Vaginal Breech Birth
Sunday, September 21, 2008 at 12:38AM I just had my first surprise breech baby. I never thought it would happen to me, but it did.
Mom labored nicely and vaginal exams found (what we thought) was a rotating acynclitic vertex. Heart tones were heard over the pubic bone, so no red flag that way, either. Within a normal amount of time, she began pushing. Mom was in the water and the presenting part was a tad hard to visualize. When we were able to see clearly, the baby's "head" looked awfully white, so we got her out of the tub immediately. On the bed, we saw the white... butt cheek? side of the head? There was hair, bone - and no meconium, so it was still confusing. A (long - minute, maybe?) vaginal exam couldn't determine position - no anus seen or felt, no vulva or testicles - but I made the call to call 911 anyway and exhorted mom not to push anymore. As we called 911, some meconium began to ooze from the 5:00 position and I was much more convinced that the baby was breech.
911 came in shifts of the police, then the fire dept. then the ambulance. My client was on the gurney and out the door 7 minutes after calling 911. I called the hospital to alert them and flew behind the ambulance.
Mom had a "crash section" (emergency, general anesthesia cesarean) exactly 20 minutes after my making the decision to call for help.
The baby was, indeed, breech, an acynclitic frank breech - explains why there was no anus or genitals visualized (the baby is a boy) and the hair we saw was copious lanugo (body hair). The baby's bottom was very small which would explain the bonyness during the exam, plus as he was "crowning" ("breeching"), it would have stretched any loose skin up into the vagina, making it even more challenging to feel the body part as butt. I can't stress the oddness enough; I am very adept at vaginal exams, but this was so confusing, which aided my decision to transport. Anything that was that confusing was wrong and I had to listen to it.
After my assistant called 911 and before they arrived, she asked me how sure I was the baby was breech. I said 60%, but that it was crucial we call for help anyway. I also told her, on the drive to the hospital, that we had to be 100% fine with a cesarean even if the baby was vertex... that erring on the side of safety was much more important.
I've hesitated telling this story because I know many natural birth folks will be livid at my decision to transport. Heck, the breech was crowning when I called 911! Why not just continue through the birth?
Several things come into play when making this sort of decision (for midwives in general and me in particular).
- Knowing that most midwives who are prosecuted in this country are because of breech babies that die.
- Remembering that breech babies are out of my legal scope of practice.
- Knowing that I haven't ever seen a breech baby born vaginally, much less managing one.
- This woman being a primip (first time mom) and that even docs that do breeches won't do a primip breech.
These thoughts flashed through my mind within a second or two; I wasted no time calling 911.
(Just so people know, the mom is completely satisfied with her experience and my choice. She is sad she was asleep for the baby's birth, but glad everything came out okay. She is aware that other midwives might have [attempted to have] delivered her baby vaginally, but is fine with my decision to make sure her baby [and she] were kept safe. Also, it's important to know that she was receiving co-care with CNMs and had seen a midwife 2 days earlier and the baby seemed vertex and our own evaluation in labor was also a vertex presentation. While I would still have been okay being the only one missing the breech, it was very validating that, if the baby was breech for awhile [which it seems he was because of his postpartum position having his legs up by his ears], I wasn't the only one who missed it.)
So, I hesitated sharing the story because of the judgment I know will come, but my peers helped me come to a place of peace that 1) I wouldn't have changed anything I did 2) I was 100% sure of my decision at the time - and now 3) others can't know what they would do unless they were presented with the same situation and 4) they (the midwives in my Peer Review) would have done the same thing.
As I decided to share this story, in the news comes this horrifying story about an LM, CPM losing not one, but TWO breech babies within a 6-week period.
(Please read the report - I am going to discuss it here and it won't make sense without having read it first.)
The above link leads to the Medical Board's decision to suspend Kristina Zittle's license. Throughout the paper, it outlines the multitude of mistakes this midwife seems to have made in two different deliveries. Having read a hospital complaint about me, I understand the (sometimes) odd viewpoint medical folks have about midwives and there are certainly questions I have about some aspects of what they claim unfolded, but if we were to take this as gospel, I think midwives, students and clients can learn a lot from these examples.
The Medical Board says that Patient (Client) A and B are not suitable candidates for a homebirth because they are morbidly obese and A was a gestational diabetic. Apparently, Ms. A told the midwife different home blood glucose numbers than she told the hospital upon admission; the numbers much higher than she told the midwife. A refused the 3 hour GTT despite failing the 1 hour. (Is this something we should risk out for? Something to think about. With A's 1 hour of 169, I would probably just assume she had GDM, but would be concerned she might need insulin later in the pregnancy, so would highly encourage the 3 hour GTT.)
One of the complaints is she didn't obtain the patient's records for 3 weeks, but I am here to tell you, first, it is not a law that practitioners even give the records to another practitioner; it is a courtesy that they do. Also, I have had to request records as many as three times before being sent anything. That can take 3 weeks!
The midwife did not test the mom for GBS after her being GBS positive in a previous pregnancy. I have gotten a lot more conservative with GBS testing, but used to be more discouraging of the test, but after having a mom with systemic GBS (she delivered in the hospital with antibiotics; no attempt at a homebirth), I am more respectful of the bacteria. If women refuse the test, I like them to do the natural remedies as a precaution (yes, I know they are unorthodox, but I have seen them work a number of times) and also am quite alert to symptoms and very aware of the time frame with ROM (rupture of membranes).
The midwife didn't see the client for a long time - not when her water broke, nor when contractions started. I have BIG issues about midwives who don't go see their clients when labor begins in earnest (and that includes ROM without contractions). I think it is lazy at best and dangerous at worst. In fact, it looks like the midwife was so lazy that she had the woman's husband clean his wife's vagina with chlorhexadine and then do a vaginal exam on her! Was this before she made the choice to come to the house? sigh
Hey, what was the woman doing with chlorhexidine if the midwife wasn't worried about GBS? This is a soap used to "rinse" the vagina of bacteria before the birth and is commonly used when a woman doesn't want to take antibiotics in labor. Did the woman test positive for GBS and it not be charted? I wonder. As it turns out, the baby was also positive for GBS.
The really agregious part was when the midwife changed the woman's due date without an ultrasound to confirm (or deny) the change. With fat women, it is really important to know how hard it is to feel the baby and gauge its size. And with a woman with a 1 hour glucose number of 169, you would automatically question whether the baby was macrosomic. Palpation on a fat woman with a big baby would NOT precipitate changing the due date to an earlier time.
I have no medical proof to back this up, but I find that fat women have their membranes rupture before labor begins a LOT. It happened to me personally three times and has happened in at least a dozen other fat women I have assisted over the years. I've heard about it even more than I have experienced it. Midwives do speak about nutrition playing a part in keeping membranes intact, so why couldn't over-nutrition/crappy nutrition cause PROM? So, that this mom's membranes ruptured, possibly 6 weeks pre-term wouldn't be far-fetched.
