tag:blogger.com,1999:blog-88360867908096625302024-03-19T00:40:42.585-07:00Oregon Homebirth RealityUnknownnoreply@blogger.comBlogger3125tag:blogger.com,1999:blog-8836086790809662530.post-33012925284145815692012-07-06T15:56:00.000-07:002012-07-06T15:56:14.775-07:00Risk is No Game When You're The One Dying<div class="post-body entry-content" id="post-body-5825954210932374252">
Earlier, we looked at how Oregon's homebirth risk assessment protocols
are pitiful by comparison to those of nations where homebirth is
mainstream and popular, such as the Netherlands--nations whose records
are held up as an argument in favor of homebirth in the USA, even though
the comparison is far from fair given that midwives in those countries
receive far more education and training, not to mention supervision,
than our direct entry midwives. But now let's take a look more closely
at how dangerous and ludicrous the non-absolute risk criteria list is.
The most recent list can be found on <a href="http://www.oregon.gov/OHLA/DEM/docs/DEM_rules/DEM_4-4-11_5-19-11_9-1-11_Temp_Rules_Final.pdf">page 19.</a>
Remember, if a woman or baby develops one of these conditions, the
midwife is not required to do anything but consult with "another
licensed Oregon healthcare provider." In practice, this seems to most
often be either another DEM or a ND--naturopathic doctor. Not an OB or
MFM doctor, or even a nurse-midwife.<br />
<br />
<b>(A) Conditions that could negatively affect maternal or fetal status
that require ongoing medical supervision or ongoing use of medications. </b>Vague to the point of useless as a guideline.<br />
<br />
<b>(B) Inappropriate fetal size for gestation.</b> On the small side, this could be <a href="http://www.americanpregnancy.org/pregnancycomplications/iugr.htm">Intrauterine growth restriction or IUGR.</a>
As you can see if you follow that link, IUGR can be in itself a sign
that warns of other serious problems such as abnormalities with the cord
or placenta. There's no way to know for sure what's going on without OB
follow-up, including detailed ultrasound studies. A baby with IUGR is
at risk for hypoxia at birth, meconium aspiration syndrome,
hypoglycemia, and life-long disability (as well as some other things
detailed at the link.) Untreated, a baby with IUGR can die in utero.
Small for gestational age could also mean you've got the due date
wrong--I'm thinking now of that Birthingway study where she found that
more than a quarter of the charts were missing a LMP date entirely.
Ultrasound is the only way to have any clue what you're dealing with in
this situation. Any of these conditions could be serious to the point of
fatal if left untreated until the last minute. It is ridiculous to say
that simply chatting with a naturopath would suffice. OB consult should
be mandated.<br />
<br />
On the large side, <a href="http://en.wikipedia.org/wiki/Large_for_gestational_age">large for gestational age</a>
could mean a mother with undiagnosed diabetes, or the dates again could
be wrong. It could also be a sign of hydrops fetalis, which is
absolutely fatal if untreated but if caught early can be treated quite
effectively. It could also be a sign of a birth defect or genetic
anomaly. A baby born to an undiagnosed diabetic mother faces many risks,
including stillbirth, shoulder dystocia, and hypoglycemia. Determining
what is going on requires diagnostic tests and skills that midwives and
naturopaths do not have; OB consult should be required.<br />
<br />
<b>(C) Significant second or third trimester bleeding</b>. "Significant" here means we're not talking about a little spotting from a friable cervix. <a href="http://www.emedicinehealth.com/pregnancy_bleeding/page2_em.htm#Bleeding%20During%20Pregnancy%20Causes">"The
most common cause of late-pregnancy bleeding is problems with the
placenta. Some bleeding can also be due to an abnormal cervix or
vagina."</a> Bleeding at this stage can indicate placenta previa,
placental abruption, preterm labor, uterine rupture, fetal vessel
rupture, and other conditions...all serious and in need of assessment by
an OB.<br />
<br />
<b>(D) Abnormal fetal cardiac rate or rhythm</b>. This can be a sign of serious distress or a congenital heart defect. <a href="http://uvahealth.com/services/childrens-hospital/pediatric-services/fetal-heart-program/fetal-heart-program">The
American Heart Association recommends that a woman be referred for a
fetal echocardiogram (a non-invasive test that gives a detailed look at
the unborn child’s heart)</a> in this situation. This must be done using
high resolution ultrasound and requires an OB (more likely MFM) consult
and a pediatric cardiologist. Midwives and naturopaths are not
qualified to assess fetal arrhythmias.<br />
<br />
