New Regulations of Midwives in Virginia

Obstetricians and certified professional midwives have differing philosophies when it comes to ushering babies into the outside world.

However, a bill before the General Assembly might bring them into a closer working relationship. At least, that's the hope of certified professional midwife, Brynne Potter.

Del. Matt Lohr, R-Harrisonburg, has introduced a bill that would amend the regulation of midwifery.

It would require that midwives inform patients of potential risks associated with delivering at home, "including but not limited to special risks associated with vaginal births after a prior C-section, breech births, births by women experiencing high-risk pregnancies, and births of twins or multiples."

Lohr said the bill is motivated by a desire to protect mothers and children, and was brought to him by Dr. Catherine Slusher, an obstetrician and gynecologist in Harrisonburg.

"Right now, midwives, when they begin working with patients, they have to go over forms about their practices and what they do, and what we're trying to add. ... is a notification sheet that basically educates patients on high-risk categories," he said. "It just comes down to safety.

"I certainly support midwives and support what they do. We just need to make sure we are giving these women all the information that they need."

A second Lohr-sponsored bill, which would deny reimbursement to midwives who attend high-risk home births, didn't make it out of committee.

While researching several cases involving midwives that went before the Virginia Board of Medicine, Lohr said he found that each involved a high-risk patient.

According to the Board of Medicine's Web site, a Virginia Beach midwife's license was suspended for at least two years following two stillbirths to morbidly obese women who delivered breech babies.

In one case, the mother carried strep B, and failed a one-hour glucose-tolerance test, according to a Board of Medicine order. The midwife moved up the woman's estimated due date, and waited more than 24 hours after her water broke before performing a vaginal exam, the order says.

Despite the fact that the baby was premature and she'd never delivered a breech baby, the midwife didn't send the patient to the hospital, and in fact didn't call paramedics until the lifeless baby was born, the order says. The midwife had the mother sign a consent form to continue the delivery despite the breech position of the baby.

"However, the informed consent to a home vaginal breech delivery signed by Patient A and her husband did not specify stillbirth or death of the baby as a risk of such a delivery," the order says.

The baby had a ruptured liver and a strep B infection, it says, and an autopsy indicated a C-section could have saved the baby, who was born in January 2008.

The same midwife was involved in another stillbirth last June. That mother was Rh negative and was 42, among other risk factors.

In that case, the midwife spoke to paramedics about the partially delivered breech baby, telling them to wait a half hour for her to get to the patient's home.

Lohr said the bill was originally met with some opposition, but now the midwifery lobby has come on board, Lohr said.

That's true, said Rebecca Bowers-Lanier, lobbyist for the Commonwealth Midwives Alliance.

"We decided that we not only support it, but [wanted to] strengthen it so that all midwives can work with the Board of Medicine in creating standard practices around informed consent and disclosure," Bowers-Lanier said.

While midwives provide informed consent throughout every stage of pregnancy, she said, "it hasn't been standardized, and they realize that."

Potter, who is the policy liaison for the Commonwealth Midwives Alliance, said she thinks the proposed legislation will be "precedent-setting."

"The thing I'm most excited about is medicine and midwives are going to be on the same page," she said. "I feel like this is the first step in a peace process between physicians and midwives practicing in Virginia."

Good communication between ob-gyns and certified professional midwives will benefit mothers and babies, said Potter, who practices in Charlottesville. The bill should help reassure physicians that midwives are providing their clients with adequate, informed choices, she said.

The midwives alliance is submitting a substitute to the bill that would require information given to expectant mothers be "evidence-based," Potter said.

"We will let the evidence, the research, the studies dictate what we tell our clients in terms of risks of home births," she said. "That is the midwife model of care."

Most women interested in having their babies at home are healthy, according to Potter, who says she attends about 40 births a year.

About two dozen certified professional midwives practice in Virginia, Bowers-Lanier said. These differ from nurse-midwives who mainly work in hospitals in collaboration and consultation with doctors.

Marshall University and Shenandoah University have recently teamed up to offer a master's degree in nurse-midwifery. Shenandoah has had the degree program for several years now.

"Certified professional midwives only attend births outside of hospitals," Bowers-Lanier said.

She said the C-section rate for women who use midwives is between 5 percent and 9 percent, compared to 31 percent for women who give birth in hospitals in Virginia. Bowers-Lanier said about 10 percent of women who intend to have home births wind up in the hospital.

"Most people go in for pain relief," she said. "They just can't make that final push and they need pain relief."

Slusher, of Harrisonburg Ob-Gyn Associates, said she and other obstetrician-gynecologists have seen cases of midwives attempting to deliver babies for women who have previously had C-sections. The American College of Obstetricians and Gynecologists recommends that labor only be tried if an obstetrician, anesthesiologist and operating room are immediately available, she said.

"These patients are at risk for uterine rupture," Slusher said.

That almost always results in a dead baby and is dangerous for the mother, she said.

"Our concern is for women to think it's an OK thing to do at home," Slusher said.

There have been failed attempts at home deliveries after C-sections, she said, which led doctors to realize this practice was occurring.

"I'm not opposed to people having choices and being able to do what they need to do, but I do think the people responsible for home deliveries ... need to also assume the responsibility to conduct them in a safe fashion," Slusher said. "I have no idea how many are going on in the region. What I'm concerned about is if one is going on and [the uterus] ruptures at home, [and] the mother and baby die, that's one too many. Especially, if that person wasn't appropriately counseled that it was an inappropriate delivery to try at home.

"Anything that we can do to make the home midwifery practices safer and more practical would be welcomed by the obstetric community because when they have disasters, they fall in our laps unexpectedly for cleanup. They fall into whoever's on call lap. You have inherited a disaster and get the privilege of dealing with it and owning it. When you have never been consulted throughout the entire pregnancy and when it's inappropriate, it becomes an even greater problem."

Contact Sally Voth at svoth@nvdaily.com

http://www.nvdaily.com/lifestyle/2009/02/legislation-would-impose-new-r.html