Taking obstetric advice from a doula is like taking architecture advice from a cleaning woman.

Sure, a cleaning woman cares for a home, business facility or skyscraper, but she knows nothing about how to build any of those things, and only a fool would think otherwise.

Sure, a doula knows how to care for women in labor (rub her back, get her ice chips, encourage her), but only a fool thinks she knows anything about obstetrics.

Case in point: Vicki Markam Williams, the woman who runs the Facebook group Pregnancy and Birth after Uterine Rupture with the aim of encouraging women who didn’t die at their first VBAC [vaginal birth after Cesarean) attempt (although many of their babies did die) to take on the much higher risk of killing their babies and themselves at another VBAC attempt.

Her website explains her philosophy:

Care providers are so filled with fear, and that fear is affecting the women they care for, in attitude and in denial of choice. A section rate of one in three is indefensible, and at that rate is causing MUCH more harm than good.

I think that the risks of VBAC and PAR [pregnancy after rupture] are actually MUCH lower than women are being told. If women are really re-rupturing at the rates given above then their ruptures are not being repaired properly. There is good research to say that tears heal better than cuts (http://www.ncbi.nlm.nih.gov/pubmed/10422908) and so a repaired simple rupture (no healed edges to the hole, no placenta involved) should be stronger than a second planned section scar from an incision by knife. This is clearly being taken on board, because many surgeons are now using ‘blunt extension’ techniques, which in effect means separating the uterine muscle by tearing it along its natural planes, which leads to a stronger repair and less trauma to the tissue.

Williams is referring to a 1999 paper on the Misgav-Ladach method of C-section. First, there is no evidence that the method of tearing the uterus instead of cutting leads to a stronger repair. Second, the Misgav-Ladach technique involves a one layer closure of the uterus instead of the traditional two layer closure. One layer closures have been shown to be associated with an INCREASED risk of rupture in a subsequent pregnancy, not a decreased risk. Third, very few women undergo a Misgav-Ladach C-section, so it is irrelevant to counseling most women about the risk of rupture in a future pregnancy.

Williams continues:

I’m expecting that most of the re-ruptures are women who have had windows and scars that have opened during the trauma of a repeat section. We don’t worry about any other scar or injury to the same extent. I think that the ‘dead baby card‘ is just out-and-out blackmail. So few women carry a PAR (because most get a hysterectomy and the rest are told not to try again, of which a significant majority will heed that advice) that we will never have big enough studies to know what the numbers really look like.

I have been told repeatedly that no one has a baby after a rupture, well clearly I did, and I know others who have.

Markham had a spontaneous uterine rupture at 33 weeks* (fortunately the baby survived) and her response was to attempt a VBAC? Even though she knew that a future uterine rupture could kill her baby??!!

Her musing on the risk of future rupture is probably less valuable than the cleaning lady’s musing on what holds up a building. The cleaning lady’s architecture advice is more likely to be correct since she is living in the real world while Williams is clearly just making stuff up to support her ignorance and wishful thinking.

The idea that she was told that no one has a baby after a rupture is bizarre. The issue has been studied. Indeed there is a paper in this month’s edition of Obstetrics and Gynecology on this exact topic, Pregnancy Outcomes in Patients With Prior Uterine Rupture or Dehiscence.

I know you will be shocked, shocked to learn that Williams is spectacularly wrong.

What did the authors find?

Fourteen women (20 pregnancies) had prior uterine rupture and 30 women (40 pregnancies) had prior uterine dehiscence. In these 60 pregnancies, there was 0% severe morbidity noted (95% confidence interval [CI] 0.0–6.0%). Overall, 6.7% of patients had a uterine dehiscence seen at the time of delivery (95% CI 2.6–15.9%). Among women with prior uterine rupture, the rate was 5.0% (95% CI 0.9–23.6%), whereas among women with prior uterine dehiscence, the rate was 7.5% (95% CI 2.6–19.9%).

So, in contrast to the typical risk of rupture at VBAC of less than 1%, these women had a dramatically increased risk of rupture. And that was in patients who were NOT allowed to labor! I shudder to think what the risk is in women who actually attempt VBAC.

Williams, of course, believes that the fact that she didn’t kill her baby and herself in a subsequent pregnancy indicates that VBAC after rupture is safe. Of course, if your definition of safe is that you are not 100% guaranteed to die, even Russian roulette is “safe.”

Williams concludes her piece with this:

It is so wrong to tell women that if their babies die it will be their fault and that surgery will save everyone, because it doesn’t and it won’t

Kind of like your cleaning lady telling you that is “wrong” to tell people that violating building codes leads to unsafe buildings. The claim is untrue, and there’s no reason why anyone should listen to her in any case.