<b>(E) Decreased fetal movement</b>. <a href="http://www.americanpregnancy.org/duringpregnancy/PEwhatiskickcounting.html">"Recent
Harvard Medical School studies have found that decreased fetal movement
is associated with increased risk for stillbirth and concluded that
health care providers should be educating women about the importance of
fetal movement in an effort to reduce delay in intervention."</a> I'll let you draw your own conclusions from that.<br />
<br />
<b>(F) Uterine anomaly</b>. <a href="http://www.medscape.com/viewarticle/471012">"In
general, obstetrical complications, such as preterm delivery and first
trimester miscarriage, are higher in women with abnormal uteri. "</a><br />
<br />
<b>(G) Anemia (hematocrit less than 30 or hemoglobin less than 10 at term).</b> Anemia is associated with PROM, preterm labor, IUGR, and postpartum hemorrhage.<br />
<br />
<b>(H) Seizure disorder requiring prescriptive medication</b>. <a href="http://emedicine.medscape.com/article/272050-overview">Concerns
during these pregnancies include the risk of fetal malformation,
miscarriage, perinatal death, and increased seizure frequency.</a><br />
<br />
<b>(I) Platelet count of less than 75,000.</b> Normal is 150,000 to 450,000. Moderate thrombocytopenia is 50,000-100,000. <a href="http://emedicine.medscape.com/article/272867-overview">Thrombocytopenia in pregnancy can be caused by a number of serious diseases, including pre-eclampsia and HELLP.</a>
"Any pregnant patient with a platelet count of less than 100,000/μ L
should undergo further clinical and laboratory assessment." It could be
benign, but there's no way to tell without a medical work-up. This
condition should be referred to OB for assessment, if not treatment.<br />
<br />
<b>(J) Isoimmunization to blood factors.</b> I am blown away that this
is on here. It should be an absolute risk criteria, no question.
Isoimmunization starts off fairly mild in many cases, but can turn
severe and then deadly very, very quickly. It is treatable, however, and
with an experienced MFM even very severely affected babies can live and
recover now. But early detection, close monitoring, and swift
intervention at the first sign of problems are the key, here. <a href="http://emedicine.medscape.com/article/273995-overview">This whole article goes into a lot of technical depth, for the curious.</a>
During pregnancy, without specialist monitoring, the baby may seem
"just fine" until the point where the mother's belly swells with extra
fluid and the baby stops moving--dead from heart failure. Even if the
baby survives to birth, severe hyperbilirubinemia and jaundice can cause
brain damage and death if left untreated. Isoimmunized moms belong with
a good MFM and their babies should be born in a hospital where they can
receive the complete, life-saving treatment they deserve.<br />
<br />
<b>(K) Psychiatric disorders.</b> What's really key with this one is
consulting with the right "licensed professional." A PMHNP,
psychiatrist, or psychologist, preferably.<br />
<br />
<b>(L) History of thrombophlebitis and hemoglobinopathies.</b> <a href="http://www.ncbi.nlm.nih.gov/pubmed/17197616">ACOG guidelines should be followed.</a>
It's also worth noting that the baby may be at risk of an inherited
condition in the case of hemoglobinopathies, that must be assessed and
treated promptly.<br />
<br />
<b>(M) Dichorionic, diamniotic twins</b> and <b>(N) Monochorionic, diamniotic twins.</b> First, it's worth noting again that the Netherlands obstetric protocol automatically risks all twins out of homebirth. <a href="http://www.ncbi.nlm.nih.gov/pubmed/12634610">Monochorionic
compared with dichorionic twins have disproportionately high fetal loss
rates, perinatal mortality and morbidity. This is because of the
unpredictable vascular anastomoses and the often asymmetrical
distribution of the single placenta between both twins.</a> Monochorionic twins should be managed by an OB and delivered in hospital.<br />
<br />
<b>(O) Known fetal anomalies that require medical attention at birth.</b>
If it is known that the infant will need medical attention at birth,
that baby deserves to be born in a hospital where that care can be
promptly administered without unnecessary delay and risk to life and
limb.<br />
<br />
<b>(P) Two cesarean sections without previous successful vaginal birth</b> and <b>(Q) Three cesarean sections with a previous successful vaginal birth</b>. It's worth noting again that the Netherlands OB protocols exclude all VBACs from homebirth. <a href="http://emedicine.medscape.com/article/275854-overview#aw2aab6b5">For
women with a history of 2 or more cesarean deliveries, 10 studies
published from 1993-2010 showed that the risk of uterine rupture in a
subsequent pregnancy ranged from 0.9-6.0% (1 per 17-108 pregnancies).
