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Wednesday
May182011

What If?

Much has been said in the press (and for goodness sake, the Washington Post most of all!) about Karen Carr and the case of the breech baby who died in Alexandria, Virginia last year. For the two of you who haven’t read about this, a 43-year old woman, in her first pregnancy, having a breech baby, wanted a homebirth. Her CNM care providers explained she was high-risk and they couldn’t keep her as a client for either a home or birth center birth, referring her instead to their back-up obstetricians. The mom chose to ignore their advice and searched for a midwife who would agree to do what she wanted… to help her have her primip breech baby at home. Carr, a CPM in Maryland, but not licensed in Virginia became the (unlucky) midwife. She didn’t have a license in Virginia because they have a regulation that says a midwife cannot carry medications, including pitocin, which can save lives if the woman hemorrhages after the baby is born. Instead, she chose to forego a license in order to carry the life-saving medications, to me, a valid choice.

Let me state here that, to me, the least of the issue is Carr not having a license. She’s a perfectly acceptable midwife on one side of the line, but becomes a danger to society if she takes one step over that (state) line? That’s stupid logic and while I am not one to flagrantly ignore the law, sometimes there are extenuating circumstances when the law hasn’t caught up to the reality of the situation. Carrying life-saving medications was a choice to care for women, not to slap the legislators.

So, on September 11, 2010, the worst-case scenario of a breech birth occurred; the baby’s body was born and the head was stuck inside, above the mother’s pubic bone, still inside the uterus because the cervix wasn’t completely dilated/dilated enough to allow the head to be born. Knowing how the press skews facts, I am taking what is said with a salt lick, but even if we gave a lot of grace for the reported information, the times before Carr called for help were, in my opinion, ghastly. Twenty minutes of head entrapment and then another thirteen of resuscitation before calling EMS. The tension in my body reading that is enough to give me stomach cramps.

On Thursday, May 5, 2011, Carr plead guilty to charges of child endangerment and performing an invasive procedure without a license. She apparently regretted the decision to plead guilty to the child endangerment charge, saying she tried to do everything she could to save the baby. I don’t doubt that for one second.

Googling “Carr” and “breech” gives loads of sites where the discussions/arguments about the case rage on.

Instead of adding to the debates, I thought looking at this from a different viewpoint might be of interest.

It isn’t uncommon for midwives, student midwives and doulas to say, “I wasn’t there,” when asked to comment on cases that end badly for either mom or baby. It’s a genuine way to show compassion to the midwife and situation at hand. But I feel there is a valid lesson to be learned in discussing, and even dissecting, the heard-about event. If no one present knows the absolute facts, discussing the case as if can be just as valuable. By playing out scenarios that have gone awry, midwives build on their knowledge base, deciding in a non-emergent, un-stressful moment what they would and would not do as a midwife in a similar situation. From transferring a woman to the hospital for exhaustion to a fetal death, every scenario holds endless lessons. Sure, a part of it might be that hindsight is 20/20, but leaping off another’s difficulties/tragedies is an excellent way to learn. I’ve come to call this the What-If Game. Here are some What-If’s that immediately come to mind with regards to the Carr case. Let the discussions begin.

  • What if you were asked to attend a birth that other midwives turned away?
  • What if you were asked to assist at a birth where the midwife didn’t have much experience in the variation of the norm? (GDM, rising blood pressure, GBS+, etc.)
  • What if you were asked to assist a midwife at the birth of twins or a breech and you knew the midwife had minimal experience with that type of delivery?
  • What if you were asked to midwife a women who says she’s fully informed and still wants to birth at home despite having serious reservations yourself, but have made a commitment to helping women achieve the births they desire?
  • What if you were asked to work in a state where you were illegal and had no solid back-up?
  • What if you’re the midwife in a homebirth and things turn dangerous and the mother refuses to transport to the hospital?
  • What if you saw things were turning dangerous and you were illegal; do you have your speech ready for EMS? Practice it with others!
  • What if you are practicing illegally as a midwife, are you willing to go to prison for a mom’s right to birth at home?
  • What if complications arose and you, an illegal midwife, knew you were going to get shit if you transported, would you delay calling for help? Hoping things would resolve before you had to take that shit?
  • What if you were an assistant or doula and saw things going to hell in a handbasket and the midwife wasn't saying "Call 911!" and you knew the mom or baby needed emergency care?
  • What if you weren’t permitted by law to carry medications, would you anyway?
  • What if you weren’t permitted to suture, would you anyway?
  • What if it was up to you to decide the line between following the law and supporting a woman’s right to choose?

Let the discussions begin.

Reader Comments (28)

Some of those questions for me (pre-midwife, currently assisting, long time doula) are no-brainers. Having a woman come my way who wants a birth I do not feel comfortable providing does not conflict with my values about giving women the births they desire.

Also, I would think that having solid set of protocols would help to define your practice and your boundaries.

If I was asked to assist a twin or breech, I have to admit I would have an excruciatingly hard time saying no- but I would definitely ask who was going to be present at his birth, where the birth would be, what the plan is - and I just really have a hard time thinking I'd feel comfortable attending either of these scenarios at home, at least right now. I would very likely pass.

