Though I previously submitted an application for Florida licensure while literally in the middle of my Louisiana investigation, my application was denied and I let the dream of being a midwife in Florida go until June 2018. I once again inquired on why I was denied licensure and found out that it was questionably legal as to how the department of health denied me the first time. The new person in charge of Florida’s midwifery licensure seemed perplexed and all but encouraged me to reapply seeing that I had now graduated from an in-state midwifery school and completed all of the state’s rigid requirements for licensure. My letter to the Florida Council of Midwifery/Dept of Health is below. It also includes an explanation of everything Louisiana believed I violated in my Board Order, but does not include any attachments.
Addendum June 9, 2018
Dear Florida Council of
Licensed Midwifery,
For
the last three years, I have been working towards fulfilling the sanctions
required by Louisiana for a suspension of my midwifery license. However, I had
to complete the required sanctions sporadically as I was providing hospice care
for my grandmother, until she passed away in October 2017. In the next few
paragraphs, I will describe my quest to fulfill the sanctions of a mental/physical
evaluation, fees, understanding of board rules, and CEUs required.
Two
and a half years after the adjudication, I finally received a notice that the total
cost of the proceeding is $17,369.00. According to sanction 4: “Ms. Macaluso
shall pay a fine of $300 and all costs of these proceedings,” I am required to
pay this burdensome and egregious amount, which I am willing to do, but I am
finding difficult because I cannot be gainfully employed in the field I am
trained—midwifery or any field for that matter that requires a background check.
I have inquired if the Louisiana State Board of Medical Examiners (LSBME) will work
with my financial barriers, but it will not accept credit card payments,
installments, or community service in lieu of the $17,369.00. I have a 702
Credit Score. I am responsible and pay my bills on time. I have not received a
ticket in 22 years of driving. I am clearly willing and able to move forward
and be accountable for these required sanctions, but the LSBME is making it virtually
impossible without an income or without working with me.
In January 2018, I relocated to Florida. My former preceptor at Agape Birth and Wellness Center graciously offered me employment in the capacity of an office and birth assistant to help me earn enough to resubmit my midwifery application to the state of Florida towards earning an income to pay LSBME. In March, I received a Cease and Desist letter from the State of Florida. I am unaware of who filed a complaint or why it was even filed as I was not practicing in the capacity of a midwife (see letter). I also have two affidavits from employees at Agape Birth and Wellness Center stating that I was not practicing as an independent nor primary midwife (see attached affidavits). To avoid any more issues/letters from the state of Florida, I quit Agape Birth and Wellness Center on good terms. I currently work as an office and birth assistant at Heart2Heart Birth Center in Sanford, Florida.
My
correspondence with Esparonzia “Ronnie” Spooner (The Program Compliance Officer
at LSBME) has been sparse and not forthcoming (see attached emails). I want to
comply and fulfill the sanctions in a timely manner, however, the LSBME is
making it incredibly difficult. For example, per sanction 1: “Ms. Macaluso
shall undergo a mental/physical evaluation by a physician or group of
physicians who have been pre-approved in writing by the Board, and be deemed
competent to resume the practice of midwifery.” Towards completing this
sanction, I have had a physical conducted by my general practitioner, whom I’ve
had established care for over 10 years (see attached medical records); I am
healthy and normal. LSBME has found this evaluation insufficient. Instead, it provided
me with a list of five substance abuse facilities for which I am required to
seek my mental/physical evaluation even though no mental health nor substance
abuse is or has been in my history nor case. The two facilities closest to me
in Georgia and Alabama have declined to accept me into their programs as they
do not find that I qualify for treatment because legally nowhere in my board
order is a mental/physical evaluation appropriate.
LSBME
will not even tell me what needs to be assessed in the mental/physical
evaluation. Ms. Spooner stated in an email that I need to enroll in a substance
abuse treatment facility (again, when I do not have a substance abuse) and the
facility is to contact them with instructions on what assessments I need (see
attached emails). This process is beyond corrupt and not transparent to
withhold information from a licensee regarding what the evaluations required
are assessing. A good example of the corruption is how a facility in
Mississippi, after looking at my board order, stated that “it looks like the
board is concerned about a [fitness to practice evaluation in terms of clinical
skills, education, etc., which they do not provide at that facility].” However,
after reaching out to clarify the board order with Ms. Spooner, it was
determined that the Mississippi facility all of a sudden could provide a
“comprehensive evaluation” for $4,800 and a three-day inpatient stay (see
attached email). I have asked Ms. Spooner if I could find a facility closer for
the mental/physical evaluation, but am not allowed (see attached email).
I
have completed all of the sanction 2 requirements: “Ms. Macaluso shall obtain
additional education in the following areas: 1. Medical Record Keeping; 2.
Medical Ethics; and 3. Evaluation and Identification of High Risk Pregnancies.
All courses shall be comprehensive in nature and pre-approved in advance by the
Board.” Ms. Spooner indicated in an email to “use the courses from Louisiana
State Board of Nurses;” in addition to courses on the list from the State Board
of Nurses (i.e. www.rn.org), I have taken classes from many medical school
continuing education programs as well as organizations like MANA and AAFP. To
date, I have completed 23 classes (61.95 CEUs) in Medical Record Keeping, 13
classes (32 CEUs) in Medical Ethics, and 17 classes (53.9 CEUs) in the Evaluation
and Identification of High Risk Pregnancies, in addition to graduating from
Commonsense Childbirth School of Midwifery. Since 2014, I have completed 344.85
CEUs, not including coursework from Commonsense Childbirth School of Midwifery,
and I have applied for the NARM Bridge certificate. I have continuously sought
out education and skill training. I am a NARM preceptor. I am a member of the
Georgia Midwives Association and am in good standing. I have maintained my
skills working as an assistant midwife and birth assistant in Georgia and
Florida, respectively.
As
far as sanction 3: “Ms. Macaluso shall demonstrate her understanding of the
Board’s rules and regulations regarding Midwife practice in this state, in a
manner determined by the Board,” the LSBME will not explain how this is to be
accomplished. I have asked repeatedly (since November of 2017) and Ms. Spooner
has not yet replied (see attached emails).
On
May 18, 2018, an attorney contacted the board on my behalf (see attached email)
to see if any of these sanctions could be modified or at least put in writing
as it seems LSBME is taking advantage of the vague wording in order to make
completing these sanctions burdensome, if not impossible, thus prolonging this
indefinite suspension. LSBME has not responded.
Again,
I am willing and enthusiastic about fulfilling the sanctions. I understand the
mission of licensing boards is to not only protect the public, but rehabilitate
unsound providers. However, the LSBME’s sanctions are not only inappropriate
but not in the spirit of the law. Reintroducing me into the field of midwifery
after sanctions are approached and/or met is the goal. Although, I disagree
with the adjudication (see my explanation below), I am trying my best to
fulfill their requirements set forth to unsuspend my license. I am hoping that the
Florida Council of Licensed Midwifery will consider that if this case was
adjudicated in Florida, my license would never have been suspended. In fact, in
all likelihood, the case would have been dismissed. I am asking the Florida Council
of Licensed Midwifery to recognize my skill set, over-qualifications,
competency, EMT training, Bachelor’s degree, Associate’s degree in Direct Entry
Midwifery, and diploma from the Commonsense Childbirth School of Midwifery as
more than sufficient for licensure. I am beyond dedicated to the field of
midwifery as evidenced by the magnitude of courses, classes, and programs I
have completed towards bettering my skills and knowledge and my willingness and
patience to fulfill the sanctions. I am also asking the Council to have the
wherewithal to understand that these incredible fees and unfounded stipulations
set forth from the LSBME are simply not tenable without gainful employment as a
Florida midwife. I am asking the Council to consider my earnest efforts towards
accomplishing my sanctions and grant licensure, in some capacity, from the
state of Florida. I am not only living in an underserved area, but I work alongside
several Florida licensed midwives and doctors. I just need to have gainful
income in order to accomplish the sanctions in totality. I appreciate the
Council’s time and consideration and look forward to working with it towards a
mutually beneficial solution.
Thank
you for your time and assistance.
I look forward to your prompt reply,
JM
Although the LSBME, which
consisted of three medical doctors (a pathologist, urologist, and nephrologist,)
would appear to be able to present an unbiased and accurate assessment of the
midwifery standard of care, the fact that no midwives were used as expert
witnesses, or no obstetricians who are currently practicing reviewed my case,
it is easy to see how inappropriately my case was handled. My expert witness
was the only physician reviewing the case who not only was currently practicing
obstetrics, but has experience with out-of-hospital midwives and their
protocols and practices. He stated that I followed the midwifery standard of
care within my practice guidelines. The parents are happy with the thorough,
appropriate midwifery care they received and have testified that they would not
change any part of their birth or prenatal, intrapartum, or postpartum care.
They would happily do it all over again exactly as it occurred minus the
photographer. All of the providers (collaborating obstetrician, pediatrician,
and chiropractor) involved in the direct care of the client and the newborn are
satisfied with my care; no complaints have been lodged from any healthcare
providers. The complaint was filed by a photographer who attended the birth at
the parents’ request. Birth can be distressing to lay people who have no
medical training. Time can seem distorted, and events seem to take longer than
they actually do. Seeing a baby being born and transitioning to life outside
the womb can be disturbing, as that transition does not happen instantaneously.