Patient A repeated something I mentioned earlier: she told the midwife one thing and told the hospital another. Sadly/Oddly, I have seen this happen more than a few times. There've been times I've watched a client tell the hospital the exact opposite of what they've told me (or their midwife). I'm baffled why they feel compelled to tell the hospital one thing (the Truth?) and us something different. Is the hospital seen as more of an authority? Stronger? More deserving of the Truth? Why would women not tell us the Truth?
I believe it is because we have the capacity to risk them out of a homebirth and some women want a homebirth at (almost) any cost. I know that when I have heard a woman tell the staff something different than she told me, I will say to myself, "Hell's bells! If I knew THAT, we wouldn't have been planning a homebirth in the first place!"
This woman told the midwife she gained very little weight, whereas she told the hospital she gained over 50 pounds during this pregnancy. That is quite a discrepancy! Should women take some of the blame for lying to their midwives? How is a midwife supposed to make an educated care decision if she doesn't have all the information? Can I implore all clients to please tell your midwife the Truth and if that Truth risks you out, so be it? What is more important... a homebirth at all costs? Or a live mother and baby. For Patient A, it almost seems like the homebirth was more important. Was she also deluding herself as much as she was the midwife? I don't think so if she told the Truth to the hospital; she was selectively giving the midwife information.
(None of this excuses the midwife. I bring this up because it is an important aspect of midwifery I hope students and apprentices discuss at length with their preceptors.)
One of the repeated complaints is that the midwife didn't do enough vaginal exams. As a midwife who doesn't do a lot of exams, the question becomes, "Should I do more?"
As I was talking to my apprentice about all of this, I said that our charts/clients, when looked at with a clinical eye in the black and white of paper and seen through the filter of obstetrics would look completely different than we see them in the here and now. The Zittle papers clearly demonstrate this. Could I withstand such scrutiny? I would hope so, but know that some issues - few vaginal exams, clients who aren't risked out for refusing tests and screens, even accepting VBACs - wouldn't look ideal from others' viewpoints.
One reason we have Peer Reviews is to keep a gauge on what is "normal" in our community. If we stray too much (or too often) from the norm, our Peers will either reign us in or, potentially, we will be asked to leave the group. As far as I know of midwives (not only in my own community, but all over the country), it isn't unusual to have a woman not take a GD screen, to not do the GBS test or to not want a slew of vaginal exams, especially once her membranes are ruptured.
However, what happened with Patient A is that once the midwife did do the vaginal exam (at 6 hours post-beginning of contractions and 27 hours after SROM), the midwife presumed to find a nuchal hand when, in fact, it was the baby's foot. 4.5 hours later, another vaginal exam found the baby's whole leg through the cervix into the vagina, but mom was only 8 centimeters dilated. Why, in god's name, the midwife didn't call 911 at that point is beyond me. Instead, she obtained written informed consent (and I use that term loosely) from the parents to go ahead and deliver the baby at home. However, she neglected to add "death" to the list of possible complications which brings me to my oft repeated point:
How informed IS informed consent? And how much information is enough? And whose information is the right information? Does the woman need to hear from two sources? Three? Four? From medical books? Midwifery books? Doctors? The Internet? MDC? BabyCenter?
My own Informed Consent Form lists 50+ possible complications in pregnancy, labor, birth and postpartum and I require women to research on their own, not just taking what I have to say as gospel. I list all the above locations and include friends, family, medical libraries and more as possible sources of information with which to make their eventual EDUCATED decisions about the arisen complication and the actions we will take - together - on that complication.
In the case of Patient A, it's pretty obvious she didn't get enough information.
An interesting question arises when reading about the midwife doing CPR (which, for some reason, they make a point of saying she hadn't ever done before. Isn't that what we hope for, but practice for all the time and re-certify every 1-2 years?) - what is her assistant doing all this time? Does she have an assistant there? Or was she doing the CPR on her own?
When reading about Patient B, the Medical Board lays out why they felt she wasn't a qualified homebirth candidate. Interestingly, none of the reasons scream DON'T TAKE HER ON to me. Anyone else? Women who are fat can have uncomplicated homebirths. Women who have a history of macrosomic babies can also have successful, healthy homebirths (some women do go on to improve their diets and have subsequently smaller babies - I did as did 2 of my clients). I have assisted at home and birth center births of women over 40... one woman was 46 having her first baby! They have all done just fine. And a woman who is Rh negative? Since when does that risk a woman out of a homebirth? Even with a plethora of risk factors, I wouldn't consider Rh negative a risk factor. Odd that they even mention it - unless the woman was positive for antibodies, which it doesn't say she was.
Reading how they word things, it certainly makes me tilt my head sideways to try and see what their concerns are. Is it the accumulation of these issues in one woman? Is it one or two combined? Is that any "risk factor" makes a woman not a homebirth candidate? Wouldn't almost any woman disqualify for a homebirth? (Isn't that the goal of ACOG and the AMA anyway? To make homebirth obsolete? By disqualifying every woman, they would be well on their way!) I acknowledge there are valid risk factors for risking women out, but these reasons just didn't resonate with me. I am looking at it, examining it... to make sure I'm not missing anything.
Another odd concern was that the midwife lived more than 45 minutes away. Is that unsual? Heck, I was midwife for a woman who lived 3.5 hours away and I have had several clients who were 75-90 minutes away. When there have been any issues - baby not moving, for example - I've sent the women to the hospital until I could get there. The report says the client didn't have transportation to get to the hospital; call a cab or an ambulance, for goodness sake. There are solutions beyond sitting in the house waiting for a ride that's an hour away!
Strangely, comment is made that the midwife didn't go to the woman in a "timely" fashion when she reported losing her mucus plug or when she began having contractions. Honestly, the midwife got to the woman about the same time she would have gone to the hospital if she were birthing there. Hospitals would crap their pants if every woman came in who lost their "plug" (as the report wrote it) or who were just beginning to have contractions.
Perhaps the weirdest part of Patient B came when the ambulance crew arrived to find the body of the baby out of the mom (who was still in the pool) and when they called the midwife, she told them to wait for her (!!!!!!!!!!!!!!!!!!!!!) even though she was 30+ minutes away. AND THEY FRICKIN' LISTENED TO HER! Where was the doctor on the other end of their phone line telling them to get the woman out of the pool and into the ambulance so she could deliver her probably dead baby sooner? Who was the supervisor at the site saying it was fine to wait for the midwife? I think this was a debacle on many accounts, including the woman who stayed in the pool waiting for the midwife to arrive as well as waiting for the baby to be born.
The report says that her being in the pool was an "impediment" to getting into the ambulance, but let me tell you, I have had women nearly FLY out of pools when they needed to, even with a head between their legs, so getting a mom to move in an emergency isn't all that hard. And if she was incapacitated from fear, two or three people could have lifted her out of there, climbing in the pool, too, if need be. Again, there are other solutions beyond saying, "Oh, no! There's a pool in the way! Whatever shall we do?" Sometime along the way, the woman did get out with the baby still half out (and certainly dead by this point) and onto the gurney and into the ambulance where she was taken to the hospital where she eventually delivered the rest of the baby.
