July 4, 2012
How to Avoid a Homebirth Disaster, Part 2
When I wrote How to Avoid a Home Birth Disaster, I didn’t plan on writing a “Part 2” but the more research I did about Rebecca Fielding’s case, it became obvious that writing a Part 2 would be necessary.
I want to preface my comments by revealing that I’m the granddaughter (3 generations removed) of two 19th century midwives. One delivered babies on a Virginia plantation and the other delivered half of her community until her death in 1936. I have the utmost respect for midwives because it was a midwife from Belize and not my colleagues who taught me the art of delivering my first baby. The record of Evelyn Muhlhan is unfortunately a cautionary tale for pregnant moms who opt to deliver at home.
In the Matter of Evelyn D. Muhlhan, License No. R060032, between July 2008 and September 2011, several complaints were brought before the Maryland Board of Nursing. The law (Code of Maryland Regulations 10.27.05.01(6)states that midwives must have a collaborating physician to cover them documented in a collaborative plan also known as an “Agreement.” Each year the agreement must be updated and submitted to the Board. The Board invoked an emergency suspension for Mulhan’s license for the following reasons:
- On June 7, 2008, she performed a vaginal home delivery on a patient who had a previous c-section, Factor V-Leiden deficiency and maternal obesity. Factor V deficiency predisposes patients to blood clots. The baby had to be brought to the emergency room because it was unresponsive, had meconium and was blue. The patient weighed 295 pounds. A physician was not consulted. Fortunately, the baby lived.
- On April 14, 2010, she used Pitocin in the patient’s muscle although it’s only supposed to be given in the vein. She used an antiseptic solution to treat Group B Strep as opposed to Penicillin which is the standard of care. The patient pushed for 3 hours, Muhlhan did an episiotomy, the baby did not deliver, so she repaired the episiotomy and then sent the patient to the hospital where an emergency c-section was done. The baby was born with brain injuries.
Muhlhan also attempted to deliver an 11-pound baby at home, had a patient who ultimately ruptured her uterus and manually removed another patient’s placenta that ended in a life-threatening postpartum hemorrhage.
So what’s the message? You must, I repeat, you must investigate people in whose hands you place your life. And this applies to physicians as well. Hospitals are imperfect institutions. It is the provider who will and should protect you from those imperfections based on their skill and advocacy. Homebirths will not be for everyone. There are health conditions that simply prevent this from happening.
We are moving towards promoting quality within healthcare as opposed to procedures and money. But we are far from getting there as yet. Each one of us must do our part to protect the integrity of our lives, our babies’ lives and heal our fractured healthcare system.
April said,
July 5, 2012 at 3:40 pm
Hospitals us IM (injection into the muscle) of PItocin all the time after births to prevent postpartum hemorrhage or to treat a PPH when the mother hasn’t been given pitocin to start or augment her labor.
drlindagalloway said,
July 5, 2012 at 6:13 pm
Intramuscular Pitocin is NOT the standard of care for labor induction. The standard of care for labor induction is intravenous Pitocin.
April said,
July 6, 2012 at 3:12 pm
You didn’t qualify if you were talking about labor induction or postpartum use. You made an incorrect blanket statement. It’s shoddy journalism.
Dr. G said,
July 5, 2012 at 8:22 pm
GREAT post – thank you Dr. Burke-Galloway.
drlindagalloway said,
July 5, 2012 at 11:50 pm
You’re very welcome, Dr. G. Best of luck in your career.
Quietly, a CNM said,
July 6, 2012 at 1:35 am
I followed your links to several articles and in the end to Marylands own court records on this case. The judgement was against Johns Hopkins for their gross malpractice in failing to provide appropriate care to a pregnant woman who arrived by ambulance, with documentation at plus 1 station and who was left to languish for two hours with an ominous fetal heart rate on EFM before they deigned to provide her with the cesarean she had been transported there for. Whatever Ms Mulhan’s shortcomings may be, they are irrelevant here and are not why the baby was born with encephalopathy. Chlorhexidine Gluconate is well researched as an alternative prophylaxis for GBS, though certainly not as widely used as IV antibiotics. If JHH had been concerned the baby was septic they could have administered antibiotics directly to the infant at birth, which is the recommended protocol for a symptomatic neonate without adequate intrapartum antibiotic coverage. The GBS, the Chlorhexidine, the IM pitocin, the attempted homebirth itself are all straw men to deflect from the grim reality that this mother and baby got SUBSTANDARD and UNSAFE care in a HOSPITAL at the hands of highly trained DOCTORS.
