Byrd, Democrat icon and antithesis of Tea Party philosophy held high office in the KKK. Winston Churchill expounded Tea Party philosophy and disdain for socialism. Would you dare call him a clown?

        • Trixie

          Churchill and FDR were like BFFs. Does that make FDR a Tea Partier too?

        • Dr Kitty

          Can I call Churchill a rude, capricious, misogynist functioning alcoholic?

        • The Bofa on the Sofa

          Look clown, the Tea Party got its name from the Boston Tea Party – hardly a Tory supported event.

          Yeah, but the modern Tea Party and the ideals it espouses similarly have nothing to do with the events and attitudes that prompted the Boston Tea Party.

          The Boston Tea party was not about getting rid of government, it was about getting to be PART of government.

          “No taxation without representation”

          Modern Tea Partiers always ignore the “without representation” part.

        • baileylamb

          This is the third “Tea Party” look up the second one…

        • The Computer Ate My Nym

          Winston Churchill expounded Tea Party philosophy and disdain for socialism. Would you dare call him a clown?

          Yep. Churchill had his points, but he was a bit of a clown in other areas.

          Off even the off-topic, but hilarious: There is a tea shop chain in Britain called “The Boston Tea Party”. I’m tempted to ask them about their willingness to ship to the Green Dragon Tavern.

        • Deena Chamlee

          Winston is actually known to be an antisocial leader.

        • auntbea

          I assume you mean ROBERT Byrd? And the DemocratIC party?

      • Carolina

        I know you don’t like to ban people, but I wouldn’t be opposed to it here. He’s just deliberately inflammatory and constantly derailing the comment section. It’s really obnoxious.

    • Trixie

      Noon is a little early in the day for you to be launching an incoherent political rant, LMS. What’s going on?

    • Lombardi

      Oh I want in on this game!

      I see your lefties on a boat (Although nothing in the article tells you they are) and raise you a family of Conservatives on a boat.

      “decided to take a leap of faith and see where God led us”

      http://www.azcentral.com/news/arizona/free/20130810arizona-family-rescued-sea.html

      • Box of Salt

        And this family did indeed homebirth:
        “She said she gave birth to the couple’s 8-month-old girl on the boat, which was docked in a slip at the time.”

    • Box of Salt

      LMS1953, What on earth is wrong with you? Are you trying to prove beyond doubt that you are prejudiced and opinionated?

      Congratulations, it’s working. But it isn’t adding anything of value to the discussions here.

    • Comrade X

      Dr S – you are obviously an intelligent, dedicated and caring professional. But there is something wrong. Every so often, and recently with increasing frequency, you completely go off the deep end and start strange and often offensive frothing rants. I don’t know what is wrong, but something is. Look, you’ll probably tell my commie ass to fuck off, but if you ever want to talk, my email address is segurakatya@gmail.com. Please don’t hesitate. However silly it sounds, I’m genuinely worried about you.

      • Trixie

        I’m worried too. LMS, I really, genuinely, and without snark, hope you’re okay.

      • Lisa from NY

        Just a little warning: you want to write out your email address as follows: name at gmail dot com

        Because spammers scan web for email

        • Comrade X

          Thanks, Lisa. I’ve edited my message to reflect your advice.

        • Carolina

          I never knew that was why people wrote out email addresses 🙂 Thanks!

    • Irène Delse

      You may want to check facts before jumping on your political high horse… Remember that other family rescued at sea? Bible-worshipping Christians trying to get away from the USA because it was too liberal for their tastes:
      http://talkingpointsmemo.com/news/religious-az-abandons-has-to-get-rescued-at-sea
      Just a thought.

    • T.

      Don’t feed the troll people 🙂

      • baileylamb

        You should go to their blog and see how they let their 2 year- old hold a gun. I never understood, why some people can’t admitt that their are dumb people on all sides of the political spectrum. Not bein able to admit that, is a little bit like woo to me. All conservatives aren’t magically blameless and all liberals aren’t magically mooches.

        This is why I have a hard time picking a care provider, I always try to make sure my doctors see me as a human, and not a stereotype bad things can happen when medical professionals have biases. Luckly I lice in city with a very diverse doctor pool.

        • T.

          Talking about such a topic as the one LMS started in a blog post entitled “How babies’ brains get injured during childbirth” is trolling. There are plenty of sites to talk about politics if people want to do it.

        • Renee Martin

          People of all political persuasions are stupid. It is a human flaw.

    • Deena Chamlee

      Lmao

    • araikwao

      I can’t remember which thread contained all the mammography discussion, but uere’s a fresh new post from Gorski on it :). http://www.sciencebasedmedicine.org/mammography-and-the-acute-discomfort-of-change/#more-31027

    • Alenushka

      What does Obama has to do with being a homebrither? I voted for Oabama and I vaccinate

    • Hannah

      What does Obama have to do with anything? Enough with the trolling, LMS, it’s tiresome.

      • Renee Martin

        Derailing and ignorant tea bagging BS is his specialty.

        • Hannah

          I’ve noticed. I couldn’t bite my tongue yesterday, it seems 🙁

  • Lisa from NY

    OT: HB to hospital transfer C/S: Excessive bleeding from uterus due to prolonged labor
    http://www.homebirth.org.uk/andrealydia.htm

    • Mishimoo

      So she had what sounds like a partial rupture with her 11th large baby, also had blood transfusions, and then went BACK to homebirth?! To borrow from The Simpsons: “Won’t somebody please think of the children?”

      • Amy M

        And then almost died from accreta/blood loss after the next one…I sure hope that was her last one.

        • Mishimoo

          I couldn’t bring myself to read about the next one. I sure hope that was her last one too!

      • Jessica S.

        😀

    • Gene

      “Super homebirther of 9,10 and 11lb babies, transferring to hospital with a stuck baby, the humiliation.”

      This is the phrase that stuck out to me the most: her inability to birth a baby vaginally was HUMILIATING. More reinforcement that a woman’s self worth is tied to her ability to vaginally deliver a child.

      • Why is someone who has macrosomic babies regarded as a “super homebirther”? Since when has the size of what is forced through the birth canal been categorized as “bigger is better”?

      • meglo91

        Yes. The idiocy in that statement is breathtaking. Imagine someone saying this about their appendicitis: “Why? Why was this happening to ME? What was wrong with ME that my appendicitis was septic, inflamed, and causing me horrible abdominal pain? The humilation.” For Christ’s sake.

        • Dr Kitty

          I think this just shows that every pregnancy is different, that a slight change in foetal size or position or contraction strength and duration can change a proven pelvis into obstructed labour or SD.

          Also grand multips are not low risk.
          Your first pregnancy is riskiest, your second safest and after that they start getting riskier and riskier again.

          By 10 she was high risk for malpresentation, PPH and dysfunctional labour.

          Like a balloon, the first time you blow it up it’s really hard. If you let the air out and blow it up again- really easy. But if you do that 10 times…by the tenth time that balloon might pop.

        • anion

          It’s humiliating for her because it’s a comeuppance. For a woman who–I imagine–constantly insists that homebirth is perfectly safe and that things only go wrong if the mother is “afraid” or that problems are solely due to doctors and their Evil Interventions, it is indeed humiliating to have your body and baby loudly and obviously point out that you’re an idiot and all the things you’ve said have been wrong.

          Most appendicitis patients aren’t humiliated because they haven’t devoted their lives to “Trust Appendixes,” and “Doctors lie about your appendix because they just want to cut you for cash.”

    • Lombardi

      “This was my 11th baby (10th pregnancy) and I was planning an unassisted homebirth.” huh wait? Was one adopted? I guess that is the only way that statement makes sense.

      Also, is there any truth to this? How could you have any idea this was going on before the ultrasound?

      “Early on in my pregnancy I had a strong suspicion my placenta was anterior, as I didn’t feel the baby move until quite late. This was later confirmed by ultrasound about mid way through my pregnancy. I wasn’t really concerned as I’d had anterior placentas before, and even though they tended to encourage my babies to the posterior position (babies like to face their placenta) they always turned during labour and birthed without a problem.”

      • The Computer Ate My Nym

        One of the pregnancies could have been twins. Or adoption, as you mentioned.

      • me

        “”This was my 11th baby (10th pregnancy) and I was planning an unassisted
        homebirth.” huh wait? Was one adopted? I guess that is the only way
        that statement makes sense.”

        Twins?

      • Young CC Prof

        The article said she had a pair of twins. And yes, anterior placenta does make it harder to feel the baby move, although it’s not a reliable measure. I suppose if you’d been pregnant a dozen times and had both anterior and posterior placentas, though, you might be able to tell the difference.

  • Hush

    This is completely off topic. I find myself here as a home birth mom and a natural birth person.. I had a home birth and it went great for the baby.. except that it wasn’t quite right for me and I am not actually seemingly allowed to bring it up in our community because what I have to say is I received dissatisfactory post-partum care because of a very busy midwife. She’s not under-educated she has a PhD and she handled what happened well since I am here and fine but she also lied very blatantly on my records. She said I lost 500 cc but it had to have been a lot more than that for her to give me pitocin and then methergine and for me to be weak and have a hard time walking for weeks. I read most accounts of vaginal births where women have the baby and then can get up 10 minutes or a couple hours later, but I could barely get up the next day to shower without my heart racing and my eyes losing focus. It was a tough physical recovery.. far tougher than my first birth where they estimated I lost 500cc but I hopped up after and took a shower.. Mind you, my first birth was 2 days of labor but my second was 2 hours.. I think something was really off but I don’t have any idea what to think because people are falling over themselves not to say that the 500cc was wrong at all. ??

    • Busbus

      (This is Busbus, just can’t log in right now.) I also had a homebirth (two, actually) that went without problems. I started to change my mind on a lot of things later on and cannot imagine having another homebirth. It was a big change.
      I am not a medical professional, but what you describe about the blood loss and your state afterwards doesn’t sound right at all. I had a hard recovery both times (and definitely harder than several people I know), but I didn’t feel dizzy or strange, just dead exhausted. Not like what you describe.
      I am too tired to be particularly coherent, but I wanted to say hi from one ex-homebirth mom to another (?) and encourage you to check things out here and give this blog – and the community of commenters – a chance. Oh, and congrats on your baby, and I’m glad that everything went well for the baby.

    • Box of Salt

      Hush “I am not actually seemingly allowed to bring it up in our community”

      Stick around. Here, you can bring up anything you’d like, and we’ll listen. (Sure, not everyone’s comments are well received, but … they still get their screen time.)

      Congratulations on the new baby and best wishes for better times ahead.

    • Siri

      It sounds to me as if your blood loss was, in fact, greater than 500ml, and that your midwife should have transferred you so you could have been evaluated for blood transfusion. Perhaps one day you’ll decide to take it up with your midwife; if she did lie it was a despicable act, which would lose her her UK registration in a heartbeat. I too had a successful homebirth (2 senior midwives, 2 of my fellow students, it was great!), then asked to transfer to hospital just before my 5th baby was born (I panicked, thinking it would be a bad shoulder dystocia – it wasn’t, it was just that my bladder was full). I also used to be a midwife. Sending you good wishes and good vibes.

    • OBPI Mama

      Another “hello” from an ex-homebirther here. While my former midwife wouldn’t give us my actual medical records, I’m sure they are lies in there too. Things omitted that would give homebirth a bad name. Many midwives are so passionate about homebirth and what they do (or rather, don’t do!) that they will omit or lie so as not to give anyone any chance to look at bad outcomes. My husband thinks she destroyed the records though. What you describe does not sound normal to me!

      • The Bofa on the Sofa

        While my former midwife wouldn’t give us my actual medical records,

        Are they allowed to do that? To refuse to give a patient their medical records?