That is why the initial Apgar score is not assigned until the baby is one
minute old. The photographer has no medical training, and her allegations
clearly show that she did not understand what she saw. The photographer shared
the birth video without the birth mother’s knowledge or permission to the
client’s previous obstetrician from her prior pregnancies. The parents sued the
photographer for a breach of privacy and contract.
I held a midwifery license
in Wisconsin that was always in good standing. I was granted a license in
Wisconsin on 9/23/2013; in the three years that it was active, I had no
complaints against that license. I was granted a midwifery license in Louisiana
on 12/18/2013. As a licensed midwife in the state of Louisiana, I have met or
exceeded the Louisiana Rules for Licensed Midwives 23:2303 definition of a Licensed
Midwife Practitioner, as I have:
“Completed
all the requirements of the board including the prescribed education and
experience, passed the licensing examination, and is licensed to practice
midwifery in the state of Louisiana.”
There have been no prior
complaints against my license in Louisiana. I have been in compliance with the
definition of midwife as seen in Louisiana regulations 23:2303:
“A person
who gives care and advice to a woman during pregnancy, labor, and the postnatal
period and who is capable of conducting vaginal deliveries in uncomplicated
pregnancies on her own.”
On or about December 19,
2014 my midwifery license in Louisiana was summarily suspended. It was alleged
that I failed to disqualify a client for a home birth who was allegedly having
a high risk pregnancy. No harm was done to the client or the newborn. The
complaint was filed by a photographer attending the birth at the clients’
request. The parents have testified on my behalf that they would hire me again
for the same birth experience. They wanted to hire me for their next pregnancy,
but I was unable to accept clients since my license is still suspended.
The client, a 22 year old G3 P2 (pregnant with her third child, with two prior pregnancies and two living
children), with no prior pregnancy or health complications. This client met the
criteria of having a low-risk pregnancy as defined by the Louisiana Midwife
Practitioners Act (MPA) Chapter 46:3241(12) of a:
“Low risk patient or an individual who is at low or
normal risk of developing complications during pregnancy and childbirth as
evidenced by the absence of any preexisting maternal disease arising during
pregnancy or such other conditions as the board may identify in rules.”
The client entered my care
on 2/20/2014. Before the client can enter my care, Louisiana midwifery
regulations require an initial physician visit to assess the client and
determine if she is a candidate for home birth. The client saw not
only one physician for her initial medical evaluation, but two separate
physicians at two separate times; both of whom indicated that this client was
low-to-normal risk based on the absence of risk factors. This evaluation was in
compliance with rule 5311(A):
“The
licensed midwife practitioner must require that the client have a physical
examination by a physician and be found to be essentially normal or at low risk
before her care can be assumed. The initial physician examination shall include
the physical assessment procedures which meet current standards of care set
forth by the American College of Obstetricians and Gynecologists (ACOG).”
ACOG defines a high-risk
pregnancy as one that threatens the health or life of the mother or her fetus.
Risk factors associated with a high-risk pregnancy can include existing health
conditions, obesity, multiple births, and young or old maternal age. Since these
risk factors were absent the entire pregnancy, I concluded, in conjunction with
my supervising physician, that my client was not experiencing a high risk
pregnancy. This low-risk status was repeatedly indicated in the client’s
medical records after thorough evaluation and examination by two different
physicians at two different appointments in conjunction with my assessment, she
was considered to be at a low risk for developing medical complications during
her pregnancy; therefore midwifery care was initiated and continued in
accordance with the definition in Chapter 53, subchapter A. Standards of
Practice, rule 5301(A):
“Licensed midwife practitioners may provide care
only to low risk clients determined by physician evaluation and examination to
be prospectively normal for pregnancy and childbirth, and at low risk for the
development of medical complications. Licensed midwife practitioners shall
provide such care with supervision of a physician who is actively engaged in
the practice of obstetrics.”
According to the MPA
46:3258(A) (Professional liability) the physician’s examination constitutes a
risk assessment:
“Physician evaluation and examination as provided in
R.S. 37:3244 shall be deemed to constitute a risk assessment. A physician
performing a risk assessment is responsible only for determining that at the
time of the risk assessment the individual is at low or normal risk of
developing complications during pregnancy and childbirth. For any physician
performing a physician risk assessment, the physician-patient relationship
shall only exist for the purposes of the risk assessment and shall not continue
after the conclusion of the physician risk assessment.”
Prior to initiating care, I provided the client with a
copy of my risk assessment form to give to the supervising physician at the
client’s initial visit for the purposes of establishing and informing the
supervising physician of my legal parameters for safe and appropriate midwifery
care. The risk assessment form is one I have created which I use to assess my
clients throughout their pregnancy. This document is not a Louisiana legal
requirement, rather a tool that I have devised to thoroughly and adequately assess
my clients. Similar to the Florida risk assessment rules, had my client had a
score of (3) or more, which she never did, my practice guidelines indicate that
I would then make the appropriate consultation and/or referral. Louisiana rules
do not delineate a low risk pregnancy from a high risk pregnancy. They only
offer unapproved practice and occurrences when a referral or consultation are
advised. Thus, Louisiana rules leave the final determination of risk status to
the physician. I use this risk assessment form to discuss with the patient in
determining their risk status and evaluating their risk score at the first
visit. This client’s only risk score was 1 for previous baby over 4,000 grams
and remained a risk score of 1 throughout the pregnancy, therefore it was
determined by myself and my supervising physician to be a low-to-normal risk
pregnancy and documenting that my care was competent and in compliance with
rule 5309(A):
“All
midwives will use risk factor assessments of their clients in order to
establish their initial and continuing eligibility for midwifery services.
Clients will be informed of their risk status. All midwives have the right and
responsibility to refuse and discontinue services to clients based on these
risk factors and to make appropriate referrals when indicated for the
protection of the mother and baby. All final decisions on risk factors will be
made by the midwife and the client’s backup physician.”
As evidenced in my chart, at my client’s initial visit
with me, I reviewed the two sets of medical records from both physicians which
assessed my client to be low-risk before my care had begun. The medical records
contained the results of the medical evaluation, which did not identify any
conditions which would preclude this client from midwifery care (in compliance
of the rule 5353(A) (Initiation of Physical Care):
“General
physical examination which included the taking of a comprehensive medical,
obstetrical, and nutritional history sufficient to identify potentially
dangerous conditions that might preclude midwife care.”
It is important to note that
the client’s first physician, one that she had a relationship with for both of
her previous pregnancies, dismissed her from his care after the initial visit
on January 20, 2014. While an initial reason for dismissal was not given, the
reason of “not trusting the client’s midwife’s skills” was given in a later
email correspondence with the client even though the physician had no basis for
this decision other than a personal bias formulated from the CPM and CNM he
employs, as he has never witnessed my midwifery skills nor assessed them; he
never returned the assessment forms given to him by the patient.
Coincidentally, this physician invited the client to have her birth at his
birth center instead of at home. His birth center, the only free-standing birth
center in the state of Louisiana, opened in March of 2014, four months before
the client’s EDD. This birth center happens to be located 5 miles from my home
and well within my practice area. Also, the midwives who work at his birth
center have demonstrated a personal bias against me as evidenced by written
testimony from potential clients which disclose how the CPM at the birth center
gave them distorted, inaccurate and untrue information regarding my practice
and my past experiences. Again, not any physician in the state of Louisiana,
nor any of the 12 practicing Louisiana licensed midwives have ever attended any
appointments, labors or births nor assessed my skills; I’ve never even had to
transport a client in the state of Louisiana. The same birth photographer, who
was attending the birth of my client, happens to be employed at this
physician’s birth center. The photographer testified to showing the midwives at
the birth center the birth video without the client’s knowledge or permission;
the midwives at the birth center encouraged the photographer to turn the birth
video and all photos over to the Louisiana State Board of Medical Examiners. While
the video was shared with my attorney in February, the original complaint filed
by the photographer was not given to me until less than 24 hours before the
hearing. Therefore, my case was further hindered by not being able to view the
original complaint and not having the opportunity to depose the photographer or
other witnesses like the CPM or physician from the birth center.