So many questions still unanswered. It will be interesting watching this case unfold.
I ask us observers, especially midwives and students, to put ourselves in the midwife's position and really see how we would have acted and reacted to the scenarios. Really feel the reality of a surprise breech and how you would react to the situation. It's crucial for us midwives to play out these situations so WHEN the time comes (not if), we are prepared. If you are a midwife who is willing to attempt a vaginal breech, I really do hope you inform your clients of all the risks, not just the ones that are comfortable talking about.
I've been called a med-wife a couple of times today (on MDC and in another blog) and I sat quietly wondering if I was offended or complimented. I accept the term if med-wife means someone who takes action when the situation calls for it. I am not a hands-off midwife at all costs. I am much more concerned with the life of the mother and baby than I am worried about being liked. If that makes me a med-wife, then so be it.
I am hired to protect the mother and baby from common dangers. When the dangers are no longer common, off and running we go to the hospital. I am thankful - and honor - hospitals, doctors and nurses (including CNMs). I respect these folks for their skills and life-saving abilities.
Considering a vaginal breech birth (something that too many midwives are prosecuted for because they lose the baby that way) is something every midwife should be really careful about. I know and have seen the marvelous vaginal breech videos - even the footling breech ones like Mindy's (Psalm & Zoya), but I think in this day and age, we need to re-think the risk of the vaginal breech birth. I know that I am not willing to take that risk. And that, to me, makes a strong and good midwife... knowing my limitations and not endangering my clients with my lack of knowledge or skill. Would I like to learn how to do breech births? I don't think I would, actually. The risks (physically and legally) are just too great to me.
Thoughts?
Reader Comments (74)
I think you handled the situation beautifully--I would have done exactly the same thing--and I'm glad you had a good outcome. This is RESPONSIBLE midwifery.
I am expecting my fifth baby, planning a third homebirth after two hospital births, and I have always said that I would never consider a vaginal breech birth. My kids have all had 37-38+ cm heads that have needed a lot of molding to fit through my pelvis. Even with my fourth son, I pushed for 40-45 minutes. It seems to me that any child of mine would be at high risk for an entrapped head if born bottom first. So I'm very sympathetic to your POV here. I'm also curious about your take on Lisa Barrett's breech series. She makes it sound so doable -- it's been intriguing for me to read her posts.
I think it is so interesting that you have experienced women lying to you (or to their midwife) and then telling the truth at the hospital. Personally, I would be much more likely to lie to the hospital and tell the whole truth to my midwife! I trust my midwife's judgement much more than the horrible OBs and hospitals where I live in the South.
Whether someone agrees or disagrees with your reasons, the story is very sad.
I think it's a different story when there is a death involved. The veil of secrecy is gone and there is the compulsion to blame someone. When the hospital, over and over, blames the midwife, the women "come clean" (so to speak).
To be fair, I have also heard women lie to the hospital/doctor... about how long their membranes have been ruptured, about how long they were in labor and that I am their doula (monitrice), not midwife. However, if the baby had died from infection, I think they would have, eventually, told the truth. Does that make sense?
When I had my third, after my 10 lb 6 oz baby at home, I was so worried about having a breech baby, my CNM said to me, "You had a 10lb 6oz baby! You can fit a breech baby through there." I've used that line on clients. I won't anymore.
Marilyn,
I agree. I don't mean to gloss over the tragedy, please forgive me. I was seeing this as a learning tool - a great lesson for students and apprentices, so was, in a way, doing what the papers were doing and that is looking at things with a clinical, not emotional, eye. I am very sorry for the loss of the babies. Don't doubt that.
Med-wife- No. Midwife recognising her sphere of practise - Yes. Midwife means to be with woman, what is not written, but should be taken as implied, is 'healthy woman and baby' and that was the outcome here.
A few women will be 'honest and open' with the midwife as long as it gets them what they want. Unfortunately it is often only when things go wrong that the whole truth will really come out, and then it is often a 'truth' coloured by a wish to absolve themselves and shift the blame (hate that word) elsewhere.
Wow Barb - powerful post.
I too have seen a Crash Section for a breech (I don't know what you call Sections that are the highest emergency in the US, we call them 'Crashes' in the UK) - the woman was in hospital already & the baby was delivered 7 minutes after the decision was made to Crash in great condition.
Well done for making such a brilliant decision - the Zittle papers are horrifying in the extreme. I cannot believe she was allowed to continue practising following the 1st breech & the EMT's who listened to her need to be removed from post as well. What was she thinking Barb???
It's interesting to me, as was noted on another blog, that there is little difference between a midwife saying that the risks of attending a vaginal breech are too great for her to take on, and an OB saying that the risks of attending a VBAC are too great for her to take on. Yet the midwife who says the former is prudent, and the OB who says the latter is just a woman-hating jerk. Why the discrepancy?
I think that with your experience and scope of practice, it was appropriate to transfer. I wouldn't want an inexperienced midwife or doctor attending a vaginal breech birth. I do think, though, that using the argument "even doctors won't attend a primip with a vaginal breech birth" is a bit disingenuous. With that line of reasoning, you could promptly shut down VBAC, home birth, water birth. etc...because there will always be lots of doctors who don't do those things. Make sense?
I don't find your client's story sad or in bad judgment specifically, but in general I find it sad that there are so few options but cesarean for breech presentations, especially for primips. So I guess I really support keeping the skill set alive for those women who really feel that a vaginal birth is the best option for them.
Not sure if you want to bother with this..but what IS so dangerous about a vaginal breech birth?
Rixa... what I said was even doctors that DO breech deliveries don't do primip breeches. There is a world of difference between saying that and using the argument that doctors won't do breeches.
Hope that clarifies.
I know it wasn't quite the point, but this post really brings up the issue of informed consent for me. I'm just a doula, so not responsible for the medical decisions, but I've been present at three births lately in which the doctor did not fully inform the mother. A vacuum extraction without the mention of death, an epidural that completely denied risk at all and an episiotomy that occurred with just the preface "I think I'll make a little room here". I really think this causes mistrust and litigation. If a woman hears all the horrible things that might, though rarely might, happen and still agrees - coercion can't be cited. It's when the worst happens and she wasn't pre-warned. Then her choice was taken from her.
And as a doula, do I have the right to fill in any gaps I know of? Lots to think about with this one.
Informed consent is much more of an issue (legally) for midwives than physicians (I believe and in my experience). How many women do we know that learn of the risks after the fact? Gobs of 'em.
It isn't your job -during the birth- to give the woman the risk/benefit talk. It *can* be your job to discuss these things prenatally. Have her read Ina May's Guide to Childbirth and then spend a meeting talking about it. Teach her to say, "Can you tell me all the risks, please?" when the medical folks propose something she doesn't know about.