Even as an assistant it is my responsibility to be clear on MY boundaries as a professional- I do not have to accept every call from a midwife who needs an assistant (nor would I). When I am a midwife, I do not have to accept every client who decides she wants a homebirh and it is prudent that I do NOT accept every client. They will not all be candidates for homebirth, and of those who are, not all of them will be candidates to be in MY care.

Working as an illegal midwife goes so far against my grain that I have never sought to imagine scenarios where I would have to confront any of those issues- Right now, I can not see myself saying yes to midwifing illegally in a state that does not allow it.

May 18, 2011 | Unregistered CommenterKristina

One point of clarification that some of the Post and various other articles got wrong: there is no CPM licensure available in Maryland or DC. Legally speaking, she was not "acceptable" in any of the jurisdictions in which she practiced. The CPM is a credential upon which some states including Virginia base their licensure requirements- but it does not confer legal status (similarly as a lawyer, I have a JD but that doesn't mean I can practice law without a license from the state). It does not make sense to me why one would opt to flout the law entirely in order to carry medicines, rather than going beyond the law in order to meet with the accepted standard of care, but I see how reasonable minds could disagree on that.

It infuriates me that midwives are asked to choose between their liberty and a woman's right to determine where and with whom she gives birth. I really don't know what to say about the problem of the higher-risk births. I think a woman has an absolute right to decide to give birth at home no matter what the circumstances. I don't know what I would do as a practitioner.

May 18, 2011 | Unregistered CommenterRS

If I was asked to attend a birth that other midwives turned away, whether or not I would take the mother would depend very much on WHY she was turned away by the other midwives. If she was "high-risk" beyond what my skills and experience have prepared me to be competent and confident in caring for her, I would be glad to try to find her another care provider (whether that be a more experienced midwife, or a doctor that would be respectful of her wishes and desires), but I don't feel obligated to take any or every mom that asks me. It isn't good for them, or me, if I take someone with a situation with which I am uncomfortable, or am unprepared or unable to handle in a safe manner.

As far as assisting goes, the primary midwife may do things a little differently than I would, and that's fine, but if I'm uncomfortable with a risk that another midwife is taking (not simply that I wouldn't feel comfortable taking that risk, but if I'm concerned that she is unprepared for such a situation), I would share my concerns, and probably decline to assist.

What if you were asked to assist a midwife at the birth of twins or a breech and you knew the midwife had minimal experience with that type of delivery? Unless I was skilled and experienced in those areas (which currently I'm not), I would strongly encourage her to have a very experienced midwife at the delivery, or refer the client to another care provider with more experience in those areas. I wouldn't feel comfortable assisting in such a situation with no experienced midwife present.

If I have serious reservations, I should not be doing the birth. Don't ignore that "still small voice".

I would not be comfortable working in a state illegally with no backup.

What if you’re the midwife in a homebirth and things turn dangerous and the mother refuses to transport to the hospital? This would be a sticky situation that ideally, should be figured out prenatally. Do they really trust you? Are they willing to listen to your judgment calls on things? If this came up during labor or birth, I would call 911, continue to provide supportive care, and when the ambulance arrived, the client would have to make the final call of whether or not to refuse care.

Any midwife who decides to work in a state illegally (which I already said I would not be comfortable doing), needs to be totally ready and willing to transport if something goes wrong—and decide ahead of time that she isn't going to wait around too long because she's concerned about the consequences. She should not endanger mothers by delaying because she's worried about potential or certain consequences. I would not want to be put in this situation—it's one of the reasons I would not want to practice in a state where midwifery isn't legal.

If I was at a birth assisting, and the mother or baby needed help beyond what we were able to provide, and things were going downhill, I am completely willing to make a phone call to 911 if the main midwife wouldn't.

May 18, 2011 | Unregistered CommenterBrittany

Do not forget that tis because of the Karen Carr's of the 60's, 70's, 80's, and 90's, that midwifery has coming as far a it has, and many of you are getting the opportunities you are. The question now--have we entered the time of diminishing returns? I would say yes.

May 18, 2011 | Unregistered CommenterD'Anne

As a CNM, these questions are very simply answered: a woman with a breech presentation is NOT a candidate for a home birth. A primip is NOT a candidate for a home birth. That's it.

My view is, and always has been, that until we have NATIONAL licensing standards that require CNM certification for midwives; NATIONAL standards of practice for determining who is suitable for home birth, [and one of those standards is the availability of emergency back up services], home birth in ANY SITUATION is too dangerous to allow. You never know if the woman is "low risk" and the birth "uncomplicated" until it's over.

It isn't about the woman only. Her baby should have the right to be born safely. In this instance the woman went into labor with her eyes wide open, that she was intentionally endangering another life.

Karen Carr was an idiot to have accepted this client, but that does not absolve her of blame. She should have known better than to accept a high-risk client, and I think she should lose the [mostly worthless] license she has and be prevented from the further practice of midwifery..

May 18, 2011 | Unregistered CommenterAntigonos

I can't understand what chain of reasoning would have led to a state allowing midwives to attend homebirths but disallowing them the use of medications necessary to bridge patients to the hospital in case of emergency. Does anyone know a little more about this?

