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Entries in student midwives (2)

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.

Wednesday
Feb272008

Long Note to Students/Apprentices & Homebirth Advocates

In the comments section, you will see that the person in question is NOT an apprentice or student, but a lay person. The assumption was definitely mine as she made it sound as if she knew what she was talking about, spoke about how many midwives attended births, said things that only a midwife or apprentice would typically know. But, my assumption was wrong! Sorry for the incorrect finger-pointing.

So, I'll need to change the post around to say what I still want to say, but from a different slant.

Thanks, non-student, midwifery advocate for clarifying.

I will say, however, that anyone "defending" homebirth sure as crap should know what they are saying before putting their foot in the entire homebirth community. It really does make us look bad.

---------------

If you are going to argue on other websites or with midwifery/medical folks, please get your facts straight so you don't look foolish or make the whole of the homebirth community appear ignorant!!

A homebirth advocate (HBA) made a comment in another blog that leaves me shaking my head in utter confusion and not a little bit of concern. She cavalierly say that midwives at home can do everything short of hysterectomy for a woman who is hemorrhaging.

deep breath

Let's begin, shall we?

A discussion of a hemorrhage in the hospital was being had. The woman bled immediately postpartum and it was obviously frighting and extremely serious. It took 4 people and many steps to stop the bleeding. The steps were not outlined at this early point in the conversation.

A HBA poked her head in and said:

This makes me curious. OB nurse, can you specify what it was that stopped the hemmorhage? What steps were taken? In my state there (to my knowledge) isn't anything a home birth midwife couldn't do to stop a hemmorhage that a hospital does, short of a hysterectomy. Could you elaborate?

To say the midwife can't do anything less than a hospital does BUT a hysterectomy speaks volumes about what a midwife cannot do. Hemorrhaging women sometimes need hysterectomies! FAST!

For crying in a bucket, women wanting to birth at home should know every detail of what happens in whatever setting so they can give TRUE informed consent!

The discussion unfolds like this; my questions/comments are in black:

The OB Nurse asks and the HBA replies:

1) Do they have 4 trained people there?

There are 4 or more people present at births my midwifery practice attends. While it's standard, I doubt it's a requirement. I bet 2 is closer to the requirement.

HBA, if you are going to support homebirth and consider yourself active in midwifery legislation, it really would behoove you to know what the law mandates as well as what the standard of care is. There is no "betting" in midwifery. You either know or you keep your mouth shut or you say you don't know and go find out the answer.

2) Can they give all these Meds? Pitocin, cytotec, methergine, hemabate.

Of Course.

I would really like to know where you live that the midwives all carry cytotec and hemabate.

This is the "Adverse Warning" from the Hemabate Website. Would YOU want to use this medication outside of a hospital? I've asked before, but haven't gotten an answer - do any homebirth midwives carry hemabate? What are the standards of care of usage if you do have to use it? How symptomatic is the mom? How much blood does she need to have lost? Do you try cytotec first?

BEGIN WARNING:

The adverse effects of Hemabate Sterile Solution are generally transient and reversible when therapy ends. The most frequent adverse reactions observed are related to its contractile effect on smooth muscle.

In patients studied, approximately two-thirds experienced vomiting and diarrhea, approximately one-third had nausea, one-eighth had a temperature increase greater than 2° F, and one-fourteenth experienced flushing.

The pretreatment or concurrent administration of antiemetic and antidiarrheal drugs decreases considerably the very high incidence of gastrointestinal effects common with all prostaglandins used for abortion. Their use should be considered an integral part of the management of patients undergoing abortion with Hemabate.

Of those patients experiencing a temperature elevation, approximately one-sixteenth had a clinical diagnosis of endometritis. The remaining temperature elevations returned to normal within several hours after the last injection.

