Sunday, January 11, 2009

Failure to rescue

I'd like to propose a new way of thinking about preventable death at homebirth. A more accurate description might be "failure to rescue."

This phrase is used in analyzing quality of care in various aspects of medicine. It refers to the deaths that could have been prevented, either by more careful monitoring to recognize an emergency, providing appropriate care, or providing appropriate care in a timely fashion.

Not all homebirth deaths represent a failure to rescue. Some are caused by abnormalities incompatible with life. However, most homebirth deaths are caused by failure to rescue and it is easy to see how that happens. First, by the very nature of homebirth, it is impossible to provide appropriate care for an immediately life threatening emergency. Cord prolapse, massive abruption, and fetal bradycardia will result in perinatal death in the majority of cases. Simply by choosing homebirth, parents ensure that no one will be able to rescue a baby in immediate danger of death.

The lackadaisical monitoring, and the minimal knowledge base of most direct entry midwives dramatically increases the risk of failure to rescue due to failure to recognize the problem. That's why there are unanticipated homebirth deaths. The midwife has literally no idea that the baby is in serious trouble and therefore does nothing to prevent the death. A dead baby drops into her hands, a situation that is virtually inconceivable in a hospital setting.

The third type of failure to rescue, inability to provide appropriate care , is also more common at homebirth. Even if a DEM recognizes a problem, she often cannot handle it appropriately, and more importantly, she lacks the knowledge and equipment to perform the expert neonatal resuscitation that may be needed. Problems in this category include shoulder dystocia and breech with trapped head or nuchal arms. Most of these babies will simply die at home.

The key advantage of the hospital is the ability to rescue babies who need to be rescued. Parents choosing homebirth are simply betting that their baby will not need rescue. Unfortunately, if it does, the baby will most likely die as a result of failure to rescue.


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