If you are doula-ing for a stranger, I would say your only job is to love her and support her emotionally and physically. If she asks, then you are able to take on a larger role. Even sneaking information between nurse visits, I'd say, wouldn't be a good thing lest the woman feel overwhelmed.
Of course, if you believe she is being abused or traumatized, that is a different story. Don't foist your beliefs on your clients, though. It's an advanced doula skill... keeping one's own issues out of the birth room. I'm not specifically talking to YOU, but more a general doula note.
Does that help?
Yes Barb, I know that you said that. I guess I fail to see the logic of an automatic ban on primip vaginal breech births simply because the woman is a primip. I am sure there are doctors or midwives who will do vaginal breeches with primips (but probably very few in the US though; thinking more in places in Europe where that skill set is more common).
Rixa,
I totally agree there *are* doctors and midwives that can and will do breeches vaginally. There are certainly locations around the world that don't have a choice BUT to do them, same with many women having to (and their not thinking at all that it is a huge issue) UC because no one to assist is around (except maybe a friend or family member, but not the village/community midwife).
If it were a different time here in the states, I would have totally known what/how to do a vaginal breech. Years ago, I really wanted to learn how to do it, but I believe, for me, the political climate and the safer (in my opinion) alternative of a cesarean changed that desire.
By "safer," I mean for the baby... that there is no risk of the head becoming trapped behind the cervix or cord entanglement during the birth. I absolutely acknowledge the risks (sometimes great!) of cesarean surgery/birth and know that if the vaginal breech birth were issue/problem-free, it would be MUCH safer than the cesarean. But, to me, in the risk-benefit scale, the cesarean poses less risk to the baby. It is hard weighing the safety issues of mother versus baby... please know I acknowledge that what I am saying isn't perfect.
Thanks for letting me continue processing. It really is important for me to be able to verbalize this. Thanks for the opportunity. You are a great sounding board. :)
Barb--
I think you handled the situation wonderfully. Knowing our own limits and knowledge zones is important. So what if other midwives would have delivered the baby? You weren't comfortable with the situation. Therefore, the best outcome for both mom and baby was to be transported to an environment where other professionals could provide aid.
As for the midwife/medwife talk. It is so limiting for everyone! It drives me crazy.
Hmm... As a three-time C/S momma, I often wonder how it would have been different if I'd been allowed to deliver my footling breech firstborn vaginally. However, I am on my own path to becoming a midwife (the very very slow path!) and you've given me a lot to think about.
I live in Virginia. My midwife lived at least an hour, maybe more with traffic, from me. She told me legally they aren't allowed to administer drugs (including pit in case of bleeding) so they don't bring any (except homeopathics). Knowing those 2 things alone as the client, if I had thought there was anything about my age/history/present health that made me or my baby the slightest bit risky, I would have switched to a hospital birth. In fact, when a piece of my placenta failed to come out, I immediately informed my MW that I had no issues against transfer. I think the clients themselves made egregious errors, too.
CaliOak (This is the second try at getting this out; sorry it took so long),
There are two main issues with delivering a breech vaginally. 1) Head Entrapment 2) Cord Entanglement/Compression.
1) Because the body is smaller in diameter than the size of the baby's head, it can come through the cervix before it is completely dilated... leaving the head trapped up behind the cervix until it dilates to 10. There are methods/ideas/suggestions/rules to follow about either a) keeping a mom upright or b) keeping her horizontal until the cervix is dilated... each method having its own logic about pressure on the cervix. Depending on how a midwife was trained depends on what her philosophy is (unless she unlearns it later). Not having professional training in delivering breeches, I am more inclined to consider keeping a mom down low until the body and head can come out together, but there are valid arguments for each style.
The head is really hard, yet molds as it is being born first. Coming out the chin first, there isn't that molding that decreases the diameter of the head that typcially/normally happens in birth. If the baby is any substancial size, this is another way the head can get stuck up inside the mom even as the body is already born.
2) Because the head usually acts like a cork in the cervix, the cord most often stays up above the head, unable to fall into the vagina and be mooshed by the baby's skull, cutting off the oxygen supply. Of course, cord prolapse does occur occasionally, but usually when the head is still floating or really high in the uterus and the membranes rupture or are ruptured (too soon).
But, when you take the smaller butt or legs AND the close proximity of the cord to the butt and legs, you have a more possible recipe for cord prolapse. The cord can also get caught on any of the limbs and pulled taut as the body is coming out.
Technically, once the cord reaches the outside and air, it begins to shut down its mechanics. If the baby is still inside and the cord is outside, the baby can lose precious oxygen. That is why folks will cover the cord (that's born before the baby) with gauze that's soaked in sterile saline (a close match to amniotic fluid). This can work for a short time (and it can also not work at all), but the baby really is on a time crunch to get out if the cord has been born.
So, besides these things, limbs can get trapped and need to be broken to be born, babies can inhale when the body is born but the head has not (there is a mechanism to keep the airway free for the baby if the head doesn't come with the body).
All of this sounds gory and tragic - and it is if the birth goes these ways (as we see with this midwife's case). But, most breech births go easily and flow the way they are supposed to. However, it is the small number that don't that keep me from learning and attempting breech births.
I hope this helps!
Karelle,
Do you mean if there had been complications as you were vaginally delivering your primip footling breech? Or if you'd have successfully delivered a vaginal primip breech. Both scenarios need to be played out when figuring into the equation of suppositions.
Question: Did you attempt a VBAC with #'s 2 and 3? Was your first cesarean the catalyst for the other 2 because you didn't want/consider a VBAC? Is it now that you have had 3 cesareans you are playing the "what if" game?
It's great that you are studying to be a midwife. I love to tell students: We are a product of our experiences. This is no exception. We who work in birth HAVE to put our own experiences aside... even the unfolding of how other births have gone. There can be *trends* that we believe in/expect, but we *have* to allow women's births to be what they are without any of our own stuff/shit involved.
Your 1st birth transformed you. It will make you sensitive to cesareans in a way I never will/can be. Yet, it is imperative of you to not second-guess every cesarean -because valid ones happen every day! (I don't know you and you could already know/do this... so please don't think I am trying to patronize you... just globbing onto a teaching moment.) I had a (difficult) UC and it colors every UC birth I encounter. It's impossible not to. Yet, when we look at births through our own unique lenses, we *have* to remember the paths, walks, fates, creations and expectations of those we serve and let them unfold for them in their own way.
If we've been invited in as midwives, we are being asked to share some of our viewpoints (not all midwives believe that, but I am quite close to my clients and do), even in a broad way. Something connects us; is it our viewpoint about birth? Does the woman need something we have to alter/soothe her walk down her path? It's nearly impossible to tell until postpartum - sometimes years postpartum.
You have valuable experiences to teach women and with which to help them. When a woman has a cesarean in your care, just think how much you are going to be able to teach and comfort her! How great is that?