This risk is increased 2- to 16-fold compared to women with only a
single previous cesarean delivery. In a study of 17,322 women with scars
from cesarean delivery, Miller et al found that, when women underwent a
TOL, uterine rupture was 3 times more common with 2 or more scars
(1.7%) than with 1 scar (0.6%)</a> Uterine rupture causes catastropic
hemorrhage and almost certain death of both mother and baby if not
promptly treated by a surgical team. Women with multiple prior
c-sections should be delivering in hospital.<br />
<br />
<b>(R) Blood coagulation defect</b>. <a href="http://www.marchofdimes.com/complications_thrombophilias.html">The
thrombophilias also may contribute to pregnancy complications including
repeated miscarriage, usually occurring after the tenth week of
pregnancy; stillbirth in the second or third trimesters; placental
abruption. APS contributes to 10 to 20 percent of repeated pregnancy
losses (3, 4). APS also is associated with other pregnancy complications
(4, 5): Preeclampsia; poor fetal growth; premature delivery.</a><br />
<br />
<b>(S) Significant glucose intolerance unresponsive to dietary and exercise intervention.</b> This seems like a sneaky way of saying gestational diabetes requiring treatment with medication. So why then, <b>(T) Gestational diabetes well controlled with diet or oral glycemic medications</b> also? These two rules are unclear. At any rate, this is something that should be managed by an OB as <a href="http://en.wikipedia.org/wiki/Gestational_diabetes#Medication">there are potentially serious complications for both the mother and the baby</a>
including neonatal hypoglycemia which can be deadly and cannot be
treated outside the hospital. (No, breastfeeding alone is not enough in
this situation, we're not just talking about being a little hungry,
here.)<br />
<br />
<b>(U) Primary herpes outbreak</b>. <a href="http://emedicine.medscape.com/article/274874-overview#aw2aab6b4">Approximately
5% of all cases of neonatal HSV infection result from in utero
transmission. With primary infection, transient viremia occurs. HSV has
the potential for hematogenous spread to the placenta and to the fetus.
Hematogenous spread can produce a spectrum of findings similar to other
TORCH (toxoplasmosis, other infections, rubella, cytomegalovirus, and
herpes simplex) infections, such as microcephaly, microphthalmia,
intracranial calcifications, and chorioretinitis. </a><br />
<br />
Intrapartum:<br />
<br />
<b>(A) No prenatal care or unavailable records.</b> This is mysterious, do women routinely show up at midwives' homes in labor, rapping on the door crying for assistance?<br />
<br />
<b>(B) History of substance abuse during this pregnancy</b>. Such women
may be attempting to use homebirth as a way to avoid detection by law
enforcement and social service agencies. They require more support than
can be provided out of hospital, as do their infants.<br />
<br />
<b>(C) Signs and symptoms of infection including but not limited to a
temperature 100.4 degrees Fahrenheit or higher with adequate hydration
in the mother</b>. I would say any signs of infection DURING labor
should be an automatic hospital transport. Infections in newborns can
move very quickly and subtly, by the time you notice that the baby is
sick because the mother had chorioamnionitis, it can be too late.<br />
<br />
<b>(D) Labor or premature rupture of membrane from 35 to 36 weeks gestation</b>. <a href="http://pediatrics.aappublications.org/content/120/6/1390.full.pdf">Late pre-term neonates are high risk and belong in the hospital.</a><br />
<br />
<b>(E) Frank and complete breech presentation, as determined by vaginal examination</b>. Now that <a href="http://ohsu.edu/xd/health/services/women/services/pregnancy-and-childbirth/labor-and-delivery-tour/breech-birth-at-ohsu.cfm">OHSU offers vaginal breech birth</a> there is even less reason for a woman in this area to take on the <a href="http://www.americanpregnancy.org/labornbirth/breechpresentation.html">risk of cord prolapse and head entrapment, both of which can become fatal in mere minutes.</a><br />
<br />
<b>(F) Lack of adequate progress in second stage</b>. It's good that
they at least put this back in, but in the Netherlands criteria it's an
indication for transport to hospital, not just consult.<br />
<br />
Maternal Postpartum<br />
<br />
<b>(A) Signs and symptoms of infection</b>. I hope at least they consult with someone who appropriately prescribes antibiotics, rather than sugar pellets and magick.<br />
<br />
<b>(B) Any condition requiring more than 12 hours of postpartum observation</b>. If it's required and the midwife can't do it, mom belongs in the hospital.<br />
<br />
<b>(C) Retained placenta greater than two hours with no unusual bleeding</b>. There's still a risk of occult bleeding and placenta accreta, especially if you don't have ultrasound on hand to check.<br />
<br />
<b>(D) Evidence of urinary retention that cannot be resolved in an out-of- hospital setting</b>. If it can't be solved in an out-of-hospital setting, what is it doing in non-absolute risk criteria? Get her to a hospital.<br />
<br />
Infant<br />
<br />
<b>(A) Apgar less than 7 at five minutes without improvement</b>. This
is an objectively sick-looking baby. A baby who is bluish and not
breathing well, who may be limp and weak. Also note that there is no
"but greater than ___" clause in there. This could be a baby with an
Apgar of 1, just a faint heartbeat, and no improvement after 5 minutes.
