Birthing centers and meconium aspiration, being honest about natural birthing

I am, or was, planning tentatively on using a birthing center to deliver.  However, a very close friend just lost her baby to meconium aspiration after 36 hours of labor at a birthing center.  She was sent to the adjacent hospital, where after monitoring, the doctor on call immediately did a C section.  It was too late.  She cannot shake the feeling she tried, stupidly, to be a hero and go through with the natural birth even after it got tough after the first 12 hours.  I can't help but wonder the same thing.

I am well aware of data on the rise of unnecessary medical interventions and have been of the mind set for a long time to go natural with a midwife.  Quite frankly, now I feel like my friend's terrible experience may signal that the pendulum has swung too far for women interested in a more natural approach.  Are they expected to be heroes?  Maybe not explicitly, but the rhetoric sometimes makes it seem that way.  It is difficult to get accurate information from traditional medicine since they clearly are partially driven by the insurance/administration to protect their own interests, but honestly I feel like it is just as difficult to get accurate information on risks of natural with little intervention, whether at home or a birthing center.  This side, too, has its own interests to protect and many on this side, understandably, also don't like to admit they're not always right.

I'm reaching out to get more information from those who are trained to assist in natural births for risks and guidelines for when it's not always a great idea or how to recognize when it's not in the cards for me.  To repeat, ideologically, I'm on your side.  But to watch my friend go through losing her baby, I need more information other than "it's better to go natural and doctors usually recommend too much intervention that can be dangerous for mother and baby".  Clearly, natural can be dangerous too and there are drawbacks to both options.  Let's talk about it, please.


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Dear Tina, I can tell you are very affected by and grieving along with your friend. Of course you will be worried! We all worry no matter which decision we make in the end. If you are interested, I found a good layperson's article about meconium aspiration that answered some of the questions I had: http://kidshealth.org/parent/medical/lungs/meconium.html#

In my mind, a birth center is really just an extension of the hospital with slightly different protocols. They are usually physically very near each other, and cooperate very quickly in emergencies. The midwives are usually CNM's who are are in every way part of the "establishment" and can call on doctors if there is any concern. It's really a nice option for a healthy birth with quick emergency response, other than missing the peace and comfort of home and the independence and flexibility of homebirth midwifery. In most cases, your friend and her baby should have been just as safe there as in the hospital - probably safer due to lack of interventions.

In your estimation, what are you worried was lacking in the birth center? Do you think they let her labor too long, do you think maybe the baby wasn't monitored closely enough, were certain warning signs ignored? Since the meconium was apparently inhaled before or during labor, is there a way they could have known about the severity of the problem that was somehow missed? I just wonder if you are thinking that the baby's passing would have been preventable, perhaps by routinely sectioning it after 24 hours or less in a typical hospital birth? Or maybe there was a second concurrent problem that hasn't been reported yet.

Knowing nothing about this incident, I just wonder if perhaps it was such a severe case that it might have had the same outcome in any environment. There is no way I can guess. Like you said, you know the statistics about the health and safety of hospital, birth center, and home births. It is horrible when the worst happens anywhere, but it is also very sad when interventions actually cause these problems (not apparently the case here.)

Hugs to you and best of luck with your very tough decisions!

Shari
We have a great birth center here in Oregon (about 10 minutes from the hospitals). The midwives are open and honest about their record, and recently, when I was 7 months pregnant, they told me about another woman who just lost her baby in their birth center. They said they wanted all of their clients to know, and make their own choices about where to give birth. I am on my third birth with them, and I so appreciate their considerate honesty. The hospital here has lost several babies during my pregnancy, and yet will not talk about it for fear of lawyers and privacy violations. The risk of giving birth is, for me, much higher in the hospital, and not in the birth centers or homes, but I understand what you are talking about. I really wish there was a guarantee that if the mom picked one or the other she would have a 100 percent chance of no complications and a healthy birth, but....ah, such is this earth life. Sadly. I wish I could pray with your friend, and do her laundry or something. What a horrible, horrible thing to happen. And especially after all the months of pregnancy, and 36 hours of labor! I am just glad she has you to listen to her, and mourn with her.
Tina I am so sorry to hear about your friend's loss. It is difficult to assess what went wrong without more specific details. When a labor continues for 36 hours it is important for the woman to stay hydrated. If she is not able to take in enough oral fluids, intravenous fluids are helpful. (When a woman is dehydrated her contractions are less effective.) Intermittent monitoring can pick up baby stress--a skillful attendant will observe carefully and intervene when appropriate. When labor exceeds 24 hours the laboring woman and her attendant should begin to discuss transfer to the hospital.

