Midwife Outcomes, 300 Babies Later 6

300 Babies! Once again, I am honored and humbled to be in this position serving women and their families. I am eternally grateful for my own family who make it possible for me to do what I love; particularly my amazing husband who is my rock and my own Mother who is my biggest cheerleader and the best Grandma ever! I am also thankful for the birth center, it is a labor love and passion to work at and keep a birth center open, and I am thankful for each and every person who has worked with us in the past and present.
I have kept a detailed birth log since starting as a student midwife. I am committed to maintaining this personal tradition for a few reasons. I love periodically reading back through the birth stories, especially during trying times to remind me why I struggle and fight. I am a writer of sorts and it has now become a part of my process after each birth. And the reason I started keeping the logs in the first place, to have a record of my own outcome statistics. I cannot speak highly enough of this point, as midwives it is our duty to keep these records. Through these records we can objectively look at our outcomes to ensure that our practice is indeed providing the best care. Transparency is critical. I openly share my outcomes, some of which are difficult to share, in the hopes to inspire others and to keep myself honest. I will gladly discuss my outcomes, if the discussion is respectful and from a place of true constructive criticism.

Also, I work in a group practice, please know that these statistics are my own personal outcomes for the births that I have attended and are NOT from my birth center as a while. As a practice, we also diligently maintain and review our outcomes and participate in the national birth center data collection database, Perinatal Data Set or PDR.

Without further delay, here we go;
148 girls and 152 boys; 6 of these sweet ones were born en caul

Postpartum Hemorrhage: my overall rate is 16%, this is high and I have spent a lot of energy into looking at these numbers. (Please see the discussion from “Stats…200 Babies” and the follow up “The Great Chux Weighing Experiment”) For births 201-300 I have been weighing each and every Chux pad and recording the actual EBL down to the ml. What I discovered is that for the first 200 births, I was over estimating EBL. Also, I have been more thoughtful about what actually constitutes a PPH. One woman may lose 700ml but not require any anti-hemorrhagic medications and not develop any symptoms of high blood loss. On paper, she technically has a PPH, but did she really? I would love to discuss this question….

Shoulder Dystocia: overall rate of 6%. This is another outcome that seems very high! However, in looking back, the vast majority were mild and under 60 seconds from birth of head to birth of the body. Some practitioners may not even consider those as dystocias. In looking at each birth, if I only
included times greater that 60 seconds and births that required more than one maneuver to relieve,
then my overall rate would be 2.3% which is much more appropriate. I think that I have been too quick to “label” these births. Again, would love a discussion on this topic…..

I preformed AROM in 13% of labors and it was always done as augmentation and with informed consent after discussion with the woman and her family.

I have had 6 retained placentas. In my birth center, per state regulations we have a time limit of 30 minutes for the birth of the placenta.

I have done a manual removal of the placenta twice, both times were for active heavy bleeding related to partial separation. I have had 4 cord avulsions, only one was severe and required newborn
transport. I have found one true knot in an umbilical cord. I have had one labial hematoma, which
resolved on its own and did not require transport.

My episiotomy rate is 3%. All of the episiotomies were done due to significant fetal heart decelerations with crowning. Approximately, one third of them extended to third or fourth degree lacerations.

Lacerations; intact = 102, first degree = 87, second degree = 95, third degree = 12, fourth degree = 4. For the vast majority of the third and fourth degree lacerations, they were either as a result of episiotomy or the birth happened on the birth stool. I have recently been actively working against birth stool birth for this reason, and that I have noticed higher blood loss. I still use the birth stool in second stage, but as birth approaches I encourage the woman to change positions.

My water birth rate is 37%.
Birth positions (I have rounded these rates up or down to the nearest whole number); hands and knees = 30%, semi-reclining = 17%, birth stool = 17%, McRoberts =14%, squatting = 11%, side lying = 9%, standing = 1.5% and supine = 0.3%.

I have transported 12 newborns; 7 for Transient Tachypnea, 2 for anomalies, 1 for congenital pneumonia and 1 for pneumothorax.

I have transported 27 women after the birth; 16 for laceration repairs, 5 related to PPH and 6 for retained placenta.