And this is not criteria to transport, just to call another midwife or
whatever. Huh??<br />
<br />
<b>(B) Weight less than 2,270 grams (five lbs.).</b> Low birth weight is 5 lbs 8 oz. <a href="http://www.marchofdimes.com/medicalresources_lowbirthweight.html">Low birthweight babies are at high risk for many deadly and disabling complications.</a><br />
<br />
<b>(C) Failure to void within 24 hours or stool within 48 hours from birth</b>. Seriously? Why isn't this an absolute risk factor?<br />
<br />
<b>(D) Excessive pallor, ruddiness, or jaundice at birth</b>. If a baby
is jaundiced AT BIRTH it could be a sign of hemolysis and a bilirubin
count must be done. That cannot be done at home. <a href="http://www.medscape.com/viewarticle/541770_3">The
onset of significant jaundice in the first 24 hours of life is not
considered a normal finding and deserves careful monitoring.</a><br />
<br />
<b>(E) Any generalized rash at birth</b>. Again, I hope they consult
someone who has relevant experience and not someone who prescribes
"tincture of time" without knowing normal from abnormal.<br />
<br />
<b>(F) Birth injury such as facial or brachial palsy, suspected fracture or severe bruising</b>.
We can all agree that BABIES WITH A BROKEN BONE should be IN THE
HOSPITAL getting treated. Right? Even you folks, Birthingway lurkers?<br />
<br />
<b>(G) Baby with signs and symptoms of hypoglycemia unresolved in the out-of-hospital setting</b>. If it cannot be resolved out of hospital, why isn't this an absolute criteria?<br />
<br />
<b>(H) Weight decrease in excess of 10 percent of birth weight that does not respond to treatment</b>. Ditto G.<br />
<br />
<b>(I) Maternal-infant interaction problems</b>. Too vague.<br />
<br />
<b>(J) Direct Coomb's positive cord blood</b>. Risk of hemolysis,
anemia, and hyperbilirubinemia, should be evaluated in hospital. Do they
even check the cord blood for this in a homebirth, typically?<br />
<br />
<b>(K) Infant born to HIV positive mother</b>. I hope they refer to a professional who can provide a thorough assessment.<br />
<br />
<b>(L) Suspected or evident major congenital anomaly</b>. Why on EARTH is this non-absolute?<br />
<br />
<b>(M) Estimated gestational age of less than 35 weeks</b>. 34 week babies and down belong in the hospital. Should be absolute.<br />
<br />
<b>(N) Maternal substance abuse identified postpartum</b>. Refer back to commentary on maternal substance abuse above.<br />
<br />
<b>(O) Cardiac irregularities, heart rate less than 80 or greater than
160 (at rest) without improvement, or any other abnormal or questionable
cardiac findings.</b> This is so unquestionably a baby who needs to be evaluated in hospital, WHY is this non-absolute?<br />
<br />
Why? I really want to know why, folks. I will publish your explanations
in the comments, Birthingway lurkers et al, even if it is incredibly
asinine. Truly. I want an explanation for these criteria. Almost every
single one of them should be referred to a medical doctor and/or
hospital setting for care. These high risk pregnancies, mothers, and
babies belong in a setting where they are getting care from experts in
these complications. Not "experts in normal birth."<br />
<br />
Someone please explain this to me.
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<a href="" name="comments"></a>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-8836086790809662530.post-17532715812703404242012-07-06T15:55:00.001-07:002012-07-06T15:55:11.162-07:00The Game of Risk<div class="post-body entry-content" id="post-body-2568307527292319966">
Any plan is arguably only as safe as its contingency plan is solid.
Common and less common emergent and urgent situations must be studied
and planned for; backup must be arranged. Staff should be drilled on
what to do in case of the most dire situations, they can act quickly and
calmly in the face of an actual emergency and the panic it brings. This
is a well-accepted principle. It is why we have fire drills in schools
and offices. It is why lifeguards must be people who have been trained,
and not just any person who knows how to swim. Unfortunately, among many
"alternative" healthcare providers, risk planning is looked down upon.
It is seen as inviting "negativity." Some even believe that you can
"manifest" good or bad results simply by thinking about them a lot. This
is a childish, irrational belief, but unfortunately a common one in the
circles of direct entry midwifery. (Childish, literally--remember Mr.
