Mennonite Order Of Maternal Services

"Sevire Humanitas Est Servire Deo"

Special Circumstance Informed Consent/Informed Refusal

RE: Macrosomia Consent

Birth Outcome

January 19, 1994

Mother: M, Denice, Gr. 5 P. 3, EDC 1/19/94

Father: S, Patrick

RE: Parents declined prophylactic obstetrical care in presence of macrosomia (> 4,500 g), pendulous maternal abdomen and ballotable (unengaged) fetal head @ term after receipt of extensive information regarding increased risk and current medical criteria for intervention

California statutes do not define childbirth to be a medical or pathological condition. No California law requires a mother to seek out medical or midwifery care during pregnancy, be hospitalized for childbirth or be attended during active labor and birth by a physician or midwife. Neither residency nor status as a bona fide citizen of California obligates the state of California to provide care or payment for care rendered to pregnant women. Any voluntary arrangements made by the mother for ante or intra or postpartal or postnatal care are above that required by California law.

Client History

The mother is a chiropractor and a trained childbirth educator, currently teaching birth preparation classes in her geographical area. She has had two previous homebirths, one in southern California 10 years age and the second a baby weighing 10# 2, under my care in April 1992. Mild shoulder dystocia was encounterd which was easily resolved by a change in maternal position to hands and knees. There was no medical sequelea for either mother or neonate.

The father is dental technician making dentures and bridgwork. Both parents are have above average education and motivation. This is a planned pregnancy subsequent to a previous pregnancy ending with a documented fetal demise at 17 weeks due to cord entanglement. Both parents were more than usually nervous during this pregnancy and anxious about fetal wellbeing. Ultrasound was done on 7/12/93 at 12 weeks at Dr. __________ 's office, confirming EDC and single AGA fetus. They remain firm in their religious faith and staunchly committed to home-based maternity care except in the event of a bonafide emergency or evident pathology of either mother or neonate.

Narrative -- 1/19/94 Wednesday, 2-3:15 pm:

This is to document the nature and content of an extensive informed consent conversations on 1/5, 1/12 and today regarding the known and unknown risk factors associated with macrasomia and ballotable fetal head at term which can result in potentially serious and/or life-threatening complications for both mother and baby. The major question was the continuation of domiciliary care under the religious exemptions clause (Article 3, Section 2063) in the presence of increased risk of cord accident and complicatons of macrosomnia.

Background: LGA baby with fundal height increase from 40 cm at 38th week (12/28/93) to 45 1/2cm at 39th week (1/5/94). This marked change in a short time appears to have been caused by a pendulous maternal abdomen resulting in a misalignment of fetal/maternal axis, with subsequent cantilevering the fetal head up out the pelvis brim thus permitting the breech of the fetus to ride out in front rather than up under the maternal ribs. Vag exam confirmed the presence of a ballotable fetal head. Normal amniotic fluid levels appear unchanged from previous antepartal assessments. Fundal height on 1/12/94 was 43 cms; today it is again 45 cms.

Statement of Concern: Grossly macrosomic infant (in excess of 10#) with ballotable fetal head and long axis of baby's body not aligned with maternal body and bony pelvis, increasing the risk of cord prolapse during spontaneous rupture of membranes. Also the unusually large baby increases the likelihood of cephlo-pelvic disproportion requiring hospitalization for Cesarean delivery OR shoulder dystocia during vaginal birth. Maternal risk factors are increase in excessive bleeding in the 3rd stage of labor and immediate postpartum period. It was emphasized that Denise.'s situation does not fall within the generally-accepted definitions of low or moderate-risk pregnancy.

Discussed with parents the relative benefits and risks of prophylactic hospitalization and possibly an elective Cesarean, due either to parental choice or inability to find an obstetrical careprovider willing to attempt a vaginal birth with estimated fetal size at term of #11+:

Benefits noted to prophilactic hospital under obstetrical care were reduction in predictable risks associated with cord accidents and complications of macrosomia (CPD, shoulder dystocia, fetal hypoglycemia) via immediate access to operative delivery and neonatal intensive care nursing staff. Maternal benefit of hospitalization for labor and delivery were identified as prophylactic IV fluids with immediate accesses to intravenously administered oxytocin, plasma-expanders and blood transfusion.

It was noted that hospitalization and surgical delivery would not change or reduce normal maternal-infant risks such as Failure To Progress, infection, congenital malformations, genetic defects, or rare complications of childbearing. However, more immediate intervention or treatments of some of the conditions listed above is statistically associated with improved outcomes.

Also noted were the increase of risks associated with hospitalization, specificially increased use of pitocin augmentation of labor, iatrogenically-arrising fetal distress, subsequent operative delivery, particularly cesarean section; ie. nosoconical infection of mother and/or baby, medication errors, anesthetic accidents, drug reactions, surgical mistakes such as accidental incision of bladder or bowel, tying off a ureter, wound infection, surgical laceration of baby; fetal respiratory distress; operative or post-operative maternal hemorrhage necessitating blood replacment with comcomentent risk of transfusion reactions and exposure to diseases carried by blood products (Hepatitis, HIV). This latter category of complications could put the father and other siblings at risk due to their communicable nature and untreatable status. Very rare neonatal complications of hospitalization include mix-up of babies or abduction from the hospital.