So there it all is. In the next couple days, I will post an update with my outcomes for transfers in labor, those births are not included in these numbers. I am ready and open for discussion…

**Update on 12/31/14**
I have just finished compiling my outcomes for the Ladies that I have transferred. At my birth center, when transfers are necessary, we work with some amazing OB’s and are very lucky to have them. One of them actually does vaginal breech births! Also, once a client has transferred, we are no longer involved in the clinical management of their care.
Here goes: 39 women have been transferred by me to the hospital in labor. The primary reason was failure to progress or arrest of dilation. We do not have time limits on progress and our ladies are not on any type of clock. The decision to transfer for this reason is one based on how she and baby are handling the labor and is one made in conjunction with the entire family. They are not typically quick decisions and have a lot of thought behind them. The other major reason for these transfers was the presence of meconium in the waters. Per our state regulations, we are required to transfer for this reason unless “birth is imminent”. Of those women who transferred, 18 had cesarean sections and one gave birth via Forceps assisted delivery. This gives me a c/section rate of 5.3%.

Image credit Crowned Photography

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6 thoughts on “Midwife Outcomes, 300 Babies Later

  • Lauren Riordan

    I have also been questioning the label of PPH across the board for all women with over 500 cc blood loss. I too have been weighing and measuring lately. I believe that women come in all shapes and sizes and may have different amounts of blood to lose as part of their normal birth process. I think you are right to question– no need for meds and asymptomatic– is it truly a PPH?

  • Allie

    Very interesting post! Regarding your PPH statistics…I would just wonder why you might hesitate to give meds for someone who has an EBL over 500mL? If someone has an EBL of 700 from a vag delivery, I just don't know what would stop me from giving something just in case. Even if she isn't showing any symptoms of extreme blood loss, I still would err on the side of caution since she could still be at risk of a delayed PPH. And if a delayed PPH does occur, it would be made even worse by the high initial EBL. Hope that makes sense…

    Also interesting observations about shoulder dystocias. At my hospital, once a dystocia is noticed, it is called and charted as such whether it lasts 20 seconds and takes one maneuver or 4 minutes and many of them. Though this is partly because there is a strict shoulder protocol at my hospital which activates many people from OB and Peds responding just in case. So I would encourage you to continue labeling dystocias if you notice one even if it may make the statistics higher!

    Sorry for the spacey thoughts. These are both very interesting questions that you have posed! Hopefully others will chime in.

  • JACC

    Thank you for this post and all your posts! I love seeing your c-section rate 🙂 I hope to apply to school to be a CNM within the next year or two. I am looking at Frontier. Where did you go to school?

  • Ashley

    Good for you for objectively evaluating your stats and being willing to share them!
    I'm a Nurse Midwife who has practiced at home, birth center, teaching hospital, and private practice. My own first baby was born at home and the plan is for number 2 to be born there as well in Oct!
    Regarding shoulder dystocia, I have patiently witnessed a delay of up to 4 minutes from birth of head to body where the baby rotated spontaneously, remained pink, neck was visible, and shoulder easily palpated. On the other hand, I have seen a baby immediately turtle and turn purple, to which I have responded instantaneously with maneuvers. I do not think time can be used to define a shoulder impinged on pubic bone.
    I'm curious if the high cord avulsion rate is related to cord traction on an attached placenta under the pressure of the state mandated 30 min 3rd stage time limit.
    What low cesarean and AROM rates!
    I'm also impressed by your newborn transfer rate. That number being high seems to demonstrate your NICU expertise at recognizing sick babies and keeping them safe.
    What you think of your episiotomy rate? I've done two in my 7 year career, one for a true shoulder. Obviously 3% is still quite low. I think I'd get mom upright for a terminal decel before I'd cut. How did those babies seem when they were born?
    Thanks again for the discussion. It's so important to keep ourselves and each other accountable!

  • With Woman

    Ashley, thanks for your thoughtful response. I love discussions on these topics.
    The cord avulsion rate is a good question, looking back; two were waterbirths and in both cases the cords were very short and the Mama was very excited to bring the baby up. One was a significant vellamentous insertion and the other had no clear cause. I will typically apply very gentle traction at around 15 minutes if I haven't seen any signs of separation.
    The shoulder dystocias are tricky! I think earlier in my career I was perhaps too quick to call them. However, I have had a few true and serious ones. I was at a birth recently, the birth of the head was very, very slow and then there was a definite "turtle sign". I was very proactive and immedialtely had the woman go to hands and knees and reduced the anterior arm. So it ended up being just under 60 seconds but was absolutely a dystocia. I tend to let babies restitute and am comfortable with a time elapse between head and shoulders if everything, like you mentioned, is good. Basically, I agree with your observation about the length of time that passes versus the other 'symptoms'.
    About episiotomies; I absolutely preform them much less now that I have been practicing longer. I have become more comfortable with those decels that happen as the babe is 'making the turn' and I have become adept at the 'verbal epis'….telling the woman that her babe needs to be born quickly, etc.
    I am indeed very protective of the babes and also agree that my NICU experience has influenced my training and philosophy.
    Thanks again for the great discussion.