Adverse effects observed during the use of Hemabate for abortion and for hemorrhage, not all of which are clearly drug related, in decreasing order of frequency include:

Vomiting
Diarrhea
Nausea
Flushing or hot flashes
Chills or shivering
Coughing
Headaches
Endometritis
Hiccough
Dysmenorrhea - like pain
Paresthesia
Backache
Muscular pain
Breast tenderness
Eye pain
Drowsiness
Dystonia
AsthmaInjection site pain
Tinnitus
Vertigo
Vaso-vagal syndrome
Dryness of mouth
Hyperventilation
Respiratory distress
Hematemesis
Taste alterations
Urinary tract infection
Septic shock
Torticollis
Lethargy
Hypertension
Tachycardia
Pulmonary edema
Endometritis from IUCD
Nervousness
Nosebleed
Sleep disorders
Dyspnea
Tightness in chest
Wheezing
Posterior cervical perforation
Weakness
Diaphoresis
Dizziness
Blurred vision
Epigastric pain
Excessive thirst
Twitching eyelids
Gagging, retching
Dry throat
Sensation of choking
Thyroid storm
Syncope
Palpitations
Rash
Upper respiratory infection
Leg cramps
Perforated uterus
Anxiety
Chest pain
Retained placental fragment
Shortness of breath
Fullness of throat
Uterine sacculation
Faintness, light- headedness
Uterine rupture

3)Are some of the folks able to start another IV line well? Be really proficient at it?
Even apprentices have passed Phlebotomy and IV training. Obviously proficiency is subjective.

It just makes me angry that you would say "obviously proficiency is subjective." OBVIOUSLY to the rest of us, profiency is NOT subjective! And I also encourage you to find out if all the apprentices have had IV training - ours certainly have not.

Being taught how to do an IV and practicing on giggling friends and fellow students is NOTHING like inserting an IV to save a woman's life. Blood vessels are nearly non-existent when a massive hemorrhage is happening. Do homebirth midwives know how to do a "Cut Down?" I know I don't and unless a midwife has done medical care in the war or worked in high risk places, she won't know how to do one either. But, there are people who know how to do them in the hospital.
4) Can they place a ballon (sic) tamponade at home?

I don't know what this is, so I have no idea if they can or can't.

No, they/we cannot. If you don't know what something is, ask or look it up! There are about 80,000 websites that explain balloon tamponade when used for postpartum hemorrhage.

Look here

and

here. This site has an amazingly detailed description of what to do for a postpartum hemorrhage in the hospital. It is untrue that homebirth midwives are able to do what can be done in the hospital. If we used addition and subtraction, I am willing to bet homebirth midwives can do a fraction of what can be done in the hospital.

Read this article for a great description of using a sterile condom as a tamponade inside the uterus. (No, we can't do this either in a homebirth setting!)

5) Do they have blood that is typed and screened for the mother who has lost most of her circulation?

No, they do not carry blood products. They would place IV and transport for this. (and after any of the above treatments, unless the blood loss was mild)

Yes we do. RhoGam/Anti-D is a blood product. BE CLEAR in what you say. If you think I am being picky, you bet I am. We are being JUDGED by what we are saying. People read things like what has been posted and roll their eyes at how uneducated homebirth midwives are. We cannot afford to make foolish, careless remarks.

In another post, OB Nurse says:

What did we do for our PPH?

Started 2 large bore IV's

Gave oxytocin, cytotec, hemabate

Fundal Massage

Foley Catheter

Took her Vital Signs, monitored blood loss, and at no time did the OB stop massaging her fundus.

Also, we *could have* given her blood, which we *almost* had to do, as well as an emergency hysterectomy almost immediately if it came down to it.

I want to say right off that I was making assumptions in suggesting that the woman would have died at home. Sorry. I don't know what would have happened, because I don't know how many skilled birth attendants are normally around. In my area, one midwife attends home births without any other assistance. I do know that it took 4 of us to get her IV's started, run around getting the meds, the foley, one to massage her fundus, one to monitor her vital signs, weigh the pads, phone the blood bank, etc.

Thanks for the reply ob nurse. I wasn’t being snarky either, just curious. All the above can be easily done at home in case of a PPH. None of this requires specialized equipment, only the hands and skill of the providers. (?!?!?! Oh, really? Do the midwives you work for carry 14 gauge IV catheters? I am also distressed at the word "easily," as if these things are a hair toss backwards in difficulty level.) The difference is time to blood products and hysterectomy, which thankfully your patient didn’t need. It bears mention that my city has a couple OB squads which respond to homebirths if called. Still doesn't get a hysterectomy any faster though.