Rodgers comforting children that they cannot cause a person to die just
by wishing they were dead? That's magical thinking, a normal
developmental stage. We're supposed to grow out of it.)<br />
<br />
But homebirth is truly only as safe as the process used to "risk out" of
it (and into obstetrical care in the hospital) is complete, thoughtful,
and conservative. The <a href="http://arcweb.sos.state.or.us/pages/rules/oars_300/oar_332/332_025.html">risk assessment protocols</a> for Oregon DEMs have again been changed. You can see how they differ from <a href="http://nest-midwifery.com/Nest_Risk_Criteria.pdf">the 2009 version of the same.</a>
The criteria have been tightened up slightly in a few ways, but overall
loosened substantially from the original 1993 criteria (see table). The
legislators who allowed direct entry midwives to be licensed through
the state in the first place approved a far more conservative set of
safety guidelines than what is currently in place. These changes--for
instance, moving from no VBACs to almost any VBAC; no multiples to most
kinds of twins; no malpositioning to any breech and back down to no
footling breech--have been put in place by the DEM board, without any
outside oversight. What is worth examining in some detail is not just
how the Oregon absolute and non-absolute risk criteria have changed, but
how they compare to the homebirth systems that are so often held up as
examples of why homebirth is safe. We cannot expect to get the same
results as the Netherlands, Canada, or New Zealand if we are failing to
be as conservative in our safety standards as those nations.</div>
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<a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXh1cISQSUwXxIIR7eSDLTvikbiA0gZuao3BKdq9rYpBrRV8ncg3U1T055pb934g04E1txF8jMYDhRHhKcut-HqyCPfxNFUSvxJHUN4Wic18-cwz8DNs-eO3ytEvBNKldjJu9hzaAYHtR6/s1600/absolute+risk+criteria_001.jpg" imageanchor="1" style="margin-left: 1em; margin-right: 1em;"><img border="0" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjXh1cISQSUwXxIIR7eSDLTvikbiA0gZuao3BKdq9rYpBrRV8ncg3U1T055pb934g04E1txF8jMYDhRHhKcut-HqyCPfxNFUSvxJHUN4Wic18-cwz8DNs-eO3ytEvBNKldjJu9hzaAYHtR6/s1600/absolute+risk+criteria_001.jpg" /></a></div>
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<br />
<br />
Even
a quick scan of the risk criteria by a careful eye shows many problems.
For one thing, the list is very brief; many potential serious and
common risks are not even weighed or considered. Compare it with the far
more comprehensive and methodical list from the <a href="http://www.cmbc.bc.ca/Registrants-Handbook-13-07-Handbook-for-Midwifery-Clients.pdf">British Columbia College of Midwives</a>
and the sloppiness and shortcomings of the Oregon list are readily
apparent. In almost 20 years, how is it that the board has not managed
to come up with something as thorough as the Canadian risk criteria? For
another thing, some of the determinations rely upon diagnostic tools or
skills that DEMs are unlikely to have on hand--for instance, AIDS in an
infant is an absolute risk factor according to the 2009 standards, but
HIV is a non-absolute risk factor. How is a midwife to determine the
difference on site, without being able to determine viral load, T cell
count, or the presence or absence of AIDS-related complications?<br />
<br />
"Absolute risk" is a condition that rules out homebirth as a
possibility. The patient(s) must be referred out to hospital care
immediately. "Non-absolute risk" is much blurrier in meaning. Oregon law
only requires that the midwife consult with another professional about
the situation and obtain "informed consent" from the patient. Another
disturbing contrast with the BC system is that while for many
conditions, Canadian midwives must consult with a physician and proceed
as advised. Oregon midwives must consult with "another licensed
professional" but it need not be a medical doctor. It could be a
naturopath, in fact, or even just another midwife. Considering the
extreme seriousness of many of the conditions on the non-absolute risk
list (ie platelet count below 75,000; persistent unexplained fever over
101; labor at 35 weeks gestation; isoimmunization to blood factors) this
is extremely alarming. Other direct entry midwives are no more trained
in these high risk situations than the direct entry midwife calling the
consult. Naturopaths are often not trained in them either, as they lack
the inpatient experience that a licensed MD or DO must have. And the
looseness of the law makes this a judgment call where the safety depends
entirely on whether your midwife is cautious or reckless. A cautious
midwife may choose to take an infant weighing less than 5 lbs or with a
"suspected major congenital malformation" to the hospital. A reckless
one may call a naturopath who in turn suggests breastfeeding and
homeopathy...while a premature or growth-restricted baby slowly dies a
preventable death, or major malformations begin to claim an infant's
life even though in a hospital, treatment would be available and
effective.<br />
<br />
And under current Oregon law? The reckless midwife would be absolutely
justified, protected, and in the right. This is sick and wrong.<br />
<br />
A number of the conditions Canadian midwives must refer for transfer are
on the Oregon non-absolute list, or are not named on the Oregon lists
at all. If we are looking to Canada's outcomes to justify licensed
direct entry midwifery in Oregon, why this discrepancy? But the
difference is far more jarring and obvious when you compare the Oregon
list of standards with <a href="http://europe.obgyn.net/nederland/?page=%2Fnederland%2Frichtlijnen%2Fvademecum_eng_sec5">that of the Netherlands,</a>