        That sounds extremely unethical to me.

    • Trixie

      Hello and welcome. Out of curiosity, what was your midwife’S PhD in?

      • Hush

        She’s a CNM, NP, and I’m not sure what her Phd is for. I assumed it was something health related but she doesn’t have it listed on her webpage, so perhaps it has nothing to do with midwifery. She verbally told me about when she was working on her doctorate, so I just assumed it was related to nursing.

        • Trixie

          Would you care to share her name so someone could look it up? Or you might be able to Google it yourself.

    • Elizabeth A

      At this juncture, it’s quite difficult to estimate your blood loss,
      and I can’t speculate on what other problems have arisen after your
      labor that caused the problems you experienced. I am not a doctor, but it seems to me that, far from handling your situation well (since you are still here), you are still here because you were lucky. Many medical problems will resolve with time, so a very bad practitioner can appear to do things right (by the standard that the patients survive it) for a very long time.

      Post-partum care has always seemed like a weak spot in homebirth midwifery. Even when things go well, post-partum visits often appear to get short shrift. When things go badly, the midwife seems just as likely to vanish as anything else.

      I am glad you recovered. Welcome here.

    • Young CC Prof

      MANA’s own study of home birth outcomes, with all medical data supplied by midwives themselves, found that 15% of home birth mothers lost more than 500 cc and 5% lost more than 1000. In the hospital, only 3.4% of vaginal births involved blood loss of more than 500 cc.

      Hemorrhage severe enough to cause disabling anemia during the postpartum period is a fairly common outcome of home birth, mostly due to clumsy or nonexistent management of the third stage of labor. Many NCB “midwives” promote a “physiologic third stage,” which has no benefits of any kind and is much crazier than trying to avoid unnecessary c-sections or give birth without pain medication.

      If you look at childbirth customs around the world, many call for a period of several weeks of bed rest for a new mother, and I think this is one reason why, that a completely “natural” human birth causes dangerous blood loss quite routinely.

      This fact is, in a way, much more dangerous to the home birth movement than the 1-3 per thousand excess risk of baby death, because 1 per thousand sounds like a small risk, but excessive blood loss is downright commonplace.

      Worse, it disproves the entire raison d’etre of the home birth movement, the alleged better maternal experience, and avoiding the dreaded c-section with longer recovery.

      • Trixie

        Well, according to the Public Health Scholar, people trained in water birth know exactly how to gauge blood loss in a kiddy pool. Clearly you aren’t educated.

    • Amazed

      I am glad you recovered. I am still curious, though. As far as I know, PhD has something to do with Philosophy or Philology? Does your midwife’s PhD has something to do with midwifery or medicine? Because it sure looks to me that she was clearly under-educated where childbirth was concerned.

      • The Bofa on the Sofa

        As far as I know, PhD has something to do with Philosophy or Philology?

        “Doctor of Philosophy” but it can be in almost any subject.

        But I will second the comment, and the question below. What was her PhD in? I have a PhD, but that does not make me qualified to be a midwife.

        Actually, if I know her name I can look up her PhD, assuming it is legit.

        • Trixie

          I’m betting it’s a social science.

          • Bombshellrisa

            How much you want to bet its anthropology?

          • Trixie

            That’s my first guess, but also maybe Sociology or Women’s Studies.

          • Hush

            Women’s studies is actually it. She does have a MS in midwifery.

          • Trixie

            Ding ding ding ding ding!

            And yet, she had no problem being so profoundly un-feminist to you that she lied to you about your condition and bullied you into silence and compliance when you became a potential liability. That’s the exact kind of thing she probably complains that male hospital doctors do.

          • Trixie

            Let me guess, she also has certification in some other pseudoscience, acupuncture maybe? Or nutritionist?

          • Hush

            Not that I know of.

          • Renee Martin

            She should have been good. I am sorry she was not.

          • Bombshellrisa

            Master in science from what university? If it’s Bastyr that is a joke

          • Hush

            NYU.

          • The Bofa on the Sofa

            How much you want to bet its anthropology?

            I am pretty much guaranteeing it is NOT midwifery.

          • Squillo

            I don’t know. In the U.S., some APRNs have PhDs in nursing (and there’s a push to increase the number of doctorally prepared nurses, presumably to increase teaching capacity). I know several CNMs with PhDs in nursing whose research topics are, unsurprisingly, in obstetrics/midwifery-related fields.

            Of course, having a PhD doesn’t necessarily translate into being a superior practitioner.

          • Trixie

            Women’s Studies. See below…

        • Amazed

          “I have a PhD, but that does not make me qualified to be a midwife.”

          Yeah, that’s the part that smells bait and switch of me. In my book, having a degree in certain field equals under-educated in all other fields where a degree is needed and achievable.

        • Hush

          I don’t want to tell you her name. It’s not that I’m not a legit person, it’s that if I got caught talking about this specific midwife at all I would be, for lack of a better term, ex-communicated. Her Phd is probably not related to nursing, as it’s not on her webpage. Her CNM and her NP are listed there. She spoke about working on her doctorate, so I just assumed it was related to the nursing field.

          • Trixie

            There are a lot of other commenters here who have felt this threat of being ostracized. I’m sorry. You could always email Dr. Amy privately.

          • The Bofa on the Sofa

            OK, I know you face being shunned, but I have to ask … how does that bother you? Why are you so concerned about acceptance by a group that would throw you out for having the audacity to question the capability of your midwife? For checking in to her credentials?

            “Shun the unbeliever!” This is your HEALTH and the life of your baby, not some religion.

            Seriously, if you had said you were concerned about your personal ID, that would be one thing, but you have admitted it’s not about that, it’s about being thrown out of your congregation.

            Do you think that’s right? That you should be shunned just because you check up on your midwife’s credentials? You know, the one abandoned you after your baby was born?

            Why would your so-called friends want to protect HER and not you? Great bunch of folks there.

          • Box of Salt

            Bofa, “OK, I know you face being shunned, but I have to ask … how does that bother you?”

            Not everyone is Groucho Marx.

            Hush seems to be facing losing a support network during a time when she needs support.

            I hope she finds out that she can get that support elsewhere – and that includes here.

          • The Bofa on the Sofa

            The key is, is it REALLY a “support network” for her? Who are they supporting? If they are going to turn on her that easily, then I don’t know if that’s what I’d call support.

          • Box of Salt

            Bofa, ” is it REALLY a “support network” for her?”

            It was. And, based on her comment, she still sees it that way.

          • Renee Martin

            She may see it that way, but it doesn’t make it so.
            Nothing hurts more than having friends you thought were there for you dump you because you didn’t like your HB MW. That is not support. It is forced censorship.

          • Box of Salt

            Renee Martin – I agree with you. I just thought that the situation called for a gentler approach than Bofa’s. I hope Hush reads your comments today, and takes them seriously

          • Hush

            Well, it’s like this. They, and well I, perceive themselves and their beliefs to be under direct assault rather frequently by the rest of society.. It’s really common for people to have nasty reactions to home birth. As a result they kind of have a wall built up around them and particularly their good practitioners. But, you know, I can’t really parse that with the way I was treated post-partum.. I find myself at odds with all the other women who felt so happy with their care… Maybe they were happy because they had no complications or were treated by a well-rested midwife. Maybe I’m just sensitive. I wouldn’t say she abandoned me, precisely. She left because she had appointments. She left me, then sent back over her student who is an RN to make sure I was okay. I think a lot of people are “abandoned” by their doctors and left with residents.. that’s not much different.. My main issue is not that really that she left me, though I felt a sting and a bit afraid when that happened, it’s that she knew I could not do stairs for weeks but didn’t speak the words “hemorrhage” or really suggest anything at all about it .. I am suspicious for a few reasons but I don’t want to really describe it. Also, they’d protect her because I’m newer.. and ex-communicate me for just talking outside of our group because those are, well, the rules..

          • Young CC Prof

            Um, you’d just given birth and were seriously not OK. You shouldn’t have been left alone at all, not even for a few minutes. If she had to leave that badly, she should have called an ambulance.

          • Hush

            I agree with you I was not well enough to be left.

          • Trixie

            You could have easily died. It would have been because of her negligence.

          • Hush

            And so, I am worried about my friends who are pregnant because I don’t think either option for their care is 100% evidence based.

          • Trixie

            In the hospital, mothers don’t generally nearly die of hemorrhage, then get lied to about it, then abandoned.
            I’m not trying to make you feel bad for choosing a home birth, but you have to see now that in the hospital, your health would have been much improved.

          • Hush

            Not necessarily here. I had obscenely high blood pressure after my first baby and the hospital doctor that hated me downplayed it. 200/180 and they were “Well maybe you might have a problem with your blood pressure” and didn’t follow up.

          • Young CC Prof

            That was also outrageously irresponsible. Postpartum preeclampsia is a real thing. Did they at least test your urine?

            Just on the basis of outcomes, though, severely negligent care is less common in the hospital.

          • Hush

            They not only did not test my urine they discharged me with my blood pressure that high. That doctor did not like me, though, because I filed a complaint against him and said I didn’t want him to care for me. For me negligent care seems to just be the norm with either mode of care unfortunately..

          • The Computer Ate My Nym

            They not only did not test my urine they discharged me with my blood pressure that high.

            WTF?! That’s organ damage and stroke risk range. That’s not in any sense ok.

          • Renee Martin

            I am glad you reported him. I am also sorry you got TWO worthless POS so called maternity care providers.

          • Trixie

            I’m sorry you had a poor hospital experience. That treatment is not okay either.

          • Hush

            I chose home birth for a reason. I was disappointed with it, too.

          • Trixie

            No, you were not being sensitive. What she did borders on criminal. You were not well and needed a hospital. You had probably already paid her, right? So her incentive was to get the hell out of there.

          • Hush

            She was covered under my insurance. Same as any health pro. Is every health pro trying to get the hell out of there simply because they’re guaranteed to be paid?

          • Young CC Prof

            No. For one thing, actual pros who walk away from their responsibilities without properly handing them off tend to get FIRED.

            I sometimes have working nurses in my classes, trying to earn higher degrees. I remember one lady (who worked nights in the ICU) was late for class one day and told me “I was about to leave and a patient coded.” And I said, “OK! You deal with that!”

          • Hush

            She said that they couldn’t contact the patients because they are not on the grid. I said okay. I was really not in a state to tell someone to leave so I wish she’d used better judgment but I was okay. I am okay. I have a hard time with this particularly because she’s more than just a lay-midwife. I hired her because she was well educated.

          • Young CC Prof

            Unfortunately, outcomes for homebirth CNMs and homebirth lay midwives are almost identical. It doesn’t seem like it should be that way, but it is.

          • Renee Martin

            If you read here long enough, you will learn that NCB philosophy trumps education and skill when it comes to HB.
            Once a MW chooses to attend HB, they seem to lose their ability to do whats actually evidence based. Their HB stats aren’t much better than the LDEMs! (accredited CNM BC are the one exception of better outcomes OOH) I am sure it has to do with even being willing to attend HBs, but also because if the isolation in the HB community allows you to get far away from standard practice. .
            Your CNM was better than a LDEM, because you didn’t die. But that is not saying much.

            You did your best, and hired what you took to be a skilled professional. BUt her philosophy has compromised her ability to care for patients properly.

          • Trixie

            Okay, so you’ve got insurance that covers homebirth. That’s very rare.
            At this point I’d hardly call her a “pro,” though. She got the hell out of there because she and you were in bad shape and she didn’t want the blame or responsibility.

          • Hush

            I live in New York. Licensed home birth midwives are covered here by insurance.

