Midwife charged in DC? Karen Carr, CPM...

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Bingo - Give this poster a spa-vacation. This is a human rights issue.

Human rights? The mom had the right to give birth however she wanted to, and the FBI wasn't going to burst in and force her to a hospital. As was mentioned above, if Karen had been licensed, she would be facing her licensing board. Since she was taking money for a medical service she wasn't licensed to provide, and in the course of providing that medical service a baby died, she's now in criminal court.

The wisdom of delivering a 43-year-old primip with breech presentation at home is a different discussion. The mom has the right to do what she wants with her body, but she does NOT have the right to have a professional put her own career on the line by attempting something risky. That's why many OBs won't do vaginal breech deliveries, and also why many OBs won't do elective CS. It all depends on the current knowledge about safety and risk, as well as the professional's level of comfort with a given scenario.

Look, this is true. This is why many women with preeclampsia or HELLP syndrome are encouraged to have their babies vaginally rather than opting for an immediate c-section. Less risks to mom and baby to birth vaginally as opposed to surgery on a mom who could have a potentially very low platelet count. Some of my patients would prefer to be given a c-section, but the evidence says a vaginal delivery is safer. Not saying all OBs operate under the most recent, best evidence, but why are we admonishing all OBs without realizing that many midwives (like Carr) aren't necessarily taking the time to read/practice the most up-to-date evidence either? She's not affiliated with a hospital, making it far more expensive to have access to current journal articles on these topics. She works out of her home and is not practicing side-by-side with other professionals on a daily basis. Someone mentioned that this shouldn't be investigated by the law, rather Ms. Carr should undergo "peer review" with her fellow midwives. How would that resolve the ego of a midwife who thinks that every client (regardless of risk) is fair game. Studies show that women with multiple cesareans have a much higher risk of placenta accreta, increta and percreta yet some of these midwives are all too happy to take on a homebirth client who has undergone 3+ cesarean sections. Without access to ultrasound, the potential for an undiagnosed complication such as this (and subsequent maternal death) is great.

I think your deep hatred for homebirth is preventing you from understanding anything about this case. You want to talk about ego in the OB world? Hahahahahaha...............

[Anonymous]

Anonymous wrote:I am the poster who had a breech delivery with Dr. Udwin. You really are only seeing things through your lens of trust and belief in a non medical model of birth. Have YOU ever been in a hospital with a breech baby or are you simply repeating what you might have heard culturally or perhaps through your homebirth assistant/midwife/doula? You were not there for the discussion. You were not there for any part of what went on with my hospital breech delivery so don't make assumptions based on what YOUR lens looks like.

NP, not the PP you were refering to. I am a former patient of his and hoped to VBAC with him, he stopped practicing before my due date. He had a formidable set of skills in handling difficult deliveries. It was a huge loss when he stopped practicing. For anyone reading, many of the remaining docs at Gtown are also very VBAC friendly.

My first c-section was due to a footling breech presentation. At one point the baby was frank and we did a LOT of research on breech deliveries. It was out of my comfort zone and then ultimately no longer an option when she shifted positions. The head getting caught or the possibilty of nerve damage in arms was too great a risk for me, I prefered to assume the risk of the c-section. I think that the romantic presentation of home birth and fear mongering about hospitals really do people a disservice. It is one thing to attempt a breech or VBAC delivery in a hospital where an emergency c is possible quickly enough to prevent brain damage. To do so at home is foolhardy. That poor little soul will never have a chance to grow up. Had his mother not encountered the birth assistant at Birthcare it is entirely possible that she would be playing with her baby right now.

[Anonymous]

You guys want to know ultimate irony? If you see a newborn baby in the ad at the top of this page, that baby was caught by Karen Carr.

[Anonymous]

http://www.drmomma.org/2011/04/local-midwife-faces-30-years-in-prison.html#comments

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Bingo - Give this poster a spa-vacation. This is a human rights issue.

Human rights? The mom had the right to give birth however she wanted to, and the FBI wasn't going to burst in and force her to a hospital. As was mentioned above, if Karen had been licensed, she would be facing her licensing board. Since she was taking money for a medical service she wasn't licensed to provide, and in the course of providing that medical service a baby died, she's now in criminal court.

The wisdom of delivering a 43-year-old primip with breech presentation at home is a different discussion. The mom has the right to do what she wants with her body, but she does NOT have the right to have a professional put her own career on the line by attempting something risky. That's why many OBs won't do vaginal breech deliveries, and also why many OBs won't do elective CS. It all depends on the current knowledge about safety and risk, as well as the professional's level of comfort with a given scenario.