In addition to the five
prenatal visits with two different obstetricians, this client had 12 prenatal
appointments with me, all of which found the client to be low risk and in
compliance of rule 5317(A). At every visit, her estimated weeks gestation was
calculated, fundal height measured, fetal presentation determined by Leopold’s,
fetal heart tones taken, fetal movement verified, assessment for any signs and
symptoms of preterm labor recorded, cervical exam conducted (if requested or
when appropriate), blood pressure measured, edema assessed, weight taken, urine
dipped with the urinalysis reagent strips to provide tests for the
following: glucose, bilirubin, ketone, specific gravity, blood, pH, protein,
urobilinogen, nitrite and leukocytes. Urinalysis strips are useful in the
preliminary screening for diabetes, liver diseases, hemolytic diseases,
urogenital, and kidney disorders. Aside from a trace amount of protein seen on
a urine dip at 18 weeks and 4 days at the supervising providers office, all of
the vital signs and all of the tests on the strip for urine dips remained
within normal limits and negative, respectively, for the entire course of
pregnancy, both at prenatal visits with me and also with the supervising
physician, further underscoring the conclusion that this client did not have
kidney disease nor any other underlying, chronic, or acute illness, disease, or
infection. Additionally, both myself and the physician had similar fundal
heights within 1-2 cms of each other at each visit, indicating a corroborating
measurement with was well within normal measurements for a baby of
average/large constitutionally-sized newborn. Likewise, no edema was seen by
either providers at any time. Besides normal routine antepartum care, the
client had all of the required tests seen in rule 5355(A) and 5313:
“The
midwife shall conduct or arrange for additional laboratory tests as indicated,
including Rh antibody screening, blood sugar screening, gonorrhea culture, and
periodic hematocrit or hemoglobin screening.” “Clinical
pelvimetry… GC screen, blood group and Rh, hematocrit or hemoglobin, rubella
titer, and urinalysis. Additionally…a VDLR test.”
Per
Louisiana rules, the glucose screening is not required. Additionally, it is of
importance to note that a urinalysis was required and performed at the initial
examination by the first physician. The urinalysis was determined to be normal
and not requiring any follow-up care. My client was under the care of this
first physician, whom she notified via a phone call of her visit around 12
weeks gestation to an urgent care clinic to see an emergency-care physician
regarding a “kidney infection” as reported by the client. At the urgent care
clinic, the client was given antibiotics and a steroid injection after which
she called her first physician to inform him of her infection and inquire if
the antibiotics were safe for use in her pregnancy. The first physician
confirmed that her antibiotics were safe and to set an appointment for an
initial visit in about a month at which time her infection cleared as evidenced
by the lack of signs and symptoms and a test of cure. At my initial visit with
the client, she informed me of her prior “kidney infection.” The client’s
history was free of urinary tract infections and related kidney disorders and
disease. Additionally, if the client had the alleged “kidney disease,” she
would have presented in her pregnancy with signs and symptoms of kidney disease
and would have been evidenced by
protein in urine, edema, urinary tract infections, hypertension, low blood cell
count, appetite loss, general
ill feeling and fatigue, headaches, itching and dry skin, nausea, weight
loss without trying to lose weight—none
of which this client presented with at any time during her pregnancy and usually
associated with chronic kidney disease in pregnancy (Williams and Davison,
2008). This client did not experience preterm labor or low birth weight further
indicating a healthy, low-risk pregnancy. Therefore, I concluded based on medical
records from the two initial visits with the two different physicians at two
different times that indeed the infection had been of short duration, responded
well to antibiotic treatment and had completely resolved, returning her to low
risk status. Given that antibiotics were administered in an out-of-hospital
setting, a follow-up negative test of cure a month later, no signs and symptoms
of chronic disease, and no present signs or symptoms of infection, I concluded
that the transient infection had cleared and was no longer present. Thus, it was determined that this client did not have kidney
disease or any kidney dysfunction outside normal pregnancy parameters. According to the
American Association of Family Physicians, posttreatment urinalysis and urine
culture are unnecessary in patients who are asymptomatic after therapy. Also, the
British National Formulary offers the following information: “After finishing the antibiotic therapy indicated by the
prescriber, the pharmacist should give a follow-up appointment to the pregnant
woman. A dipstick urine test is encouraged after treatment of the primary infection
to ensure response and then monthly for the remainder of the pregnancy to
monitor for recurrence” (2011).
Informed consent was implemented throughout various
stages of the pregnancy and signatures were collected on appropriate informed
consent documents after thorough discussions with the clients occurred and
adequate time to discuss risks, benefits, alternatives, as well as answer any
questions pertaining to tests, and screenings regarding standard midwifery care
offerings was conducted. This was in compliance with rule 5315(A1) (Acceptance
of Clients):
“Prior
to the acceptance of a client for care, a licensed midwife practitioner shall
inform the client orally and in writing that: Certain risks and benefits exist
for home birth and certain risks and benefits exist for other childbirth
alternatives (including hospital, physician-assisted birth). The midwife is
responsible for informing the client of the risks and benefits of all
childbirth options to ensure informed consent.”
The Louisiana State Board of
Medical Examiners (LSBME) is authorized to “promulgate and publish rules and
regulations for the purpose of administering the provisions of [The Midwifery
Practitioners Act (MPA)],” not to constrict the practice of midwifery, which
the LSBME unlawfully does when it refers to “back-up physician” in rule 5315
(A4):
“The client must make arrangements for the services
of a backup physician located within a 50 mile radius of the client’s home and
the planned delivery site.”
A practice rule cannot be
enforced if no authority for the rule is given in the practice act. The LSBME
demonstrated its understanding of this violation by conveniently wording that
“the midwifery rules contemplate” a back-up physician, because it is unlawful
to require one according to the MPA. A back-up physician is neither defined nor
mentioned in the MPA. The MPA requires the midwife to produce “a description of
the protocol for transfer to a hospital.” Similar to Florida law, the MPA
states that:
“No physician or other healthcare provider as
defined in RS 40:1299.41, no hospital as defined in RS 40.2102, or no
institution, facility, or clinic licensed by the department shall be: deemed to
have established a legal relationship with a licensed midwife solely by
providing a risk assessment as defined in this section or accepting a transfer
of a patient from a licensed midwife.”
I satisfy all of the
required information through the use of an “Emergency Back-up Form” identical
to one used in Florida. I complete this form, using the patient’s preferred
physician, group, hospital, and other parameters like distance to nearest
hospital with emergency services, distance to nearest hospital with obstetrical
services, distance to nearest hospital with nearest NICU. This form is
completed prenatally. This client did make arrangements within 50 miles of her
home and the planned delivery site for the services of a backup physician. The
requirements imposed by 5315 (A4 and A5) were satisfied:
“The midwife will develop and implement a plan for
obtaining consultation from and/or referral to the client’s backup physician,
and will consult with the client’s backup physician or transfer the client when
necessary.”
The client made an informed
decision to decline the glucose screening as she desired minimal screenings as
part of her care; however, per my protocols, she was carefully monitored
throughout pregnancy for signs or symptoms (blurred vision; fatigue; frequent
infections including those of the bladder, vagina, and skin; increased thirst;
increased urination; nausea and vomiting; weight loss despite increased
appetite) associated with diabetes and through urine dips, diet and exercise
counseling; no signs and symptoms of diabetes was seen in this pregnancy. The
American Dietary Association and ACOG guidelines state that a low-risk
pregnancy requires no glucose testing for those women meeting all of the
following criteria: age <25 years; weight normal before pregnancy; member of
an ethnic group with a low prevalence of diabetes; no known diabetes in
first-degree relatives; no history of abnormal glucose tolerance; no history of
poor obstetric outcome. This client met all these criteria; she was 22 years
old, 5 feet tall, 115 pounds (prepregnant weight) or 18 BMI, 160 pounds
delivery weight, not a member of an ethnic group with a prevalence of diabetes,
no known first-degree family members with diabetes, no history of abnormal
glucose, and no poor obstetric outcome. Therefore, I could safely discuss her lower
risk status for having gestational diabetes, even with a history of a large
baby, even though I counseled and encouraged the glucose screening. The mother
documents her knowledge and understanding of her risk in having a homebirth
with a history of large babies as evidenced by her birth plan which states:
“Make yourself comfortable,
you are more than welcome to chill on the couch, play with my kids, read a
book, help yourselves to something in the kitchen. We are having a hypnobirth.
Please nobody talk to me during labor (with the exception of my husband), if
you need something, you are more than welcome to ask my husband. If I retreat
to my kid’s room this means I want to be alone. I’m fine with people observing
me in there, but I don’t want to know you are in the room. In other words,
don’t touch me, stand off to the corner, and shhh… I do not want my baby to
have formula for any reason, I would like my baby to receive all of its blood
from the placenta, so I want the cord to finish pulsing.” Anything that has to
be done to the baby can be done with the cord still attached. If we end up
going to the hospital, someone please save the placenta for me. Do not let them
put triple dye or eye ointment on my baby. I do not want my baby to receive
vitamin K or Hep B. No routine tests unless there is a suspected problem (not
baby is big so let’s check blood sugar.) I’ve been known to have big babies,
unless there are symptoms of an issue I’m fine assuming all is fine with the
baby’s blood sugar…I’d like for this to be as least traumatic for myself and my
baby, so if something isn’t completely necessary then I really would like to
avoid it.”
Frye notes that Macrosomia
can be applied to all large babies, but is a rather vague term.
Large-for-gestational age (LGA) babies tend to be clumped into a pathological
category denying the fact that healthy, bigger-than-average babies are often
born to well-nourished women. Indeed this client was counseled to have a
healthy diet and she was following the Brewer’s diet, one that notoriously
creates larger, healthy babies. Because this baby, as seen on the 36 week
ultrasound had all measurements in proportion, or symmetrical, one can concur
that the baby was constitutionally destined to be large as the hereditary
pattern may suggest. Well-nourished women also may carry slightly past their
due date, which is what happened in this client’s pregnancy. This leads to
babies who are born healthy in every way but may be larger than average. Additionally,
a significant number of hospital births now take place after induction and as
scheduled repeat cesareans, many of which are done at 38-39 weeks of pregnancy,
resulting in lower birth weight babies and increased risks of
prematurity-related problems. Statistically, these interventions “lower the
bar” for what is considered a large baby.