Discussed advisability of OB consultation and ultrasound. Parents declined all medical interventions or dx procedures at this time, agreed to reconsider if no SOOL (spontaneous onset of labor) by Monday, 1/24.

Parents were instructed in the biomechanics of shoulder dystocia and given a demonstration of the McRoberts maneuver and hand & knees position. I emphasized the critical importance of having a second well-experienced midwife present for the birth due to possible need to employ this extreme maternal posture to free the anterior shoulder. They agreed to this precautionary measure.

Due to LGA, suggested mother do daily kick counts (same time each day) and wear a very firm abdominal binder to help align fetus with pelvis and assist decent of fetal head into pelvis, possibly decreasing likelihood of cord accident.

Prayer requested by parents for spontaneous onset of a briskly-progressive labor within next 5 days

Prayers by practitioner for good outcome and guidance regarding management of these issues and wisdom in carrying out caregiver functions.

Parents requested to make appointment with obstetrician on Monday if no SOOL by then.

Management plan for this family is as follows:

1) Continued recommendation of OB consultation and prophilactic hospitalization for labor and birth

2) Request OB consult and ultrasound/NST if more than 8 days post date

(adjusted EDC 1/20/94 based on menstrual hx and 7/12/93 somagram

3) Define success as SOOL of a briskly progressive nature accompanied by progressive dilation of cervix with NO evidence of fetal umbilical cord prolapse and appropirately decent of fetal head with a rapid 2nd stage

4) Presence of second experienced midwife

5) Criteria for Transfer -- inadequate forces of labor, non-progressive labor, prolonged 2nd stage (more than 30 minutes after spontaneous and sustained urges to push [SUTP]), other standard indications of diminution of fetal or maternal wellbeing.

Parents live within 5-7 minutes of a major medical center and there are no physical barrier to their home nor inclement weather or road conditions that would delay emergency transport.

Narrative -- 1/24/94 2:10 pm phone conversation with the father regarding OB consultation:

Reiterated above concerns plus additional concern about fetal hypoglycemia during intrapartum resulting from placenta insufficiency due to post-term pregnancy. Emphasized again that D.....'s pregnancy did not fall within the generally-accepted definitions of normal/low-risk domiciliary criteria. However, in the presence of full disclosure of risks, the final decision properly belonged to them. Parents declined OB consult at this time but agreed to see OB if no baby by Friday.

Narrative -- Spontaneous delivery of baby boy S...... 1/25/94

4:35 am -- Father called to reported SOOLabor (active phase) @ 1:am, UC q 5 mins X 60+", mother feeing pelvic fullness, requested midwife to come

5:20 am: Mother sitting in rocker, smiling and relaxed between UC

FHT 140s, good long-term variability with no periodic changes; Membranes intact, no exam done as it did not appear that progressive labor was occurring as of yet

6:35 am SPOM, light mec, FHT within normal range, long-term beat-to-beat variability between 3-8 bpm (counting in 5 second intervals over span of 60 seconds); Vag exam revealed evident cord prolapse, dilation 5 cm, vertex at Zero station, sutures transverse

6:50 am SUTP (spontaneous urges to push), second midwife called, mother standing in bathroom leaning on dresser

7:10 am Intense bearing down efforts, mother asked to move to bedroom; mother's choice of positions was Dutch midwives birth stool

7:13 -- fetal head/hand crowned and delivered, accompanied by baby's arm which was extended up along side of it's head, making for a compound presentation. Large amounts of meconium-stained amniotic water expelled with baby -- deLee for mec

7:16 -- no further decent of baby with two successive pushes -- mother asked to bear down forcefully, told she will need to assume McRoberts position if no delivery of baby on the next contraction. Mother spontaneously applied abdominal force to herself, pulling uterus back towards maternal spine to better align baby

7:17 baby delivered spontaneously, tight nucal cord X2, head deeply purple, body white and limp, no spontaneous respirations at birth, FHT approximately 90

baby untangled from cord, dried off and stimulated, 100% O2 by positive pressure X 6; baby gasping and spontaneous respirations established at approximately 1 minute

Mother bleeding excessively, IM pit i amp, helped to bed, laid flat and given oral fluids, mother and baby covered with blankets to keep warm

7:20 am Second call midwife arrived!

7:40 am spontaneous expluson of placenta, bleeding moderate, perineum intact

Perinatal Outcome

Baby's weight 12#, (5500 g) length 23"; head circumference 37 1/2 cms, chest circumference 42 cms, abdominal girth 43cm (after meconium expelled at birth!)

Mother and baby fine

Father and midwife recovering slowly!

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