Perhaps you could title your third installment: How to avoid a Hospital Birth Disaster. You might start with a paragraph on discrepancies in medical treatment when in Baltimore with an Hispanic surname. And then fill your readers in on why we had to have EMTALA passed, to prevent private hospital emergency rooms from turning away women in labor and dumping them on charity and public hospitals on the ‘other’ side of town.
drlindagalloway said,
July 6, 2012 at 12:02 pm
You are SO missing the point. As I stated, a hospital is an IMPERFECT, repeat, IMPERFECT institution. And therefore, the provider, I repeat, the PROVIDER as in, midwife and physician, must be the skilled advocate to protect the patient. Had the midwife consulted a PHYSICIAN which she is legally mandated to do in the event of an emergency, this disaster might have been avoided. Why? Because there would have been a physician who was responsible for managing her case. She entered an INSTITUTION with all of its inherent flaws and she was not protected. THAT, is the point. I have been a patient safety advocate for more years than I care to admit. Should there be a 2 hour wait period before a lab is returned, of course not. But had there been a nurse or physician advocate who was made aware of the patient’s condition, IN ADVANCE, there would have been safety measure to avoid the problem.
You have no idea how professional organizations whom I won’t mention, want to shut down the entire home birth movement. If you are going to deliver babies at home and fight an institution, then you have to follow the rules. You have to be “squeaky clean” so that no one can challenge you based on deficiencies and blatant breaches of the standard of care. Ms. Muhlhane’s record as a midwife gives the professional institutions fodder upon which to continue to attack your movement. I, personally, am concerned about patient safety whether it’s at home OR in the hospital. Again, there are innocent babies at stake here. Lest, we forget.
Sharon said,
July 6, 2012 at 5:57 am
What was the client’s choice on the antiseptic wash? Althought standard recommendation in the US is antibiotics for all( not necessarily penicilin) it is not required that patients accept this type of treatment. Antiseptic washes are used in other places and are recommend in LOW TECH environments. I agree that there was a gloss on the pitocin, IM injection standard for PP hemorrhage, IV for induction and if it is being used for induction then IV to follow up for hemorrhage.
drlindagalloway said,
July 6, 2012 at 12:09 pm
In one of Ms. Mulhane’s cases, it was the Neonatologist who filed a complaint because of the use of Hibiclens. He was faced with the challenge of a severely compromised baby who was GBS positive and had been treated with an “off-label” treatment. He was infuriated because GBS sepsis kills babies and he was now facing a preventable emergency and possible death. Ladies, there are rules and standards that must be adhered to in the practice of medicine. If a patient refuses the traditional standard of care, then she must sign a Refusal of Treatment. The practice of medicine is based on evidenced-based protocols not choices based on convenience or predilection. Because when things go array, authorities go back and they review the standard of care and if it was breached there is absolutely no defense. None. Moral of the story: An ounce of prevention is far better than a pound of cure.
anais said,
July 6, 2012 at 9:41 pm
“The practice of medicine is based on evidence-based protocols not choices based on convenience or predilection”.
Well this study actually shows quite the contrary.
http://journals.lww.com/greenjournal/Abstract/2011/09000/Scientific_Evidence_Underlying_the_American.3.aspx
From the perspective of parents who come to the conclusion that they cannot trust the medical care they might get in labor and delivery, this can explain why they would choose a different route.
drlindagalloway said,
July 6, 2012 at 10:02 pm
The “different route” still has to adhere to a process where patients are going to be safe.
RN said,
July 26, 2012 at 7:43 am
Thank you so much for posting this. Your assessment is dead on. Unfortunately, Evelyn lied to her clients about having a backup physician and also about having any indictments against her. I have friends who directly asked these questions.The Board of Nursing did not make any of this information public until after she finally lost her license. I am not sure how her clients could have discovered these things about her, other than taking your advice about actually meeting with the supposed backup physician. Excellent suggestion.
drlindagalloway said,
July 26, 2012 at 1:28 pm
You are very welcome and I really appreciate your comments speaking from the perspective as a nurse. One of the suggestions I make in my book is for a pregnant mom to speak with the L&D nurses to obtain a second opinion about a healthcare provider that she’s contemplating seeing for prenatal care. I really wish The Smart Mother’s Guide to a Better Pregnancy had the same type of publicity as What to Expect because there are so many more “practical but life saving” suggestions in the book that would be helpful to patients. Perhaps, you can spread the word. Again, thanks for your comments.
Erica said,
January 22, 2013 at 8:54 pm
Evelyn was my midwife and I am saddened that women have lost another competent midwife in the Maryland area. She assisted me in the birth of my 10 lb 4 oz baby girl 19 months ago. She gave me the dignity I never received during my prior hospital births. She was cautious throughout my pregnancy and attentive during my birth. With regards to the pitocin being injected into the muscle…this is interesting to me that you cite this as negligent when I receive the same muscular injection by an OBGYN in a hospital in 2009! Why? Because the OBGYN was concerned I maybe have a postpartum hemorrhage after a precipitous birth. By the way, the hospital birth by an OBGYN was the most degrading experience of my life. Not all OB’s are bad, but this one was…which is why I sought out Evelyn when I became pregnant again. She is an amazing midwife who cares for her patients.
drlindagalloway said,
January 22, 2013 at 11:53 pm
Thanks for your comments, Erica. It’s always nice to hear from patients who have first-hand experience with the midwife or physician.