Look, this is true. This is why many women with preeclampsia or HELLP syndrome are encouraged to have their babies vaginally rather than opting for an immediate c-section. Less risks to mom and baby to birth vaginally as opposed to surgery on a mom who could have a potentially very low platelet count. Some of my patients would prefer to be given a c-section, but the evidence says a vaginal delivery is safer. Not saying all OBs operate under the most recent, best evidence, but why are we admonishing all OBs without realizing that many midwives (like Carr) aren't necessarily taking the time to read/practice the most up-to-date evidence either? She's not affiliated with a hospital, making it far more expensive to have access to current journal articles on these topics. She works out of her home and is not practicing side-by-side with other professionals on a daily basis. Someone mentioned that this shouldn't be investigated by the law, rather Ms. Carr should undergo "peer review" with her fellow midwives. How would that resolve the ego of a midwife who thinks that every client (regardless of risk) is fair game. Studies show that women with multiple cesareans have a much higher risk of placenta accreta, increta and percreta yet some of these midwives are all too happy to take on a homebirth client who has undergone 3+ cesarean sections. Without access to ultrasound, the potential for an undiagnosed complication such as this (and subsequent maternal death) is great.

I think your deep hatred for homebirth is preventing you from understanding anything about this case. You want to talk about ego in the OB world? Hahahahahaha...............

Pardon me, why do I have a great hatred of hb? Is this because I believe that some patients are too risky for it? Homebirth is a wonderful option for low-risk women, emphasis on the low. You are typically so black and white, us vs. them. If OBs are arrogant (as many are) then so is a hb midwife who willl take on a client with any level of risk.

[Anonymous]

Anonymous wrote:

Anonymous wrote:

Anonymous wrote:Bingo - Give this poster a spa-vacation. This is a human rights issue.

Human rights? The mom had the right to give birth however she wanted to, and the FBI wasn't going to burst in and force her to a hospital. As was mentioned above, if Karen had been licensed, she would be facing her licensing board. Since she was taking money for a medical service she wasn't licensed to provide, and in the course of providing that medical service a baby died, she's now in criminal court.

The wisdom of delivering a 43-year-old primip with breech presentation at home is a different discussion. The mom has the right to do what she wants with her body, but she does NOT have the right to have a professional put her own career on the line by attempting something risky. That's why many OBs won't do vaginal breech deliveries, and also why many OBs won't do elective CS. It all depends on the current knowledge about safety and risk, as well as the professional's level of comfort with a given scenario.

Why exactly would she be facing her licensing board? I think you are lacking a fundamental understanding about the midwifery model of care.

The parents of this baby are obviously very upset. When you think that your care provider has made a mistake or been negligent, you complain to their licensing board and explain why you think they shouldn't be able to practice anymore. There are tons of examples of babies who have died during homebirth, but the parents didn't file a complaint. This case appears to be different.

And why should midwives be exempt from review? Does the midwifery model of care include not being responsible for bad outcomes?

[Anonymous]

Anonymous wrote:

Anonymous wrote:...publication excerpts by Dr Richard Fischer, Prof of Fetal Maternal Medicine, Cooper Univerity Hospital, NJ, from April 2011.....