One last thing... my German hebamme (midwife) had had 2 cesareans, no vaginal births at all, yet she was a wonderful, magnificent homebirth midwife. Don't ever let anyone tell you that just because you haven't had a vaginal/homebirth you won't make a good midwife. It ain't true.
DN: Your midwife doesn't bring herbs? It makes me cringe thinking about not having pitocin and methergine at a birth. I couldn't do it. But for women who don't have it, herbs are a MUCH better way to contract a uterus than homeopathy. I'd ask your midwife if she is opposed to your having them at your birth. Many of my clients prefer herbs before the pit... which, if it is not a gushing hemorrhage, is fine. Google "herbs for postpartum hemorrhage" to see which ones resonate for you.
Barb,
you rule.
Well, that's sweet!
*blushing*
I had my first CS for a single footling breech. There are times, like when I hear of someone having a good outcome homebirth with a footling breech, that I think, "Geeze, I should have at least tried. I could have done that" and then there are times, like when I read of bad outcomes, that I am so thankful that I had a cesarean. I'm also very thankful that my next baby was vertex and I had a wonderful home VBAC. Most importantly in your situation, baby is healthy, mom is healthy, and mom is "at peace" (for a lack of a better term) with the surgery. Thank you for your honesty and putting yourself out there.
Hey Barb,
Wow, lots to respond to! :) I'm not opposed to c/s in the cases where they are medically warranted. I liked your med-wife nickname. I think I'd like to be something like that when it's my turn. My story:
#1 was discovered to be footling breech at my 39 week check. Dr. H immediately recommended a c/s. Hubs & I got a second opinion - also for a c/s. 3 days later he was born via c/s. I never labored.
#2 was a routine repeat. i didn't know any better. I knew I didn't want another c/s but i didn't think i had a choice. My 10lb baby was delivered at 37 weeks. I never labored.
For #3 I wanted a vbac & a midwife. I shopped around. I even came to see you (met you at an ICAN meeting once). But my insurance was crap so I went back to my OB. He promised he would at least let me try for the vbac. At 41 weeks, after a week of start & stop labor, my 10 lb baby was delivered via c/s. Apparently he was lodged on my hip and I have a uterine deformity that created a lip at the top (think heart shape) which keeps the babies from turning into proper presentation.
I'm not studying to be a midwife yet - i'm getting a master's in psychology right now. My thesis is on evolutionary birth practices - don't know specifically what yet. After my master's, i'll start nursing school and continue from there into midwifery. Maybe one day I'll get my PhD in psych and do research related to midwifery.
I love reading your blog and all of your insights into different midwifery situations. I hope I can do as good a job as you seem to when it's my turn. :)
I had typed up a huge response to this post when it was first published but somehow, it never made it to the page here. After reading all of the responses, I think Rixa really put into words what I wanted to say (and more succinctly!) better than I managed to do. I don't think your decision in your specific situation was wrong, necessarily (though I must admit that I would have been livid and completely unsatisfied had it been me being subject to fetus extraction because my care provider had no experience with my particular situation but that isn't something I would consider your fault, either).
What disturbs me about this entire thing is the base issue, here. The fact is that breech birth isn't really any more risky than prophylactic cesarean. The risks are just different. And I must point out again that "better safe than sorry" doesn't work if there is nothing imediately wrong. If it's not *necessary* then it is NOT safer. Obviously, when you have seconds to make a decision (or you think you do, anyway) you make the best choice you can and stay confident in that decision. But why should that be a position you or any other care provider is suddenly slammed into? Why should mothers suddenly be crashed into it as well? Why haven't you ever seen a breech baby born? And not just you, but the vast majority of maternity caretakers in this country? What really makes breech potentially risky in the US is the complete lack of experience that care providers have. The support needed form the birth professionals in that instance is quite different from that of the delivery of a vertex baby. Insisting that the cure is more cesareans, particulary for premips, is counter-productive. It's switching from one set of risks to another and to me, that's not productive. IT's just moving the big steaming pile of poop form one spot to another but not actually cleaning it up.
I have so many mixed feelings about these three stories. My footling breech baby was born fine, despite her compound presentation. I can't express enough how grateful I am that I didn't transfer to the hospital and get my baby extracted through a gaping hole in my body, subjecting her to a risk of death 4times greater just from being born surgically, to say nothing at all of the risks to my person. At the same time, though, as with any other issue surrounding birth, I don't have a rosy, romantic view of the issues surrounding breech birth. I know things can go wrong, there, as with any other area of birth. I think we certainly need to "rethink" breech birth, but I don't think it's the midwives and ob's that are advocating vaginal delivery that need to rethink things. I think society as a whole needs to do everything it can to keep NORMAL delivery a safe option for mothers and reducing their options to nothing but surgery is not safe, it's not even sane. When care providers are stuck in a situation where three out of the four top concerns are for themselves, their legal issues and THEN the mother, there is a problem. And it is directly related to lack of knowledge. You are forced into making a decision about the potential life and well-being of two human beings with a total lack of information. I think that is a great shame.
NGM, you have such a heart for the abused women of this world. You have a desire to reach out and really give women some power, helping them to their feet, if it were. Healing seems to be a big part of your work and yet you have no desire to learn the art of assisting a woman to deliver a breech baby? I'm confused by this- it seems counter-intuitive to me. I would think that learning the art and providing women with an actual *choice* would be very important to you, being such an advocate for informed consent and choice as you are. Would you mind shedding some light on that for me? I don't have the perspective you do, lol, so I'm really confused about this!
Rebekah,
What a great comment! I'm really glad you shared your thoughts - and in a kind and respectful way. Thank you so, so much.
I don't want to learn how to do breech births for two major reasons... well, three.
1) I don't believe I would have access to someone who can teach me to do breech births in the safest way - and access to enough breech births to get me comfortable with them. I watched at least 3 shoulder dystocias before assisting at one. I assisted at least 2 before being the primary with an experienced assistant. The prospect of that many breeches would require my traveling around the country as midwives planned for breech home deliveries. I don't want the first breech I see to be one I am managing the delivery for!
2) Legal reasons. I know it sucks as a reason, but it's true.
When I became a CA legal midwife, I said I would *never* allow the law to dictate my practice. That statement has come back to bite my butt a number of times. There is, for me, no way to adhere to that dream. I've been in jail and it was awful. Prison would have to be even worse. I just don't think I could put myself, purposefully, in the position of possibly going to prison.
3) Please know I understand the trading of risks and how really, really horrid that is as an option. But I just don't want to take the chance on losing a baby because of my lack of skill. I would never forgive myself.
Thanks for asking.
Barb, can I just say that I find this comment: "ugh I must admit that I would have been livid and completely unsatisfied had it been me being subject to fetus extraction" one of the most offensive things I have read. I hate the way the natural birth community degrades others by such nastiness. Do what you want with this comment, you do not have to post it. But I would love to read your opinion on this. As a natural birth supporter, and doula, who has both vaginal births & then c-sections....it just pisses me off. I think that this mentality is very dangerous to mothers & babies.