          • Trixie

            http://www.skepticalob.com/2014/01/risk-of-anoxic-brain-injury-is-more-than-18-times-higher-at-homebirth.html
            Did you know that in your state, and surrounding areas, homebirth was shown to vastly increase the risk of brain injury?

          • Hush

            With a CNM that has at least a masters degree?

          • Trixie

            Since those are the type of midwives that practice in NY, yeah, probably mostly CNMs or CMs.

          • Hush

            Being from the community, Trixie, no. Those are not generally the home birth midwives. Off the grid midwives are very common here in the Amish community and the alternative community. They are not LM/CM/CNM in general.

          • Hush

            They might be what is included in your statistics but they also may not be because midwives here are not necessarily licensed. I don’t know. If it were, I would be upset because I think that our more educated midwives could do so much better if they acted in more conservative/less “woo” as you all say it, ways.

          • moto_librarian

            You may be able to report this to your insurance company. I don’t know whether or not it can be done anonymously, but look into that option.

          • Trixie

            I think reporting her to your insurance company is a great idea.

          • moto_librarian

            This whole insular culture of NCB is detrimental to women. I understand why you don’t want to speak out about it publicly, because you face losing many friends, but what happened to you was WRONG. You are not being “sensitive” – you received substandard care that could have killed you! Your symptoms are entirely like mine after I had a pph, and you deserved better care than this.

          • Renee Martin

            Hush-
            CUT YOUR LOSSES, get out now. They are NOT your friends. Friends allow you to think for yourself and love you even if you differ on things like HB.

            My dearest local friend was once in a group like this, they were long time friends, a solid little, supportive band of buddies. You know, the kind of friends all women love to have.

            Then she started realizing that HB was dangerous, and that some of the MWs in town, the ones her friends used, were dangerous. Even responsible for deaths, let alone all the other stuff that gets brushed off. When she brought it up, she was silenced, when she tried to bring it up, she was pushed out totally.

            They didn’t tell her why, they just quit calling, quit replying to ghert, just total silence from ALL but one. They just quit being her friend after YEARS, and she is a loyal friend like no other, and worth any extra effort (really is their loss).
            The thing that made them turn on her? She wasn’t in love with Ina May and said so. HERESY!!!

            She was hurt, and it took awhile to even know what happened. One person told her why the others shunned her, but none of the rest of them would even bother to talk to her about it.
            THIS IS TYPICAL OF THIS CULTURE. This story repeats itself regularly, with others, all over the nation.

            These people will NOT be there for you, unless you tow the party line. I am dead serious when I say its better to have no friends than ones this worthless. You can make new friends. Healing the hurt from this kind of treatment is much harder.

            I am totally serious. You do not need friends that would treat you like an enemy over something totally normal. If you had been treated this way by an OB, they would want to crucify them, but a MW makes it ok?

            You aren’t too sensitive, you are just the only one in that group with a functioning brain capable of critical thinking. Once you drink the kool aid, so to speak, you lose the ability to see things clearly.

            I am in crunchy town, I am new here. I call it the center of woo-niverse. And even I have cool friends that aren’t total assholes like those ones.
            Best luck.
            YOU DESERVE BETTER

          • I can only imagine how hard it is coming from deep in the movement. I’m the friend b mentioned by Renee below, and I’m sorry you’re facing excommunication. It’s miserable and it hurts. You do deserve better (even though I still tend to blame myself for my own excommunication) and this is one of the only places I speak freely about the party line too. Even though I wasn’t even a “church member”

          • We’re on a bridge, Charlie.

    • Mike Stevens

      As a doctor, I know that it is incredibly difficult to quantitate blood loss. Sometimes a cup full of blood splashed over a large area makes it look like you have lost a couple of pints, sometimes a large quantity is grossly underestimated because it soaks into swabs/pads/clothing, or goes down the loo.

      • LMS1953

        I once was in a group of 3 OBs whose function was to back up 4 CNMs in a birthing center. They refused to get admit CBCs because “that was not a positive affirmation”. So they called me the morning after a delivery the evening before to report a Hgb of 6.0. I asked what the antepartum H/H was and what the platelets were. That was when I got the positive affirmation schtick. Well, what are the platelets now? We only get an H/H. Her 28 week Hgb was “fine”. What was it? I don’t know the exact number but it was fine. Well, I have seen many cases where a Hgb of 12 at 28 weeks drops to 9.0 at 40 weeks. It is one thing to drop from 12 to 6 and other thing to drop from 9 to 6. What was her EBL from delivery. I don’t know, it was a waterbirth so it was hard to estimate. Jeesh

        • Young CC Prof

          They refused to get admit CBCs because “that was not a positive affirmation”

          So if I get in the passenger seat and buckle up my seatbelt, am I failing to affirm my faith in the driver’s skill? I suppose we should all remain unbuckled because we trust cars! After all, the risk of even a minor car accident on any given day is orders of magnitude smaller than the risk of PPH from any given birth…

          • Anj Fabian

            Dumbest damned excuse that I have ever heard.

            If you are all in favor of evidence based anything, you should be all in favor of collecting evidence.

        • The Computer Ate My Nym

          It is one thing to drop from 12 to 6 and other thing to drop from 9 to 6.

          It also depends on how fast it happened: It’s one thing to get a bit iron deficient due to increased utilization during pregnancy and drop down to 9 over several months, another to lose blood acutely and drop from 12 to 9 over a matter of minutes to hours. Still, if the patient’s not sick enough to need a hospital, just send them to your local hematologist and s/he’ll give them some IV iron, which, if nothing else is going on, should solve everyone’s problem.

          • LMS1953

            IV iron is not without risk. I have seen the skin of entire forearms sloughed after infiltration. I agree, the rapidity of the fall in Hgb was the key. I had no way of knowing if it dropped from 12 to 6 in 10 hours or 9 to 6. I had no way of knowing if she had Von Willebrands – PPH being a common presentation. Her MCV was normal so I figured she did not have chronic Fe deficiency. Her resting pulse was 110 and she was pale and dizzy. My usual protocol is to transfuse for Hgb <7 since there is no reserve to combat more blood loss nor to fight off infection. She accepted my advise and after 3 units she got back to 10.5, pinked up and did just fine. I could not get the CNMs to later obtain tests for vWD – what the hell did I know, I was just an obstetrician. Ironically, a week later an adolescent came in with menorrhagia. Her mom was with her and was quick to add that she had PPH delivering that daughter and eventually had a hysterectomy for chronic menorrhagia. I had them both tested and yup, they both had vWD. I tried to arrange a lunchtime case presentation and to introduce the California protocol for PPH but the clinic just blew me off. Their patients were low risk and healthy and it was important to trust birth. How did we ever get here as the human race. I swear on the Sabbath that is the honest truth!

          • The Computer Ate My Nym

            High MW iron dextran or something newer? Agree, either way, it’s not risk free. Then again neither is blood transfusion but I agree that someone with a hgb of 6 and tachycardia needs blood unless they absolutely refuse.

            I tried to arrange a lunchtime case presentation and to introduce the California protocol for PPH but the clinic just blew me off.

            Sigh. Unfortunately, I can believe it.

          • Mishimoo

            Side note – vWD always makes me think of Dobermans and German Shepherds.

        • Renee Martin

          How about you stick to THESE kind of posts?

      • Hush

        As a total novice I ask this.. Would symptoms the woman is feeling not help you assess that a bit? Like, a woman who is having trouble walking at all without her vision blackening and her heart pounding out of her chest? Would that be a clue about blood loss? If she couldn’t talk to you after a birth coherently or get herself up off the floor would that be a clue to blood loss.. or do you not take that into account? (I’m not being snarky at all, I seriously don’t know how you gauge blood loss at all)

        • Trixie

          Were you transferred to the hospital when you had those symptoms?
          Are you okay now?

          • Hush

            I was not transferred for any of those symptoms. I am fine now.

          • Trixie

            I’m glad you are okay now. I hope you have followed up with a medical doctor recently to make sure everything is good.

        • Mike Stevens

          I agree, signs of significant blood loss will be lightheadedness, possible fainting and collapse, racing heart beat, low blood pressure (if measured). If that’s what you had then it is likely you lost more than 500ml, yes.

    • Captain Obvious

      From our state’s obstetrical hemorrhage project slides to help decrease maternal deaths due to post partum hemorrhage.
      “Approximately 160 million women become pregnant around the world each year. Of these, 15% develop complications related to pregnancy, which leads to the deaths of about 600,000.
      National mortality rate due to hemorrhage is 7.7/100,000. In Washington DC it is 22.8/100,000. According to the WHO 2005, 127,000 maternal deaths occur per year due to PPH.
      In the USA, 2-3 women die every day due to pregnancy related complications. Obstetrical hemorrhage is the most preventable cause of maternal mortality. Other causes include preeclampsia, HTN, heart disease, embolism, and infection.”
      I thought the MANA survey or the Cornell study found PPH to actually be more common with Homebirth than hospital birth, opposed to what many NUCB followers claim that PPH is nearly unheard of (undocumented more likely) at Homebirth.

      • Young CC Prof

        The MANA study found that PPH was 4-5 times more common at home birth. WITH midwife estimates of blood loss, instead of the more accurate hospital measures.

    • The Computer Ate My Nym

      500 cc is about the amount of blood you lose if you donate blood. That much blood loss shouldn’t make you weak and dizzy in and of itself. It’s possible that 500 cc of blood loss plus another problem (i.e. maybe you were anemic before for some reason or you had post-partum thyroid issues, etc) could cause these symptoms. But I strongly suspect that you’re right and the basic issue here is vast underestimation of blood loss.

      It’s not clear to me from your post how long ago all this was and whether you’re still feeling ill, but if you are I’d suggest you see your primary doctor for a quick cbc and other testing as needed.

      • The Bofa on the Sofa

        That much blood loss shouldn’t make you weak and dizzy in and of itself.

        It is not uncommon for blood donors to be weak and/or dizzy after donation. That’s why they make you hang around for 10 minutes and give you juice and cookies, so they can monitor you.

        There are always people who stand up after their juice and cookies and pass out.

        • Young CC Prof

          Blood donors sometimes feel “off” for a few hours, but recover once they eat, drink, and restore normal volume. Feeling weak for days or weeks requires the kind of blood loss that produces real anemia.

          • Anj Fabian

            The worst I’ve ever felt is the need for a good long nap and an early bedtime.

            I don’t know what my N is, but I’m over ten gallons at this point, so my cumulative anecdata is significant.

        • The Computer Ate My Nym

          You’re right, though the more usual cause of weakness and dizziness after blood donation is a vaso-vagal reaction (the blood vessels open too widely and cause a decrease in blood pressure) rather than anemia per se. In any case, blood donors shouldn’t still feel weak and dizzy weeks later*. Certainly if you feel a racing heart rate and like you’re about to pass out a day after donation something is wrong.

          *Unless they’ve actually managed to run their iron stores down to nothing by donating too often. (Says the Rh- CMV- donor…)

    • fiftyfifty1

      A 500cc postpartum bleed should not cause symptoms of heart racing and difficulty seeing unless the mother also went into the labor really anemic to begin with (which should have been tested for by any provider).

      You now have had a PPH (post partum hemorrhage) with both of your babies. The first, at 500cc, would have risked you out for any future homebirth in every other 1st world nation (Netherlands, UK etc). The reason is that having had one abnormally high bleeding amount puts you at much higher risk for having another. Now you have had 2 PPHs, and the second, by all appearances was *quite* severe. With symptoms like yours, I would say it was sure to be over 1,000cc. Please, please, do not birth at home again. The next time could leave you babies without a mother.