May 19, 2011 | Unregistered CommenterChristie B

Antigonos: Of course you know your viewpoint is on the other extreme of many/(most?) of my readers, but is a very important one. You and I disagree on plenty, but I'm definitely more aligned with some of your beliefs as I've gone through my midwifery life. I *really* would love to see standardization, too. But, that isn't a big surprise. Thanks for commenting.

May 19, 2011 | Registered CommenterNavelgazing Midwife

Christie B: Midwives have been fighting for licensure and regulation in most states. The opposition takes many forms, and one technique for opposing homebirth midwives is to make one aspect of their practice illegal. Carrying medications is deemed as "practicing medicine without a license" and is illegal. Midwives can be arrested for carrying the lifesaving tools they need at births, and therefore are less likely to practice. Victory for the anti-midwife folks.

We actually discussed a lot of these issues in class, and came up with a really good solution to the problem of attending a birth you aren't sure about. The question you have to ask yourself is whether you want to learn how to assist at this kind of delivery. If the answer is no, then you politely decline. If the answer is yes, you can accept the client, but tell them in no uncertain terms that you don't have experience with twins/breech/VBAC/whatever and say that you don't feel comfortable accepting her as a client without backup, and would she mind if another, more experienced midwife were present at her birth, to ensure her maximum safety? I imagine a lot of women would say yes to this arrangement. That way the woman is safer because there is someone there with you who knows what to do and has more tricks up her sleeve, and she can help you out so you aren't just giving your client the homebirth she wants, you're also learning and increasing your skills.

Situations like twins, breech, and VBAC (I'm lumping VBAC in with those because it's considered to be another high-risk situation) are interesting to me because I have such conflicted views on them. My gut reaction is to say no, these women and babies would be safer in the hospital because it's a risky situation and something could go wrong! But then I have to stop and think again, because unfortunately, in the hospital most of these women will end up with C-sections. Most doctors won't even try to deliver a breech baby vaginally, and while they will try with twins they're usually prepping the OR. I personally think it's safer for the woman to avoid the auto-C-section, and I think her best chance of that is at home with a seasoned midwife. I wish there were another choice, but for a lot of women there is no middle ground available between the options of C-section in the hospital and vaginal birth at home.

It boggles my mind to think that if doctors were willing to actually practice medicine (as opposed to surgery), a lot of women wouldn't want midwives. Instead, doctors dig in their heels with archaic and uneducated practices and drive women away. Why are we even debating these high risk issues? This is what doctors are FOR! Yet the physicians are abdicating their responsibilities to women and forcing high risk pregnancies out of the hospitals just because women want a real chance at delivering on their own. It makes me sad.

May 19, 2011 | Unregistered CommenterEmily D.

I really wonder if part of what happened here is because of the faulty system we have. Why did she wait so long? Was it because she thought that her job and professional life at stake...was she wishing that she could transfer, but maybe just a few more min. and the baby would be out so that she wouldn't have to worry about the legalities of it all. Was she imagining the time and effort it might take so that people would listen to her and her assessment...and that maybe if she could just get the baby it, that might be safer? If she called EMS would they even have the medical skills that she had that might save this baby's life (and I've heard some bad stories related to that too)? Or maybe if she could just get this baby out, that wouldn't be a worry. She could have been calculating the time it would take to call EMS, describe the situation, explain who she was, tell them how to help the woman, take them to the hospital, and go through the same thing there, vs maybe she could get this baby out in time.

We have a faulty system, that creates a lack of care for women who do need to transfer. I think if a better system was in place so that a midwife had the ability to a faster, easier, less painful transfer, there would be a lot more healthy moms and babies out there. That and I agree with standardizing of the midwifery practicing. I think if we could have gotten both of these things in line, this might have been a different situation...in that the transfer would have happened much sooner with less problems attached. That might have made a difference.

