Baby Daxton was born at the Carolina Community Maternity Center, the birth center in Fort Mill, South Carolina, that I used to own. He died shortly after his birth on January 20th, 2015. On June 4th at the coroner’s inquest, I took notes furiously as Daxton’s father, R.G., testified. This summary, based on those notes, tells the story of Daxton’s birth from his father’s perspective. Where my notes are unclear, either due to the nature of note-taking or my inability to hear at the time, I have put my best guesses in brackets. My commentary also appears in brackets.
M.G. [Daxton’s mother] heard about the birth center from a client of the chiropractor that she worked for. The couple went for a tour and decided that they wanted Christine Strothers to be their midwife. She was an RN as well as a midwife, which they felt provided extra “security.” They met Lori Gibson and liked her, and requested that she be the “second midwife” at their birth.
[South Carolina birth center regulations require two midwives to be present at every birth. Christine was arguably the most popular midwife at the birth center while I was there. I believe that her RN credential and her hospital Labor & Delivery experience, which she often mentioned, gave most parents a sense that she was a safer choice.]
They had no issues during prenatal care, but they started getting worried about risking out due to approaching 42 weeks gestation. Christine told them they could switch to using the ultrasound due date instead of the date established by “last menstrual period” to get an extra week. She did not discuss any risk factors of approaching 42 weeks gestation, only that the rules stipulated that it wasn’t allowed to go beyond that point. Thus, M.G.’s due date was moved from January 5th to January 12th.
[Note: this is a common practice among midwives. I did this myself. We don’t want our clients to risk out for being past their due date, so if we can find any excuse to move the due date later, we will. Seldom, if ever, are the true clinical risks of going postdates seriously discussed with clients. Most of the time, clients are under the impression that the “risk” is simply not getting the nonhospital birth they envisioned.]
The evening of January 19th, M.G. went into labor. R.G., M.G., and her mother arrived at the birth center at about 2am on the 20th. Christine put M.G. into the bathtub and used the doppler to listen to the baby. She listened for a few seconds and said that if that was the baby’s heartrate, it was way too low. She listened a few more minutes, the baby’s heartbeat came back to where she felt comfortable with it, and she said that she thought they were “back on track.”
[In hindsight, this was probably Daxton’s last best chance to live and a vital opportunity missed. In all medical likelihood, Daxton was showing serious signs of distress by 2am when Christine was concerned about his heart rate.]
M.G. labored in the tub for over two hours. During this time, apprentice midwife Stacy Gunter came into the room. Later, midwife Lori Gibson also entered the room. Fetal heart tones were checked “several times.” M.G.’s water was suspected to have broken while she was in the tub. Christine suggested that M.G. leave the tub so that she would progress better.
[It is entirely feasible that a midwife would suggest that a client get out of a tub to help her progress. However, an alternative theory is that the midwives noted meconium staining in the amniotic fluid and/or heard a fetal heart rate that caused them concern. When a midwife suspects fetal distress, asking the client to get out of the tub is very common. It is much easier to resuscitate a compromised baby when the client is on the bed, rather than trying to do so over a tub of water. Christine’s true motivation for getting M.G. out of the tub at this time is known only to her.]
When M.G. got on the bed the midwives checked the fetal heart rate again. They then put an oxygen mask on M.G.’s face and told her it was to help her calm down. M.G. expressed that she did not want the oxygen mask, but they insisted that she needed it. For the next 30 to 60 minutes she wore the oxygen mask, and then was permitted to remove it for a while.
[Oxygen is not generally used to help moms calm down. It is usually used because the fetal heart rate sounds worrisome. It defies belief that they would require a woman who did not want to wear the oxygen mask to wear it for over half an hour simply because they thought it would calm her down. Over thirty minutes is a very long time to be worried about a fetal heart rate and not at least discuss, if not arrange, transport.]
Shortly before M.G. started crowning [when the baby’s head is close to being born] the midwives told her to put the mask back on to help her relax. They instructed her to breathe the oxygen in deep to get oxygen to the baby.
[Again, oxygen is not generally used to help people relax. In all likelihood, they were worried about that baby. The phrase “breathe deep to get that oxygen to the baby” will sound familiar to almost any midwife; that is exactly what we say when we are hearing decelerations in the fetal heart beat that concern us.]
Around time of crowning, the midwives became very concerned that the baby’s heart beat could not be found. They shifted [the Doppler? Or M.G.? My notes are unclear] around and finally did find the heartbeat.
[Note: it is possible to detect the mother’s pulse through her abdomen and mistake it for the baby’s heartbeat. This could possibly have happened in this case.]
The couple was later informed that M.G. crowned for about 9 to 10 minutes. A sense of urgency seemed to increase among the midwives as the birth approached. They started talking to the couple less, and to each other more. Christine noted aloud that she saw the baby’s head moving, and instructed M.G. to “keep breathing the oxygen.” Christine told one of the other midwives to get the manual resuscitator ready [Ambu bag and mask]; she said she didn’t think they were going to need it, but she wanted to have it close by just in case.
[This part of the father’s testimony painted such a vivid picture, I felt like I was there. This is not a story that a layperson without experience at midwife-attended births could possibly have made up. This is exactly what it’s like when you’re at a birth and things are tense because you are worried that a baby may be born compromised.]
