If the obstetrician-authors of this AJOG article had not been so obsessed with their political agenda, the headline of their paper would logically (but still hyperbolically!) read:
“Midwife-attended hospital birth nearly two times safer than OB-attended hospital birth“
The reported incidence of critically low 5-min Apgars for hospital midwives is one out of 11,745, while it is one out of 6,496 for OBs .
As an L&D nurse for 15 years before cross-training into mfry, I saw hundreds of babies that required resuscitation, including quite a few with zero 5-min Apgars. If you inject laboring women with a huge (100 mgm) dose of the narcotic Demerol, along with 1/150 grain of scopolamine which was repeated every 2 hrs, make them push for hours while lying flat on their backs, then give them general anesthesia and pull their babies out with forceps, you will see a very large number of neonates will have ‘adverse outcomes’. We had babies that failed to breathe everyday, so I got a LOT of experience resuscitating newborns and once or twice a month, an apparently normal baby could not be resuscitated.
However, as a midwife in the greater San Francisco Bay area since 1979 I have attended about 2,000 PHBs (incl. hospital transfer) — my own clients as well as co-managing or as ‘second call’ for other midwives. In all these home births and/or hospital transfers, I have never been present when I, the other midwife, or a hospital obstetrician/NICU team had a baby with a zero 5-minute Apgar.
So far the only perinatal deaths that I have personally experienced as a midwife involved a fetal demise in labor in a PHB attended by an MD (I was 2nd call), and a client of mine who suffered a cord prolapse. This required an emergency transport and emergency CS, but despite an extremely rapid response, the baby died some months later of severe neurological complications. [see ASIDE @ bottom for additional information]
Of the dozen or more midwives who regularly participate in our local peer review during the last 20 years, only one has reported a live-born baby with a zero 5-min. Apgar.
In my experience of contemporary childbirth at home and hospital both, the rarest event of the already rare prenatal mortality is the live-born baby with a zero-Apgar at 5 minutes.
Personally, I put this likelihood in a category called: ‘when pigs fly’.
Having seen more than my share of ‘bad babies’ in the hospital, I find it hard to believe that either end of Chervenaket‘s paper provides an accurate picture.
I don’t believe that:
- PHB midwives are responsible for killing one baby out of every 615 births they attend
OR
- Obstetricians and hospital midwives figured out how to virtually eliminate all critically low Apgars by having reduced their occurrence to one out of nearly 12,000 live births
If the obstetrical profession is as dedicated to making childbirth safer for babies as they say, then these extraordinarily good numbers for hospital midwives — only 1 zero 5-min Apgar out 11,776 live births — would be equivalent to a new wonder drug, that is, “a must-have” for every hospital. When should be marching outside of hospitals with signs demanding that their hire nurse-midwives to attend births for all healthy women with normal pregnancies.
Questions about the study’s Accuracy & Relevancy
Issues of accuracy and relevancy still abound in regard to these reports of dramatically increased rate of zero Apgars in live-born babies and greatly increased rate of NN seizures and other neurological disorders associated with PHBs.
The lack of additional information to assess the validity of these claims is a serious barrier. We don’t have any other medical or demographic data on the nature of the midwife-attended PHB group — for example, were the PHB records used in the study from recent births, or did they include records from many years ago? Was the number of low 5-minute outcomes higher in the past and lower in the most recent births, or did the rate remain stable over several years of data?
Were the midwives actually present during the labor, or did they arrive at someone’s home only to find a meconium-covered, severly depressed baby emerging? What kind of risk factors and complications were involved in these cases (both home and hospital), such as shoulder dystocia (unable to reliably predict, not setting-specific) versus diabetic mothers, post-mature and/or breeches babies, etc, which are generally better handled in the hospital.
Were some of the reported zero 5-min Apgars for babies actually for stillbirths after an antepartum or intrapartum fetal demise?