The Cochrane
Review found:
“The best way
of identifying and treating women with abnormal blood glucose tests in
pregnancy is not known. Raised blood glucose levels during pregnancy is known
as gestational diabetes. This abnormality may be associated with bigger babies,
more difficult births and could be associated with higher rates of operative
delivery such as caesarean section. The review of eight studies (1418 women)
suggests that offering specific treatment for gestational diabetes may be
associated with better baby and mother outcomes, but has not found robust
evidence on the best choice of treatment which provides the better outcomes for
these women and their babies, even if identified correctly. More research is
needed to assess long-term mother and baby outcomes. Women
are often intensively managed with increased obstetric monitoring, dietary
regulation, and insulin. However, there has been no sound evidence base to
support intensive treatment. The two main approaches to screening are ‘universal’ where all women undergo a screening test for gestational diabetes screening;
and ‘selective’ where only those women at ‘high risk’
are screened. It is however unclear whether screening
for gestational diabetes screening leads to better health outcomes and if so,
which screening strategy is the most
appropriate. Therefore, it was concluded that there remains insufficient
evidence to determine if screening for
gestational diabetes, or what types of screening,
can improve maternal and infant health outcomes.”
Henci Goer’s research states:
“Santini
and Ales report results from a national trial that occurred in the early 1980’s
when some doctors at Cornell University Medical Center screened women for gestational
diabetes (GD) routinely and others did not. No differences in perinatal mortality,
morbidity, LGA or macrosomia rates were found between screened and unscreened
populations, but women in the screened population were more likely to have
primary cesarean sections (19 percent versus 12 percent), more clinic visits,
more fetal surveillance tests, and more prenatal hospitalization (Santini et
al. 1990). As Santini and Ales’ study suggests, not only does GD management
offer little benefit, it confers risks, the gravest being a marked increase in
cesarean section. Many doctors view high cesarean rates as a reasonable
trade-off for preventing shoulder dystocia. This ignores that many shoulder
dystocias occur in non-macrosomic infants (Keller 1991) and that the increase
in cesarean rate for infants weighing over 4000 g has not improved outcomes
(Boyd et al. 1983); not to mention the role typical obstetric management plays
in causing shoulder dystocia. Increased
likelihood of cesarean is not the only risk of GD management. Finally, the poor
predictability of the fetal weight estimates and surveillance tests doctors
feel obliged to order, even the belief that GD is a high-risk condition,
undoubtedly lead to countless unnecessary inductions and operative deliveries.
Researchers take note that sonography to estimate fetal weight did no better than
a coin toss at predicting macrosomia and recommended it anyway (Combs
et al. 1993).”
Because
gestational diabetes affects only a small amount (approximately 3-6%) of
all pregnant women it is important to recognize that some clients will exercise
their right to refuse the screening. Even ACOG recognizes a woman’s right to
decline the screen:
“These [gestational diabetes] guidelines should not be construed as
dictating an exclusive course of treatment or procedure. Variations in practice
may be warranted based on the needs of the individual patient, resources, and
limitations unique to the institution or type of practice. (ACOG, 2001) Pregnant women’s autonomous
decisions should be respected. Concerns about the impact of maternal decisions
on fetal well-being should be discussed in the context of medical evidence and
understood within the context of each woman’s broad social network, cultural
beliefs, and values. In the absence of extraordinary circumstances,
circumstances that, in fact, the Committee on Ethics cannot currently imagine,
judicial authority should not be used to implement treatment regimens aimed at
protecting the fetus, for such actions violate the pregnant woman’s autonomy.
(ACOG,
2005)”
Per Louisiana standards,
this client was eligible for a home birth as determined multiple times by the first
physician, the supervising physician and my assessment. Sound judgement was
used in determining the client’s qualification for an at-home birth, again, as
evidenced through the absence of risk factors on the assessment form and by the
supervising physician’s continued assessment that the client was low-to-normal
risk for an at-home delivery. The state’s expert witness testified that the
supervising physician’s initial assessment was based on misinformation supplied
by the patient, even though in my medical records requested from the physician
are complete for a patient history. Therefore, it can be concluded that the
state may have removed pages from the supervising physician’s medical documents
to make it appear as though information was being withheld. This unethical,
unlawful maneuvering was found at every step of this investigative process to
my detriment.
At no time during the
pregnancy, did certain medical conditions and/or noncompliance with my
requirements or physician recommendations preclude my attendance at the birth
or continued midwife care during any phase of the pregnancy, in accordance with
rule 5315(A3). Likewise, under my care, the requirements for the supervision of a
physician exceeded that which is required by rules in the definition set forth
by 23:2303:
“The client
shall be seen by a physician for the physical examination at least once during
the first or second trimester of pregnancy and again at least once within the
last four weeks of pregnancy.”
In compliance with rule
5319(A)(Physician Visit), my client was evaluated and assessed at 35 weeks and
5 days, by the supervising physician to be low risk and have no medical
contraindications for delivery by a licensed midwife or for a home birth:
“Each client must be evaluated by the supervising
physician at or near the thirty-sixth week. The purpose of this visit is to
ensure that the client has no potentially serious medical conditions and has no
medical contraindications for delivery by a licensed midwife practitioner or
for home birth.”
This initial physician examination and evaluation
included clinical pelvimetry, which is important to note because I used this
satisfactory evaluation in confirming my pelvic assessments conducted at the
client’s 39 week prenatal visit where I conducted a pelvic exam. In conjunction
with this client’s history of a proven pelvis and normal, spontaneous, vaginal
birth of a 10 lb 14 oz baby at home without the attendance of a healthcare
provider and these separate, but conferring clinical findings of an adequate pelvis
lend towards my decision to continue to care for this client even with the
ultrasound report showing fetal weight in the 95th percentile. The
client understood she was at a higher risk for having a larger baby since her
husband’s family history includes 12 pound babies delivered vaginally from
normal, healthy women. The client’s first baby was with a different father and
was delivered in a normal, spontaneous, vaginal delivery at 38 weeks gestation
weighing 7 lbs 6 oz.
My assessments, including a clinical
pelvic assessment and a normal fundal height measurement (within 1-2 cms of
estimated weeks), concurred with those of the collaborating physician, that
this client’s pregnancy was progressing normally and she could be expected to
have a normal, healthy, low risk labor and birth. I utilized appropriate risk factor
assessments, counseling, preparation for childbirth, and appropriate
supervision throughout the pregnancy in assessing the client’s health status as
normal and low risk. The scope of practice as defined by the MPA 46:3244(B)
states that:
“The licensed midwife may provide care to low risk
patients determined by physician evaluation and examination to be essentially
normal for pregnancy and childbirth. Such care includes prenatal supervision
and counseling; preparation for childbirth; and supervision and care during
labor and delivery and care of the mother and the newborn in the immediate
postpartum period if progress meets criteria generally accepted as normal as
defined by the board.”
Under my care, on 7/21/2014 this
client’s labor began. The client had an appointment scheduled later on that Monday
with the supervising physician as she was approximately 41 weeks 1 day.
However, because the client had a miscarriage the month before this pregnancy’s
conception and is tandem nursing her 2 and 4-year olds, it was not entirely
clear when she ovulated nor when she conceived; hence an uncertain estimated
due date. Additionally, her first ultrasound was at 23 weeks, which is not
accurate for a “dating” scan. Therefore, these due dates are approximate.
I arrived at the client’s
home around 5am. I introduced myself to the photographer but did not say any of
the things she attributed to me saying. For example, if I truly was
uncomfortable with a photographer at the birth, I would have asked her to
leave. Later in the labor, the photographer asked how many centimeters the
client was at that time. Per HIPAA, I do not disclose medical information,
rather deferring the photographer to ask the client, if she needed to know such
details. The photographer, who again, had no medical training and has only
attended one other homebirth, stated in her initial complaint that I “was not
using any maneuver that [she’s] seen used in similar situations.” Besides the
reason that this was not a shoulder dystocia, the photographer did not see any
of the same maneuvers as she has seen in the hospital because she was at a home
birth and our standard of care is based on ambulatory clients. The father
testified that the baby did not fall out and onto the floor, as the
photographer alleged. Again, without medical training, it is difficult to
ascertain what a limp, from partially flexed newborn looks like, which was
clearly the case as to why the photographer said the baby was “completely
limp.” As the baby was born, her tone was not one of a baby with no tone; she
had some flexion, and after about 90 seconds her flexion reflected that of a
healthy, normal newborn. The photographer claimed that she never saw me
suctioning the baby, which is not true. The father testified to seeing me
suction the baby, take fetal heart tones, and vitals on both the mother and
baby. However, because she was behind a camera lens, standing about 5 feet
away, in a doorway, behind three other people, she may have missed all that I
was doing. Plus, when I decided to activate 911, I asked her to make that call
and she left the room entirely; therefore she could not claim to have seen or not
seen me do a certain procedure when she was not in the room the whole time. The
baby’s and mother’s vitals were being monitored at all times. Again, without
medical experience, it is hard to know when or how vitals are being taken. For
example, the base of the umbilical cord was being palpated for the baby’s heart
rate, if the Doppler was not being used. The cord was clamped and cut about 20
minutes postpartum, well after the baby had successfully transitioned to
extrauterine life, the cord had ceased pulsing, it was white and flaccid, and
the placenta had detached. The cord bands I use to clamp the cord require the
cord to be cut before I can clamp them. Some residual blood that was in the
cord leaked out after cutting, but was quickly soaked up in a 2×2 gauze pad
after clamping was finished. The photographer was mad that I did not wait for
her to be poised for photo before cutting the cord, so we “redid” the cord
cutting later with the father cutting the cord. I was never rude or demanding
to any of the assistants at the birth.