    • moto_librarian

      You lost a helluva lot more than 500 cc! I haven’t looked at the specific volume numbers from my own pph, but I know that they left my I.V. in because they told me that if my hematocrit dropped one more point, they were going to transfuse me. I was too weak to stand up or walk for the 24 hours after delivery, and I didn’t even try to shower until the second day. I was prescribed heavy duty iron supplements, but even with those, I didn’t really feel right until a good 6 weeks after delivery. Your midwife is covering her ass and is fabricating “evidence” to back up her lie. She should have sent you to the hospital ASAP!

      It is completely true that no one in the NCB community wants to hear about a less than optimal birth experience, especially if you achieved the coveted “prize” of an unmedicated vaginal birth and still found it to be a less than optimal experience. Is your midwife a CNM? If so, you should report this behavior to your state nursing board. If she is a CPM, I hold out little hope that anything will be done about it if you file a complaint with MANA.

    • NoLongerCrunching

      I’m sorry for what you went through. Though I was given great care from my CNMs, my eyes have really been opened by reading this site, with all the amazing commenters. I hope you stick around so you can get a different perspective than what you’d get in homebirth circles.

    • Renee Martin

      Your MW was a dangerous idiot, and you and baby are lucky to be alive with such substandard care. You probably needed a transfusion if you felt that way after blood loss. I am just glad she even bothered with the meds, had you had a CPM you might be dead. It seems that as son as MWs chose HB, they put their philosophy first. Its deadly.

      What you are experiencing with not being allowed to express yourself, is par for the course. Any HB or NCB mom that loses a baby, get injured, or just thinks her care was poor, better not say a thing. Doing so is not allowed. The subculture of HB is one of extreme conformity and censorship- both peer based, and self censorship. This leads to hiding issues that really need addressed, and harassment of dissenters, no matter how mild.

      I sure hope you find a nice hospital based CNM or OB practice, and find a hospital next time.
      YOU DESERVE BETTER

    • Rosalind Dalefield

      I’d say you lost a lot more than that. I lost 1.25 litres after my third baby and was white as a sheet for a few days but never faint, no tachycardia, no problem with my eyes. You are probably lucky to be alive.

  • Trixie

    Silly Dr. Amy — this can all be prevented by “watching and praying and holding that space of intuition.”

    • Young CC Prof

      That Elaine actually does seem to understand the science, we just, um, differ in our interpretation. “The hospital staff tries to ‘catch’ late decels early before the baby is in trouble.”

      Yes, yes they do. Because if you wait until the distress is certain, it’s too late.

    • Elaine

      It galls me that this question is being asked by someone who in any way represents herself as an expert on birth. It would only be appropriate coming from someone who is not pretending to know more about birth than a layperson can apprehend by taking your average childbirth class and reading a couple of books.

      As a pharmacist, this sounds to me like the equivalent of a pharmacist asking “So I need some help understanding why the patient was switched from Amoxicillin 875 mg to Ciprofloxacin 500 mg? 875 mg is stronger than 500 mg so the Amoxicillin should have been better.” And I wouldn’t want that person within a mile of my drugs.

    • Medwife

      Grr. So much to correct in those posts, but Sharon hodges’ “listening longer (to late decels) to determine what I was hearing”… Gah. If she’s auscultating late decels, since she is AUSCULTATING and you can’t get variability that way, it’s time to switch to continuous EFM! Especially if she’s at home, god, she’s just wasting time that she should be using to transport. And this is someone who apparently sees herself as particularly cautious. Scary.

    • Bombshellrisa

      “Mothers intuition balances out heart rate patterns”? Wow.

      • Sue

        So hospital combines science, technology and intuition, and HB is just about intuition. That sums it up nicely – thanks.

      • Lisa from NY

        Blame the mother for the dead and brain-damaged babies.

    • Renee Martin

      “The problem is that the hospital staff tries to “catch” late decels early before baby is in trouble.”

      If you find this a problem, then you have no business as a MW. Scratch that, you have no business being around women or babies, period.

      I sure hope the person asking the question is a student, and not already seeing victims, er, patients.

      • Allie P

        That’s it in a nutshell. They believe there’s no point in doing anything until the baby has actually experienced problems. No c-section is necessary unless it is discovered afterwards that the baby was dying. If the baby came out “fine” then the c-section was “unnecessary.” BS.

        • The Bofa on the Sofa

          I was listening to Dr Radio on Sirius/XM (channel 81) the other day, and it was completely unrelated, but the comment was something like, “People don’t understand how much of medicine is about preventing complications.”

          Real medical providers realize that when you get to the point of having an emergency, then it has gone to far. Emergencies are bad, pretty much by definition. Outcomes in emergency situations are much worse than in non-emergencies. Therefore, you wan to avoid emergencies.

  • meglo91

    Trusting birth is for fools. My first daughter was born after a fairly uneventful labor. She had a few late decels while I was pushing. After 2 hours I wasn’t getting much of anywhere, so my OB calmly told me she could either use the vacuum or we could do a c-section. I went for the vaccum and my baby was out in about 10 minutes. Her Apgars were 6/7, and the docs said she was “shocked” — by the trauma of labor, the trauma of her birth, and the vacuum. What if I hadn’t been in the hospital? Would “shocked” have turned into stillborn? I look at her on the couch next to me, a bright and healthy 3 year old being read to by her daddy, and I wonder.

  • Sue

    Imagine what the community might think of home birth if we knew the true morbidity – and particularly HIE – rates in OOH birth.

    • birthbuddy

      OOH HIE rate = 18X the hospital rate. It should form part of the standard consenting process. It should not be minimised as doctors fear mongering.

      • Young CC Prof

        That’s the rate at which homebirth babies with hypoxia are promptly transported and diagnosed with HIE severe enough to benefit from brain cooling.

        True incidence of all avoidable morbidity, including maternal? No one knows, although the MANA study provides disturbing clues. One of the things that freaked me out was that 400 babies had no APGAR recorded at all, and of the babies with recorded APGAR less than 7, over 100 weren’t transported to the hospital.

        Um, who the heck looks at a baby who just flunked an APGAR and doesn’t call an ambulance?????

        • fiftyfifty1

          “One of the things that freaked me out was that 400 babies had no APGAR recorded at all, and of the babies with recorded APGAR less than 7, over 100 weren’t transported to the hospital.”

          The APGAR, a tool invented by men to trick women into believing they needed their help with childbirth!!!

          …Oh whoops, actually invented by a *woman* to identify which babies needed extra careful attention and monitoring in the immediate postpartum period. And it’s saved countless lives.

          • Lizzie Dee

            Invented by a woman because it is very difficult to identify which babies will have long term problems and which won’t.

            Something about this article makes me uneasy – but I am not sure what. If (some) women, those inclined to homebirth mainly, don’t know or won’t accept that babies can die, there seems to be even less attention paid to the possibility of brain damage – and little said about it when it happens. I know from experience that it is the Great Unmentionable, but when women say they know and accept the risks, are they factoring in this one?

          • Medwife

            Some of them on MDC I’ve seen say they would rather their baby die than be brain damaged. It’s awful to read.

          • Lizzie Dee

            That is a fairly widespread mainstream opinion, for all
            sorts of reasons, some good and some not so good.

            Choosing a homebirth is one way of increasing the chances of a death rather than a disaster, I suppose, given that speedy action and expert help make all the difference. What do people mean by “Not meant to live”anyway?

            Two things trouble me about this article; one is the implication that brain damaged babies don’t happen in hospital. They do. Much less likely with proper,
            cautious care – but given the present climate that is not always synonymous with hospital care. WHY didn’t cEFM reduce the incidence of CP? Is it really because birth injuries don’t cause brain damage? A very convenient belief when litigation is so feared. Could an alternative explanation be an over-optimistic belief in false positives sometimes, or not reading the damned thing properly? (That has improved nowadays as well.)

            Obviously I know more children than is usual with brain damage/cerebral palsy – most born in
            hospital after hair-raising/careless vaginal deliveries.

            The second thing is the skating over the reality of the devastation that can be caused. Things ARE better than they were when my daughter was born, and the
            input of paediatric neurologists really can make a huge difference. As in everything related to childbirth, luck and accurate knowledge are the things
            that make a difference, not the degree of trust.

          • Box of Salt

            Lizzie Dee “when women say they know and accept the risks, are they factoring in this one?”

            I doubt it. I don’t think they’re even accepting the other risk (death).

            I am often struck how folks talk about what the numbers are without internalizing what exactly the consequences are should they end up as “the one.”

          • Ennis Demeter

            Invented by a woman who became an anesthesiologist because she was told no one would hire a female doctor, and people don’t pay attention to who their anesthesiologist is.

  • MLE

    The more I read here, the more I want any future children to be born via CS. Yes I am now a Dr Amy minion stereotype, mad to be cut open under harsh lighting. Vaginal birth just seems too damn risky for very little reward. My first was born slightly purple and did not give anyone cause for alarm, but how many brain cells did the labor process cost him? I’m not willing to sacrifice any brain at all for a vaginal birth.

    • Elizabeth A

      I think vaginal birth is probably usually safe. For certain values of “usually.” I remember reading history books about midwives that included a comment that, nine times out of ten, a healthy young woman could give birth, unattended, in the open fields, and be fine. But there was no way to tell which one was the tenth. (Also, note qualifiers – healthy and young were not defined by my text.)

      FWIW, my c-section was peaceful and painless.

      • MLE

        I think what has made an impression on me is that it is impossible to tell if it will be safe until you’re in the middle of it, and prior uncomplicated births don’t seem to be a perfect indication of how each subsequent baby will fare, since it’s the same body but a different baby.

        • Young CC Prof

          Prior uncomplicated births are no absolute guarantee, but they DO have considerable predictive power, especially if you’ve had basic prenatal tests to rule out complications specific to this pregnancy, like, say, twins.

      • Lizzie Dee

        I think when it comes to the history of midwifery the number of healthy young women who were not fine is fairly convincing. It is modern obstetrics that changed that, and now you don’t have to be either to do well.

    • fiftyfifty1

      Subsequent vaginal births after a first, uncomplicated, birth are statistically very safe as long as all prenatal testing is normal.

      • MLE

        As YCCP mentions below, it’s no absolute guarantee. As a paranoid control freak, I demand a guarantee! Actually I think I’ll just make it clear that at the slightest sign of trouble, I want action, in case anyone is worried that I might be the type to object to an unnecessarian.

        • Haelmoon

          Unfortunately, a c-section is not a guarantee either. Sometimes C-section deliveries can be very difficult also, and I have had flat babies from elective c-sections because I had trouble getting the baby out. This can especially be true wit repeat c-section, with significant maternal scaring or with breech babies. Mind you, I would take these difficult sections over a difficult vaginal delivery.
          I am an obstetrician, not a pizza delivery man – I make no guarantee about the delivery at all!!

          • MLE

            Yeah, the only safe solution is to beam them out, and it will be a while before that technique is perfected. Stuck in a tiny tube just seems like an undesireable place to be in the event of an emergency.

    • Sullivan ThePoop

      My nephew was born blue and needed a little time in the NICU, C-section not vaginal. If he lost any brain cells I can’t tell. They have not invented anything childproof that he cannot figure out.

      • MLE

        Imagine all those blue HB babies who don’t get extra help 🙁

    • Hannah

      I am pregnant with my first and am increasingly feeling like I want an elective c-section. I have just heard so many horror stories in my personal circle lately, particularly female cousins, that I feel like it’s the only way to have control of the situation. On the flipside, all of these horror stories involved midwife-led care in Australia and Canada, and situations where woo was trumping science in a hospital setting until things got heavy.

      I am giving birth in the US under the care of an OB, so I am hoping that I won’t have to deal with some of the things my family and friends have recently.