The critical information we needed, but not supplied by Grunebaum & Chervenaket, were the two other, but equally critical Apgar scores – the one minute and the 10 minute Apgar. Were these zero 5-min Apgars on babies that were actually stillborn, but because midwives are not authorized to declare stillbirth, these babies still have to transported by EMTs to the hospital as an ’emergency-in-progress’, while paramedics perform bag and mask resuscitation all the way to the hospital.
Only after additional, but failed attempts in the hospital ER will the baby be pronounced dead. The time of death is determined by the ER docs some 30-60 minutes later than the time of birth. If the parents don’t agree at that point to take the baby off life-support equipment, it may be long as several days.
Whenever the time of birth differs from the time of death, a certificate of ‘live’ birth has to be filed if a heart beat was detected (even briefly) or the baby may have taken a breath. This includes the moment of delivery, when it is hard to be sure exactly what is happening. This is especially an issue in a prolonged shoulder dystocia, which can actually be the result of a completely flaccid baby who is already profoundly depressed or has already died. In these cases, the cardinal mechanisms of descent & rotation don’t’ work because the musculature of the baby’s body is completely without tone.
When filling out the birth registration data later, hospital personnel (who were not present during any of this) dutifully fill in the blanks for 1, 5 and 10-minute Apgars as unknown, 0, & 0, which would seem appropriate for a baby who wasn’t able to be resuscitated. While still tragic, these are not lives births. However these stillbirths would NOT be properly recorded for what they actually were — an antepartum or intrapartum fetal demise — due to the inability of midwives to legally determine that fact of a stillbirth and the many layers of bureaucracy between the birth attendant and the person filing out the birth registration forms.
Unfortunately, I see this negative and unrepresentative study as having somewhat of a golden lining, as it provide an opportunity for all categories of state certified midwives to lobby for hospital privileges. However I don’t think the outcome that ACOG members were looking for.
Apgar Wars commentary continues in part 4
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ASIDE on PHB-related cord prolapse fatality discussed above (not part of “Apgar Wars” commentary):
[ Being 39 minutes from an operating room was the single most important factor in what otherwise would have been a preventable tragedy. However that is NOT the only critical issue. While the exact impact of prematurely clamping and cutting this depressed baby’s umbilical cord the instant it was delivered by emergency CS is unknown, it is clear that it took a very serious situation and made it significantly worse and likely tipped the scales towards (rather than away) from a fatal outcome.
As the baby is lift up and out of the uterus at delivery the obstetrical surgeon, the block in circulation of blood throughout the baby’s cord is released. Prior to being born and having one’s umbilical cord cut, approximately 1/3 (or 100 ml) of a baby’s total blood volume (240 lm) is circulating through the umbilical cord to the placenta and continually being returned as freshly oxygenated blood to the baby.At this point in the baby’s care, the baby’s own, warm, Ph-perfect, and oxygen-enriched blood in the umbilical cord circulation once again becomes available to the baby if the cord is not clamped. All it takes is to refrain from clamping and cutting the cord until the normal ‘placental transfusion’ process completes itself, which only take 2 or 3 minutes.
The more critical a baby’s condition is due to prematurity or fetal distress (as in this case), the more the neonate desperately needs his or her full blood volume. Should the baby require resuscitation, this can be provide during the 3 minute period of third-stage placental transfusion by placing a sterile sheet over the mother’s legs and working on the baby while it is still attached by the cord to the undelivered placenta.
Unfortunately, hospital policy in the US in case of emergency delivery is to double clamp and cut the umbilical within seconds of the delivery in order to get legal proof (via the baby’s blood gases) that the baby was profoundly depressed at birth and whatever bad outcome may result was not the fault of the physician or hospital.
However the already oxygen-deprived baby is also deprived of approximately 100 cc of its own well-oxygenated blood or 1/3rd its total volume.
One cannot but note that perhaps this baby would have survived if protocols in American hospitals were focused on maximizing the baby’s welfare, rather than insuring legal protection for the institution.
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