Three types of vaginal breech deliveries are described, as follows:
•Spontaneous breech delivery: No traction or manipulation of the infant is used. This occurs predominantly in very preterm, often previable, deliveries.
•Assisted breech delivery: This is the most common type of vaginal breech delivery. The infant is allowed to spontaneously deliver up to the umbilicus, and then maneuvers are initiated to assist in the delivery of the remainder of the body, arms, and head.
•Total breech extraction: The fetal feet are grasped, and the entire fetus is extracted. Total breech extraction should be used only for a noncephalic second twin; it should not be used for a singleton fetus because the cervix may not be adequately dilated to allow passage of the fetal head. Total breech extraction for the singleton breech is associated with a birth injury rate of 25% and a mortality rate of approximately 10%. ...
Risks...
Lower Apgar scores, especially at 1 minute, are more common with vaginal breech deliveries. Many advocate obtaining an umbilical cord artery and venous pH for all vaginal breech deliveries to document that neonatal depression is not due to perinatal acidosis. ... Fetal head entrapment may result from an incompletely dilated cervix and a head that lacks time to mold to the maternal pelvis. This occurs in up to 8.5% of vaginal breech deliveries. Dührssen incisions (ie, 1-3 cervical incisions made to facilitate delivery of the head) may be necessary to relieve cervical entrapment. However, extension of the incision can occur into the lower segment of the uterus, and the operator must be equipped to deal with this complication. The Zavanelli maneuver has been described, which involves replacement of the fetus into the abdominal cavity followed by cesarean delivery. ... Nuchal arms, in which one or both arms are wrapped around the back of the neck, are present in 0-5% of vaginal breech deliveries and in 9% of breech extractions. Nuchal arms may result in neonatal trauma (including brachial plexus injuries) in 25% of cases. ... Cervical spine injury is predominantly observed when the fetus has a hyperextended head prior to delivery. ....Cord prolapse may occur in 7.4% of all breech labors. This incidence varies with the type of breech. ...
Candidates
... After 37 weeks' gestation, parents should be informed of the results of a recent multicenter randomized clinical trial that demonstrated significantly increased perinatal mortality and short-term neonatal morbidity associated with vaginal breech delivery (see Comparative Studies). For those attempting vaginal delivery, if estimated fetal weight (EFW) is more than 4000 g, some recommend cesarean delivery because of concern for entrapment of the unmolded head in the maternal pelvis, although data to support this practice are limited.
A frank breech presentation is preferred when vaginal delivery is attempted. Complete breeches and footling breeches are still candidates, as long as the presenting part is well applied to the cervix and both obstetrical and anesthesia services are readily available in the event of a cord prolapse.
The fetus should show no neck hyperextension on antepartum ultrasound imaging (see the image below). Flexed or military position is acceptable. ...
It had been commonly believed that primigravidas with a breech presentation should have a cesarean delivery, although no data (prospective or retrospective) support this view. The only documented risk related to parity is cord prolapse, which is 2-fold higher in parous women than in primigravid women. ...

Wow, right out of your own post. For all of you who are so completely positive that cesarean was the best and "only rational" choice to make, what are you basing that opinion on? Where is that substantial risk that everyone is talking about and where is the data to prove it? Doctors in this country recommend cesarean for breech, primarily because it reduces their liability. There is little evidence that breech is overwhelmingly risky...

Ehh, if you had read the whole post you'd understand that there is a LOT of evidence that it carries higher risk!!! The sentence you bolded cannot be taken out of context. The entire text is 15 times as long, and this very last part refers to the risk for primigravidas as opposed to multiparous ONLY, and between both for vaginal breech delivery, not compared to other methods of delivery, I'm sorry, I should have clarified this.

[Anonymous]

"And why should midwives be exempt from review? Does the midwifery model of care include not being responsible for bad outcomes?"

In fact, some homebirthers seem to think that midwives should not be considered responsible for bad outcomes -- that by choosing to HB, the mother alone is responsible for the outcome.

I'm sure the OBs would loooveee to figure out how to convince their clients of that sort of reasoning.

[Anonymous]

Anonymous wrote:"And why should midwives be exempt from review? Does the midwifery model of care include not being responsible for bad outcomes?"

In fact, some homebirthers seem to think that midwives should not be considered responsible for bad outcomes -- that by choosing to HB, the mother alone is responsible for the outcome.

I'm sure the OBs would loooveee to figure out how to convince their clients of that sort of reasoning.

Well then why have a midwife at all? If she's just there to catch the baby and not be responsible if anything goes wrong, why wouldn't I just call my sister in for free and take my chances?

[Anonymous]

There was just a story about this on the news.

OMG the mother was 43 and a FTM AND breech!? She should have risked out of EVERYTHING but a c-section. Sorry, momma, but you're not going to have a good outcome with the triple whammy of AMA, FTM, and breech. I'm pretty sure even Dr. Tchabo won't delivery a breech vaginally if it's a FTM -- your birth canal just isn't proven or "broken in" enough.

[Anonymous]

Anonymous wrote:There was just a story about this on the news.

OMG the mother was 43 and a FTM AND breech!? She should have risked out of EVERYTHING but a c-section. Sorry, momma, but you're not going to have a good outcome with the triple whammy of AMA, FTM, and breech. I'm pretty sure even Dr. Tchabo won't delivery a breech vaginally if it's a FTM -- your birth canal just isn't proven or "broken in" enough.

Based on this thread Dr. Tchabo said he would deliver but he was due to be out of town and couldn't guarantee that he would be around when the mom went into labor. That's when the parents decided to seek out Karen.

[Anonymous]

Anonymous wrote:There was just a story about this on the news.

OMG the mother was 43 and a FTM AND breech!? She should have risked out of EVERYTHING but a c-section. Sorry, momma, but you're not going to have a good outcome with the triple whammy of AMA, FTM, and breech. I'm pretty sure even Dr. Tchabo won't delivery a breech vaginally if it's a FTM -- your birth canal just isn't proven or "broken in" enough.

which channel? do you have a link?