May 19, 2011 | Unregistered CommenterRachel

asked to attend a birth that other midwives turned away?
I would guess I am on the conservative end of the spectrum, but in this (Carr) case, if the CNMs were punting up up the medical ladder, and the OOH midwife has fewer resources at her disposal than the hospital-based care providers, it seems like the mother's risk factors indicate that she is not a good candidate for a homebirth, so I would refuse.
assist at a birth where the midwife didn’t have much experience in the variation of the norm?
I am not a midwife, but I wouldn't attend a birth if I felt the care provider wasn't competent to provide care in the event of a complication or medical emergency. The midwife's job is to assure the health and well-being of the mother and baby, and part of that is monitoring the pregnancy and birth so she can spot when things are going too far from 'normal' and intervene in a timely manner. As a doula, that's not my bailiwick.
assist a midwife at the birth of twins or a breech and you knew the midwife had minimal experience with that type of delivery?
Hells no, see above. I'd question why she'd put herself in that position.
woman who says she’s fully informed and still wants to birth at home despite having serious reservations yourself, but have made a commitment to helping women achieve the births they desire?
My commitment is to help women have satisfying, safe, peaceful births, not wish fulfillment. As a doula, I'd have a tough-love straight talk with the woman:
Having a healthy, live mother and baby is what we all, mothers, fathers, care providers alike, most desire from birth. You need to be very clear that based on the constellation of medical realities that you and your baby present with, home is simply not an appropriate choice. The homebirth you desire is not in the cards based on your medical status, but you can still work on having as good a birth as possible in the hospital.
Ultimately, a midwife is not there to be a witness, hold a sacred birth space, or help wombyn achieve a blissful birth. She is there to monitor and ensure the well-being and health of a mother and her child. Part of that duty involves telling the mom when home is not safe, and you and baby are better off at a hospital, whether or not that is your desire.
midwife in a homebirth and things turn dangerous and the mother refuses to transport to the hospital? doula saw things going to hell in a handbasket and the midwife wasn't saying "Call 911!"
I'd be calling me some 911 - better to have an angry, live mother, a midwife knee-deep in legal dooky, and a minimally compromised baby than to have mother or baby suffer an adverse outcome that could have been averted with prompt emergency assistance. If there's something BAD (head entrapment, abruption, etc.) minutes matter, and even having an EMT station next door would probably not be enough to help in many true emergencies. But I would not want to feel that I had done nothing, when I could have done something.
weren’t permitted by law to carry medications, would you anyway? What if you weren’t permitted to suture, would you anyway?
If you are illegal anyway, why not carry the meds. and suture? In for a penny, in for a pound, and you might as well be the most skilled and competent care provider you can be.
decide the line between following the law and supporting a woman’s right to choose?
There's law of man, and law of nature. As a midwife, you can flaunt the laws of man, but the laws of nature will bite hard, and there's no sneaking around them. Nature doesn't care about blissful birth or your right to choose the setting for your baby's birth. Nature doesn't care if your baby dies, or you either, but other people do. Again, I come back to the primary responsibility of the midwife being to use her judgment and clinical training to ensure the safety and well-being of mother and baby, and part of that means knowing when to say, "I am not the right person for this job."

May 19, 2011 | Unregistered CommenterKatherine

Katherine: BEAUT-ifully said!! LOVE your thoughts. Really, really found myself nodding nodding nodding. Fantastic. Thanks for writing it all out.

May 19, 2011 | Registered CommenterNavelgazing Midwife

Knowing Karen Carr well, and being blessed to attend births as her student, I know that the women she serves are losing a lot because of the events of the past several months. There will always be stories of bad outcomes, however the midwife that I know doesn't put mothers at risk because she is a "rogue midwife" she simply attends to women because she has a huge heart. There is very little of the woman that I know in the newspaper articles which have been so widely discussed. She is a humble woman who never advertises. She doesn't boast. She is self-educated and very intelligent. Yet, she never thinks twice to ask for another opinion. I know I have been asked for mine a time or two. We forget that breech birth is risky even with a c-section. Karen has delivered many breech babies. She is most likely more skilled in Breech birth than the majority of providers in the state of Virginia or Maryland. Yet, she doesn't take them lightly, this birth was discussed and planned. The parents are surely sorry...any parent would be. I have lost a baby. I blamed myself for things that weren't even my fault. I blamed others for things that probably didn't have an effect. It is the nature of grief. The state capatilized on that grief to use Karen Carr as an example of why homebirth is wrong. All the midwives in Virginia and Maryland did NOT rally around her...many turned their backs. Why? The short answer is that they think they can do it right and become acceptable. The truth is, we as homebirth midwives will NEVER be acceptable.

I am heartbroken over these events. Sad for my friend, sad for the parents who have lost a baby. It has shaken me to the core.

I fault the State of Virginia for much of this. Their insistence on keeping meds out of the hands of midwives and the convoluted nature of the regulation of licensed midwifery under the medical board keeps a level of fear in all the midwives in the state which makes homebirth a catch 22 under the best of circumstances. It would seem better to be unlicensed than to practice under this kind of tension. Yet, we as midwives ask for this when we look to the state to make us legitimate. I wish that it were as easy as having a license and a certification to show that we are skilled.

Karen Carr has the kind of integrity which is not seen much in this world anymore. She refused to comprimise what she felt was not sound for the sake of her clients and she paid a heavy price for that integrity. She will likely never be able to help another woman. She and her family have suffered a huge strain. Her life will never be the same and she doesn't forget the family or this poor little baby...far from it. She remembers everything.

I don't know what the answer is, but I know it is not what we have now.

May 19, 2011 | Unregistered Commentermidwife

Babies should not be sacrificed on the alter of subverting a crappy system. Complain about the system (and rightfully so!), work to change the system--but if you can't provide safe, competent care because the system is crappy, for God's sake, respect the limitations of that system. This goes so far beyond just carrying meds you're not supposed to have.

Although I'm not sure I can stand behind 100% of antigonos's comment, I have to say, I agree with this part:

"It isn't about the woman only. Her baby should have the right to be born safely."

Yes. Babies have a right to be born safely. In many cases--perhaps most cases--the safer place is at home, with a qualified, experienced midwife. But in some cases, as much as we hate it, that place is at the hospital. And further, in some cases, that birth is a Cesarean birth. We cannot allow ourselves to rage so hard against hospital culture and C-section culture that we lose sight of safety.

May 19, 2011 | Unregistered CommenterAnonymous

What if you were asked to attend a birth that other midwives turned away?