The photographer and doula
offered to help me at multiple times during the labor and actually you can see
the photographer gladly handing me the mirror in the video. About 25 minutes
postpartum, the mom did feel weak as she was getting out of the tub, so to avoid
a vagal response, I laid her down on a spot beside the tub. It is common standard
of practice to have a place beside the tub for mothers to rest, if making it to
the bed may be unwise. Again, it is understandable to the layperson to not
understand what a placenta looks like, but seeing that the photographer was on
the other side of the room taking photos of the baby and father, it is not
unfathomable that she could not have heard me say that the placenta was
delivered intact or she could have heard the doula state that she just needed a
piece for encapsulation per the client’s wishes. I am really not sure why the
photographer was even concerned with the placenta. She did not take any photos
of it. With the delivery of the placenta, the client lost about 500 cc of
blood, which is considered a sign of pending post-partum hemorrhage (PPH). This
potential PPH resolved with usual management and delivery of the placenta. I
did auscultate the baby several times after birth and after the newborn exam
because I was hearing some “junky” sounds, transient and not unusual in the
first few minutes of life, which is probably what the photographer overheard me
explaining to the parents, but as mentioned before, I do not converse about
vital signs with photographers or any laypersons at births, so misunderstanding
could occur since she was hearing this second-hand. Before leaving the birth,
while I was finishing charting, I asked the photographer if she had any questions
about the birth and explained that if she needed to process the birth, I would
be happy to discuss it with her at any time postpartum. She did not seem
uncomfortable at any time with the birth or postpartum period and stated she
had no questions. The photographer did not leave as soon as possible after
birth, she stayed almost 3 hours postpartum.
A local, Louisiana licensed
midwife, watched the birth video and agreed that she would have not done
anything differently during the labor or birth. She stated that my actions were
within the standard of care for midwives in Louisiana. Per the client’s written
birth plan, she desired a private, noninterventive birth alone with her
husband:
“Make yourself comfortable,
you are more than welcome to chill on the couch, play with my kids, read a
book, help yourselves to something in the kitchen. We are having a hypnobirth.
Please nobody talk to me during labor (with the exception of my husband), if
you need something, you are more than welcome to ask my husband. If I retreat
to my kid’s room this means I want to be alone. I’m fine with people observing
me in there, but I don’t want to know you are in the room. In other words,
don’t touch me, stand off to the corner, and shhh…”
The photographer spent much
of the labor in her car or on the couch in the living room away from the laboring
mother who spent most of her time in her kids’ bedroom. The photographer even
left the client’s house and went home for several hours during the labor. Because
I was not in the room the entire time with the client, per her wishes, I
observed as unobtrusively as possible and took vital signs as required to make
sure mother and baby were doing well, the photographer misconstrued this lack
of continual presence as lack of care. This could not be further from the
truth. During
labor, as evidenced by my chart and also as explained at the hearing by the
client’s husband who was nearby the client for nearly the entire labor, his
testimony included seeing me taking fetal heart tones with my Doppler and
taking vital signs (pulse, blood pressure, and temperature). Furthermore, Louisiana
midwifery regulations do not indicate how fetal heart tones are to be assessed.
I used my Doppler, palpation, and observational skills to assess FHT, demonstrating
that I was in compliance with rule 5355(B):
“Fetal
heart rate and rhythm shall be made at least every 30 minutes during first
stage, after each contraction in second stage and after rupture of membranes.
The duration, interval, and intensity of uterine contraction and material blood
pressure shall be recorded at least every hour and immediately after delivery.”
With descent especially
during crowning, fetal heart sounds are more difficult to follow with an
anterior placenta and posterior baby. Therefore, it is advantageous to use
other methods of determining fetal well-being; one of the most tangible and
easily monitored indications of fetal well-being is the fetal movement that
occurs between contractions. The mother felt this movement after the head was
born in between contractions. The mother did not indicate any fetal movement
during the contractions, nor did I feel or visually see any fetal movement during
contractions, suggestive of normal, healthy fetal behavior. According
to research, abnormal patterns in the second stage are only significant if
there were abnormal patterns in the first stage of labor (Sheiner et al.
2001; Loghis et al. 1997; Wu, Chen & Wang
1996). There were no abnormal patterns in first or
second stages; therefore I could remain assured that the FHT would remain
normal in the second stage and delivery. I attended to the condition of the
baby by auscultating the fetal heart rate with a Doppler equipped with a
display so that unnecessary sound was not heard (per the mother’s birth plan),
evaluating the scalp color, checking perfusion of the scalp, and assessing the
fetal heart rate by watching the anterior fontanelle. The color of the scalp is
a good gauge of fetal well-being and oxygenation. This is noted as pink to
pink-lavender. Blanching the caput on the scalp with color returning in no more
than three seconds is suggestive of good perfusion. An increasingly dark color
in a vertex presentation almost always indicates venous congestion in the
baby’s head from impaired blood return, which was not evident at any time in
this delivery. The father of the baby, who was with the client for nearly the
whole labor and delivery, testified to witnessing my fetal heart tones
assessment many times during labor. Therefore, despite the lack of video evidence
of a clinical fetal heart tone measurement with a Doppler, fetal heart tones
were being assessed via “special observational skills required for
out-of-hospital deliveries” as recognized as stated in Rule 5303(A)
(Skills), after the birth of the fetal head.
Crowning of the fetal head was normal-to-fast for an
occipital posterior (OP) baby, which is correlated to a longer, more painful
labor and birth. If crowning had taken longer, I would have noted this and
prepared for a complication like shoulder dystocia, but since the mother had a
normal (about an hour) second stage and crowning was just as efficient (within
2 contractions) I could safely conclude that the birth was at a low risk for a
shoulder dystocia. Plus, this client and her husband stated that their previous
baby (10 lb 14 oz unassisted birth) had been born the same direction (OP), with
the same physiological pause in the delivery, reconfirming once again that this
client’s proven pelvis could birth this OP baby.
Total time in labor was 10 hours
and 17 minutes, very normal for a third baby. Second stage was just over one
hour, well within the normal amount of time for a labor that was progressing
normally, not protracted in any way, physiologically unfolding as necessary
with a normal, adequate descent of the fetus, indicating a low risk for
shoulder dystocia. This baby had been in an occipital
posterior (OP) position for most of the client’s pregnancy probably associated
with the anteriorly-placed placenta. An OP position is not wrong or a problem,
it is a head-down position. It is not caused by anything the woman does or does
not do. Instead, it is a variation that occurs when a baby gets into the
‘optimal position’ for his journey through his mother’s unique body. Only 5% of
babies will be born in the OP position, which is important to note, as many
providers will have very limited experience with seeing an OP baby; therefore
they will not be able to accurately assess the situation or will incorrectly
compare the OP presentation to an occipital anterior (OA) position which occurs
in 95% of births. Because of the sacrum and pelvic floor, the OP baby usually
does not have the room to maintain as much flexion as the OA fetus. This
client’s fetal head was well-flexed and maintained it upon birth, further
indicating adequate room in the maternal pelvis. I assisted with maintaining
flexion by supporting the maternal tissues nearest the fetal forehead. After
the head was born, perfusion was maintained, the baby was not trying to breathe
(the baby was well oxygenated through the placenta), the water in the tub was
clear, no turtling sign was ever seen, no meconium or blood was evident,
indicating no shoulder dystocia or other complication. Using my hand, I ran my
fingers around the fetal neck to check for a nuchal cord, which was not
evident, and position of shoulders, which was transverse. I felt the top of the
shoulders perpendicular with the long axis of the head, a reliable indicator of
the location of the long axis of the shoulders (Frye, 2004). The neck did not
seem unduly stretched or twisted in any way, further confirming that this was
not a shoulder dystocia.