Williams is criminally ignorant. She shouldn’t be allowed to care for a houseplant, let alone a pregnant woman.

 

*Williams’ rupture was not associated with an induction for stillbirth as originally reported.

Several weeks ago I wrote about the one size fits all approach of homebirth midwives. No matter the question, the answer is always homebirth.

Natural childbirth advocates have a one size fits all approach, too:

Personal characteristics are irrelevant. Advanced maternal age, maternal obesity, pre-existing maternal disease? It doesn’t matter because the counseling and treatment plan are always the same: you can and should have an unmedicated vaginal birth.

Medical history is irrelevant. Had a previous shoulder dystocia, C-section, postpartum hemorrhage? Who care? You can and should have an unmedicated vaginal birth.

Complications are irrelevant. Baby is breech, have gestational diabetes, colonized by group B strep? Who cares? You can and should have an unmedicated vaginal birth.

Labor complications are irrelevant. Dysfunctional labor, prolonged rupture of membranes, pushing for 4 hours? Who cares? You should still stay home because you can and should have an unmedicated vaginal birth.

In my piece about homebirth midwives, I ascribed this one size fits all approach to ignorance and dogma, and that goes for natural childbirth advocates as well. Ignorance refers not only to obstetrics, but also to basic statistics. One facet of this ignorance is the mistaken belief that statistics for a group as a whole apply equally to each individual.

Take the case of VBAC (vaginal birth after Cesarean). The overall success rate for attempted VBAC is nearly 76%. Natural childbirth advocates think that means that each individual woman’s chance of a successful VBAC is also nearly 76%. Nothing could be further from the truth. Both the chance of having a successful VBAC and the chance of a uterine rupture are modified by past medical history and factors in the current pregnancy. That was the take home message of the lecture on VBAC that I attended at the recent Harvard Medical School Review of Obstetrics .

For example:

History of a previous vaginal birth impacts the chances of successful VBAC Women who have had a previous vaginal delivery (VD) have an 86% chance of successful VBAC, and women who have had a successful VBAC in a previous pregnancy have a nearly 90% chance of having another. But for women who have never had a VD, the chance of successful VBAC is only 61%.

The reason for a previous C-section also impacts the success rate of attempted VBAC If the previous C-section was done for a non-recurring condition like breech, the chances of successful VBAC are higher than for women whose previous C-section was performed for dystocia.

The larger the baby, the lower the chance of successful VBAC Although macrosomia (baby larger than 4000 gm) in the absence of other risk factors is not an indication for repeat C-section, the size of the baby definitely affects the chance of success. For example, while a woman who had a previous C-section and no vaginal deliveries has an overall chance of successful VBAC in the range of 60+%, the chance of success drops to 38% if the baby is over 4500 gm. And if the previous C-section was done because the baby didn’t fit, the chance of a successful VBAC with a baby over 4500 gm is only 29%.

Other factors also have a large impact on success For example, if the baby’s head has not descended into the pelvis at the start of labor, the chance of successful VBAC drops to only 10%.

Maternal factors affect success The chance of successful VBAC drops as maternal age increases, and as maternal BMI (body mass index) increases. Women over age 35 and women with a BMI greater than 30 have a lower chance of successful VBAC.

The most dreaded complication of attempting a VBAC is rupture of the uterus, leading to massive hemorrhage, death of the baby and possible death of the mother. The risk of rupture also depends on the circumstances surrounding the previous C-section and characteristics of mother and baby in the current pregnancy.

Overall, elective repeat C-section is safer for the baby, and vaginal delivery is safer for the mother But those risks are not equal. The risk of death of the baby in attempted VBAC is 10X than the risk of death of the mother from a repeat C-section.

The worst situation for both mother and baby is a failed attempt at VBAC. While the overall risk of uterine rupture is 7/1000, that jumps to 23/1000 in a failed attempt. Therefore, the risk of rupture is directly dependent on the chance of success.

Other factors also affect the risk of rupture These include the type of incision on the uterus (transverse is safer than vertical), the length of time since the last pregnancy (an inter-pregnancy interval of less than 6 months triples the risk of rupture), and the timing of the previous C-section (a preterm C-section has a higher risk of rupture in a subsequent pregnancy than a term C-section).

The bottom line is that an individual woman’s chance for a successful VBAC and risk of a uterine rupture depend on her specific circumstances.

Should a woman try for a VBAC?

Natural childbirth advocates, who take a one size fits all approach to everything, will counsel every woman to attempt a VBAC and quote an overall risk of success that may not actually apply to that woman.