As a labor/delivery nurse I will say that babies born vaginally expel amniotic fluid, mucous and/or meconium because of the squeezing action of moving down the vaginal passageway. They are often vigorous even though there was meconium in the amniotic fluid. Babies born by c-section have difficulty expelling mucous and fluids they swallow during the surgical birth.

As a nurse that has worked in the homebirth setting and the hospital, I would like to see more communication between the 2 approaches to birth. Each approach has something to offer the other. Homebirth practitioners need to be very observant and have access to timely hospital transfer.br /> br/>
I hope this helpful, Tina.
I recently saw a story about a woman who gave birth in the hospital and died during the birth. The cause was an amniotic embolis. Tragic. I know a woman who was PG at the same time I was. She went to the hospital to give birth. Sometime during the final stages of her labor, her placenta abrupted. She was being monitored by all the high tech equiptment available and they rushed her in for an immediate c/sec. However, it was too late. The baby died from lack of oxygen. The mother required a transfusion and almost died herself. Unfortunately, sadly some women and/or babies will die during either Pregnancy or Childbirth.

Even with all of our modern technology and medical advances we have yet to be able to completely eliminate the risks to the mother or baby during PG & childbirth. A mother has a 1/10000 (1/2500 w/a c/sec) chance of dying during birth. The baby has about a 4/1000 chance of dying. All studies show that the maternal and neonatal mortality rate is the same with Hospital Births as it is with Out of Hospital/Home Births. Meaning that neither mother or baby is less likely to die in a hospital. However, other complications to the mother and baby, from ioogenic causes and risks incurred with several interventions are more likely in a hospital. If the mortality rates are the same but risks of complications are lower without the interventions, and giving birth outside of the hospital reduces your chances of interventions--purely spoeaking by the numbers--an out of hospital birth still carries the lowest combined risk for mother and baby. Not no risk--just lower.

If we could give birth in a hospital with all the technological bells and whistles and get a guarantee that no babies would die we would all be lining up outside the hospital to give birth. Unfortunately, that is just not the case. Babies die in the hospital too. By the same causes that some die in out of hospital deliveries. Your friends baby, statistically speaking, had the same risks of dying regardless of where the birth took place. Babies die in the hospital from the same thing your friends baby died from, and that may have been the case for her, regardless of where she was born (babies actually die more often from that specific cause in the hospital because the use of pitocin & other interventions) often stresses the baby which is the leading cause of passing meconium in utero).

When it comes to monitoring and assessing risk, there are no guarantees. Midwife or OB. In the hospital or out of the hospital. Sometimes things happen that the baby doesn't survive and no amount of risk assessment, interventions or MW/doctor's skill changes it. I don't mean to sound callous and my heart breaks for your friend and for the added stress/anxiety it causes to know someone who lost a baby when you are expecting one yourself. But sadly, PG & birth aren't without risks to the mother or baby, and in that respect, you have to assess the risks based on the numbers--which show that overall a hospital based birth with a skilled is not safer than a out of hospital birth for normal uncomplicated deliveries--and hope for a good outcome.
Sure, babies and moms still die, but the rate is very low nowadays. And hospital birth IS safer than home birth- HB is 2x more dangerous with a CNm and 3x more with a CPM/DEM.

In Colorado, the CPM HB mortality rates are super high, and this is using THEIR OWN STATS!
http://www.dora.state.co.us/midwives/Newsletter2010.pdf
Their mortality rate for 2009 was 11.3!!!!
http://4.bp.blogspot.com/_TBIyP9vftYk/TLXzuuCG2hI/AAAAAAAAAck/wuSWm...

Even in the Netherlands where Mws are well trained and transport is in place, midwifes with LOW risk women have worse outcomes and more deaths than OBs HIGH risk patients. 65% of those MW deaths are HBs! This paper was JUST published in November so I can see why no one is familiar with it yet.