"Fetal extraction" is a rather crude and mean way to describe a child's entry onto the earth. It's pretty offensive to the mom *and* baby, if you ask me. However, I just left it alone. Women who use language like this are usually still mourning, but in the anger phase. I always hope they will move past that and soften their voices. It doesn't always happen.
Not acknowledging the philisophical and spiritual reasons a baby might be born by cesarean is common, too, in the mourning phase. For all we know, the baby I sent to be "extracted" CHOSE me to be there so he didn't die from head entrapment.
Women grow from adversity - if they allow themselves to. I mean, I had the most medicalized hospital birth with my first baby, thinking it was the greatest birth going... and look! I still found my way to being a midwife who does homebirth. If *I* could beat a path through the forest, there's hope for everyone.
Women who have (unwanted) cesareans tend to learn from them. They learn 1) they don't want to do them again 2) how to avoid repeating their cesarean experience, even if that simply means choreographing their next cesarean 3) they become a beacon of information for others who are in the dark (so to speak) about VBAC 4) if they go on to VBAC, they are a walking advertisement that VBAC is possible.
Not every woman who has a cesarean is pissed about it. I think that makes the angry cesarean moms even angrier. "Don't they know?!" Blessedly, my own clients tend to mourn and then get on with their lives. They acknowledge the sadness of the loss of a vaginal birth, however they also understand WHY they had a cesarean. They weren't railroaded into one as too many women in hospitals find themselves experiencing.
This particular mom is extremely spiritual and believes the child needed to be born via emergency cesarean, that something might have happened if he hadn't (and that doesn't have a lot to do with my feeding them since I was out-of-town in their early postpartum time) and he chose his time and place to be born.
See, the hospital was evil to my assistant and I. Initially, they were very angry and mean to the clients, too. However, the family won them over by the time they left the hospital, the mean staff hugging them and wishing them well. They believe that was part of their walk - to demonstrate the wisdom of a homebirth family and their normalcy.
How many lives are touched by our births? ALL of them... vaginal and cesarean. When women can dig out of the anger, they find a gentler world than they pictured in the vortex. "Fetal extraction" becomes obsolete and "cesarean birth" replaces the term and meaning.
I've been thinking this post over for awhile. When I was in my phase of assimilating every thing I possibly could about birth, I came across the study that was going around MDC about breech birth. The study, which I can't find at the moment, suggested that breech birth is actually safer if done vaginally with an experienced attendant, as the risks of c-section trump the risks of a vaginal breech (if I remember right). In my world of seeing everything in black and white, I filed this info away in my brain and decided that if I ever have a breech presentation baby, I will want to deliver it vaginally. However, your post here is messing with my neat little black and white world, and now I am confused.
I can see why as a midwife you don't want to learn to do vaginal breech (because of the legal implications). But what are your actual thoughts on the safety of vaginal breech birth for a mother who is making that choice? Is it not true that c-sections are riskier than vaginal breeches? And even if the risks are exactly the same, how do you make that choice as a mother? If the mother is not a primip and is with an experienced attendant, do you think vaginal breech birth is a good choice to make? Or would you always opt for a c-section?
Jennifer,
First, I am glad I am making you think. Isn't it interesting to learn things aren't just black and white? The shades of gray FAR outnumber the two poles of that black and white.
If the woman is a multip with an experienced provider, I would agree the vaginal breech is a great option. The cervix already has opened before, so labors/births tend to be more straighforward.
I believe I *have* shared my beliefs of a primip vaginal breech, legalities notwithstanding. If it were me, I would have a cesarean once I went into labor. That, of course, is AFTER trying everything under the sun to turn the baby, including a version as late as I possibly could get someone to do one before the birth.
Cesareans are a *different* risk than a vaginal breech. We all know the risks of cesareans and I believe I have outlined the risks of a vaginal breech, so weighing them is like comparing apples and oranges. And weighing the risk is exactly what needs to be done. *I* believe that the risk to the baby is greater than the risk of a cesarean, but I don't have any research to show it. However, I know LOADS of women who have had cesareans without (severe, life altering PHYSICAL) problems yet have heard too many tragic outcomes from vaginal breech babies. Granted, stories make the news BECAUSE they are so rare, but even just these two babies in this story is enough to make any intelligent person sit up and take notice.
How *does* a mother make the choice? How does a mother make the choice between feeding herself or feeding her child? How does she choose between paying the rent or giving her child a birthday present? How would a mother decide to take her child off life support?
There are no perfect answers and there is no way anyone else can make the decision for another - unless that someone were being hired to do just that.
(I assume you were asking about a mom who is still pregnant and weighing her options, but I thought I needed to explain how *I* or any other care provider can make the decision for the mom.)
Does that help?
I don't comment as much anymore because it always seems like I say the same thing, ie "gosh I learn a lot from you." But, er, gosh I learn a lot from you!
I'm three months into my third year of medical school now, which means I am actually dealing with patients instead of just textbooks. I haven't done my OB rotation yet (hopefully in November-December), but still planning on going in that direction. One thing which struck me in this post (of the myriad things) was the element of what is reported and to whom. It's something medical students deal with -- this morning, one of my patients gave a different story to me, to my intern, and to my attending. Little differences like "I have not had any chest pain this morning", "My chest pain is still as bad and painful as it was yesterday and has never gone away," and "Oh, this is just the chest pain I have off and on all the time, it's nothing new." Some patients confide in the nurses, some confide in the medical students, some only give important information to the doctor they perceive as being "in charge," usually the attending or a specialist consulting on a case. Everybody knows this goes on, but it's still very frustrating to base your presentation on what the patient tells you, then have a completely different story come out when your team sees him/her. I think it may have something to do with comfort levels in some people, or a perception of who "really needs" the information to make the "real" decisions. I don't know. It's not just you, in any case -- although I think you have a great deal more at stake when you are not given the full story, all things considered.
I'll go back to lurking now, not pepper your blog with fangirl comments comparing you to Yoda, but I'll be here soaking up insight in my quiet little corner. ;) Thank you!
Sarah,
Thanks for the validation about people telling providers different stories. The tendency is to think it is simply a trust issue, but I don't find that at all. Women *have* trusted me, yet feel compelled to tell the doctor a completely different story. Or, interestingly, vice versa.
Thanks for the fan mail. *laughing* Everyone can use some every once in awhile.
Please, please make sure to let us know when you do your OB rotation. I can't WAIT to hear about it! You go girl... hang in there and do it for all of us who wish we could change the system.
A quick aside to the medical student who commented: I always tell students when I'm working with them not to take personally that patients tell the student one story and myself another. I like to think that all the careful questioning the student does merely jogs the memory and starts the patient thinking more thoroughly about their symptoms and experience, so that when the attending comes in the patient has clarified what they what to say in their brain and a different story comes out to the attending. I don't think it's usually any kind conscious decision to tell differing things to different levels of providers - it's just the nature of repeating your story over and over. Having a student talk my patients first sort of "primes the pump" and then I sometimes get to the bottom of the issue more easily!