In contrast, obstetricians, who provide care customized to the individual woman, can offer her a realistic assessment of her chances of a successful VBAC, and a realistic assessment of the risk of a uterine rupture. Ultimately, of course, each woman has to decide for herself which risks she is willing to take, but she can only make an informed decision if she has all the information. The one size fits all approach does not allow her to make an informed decision.

Only a personalized risk assessment, based on HER history, HER medical conditions, and the size and position of HER baby will allow her to make an informed choice for VBAC or elective repeat C-section.

After that title, you’re undoubtedly looking for the photo containing graphic violence. Would you believe that it’s the picture at the top of the post?

Yes, that picture of the beautiful baby Mary Beth in her coffin after her death at homebirth.

That picture was reported as containing graphic violence. Twice! Once when the picture was posted on one of my Facebook groups and once when Bambi, Mary Beth’s mother, posted it.

Who would report a beautiful, heart breaking photo as containing graphic violence and why? I have some ideas.

Gina Crosley-Corcoran, the Feminist Breeder, finds pictures of babies who died at homebirth to be profoundly frightening and has encouraged her readers to view them the same way.

In other words, Gina, like most homebirth advocates, desperately wants to bury babies who die at homebirth twice. First in a tiny coffin in the ground; a second time by erasing their existence from public view.

Gina, like most homebirth advocates, can’t handle the truth about homebirth: it kills babies who didn’t have to die.

And the claim about graphic violence? The extraordinary picture of Mary Beth does violence to the idea that homebirth is a safe, beautiful experience. If women understand that homebirth leads to preventable deaths, most of them are going to stop choosing homebirth. Rather than looking at women who choose homebirth as brave and empowered, they will start viewing such women with contempt, in the exact same way as parents who refuse to vaccinate are now viewed.

That fear is compounded by her rabid hatred of me. Referring to the Facebook group Fed up with natural childbirth where the photo was posted:

She can hate me all she wants. I’ve proven that I can defend myself quite well.

At this point, I view Gina as a bug on the windshield of my life: annoying, occasionally in my line of sight, but thoroughly squashed long ago.

Rail against me all you want Gina, but when it comes to women who read my blog and participate in my Facebook groups, have a little human decency. If a mother wants to post a beautiful picture of her baby who died at homebirth to prevent another mother from experiencing the never ending pain, don’t deride it as a scare tactic and don’t inspire others (or was it you?) to report those photos to Facebook for containing “graphic violence.” It makes you look like a heartless, hateful fool.

When will these midwives and doulas learn that the response to a stalled labor is NOT to ask your Facebook friends? The correct response is to TAKE THE PATIENT TO THE HOSPITAL!

I’ve been alerted to another potential homebirth disaster in progress posted on the Birth Professionals International Facebook page.

Apparently this mother has been in labor for FOUR DAYS!

The suggestions range from the moronic to the criminally stupid, including:

This:

And this:

Even with such shamefully negligent care, it is still possible this will work out okay, but the chances will be dramatically increased if they go to the hospital now. Let’s hope someone alerts them to this and that they do the right thing.

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.

With apologies to Rodgers and Hammerstein. Sung to the tune of the South Pacific classic “You’ve Got to Be Taught”:

You’ve got to be taught
To hate and fear,
You’ve got to be taught
From year to year,
It’s got to be drummed
In your dear little ear
You’ve got to be carefully taught.

You’ve got to be taught to be afraid
Modern obstetrics is just a charade,
Your quest for experience will be betrayed,
You’ve got to be carefully taught.

You’ve got to be taught to be dismayed
Of the dread intervention cascade,
started by Doc so his golf game gets played,
You’ve got to be carefully taught.

You’ve got to be taught to be portrayed
As a woman whose placenta will never degrade,
Breech, twins or VBAC, be never afraid,
You’ve got to be carefully taught.

You’ve got to be taught to always downgrade
Tests, EFM, heplocks, technology arrayed,
flat on your back you will always be laid,
You’ve got to be carefully taught.

You’ve got to be taught to be afraid
That’s deep at the heart of our clever crusade,
Doctors as evil are often portrayed,
You’ve got to be carefully taught.

You’ve got to be taught our masquerade
As folks for whom blame we will always evade
That’s why our service is always prepaid,
You’ve got to be carefully taught.

You’ve got to be taught before it’s too late,
Before you are term or week thirty eight,
To hate all the people your Facebook friends hate,
You’ve got to be carefully taught!

