OBs and Midwives: The Double Standard

We can blame OBs but we cannot blame midwives.

In a hospital: interventions, inductions, c-sections --> fault of the OB

Yes, a mother must give consent for an epidural. Yes, a mother has to give consent for an induction. Yes, a mother has to give consent for a c-section. But it's still the OB's fault. They offered. They unrightfully scared the mother. And so on.

On the flip side....

At a home birth: death, brain damage, injury --> fault of the PARENT

Yes, you read that correctly.

Sorry, parents, but this is something you need to understand up front. You need to take responsibility for your decision to have a home birth if something goes wrong. Regardless of the details, people in the home birth community will ban together and bail out the midwife and do whatever they need to do to protect her. It has happened and continues to happen over and over and over again. Expecting accountability = persecution or a witch hunt!

If you have a home birth loss and if it was due to negligence on your midwife's behalf, you may be met with comments such as these... these are actual comments made to (or referring to) home birth loss moms. I have cut and pasted them. These are, sadly, just a very small sampling of the types of parent-blaming comments I have read!!

"at any time she felt it was needed, she could tell them she wanted to be transferred... I am sorry for the parents who lost their precious child, but they made the choice to have the child there (at a free-standing birth center), and they made the choice to stay even when complications arose."  (the mom she is referring to actually had no idea complications had come up… so much for informed consent!)

"What's abhorrent is the need to carry malpractice insurance because we are such a sue happy country because no one can take responsibility for their choices. There is NEVER any guarantee that things would have turned out differently if other choices had been made no matter what the "professional" people claim."

"They weren't hostages. They could have called an ambulance themselves, right? Just asking."

"I find it disheartening that the parents are not accepting any accountability themselves for the decision they made."

"I truly feel bad for the [family]. However, with all the resources we have at our finger tips, doing research on something so important only after a tragedy happens is somewhat negligent in itself."

"When we can let go of the blame in a child's death, we heal!"

**

So let’s turn those comments around for mom’s who have had what they believe to be an unnecessary c-section:

“When we can let go of the blame in a c-section, we heal!”

"I truly feel bad for the [family]. However, with all the resources we have at our finger tips, doing research on something so important only after a c-section happens is somewhat negligent in itself."

"I find it disheartening that the parents are not accepting any accountability themselves for the decision they made to consent to have a c-section."

"They weren't hostages. They could have told the OB that they will not consent to a c-section, right? Just asking."

"What's abhorrent is the need to carry malpractice insurance because we are such a sue happy country because no one can take responsibility for their choices. There is NEVER any guarantee that things would have turned out differently if other choices had been made no matter what the "professional" people claim."  (sweet!! OB’s, just ask your patients to own up to the outcome 100% and you no longer need to pay thousands and thousands of dollars for your malpractice insurance!!)

"at any time she felt it was needed, she could tell them she refused a c-section... I am sorry for the mom that she had to have a c-section, but they made the choice to sign the form.”

Harsh, huh?

B/c most home birth midwives do not carry malpractice insurance and b/c they really don't have a governing body (like a medical board), there really is no recourse if a midwife practices negligently here in the USA. Even if she does so multiple times. She can keep right on practicing. So your chances of being able to have any justice in the shape of a lawsuit or such is slim to none. And to top it off, you have people that will back your midwife regardless of her actions and tell you to basically suck it up and take responsibility. 

I cannot even imagine what it would feel like to not only lose your baby due to a negligent care provider, but then on top of it, having to read about how people are blaming them - the parents. The PARENTS are negligent when death happens at a home birth. The PARENTS didn't do enough research. The PARENTS didn't speak up. The PARENTS should know when things become dangerous - even if they are being assured by their PROFESSIONAL CARE PROVIDER that it is not dangerous.

You can only complain about informed consent in a hospital setting. Not at a home birth. A midwife is infallible, basically. Parents - be prepared to 100% own your home birth outcome!!

Does this sound fair? No. But it’s the sad reality of the situation and something that was so shocking/horrifying/heartbreaking for me to see in the home birth community. Blame your OB and you'll find an entire community that has your back, that will share in that blame you cast on your OB, that will coddle you and love on you and "empower" you by telling you "it's not your fault, shame on that doctor of yours!!" But if things go wrong at your home birth and you again want to blame your care provider - your home birth midwife - well, don't expect that same community to stand behind you. B/c they are behind the midwife.

**

Please note: The point of this blog post is not to say that OBs are never at fault and that women are never mistreated in a hospital. The point is, if negligence happens on behalf of  a care provider, there should be recourse and accountability. A woman is not expected to know as much as her professional care giver, no matter where she chooses to give birth. Responsibility falls on the care giver to act ethically, in the best interest of the patient. This is why every health care professional in the United States is required to have malpractice insurance… except home birth midwives.

Home vs Hospital: The Equipment

Home birth midwives carry with them certain items to use in case of an emergency - b/c no matter how low risk a mom might be, emergencies can and do happen in childbirth and as such, they need to be prepared. I've heard or read many, many times from mothers/fathers/couples that have chosen home birth (or freestanding birth center) that “their midwife carries with them all the necessary equipment in case an emergency arises.” So I want to present a clear cut list for each setting of the equipment available in case of an emergency.

There is a slew of equipment needed and provided in both situations that I am not going to get into - such as gauze pads, chux pads, sterile gloves, etc. What I'm focusing on is the equipment used either to detect issues or for life saving measures.