the country whose high rate of homebirths and relatively favorable
outcome statistics are so often held up as an argument in favor of
American direct entry midwife-attended homebirths. Nevermind that Dutch
midwives are more like American nurse-midwives than our poorly trained
and unregulated "CPMs." Looking at the very strict, conservative, and
comprehensive standards Dutch midwives work under, it is clear that we
cannot expect to see Dutch results with our sloppy Oregon risk criteria.<br />
<br />
For instance, the first three sections of the Dutch criteria, dealing
with medical history and prior pregnancies, has no equivalent in Oregon
statutes. The Oregon risk criteria deal almost exclusively with the
present pregnancy and conditions that may arise within it. This is a
huge oversight, considering the impact that medical history and
pre-existing conditions can have upon a pregnancy. I think, because DEMs
are trained narrowly in "normal birth"--they are more "birth assisting
techs" than true midwives in the sense that Dutch midwife or a
nurse-midwife is a midwife--they simply were too ignorant of all the
possibilities to think of them for their risk criteria list! For
instance, while the Dutch standards address alcohol abuse (common!) and
chronic conditions like MS or rheumatoid arthritis, the Oregon standards
only tangentially address the latter under the umbrella of "conditions
that may need medication," a non-absolute factor. The Dutch standards
require twins and breech babies to be born in a hospital, while the
Oregon standards do not. Yet the 1993 Oregon standards were in line with
the Dutch standards! Why the change? There have been no scientific
breakthroughs validating looser protocols. It seems a clear case of
letting the people with a financial interest in increasing their reach
(DEMs) have too much oversight over their practice protocols, and not
enough legislative moderation imposed to slow them down. The Dutch
require hospital transfer after 24 hours of ruptured membranes. The
Oregon standards don't even list that as a non-absolute risk
factor--only after 72 hours AND the deadly infection chorioamnionitis
has set in must Oregon DEMs transfer under penalty of law. Yet in 1993,
the standard was just 72 hours...choreoamnionitis was clearly added in
later not to protect patients, but to sweeten the deal for DEMs who
feared transferring care and perhaps losing out financially or legally
when they did so. Failure to progress in labor--a warning and risk
factor for many potential problems such as shoulder dystocia, postpartum
hemorrhage, and maternal exhaustion--are risk-out criteria after a set
time in Dutch regulations. It was also an absolute risk factor in 1993
Oregon law. Now it is not even a non-absolute risk factor; women in
Oregon can continue in labor indefinitely at the hands of a negligent
midwife, <a href="http://oregonmidwifereviews.blogspot.com/2011/08/why-licensing-needs-to-be-mandatory-and.html">as poor Margarita Sheikh did</a> and the midwives are accountable to no one for this poor treatment of their patient.<br />
<br />
The creeping risk factors in Oregon are in opposition to the findings of
scientific evidence. For instance, take late prematurity. Recently,
much has been made of the evidence that babies born prior to 39 weeks
aren't really ready. While 34-37 week babies were once thought to be
mostly ok, we are now learning that they may face long-term effects in
brain development and other aspects of their health. This has been the
driving force to reduce elective c-sections that take place too early,
inductions before 39 weeks, and other such potentially risky
interventions. The Dutch criteria require transfer to hospital care in
the case of rupture of membranes prior to 37 weeks. The 1993 Oregon
criteria require transfer with rupture of membranes prior to 36 weeks.
But the 2009 Oregon criteria don't require the baby to go to the
hospital unless it is THIRTY FOUR weeks. Incredible. Unprecedented.
Where are they getting these numbers? After all, a baby of 35 weeks
gestation still has a 12% risk of respiratory distress
syndrome--compared to the 3.5% risk at 37 weeks or virtually nonexistent
risk in a 40 week baby with no other predisposing conditions. <a href="http://www.perinatology.com/calculators/mmptlc.htm">(See calculator here.)</a><br />
<br />
What justifies these reckless Oregon protocols? And where will the
creeping upwards in high risk stop? Will 33 weeks at home be argued for
next time the criteria are reviewed? After all, <a href="http://www.homebirth.net.au/2009/01/premature-babies.html">stunt "midwife" Lisa Barrett in Australia is all for it</a>--don't
let the fact that she's being investigated by the coroner disturb you
too much. (Warning, link contains nudity and graphic birth scene, not to
mention appalling and nauseating stupidity and disregard for human life
and limb.)<br />
<br />
In fact while I find the Oregon protocols ignorant and lacking when it
comes to the health of the mother, it is in regards to the well-being of
the infant that I find them the most alarming and disgusting. To get
perspective on what other homebirth-friendly areas allow in this regard,
I compared the protocols to <a href="http://www.adhb.govt.nz/newborn/Guidelines/Admission/NICUAdmissionsDischargesAndTransfers.htm">NICU or Level II admission standards in New Zealand.</a>
It seems a safe assumption that if New Zealand professionals, who are
used to midwifery care and homebirth being integrated into their
maternal care system, think a baby should be in the NICU or SCBU as I
think they call the step-down units over there, a baby with the same