A new guest post from the “Medwife“:

The case

A 42 year old mother of one presents in the first trimester of her pregnancy to begin prenatal care. Her first pregnancy was uncomplicated at 26 years old with a spontaneous vaginal delivery of a 7ib 4 oz infant in a rural community hospital at 41.6 weeks after three days of prodromal labor. The mother presents for current pregnancy feeling overwhelmed, but excited. She expresses her desire for low intervention care because she ‘trusts birth.’

Homebirth midwife

The mother begins prenatal care with midwife, advised against dating ultrasound after being informed of risks of autism. Trust birth philosophy reinforced, Advanced maternal age is just a variation of normal. Prior postdates pregnancy discussed; midwife concurs ‘babies know when to be born’ and mother is excited to avoid pressure to deliver prior to 42 weeks. Extensive discussion of kale diet, yoga and pelvic rocks. The midwife does not accept Medicaid and an out of pocket cost negotiated and contract signed.

An intimate relationship develops over the course of hour long prenatal appointments at which plans for her doula, birthing pool and birth kit are discussed. Fundal heights are measured as normal, however blood pressures tend to trend up at the end of the 3rd trimester. She is reassured it’s just a little elevated and the mother is thrilled her midwife doesn’t use fear mongering or scare tactics like she reads about on BabyCenter. In the meantime, her midwife crowd sources Facebook and receives recommendations to ‘trust birth’, ‘babies don’t have expiration dates’, ‘Epsom salt baths’, ‘kale smoothies’ and to ‘explore her emotional acceptance of pregnancy’ as measures to respond to increasing blood pressure.

At 38 weeks, contractions begin and labor progresses rapidly as the mother is surrounded by family and birth team. A limp apneic infant is brought to the surface of the water and the mother is encouraged to speak to her baby to ‘bring her earthside’. After several minutes, resuscitative efforts are initiated and eventually EMS is notified. Efforts to resuscitate the infant fail and as the mother is consoled by the midwife she is reminded ‘some babies just aren’t meant to live.’

For an additional fee the placenta is encapsulated.

A year later, a mother sits alone in her living room where her birthing pool had been. Empty arms and a heavy heart, wondering if she just didn’t ‘trust birth’ enough.

Medwife

At the first prenatal appointment, a thorough history and physical exam is completed. Dating u/s confirms the estimated due date. The medwife counseled the patient on folic acid, diet and exercise, weight gain and initial prenatal labs. The risks of advanced maternal age were discussed including increased risk premature birth, preeclampsia, diabetes, intrauterine fetal demise (stillbirth) and chromosome disorders. The medwife offered amniocentesis to the mother and explained the planned increased antepartum surveillance at 36 weeks with recommended delivery at 39 weeks in light of advanced maternal age.

Amniocentesis reveals an unusual chromosome disorder (mosaic) with elevated risk of stillbirth, intrauterine growth restriction and cardiac defects. After counseling provided, the patient desires to continue pregnancy. Medwife arranges maternal-fetal medicine consult, genetic counseling consult, Level II ultrasound and fetal cardiac ultrasound. Antepartum surveillance plan developed between MFM, OB and Medwife. Patient agrees to the plan, but expresses a desire to avoid induction of labor. Medwife acknowledges and discusses concerns at length while balancing risk status and emotional needs of the mother.

At 36.6 weeks, EFW (estimate fetal weight) percentile decreased from 36% to 5% with normal amniotic fluid, BPP 6/8 (absent fetal breathing movements) mildly elevated systolic/diastolic umbilical artery waveforms (an possible indication of decreased placental blood flow) and reactive NST (non-stress test) after prolonged monitoring. Blood pressure elevated at 140’s/80-90’s. Medwife consults OB and maternal-fetal medicine specialist, and the decision is made to proceed with delivery. Labor & Delivery is notified and the neonatologist is aware of genetic diagnosis. Extensive discussion regarding risks and benefits of induction, concerns regarding genetic diagnosis, onset growth restriction and elevated blood pressures. She initially declines with concerns regarding the danger of delivering prior to 39weeks according to the March of Dimes. Risk factors and concerns are discussed at length; patient agrees to proceed with cervical ripening, heplock and continuous electronic fetal monitoring. Pain management options discussed. Mother is disappointed she is no longer a candidate for labor tub and expresses concerns regarding ‘cascade of interventions.

She presents to Labor & Delivery for cervical ripening with onset of uterine contractions 6 hours after dinoprostone placed and nonrecurrent variable decelerations responding to position changes. Over course of several hours she progresses to 5cm, SROM (spontaneous rupture of membranes) and variable decelerations becoming recurrent. OB and neonatologist remain on the unit, anesthesia is in house and aware of patient status.