At this
time, the head was snug (not turtling) against the maternal tissues, and the fat
face was pink-to lavender. With the next contraction the head should externally
rotate, signaling that the shoulders have made their rotation preparing for
birth and the neck will appear. According to Frye, it is very important to give
the baby a chance to spontaneously rotate shoulders. Usually shoulders are born
in the next contraction, but if they are not, it is fine to have hands poised
but off the baby until the next contraction. Not providing support allows the
weight of the head to assist internal rotation and birth of the posterior
shoulder, especially when the mother is upright. Many providers manipulate the
head without regard to timing contractions, allowing little patience in waiting
for the uterus to assist in rotation of the shoulders or further descent of the
newborn. Sutton and Scott explain that an upright maternal position in
conjunction with the shoulders being born spontaneously, the need for
episiotomy and the rate of shoulder dystocia is rare, almost nonexistent
(1996). After the head is fully born, it is common practice to wait for the
next contraction for the shoulders to rotate.
Kotaska and
Campbell’s research found that “a belief that prolonged head-to-body
delivery interval endangers the newborn underpins the common obstetrical
practice of delivering the baby’s trunk immediately after the head is born.
Without intervention, however, birth typically occurs in two steps: once the
fetal head is delivered there is usually a pause, and the rest of the infant is
born with the next contraction. Allowing a two-step delivery does not increase
the risk of fetal harm, and may lower the incidence of shoulder dystocia. A
two-step approach to delivery should be considered physiologically normal. This
has implications for the definition of shoulder dystocia” (2014).
Snug shoulders are often given the misnomer “mild” shoulder dystocia and
most likely do not meet the definition of the impingement (or impaction) of the
anterior shoulder or both shoulders above the pelvic brim. Snug shoulders can
occur with a large baby, an adequately shaped pelvis, and a somewhat obese
mother, which together comprise a soft tissue dystocia. The head is born very
slowly but the midwife does not need to push the perineum back manually in
order for the head to be born. The baby’s face is fat but the baby does not really
exhibit the turtle sign as the head goes through both restitution and external
rotation. The shoulders are tight and take more effort to deliver, but making
sure the shoulders are in the oblique diameter of the pelvis, a little
suprapubic pressure, and an exaggerated lithotomy position readily take care of
the problem, as does having the mother get into the hands-knees position
(Varney, p. 884). The incidence of shoulder dystocia is generally reported as
less than 1 percent. According to Varney’s Midwifery, shoulder dystocia may
occur from 0.2 to 2 percent of vaginal cephalic deliveries, yet an accurate
figure probably does not exist due to problems with accurately establishing the
incidence of shoulder dystocia. The textbook also notes that defining shoulder
dystocia is critical to determining what steps to take to resolve it. The basic
and anatomically correct definition of shoulder dystocia refers to cephalic
presentations in which the anterior shoulder is wedged above the symphysis
pubis instead of entering the true pelvis; however, in the clinical setting,
the diagnosis is subjective and based retrospectively on observation (Varney,
p. 883).
The Unnecessarian states that the following quote is from page 140 of Munro-Kerr’s
Operative Obstetrics (2007) by Baskett, et. al.:
“Unfortunately, attempts to find factors that will accurately predict
shoulder dystocia and allow a practical prevention strategy have been
unsuccessful. Most of the antepartum risk factors have fetal macrosomia as the
underlying theme. Many of these risk factors are common, while the condition
they predict, shoulder dystocia, is not. Furthermore, the risk of serious fetal
injury associated with shoulder dystocia is rare. The hope that ultrasound
prediction of fetal weight and more detailed ultrasound measurements such as
shoulder width would provide an accurate level of risk have been unfilled.
Indeed, for the macrosomic fetus, clinical estimation of fetal weight is as
accurate as that predicted by ultrasound. Even if one could predict fetal
macrosomia accurately, it would be of limited value. About 95% of infants
weighing over 4000 grams will not have shoulder dystocia. It has been suggested
that elective caesarean for fetuses weighing more than 4500 grams would reduce
shoulder dystocia and fetal injury. A decision analysis model has shown that
this strategy would be both clinically and cost ineffective; it was estimated
that to prevent one permanent brachial plexus injury 3695 caesarean sections
would be required. Furthermore, the majority of cases of shoulder dystocia
occur at fetal weight less than 4500 grams. Thus, both the antepartum and
intrapartum risk factors lack sensitivity and specificity. Having said that,
there are individual cases with cumulative risk factors such as maternal
diabetes and estimated fetal weight > 4250 grams which may be best delivered
by caesarean section. A combination of factors such as clinical fetal
macrosomia with a protracted late first stage of labor and slow descent in the
second stage requiring assisted mid-pelvic delivery may dictate that caesarean
delivery would be more prudent.”
Because shoulder dystocia involves both the size of the baby and the size
and shape of the mother’s pelvis, it is important that the clinician determine
that the mother’s pelvis is adequate to deliver a healthy baby. In addition to performing pelvimetry during
pregnancy to determine that the mother’s pelvic architecture would accommodate
a good sized baby, I knew that this client’s pelvis had been proven adequate
for a large size baby in her previous delivery.
However, having not known the baby’s true weight, it is impossible for me or
any other provider to have an exact assessment using fetal weight in managing
this delivery. It is not illegal nor against regulations to attend or deliver a
macrosomic baby at a home birth. Furthermore, the allegation that this mother
had a true shoulder dystocia for her second birth is unfounded. The mother has
no medical background and reported “an approximate two-minute shoulder dystocia”
with the birth of her second child that resolved after she stood up. However,
both physicians noted in their medical charts that this client had a “NSVD” for
the birth of this baby because, according to most definitions of shoulder
dystocia, it cannot be resolved without maneuvers and assistance, none of which
this mother could perform on herself during delivery. Therefore, I concluded
that while the mother may have perceived her second birth as a shoulder
dystocia, it was another anomaly due to the OP position of that baby. Coupled
with no other injury or complications, there was no justification for induction
or cesarean.
The Unnecessarian also refers to the
obstetrics textbook, Munro Kerr’s Operative Obstetrics (2007) by
Baskett, et. al., which states the following on pages 139-40:
The rate of repeat shoulder dystocia
in a subsequent vaginal delivery has been reviewed in six series and the risk
of recurrence ranges from 1.1% to 16.7%. The average recurrence rate was relatively low at 10.1%. However,
in a case with previous shoulder dystocia and brachial plexus injury or other
complication, caesarean section could be justified in the next pregnancy. Six
studies were reviewed with a combined total of 2054 subjects. Data was
collected between 1980 and 1999.
SD (shoulder dystocia) is an unpredictable high-stress
medical situation for which there is no uniformly helpful protocol. In
addition, some doctors define SD’s occurrence when basic maneuvers are
required; others call it SD when more difficult measures are required. All
doctors frequently encounter these situations so strict definitions are somewhat
arbitrary. Most doctors have encountered many a case of significant shoulder
dystocia where there are absolutely no risk factors. There are various guidelines
for handling such deliveries well-known to the practicing doctors including
ACOG educational bulletins on the subject. Despite studies dating back over
thirty years that attempted to define reliable predictors of SD, there are no
management protocols that, if followed, will consistently prevent SD-related
brachial plexus injury. For example, the most recent ACOG practice bulletin
states, “shoulder dystocia is most often unpredictable and unpreventable…. In
each case, risk factors can be identified, but their predictive value is not
high enough to be useful in a clinical setting.”
After
the head emerged, I looked at my wristwatch and announced the time. It was
almost exactly two minutes later when the mother had her next contraction, not
an uncommonly long wait for a normal physiological delay and not a diagnosis
for shoulder dystocia. As we waited for the next contraction, the mother could
feel the baby rotating and gathered her strength to push the baby out. We
discussed changing positions, but the mother was comfortable in a semi-sitting
position in the birth tub as she desired a water birth. However, after the next
contraction and the weak pushing efforts of the mother, the fetal head did not
move indicating that assistance was needed. I immediately assisted the mother
into a squatting position, where I continued to assess the position of the
fetus and encourage the mother to push, but she was no longer having a
contraction. I could feel that after the mother got into the squat position,
her baby’s head was wiggling as restitution occurred. Likewise I could feel
that the shoulders had rotated to an oblique position and descended further
into the introitus. “However, not every persistently posterior labor follows
this pattern, and the etiology of persistent posterior positioning and rotation
remains not fully understood” (Frye, 2004). I asked the mother to get out of
the tub and she stood up and continued to attempt to push. The shoulders should
normally emerge spontaneously, but with the OP position of the baby, the
mother’s weak pushing efforts, and tight perineal muscles I needed to check
again for a tight cord or a nuchal hand that could be hindering emergence. Often
mistaken for shoulder dystocia are snug shoulders. Sometimes the descent of a
big baby will be delayed as it squeezes through the healthy, well-padded soft
tissue of the birth canal. This can, at first, appear to be a bigger problem
when it occurs before the shoulder emerges, namely bone-on-bone dystocia. The
suction must be broken to advance the baby (Frye, 2004). Additionally,
I also palpated the mother’s abdomen above the pubic bone to determine if I
could feel a shoulder lodged behind the pubic bone, which I could not feel,
because it was not a shoulder dystocia. As the client stood in the tub, it was
determined by palpation that neither a tight cord around the neck nor a
compound presentation was evident, therefore I decided that more guidance was
necessary to effect birth, but that this needed to be accomplished outside the
birth tub.