That said, the risk is STILL low overall. But it's important to realize that home birth will never be as safe just because of the delay in an emergency.
If this is the Wax paper you are referring to, and I am sure it is, it has some very significant flaws in methodology. For one, it includes UNPLANNED HB in its statistics which skews the numbers dramatically. Check out the CDC Wonder website. Play with it, put in the different providers and places of birth...then see for yourself that, regardless of the spin put on HB in the media and by the ACOG, in low risk pregnancies CNM in home or out of hospital births have the best outcomes--better than OBs in the hospital, even when you remove the high risk patients from the data set. Lots of people know about the paper, but most have dismissed it as invalid/inaccurate due to its flawed methodology. Google "wax paper homebirth" and do a little reading on the topic specifically on the flaws in their methodology. Look up and read other, more reliable studies done, which show a very different result. Are you familiar with the Cochrane Collboration? See what they have to say about planned HB v Hospital birth http://www2.cochrane.org/reviews/en/ab000352.html

As for maternal and neonatal mortality, the risk, sadly is not a low as most would like to believe. In America, our maternal mortality rate is going up and is higher now than it was 20 years ago. By almost double. 2 women die every day in America from complications of pregnancy/birth. In addition to the women that DO die, in 2004-05 nearly 70,000 women almost died from pregnancy/birth and 1.7 million every year suffer complications that affect their health. We rank 40th overall in Maternal mortality even though we spend over $86 Billion dollars a year on medical coverage for pregnancy and birth, more than any other country.

You mentioned the Netherlands...you realize they have a lower maternal and neonatal mortality rate than we do? That your chance of dying during PG or birth is more than double in America than in the Netherlands? Even though most women don't deliver in a hospital but instead at home or in a birthing center.

Amnesty International considers our maternal mortality rate to be so bad they have delared it a violation of human rights. Check out this link and do some reading. I think you will find that the relatively "low overall" risk is actually not as low as the media and the ACOG would have us believe. http://www.amnestyusa.org/dignity/pdf/DeadlyDelivery.pdf

Check out these links for more info and rankings by country on maternal and neonatal mortality.
http://whqlibdoc.who.int/publications/2007/9789241596213_eng.pdf
http://www.who.int/whosis/whostat/EN_WHS10_Part2.pdf
http://www.who.int/healthinfo/statistics/mortality_neonatal/en/inde...

As for the delay in case of an emergency...do you know what they mean when they say "decision to incision" time? Depending on the time of day and the size of the hospital it may be as long as 1 hour, but averages about 30-40 minutes. In the case of a TRUE emergency w/the baby they have about 4 minutes to get the baby out before hypoxia sets in. NO hospital has a decision to incision time of 4 minutes. So, while many HB opponents use this argument it is really irrelevant. This is why some babies don't survive. Things happen that no amount of drs or technology or medicine can prevent/fix. If a MW is well trained and the hospital is a reasonable distance she can recognize a problem, alert the hospital, and get the woman to the hospital and into the operating room within the same time frame of that hospital's decision to incision time. Add this to the fact that many of the "emergencies" that occur during normal labor/delivery are a result of the interventions that occur at the hospital and you will find, as all reliable studies have shown, that in low risk pregnancies, planned HB is just as safe as hospital birth, with a much lower incidence of interventions and c/sec.

I looked at your links and the info on the second link doesn't match what is reported on the first. The numbers they reported were quite high but I am impressed that they list them. Never see a OB or a hospital tell you in a newsletter how many babies have died in their care. And those numbers don't necessarily apply to all states or all HB stats. A six-year study done by the Texas Department of Health showed that the perinatal mortality rate for CNM in HB was 1 per 1,000,
non-nurse midwives was 1.9 per 1,000, and doctors' rate in a hospital was 5.7 per 1,000.
When we went totally natural, before modern medicine, the maternal and neonatal death rates were much higher. So yes, you can go "too natural" or not intervene when appropriate. The difficulty is striking that balance between intervening too little and intervening too much. Studies generally show that birth centers are safe to use when birthing for low risk women, but you need to have midwives that are monitoring the situation and who are willing to recommend transfer when necessary. Technology is not bad, it has saved many lives, but misuse of technology can be bad.

I absolutely agree with what Carol said here,
" I would like to see more communication between the 2 approaches to birth. Each approach has something to offer the other. Homebirth practitioners need to be very observant and have access to timely hospital transfer."
They can trace the decline of Maternal Mortality to 2 things: Sulfa drugs (treated infections) and blood transfusions (saved women that hemorrhaged). Historically, when birth started occurring with doctors in the hospital, only the rich were able to afford it. The poor, which was a majority of women, still gave birth at home with Midwives. Guess which group had the highest mortality rate? The rich women that delivered in the hospital with access to all the doctors and medicine. And over the last 20 years, while our use of technology, medicine, and interventions during PG & L&D, has dramatically increased so has our maternal mortality rate....