*I would not choose to attend a birth based on what another midwife decided. Each one of us has our own boundaries and protocols and not every midwife should serve every woman.

What if you were asked to assist at a birth where the midwife didn’t have much experience in the variation of the norm? (GDM, rising blood pressure, GBS+, etc.)

*I have been in this position before and I declined to assist. I was not comfortable with the midwife's skills {or lack thereof} nor was I confident that I would not second guess her judgements so I chose not to participate in that birth.

What if you were asked to assist a midwife at the birth of twins or a breech and you knew the midwife had minimal experience with that type of delivery?

*Same answer as above. If I do not trust the midwife's judgement or skills then I will not assist with her and I would be doing the parents a huge disservice by supporting her with lack of faith in her abilities.

What if you were asked to midwife a women who says she’s fully informed and still wants to birth at home despite having serious reservations yourself, but have made a commitment to helping women achieve the births they desire?

*I would not serve as a midwife for anyone that I have serious reservations for. I do NOT believe that every woman is a candidate for a home birth. If she truly wants a home birth then she will have to find someone else.

What if you were asked to work in a state where you were illegal and had no solid back-up?

*I believe one of the BIGGEST problems with homebirth is the lack of continuity of care due to the adversarial relationships between OBs and homebirth midwives. The countries where homebirths have better outcomes are the countries where midwives enjoy better relationships with medical professionals, are considered to be a part of the team and have hospital privileges for ease of transporting their clients in an emergency and they do NOT attend high risk births at home... the high-risk providers {OBs} do that!
To answer the question, I would not attend births in a state where I did not have solid back-up. Period. It is not safe for my clients for me to wing it. Both the mother and baby's lives depend on my ability to care for them in an emergency and if I don't have back up, their care could be compromised.

What if you’re the midwife in a homebirth and things turn dangerous and the mother refuses to transport to the hospital?

*I know some women would take issue with this, but if I am the midwife in this case and I am hired for my experience and expertise, I would expect in an emergency situation that I would make the final call. In my opinion Karen Carr should have called 911 sooner. I wondered if maybe the parents didn't want her to or something... but I thought about it later, that it doesn't matter. The midwife here is the one going to jail, not the parents, she is the one that is LEGALLY responsible for the outcome regardless of who is making the decisions. If the parents want a midwife they must have some faith in her judgement, which is why they hired her in the first place.

What if you are practicing illegally as a midwife, are you willing to go to prison for a mom’s right to birth at home?

*I would NOT practice illegally in any capacity.

What if complications arose and you, an illegal midwife, knew you were going to get shit if you transported, would you delay calling for help? Hoping things would resolve before you had to take that shit?

*If my taking shit means that a baby lives, then hell no! The mother and baby's health and life comes first. Period. I would never be in that situation however because I would not practice illegally.

What if you were an assistant or doula and saw things going to hell in a handbasket and the midwife wasn't saying "Call 911!" and you knew the mom or baby needed emergency care?

*For one thing as a doula, it isn't my job to even KNOW that a mom would need 911 called. That's the midwives job and responsibility. I would not work with a midwife whose judgement I did not trust or feel would jeopardize a woman/baby's health/life like that.

What if you weren’t permitted by law to carry medications, would you anyway?

*I would not be a midwife in any capacity without carrying medications. They can be lifesaving.

What if you weren’t permitted to suture, would you anyway?
*Depends on the degree of the tear and what other back up care I had arranged. The health and care of Mom and baby comes first.

What if it was up to you to decide the line between following the law and supporting a woman’s right to choose?
*What if? Then, midwives' would be held responsible based on the quality of their education and midwifery would be standardized across the board with the education of midwives improved. Too many women these days can take a midwifery skills lab, read a few books, and call themselves a midwife and that is beyond scary to me!

May 19, 2011 | Unregistered Commenterbookwormmama

You never know if the woman is "low risk" and the birth "uncomplicated" until it's over.

Okay, aside from my feelings on homebirth, this fails on a logical level. The second half of this statement is undeniable-- you can't know the outcome of an event until it is over. But the first half is flat wrong, no matter if we're talking about homebirth or blackjack. Low risk means the risk is low. The chances are low. Not non-existent, just low. It is a term based in relativity.

You CAN know that a woman is "low-risk"-- accounting for differences in opinion and diagnoses, of course, as it's a subjective label by nature. But by definition, it is not something that is necessarily validated or invalidated by the actual outcome. Not on an individual basis, anyway.

There is something disturbing about such a statement coming from a medical professional (as I have often heard it) and I know what it is-- the underlying twin implications that A) medicine has no way of determining risk/benefit of any behavior, condition, etc.-- or to take it further, that it has no clue as to causal relationships whatsoever, making medicine essentially unscientific and practically useless, and B) because of this, we should treat absolutely everything in life as a worst possible case scenario. Or at least a worst possible case scenario waiting to happen.