She rapidly progresses to fully dilated/+1 with urge to push. Minimal descent is noted with pushing efforts accompanied by prolonged decelerations, intrauterine resuscitation initiated with position changes, intravenous fluids, oxygen and terbutaline. OB present in room, Medwife and OB discuss vacuum assisted delivery with plan to proceed to the OR if not immediately successful. Patient agrees. Shortly thereafter, bradycardia ensues and OB applies vacuum and a 2300 gm female infant is delivered with Apgars 8-9. A small, thin placenta is delivered with velamentous insertion and sent to pathology. Pathology report reveals a 284 gm placenta (50% for 25-26wk gestation) with variable thickness of 0.5cm-1.25cm, maximum width 7cm and multiple succenturiate lobes.

After an uneventful 24 hour course, mother and baby are discharge to home. A year later, a developmentally appropriate and stubborn little girl toddles into the clinic with her mother, a pink tiara in one hand and a sucker in the other.

The Medwife reports:

Lost many nights of sleep during this woman’s pregnancy and barely made it to my call room to vomit after a thorough evaluation of the placenta and days away from stillbirth. I’m still not sure how that placenta managed to sustain a fetus as long as it did. I keep a copy of the placental report with the end of the EFM tracing and a first birthday photo stapled to it on a corner of my desk. Reminds me just how much birth can’t be trusted, risk factors can’t be ignored and safe midwifery care cannot be practiced in isolation.

The Medwife counsels other midwives:

This is the essence of evidence-based medicine, availability of resources and collaborative care. This is NOT ignorance of risk factors in favor of touchy feely goodness, birth teams and spectator stunt birthing and this most certainly WAS NOT a baby who wasn’t meant to live.

To homebirth midwives: this isn’t about politics. If you cannot find OB backup or have a rapport with your local hospital … perhaps you need to reevaluate why that is. You have found a way to manipulate mothers, ignore risks, bury your heads in the sand, get paid for it and walk away without remorse or liability … only to do it again. If your philosophy involves taking risks, avoiding interventions at all costs and vilifying the obstetrics community, perhaps the only politics at stake here are those you have created for yourselves. To waive the ‘politics’ card is insulting to the midwives who work endlessly to support pregnancy and birth, maintain a high level of professional collaboration within the medical community and are at all times aware of their resources. Why? Because that is the true value of Midwifery.

So the next time you leave a mother with empty arms and a broken heart, don’t you dare whisper “some babies aren’t meant to live” or “she would have died in the hospital too”. It’s not true and I’ve got the tiara to prove it!

A little more than a week ago I pondered why the American College of Nurse Midwives has thrown ethics to the wind by supporting waterbirth although it has been shown to be deadly. It is one example of the way in which CNMs value their professional autonomy over scientific evidence.

Now comes another in, of all places, the Journal of Midwifery and Women’s Health. Three CNMs have written an extraordinary paper that demonstrates far more powerfully than I ever could that CNMs reject science based standards that might limit their autonomy, as if science based standards are somehow discretionary. The paper is Formulating Evidence-Based Guidelines for Certified Nurse-Midwives and Certified Midwives Attending Home Births by Cook, Avery and Frisvold.

The study was simple and straightforward:

Following a review of home birth guidelines from multiple countries, a set of home birth practices guidelines for US CNMs/CMs was drafted. Fifteen American Midwifery Certification Board, Inc. (AMCB)-certified home birth midwives who participate in the American College of Nurse-Midwives (ACNM) home birth electronic mailing list considered the use of such a document in their practices and reviewed and commented on the guidelines.

In other words, the authors compiled evidence based standards that guide the practice of homebirth midwifery in countries like the Netherlands, the UK, Australia and Canada.

The response of the CNM reviewers was horrifying:

The primary concern expressed was that an adoption of national guidelines could compromise provider autonomy.

Apparently the CNMs favored the implementation of evidence based standards for American homebirth until they saw what the evidence showed. When they learned they were not practicing in accord with international evidence based homebirth standards, they decided to ditch the standards instead of changing their practice.

That, in a word, is unethical.

What were these international standards that CNMs rejected and where did those standards come from?

Five countries with provincially or nationally promulgated home birth midwifery guidelines met these criteria: Australia, Canada, the Netherlands, New Zealand, and the United Kingdom. Published guidelines of these countries were then reviewed for common themes. The following criteria for planning a home birth emerged: determination of low-risk pregnancy, informed consent, hospital transfer if complications arise, singleton pregnancy, fetus in the cephalic presentation, no history of previous cesarean birth, and term pregnancy.