condition in an Oregon home should be headed for the hospital.<br />
<br />
On admission to level 3 in NZ, I found two questionable equivalents on
the Oregon list. Since OR does not require transport for a Coombs
positive (it's non-absolute--so call your favorite naturopath to see
what kind of sage to burn) Oregon DEMs cannot know if a baby needs an
exchange transfusion or not. They cannot diagnose polycythemia or
anemia, either, two other indications for exchange, and are likely to
dismiss jaundice as "physiologic." Also, since DEMs are not required to
transport a baby who needed PPV at birth so long as eventually he perks
up to an APGAR of 7 by 10 minutes of age, that baby will not be
monitored in Oregon as he would be in New Zealand. Dangerous, since
respiration isn't a given and can decline without warning in neonates if
it was shaky to start with (as too many homebirth loss parents know).<br />
<br />
For admission to level II ("feeder grower" as some may know such units
here) NZ guidelines require it for infants under 5 lbs 8 oz. Oregon
midwives must only consult that friendly naturopath or her buddy midwife
even if an infant is under 5 lbs. 36 weekers go to level II to get
checked out in NZ; in Oregon, you call your naturopath if you've got a
34 weeker. Respiratory distress for an hour sends you to get a look over
in level II by NZ standards; in OR you can be grunting and tachypnic
and in distress for more than 2 hours before your midwife is required to
take you in. Signs of bowel obstruction are considered by NZ
guidelines, but not by OR. Metabolic problems get you a doctor's exam in
New Zealand, in Oregon your midwife must only call a friend to validate
her less-than-informed opinion of your condition. A NICU doc must look
over New Zealand babies with major malformations; Oregon babies
suffering the same pain merit only a quick chat over the phone with
another professional.<br />
<br />
All I can say is, it really seems better to be a newborn in New Zealand
than to be born at home in Oregon. It sounds a lot safer to be a NZ
baby, and it sounds like the adults in charge of their midwifery boards
and government are thinking a lot more of their needs and comfort and
right to not be left suffering at the whims of a midwife who either
doesn't know any better or is too arrogant to throw in the towel and ask
for help.<br />
<br />
All this shows one thing with incredible clarity: Oregon direct entry
midwives are not doing a good or responsible job regulating themselves.
They are taking advantage of the relative autonomy granted them by the
state to put in place an ever-upward-creeping standard of allowed high
risk pregnancies and births that they can attend and profit from. Like a
game of "Risk," DEMs have claimed one continent of risky births and are
on their way to claiming more--until they win, and Oregon citizens
lose. This is done without any heed to scientific evidence or global
homebirth standards. And it is done with callous and cruel disregard to
the safety of Oregon newborns and their mothers and families. The Oregon
legislature must act immediately to put this game of risk to a halt. As
a stop-gap, the original 1993 standards, approved by Gov. Barbara
Roberts, should be put back into place. And then, a panel of experts
should review the standards of care in nations like the Netherlands, the
UK, Canada, New Zealand, and Japan; the scientific literature; and the
track records of Oregon DEMs and come up with a comprehensive safety
plan that serves mothers and babies and NOT simply the needs or wants of
direct entry midwives and their high-paid Oregon Midwifery Council
lobbyist, or "birth activists." The panel of experts may contain DEMs,
but it must also include MDs and/or DOs, nurse midwives, OB nurses, and
public health statistics experts. The safety of Oregon families is worth
a REAL effort, not this shoddy, incomplete, ever-loosening current
"risk criteria" in place today.
</div>Unknownnoreply@blogger.com0tag:blogger.com,1999:blog-8836086790809662530.post-8360281399656996182012-07-06T15:48:00.001-07:002012-07-06T15:48:55.904-07:00I had a bad experience with an Oregon midwife. Now what?<br /><h3 class="post-title entry-title">
<br /></h3>
<div class="post-body entry-content" id="post-body-4415717535122142932">
<br />
1. Document to the best of your ability. Write down your experience as
thoroughly as you can as close to the events as you can. If you blog or
use an online journal, post it there--even under the "private" setting
on LiveJournal--to show clearly the dates and times. Get a copy of your
records from your midwife. Look over them, googling any abbreviations or
medical terms you are unfamiliar with as needed. If there are big
discrepancies between her record and yours, write that down in your
journal/notes also. You will be thankful for these notes later because
the memories will start to fade and having it in black and white will
mean a lot in so many ways.<br />
<br />
2. If possible, talk to your midwife and ask her questions about what
happened. BE SURE TO WRITE DOWN YOUR OWN VERSION OF EVENTS FIRST because
many irresponsible midwives will try to talk you out of your own
feelings, perceptions, and memories of events if they are not
complimentary to her. I know this step can be emotionally really
difficult, even impossible, and if you need to skip it, go ahead and
skip it. It just can be interesting to hear how she explains things, but
you need to first and foremost protect yourself.<br />
<br />
3. Talk to any OBs, hospital CNMs, pediatricians, neonatologists or
other mainstream medical personnel who may have become involved in your
care. Professional ethics may prohibit them from outright saying "dang,