To state that we cannot know if someone is/was at low risk for an adverse event until after the fact is to state that we have NO IDEA what the risk of, say, lung cancer is for someone who has no family history of cancer, never smoked, lives in clean mountain air, eats the world's "healthiest" diet, etc., etc. Further, it implies that if such a person ends up with lung cancer, that means he was never at "low risk" for it. The same could be said for someone who doesn't drive, rarely rides in a car, never in one that travels over 25 mph, always wears a seatbelt, etc. Such a person is at relatively low risk for dying in a car accident. If she does die in a car accident-- a possibility not precluded by the low-risk label!-- that does not make her retroactively high risk. Frankly, that's ludicrous, and if nothing can ever be labeled low-risk except in retrospect, we cannot prescribe or recommend any behavior, medication, course of treatment... except to recommend that everyone prepare for every possible bad outcome-- every possible disease, condition, injury-- at all times.

And before I'm told THAT is a ridiculous exaggeration, I'd like to remind us all that we were just told we cannot possibly know in advance whom is at low risk for what.

May 20, 2011 | Unregistered CommenterDreamy

So many people are saying that they would not practice illegally. But there wouldn't have been ANY homebirth in most parts of the country in the 70's and 80's at least, if women had not been willing to practice illegally. I salute them. I am not a midwife, although I would have liked to have been one. I caught a few babies, one of my grandchildren and a friend's 8th and 9th, but I considered myself a mother, a friend, at those births, not a midwife. If I had been a midwife I hope I would have been prudent enough to practice within my skills. Honestly I am terrified at the thought of doing so illegally, but I honor those who took that risk when there was no other way for women.

As I have said, I have a friend whose surprise breech Karen Carr caught; she was there as a back up midwife but took over when they realized the baby was breech, and a footling breech to boot. My friend thought she was very skilled.

It does appear that she made an error in judgment to accept this case. A 43 year old woman has a more rigid cervix than a younger woman even if she is ever so fit and young looking. Head entrapment by the cervix is a known deadly hazard of breech deliveries. But so often women give birth despite such risk factors, when they have been told they couldn't possibly do so, and Karen must have helped many women do so. I guess she got used to pushing the envelope, and this time she pushed it too far.

Does anyone think calling sooner would have helped anything? From what I read, a crash C section in a hospital has only a minimal chance of saving a baby whose head is entrapped, and in the home the time factor in waiting for 911 and getting to the hospital would rule that out. I think she was thinking only that the baby's only chance was getting it out then and there and resusitating it. Once the head entrapment developed the baby probably had very little chance either way. Isn't this true? The EMS wouldn't have known as well as she how to free the baby, but would they have better ways of resusitation? Do they shock babies or give them cardiac drugs? I honestly don't know the answers to these questions. If that is the case, she should have had someone call while she extracted the baby. Certainly if one is practicing illegally one has to commit to doing the best thing for mother and baby despite the risk to oneself, something which requires impeccable courage and honesty.

I do hope the mother was at least told the risks in a realistic way. No one really grasps how awful such a thing will be or that the risks really apply to themselves. But still one must be honest in presenting them.

I do not at all think that she should not practice midwifery again, anywhere. Quite a few doctors have lost a baby. The OB who did my VBACs told me he lost one while he was in training because he didn't know what to do to resolve a shoulder dystoccia. Needless to say, he was not charged with a felony! He went on to be an excellent, skilled obstetrician, who was a boon to many women, although his enduring fear of shoulder dystoccia somewhat marred my third child's birth. I believe that Karen Carr has been a boon to many women and could continue to be so. I imagine she would practice with more conservative criteria hereafter. (And that some women will go to the hospital and have unnecessary C sections because of it.)

I am not sure how to end this. Maybe by saying, that while people should be reasonably prudent, I don't think the aim should be to eliminate all risk. The cost of eliminating all risk is too high. Of trying to eliminate all risk, I should say because when you get down to the smallest percentages of risk, you get to where the risks of what you are doing to eliminate risk begin to operate.

Susan Peterson

May 20, 2011 | Unregistered CommenterSusan Peterson

Dreamy: RIGHT ON!

Susan: What you did/said is exactly what I *didn't* want to say in this piece. I did *not* want to tear up what Karen did, but to have midwives/students role play what *they* would do.

May 20, 2011 | Registered CommenterNavelgazing Midwife

NGM, I seem destined never to get it right with you.
I couldn't role play because I am not a midwife, so perhaps I should have stayed away from this post. But I have been thinking about this so much it was hard to do that. Sorry. But I don't think on the whole I was "tearing up" what she did. On the whole, I was defending her, her reasons for her choice and her intentions. I know, you didn't want that either. But someone above actually said she should never be a midwife again, and I thought that should be answered.
The post by the woman who knows Karen didn't use the format you wanted for responses either. I am glad she said what she said, but if you were determined to have only posts of the "what would I do" variety, why didn't you intervene after her post?

I was only trying to think this through for myself; sorry I used your space to do it in.
Susan

May 21, 2011 | Unregistered CommenterSusan Peterson

Hmmm... I don't *feel* like I'm especially critical of you, but perhaps I feel comfortable with you and feel I can say stuff without pretense? You have some really great things to say on so many topics, I certainly don't want you to be quiet or anything like that.

Sorry if you feel picked on... not my intention at all, but I'll keep an eye on my attitude. Thanks for saying something.