  • S

    “The signs of fetal distress are often too subtle to be detected by simply listening to the heart rate though it would be glaringly obvious on an electronic fetal monitoring tracing.”

    I wonder if it would help clarify your point to link back to the post in which you explained this point in detail. I am guessing a lot of the women who fear EFM false positives don’t really understand the trade-offs.

  • Elaine

    OT: wondering, O wise obstetrical types, if my son might have been running out of time due to an aging placenta. He was born at 40+2; uneventful pregnancy, spontaneous labor without incident, born healthy. After he was out, MW was concerned about my blood loss, tried cord traction & cord broke off. She ended up having to manually extract the placenta (OUCH) and it came out in pieces. Also he had basically no vernix and his hands were very wrinkly. I contrast this to my daughter who was born at 40+4 covered in vernix, no wrinkles, and placenta came out in one piece. Thoughts? I mean, obviously it doesn’t change anything now, and he is fine, but inquiring minds like to know. I keep meaning to ask my MW at a followup visit and keep forgetting.

    • CanDoc

      Either placenta/baby matured more quickly first time around, or dating was less accurate than you thought and first baby was in fact MORE overdue than the second baby. Good recent research shows that dating by Last Menstrual Period date is much less accurate than we always thought, women ovulate at all different times during the month.
      Cord pulling of the placenta and manual removal really aren’t related to this at all, but related to attempts to remove a placenta that has not separated from the lining of the uterus. I tell all of our new medical students and residents on the first day of the rotation that if they pull the cord off the placenta then they fail the rotation. I’m only half-joking. I’ve done it myself three or four times (in 16 years of 200 deliveries per year, just saying’).

      • Elaine

        Both sets of dates were equally accurate. I charted with both so had ovulation pinpointed to +/- a day. That is interesting that they could have grown at slightly different rates. I think their weights were comparable, since she outweighed him by 4 oz, but he pooped twice before getting weighed, so that might have been those few ounces.

        As for the cord thing, that makes sense. It did seem like she was in an awful darn hurry to get the placenta out. She said that based on her experience she was concerned about my blood loss and didn’t want to wait. She said she estimates a manual extraction has to happen in maybe one out of 50 births. I can either believe that she made the right call, or think she jumped the gun and should have waited a bit, so since I don’t have the experience (i.e. any) to evaluate it I’ve chosen to stick with thinking she made the right call.

        It’s kind of funny actually, I am really pretty low-intervention… I just feel like I don’t want anybody bugging me if everything is progressing smoothly, and I still really don’t want a c-section despite all the c-section love I read here. (Of course, if an intervention or c-section became necessary, that’s a different story, but I’m pretty satisfied with my two super-low-intervention unmedicated births.) But I’m not really that bothered by this one even if in hindsight it wasn’t necessary, because hey, it’s not like it increased my risk of a c-section, since the baby was already out. And I had a baby to focus on so it kind of made everything else not matter so much.

        • fiftyfifty1

          Almost everyone would be pretty satisfied with two smooth, easy vaginal births that ended without complications. The “c-section love” that you read here comes from women who did not draw the same happy hand of cards that you did.

          If your first vaginal birth had been a decidedly un-smooth experience that required months of rehab and left you with permanent urine and stool control problems (as mine did) you might be expressing some C-section love yourself.

          Wish I could guarantee an easy uncomplicated birth for every mom and baby (by whatever route is best for that pair).

          • Elaine

            Oh yeah, I get that. I’m just saying that not having had cause to have or therefore be grateful for a c/s, I am still in the “really want to avoid” camp for me personally, and should I have another, not needing a c/s is still one of my hopes for the birth (though obv. less important than the ‘live healthy baby’ hope).

            However, despite my disinclination to be hooked up to more things than necessary, I care less about avoiding an epidural than I used to, and may try to get one if my water breaks first next time, based on the contrast in difficulty between my labor with my daughter (water broke before any contractions) versus with my son (broke right before pushing).

          • Young CC Prof

            For a woman who’s previously had relatively easy vaginal births, hoping not to need a c-section the next time around is pretty reasonable! (It’s also pretty likely.)

        • Medwife

          Ah, the third stage. People think the drama’s over once the baby’s out but the third stage takes such delicate management. If you were bleeding heavily while the placenta was still in the uterus, and the bleeding isn’t coming from vaginal trauma, it’s often because the placenta has partially detached. Gotta get that sucker out. If manual extraction is necessary, that’s when you’re really grateful for an epidural being in place. Otherwise IV medication helps a bit, but it’s wretched.

          (I’m aware that I’m oversimplifying 3rd stage management)

          • Elaine

            Yeah, pain relief during that process woulda been nice… Every bit as bad if not worse than 2nd stage. If having needed a manual extraction once would make me more likely to need one again, that would be another big point in favor of getting an epidural for any subsequent births.

    • No vernix and “wrinkly” are classic for postmaturity in general, not necessarily connected to poor placental function. Vernix typically disappears after the 38th week, so if your second baby, term by dates, had a lot, your dates by LMP were probably a little off.

  • Kelly

    These people need to spend a week shadowing a parent who has a severely disabled child. Then decide if they want to risk it. I am sure they would then see that it could happen to them. This just makes me so mad because I know that if my parents could have done something to prevent my brother’s severe disability, they would have done any kind of test or surgery to give him a normal life.

    • DaisyGrrl

      I spent most of my teenage years volunteering and working with individuals who had various developmental disabilities. Almost all of them were confined to a wheelchair and were non-verbal. For a while I considered a career working with these individuals. I don’t think people truly understand unless they’ve lived it, but I’ve gained an appreciation for how much hard work is involved in caring for severely disabled people. It’s a tough slog, and I hope your family has had the resources and support you need in caring for your brother.

      • Kelly

        We thankfully have lived in an area that has many resources and can give my mom a break. She is an amazing woman and the doctors and social workers always give her complements on how clean and well taken care of he is. I say we are very lucky to be in this situation and at the same time, it is still hard. I think it is awesome that you were able to volunteer. I had some pressure by many people to work with people with disabilities but I came to the realization early on that I was only comfortable taking care of my brother and instead chose a different career path. We have had some amazing teachers and helpers over the years that took amazing care of him and we will forever be indebted to them.

  • BroccoliSoupTown

    I had a baby last month, and it was a repeat c-section because my first two were emergency c-sections. I’m glad I didn’t have the option to labor because my baby’s umbilical cord was wrapped twice around his neck so tightly he had a brachial plexus injury. I can’t imagine how much more damage would have been done if I had delivered him vaginally, with the cord pulling tighter and tighter as he descended through the birth canal. Even just the few minutes it took to pull him out caused lower apgars – the doctor said the strangling “stunned” him and they had a very difficult time getting him to breathe and move. If even the best obstetricians in my region delivering in the best hospital in my state couldn’t prevent long-term injury to my son, how could anyone say a poorly-trained lay midwife could do better in a pool in my living room?

    • Jessica S.

      Congratulations on the new baby and I’m so glad it didn’t end tragically!

    • sdsures

      Mazel tov!

  • PenFox

    Thank you for this discussion. Other than a few weeks of prodromal labor, my first pregnancy seemed completely normal. I went into labor at 40+2 and due to CEFM we saw troubling fetal tracings emerge around the 6th hour of active labor. When the OB broke my water, we saw meconium. It was off to the OR, and my beautiful son was healthy and happy (8/9 APGARs) when born. The placenta was sent off to pathology, but I didn’t follow up on it until a year later. I was immensely grateful for having a decisive, compassionate, thoughtful medical team (including the OB, the nurses, the anesthesiologists, etc.). Even so, I sometimes wondered whether the c-section was “necessary”– I am the only woman in my family to ever have one. A year later, I asked about the pathology report, and it turns out that the placenta was much smaller than typical and had a velamentous cord insertion. I am so grateful that I trusted evidence based medicine and didn’t protest the c-section. If I had insisted on “trying” to continue labor, who knows what terrible result may have ensued.

  • Jessica S.

    Speaking as a woman currently pregnant, I can scarcely fathom refusing monitoring during labor, or any other practice that is meant to keep watch over the baby. I mean, nine months is a long time to grow and nurture this budding life, and an eternity to SUFFER all of this pregnant nonsense (only 14 more weeks to go – oh god, I still have 14 weeks to go?!?) to just be like “meh, I trust birth”. Only people who deny or are un/misinformed of the fragile actualities of birth can so blithely write them off.

    • Hannah

      Nearly 27 weeks here (I know what you mean, STILL 14 WEEKS TO GO?), and I feel exactly the same. The only thing is that I have so many friends and acquaintances who think I am the uneducated one, because I didn’t watch Business of Being Born and swallow that crap whole. Never mind that I can tell them all the reasons why it is, objectively, bullshit.

      • Jessica S.

        That would drive me bonkers! My sister-in-law is just two weeks behind me, and luckily she’s not swept up in the woo, so I don’t have to tolerate anything. 🙂

        • Hannah

          Yeah, I mostly get frustrated when my friends in Australia feel sad for me that I am giving birth in the US and am therefore guaranteed to have a cesarean.
          Meanwhile those that have chosen to go public and have midwife births in Australia are seriously being told to go to Spinning Babies to prevent the horror of a cesarean or being told that there’s no worries until 40+14.

          • Young CC Prof

            “The infant mortality rate of your country is the probability that your infant will die. The c-section rate of your hospital is the probability that you will have a c-section if you deliver there.”

            Um. No?

            We run into this classical logical fallacy in education, only it’s phrased as, “The graduation rate of a school is the probability that you will graduate if you go there.”

            YOUR probability depends on a lot of things, many of them independent of where you are. People need to understand this.

          • Hannah

            I am confused, are you replying to me? I didn’t say that at all!

            By ‘because infant mortality’ I meant that they’d watched BoBB and read a few blogs and completely misunderstood which rates apply to what. (i.e. infant mortality has nothing to do with the outcome of my pregnancy or birth).

          • Hannah

            I am a bit confused, I didn’t say:

            “The infant mortality rate of your country is the probability that your infant will die. The c-section rate of your hospital is the probability that you will have a c-section if you deliver there.”

            I feel like there’s some posts missing here, or something.

          • Young CC Prof

            No, you didn’t say that. People freaked out over the US infant mortality rate essentially do, however. Sorry if I was unclear.

          • Hannah

            That’s what I figured, the phrasing just confused me. I couldn’t agree more with what you said, I just thought you were quoting ‘me’, haha!

          • sdsures

            People fixated on a given hospital’s CS rate drive me absolutely batty. What if that particular hospital is in a city centre and has a NICU in it, and therefore may be the go-to hospital for labour complications in an emergency? Their rate would be higher by virtue of geography, not by some evil conspiracy of the OB department.

      • AmyP

        It’s not a bad postpartum view–I watched it and the sequels while breastfeeding my last baby. (They do one with a road trip to The Farm.) Not sure how they managed to make the hospitals look so scary–I guess that’s why you go to film school.

        I wouldn’t watch it while pregnant, though, and I definitely looked away during the epidural insertion scene. I’ve had three of them and I don’t need to see what it looks like from the rear.

        • Hannah

          I watched it before I was even pregnant and it’s actually how I came to find the Skeptical OB. I am so glad that I was educated on what a crock of shit NCB is long before it was ever really relevant to me.

          It’s all about how you edit the footage. My brother is a film grad and now in directorial school and I showed him a little of it and he said Lake obviously learned from the Michael Moore school of convenient editing.

    • LadyLuck777

      Bwahaha! I’m jealous of you both. I’m only halfway and already I’m looking forward to finding a comfortable sleep position again. I completely agree – I am not spending all this time cranky, weepy, bloated and hungry just to blow my skirt up. I will do everything possible to ensure this is a healthy baby!