Barb,
Damn that gray area :p
But thanks, that does help.
Since I'm not a primip, if I find myself pregnant with a breech I will just have to make sure I find an experienced provider, and try to get the baby turned, and maybe weigh my options at the time if it happens.
I was born vaginal breech by the way. I was a second baby and born frank breech with forceps. It wasn't pleasant for my mother or for me. My bottom was so swollen and bruised my dad thought I was boy. And I was by far my mom's worst labor and birth out of her four kids. So the discussion of breeches always perks my interest.
Any idea how a Californian should go about making life miserable for whoever outlawed vaginal breech births here?
I get not doing home birth breechs as a policy statement...but life happens. What if your second cousins nieces great uncle gives birth in the boonies and by accident you (or any care provide) is the only one there?
As a client I'd much hope my provider knew how to do this even if they didn't want too..because what if the birth is too fast to transfer? Or if the EMTs were as stupid as the ones in that tragic story in your post?
As a Californian this state passing laws that eliminate an entire skill set from the obstetrics/midwifery and family doctor/primary cair physician fields worries me. Caution is good but pursing ignorance seems like a bad idea. Especially since California tends to be the national guinea pig.
I keep "hearing" midwife w/ a knifes post about doing vaginal breech births. Maybe there are differences I'm not picking up...(home vs hospital, OB vs midwife, being able to push the baby back in wheel the patient down the hall and do a c/s) she did mention forceps...But she also mentioned how hard it was for an OB to learn to do forceps and breech vaginal deliveries. I don't think mwak is in California.
I don't know. I'd just be much happier if somebody (in general) knew how to do this and don't like my state making its medical people less equipped. Whether a practitioner wants to use something in their routine practice or not the training should be available.
CaliOak,
Now, we *are* trained how to do them in an emergency... if the baby kept coming, I would have absolutely known what to do (or what NOT to do), but mom had the baby in that same non-forward-moving position for at least 20 minutes, so the prospect of a straightforward delivery, to me, is lessened. Plus, please remember the baby was acynclitic; if he'd have been in the proper position, he might have flown out... and wouldn't that have been nice?
I'm sorry that it disturbs you so much that we aren't learning the skill. I wouldn't even know who to go to in order to learn! I just got a comment from a doula in San Francisco who works with a midwife who has done several breeches. If that were possible, how fortunate for midwives who would like to learn from her.
I don't think I would be the right person to attend a breech birth - even as an observer. I think I bring too much fear and that isn't needed at variations in birth. It would take some inner work for me to release the worries before I would permit myself to attend a vaginal breech birth.
I've really loved watching the comments on your post! Your honestly regarding your fear around attending a breech birth was heartwarming. It takes a lot to admit our own limits. Good for you for knowing yours.
Since you posted this, I have had a question swirling around in my head. You said it took approx. 7 minutes from the time you called 911 until aid arrived. I am wondering, how did you fill those 7 minutes of waiting? Perhaps it was nothing more than waiting but I am wondering how you (and Donna) supported the laboring mom while you waited. How did she handle the news of the breech.
I am sorry if this is too personal or if you don't feel comfortable sharing. I am just interested in how we fill "bridge moments." Those moments in life that are so brief but so important--almost like birth itself.
If you feel like providing some shadowing for what happened in those 7 minutes, I would be very interested.
Donna wasn't my assistant for this birth.
It was about 2 minutes for the police to arrive, another 2 for the paramedics to arrive and then another 2 for the ambulance to get there. She was *easily* out of the house about another 2 minutes later.
So, it was hectic, but I think you ask a really great question... and one I have answered before, but am glad to answer again.
When we make the decision to transport, I immediately start talking to the client, letting her know what I found/what's happening that's sending us to the hospital through EMS. I tell her how the baby is doing, how she is doing and then begin to prepare her for all the things to come. I let her know many men in uniforms will descend on the room, they will be asking her a lot of questions, many of them the same ones - and ask her to please be patient and answer the questions as many times as she is asked.
I tell her someone will come and take her blood pressure, someone will be starting an IV and all the while, people will be asking me, her partner and her a thousand questions.
I tell her the best she can do is stay centered and calm... we all collectively breathe slowly... and I ask everyone else to stay calm, please.
With this woman, I never took the doppler off the baby until she was on the gurney, even when we had her rotate to hands and knees, butt up in the air (that lasted about 2 minutes until the ambulance arrived and made her lie on the gurney).
I keep a running dialogue going about how the baby is doing, how she is doing ("you are doing so well even with all this change... do you have any questions?") and answer the ever-present question from the family: How's the baby doing? Moms *always* say they are fine as long as the baby is fine. With this mom, I told her over and over her baby was doing really well... that if s/he was born right now, it would be okay, but it would be better if she didn't push so she could get to the hospital first.
Amazingly, women are able to follow any instructions to keep their babies safe. The pushing urge has been known to flee during transports. Some women will barely push. For those that couldn't birth the baby through pushing at home, I have often prayed for a delivery in their car or in the ambulance; that's never happened.
I talk softly, yet clearly and firmly. I speak to the partner as much as the woman and then when EMS arrives, turn my attention a little to them, answering their questions, giving report and doing anything I can to expedite the transport. (I really need to do some new EMS in-services re: transporting clients.) I am always touching the woman (and/or the baby) until she is wheeled out of the house. I tell her I will be right behind her and will meet her at the hospital.
All the while, the assistant is writing times down, doing vitals, getting the furniture out of the way, soothing family members and standing outside to wave down EMS. All at the same time.
*whew*
I do a lot! All of us midwives do.
Hey Navelgazer!
The more I read, the more I wonder how you've stayed the course all these years. Bless you for doing the great service of midwifery. :-)
I think you make very responsible choices in your care, and I'm so glad you've found a hospital/doctor/CNM network that supports your efforts. Dr. Wonderful truly is wonderful. :-)
On a personal note, I'd be very curious about the Rh comment too - I'm Rh negative, but (as you well know) delivered my first baby in a birthing center, and my second at home. Both w/ you by my side. Things that make you go "hmmm."
I wish you continued good luck in your journey. Please keep us posted as to the developments in VA.
--Amy
I talked with a friend of Zittle (who is also a midwife) and many things in the report are NOT true for example, that she told the EMTs to wait for her to get there before doing anything. She did not tell them that at all. There were many things blatantly wrong in the report or places where the doctors twisted her words. Maybe there were some things she should have done differently but it is probably a good idea to remember that not everything you read is true.
Barb--
Thanks for taking the time to answer me about what happens between the call and the EMS arriving. I am sure each situation is different but it was great to hear what happened at this birth.
I love hearing how present you are during these moments of high-stress. Good for you! What a wonderful skill to bring to mid-wifery.