Again, I
asked the mother to remove herself from the tub and I assisted her safely out
into a standing position facing the tub. By both sight and touch I could determine
that the shoulders were snuggly waiting just inside the introitus. The mother
was upright and did not reach to assist the birth herself, therefore I reached
around the back of the mother and with my left hand I formed a collar for the
baby’s neck by holding the fingers of my left hand in the shape of a “C” and
poised that palm at the back of the baby’s neck. I was prepared to apply my
palm to the upper back and support the shoulders with my fingers as they
emerged, directing support against the back and shoulders, rather than to the
side of the neck. No excess force or traction was applied to the head; at no
point did I shake the fetal head from side to side as it was alleged.
A
woman’s body is physiologically incapable of opening and allowing a baby
through unless she gives in to the process, releases and lets go.
Unfortunately, anytime the laboring women tenses or tightens in response to
fear, pain, or anxiety, the uterine muscles also tighten, making the
contractions less effective, inducing more pain, and slowing down the entire
process. The state’s expert witness (a non-practicing obstetrician) stated that
after watching this birth, she concluded that it was “traumatic” even though
she was not even present for the birth. Hearing a woman vocalizing as a natural
coping mechanism for labor can be unsettling to practitioners whose patients
typically labor with epidurals. Midwives who attend unmedicated births in homes
and birth centers are used to the noises women make in advanced labor. Because
physicians, like the expert witness, have never seen a home birth, a water
birth, or an OP birth without medications, it is easy to assume that the
experience would be traumatic, if screaming was ensuing. However, as stated
earlier, OP babies are notoriously more painful than an OA delivery, and this
baby’s size was bigger than most, making it more challenging than a typical
birth. The mother and father did not think the birth was traumatic in the
slightest bit. With the combination of the large part of the fetal head causing
a great stretching and tension on the perineum, and a mother, who was visibly tense and
unable to mentally assist in her pushing efforts, I used an indigenous
technique utilized by midwives all over the world to assist in the birth called
“shaking the apple tree” (Gaskin, 2012). This is also known in birth ritual
circles and belly dancers as shimmying and has been used for centuries in
helping babies descend in labor. I applied this technique by placing my hands
on the backs of the client’s thighs just under the buttocks and vibrated in a
gentle, rhythmic fashion until the fetal body emerged. This technique releases the
maternal tissues helping to relax the pelvic floor, the buttocks, and the thigh
muscles to encourage spontaneous delivery. Feeling that the perineum was taut
and knowing that there is no consistent evidence that
an episiotomy is needed in this scenario (although it can help in certain
situations), I chose not to perform an episiotomy as it was felt that the patient’s
body habitus would negate the effectiveness of an episiotomy and more time
would have been spent moving the mother into position to perform this procedure
because I was being
cognizant of the time that elapsed, so that the continuation of appropriate and
coordinated maneuvers could be ensured. The
head-to-body delivery time was about 4 minutes and 20 seconds (well within a
safe timeframe for a baby to be born), based on the time I looked at my watch
after the head was born until the sound of the amniotic fluid splashing on the
floor after the baby was born.
Similarly, in a study of over 8000 births,
Stallings et al. observed no correlation between head-to-body delivery interval
and cord pH in 134 cases of shoulder dystocia. Among
cases lasting three minutes or more, the mean pH was 7.26; the pH remained
normal when two or more maneuvers were required and when neonatal brachial
plexus injury occurred. “The implication of these findings is that a ‘rush’ or
‘crash’ delivery of the fetus with shoulder dystocia is unnecessary.” Once
delivered, the fetal head is exposed to atmospheric pressure. While the uterus
is flaccid and the mother is not pushing, intrauterine pressure is 10 to 15mmHg
above atmospheric, allowing venous return from the fetal head to the fetal
thorax. With a contraction, intrauterine pressure rises to 60 to 80mmHg and
with maternal effort, to more than 100 mmHg above atmospheric. At this
pressure, venous blood cannot return from the fetal head to thorax, and cerebral
perfusion ceases. Local brain hypoxia and metabolic acidemia can occur rapidly,
even though circulation and oxygenation of the rest of the body remains normal.
During shoulder dystocia, then, limiting maternal pushing efforts between
contractions (while maneuvers are performed) preserves cerebral perfusion as
much as possible.
By inference, a prolonged
head-to-body delivery interval without uterine
contraction or maternal pushing effort is not harmful to the fetus. In cases of
shoulder dystocia, the risk of HIE increases as the head-to body delivery
interval increases beyond five minutes; however, the uterine contractions and
maternal Valsalva efforts during this interval impair fetal cerebral
circulation. In a two-step approach to delivery, we conclude that a
head-to-body delivery interval of up to four minutes between contractions is
common, is safe, and may reduce the incidence of shoulder dystocia. After
delivery of the head, it would seem that shoulder dystocia should be diagnosed
only if delivery of the shoulders does not occur with maternal pushing efforts
(and possibly gentle traction) that accompany the next contraction.”
Because the mother’s pushing efforts
were not effective and gentle traction was not being used, I concluded that a
physiologically normal delay was occurring. While I was remaining cognizant of
the time of the head-to-body delivery interval (HBDI), it is of importance to
note that it is generally agreed that delivery within 4-5 minutes is safe as
concluded in a retrospective study by Leung, T et al. that Cord arterial pH
drops with HBDI during shoulder dystocia, but the risk of acidosis or hypoxic ischemic
encephalopathy (HIE) is very low with HBDI < 5 minutes. (2011)
Although the charges state that
“clear video evidence exists,” the birth of the baby is not visible on the
video. Therefore, it is impossible to prove that I “shook the baby’s head in a
side-to-side motion” and that I “dropped the baby on the floor,” neither of
which I did. Babies experiencing a shoulder dystocia do not just fall out
unless specific maneuvers are performed—none of which I did because it was not
a shoulder dystocia. While yes, the baby did shimmy out, which could appear
like the head may be shaking, instead I was stabilizing the head while I
assisted in the delivery. No harm was done to either the mom or baby. There is
no brachial plexus injury. Again, while no video evidence exists of me
“dropping the baby on the floor,” it was all other witness’ perspectives that I
placed the baby on a towel on the floor, which is precisely what happened after
the vaginal delivery of this constitutionally large
infant weighing 11 lbs 5 oz, with an intact cord. While I did check for a
nuchal cord, usually variable heart rate decelerations during labor would have
alerted me to the possibility of a nuchal cord. Since variable decels in labor
did not occur, I could assume that a nuchal cord was not present. However,
after delivery, I gently laid the baby on a towel on the floor so that I could
unwrap a cord that was around her left arm. The cord was long enough to do this
safely. I assessed the baby and vigorously stimulated by flicking the soles of
the feet and patting the baby’s back.
At first it was difficult to tell the color of the
baby as so much vernix was present, but after removing it, I could see the
baby’s skin color was pink indicating excellent perfusion. I cleared the nose
and mouth using a blue bulb syringe and towel. I both felt the base of the
umbilical cord and used the Doppler to get a fetal heart rate, which was always
in normal range (above 120 beats per minute). Baby’s breathing was transitioning
normally and adequately as evidenced by the lack of grunting, no retractions,
no flaring nostrils. However, I did hear adventitious sounds. In adults,
adventitious sounds are abnormal. However, in newborns, these are normal and
referred to as “junky” sounds in midwifery vernacular and may indicate a
problem but are most often due to unabsorbed fetal lung fluid. When present,
these are heard right after birth and require observation along with other
signs that indicate absence of problems, and will become increasingly less
obvious by the newborn exam. I differentiated between a pathological crackle by
auscultating the lung fields as I moved up the respiratory system and observing
the baby establishing normal respirations. The crackles originated in the upper
airway indicating normal sounds which would be cleared with breastfeeding and
time. The newborn’s Apgar scores were 8 and 9, at the one-minute and
five-minute time point, respectively, which indicates a healthy newborn who is
successfully transitioning to extrauterine life; a five minute APGAR score of 7
or above is considered normal. Frye also notes that there may be some crackling
sounds from residual lung fluid on auscultation of the lung field. Crackles may
be noted interspersed with periods of apnea, usually lasting ten seconds or
less each. Normal babies whose cords are still intact may take the first 30-90
seconds of life to fully transition with nearly all healthy babies breathing
within 3 minutes. The intact cord continues to oxygenate the baby from the
placenta while the baby transitions normally, and when the baby is breathing
effectively the Wharton’s Jelly will form in the cord and slow the blood flow,
signaling the baby is successfully transitioning from fetal to neonatal
circulation. Lung sounds may not completely clear for 60 minutes.