      • Jessica S.

        I can’t wait to sleep on my stomach again, and I’m not even a stomach sleeper. I’d just like to have the option!

        • LadyLuck777

          I am a stomach sleeper, so anytime I happen to fall asleep on my back on the sofa it’s a wonderful day.

        • Hannah

          I am a stomach sleeper and I still occasionally sleep sort of on my stomach but twisted a little so the little one doesn’t get smushed. The worst is accidentally ending up on my back and getting this weird pressure that wakes me up!

      • Hannah

        Get the Snoogle. You’re welcome.

        Honestly, I felt ridiculous, but it is the greatest bed-related invention since Tempurpedic Foam and 1200TC sheets.

        • sdsures

          My husband and I have Egyptian Cotton bedding, because of his fibromyalgia, which causes severe skin hypersensitivity. Well worth the extra expense. (We got two sets of bedding because I sometimes have accidents due to my cerebral palsy; the mattress also has a plastic cover, but I don’t remember where we got the mattress.) I do remember we drove out to the store to actually test the mattress, but we got the bedding off Amazon. Our previous mattress was memory foam, but we like this spring one much better.

  • Neonatal fellow

    Dr. Amy, thank you for this wonderful, straightforward description of HIE – now preferably referred to as neonatal encephalopathy (legal reasons). This, to me, is why homebirth along with free-standing birthing centers will never make sense. To the neonate, time = brain. Anything can happen at any time; why wouldn’t you want a neonatologist or at least a pediatrician there ready to save your baby?

    • Jessica S.

      Amen!

    • LMS1953

      Interesting …. We have to call it a “non-reassuring test of fetal surveillance” instead of fetal distress – for legal reasons. But, let’s take a cohort of babies delivered electively by repeat C-section in the 38th week and compare it to a cohort of vaginal deliveries of primips in the 41st week as regards to the risk of HIE/NE. If HIE/NE were mainly due to antecedent antepartum incidents/conditions, then the rates should be similar. But I’d bet they are not – not by an order of magnitude.

    • BroccoliSoupTown

      A freestanding birth center in my hometown just got shutdown for that very reason. A baby died because being a 10 minutes away from a hospital ended up being 10 minutes too far.

  • Jessica S.

    Excellent post, Dr. Amy!

    Whenever I read detailed accounts of what a baby experience during labor and delivery – and I’m talking about an “average” scenario like the hospital, setting aside the increase risk of distress that occurs during stunt births shenanigans – I’m relieved that our autobiographical memory is essentially nil the first few years of life. 🙂

  • LMS1953

    This is what galls me about the canard of “evidenced based medicine”. Just say the words and like swallows to Capistrano and Monarchs to Mexico, the crunchies come swooping in. Witness the reaction to the paper about evidence based standards of care for midwives and home birth. Since everything they do is “natural” it can be assumed to be harmless. They demand evidenced based rigorous studies to prove their interventions and woo are harmful. That is what the crunchies thought they were going to get with the scope of practice paper. After they tried to wrap their heads around the notion that the standards would RESTRICT their autonomy (another catch-word) and scope of practice, they all flew away – back to the unthreatening branches of the Woo Tree.

    On the other hand, common sense notions like continuous EFM being more efficacious at picking up ominous FHR tracings than intermittent auscultation are dismissed as “non-evidenced based” and by “logical” deduction cause harmful cascades of intervention. As if we can go, “Here you go Mom, here’s your number. You will be randomly assigned to one of two groups. One arm is continuous EFM. The other is going to be intermittent auscultation. We are trying to find out if EFM decreases the risk of HIE, newborn seizures and death.. Or if EFM is just a ploy by the penocracy to scam money out of the business of birth and get more money from unnecessary C-Sections.

    The same thing can be said for waterbirth. Water is natural so it can assumed to be harmless. Logical inferences such as the risk of drowning, hyponatrium, cord avulsion and sepsis are dismissed as infinitesimal and rigorous studies are demanded to prove the risk.

    However, any medical/surgical interventions WE do are assumed to be bad/harmful and rigorous tests are demanded to prove efficacy and an overwhelming benefit:risk ratio. It is clearly a double standard. So I warn the reader to understand that when something is called or the demand is made for evidence based medicine/studies think of the manipulative agenda that is working behind the scenes.

    • Young CC Prof

      LMS, I think I’ve told you this before. Your problem isn’t with evidence based medicine, it’s with EBM done poorly, or with quacks who claim to be doing EBM while in fact doing whatever “feels right.” Calling something EBM doesn’t make it so any more than calling your cat a dog will make it a dog.

      • Jessica S.

        I like to call the not-really-evidence based medicine anecdote based medicine. To me, *real* evidence based medicine is science based. Woo practitioners won’t usually use the term “science-based” unless they’re particularly deluded. Then again, there are sites like The Thinking Moms Revolution (or whatever it’s called) so clearly irony is lost on that bunch of people. 🙂

        • yugaya

          I like that, “anecdote based medicine”. So often what I have read that was referred as *article* or a *paper* or a *study* on NCB websites is nothing more than a bunch of anecdotes and random quotes carefully stitched up together, only appearing scientific enough to fool someone who is not used to trawling heaps of real scientific studies on regular basis.

          Come to think of it, that MANA study is probably a good example too, with all the lax methodology and administrative changes and the missing data black holes…

      • LMS1953

        Prof, I completely agree. I was just pointing out that EMB has an enormous capacity of being biased and agenda driven. It is now a magic catch word that is very useful for propaganda purposes. For example, what do you think is the agenda behind the “evidenced based recommendation” that mammograms not be started until age 50? Or the agenda behind the 39 week rule? You know, there is Level of Evidence that is assigned to the practice patterns of experienced, well-educated practitioners. But it is given the rank of the deuce of clubs. Where is the evidenced-based proof of that?

        • Young CC Prof

          Actually, there is evidence behind the recommendation not to start mammograms before 50. It’s mathematically and biologically sound, but it’s really complicated. Let me know if you actually want an explanation, because it’ll take a WHILE.

          • LMS1953

            I think there is probably good evidence that from a cost/benefit analysis that no health care should be given prior to death. After that, a prompt cremation or burial to prevent the spread of disease.

            I know why the recommendation was made. I read all about it. Call me a Luddite, but I am not going to manage by patients that way.

          • Young CC Prof

            But it’s NOT based on saving money. The cost of a mammogram has nothing to do with it. Health insurers absolutely want breast cancer diagnosed earlier! Compared to Stage 1 breast cancer, Stage 3 breast cancer still has pretty good 5-year survival rates, but it costs 10 times as much to treat. Unlike cancers of the internal organs, it’s pretty much unheard-of for breast cancer to go unnoticed until death is near.

            Listen carefully. It goes against every good doctor’s instincts, but it’s solid.

            First, mammograms just plain don’t work as well on young women. Too much tissue, and it’s too dense and glandular. Radiologist can’t see anything. Which means you’re going to get double-digit percent call-back for an ultrasound or MRI. And those women will be stressing, even though there’s absolutely nothing wrong.

            Second, in women over 50, about 90% of positive mammograms are false positives. In young women, cancer is much rarer, so the false positive rate is even higher, which means women get callbacks for biopsies. More procedures and anxiety, to catch very VERY few cancers.

            Third, there’s something called over-diagnosis. About 25% of small early breast cancers are what’s called “indolent,” meaning they are growing so slowly the patient will die of old age before getting sick from it. We currently have no way to distinguish indolent cancer from kill-you-soon cancer other than watching to see if it spreads, so we just have to treat everyone with surgery and chemo. Which means a lot of people suffer chemo for no darned reason at all.

            Fourth, the scariest breast cancer is the kind that strikes young women and moves fast. Even if you did annual mammograms, they would still miss most of those cases, because it goes from microscopic to metastatic in far less than a year.

            Fifth, points 1-4 show that annual mammograms of young women will accelerate diagnosis of very very few cancer cases. Because the benefit is so tiny, you have to look at the risk: extra radiation earlier in life. Why do x-rays for nothing?

            Of course, for women who have an alarming family history, or who have symptoms, go right ahead! But routine mammograms for all women just aren’t effective until around 50.

          • LMS1953

            Listen carefully, all of what you say, in practice, is horseshit. I will continue to advise and order first mammograms at age 40. You are welcome to sit on your early indolent breast cancer from 40-49. I’m sure everything will work out just fine.

          • Fish

            There is good evidence that mammograms don’t save lives. On what basis are you ordering them earlier?
            You want to not change the outcome for more people?

          • Siri

            That. And to be different, and special. At his patients’ expense.

          • Box of Salt

            LMS1953 “Listen carefully”

            Perhaps you would benefit from reviewing the literature cited in these two SBM posts (OK, yeah, but Gorski knows a lot more about breast cancer than he does homebirth):

            From 2009 http://www.sciencebasedmedicine.org/the-uspstf-recommendations-for-breast-cancer-screening-not-the-final-word/

            More recently http://www.sciencebasedmedicine.org/the-canadian-national-breast-screening-study-ignites-a-new-round-in-the-mammography-wars/

          • LMS1953

            http://www.mskcc.org/blog/recent-study-should-not-change-mammography-guidelines

            Sloan Kettering Cancer Institute says that it is horseshit too.

          • Box of Salt

            LMS1953 “SKC says”

            So now we should each surf the web looking for more opinion pieces which confirm our own?

            I suggested reviewing the literature, and posted Gorksi’s pieces because he links to the literature as well as analyzing it, rather than just telling us what to think.

          • LMS1953

            Well, mammograms starting at age 40 is the standard current recommendation promulgated by ACOG, but I guess your God Gorski is much more authoritative than the panel of experts who wrote the ACOG recommendation. BTW, brevity is not God Gorski’s hallmark, is it? After a dozen swipes of my iPhone page, I kinda lost interest. But, by all means, Trust Gorski with your indolent little ol’ age 40-49 breast cancer. And if it leaves your children orphaned, they can rest at ease that it was a statistically justified death.

          • The Bofa on the Sofa

            I guess your God Gorski

            Ha ha ha ha ha!!!!

            You are friggin clueless.

          • Young CC Prof

            OK, what you’re saying bothers me, and here’s why. It’s not because you disagree with me, Gorski or anyone else. You’ve been presented with a challenge to your current beliefs, one that comes from some creditable sources. And you’ve dismissed it rather than engaging with it and critically examining the evidence on both sides.

            If you pointed out some potential weaknesses in the studies that show routine mammograms before 50 do not reduce the cancer death rate, I’d love to hear it and learn from you. But that’s not what you did. You mocked the very idea that a much-touted medical test might be far less valuable than we once thought.

            If you want to disagree, disagree. Just do it better, I know you can.

          • The Bofa on the Sofa

            If you want to disagree, disagree. Just do it better, I know you can.

            For pete’s sake, YCCP, YOU could give a far better argument against his position than he did!

            Then again, that’s because you actually understand the problem. Unlike him.

          • Siri

            Charming. Are you a teenager? Oh, an old man? A doctor? Why can’t you be civilised, then?

          • birthbuddy

            You could be a little more civilised too.

          • Box of Salt

            LMS1953 “BTW, brevity is not God Gorski’s hallmark, is it? . . . I kinda lost interest.”

            OK. So not only are you too lazy to click on Gorksi’s links and read the original papers, you’re too lazy to finish reading Gorksi’s post, because it’s too detailed. Got it.

            Last night I thought about referring you to Siddhartha Mukherjee’s The Emperor of all Maladies, but rejected the idea because I haven’t finished the book myself yet (and I’ve had it for over a year).

