A new guest post from the “Medwife“:
The case
A 42 year old mother of one presents in the first trimester of her pregnancy to begin prenatal care. Her first pregnancy was uncomplicated at 26 years old with a spontaneous vaginal delivery of a 7ib 4 oz infant in a rural community hospital at 41.6 weeks after three days of prodromal labor. The mother presents for current pregnancy feeling overwhelmed, but excited. She expresses her desire for low intervention care because she ‘trusts birth.’
Homebirth midwife
The mother begins prenatal care with midwife, advised against dating ultrasound after being informed of risks of autism. Trust birth philosophy reinforced, Advanced maternal age is just a variation of normal. Prior postdates pregnancy discussed; midwife concurs ‘babies know when to be born’ and mother is excited to avoid pressure to deliver prior to 42 weeks. Extensive discussion of kale diet, yoga and pelvic rocks. The midwife does not accept Medicaid and an out of pocket cost negotiated and contract signed.
An intimate relationship develops over the course of hour long prenatal appointments at which plans for her doula, birthing pool and birth kit are discussed. Fundal heights are measured as normal, however blood pressures tend to trend up at the end of the 3rd trimester. She is reassured it’s just a little elevated and the mother is thrilled her midwife doesn’t use fear mongering or scare tactics like she reads about on BabyCenter. In the meantime, her midwife crowd sources Facebook and receives recommendations to ‘trust birth’, ‘babies don’t have expiration dates’, ‘Epsom salt baths’, ‘kale smoothies’ and to ‘explore her emotional acceptance of pregnancy’ as measures to respond to increasing blood pressure.
At 38 weeks, contractions begin and labor progresses rapidly as the mother is surrounded by family and birth team. A limp apneic infant is brought to the surface of the water and the mother is encouraged to speak to her baby to ‘bring her earthside’. After several minutes, resuscitative efforts are initiated and eventually EMS is notified. Efforts to resuscitate the infant fail and as the mother is consoled by the midwife she is reminded ‘some babies just aren’t meant to live.’
For an additional fee the placenta is encapsulated.
A year later, a mother sits alone in her living room where her birthing pool had been. Empty arms and a heavy heart, wondering if she just didn’t ‘trust birth’ enough.
Medwife
At the first prenatal appointment, a thorough history and physical exam is completed. Dating u/s confirms the estimated due date. The medwife counseled the patient on folic acid, diet and exercise, weight gain and initial prenatal labs. The risks of advanced maternal age were discussed including increased risk premature birth, preeclampsia, diabetes, intrauterine fetal demise (stillbirth) and chromosome disorders. The medwife offered amniocentesis to the mother and explained the planned increased antepartum surveillance at 36 weeks with recommended delivery at 39 weeks in light of advanced maternal age.
Amniocentesis reveals an unusual chromosome disorder (mosaic) with elevated risk of stillbirth, intrauterine growth restriction and cardiac defects. After counseling provided, the patient desires to continue pregnancy. Medwife arranges maternal-fetal medicine consult, genetic counseling consult, Level II ultrasound and fetal cardiac ultrasound. Antepartum surveillance plan developed between MFM, OB and Medwife. Patient agrees to the plan, but expresses a desire to avoid induction of labor. Medwife acknowledges and discusses concerns at length while balancing risk status and emotional needs of the mother.
At 36.6 weeks, EFW (estimate fetal weight) percentile decreased from 36% to 5% with normal amniotic fluid, BPP 6/8 (absent fetal breathing movements) mildly elevated systolic/diastolic umbilical artery waveforms (an possible indication of decreased placental blood flow) and reactive NST (non-stress test) after prolonged monitoring. Blood pressure elevated at 140’s/80-90’s. Medwife consults OB and maternal-fetal medicine specialist, and the decision is made to proceed with delivery. Labor & Delivery is notified and the neonatologist is aware of genetic diagnosis. Extensive discussion regarding risks and benefits of induction, concerns regarding genetic diagnosis, onset growth restriction and elevated blood pressures. She initially declines with concerns regarding the danger of delivering prior to 39weeks according to the March of Dimes. Risk factors and concerns are discussed at length; patient agrees to proceed with cervical ripening, heplock and continuous electronic fetal monitoring. Pain management options discussed. Mother is disappointed she is no longer a candidate for labor tub and expresses concerns regarding ‘cascade of interventions.
She presents to Labor & Delivery for cervical ripening with onset of uterine contractions 6 hours after dinoprostone placed and nonrecurrent variable decelerations responding to position changes. Over course of several hours she progresses to 5cm, SROM (spontaneous rupture of membranes) and variable decelerations becoming recurrent. OB and neonatologist remain on the unit, anesthesia is in house and aware of patient status.
She rapidly progresses to fully dilated/+1 with urge to push. Minimal descent is noted with pushing efforts accompanied by prolonged decelerations, intrauterine resuscitation initiated with position changes, intravenous fluids, oxygen and terbutaline. OB present in room, Medwife and OB discuss vacuum assisted delivery with plan to proceed to the OR if not immediately successful. Patient agrees. Shortly thereafter, bradycardia ensues and OB applies vacuum and a 2300 gm female infant is delivered with Apgars 8-9. A small, thin placenta is delivered with velamentous insertion and sent to pathology. Pathology report reveals a 284 gm placenta (50% for 25-26wk gestation) with variable thickness of 0.5cm-1.25cm, maximum width 7cm and multiple succenturiate lobes.
After an uneventful 24 hour course, mother and baby are discharge to home. A year later, a developmentally appropriate and stubborn little girl toddles into the clinic with her mother, a pink tiara in one hand and a sucker in the other.
The Medwife reports:
Lost many nights of sleep during this woman’s pregnancy and barely made it to my call room to vomit after a thorough evaluation of the placenta and days away from stillbirth. I’m still not sure how that placenta managed to sustain a fetus as long as it did. I keep a copy of the placental report with the end of the EFM tracing and a first birthday photo stapled to it on a corner of my desk. Reminds me just how much birth can’t be trusted, risk factors can’t be ignored and safe midwifery care cannot be practiced in isolation.
The Medwife counsels other midwives:
This is the essence of evidence-based medicine, availability of resources and collaborative care. This is NOT ignorance of risk factors in favor of touchy feely goodness, birth teams and spectator stunt birthing and this most certainly WAS NOT a baby who wasn’t meant to live.
To homebirth midwives: this isn’t about politics. If you cannot find OB backup or have a rapport with your local hospital … perhaps you need to reevaluate why that is. You have found a way to manipulate mothers, ignore risks, bury your heads in the sand, get paid for it and walk away without remorse or liability … only to do it again. If your philosophy involves taking risks, avoiding interventions at all costs and vilifying the obstetrics community, perhaps the only politics at stake here are those you have created for yourselves. To waive the ‘politics’ card is insulting to the midwives who work endlessly to support pregnancy and birth, maintain a high level of professional collaboration within the medical community and are at all times aware of their resources. Why? Because that is the true value of Midwifery.
So the next time you leave a mother with empty arms and a broken heart, don’t you dare whisper “some babies aren’t meant to live” or “she would have died in the hospital too”. It’s not true and I’ve got the tiara to prove it!