May 21, 2011 | Registered CommenterNavelgazing Midwife

Pray tell what was wrong with Susan's post? She deconstructed things quite nicely. Others were down right critical and sanctimonious--and you had trouble with Susan's post? She is voicing many things that need to be said. And I usually/often don't agree with Susan!
Am also gobsmacked that after 30-40 years of this, women in birth accept the "official" story of what transpired. What is the agenda of those that do?

May 22, 2011 | Unregistered CommenterD'Anne

I don't think of it this way. I put myself in the place of the mother and baby.... NOT in the place of what a care provider would/should/could choose.

If I were a first time mom again, faced with a breech presentation, and no doc would "let" me try to deliver vaginally.. and no CNM would "let" the same..

Knowing my researching nature, I'd refuse to accept that. And look for someone to deliver at home.

Shoot. As a well-tested pelvis (15" posterior head) I'd be denied frank breech at all nearby hospitals here.

The Amish midwives would be more than happy to oblige, though. A first time mother, too.

I think that you're asking the wrong questions.

What are the reasons behind the refusal to accept a woman's choice as a woman's choice? WHY are physicians/CNM's dictating to women what they should/should not do with their bodies.... with little real research behind these "choices"?

I am sure it was made clear to this patient why the other midwives said no. "DEAD BBBAABBBBBYYY!!!!!!!" Do they not recognize the sheep who cried wolf ?

Why did karen say yes? Probably for the same reason, that if I were a midwife, even with little experience, would say yes (in lieu of finding a midwife with more experience with breech.. which.. actually I could but that's beside the point) .. because I believe in women's choices. I wouldn't want her to do it by herself, considering I'd be certified in various things if I were a midwife (like, neonatal resus and basic delivery complications and PPH and etc..) I don't put much stock in folks practicing out of a law textbook tho... If someone is suing.. either Karen didn't provide full disclosure.. she was ignorant.. OR more likely the patient is renigging after experiencing OMG THE RISK OF CHILDBIRTH IS FOR REALZ?

I am much more jaded. Apparently.

May 22, 2011 | Unregistered CommenterElElRi

Other midwives--licensed and legal--said 'no' to the mother not because she was breech and they didn't do breeches, but because they were BOOKED. The CNM's felt fenced in by politics but gave her a list of midwives that did breeches. There WAS an OB that said he would do her breech--if he was on call, otherwise she'd get sectioned.
How does that change this 'conversation'?

May 23, 2011 | Unregistered CommenterD'Anne

I don't have a lot to contribute (being an inexperienced doula) except that if a mom had been turned away by other midwives and she was either going to UC or hire me, I'd probably do it.

May 23, 2011 | Unregistered CommenterMeg

I *totally* understand how it feels that way now, Meg. Before I was licensed and while I was still working *under* other mw's, I vowed to NEVER allow the law to limit my midwifery... to NEVER let the law tie my hands. But, once I was licensed, I realized that the LAW is written for a reason, not to arbitrarily annoy me and deprive my clients. There *is* the reality that the whole of ACOG wants to limit/eliminate homebirth midwifery, but when midwifery is legal, the rules/laws/protocols enacted are there because there's been proof of increased risk in the homebirth setting.

That doesn't mean I didn't go against The Law/Protocol, but, happily, California has a statement in its law that says EVERY woman has a right to self-determination, she being able to go against *all* advice if she finds a midwife who'll attend to her. If Carr had been legal here in CA, the whole issue would be moot and there wouldn't be any investigation (or there shouldn't be) because of that one line in our regulations.

Our law limits VBACs, but I am a huge HBAC proponent, so did them as often as a woman asked. I think I only turned a VBA3C away, but there were other circumstances, too, not just the previous cesareans.

But, until you *are* in the place to *legally* (or in reality) accept the responsibility of two lives in your hands and that reality includes being willing to go to prison for your actions, I'd encourage being really careful in saying you would be there just because a woman says she's going to UC. Sad to say, but women can be manipulative in trying to get someone to do something they don't want to do because they (the pregnant woman) wants/needs something from the midwife. It's an experienced midwife who can discern when a woman really has no options vs. the woman who doesn't *like* her options and who is manipulating the midwife because of her strong/power-full needs/desires. I *have* had women give me horrible stories trying to get me to be the midwife, using the emotional blackmail of "if you don't help me, I'm going to UC," but I turned them away anyway. The midwife who falls into the manipulative client's trap, unexpectedly finds herself in deep shit when it's discovered that the woman *really* wanted a homebirth to stay out of the hospital because she is a drug addict and didn't want her baby tested/taken away.

If we believe a woman is ultimately responsible for her own birth, then she is responsible for her birth whether a midwife is there or not. If YOU *know* she should be in the hospital, for whatever reason and you take her on as a client, are you *really* serving her?

Play out a thousand scenarios like this... experience several... then come back and let us know what you would do. It might not change, but it might very well.

May 24, 2011 | Registered CommenterNavelgazing Midwife

One very curious bit that has been left out of all the stories is 'what was the labor like?' Did this mom have a good labor pattern? Were her contractions progressive and consistent? Everything I have been taught about breech birth says that if labor progresses well, then the delivery will too. There is also no mention of whether mom was instructed to hold off on her pushing urge for the recommended 45 min to an hour to allow for absolutely complete dilation.