Then:

After collection, review, and summary of these international guidelines, the primary author synthesized the information into draft home birth guidelines that could be used by US CNMs/CMs. The resulting 10-page document (see Supporting Information: Appendix S1) includes recommendations about licensure, physician collaboration, hospital transports, informed consent, documentation, client screening, equipment, medications, birth assistants, routine care of the mother and newborn, and emergency care of the mother and newborn

Five different countries; agreed upon basic standards for care… rejected by the CNM reviewers.

Even the authors were shocked:

… [T]he authors were surprised that the reviewers expressed greater interest in developing and implementing national home birth midwifery guidelines prior to reviewing the proposed guidelines versus after their review…

The primary concern raised by the reviewers was whether or not guidelines would impact their autonomy. Guidelines are intended to provide best practices from which providers can meet individual client needs but also discourage providers from diverging from safe practices. The reviewers specified that the proposed guidelines might not support them if they choose to attend the home birth of a woman with a breech presentation or a twin gestation or a woman who desires a trial of labor after a previous cesarean. While CNMs/CMs attending home births may have the skill to attend such births, the safety net available in an institutional setting is advantageous and may be preferable for such births…

Indeed, the authors feel compelled to re-state the obvious requirement for ethical practice:

Although ensuring client safety may at times conflict with provider and client preferences, safety is the first priority for improving the quality of health care.

Apparently not for CNMs.

The authors note:

Fundamental to international home birth guidelines that were examined in this project is a distinction between low risk and high-risk maternity criteria. Normal birth has been defined in a joint statement by the Society of Obstetricians and Gynaecologists of Canada; the Association of Women’s Health, Obstetric, and Neonatal Nurses of Canada; the Canadian Association of Midwives; the College of Family Physicians of Canada; and the Society of Rural Physicians of Canada as spontaneous labor with a singleton fetus in a
vertex presentation at 37 to 42 weeks’ gestation after an uncomplicated pregnancy. This definition is consistent with the World Health Organization definition and the UK Maternity Care Working Party definition supported by the RCOG and RCM. (emphasis in original)

We already know that American homebirth midwives (CPMs, LMs, DEMs) lack basic professional ethics. Now comes stunning confirmation that American CNMs attending homebirths are equally ethically bankrupt.

What should American women take away from this study?

It is yet more evidence that midwives who attend homebirths (CPMs and CNMs) value their professional autonomy over whether your baby lives or dies. It is more important for them to maintain control over you (and collect a fee from you) than to accurately advise you. Moreover, the homebirth safety data from countries like the Netherlands and the UK can’t possibly apply to homebirth in the US because even homebirth CNMs refuse to follow the guidelines that govern homebirth in those countries.

Homebirth is a fringe practice. We can argue about whether it might be safe under ideal conditions, but it CANNOT be safe in the US because the midwives who attend homebirths (CPMs and CNMs) explicitly reject safety standards. And as long as they continue to do so, babies (and sometimes mothers) will continue to die preventable deaths at their hands.

Imagine if smokers blamed cancer and emphysema deaths on pulmonologists. If only those lung doctors would invent a safer tobacco cigarette many fewer people would die of lung cancer, right?

Imagine if vaccine rejectionists blamed the pertussis deaths in children who are unvaccinated on pediatricians who won’t treat unvaccinated patients. If only the parents could have taken their coughing, vomiting, whooping baby to the local pediatrician instead of the hospital ER, the chances of the baby surviving might have been increased, right?

Imagine if the survivors of people who shun conventional cancer treatments claimed that oncologists were responsible for the deaths of those who chose alternative treatments. After all, if oncologists had created chemotherapy that was gentler, the person who refused chemotherapy might have accepted it, right?

We recoil from those claims for very good reasons:

Pulmonologists have no responsibility for improving the safety of cigarettes. The people who bear the ultimate responsibility for tobacco caused lung cancer are the people who choose to smoke.

It’s not the job of pediatricians to improve the safety of vaccine refusal. The people who bear the ultimate responsibility for a vaccine preventable death are those who refused vaccines.

It is not the job of oncologists to make chemotherapy as pleasant as alternative “treatments” (although they are indeed trying to do so). The people who bear ultimate responsibility for dying a chemotherapy preventable death are the people who refuse chemotherapy.

Now tell me: whose fault is it that homebirth is not safe?

Yesterday I wrote about Elizabeth Heineman, currently publicizing a book long apologia on her son’s death at homebirth. Where does Heineman place the blame? On everyone but herself. Indeed, in an especially creative attempt to avoid responsibility for choosing homebirth, Heineman actually blames “politics.”

I believe that after decades of successful practice and no bad outcomes, Deirdre made the wrong judgment call in not referring me to a doctor once I was a week postdate. I believe that judgment call resulted in Thor’s death.