your midwife sure was a fool" but you can glean insights by asking
questions like "if I see you for my next pregnancy and this complication
happens again, how would you handle it differently?" or "do you see
this happen a lot in your hospital?" Ask them to explain any terminology
you don't understand, too.<br />
<br />
4. Assuming your midwife is a licensed "direct entry" midwife (LDEM or
LM are the usual abbreviations; many will also be a CPM but that is not a
state-regulated classification) the next step is to file a complaint
with the <a href="http://www.oregon.gov/OHLA/DEM/index.shtml">Oregon Board of Direct Entry Midwifery</a>. If she was a nurse midwife/CNM the appropriate board would be <a href="http://www.oregon.gov/OSBN/">the state board of nursing.</a> If she was a naturopathic doctor or ND, the appropriate board is <a href="http://www.oregon.gov/OBNM/">the board of naturopathic medicine</a>. You can print a PDF complaint form for the DEM board <a href="http://www.oregon.gov/OHLA/docs/AgencyForms/OHLA_ComplaintForm.pdf">from the OHLA site.</a>
Fill out the form completely and don't hesitate to type up your story
in detail and attach it to the form. Mail it in and be sure to note the
date you mailed it on. About a month later, if you haven't heard from an
investigator at OHLA, give them a call and say you are following up on a
complaint. Be persistent and make sure that you talk to an actual
investigator assigned to your case at some point, not just to assistants
and front desk people. Be sure you make clear the seriousness of your
complaint and that you are going to follow through on it completely.<br />
<br />
This step is vital and must not be skipped. It is important that every
woman who has been mistreated, subject to malpractice, abused,
abandoned, or otherwise harmed or treated poorly by a DEM in Oregon file
a complaint with the board. It is the only way our leaders in Salem
will start to get the picture of just how bad this situation has gotten.
A lot of women never take this step because it seems aggressive, or
they fear that it will have devastating consequences for a midwife who
they still might feel ambivalently about. But it is really, really
important to get this on the record. You are not doing this for yourself
so much as you are for women who hire this midwife in the future. Women
who might end up with a permanent health issue, or a disabled baby or
even dead baby, because of incompetence or recklessness on the part of
the midwife. If she has a stack of complaints from former clients
showing a pattern of bad behavior, when that next woman complains she
has a better chance of getting justice.<br />
<br />
At the same time, don't expect much from OHLA. They can take YEARS
puttering around investigating a claim, and then often no matter how
egregious the midwife's misconduct, she gets NO disciplinary order or at
most a small fine and ordered to turn in records for a couple births.
You saw what happened to Jennifer Gallardo when her recklessness killed
two babies in short order: NOTHING. So don't expect anything dramatic or
satisfying to happen when you file your claim. This is a formality
only.<br />
<br />
5. If financial misrepresentation/fraud was involved in how your midwife mistreated you, you can also file a complaint with <a href="http://www.doj.state.or.us/help/explain_consumer_complaint.shtml">the Oregon Attorney General. </a><br />
<br />
6. If you have OHP/Medicaid and you believe your midwife engaged in fraudulent financial behavior, you must also report her to <a href="http://www.oregon.gov/DHS/aboutdhs/fraud/">the Department of Human Services.</a><br />
<br />
7. If your midwife in any way violated your privacy, including telling
your story without your permission online or talking about it in front
of other patients you MUST file a <a href="http://www.hhs.gov/ocr/privacy/hipaa/complaints/index.html">HIPAA complaint.</a>
It is absolutely essential that women can expect complete
confidentiality in their healthcare especially around things as
sensitive and intimate as pregnancy and childbirth.<br />
<br />
8. Once you have finished dealing with OHLA and they have sent you a
letter saying that your complaint file is closed, consider if you are
satisfied with the disciplinary actions (or more likely LACK of
disciplinary actions) they decided upon for your midwife. If you think
it was inadequate or that your complaint was not handled properly or
considered seriously enough, PLEASE <a href="http://www.leg.state.or.us/writelegsltr/">WRITE TO YOUR LEGISLATOR!!</a>
This is very, very important as the only way at this point to make the
OHLA grow teeth and the rules and regulations about midwives to become
really effective at keeping homebirth a SAFE option is to get our state
lawmakers to see what is going on.<br />
<br />
9. Get the word out about midwife malpractice and unprofessional
behavior through the "grass roots." Be sure to leave your midwife a
negative review on <a href="http://www.yelp.com/c/portland/health">Yelp.</a>
At the moment it is the most popular review site, but there are others
and you can leave reviews on those as well if you wish. Tell others who
are considering homebirth to steer clear of the midwife you hired, and
tell them why. Any time someone online or offline sings the praises of
your midwife as the best thing ever, say something, even if it's just as
brief and vague as "well I had a totally different experience with her,
I wouldn't recommend her to anyone." You may be considered "mean" for
doing this but remember why you are doing it: to protect other women and
their babies from harm and suffering.<br />
</div>Unknownnoreply@blogger.com0