What if?
Would I take her after others had turned her away - yes.
I believe in full disclosure of experience, informed consent and practice guidelines. Midwives are losing the skill of breech delivery because so many are refusing to attend breeches and so many states have made home breech birth illegal. Head entrapment -vs - shoulder dystocia, the throw down of the century. Neither is predictable and neither is preventable. Both can have dire consequences.

Twins - My practice protocol is to have a provider for each baby and mom. That means I will never attend a twin birth alone. And in the interest of full disclosure, I have never attended a twin home birth. Most twin moms are too scared by their OB's to even speak the words home and birth in the same sentence.

Fully informed woman with my reservations - She would be fully informed of my Informed Refusal of Treatment Statement which clearly spells out that I will 1.leave her in labor and 2.call 911 if she refuses to transfer to hospital. When you push me beyond my comfort level and place your baby at unnecessary risk, I humbly turn you over to EMS. For those who are outraged, I have never, ever, ever had to do this. But I would.

Illegal practice - Nope. No way. Too much at stake for me, my family and most importantly the mom and baby. If you don't abide by the law, can you reasonably expect to be protected by it?

Since I will never practice illegally, I don't need a speech for EMS. I do, however, have a transport form that contains mom and baby's vital information and the reason for transfer of care.

As an assistant or doula what would I do..... For this reason I only work with doulas I know and trust. It is not a doula's responsibility to have the clinical acumen to know what needs to happen. I practice very conservatively and would be pretty pissed if a doula panicked and called EMS unnecessarily.

I am not permitted by law to carry pharmacologic drugs, and so I don't.
Suturing is a gray area. A lot of the midwives I know suture. Some don't.

A woman always has the choice to birth unassisted. I follow the law - or in my area, the lack of the law - so that I will remain able to serve other women. If you must have Pitocin at your birth in this state, then you must birth with a CNM or OB which pretty much means you must birth in the hospital. Do I like this? NO. But it is the way it is.

May 26, 2011 | Unregistered CommenterErika

I just wanted to address the issue of suturing...I was born in a midwifery alegal state, and planned a homebirth in a midwifery illegal state. In or outside the law, I wouldn't hire a midwife who didn't suture, because my mother and aunt both had to be transferred after various births just for stitches. Yes, better to be stitched by someone competent, of course, but in an alegal/illegal state, transferring for something so minor is a plain old pain in the tush. And both mom and aunt left new baby with the other woman because the hospital would most likely have taken baby for "observation." So I want a midwife who knows how to suture and won't transfer me unless I *need* a surgeon.

May 31, 2011 | Unregistered CommenterAmelia

Hmm... You know, I found your blog by accident and I'm not really sure how to react to certain things. I really like some of your statements/stances and you seem like a very dedicated and rational person. Let me point out that I identify as secular humanist with feminism being a large part of that, seeing as my life experience is that of a woman.

I am for women's right to choose, hands down... And reproduction is a huge part of that. However, I'm not 100% sure whether pregnancy and birth is MORE about the woman. On one hand - the woman is giving tremendous resources from her own body to allow a fetus to develop and hopefully become a child. On the other, the whole point of 'deliberate' pregnancy & childbirth is to produce a child, no?

So, and this is my opinion, I feel a bit iffy about the mamas-and-homebirth rah-rah attitude. Of course it's important to be able to do this task of creating new life on your own terms (hopefully in tandem with your partner?). BUT should a mother's dreams of an ideal pregnancy & birth take precedence over the baby's safety and well-being? Furthermore, are personal comforts and privilege more important than doctors' expertise and laws?

(I am of the opinion that having access to and using doulas and midwives and choosing homebirthing inspired by ideology, not necessity, is rather privileged - not in a negative or derogatory sense, but these are comforts one looks to when one has a certain level of security and class status already, no?)

June 7, 2011 | Unregistered Commenterm.m

m.m: I recently attended a talk by Jennie Joseph that talked about how the midwifery model of care is revolutionizing maternity care among the African American women in her city, especially but NOT exclusively those of lower socioeconomic status. By focusing less on ideology and more on the kind of practical, woman-to-woman care that midwives provide, she is getting real results and is improving the outcomes of women who otherwise frequently fall by the wayside.

I am only a student midwife; I cannot speak for others nor should you interpret my words as somehow speaking for midwives as a whole, but the midwifery model of care honors the woman and her baby as equals, since an unhealthy mother (physically, spiritually, emotionally, mentally) will not provide healthy care for her baby. I don't know a single midwife who would sacrifice the health of a baby for some notion of an "ideal" birth. Midwives are all about improving outcomes, not sacrificing babies on the altar of feminism! The medical model of care says that all women need to be in the hospital and they need to do what their doctor says. The midwifery model of care says that women, when truly informed about their choices and the potential consequences, will make the best decisions for their babies.

The cool thing is that evidence is saying that the midwives are right. Moms AND babies are safer in the hands of a midwife. I'm not just talking about survival, I'm also talking about overall health, thriving, well-being, etc.

I agree with you that there are some women who seem to exalt birth as this all-encompassing goal and they won't let anything stand in the way of doing it their way . . . but all the midwives I know are as frustrated by those clients as you are. :)

June 7, 2011 | Unregistered CommenterEmily D.

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