Here's what a (typical) certified home birth midwife will bring with her to a home birth:

• Fetoscope or Doppler (or both) - to detect the heart rate of the baby
• One oxygen tank
• Infant mask (used with oxygen tank)
• Adult mask (used with oxygen tank)
• Blood pressure cuff
• Suturing items - to stitch tears for the mother
• Thermometer - to check for fever for mother, which can indicate uterine infection
• Lidocaine - to numb mom locally while she is being stitched up
• Pitocin - in case of postpartum hemorrhage
• Methergine - in case of postpartum hemorrhage
• Bulb syringe - to clear airways of the baby, especially in case resuscitation is needed
• IV equipment - if mom needs antibiotics in case of GBS or prolonged rupture of membranes
• Pegnancy and labor records and charting, including blood type - in case of transfer, to ensure accuracy and increase speed
• A midwife may or may not have an assistant with her
• Midwife should be current in the following skills:
• Neonatal Resuscitation (chest compressions and mouth-to-mouth)
• Basic Life Support (some may have Advanced Life Support training)

I would ask your midwife ahead of time to make sure she carries (at least) these above items and has (at least) those certifications. The items should be in good working order, drugs should not be expired and midwife should be very familiar with exactly how to use each of these items and medications. Be your own advocate! Don't be afraid to ask questions ahead of time.

Now keep in mind, if the midwife is not certified she will not have access to things like Pitocin (or any medications), Oxygen, an IV, etc or any item that could get her in trouble with the law for practicing medicine without a license (at least, she will not have legal access to such items).

Ambulance:

A Paramedic will have the knowledge, skill and certain equipment to be able to help in the case of an emergency. However, while a Paramedic can certainly provide life saving support, they should not be considered a fool proof back-up plan. Quoting a Paramedic: “We can do neonate intubations but we do them SO seldom that it’s not a skill all medics are up to par on. This goes for babies & pregnancy in general. In an emergency childbirth scenario where minutes can make the difference in life and death, NOTHING in an ambulance can save a baby; it can only be a very temporary bandaid while we drive as fast as we can to the closest hospital.”

Response Time:
In a non-emergent transfer, travel time or response time will likely not be an issue. However, being "5 minutes from the hospital" may not be close enough when minutes can make the difference between a perfectly healthy life and death or neurological damage or injury or blood loss resulting in a transfusion or hysterectomy. Regardless of the scenario, emergency or not, a home birth transfer will take much longer than 5 minutes to get a laboring woman in her home (or birth center) to a hospital, in the right hands at the hospital, admitted, monitored and ready for a doctor to deliver a baby. I address this in my first blog post under the section "Is Our Hospital Really Close Enough" giving the example of a home birth transfer I attended as a doula; it was a very eye-opening experience for me. 

Hospital:

• All of the above listed home birth equipment and medications, plus…
• Electronic Fetal Monitor (EFM) - this detects the baby’s heart rate and the contractions. EFM vs Doppler gives nurses a much clearer picture of the baby's heart rate to make sure baby is getting all the oxygen baby needs. Heart rate variability is normal for the baby but it's important to know when changes to the heart rate occur in relation to when contractions happen. A heart rate of 155 BPM might sound healthy and wonderful when checked every 10 minutes or so but with decels at the end of a contraction, it can be a serious sign of distress. The decels may be so slight that unless you are looking at a print out (the EFM strip), you would not know they are happening.
• An endless supply of oxygen
• Cytotec - for postpartum hemorrhage
• Vacuum and/or forceps (though forceps are not common anymore) - if the baby’s health depends on immediate delivery, a vacuum can be used to help guide the baby through the birth canal while the mother pushes
• Blood Bank - for postpartum hemorrhage requiring a blood transfusion
• Operating Room and all personnel needed for an emergency c-section or for postpartum hemorrhage treatment/surgery (see Sara's birth of her son - an emergency surgical repair saved Sara's life after she suffered a cervical laceration; see Amber's experience as a doula and Becky's birth of her second child - immediate emergency c-sections saved the lives of those two babies)
• Ventilator - a machine that facilitates breathing (see Christine's Birth Story of Baby Penelope and how a ventilator saved her daughter's life when she was born)
• Specialized diagnostic equipment and staff
• A skilled team of nurses and doctors that are current in the following skills (these skills are frequently used either on the job or through hospital drills):
• Neonatal Resuscitation
• Advanced Life Support
• Intubation (and obviously the equipment for such) – provides a much more effective way to oxygenate a person (of any age) compared to resuscitation

Also keep in mind, to be trained in Neonatal Resuscitation or Life Support every few years and practicing only on a dummy is very different than using those skills on-the-job in a true emergency, on a real mother or baby. In a hospital, you have other sets of eyes and hands to help, to shout direction or take over in case someone freezes or forgets under pressure, you have a back-up for your back-up for your back-up. They will be able to tend to baby AND mother at the same time, if needed.

From a nurse midwife student: "Not only is there a team full of certified, competent people, but in a hospital, they are running dystocia drills or practicing for other obstetric emergencies. These are people who have practiced working together, who have assigned roles, and in addition to all the drills, have seen their share of real emergencies. They not only have a pediatric and adult code teams, but depending on size and type of hospital, they may also have OB rapid response and code teams as well,as they do in my hospital. It's a well oiled machine."

Nurses will keep a watchful eye on mother/baby in the hospital not just during the immediate postpartum period but for the length of their stay, checking vitals and looking for signs of infection, breathing complications, arrhythmia, postpartum hemorrhage, seizure, undetected birth defects, etc.

It is true that an Operating Room may or may not be available immediately when an emergency c-section is needed. In some cases, a doctor can have a baby born via cesarean in less than 5 minutes, including travel time from the Labor and Delivery Room to the Operating Room. In other cases, it may take longer depending on the availability of the Operating Room, anesthesiologist and obstetrician. However, the added commute from a home or birth center will certainly not help facilitate a c-section any quicker – in addition to travel time, the hospital must do its due diligence to admit the mother and monitor the baby and mother before performing any emergency surgery.