According to Frye, tone varies at birth as did in
this situation and crying was not evident right away, but again, homeborn
babies frequently do not cry at birth because of the gentle handling, and lack
of crying is not necessarily indicative of a problem. Because I knew my
assistant was not well-versed in neonatal resuscitation protocol, I chose to
err on the side of caution and activate EMS after the mother turned around and
asked what happened and what was wrong. Because
I believe that the baby’s well-being is directly related to that of
the mother and the mother has a strong intuitive link with her baby as to how
the baby is doing during labor, I listen to mothers. This additional way of
assessing fetal well-being is especially helpful if there is a good indication
that all is well. If the mother is not certain or clearly states that the baby
is in trouble, it is important to heed this concern, regardless of what
clinical signs indicate. After asking the photographer to activate 911, I continued
to stimulate and assess the baby for about 30 seconds. I also discussed the
mother’s concerns which were not clinically relevant to her newborn’s
condition. Therefore, because the heart rate was normal, amniotic fluid was
clear, baby was term, and respirations were established, it is within standard
of care, according to Neonatal Resuscitation Program guidelines to keep baby
warm, dry and stimulate, clear the airway, and continue assessing heart rate,
color, and breathing—all of which I accomplished. PPV or any other
“resuscitation” was not indicated on a baby who was transitioning normally to
extrauterine life but just needed more time. It was at that time, with the
mother’s input, that I felt the baby was adequately transitioning and the call
to 911 could be discontinued. The newborn’s APGAR scores were 8 and 9 for one
and five minutes respectively. The client asked to get back in the tub after
the birth because she wanted to sit and breastfeed her baby, which she did
within a few minutes of birth, further underlying the normal, healthy
transition this newborn made. Since the client’s skin was pink, soft, warm, and dry, her respirations were
normal (12-15 rpm) and her pulse was around 80 bpm, this indicated a normal
postpartum transition. Mother and baby were not separated as protocols for
delayed cord clamping were followed and baby breastfed successfully within the
first few minutes after birth. There were no allegations of harm to the mother
or newborn; the mother and baby are doing well, the baby is meeting all
milestones and growing appropriately with no signs or evidence of brachial
plexus injury.
Following
the newborn exam, I continued to assess the baby as needed, ensuring that the
baby was stable as evidenced by established respirations, normal temperature,
and strong sucking (LA RS 5327(A)). The newborn never exhibited any signs of
respiratory distress. No retractions or nasal flaring were seen. No grunting or
shallow, rapid breathing was evidenced. The baby remained pink. Temperature
remained within normal limits. The baby breastfed well during the immediate
postpartum period. The client was informed, per Louisiana regulations, to
contact their pediatrician or family doctor. This client routinely visited a
chiropractor for her and her family’s care and exercised her right to visit
this practitioner at 48 hours postpartum. Furthermore, my birth written summary
and availability for consult was also in compliance with the rule 5357(E) and
5343(A), respectively:
“The midwife shall
recommend that the parents immediately contact the pediatrician or family
doctor who will be assuming care for the infant to arrange for a neonatal
examination. The midwife shall provide the doctor with her written summary of
labor, delivery, and assessment of the newborn and shall be available to
consult with the doctor concerning the infant’s condition.”
“The licensed
midwife practitioner must recommend that any infant delivered by the midwife be
evaluated by a physician within three days of age or sooner if it becomes apparent
that the newborn needs medical attention for problems of, but not limited to,
congenital anomalies.”
According to the regulations, I am
required to leave a summary of the labor, delivery, and assessment of the
newborn, of which I did. The forms entitled newborn assessment and newborn
examination were not exact duplicates, and I did not testify to making copies,
but rather transcribing one page to another. The Immediate Newborn Assessment
left with the parents did include the words: “Dystocia and PPH” next to
complications. I did see a delay in the birth of the newborn, and not a
shoulder dystocia, therefore, I indicated it as such. Likewise, as the placenta
was delivered, the client lost about 500 cc of blood, which is considered a
PPH. The PPH resolved upon management and delivery of the placenta. After the
initial newborn examination, I did notice some of the information on the form was
transcribed incorrectly by an assistant and the newborn needed further
assessment as evidenced by crackles heard in the upper respiratory tract. As
testified by the photographer and client’s husband, I transcribed the newborn
assessment form and newborn exam to another form while at the client’s home,
before leaving. These forms, while not identical, were not required by law to
be replicas nor were they significantly different. I followed the rule 5347(D)
pertaining to record keeping and report requirements that states that a summary
shall be prepared for dissemination to fellow healthcare providers upon
request.
“The attending midwife shall prepare a summary, of labor,
delivery, and assessment of the newborn using the Hollister form, or an
alternate form containing substantially similar information. One copy of each
summary shall be retained with the client’s chart and one copy transmitted to
the pediatrician or family doctor.”
Because the newborn weighed more
than 9 pounds, I obtained consultation from a CPM/LM and referred the newborn
to medical care during the postpartum period per regulation 5363(D8):
“The midwife shall obtain medical consultation or refer for
medical care any infant who: weighs more than 9 pounds or 4,100 grams.”
As part of a mother’s
routine postpartum physical, the mother, through the hemoglobin A1C of 5.3% and
a fasting blood glucose of 89 mg/dL, was determined not to have diabetes. The
hemoglobin A1C test measures glycated hemoglobin, a
form of hemoglobin that identifies the average plasma glucose concentration
over the previous 3 months prior to the test.
At around 2.5 months postpartum, when the client and
her newborn were well outside of my legal care, the client chose to make an
appointment with a pediatrician concerning her newborn’s weight gain and tongue
tie. The pediatrician did not request this client’s medical records from me
rather the client brought in her birth summary.
References:
http://www.ACOG.org
Baskett TF.
Shoulder dystocia. Best Pract Res Clin Obstet Gynaecol. 2002 Feb;16(1):57-68.
Boyd ME, Usher RH, and McLean FH. Fetal
macrosomia: prediction, risks, proposed management. OBSTET GYNECOL 1983;61(6):715-722.
Buckley, S. J. (2008). ‘Gestational Diabetes Testing’.
In Gentle Birth, Gentle Mothering: A Doctor’s Guide to Natural Childbirth and
Gentle Early Parenting Choices.
Buhling KJ, Elze L, Henrich W, et al; The usefulness
of glycosuria and the influence of maternal blood pressure in screening for
gestational diabetes. Eur J Obstet Gynecol Reprod Biol. 2004 Apr
15;113(2):145-8
British Medical Association. The
Royal Pharmaceutical Society of Great Britain. British National Formulary,
Number 61. 2011.
Cochrane
Review Screening
for gestational diabetes and subsequent management for improving maternal and
infant health. 11 February 2014
Combs CA. Singh NB, and Khoury JC. Elective
induction versus spontaneous labor after sonographic diagnosis of fetal
macrosomia. OBSTET GYNECOL 1993;81(4):492-496.
Farrell
M. Improving the care of women with gestational
diabetes. MCN
Am J Matern Child Nurs. 2003
Sep-Oct;28(5):301-5.
Flannelly G, Simm A. A study of
delivery following shoulder dystocia. British Congress of Obstetrics and
Gynaecology, Dublin 4-7 July 1995. Abstract 516. London: Royal College of
Obstetricians and Gynaecologists.
Frye, Anne. Holistic Midwifery:
Volume II Care During Labor and Birth. (2004).
Garrison A. Screening, diagnosis, and management of
gestational diabetes mellitus. Am Fam Physician. 2015 Apr 1;91(7):460-7.
Gaskin, Ina May. Spiritual Midwifery
(2012).
Ginsberg NA, Moisidis C. How to predict recurrent shoulder dystocia. Am J Obstet
Gynecol. 2001 Jun;184(7):1427-9; discussion 1429-30.
Goer, H. OBSTETRIC MYTHS VERSUS
RESEARCH REALITIES: A GUIDE TO THE MEDICAL LITERATURE. Westport: Bergin and
Garvey, 1995.
Hod M. et al. Gestational
diabetes mellitus: a survey of perinatal complications in the 1980’s. DIABETES 1991;40(Suppl 2):74-78.
Kotaska
A, Campbell
K. Two-step delivery may avoid shoulder dystocia:
head-to-body delivery interval is less important than we think. J
Obstet Gynaecol Can. 2014 Aug;36(8):716-20.
Leung
TY1, Stuart
O, Sahota
DS, Suen
SS, Lau
TK, Lao
TT. Head-to-body delivery interval and risk of fetal
acidosis and hypoxic ischaemic encephalopathy in shoulder dystocia: a
retrospective review. BJOG. 2011 Mar;118(4):474-9. doi:
10.1111/j.1471-0528.2010.02834.x. Epub 2010 Dec 24.
Lewis DF, Raymond RC, Perkins MB, Brooks GG, Heymann
AR. Recurrence rate of shoulder
dystocia. Am J Obstet Gynecol. 1995 May;172(5):1369-71.
Olugbile A, Mascarenhas L. Review of shoulder dystocia at the Birmingham Women’s
Hospital. J Obstet Gynaecol. 2000 May;20(3):267-70.
Santini DL. and Ales KL. The
impact of universal screening for gestational glucose intolerance on outcome of
pregnancy. SURG GYNECOL OBSTET
1990;170(5):427-436.
Smith RB, Lane C, Pearson JF. Shoulder dystocia: what happens at the next delivery? Br J
Obstet Gynaecol. 1994 Aug;101(8):713-5.
www. Unnecessarian.com
Varney, Helen. Varney’s Midwifery.
(2003)
Williams, D and John
Davison. Chronic kidney disease in pregnancy.
BMJ. 2008 Jan 26; 336(7637): 211–215.
WHO. Optimal
timing of cord clamping for the prevention of iron deficiency anaemia in infants.
January, 20, 2015