I believe the likelihood of her making the wrong judgment call was heightened by the fact that she felt under siege. I believe the warfare between the medical profession and out-of-hospital midwives made her reluctant to refer a low-risk pregnancy with no sign of trouble to a doctor …

It’s those obstetricians! They are responsible for her baby Thor’s death because they refuse to collaborate with homebirth midwives.

No, they’re not responsible for Thor’s death any more than pulmonologists are responsible for tobacco related deaths, or pediatricians are responsible for vaccine-preventable deaths or oncologists are responsible for the deaths of those who refuse chemotherapy. They are not responsible because they offer a safer alternative to the unsafe choices that people make. They are under no moral obligation to mitigate the danger of unsafer choices, beyond counseling against them.

Homebirth is the same. If you choose homebirth and your baby dies as a result, you bear responsibility.

You are not the only one who bears responsibility; there is an entire industry of natural childbirth and homebirth “professionals” feeding you lies about homebirth safety and they should be held accountable, too. But there is not a homebirth advocate alive who does not recognize that her choice is a rejection of conventional medical advice and a transgressive choice. Indeed many homebirth mothers choose homebirth precisely BECAUSE it is a rejection of conventional medical advice and a transgressive choice.

To the extent that homebirth midwives attempt to obtain informed consent, they almost always declare that in the event of disaster, they are not responsible. The consent forms often require the mothers to specifically accept responsibility for any bad outcomes. And indeed, when the inevitable tragedies occur, they turn in anger toward homebirth loss mothers who dare to expect accountability of homebirth midwives. The was NEVER part of the plan. The mother always knew that she was rejecting conventional medical advice and she is supposed to shoulder the responsibility for that decision, not those selfless “birth workers” who were merely giving her what she asked for.

When it comes to responsibility, homebirth is a game of musical chairs. There are lots of people and chairs at the beginning of the game: the midwife, the doula, the cranio-sacral therapist, all the providers of homebirth services start out with chairs. The minute a woman starts labor at home, the homebirth midwives and mothers pull out all the chairs, but one, the obstetrician’s chair. You remember the obstetrician. He or she is the one the mother ignored as not evidenced based, profit hungry, and driven to perform unnecessary C-sections just to get to his golf game. THAT obstetrician, the one the mother didn’t trust, it the ONE person she expects will save her baby and her if anything goes wrong.

The ultimate problem, though, is that American homebirth is not and can never be as safe as hospital birth. It is simply impossible because it is the hospital and the expert personnel and safety equipment that makes hospital birth safe. When you reject the safest choice, doctors are not ethically obligated to make your preferred unsafe choice safer.

When a person dies of a tobacco related illness, he or she is ultimately responsible, not the doctors who didn’t make cigarettes safer.

When a baby dies of a vaccine preventable illness after a parent rejects vaccines, the parent is responsible, not the pediatrician who advised against it and refused to care for the child thereafter.

When a person dies of cancer after refusing cancer treatment, he or she is responsible, not the oncologist who advised against it and refused to administer the alternative “treatment.”

And when a baby dies at homebirth, the mother is responsible, not the obstetrician who advised against it and refused to collaborate with a midwife he did not trust.

Homebirth mothers are very happy to claim credit when they dodge a bullet by refusing conventional care. If they are willing to claim credit, they are responsible when things go wrong. Homebirth is INHERENTLY unsafe and American homebirth will NEVER be as safe as hospital birth. Obstetricians are not responsible for making unsafe choices safer. Mothers are responsible for making unsafe choices.

Heineman’s midwife deliberately chose to ignore standard obstetrical practice, not because she didn’t know any better, but because she thought she could get away with it. After all, she had gotten away with it in the past.

Politics did not kill baby Thor. His mother’s decision led to his death. Had she chosen to accept conventional obstetrical care, Thor would almost certainly be alive to day. Heineman bears the ultimate responsibility, and her efforts to avoid that responsibility, while understandable, are shameful nonetheless.

American homebirth advocacy is filled with mistruths, half truths and outright lies.

The biggest lie, of course, is that homebirth is safe. It’s not. American homebirth has a death rate 2-9X higher than comparable risk hospital birth, depending on attendant.

The second biggest lie is that homebirth advocates take responsibility for their decisions. Yes, they are happy to take credit for decisions that ended up with a live mother and a live baby. When it comes to bad decisions, however, if their baby was one of the many babies who die at homebirth, they shed responsibility like water off a duck’s back. It was everyone’s fault but their own.