[Anonymous]

Anonymous wrote:...publication excerpts by Dr Richard Fischer, Prof of Fetal Maternal Medicine, Cooper Univerity Hospital, NJ, from April 2011.....

Three types of vaginal breech deliveries are described, as follows:
•Spontaneous breech delivery: No traction or manipulation of the infant is used. This occurs predominantly in very preterm, often previable, deliveries.
•Assisted breech delivery: This is the most common type of vaginal breech delivery. The infant is allowed to spontaneously deliver up to the umbilicus, and then maneuvers are initiated to assist in the delivery of the remainder of the body, arms, and head.
•Total breech extraction: The fetal feet are grasped, and the entire fetus is extracted. Total breech extraction should be used only for a noncephalic second twin; it should not be used for a singleton fetus because the cervix may not be adequately dilated to allow passage of the fetal head. Total breech extraction for the singleton breech is associated with a birth injury rate of 25% and a mortality rate of approximately 10%. ...
Risks...
Lower Apgar scores, especially at 1 minute, are more common with vaginal breech deliveries. Many advocate obtaining an umbilical cord artery and venous pH for all vaginal breech deliveries to document that neonatal depression is not due to perinatal acidosis. ... Fetal head entrapment may result from an incompletely dilated cervix and a head that lacks time to mold to the maternal pelvis. This occurs in up to 8.5% of vaginal breech deliveries. Dührssen incisions (ie, 1-3 cervical incisions made to facilitate delivery of the head) may be necessary to relieve cervical entrapment. However, extension of the incision can occur into the lower segment of the uterus, and the operator must be equipped to deal with this complication. The Zavanelli maneuver has been described, which involves replacement of the fetus into the abdominal cavity followed by cesarean delivery. ... Nuchal arms, in which one or both arms are wrapped around the back of the neck, are present in 0-5% of vaginal breech deliveries and in 9% of breech extractions. Nuchal arms may result in neonatal trauma (including brachial plexus injuries) in 25% of cases. ... Cervical spine injury is predominantly observed when the fetus has a hyperextended head prior to delivery. ....Cord prolapse may occur in 7.4% of all breech labors. This incidence varies with the type of breech. ...
Candidates
... After 37 weeks' gestation, parents should be informed of the results of a recent multicenter randomized clinical trial that demonstrated significantly increased perinatal mortality and short-term neonatal morbidity associated with vaginal breech delivery (see Comparative Studies). For those attempting vaginal delivery, if estimated fetal weight (EFW) is more than 4000 g, some recommend cesarean delivery because of concern for entrapment of the unmolded head in the maternal pelvis, although data to support this practice are limited.
A frank breech presentation is preferred when vaginal delivery is attempted. Complete breeches and footling breeches are still candidates, as long as the presenting part is well applied to the cervix and both obstetrical and anesthesia services are readily available in the event of a cord prolapse.
The fetus should show no neck hyperextension on antepartum ultrasound imaging (see the image below). Flexed or military position is acceptable. ...
Primigravida versus multiparous vaginal breech delivery: ....It had been commonly believed that primigravidas with a breech presentation should have a cesarean delivery, although no data (prospective or retrospective) support this view. The only documented risk related to parity is cord prolapse, which is 2-fold higher in parous women than in primigravid women. ...

OK PP here, sorry for the confusion about the last sentence due to omitted section header. Also bolded some parts.

Do midwifes, including Carr, that attempt breech vaginal deliveries know how to make a Dührssen incision into the cervix?
Do they know how to do the Zavanelli maneuver to bring a baby with an entrapped head back into the abdomen to do an emergency c-section?
Do they do an ultrasound prior to their attempt to exclude a hyperextended head 'stargazing' position of the breech baby which has a 73% risk of cervical spine injury if vaginal delivery is attempted according to the Ballas et al study?

...those are some of the questions that I have... and that other mothers-to-be considering vaginal breech delivery at home should also seek answers to, and that may be adressed in court in this case...

[Anonymous]

Anonymous wrote:

Anonymous wrote:There was just a story about this on the news.

OMG the mother was 43 and a FTM AND breech!? She should have risked out of EVERYTHING but a c-section. Sorry, momma, but you're not going to have a good outcome with the triple whammy of AMA, FTM, and breech. I'm pretty sure even Dr. Tchabo won't delivery a breech vaginally if it's a FTM -- your birth canal just isn't proven or "broken in" enough.

which channel? do you have a link?

Fox5. Don't have a link, because you can't find a damn thing on their website!

[Anonymous]

Anonymous wrote:which channel? do you have a link?

http://www.myfoxdc.com/dpp/news/local/midwife-charged-in-virginia-with-involuntary-manslaughter-041911