            I will refer you to it now. Ironically, the chapter where I left off discusses lead time bias – exactly the problem involved in all these screening debates.

            The issue is not as clear cut as you want to make it.

            Let me know when you get your first mammogram, LMS1953, and worry about what it might show.

            Never mind. Just let us know when you start using your brain instead of being a reactionary against all change.

          • MLE

            I’m with you until the indolent part. I would rather not wait until something spreads to determine that it is in fact going to kill me. The fact that other women are going through chemo for “no reason at all” shows that they probably feel the same. Kinda like the constant fetal monitoring vs intermittent, in fact. It sounds like the bad stuff is getting caught at the expense of a lot of non life threatening problems being identified and treated as well.

          • Young CC Prof

            That’s pretty much the conclusion of most reasonable people about the indolent breast cancers, too. Yes, it stinks that we can’t tell the difference, but for now, treating all the breast cancer seems like the best option, especially since there is a 70-80% chance that the cancer needed to be treated anyway.

            However, the other thing to keep in mind is that those indolent lesions affect the cancer survival numbers and make screening programs look like they are saving more lives than they really are.

            Now, for prostate cancer, the ratio of dangerous to indolent lesions is much MUCH lower. So low that, in some cases, the probability of the cancer killing the patient is the same as the probability of the chemo killing the patient. So for early-stage prostate cancer, the recommendation is watch, not treat.

          • Young CC Prof

            Actually, you reminded me that I was using the fact about indolent lesions incorrectly. It’s not so much a downside to mammograms as it is a giant research pothole: The most, um, optimistic, studies of mammogram efficacy are about survival rates, and when you take a bunch of people who weren’t going to get sick either way and throw them in the denominator, surprise surprise, the numbers get better.

            The only valid measure of the success of a cancer screening program is a decrease in the death rate across the entire screened population.

          • MLE

            Makes sense. I am hoping for better screening techniques then, instead of focusing on decreasing screening rates.

          • Siri

            I would never accuse LMS of being a good doctor.

          • DaisyGrrl

            I would. I definitely disagree with his politics and he generally comes across as an ass, but I also see a doctor who cares deeply about his patients’ outcomes and takes pride in his work. If I walked into emergency in labor and LMS was the doc on call, I would think I was in good hands.

          • Siri

            I’d walk out! I think he’s arrogant, paternalistic, sexist and a victim of severe cognitive bias.

          • Siri

            See also his ‘horseshit’ reply to Young CC Prof below. Mammograms at 40? Gimme a break. I don’t want a doctor like that.

          • birthbuddy

            Siri, you have a choice. Don’t use LMS as your doctor. Done.

          • DaisyGrrl

            Fair enough. But most of the doctors I’ve seen in my life have matched at least 2 of those descriptions and some have hit all four. The most important question for me is whether the doctor is able maximize the possibility of a good outcome. Personal traits that are agreeable to me come second. How many killer midwives are soooo nice and listen to the patient’s desires and are bestest friends? Also, just because he’s an ass here doesn’t mean he’s an ass to his patients. It doesn’t mean I’d want to have a beer with him – just that I could do far worse in terms of docs in an emergency.

            I do agree with you about the mammograms at 40 bullshit. It’s interesting watching anyone wrestle with counter-intuitive findings. I’ve seen the very same reaction from many providers on boards discussing the mammogram study. I wouldn’t accuse all of them of being bad docs.

          • Siri

            I agree with you in general; I just think that LMS is a bad doctor, not because he is an ass, but due to how he reacts to other (better) viewpoints. Stubbornness can be good or bad; if you persist in doing wrong, it’s bad. As in, bloodletting kills, but imma ignore that and keep doing it. Mammograms hurt! I don’t want them at 40! And I don’t want a doctor with a closed mind.

          • DaisyGrrl

            Fair enough. A doctor with a closed mind is not good. They’re the ones who insist they see a horse when a zebra is staring them in the face. Or refuse to wash their hands because germs don’t exist. But I think many good doctors are going to be wrestling with the mammogram issue for a while. On other blogs, radiologists lost their collective shit over the study results and accused the study authors of academic fraud and lying and all sorts of stuff.

            I don’t see any point in getting a screening mammogram at 40 (never had one, don’t know how it would feel), but I really appreciate the work done by Dr. Gorski and others in breaking down why the study is valuable and some of the complexities in the issue. Working past your own cognitive bias is hard work, so I’m willing to cut a certain amount of slack on that one.

          • Medwife

            I am reading an absolutely fascinating book called “Thinking, Fast and Slow”, by Daniel Kahneman, and I wish I’d read it before I ever took a statistics course. The author lays out a lot of evidence about cognitive bias, decision making, and how everyone from the most expert of experts to total laypeople fall prey to various types of bias. It’s a great read and I wish LMS would read it. Everybody should!

          • DaisyGrrl

            I think my brother-in-law might have that book. He’s doing a degree in some sort of related field and loves talking about this kind of thing. I’ll see if I can borrow it.

          • Young CC Prof

            There are many good doctors who have rejected the new mammogram guidelines. Why?

            -Because the docs prescribing routine screening mammograms are either family practitioners or OB-GYNs, and they have a lot of other things to keep up on. When experts disagree, and you don’t have days to analyze the evidence yourself, just sticking with the more conservative choice seems safest.

            -Because the math and science behind them are weird and complicated.

            -Because the harm from too many mammograms is small on an individual level.

          • birthbuddy

            I agree. LMS would not hesitate to do the right thing to save your baby. Who needs a friendly incompetent.

          • Trixie

            I would trust him 100% to perform surgery on me and save my baby’s life.

        • Siri

          ‘Practice patterns of experienced, well-educated practitioners’. Like bloodletting. And blistering. Cataplasms. All the lovely quackery perpetrated and perpetuated by experienced, well-educated practitioners of yore. Or Dr Jay Gordon, who ‘knows’ that autism is increasing in reality, not just in its rate of diagnosis. It’s a low form of evidence, and rightly so; hence I distrust any doctor who relies on it and trumpets its importance. It’s a dangerous form of ignorance.

      • LMS1953

        Prof, another propaganda charged catch word is “peer reviewed”. Of what benefit is any review by a CPM of another CPM?

  • Gene

    I frequently see a set of twins in my ED. They were vaginally delivered in a hospital. The firstborn is a fat, happy toddler full of energy and smiles. The second is neurologically devastated and will never walk or talk or smile at his mother. They were born about 15 minutes apart in a hospital. Per mom, baby #2 was fine until #1 was born. Five minutes later, heart rate began dropping and baby was in severe distress. He was born blue. Every time I hear about a twin delivery at home, I think about this family. I also think about all of the healthy and happy multiples I know who were sections. And then I think about mothers who feel bad for having a section (for whatever reason) and I just RAGE.

    Why would ANYONE risk HIE? I see it all the time and it is absolutely awful.

    • BroccoliSoupTown

      Stories like that are so tragic. My mom was a nurse for 24 years, and I think it was very telling that she wanted c-section for her own births. She saw far too many tragedies from vaginal births gone horribly wrong to take the risk with her own kids.

  • Young CC Prof

    This is why it’s sort of a good thing my baby was breech. Two days before his birth, his NST/BPP was perfect. It was only after he was born that anyone realized he simply didn’t have enough functioning placental tissue left to survive a normal labor.

    If he’d been head-down, I would have been induced instead. Of course, I’d have had monitoring, and I’d have been sent for a c-section as soon as his heart rhythms looked bad, but that would have been more difficult and dangerous for both of us.

    • Jessica S.

      Sounds like he’s already a smart cookie. He knew what he was doing. 🙂

      • Young CC Prof

        I guess he really did know how to be born: Sit there kicking Mommy below the belly button until someone let him out.

  • Carolina

    Articles like this make me so grateful for the EFM and (really unwanted) c-section that gave me my daugher — the beautifuil, intelligent, curious, and hilarious preschooler. She didn’t tolerate even the Cervadil-induced contractions very well. I can’t imagine sacrificing her brain cells, and I am so happy the people caring for me didn’t let that happen.

  • I wonder how much “subtle” brain damage is out there and if there’s any correlation between the use of CEFM and need for speech language therapy, etc. I don’t think a lot of the research actually looks at the very long-term outcomes…it might be useful.

    • Or maybe it’s just easier to blame vaccines for those kinds of things!

    • Young CC Prof

      I have a cousin, born back in 1973 before EFM was invented. His birth was long and difficult and ended with forceps. By school age, it became clear that he had a lot of issues, multiple learning disabilities, etc. He can read, but not well. He graduated high school, but not until age 20. He’s a wonderfully sweet and kind man, but he basically functions on the mental level of a twelve-year-old.

      We will never know if there’s a connection there, or what he would have been like if his first day of life was easier.

      • Siri

        My 23-year-old son was a forceps delivery after a long and horrible labour; he earned his degree in actuarial maths while working full time in PC World, being promoted to junior manager. He will be rich, all other things being equal. His birth was a mess though…

    • AmyP

      There are a lot of kids out there with learning disabilities. Some of that clearly runs in families, but some of it has to be environmental, too.

      • Until a lot more is known about the cause(s) of dyslexia and other forms of learning disabilities, I think it’s a valid speculation. All three of mine were born by C/S, but the only one born by ELECTIVE C/S is my only child who does not have learning disabilities.

        • Siri

          All my 5 vaginally born kids are tall, slim, beautiful and clever, but the eldest, a forceps delivery, is the only one likely to be properly wealthy one day… my anecdote trumps yours! :-b

      • FormerPhysicist

        There’s also a lot of subtle things we (as a society) might not bother to identify or call learning disabilities in a pre-information age society.
        There certainly could be environmental factors, too. It’s just very hard to tease it all apart.

  • Captain Obvious

    Reminds me of baby Dickey, that mother was an ICAN chapter leader and her co-chapter leader there had a Homebirth in which the baby has HIE. But she went on with her, what, 3 day Homebirth anyway.

    • Dr Kitty

      And an unrepaired second degree tear..and probably a reasonably large PPH based on how pale she looked in her “victory” pictures.

  • Trixie

    Semi-OT, but going back to the ACNM discussion. I was poking around on the Midwifery Today Conferences FB page and found this comment regarding the upcoming Harrisburg conference.
    Does this mean that if you’re an ACNM member, you can actually get real CEUs by attending Midwifery Today workshops taught by baby killing frauds? Please tell me that isn’t true and that I’m wrong.

    • I hope that’s only true if you can demonstrate that it was an attempt to correct the woo!

  • Ellen Mary

    This post makes me feel much better about my Cesaran. My baby’s Apgars were 7 & 9. That seems 2 mean he came out just in time?

  • Anj Fabian

    6. Fetal exsanguination from either vasa previa or massive fetomaternal hemorrhage

    These two almost always result in death in the OOH environment. In a hospital, the outcomes range from healthy baby to varying amounts of damage to death. Bleeding usually out happens much faster than gradual damage from HIE, which means there is even less time to detect trouble and deliver the baby so it can be treated.

  • mostlyclueless

    Thanks for this post Dr. A. It reminded me of something I’ve been wondering about for a while now that I hope you can address in a blog post someday. The evidence suggests that continuous fetal monitoring does not actually provide much benefit — which I find so hard to believe because of, you know, logic. Do you know why this is? Here is a post summarizing the current evidence on continuous monitoring that shows little benefit: http://evidencebasedbirth.com/evidence-based-fetal-monitoring/

    • Young CC Prof

      Short answer: Years ago, Cochrane published an article that claimed just that, that EFM increased c-sections without decreasing intrapartum death. However, it was underpowered, that is, too small, to detect the change in intrapartum death rate.

      That man-bites-dog study got massive press. NONE of the subsequent contradictory studies (dog-bites-man) got much press at all.