Another important site gives yet another detailed outline of what steps need to be done in a hospital hemorrhage.

Including answering this baffling question:

May I ask why the Foley?

One of the easiest ways to try and end uterine atony is by emptying the bladder! A full bladder can interfere with a uterus' attempts at clamping down. Plus, any manipulations done to the uterus for PPH care can damage the bladder if it is distended with urine. Also, a Foley is used to measure input and output - crucial in a number of ways including getting an idea of the body's system's inner workings; if urine output doesn't equal input, then something is wrong and needs to be explored immediately.

Do the midwives in your area carry Foley's? Most midwives I know do not (myself included). We/They/I carry straight caths.

“I want to say right off that I was making assumptions in suggesting that the woman would have died at home. Sorry. I don't know what would have happened, because I don't know how many skilled birth attendants are normally around. In my area, one midwife attends home births without any other assistance.”

I think that is something that varys with location. As I mentioned above, 4 providers are the standard number to attend homebirths in my area. But I don’t think that is a rule.

Doing births for over 2 decades, I haven't ever heard of taking 4 providers to a birth unless you were bringing along students/spectators/journalists/etc. Oh, except when we had twins - we had 3 LMs, 1 CNM and a highly trained apprentice, so I can see piling on the care providers in unusual circumstances, but to have 4 trained midwives/apprentices is amazingly odd, even in a city as large as the one I am in that has over a dozen Licensed Midwives working.

“What does happen in the home if mother is bleeding to death and the baby requires resus as well? That is my question. Genuinely curious, not trying to be snarky at all...”

In my area the same steps would be taken, only with fewer people as one or more would be attending to the baby.

We do say that we bring one attendant for the mom and one for the baby where I am. Not every midwife might choose to have another set of hands, but around here, it is the standard of care.

So, knowing what I know about PPH, why would I still be a midwife in a homebirth setting? Because women do weigh the risks and benefits. They, in many cases, understand the reasons for postpartum hemorrhage (distended uterus, previous history of bleeding, long labor, large baby, etc.) including the catch-all that sometimes there IS no reason that can be discovered either earlier or later. And still, they choose a homebirth because they feel the interventions that happen in hospitals might also be precipitating factors, including using oxytocin (that tires out the uterus once the baby is born), manipulation of the uterus including an aggressive third stage management and having adrenalin coursing through her system because of the fear or anger that occurs while in the hospital.

I am a homebirth midwife who also weighs the risks to my life and that of the mothers' and babies'. When a woman begins to step towards a hemorrhage late in pregnancy or during labor, transferring to the hospital is a better idea than staying at home and waiting it out. Blessedly, I've made the right decisions (for the most part) so far. Once, I should have transported sooner, but the end result was positive after the clients were very angry and disbelieving that the woman (who'd had a large HBAC) needed to be hospitalized and given blood. It took almost a year for them to accept that she was hemorrhaging and did need to be transported. I knew I'd made the right decision. This mom went on to have a fantastic hospital VBAC a couple of years later.

My main reason for writing this post is to really speak to students, apprentices and HBAs. I want them/you to really understand what you are getting into as a homebirth care provider and someone who's speaking with authority about homebirths. If YOU don't know, how iare your clients or friends going to make informed decisions? And, with this discussion being played out on the Internet, it really is important to get the facts right and to be able to argue intelligently and sanely. Giving misinformation and boasting makes ALL homebirth advocates look like asses. And we all aren't asses.

All HBAs should become hyper-vigilant in their self-education. Don't know something you read about here? Then learn about it, for goodness' sake! Don't just ask someone else to tell you what it is - get moving and learn about it yourself.

deep breath

And so, I shall finish my post about "Midwifery Education" in the next day or so and post it. Right along these lines, blurry sometimes - the knowledge, information and skills of a homebirth midwife; I'm examining myself most intently.