I just kinda skimmed through the comments so I apologize if someone else already touched on this aspect of the issue.
Why on earth are the Moms not being held accountable to the facts? The Moms lied about weight gain and blood sugar levels, refused tests, just plain did not use common sense.
How can you expect your MW to care for you and your child if you are lying to her about pertinent medical facts? The Mom who lied is responsible for her portion of this horrid outcome. Perhaps the end result would have been the same, but I would like to think that if MW had known her blood sugars and weight were out of control she would have risked her out of a homebirth.
And why on earth if you baby was hanging half out of your vagina and the EMT were there would you not just instruct them to get you to the hospital. Or better yet, when you saw that the presenting part was not the head and MW was not there to manage the birth why on earth would you WAIT to transfer until it was too late?
I think these Moms carry some blame in the deaths of their babies. Lack of education in moms choosing homebirth gives homebirth a bad name. These Moms have a responsibilty to KNOW the risks of a HB before planning one. These Moms should know the skill set of their MW before trusting the MW with their births, breech or otherwise.
I had a HB 2 years ago. Dh and I had a backup plan in place for transfer, what to do if the baby looked like it was going to arrive before the MW, we lived within a resonable distance to the hospital and had transportation, etc. Not only that but I had a stats sheet from my MW on all her births, her experience with breechh babies, twins, what her transfer procedure was, what she felt comfortable with and what she would transfer for. I had a clear picture of what she felt comfortable with and what I felt comfortable with. Either one of us at any time could have called for a transfer and the other would have agreed no questions asked.
Now the MW was also at fault. She probably would have caught the baby was in distress for hours beforehand if she had gone to check the Mom and listen to heart tones. She could have transferred for a C/S before fetal demise had she been present and doing labor monitioring. Moving a due date without U/S confirmation, in a obese, GD Mom is reckless. I am Obese myself and I understand that palpations only is NOT a good judge of fetal position. Also the fact that this MW was willing to even move forward with a breech delivery when she has never seen one managed or assisted one being managed is plain reckless. But again, the parents have some responsibility in this decision. You wouldn't let an OB/Gyn preform brain surgery so whytwould you let an unskilled MW deliver your breech baby. They should have never consented but the MW should not have asked for consent she should have transferred at that point.
I do diasgree that Avanced Maternal age, being Obese, being positive for GBS, being RH-, or even GD are reasons to risk out of a homebirth. The only reason why I would think a GD Mom should be risked out is if her blood sugars are not well controlled. And the RH- is only an issue if the mom has antibodies present, if so then yes it would be reasonable to risk her out. Some MW can carry ABX for GBS, but even without the ability to administer ABX, GBS can be managed with Chlorihexidine (sp?), No Vag Exams, monitoring maternal temps, and not exceeding a set # of hours from ROM to birth. GBS with ROM and No labor might be a reason to transfer but you won't know until you get there. Obesity and AMA in my opinion are stupid reasons to risk a Mom out.
So yes the MW made some critcal errors in these 2 births, but so did the parents. It was like the perfect storm.... all the crappy elements lined up and the cost was these 2 precious babies lives. It is truely sad. And it should be a lesson to MW and Doulas, But also to Moms and Dads.
Sorry if my comment is rambly. These stories make my blood boil. Bad MW decisions, Bad Parents decisions = Poor baby.
I just wanted to share that now that I've been practicing midwifery for several years, I can really appreciate your decision to transport as it relates to your self-imposed (and legal) boundaries as a midwife.
It is imperative that we recognize our limitations and advocate for the baby *as well* in these cases despite the 'homebirth or bust' attitude of some parents, such as could be argued in the Zittle case. As it is, the risks to mom and baby AND midwife when things don't go as planned are large- in every U.S. state. Everyone mourns a loss, but the midwife will ultimately take the heat in one way or another. Being in an unlicensed state myself, the boundaries are not always clearly marked, which requires me to be extra diligent about what my comfort level (i.e., protocol) is in managing any situation which might be perceived by some providers as outside standard of care. Not all unlicensed midwives choose to self-regulate, for which there may be consequences to the community as a whole. I have made some mistakes along the way for sure, as we all do, but I've learned valuable lessons about what works for me and my practice. There are fewer gray areas all the time, and this I'm grateful for! I think this is a journey every midwife must sooner or later make. Later potentially to her detriment in some cases. Okay, I'm stepping off of the soapbox now.
I may not agree with every single word that you post, but your words are (usually) quite eloquent and your posts are thoughtful. :) How do you find the time for balancing babies and blog posts?!
I really like what you wrote... and the others that speak about decision-making in birth. I continue working on the "Decision Making in Midwifery" post... which, btw, is how I do midwifery and write. I see my clients on the weekends and since my office is now closed, I live with a computer on my lap. Plus, I have a broken foot... and a fracture in the other one. :( I am supposed to keep my butt planted on the chair as much as possible. What else is a writer to do but navelgaze? *laughing*
Amelia,
Thanks so much for your insight into the "case." I *did* say I expected the Medical Board's story to be flawed and I *did* say IF we were going to take things as they were written... and then went on to talk about the situation. I am, in no way, saying I believe what the MB wrote to be gospel; I know better.
Thank you very much for writing... it is important for midwives and students to also know the (sometimes) twisted way situations are interpreted by officials.
Barb,
I know that you were using it for a teaching lesson--and I loved what you had to say about it. I know you know that the medical boards twist stuff around but I thought I'd let others know that Zittle isn't some HORRIBLE person who shouldn't be near pregnant women.
Almost everything in the report was twisted or untrue.
I interviewed Kristi in between the two deaths. I do not know her outside of my interview with her, but I was definitely uncomfortable with her attitude in response to several of my questions. She seemed to want to avoid doctors at nearly all costs. For example, I'm RH- and when I asked her about Rhogam - illegal for midwives to administer in VA - she said that if I could get a prescription for it, she could drive me to NC and administer the shot. If I couldn't get a prescription for it, she said she knew a doctor who could probably get it for us. [The midwives I ended up going with asked if I could continue my relationship with my OB long enough to get the shot at 28 weeks and ask my OB if he would also give me the shot after the birth - he obliged and this worked out perfectly].
Kristi also advised us that we probably wouldn't need to take our baby to a Dr. until he/she was 5 weeks old or so, which I wasn't comfortable with.
She told my husband and I about case A, which had just happened, and that she would deliver a breech baby vaginally again if she had a client in that situation. To me, it really seemed like she did not learn from the first case, though she was of course very sad about the outcome.
I, for one, am very glad that she is no longer practicing here. She seemed like a risk-taker who would avoid transferring. As the expert at my birth, my care-provider should advise me on the best course of action and if that care-provider has a personal aversion to transferring, I cannot trust her advice. Midwives like her give the rest of you a bad name.
Thankfully, there are several wonderful midwives in the area, so Zittle's clients will have other options.