Some women are more creative than others in avoiding responsibility. Elizabeth Heineman, currently promoting her new book Ghostbelly, the story of her son Thor’s death at homebirth is more creative than most. Heinemen “educated” herself and purposefully chose homebirth. Thor is dead as a result. Who does she blame? Why, politics, of course:

I believe that my nurse-midwife Deirdre is an excellent practitioner. I believe her hundreds of successful deliveries and the intense loyalty of her clientele demonstrate that she provides an important service. I believe her practice of non-invasive birthing for low-risk preg­nancies contributes to a necessary movement toward more sen­sitive forms of reproductive health care.

I believe that after decades of successful practice and no bad outcomes, Deirdre made the wrong judgment call in not referring me to a doctor once I was a week postdate. I believe that judgment call resulted in Thor’s death.

I believe the likelihood of her making the wrong judgment call was heightened by the fact that she felt under siege. I believe the warfare between the medical profession and out-of-hospital midwives made her reluctant to refer a low-risk pregnancy with no sign of trouble to a doctor…

In other words, it isn’t Deidre’s fault; and it certainly isn’t Heineman’s fault. But Heinemen is wrong. I understand that the impulse to denial is monumental in a case where your baby dies because of the decision that you made. But if you are going to elevate your denial to a book length plea to be absolved of responsibility, other people are going to offer different interpretations.

Here’s what I believe:

I believe that Elizabeth Heineman made the choice to deliver at home, far from emergency equipment and personnel. I believe that Heineman chose to ignore standard medical advice of obstetricians. I believe that in choosing a homebirth midwife, Heineman chose a practitioner who valued her personal autonomy above all else, and, as a result, let a baby die. Therefore, I believe that Thor died from his mother’s desire to have a certain kind of “birth experience” and that politics had absolutely nothing to do with it.

Saying that Heineman bears responsibility for Thor’s death at homebirth is not incompatible with feeling sorry for her loss. It’s no different than grieving for a child who went through the windshield and died because her mother didn’t buckle her into a carseat. That mother is no doubt devastated, and no feeling person can failed to be moved by that devastation, but that doesn’t change the fact that the mother, through her action or inaction, is ultimately responsible for the death.

Heineman’s description of the proximate cause of Thor’s death is both elegant and haunting:

I believe that Thor died in excruciating pain. His 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 …

And, to her credit, she does acknowledge one of the real reasons for Thor’s preventable death:

…I believe her most fundamental reason for not referring me to a doctor was much simpler: in her evaluation, it wasn’t medically necessary.

In other words, Deirdre was wrong to ignore the risk factors in Heineman’s history, but Heineman still tries to absolve her:

I believe the likelihood of Deirdre’s making a mistake was heightened by her professional isolation. I believe that isolation reduced the opportunity for informal, day-to-day talk with colleagues to remind her of risk factors that rarely come into play but which can be critical, like the dramatically higher incidence of stillbirth for women over 40 starting at 41 weeks’ gestation.”

But again Heineman has it wrong. I believe that the likelihood, indeed the near certainty of Deirdre’s ultimately making a fatal mistake, was heightened by her desire for professional autonomy. You don’t need “informal, day-to-day talk with colleagues” to understand the difference between high risk and low risk and act accordingly.

What really killed Thor?

I believe that natural childbirth and homebirth advocates (including some midwives) are perpetuating a series of big lies: that childbirth is inherently safe when the truth is that it is inherently dangerous; that childbirth without interventions is “healthier” when the truth is that it is riskier; that birth is a piece of performance art when the truth is that women have little or no control over what happens during labor; that women should judge themselves by whether they can give a specific birth performance of unmedicated vaginal birth refusing any and all interventions along the way when the truth is that how the baby is born is irrelevant, what matter most is that it is born safely.

I believe that these big lies are being perpetuated by an industry that profit from them: natural childbirth lobbying organizations like Lamaze International and the Childbirth Connection; an army of homebirth midwives, doulas and childbirth educators who would have little if any business if it weren’t for the disinformation campaign of natural childbirth: and a group of women who believe that ignoring medical authority is a demonstration of their “education” when it is nothing more than a sign of their gullibility.

I believe that babies die when celebrities with no medical knowledge like Ricki Lake evangelize and profit from their endorsement of quackery. I believe that babies die when midwives value professional autonomy over common sense. I believe that babies die when mothers locate the center of their worth in their vaginas and the transit of their progeny through them, rather than in their brains that have the power to prevent the deaths inherent to childbirth.

Simply put, I believe that babies die when their mothers choose homebirth.

And I believe that babies will continue to die preventable deaths at homebirth as long as women like Heineman refuse to take responsbility for those deaths.