When Daxton was born at 9:03am, Christine immediately put him on M.G.’s chest. R.G. could tell right away that Daxton was very limp and lifeless. [The baby or the fluid around him] was the color of chocolate milk, or maybe a brownish green color. Christine put the manual resuscitator on his face and started to use it, but she was concerned she was not getting a good seal, so she stopped using it. Christine sent M.G.’s mom out to the reception area to find another midwife to come and assist.
At that point Lisa Johnson came in with a suction tube [probably a DeLee] to try to suction out meconium. Around the same time, Stacy called 911. She did not know the address of the birth center, so there was a delay as she asked everyone what the address was. Meanwhile, Christine started CPR [likely chest compressions].
[I don’t understand why a DeLee wasn’t used before Lisa arrived with one. Did they not have one already in the room? Why not? The birth center has a mechanical suction device. Why didn’t Lisa or anyone else drag that thing out of the closet? Stacy not knowing the address is hardly surprising. Midwives don’t tend to do regular safety drills, and posting information on the wall in case of emergency isn’t “pretty” or “homey,” so we don’t do it.]
When the ambulance arrived, the paramedic entered the room and called for the EMT to bring equipment. Then he decided that they didn’t have time for that, so he went to take the baby in his arms, but the baby was still attached to his mother via the umbilical cord. It took a bit of time to find the scissors and cut the cord. As soon as it was cut, he took the baby to the ambulance. R.G. rode in the front of the ambulance to the hospital.
[Note: many midwives believe that you should never cut the cord during a resuscitation because the baby can continue to receive oxygen through the cord. By this point I think it should have been plainly obvious that Daxton was not being oxygenated any longer by the cord and placenta.]
When R.G. entered the hospital, a man stopped him to get his name, address, and insurance information. A nurse walked up and said, “We don’t have time for this,” and took R.G. back to the room where Daxton was. A team of 8-12 people were inside surrounding Daxton. A doctor stepped away to speak to R.G. The doctor explained that there was nothing they could do. He also said that he felt if Daxton had been born in the hospital, they probably would have been able to identify the issues earlier and would have been able to save him.
Please read Daxton’s Midwife Testifies for Christine Strothers’ version of the story.
Read It Could Have Been Me for my first reaction to the jury’s decision of homicide.
Oh my god. That poor father, this sweet baby. I hope those midwives never practice again.
As far as I know, they are all still practicing. It is incredibly difficult for the state to rescind a license the way the law is currently written.
Has her nursing license come under scrutiny?
I left this out for the sake of brevity (Christine’s testimony lasted about an hour) but her nursing license had actually lapsed for some time. The coroner was actually the one to bring the lapse to her attention. I assume she got it reinstated.
I’m just not even sure how to feel after reading this. So many emotions flowing. I, too, had my due date pushed back a week when I got close to 42 weeks. I, too, was asked to get out of the tub. I just can’t even imagine. My son arrived happy and healthy and all is well (thank goodness) but I just can’t even imagine being told that my decision resulted in his death and feeling like I had been “duped” by people in whom I had placed my safety and the safety of my unborn child. I know how I feel now after reading this (guilty) even with everything turning out fine, but to have things go the other way is just completely unimaginable. No words. My heart breaks for this family.
Thank you Jess for reading and for your comment. It brings to light an important truth: usually, midwives get away with risky decisions. The more risky decisions you get away with, the more you tend to make. Only once in a great while does risky behavior actually catch up with you.
How awful. I can’t even imagine being this family and losing their precious baby in such a manner.
Do you think you would have testified in a manner so as to save your livelihood when you were still practicing or is it that when you are repeatedly working this way you begin to believe your own little lies such that they almost become truth save for the voice in the deepest part of you? Or perhaps a bit of both?
That’s a really interesting question, Melissa, and really hard to answer.
I imagine that, in retrospect, their handling of the birth seemed really poor in their own estimation. I imagine their minds thought, “I can’t have done something that bad.” And I imagine they would have started rewriting the story, mentally, in a way that they could live with. And they told that story a few times until it sounded like what should have happened, and it became what happened.
I would like to be able to tell you that I would have told the whole honest truth up there on that stand if it had been me, and faced up to all possible consequences. But I know I’m human, subject to the same frailties that they are, and maybe I would have done the same as what they did. I’m glad that I will never know.
mec and decels, hmmmmm, let’s just pretend everything’s just fine. That’s what it sounds like from my reading. Pretty clear early signs that something was amiss. Too bad the midwives opted not to recognize them or to respond appropriately. You listen intermittently through a complete contraction until after the contraction has ended, and you document baseline and the presence or absence of any accels or decels heard. You listen and document according to ACOG/AWHONN guidelines. You know the street location of the birth center. It’s hanging on the wall next to the phone. You have full resus going on when paramedics arrive, complete with ventilation and chest compressions in an orchestrated and effective manner. It doesn’t sound like NRP was really happening. Unless someone was ventilating the baby while chest compressions were simultaneously being performed, this baby’s condition was not being treated.You detach the cord before paramedics get there. It’s likely been many minutes from the birth and the cord is done enough. Tragic.