    • Amy Tuteur, MD
      • mostlyclueless

        Thank you, I hadn’t seen that post before and it clears things up. Although to be honest I am still surprised that CEFM doesn’t have a larger benefit.

      • araikwao

        Fetal lactate measurements seem to be advocated in the British textbook I was reading. I know there is a study underway in Aus on whether this is a useful adjunct in reducing the false positives that lead to CS. Does it get used at all in the US?

        • Dr Kitty

          The lactate is part of the scalp blood gas and is a measure of hypoxic acidosis.

          If it is at the point where you are measuring blood gases you are deciding between vaginal delivery within the hour or CS now, because you’re already at 9 or 10cm.

          If you have a bad strip at 6 or 7 cm, you know that baby has 2-4 hrs more of labour, so you’re more likely to go straight for CS…because you’re going to have to keep doing gases to reassure yourself if the strip doesn’t change…and eventually the gas will be off…

      • LMS1953

        I “knew” from reality-based medicine that the Cochrane study on EFM was complete and utter bullshit. But, by golly it was EVIDENCE BASED MEDICINE and EVERY midwife I have ever worked with delighted in shoving that in my face. I will delight in keeping this link on my Zip drive to shove it right back.

        I am in complete agreement that in modern obstetrics, definitive studies cannot be ethically designed and many of the others will be significantly underpowered and subject to selection bias. The value of reality-based and experienced-based medicine in obstetrics needs to be appropriately weighted lest stupid and inappropriate recommendations be made.

    • I think Dr. Amy did a post on this a while ago. I know in our local hospital (a level III) CEFM is not routine…

    • Captain Obvious

      CEFM was hoped to prevent CP. It hasn’t decreased the rate of CP at all. Probably because CP is an ante partum event and not an intrapartum event. Sure CEFM increases interventions or cesarean rates. CEFM DOES decrease the intrapartum stillbirth rate and neonatal seizure occurrence by like 50%. Why does so many forget that?

    • theadequatemother

      Remember too that in hospital, you move to intermittent monitoring after a 20 min or more episode of CEFM. And if there are any decels or anything you go back on for a period of time. That’s not avail at home. All you get at home is someone listening with a Doppler and no chance of picking up changes in variability.

    • Hannah

      The thing is in a hospital (or at home with a midwife who knows what she’s doing and with a low threshold for transfer) it’s not an either or thing. A mother who starts off with intermittent monitoring can be switched to continuous monitoring as soon as anything vaguely suspicious shows up.

    • Becky05

      Really, this isn’t an accurate picture of the research. The actual text of the Cochrane review is far more nuanced. It pointed out that the review may be underpowered for a difference in mortality to be statistically significant, and that we don’t actually know how important neonatal seizures are. The review recommends long term neuropsych testing for the two groups. (Ha!) Here’s the full text of the 2006 review: http://apps.who.int/rhl/reviews/CD006066.pdf

      The full text of the 2013 review isn’t available but this is an interesting blog post by a Cochrane researcher discussing it: http://www.evidentlycochrane.net/fetal-monitoring-in-labour-the-challenge-of-balancing-the-benefits-with-harms/

      • Young CC Prof

        Interesting! The original report was published back when I was a science groupie, but one who read the popular press only and did a pretty poor job of skepticism.

        Those nuances (very important nuances) were completely ignored by the press.

        • Becky05

          Yeah, I was actually surprised when I first read the whole review. I’d always heard “RCTs show no benefit to CEFM” but I hadn’t really understood it was no where near that simple. And no one points out that in the ensuing 30 years there’s been a TON of research on which fetal heart rate patterns are indicative of a problem and which are not, that equipment is different, that labor and delivery set ups may be different. Few home birth midwives citing the safety of auscultation do a full minute of listening every 15 minutes as was done in the RCTs.

  • Ash

    Probably the thing that boggles me the most about homebirth in the USA is how incredibly lucky we are to have the most advanced technology. One can read about the suffering of women in impoverished countries who have no access to modern technology to assist them in childbirth. Life is so much better without modern interventions? Doesn’t fly with me when you read about impoverished areas who have suffered obstetric fistulas and found their lives so miserable, a group of them chained themselves together and drowned themselves.

    • Karen in SC

      For a look at births in a low-resource area, check out The Learner on the blog roll. In the past few weeks, two uterine rupture cases were discussed (with photos). How sad for these families that care was sought too late (as c-section is available).

      • Dr Kitty

        When you have low resource birth settings, the response to an entrapped breech might be decapitation with a sickle…and it get worse from that point.

        You have been warned.
        This is GRUESOME.
        http://yester.ispub.com/journal/the-internet-journal-of-gynecology-and-obstetrics/volume-11-number-2/a-desperate-destructive-procedure-by-a-laywoman-with-disastrous-consequences-an-unusual-case.html#sthash.rBqvgSj9.dpbs

        • attitude devant

          Oh my god. Oh. my. god. That poor woman. The poor baby. Although I know intellectually that c/s is a life-saving procedure, I hadn’t realized it quite as fully as I do after reading this. Um, thank you, Dr. Kitty, I think.

          • Dr Kitty

            Sorry.
            I came across that the other day (someone mentioned vanishing twin/foetus papyraceus and there was an article in the same edition of that journal) and it seemed an appropriate place to link to it.

            Not that there will ever be a good place to link to that particular case study.

            “Variation of normal” and “as safe as life gets” my arse.THAT is what happens with traditional birth assistants when the proverbial hits the fan.

            That case study is the stuff of nightmares.

          • Amy H

            Yes, but you know lots of breech babies “just slide right out.” At least I think that’s the IMG quote.

  • ngozi

    This is why even though I really didn’t like being “tied” to the bed during labor with the electronic fetal monitoring, I am glad it was there. I also have to say again that I am grateful that even though my newborn looked good on his ultasound, the OBGYN suggested a NST test that really ended up saving my son’s life.

    • C T

      There is wireless monitoring available in some hospitals. Sadly, not in my city, though. When I asked my OB about it recently, she was surprised to hear that it exists, indicating a local lack of knowledge about new technology. It’s quite disappointing to me that that they continue to tether laboring women when it’s not necessary to doing EFM.

      • Bombshellrisa

        Do they have the kind of monitor that is strapless and you just tuck the two monitors into what looks like those Belly Band things?

        • C T

          I’ve given birth twice at the hospital where she delivers babies, and both times the EFM has been not-wireless. Going again in about 10 weeks to deliver again, and I doubt they’ll have changed over. :p

          • Bombshellrisa

            The ones that tuck into a belly band do have wires but they are not uncomfortable to wear

          • Aki Hinata

            I agree! They are much better than the older wrestling belt style.

  • Therese

    I am curious about the idea that it is a painful way for the baby to go. Isn’t it more likely that death en utero from oxygen deprivation would be more like carbon monoxide poisoning, where the lack of oxygen makes the victim sleepier and sleepier until they fall asleep and die in their sleep? In both cases the oxygen deprivation is happening slowly Or is there something about CO poisoning that would make it fundamentally different?

    • The Computer Ate My Nym

      Carbon monoxide replaces oxygen on hemoglobin molecules and doesn’t trigger the same hypoxic drive as hypoxia (no molecule on the relevant position) does. What a fetus experiences might be more like drowning. However, given how low the pO2 in the uterus is at the best of times, I doubt that fetuses, even 40+ week old fetuses without any neurologic compromise, have any conscious thought, much like if you went into an airplane at 40,000 feet without pressurization you wouldn’t have any conscious thought or awareness of pain because the oxygen tension would be too low.

      • Therese

        So if the fetus did have conscious thought, might it feel similar to dying of altitude sickness? I once had a very bad case of altitude sickness, it felt absolutely horrible, but definitely not anything like drowning.

        • theadequatemother

          No no! Anoxia makes you feel warm and happy. Victims of near drowning describe a period of terror followed by a period of bliss.

        • The Computer Ate My Nym

          People lose consciousness very quickly if they are suddenly exposed to very high altitudes. Altitude sickness occurs at moderate altitudes. So I don’t think that fetuses dying of hypoxia feel much. I can’t say that with 100% certainty given that it’s a different situation–low oxygen rather than low pressure and fetal hemoglobin is different from adult beta-globin–but I think it most likely that fetuses can’t think consciously or suffer in the way that adults or newborns do. Fortunately.

    • fiftyfifty1

      There are 2 things going on with suffocation:
      1. Lack of oxygen
      2. Buildup of carbon dioxide (waste product gas)

      Of the two, it is the buildup of carbon dioxide that is much more uncomfortable. You can test this yourself with a finger oxygen meter. Hold your breath for 90 seconds (if you can!) and your oxygen level will not have changed, but you will be feeling very distressed and in pain. That is due to the carbon dioxide build up.

      With carbon monoxide poisoning, you are not getting the oxygen you need but you are still breathing off the carbon dioxide, so you don’t get the same panic response and pain.

      • The Bofa on the Sofa

        One time, I needed to get some dry ice from the bottom of the (big) tub, so I jumped in headfirst, but forget to hold my breath.

        That HURT. Carbonic acid is extremely painful.

        A good (safer) example of the pain caused by carbonic acid (which is what forms in high concentrations of CO2) is what my friends and I call “the Coke-tongue challenge.”

        Take a fresh carbonated beverage, pour it in a glass, and stick your tongue in it. See how long you can keep it there. If you have a good carbonated drink (try something like Barq’s Root Beer, which is overcarbonated), you won’t last 30 seconds. Probably not even 20. The pain is excruciating. Now imagine that in your lungs.

        The best part is that you look like a moron with your tongue stuck in a glass of soda, so that’s always fun.

        It’s the carbonic acid that gives carbonation the tingly feel in your mouth.

        • DaisyGrrl

          Thank you for giving me an excuse to have a second Coke today. It’s for science!

          • Siri

            Happy to sign off on that Coke for scientific purposes! Remember to remove your tongue from the glass behaw ic goec aww mummmm…..

          • The Bofa on the Sofa

            Don’t worry, it’s not like your tongue gets stuck

          • siwi

            I mow, dah wy I hed cake ih ouh eehaw ic coe MUMMMM!!

      • theadequatemother

        Babies have immature respiratory centres so I don’t know if their experience would be the same as ours. After anesthesia they cheerfully go apneic even if not given any opioids or any long acting agents (eg just gas). And they don’t seem distressed by that (although I usually am).

        Hypercarbia is also sedating. We call is hypercarbic narcosis and see it in adult patients after anesthesia because anesthesia decreases the sensitivity of the chemo receptors that stimulate respiration. So in a fetus with immature chemoreceptors I would assume that they just become sedated and drift off after a certain point. The gasping that occurs (agonal respirations) prior to terminal apnea is a response to anoxia present in all mammals. It is more pronounced in newborns compared to adult. Unfortunately I’m on my phone at the moment and can’t look to see f someone has done a physiology study looking at gasping in anoxia when co2 tensions are held constant so it could also be due to the hypercarbia that occurs during primary apnea. Things you lose a few years after knowing all this for your exams…..

  • Of all the risks of child-birth, this is the one that makes my blood run cold. Why on earth would we not want to everything to maximize the chance that a child has full capacity? Particularly in a world where being smart – being capable, seems to confer so many advantages?

  • Amy M

    Very informative.
    It’s heartbreaking to read the stories about birth injury, regardless of where it occurred, but even more the ones from homebirth because odds are it was preventable, or at least there was a chance. If only there had been some monitoring! Of course, most of those mothers and midwives claim it had nothing to do with being at home/would have happened in the hospital too. I hope most of them choose the hospital if they have another baby though. I bet the majority do.