I totally agree that a balance has to be struck between "going natural" and "intervening when necessary." I love what you said about technology not being bad but the misuse of it is. Very well put :)
listen to your intuition on this momma!

If this post doesn't get deleted by moderators, you should check out Skeptical OB. it's good to read both sides!
About 25% of term births have some meconium present in the amniotic fluid. Meconium aspiration syndrome is a VERY rare problem, especially when you consider 1/4 of all term births have meconium present at delivery. From a medical standpoint, we do not know why some babies become so ill from meconium and the huge majority DO NOT become ill. Babies do sometimes die from this, whether they are born in the hospital or not. This friend of yours, her baby was born in the hospital, and still died.

When catastrophic events occur, like an F-5 tornado, a hurricane Katrina, a giant Tsunami, an earthquake - nothing can stop those events - you can't move fast enough to get out of the way. This is the reality of birth .... catastrophes do occur ... less than 1% of the time. That means 99% of the time, NO catastrophe occurs.

About 1% of newborns require extensive resuscitation at birth, and those 1% are at serious risk of injury or death, regardless of the place of their delivery. The key is knowing what to do when you are presented with the 1%, and knowing that despite all of your best efforts, sometimes babies die, and that is a tragedy.

I am a nurse-midwife, practicing in the hospital now, but have done out of hospital births. If you cannot get over your fear of out of hospital birth, then have a hospital birth. But just walking through the door of the hospital does not protect you from all things. 97% of American birth occurs in the hospital - and most moms and babies that die do so IN THE HOSPITAL. Some of it is unavoidable, and some of it is in direct relation to hospital routines.
I agree with Jennifer. If you are uncomfortable with delivering out of a hospital, then by all means go to a hospital. And please, please, don't "try to be a hero." That is NOT what natural birth or out-of-hospital birth is about! The intention is not to get some sort of badge for "going natural." Most women who choose to go naturally do so because they trust their own bodies to work and wish to avoid complicating a NORMAL birth with "procedures." A lot of doctors are so used to augmenting birth, that they do not even know how to handle one that occurs spontaneously and naturally. THAT is one of the reasons some women choose to have an out-of-hospital birth.

That being said, I delivered my first child in a hospital. Although I personally believe a lot of routine care in a hospital can actually cause more issues during labor and birth, I was like you in that I still had a fear of NOT being in the hospital if something went wrong. That fear is lessening, now that I have already given birth once.

But a midwife and doula once told me that if I had any fear of doing it at home (or a birthing center), then it would be best to just go ahead and plan a hospital birth. Fear gets in the way of the whole birthing process. It causes things to go more slowly and increases pain. Too much fear can even stop a labor in its tracks or cause undue stress on the baby.

So, while I completely support home birth and even consider it the ideal, you need to consider what environment YOU will be most comfortable in. Don't allow other people's choices to make you feel guilty for not doing things the way they did. And that's exactly what natural birth and home birth is about: CHOICE. Do your own research; talk with mothers that have different birth experiences; decide for yourself what will work for you, and don't look back. Be confident in your choices!
I had a very long involved posting debate w/the Skeptical OB. I posted about HB, maternal and perinatal mortality, informed consent, and interventions in America and other countries. She said she wasn't interested in my opinions and requested I back it up w/my sources. I wrote a post FULL of links, data, and cited my sources (many were from credible journals that most ppl don't have access to) it was so long I had to post it in 3 sections. She never responded. Even after I specifically told her I had posted what she requested what was her response. Even after other ppl asked her to respond to me. For the rest of the life of that post (several weeks) she NEVER reponded to that particular post or anything else I had to say, although she continued to comment on other ppls posts. She is a zealot. Skewing results and talking in circles.

It IS absolutly necessary to read both sides. From a scientific standpoint, not opinions. You want real information? Skip the blogs and websites (even this one...its great for support and info but should not be used to make any decisions) check out WHO, CDC, Cochrane Collaboration and peer reviewed journals from this country and others. You may have to go to the library to gain access but its worth it.....

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