I spent my day at the York County courthouse at a coroner’s inquest to determine the manner of death of a baby that was born at my old birth center in January. The jury of six was given four options for manner of death: natural, accidental, homicide, or unable to determine. After listening to testimony from the baby’s father, a slew of expert witnesses, the midwives who were present, and more, the jury came back with a decision that shook me to my core.
Daxton Green’s death was determined to be homicide.
The basics of the case, which are a matter of public record now, are this: the mother was either 41 weeks or 42 weeks pregnant, depending on if you used her Last Menstrual Period (LMP) date or her ultrasound date. The doctors who testified seemed unanimous that the LMP date, which put her at 42 weeks, was the one that should have been used, but her midwife opted to use the ultrasound date instead, saying that she considered an early ultrasound more accurate than LMP. The midwives all told the same story: the baby’s heartbeat was always just fine, and they put the mother on oxygen only to treat her lightheadedness and help her collect herself. The amniotic fluid was clear until the baby’s head was born and shoulders released, at which point heavily meconium-stained fluid was revealed. They attempted to resuscitate him and called 911. The baby was declared dead shortly after arriving at the hospital.
The witnesses who testified included: the father of the baby, the doctor who saw the mother for her two required medical visits during pregnancy, the paramedic who responded on the scene, the EMT who responded, the perinatal nurse administrator with the Department of Health and Environmental Control, a maternal-fetal medicine (MFM) specialist, the pathologist who performed the autopsy, the midwife who managed the labor and birth, the second midwife present, another midwife who was on the premises, the apprentice student midwife present, a perinatologist, and the baby’s grandmother. The birth center’s consulting physician was unable to attend due to a death in her family, but her testimony was read aloud to the jurors.
The medical witnesses (specifically the MFM, the pathologist, and the perinatologist) were all very clear that the midwives’ story did not make sense to them. They testified, based on their examination or on the records that they reviewed, that Daxton was completely overwhelmed by meconium, completely, inside and out. No one thought it was feasible that the midwives could have seen clear fluid. They indicated that the midwife should not have moved the due date, did not adequately monitor the baby during labor, and did not do a proper resuscitation. They indicated that oxygen should never be used for the purpose that the midwives stated, but that it could be used during repeated deep decelerations that should cause great concern for the baby’s wellbeing. The perinatologist made it clear, as the director of neonatal care at a well-known local children’s hospital, babies do not die like this in the hospital. This death would have been prevented in a hospital setting.
The jury heard all the testimony and received all the evidence. They deliberated for a while and returned to the courtroom. The coroner, in a judge’s robe, asked them for their decision. When she read that word, homicide, I gasped. My whole body went numb. I was truly absolutely stunned.
I would like to believe that I would have listened to that baby more carefully than they did. I would like to believe that I would have listened more often and for longer periods of time. I would like to believe that I would have seen the meconium and reacted appropriately when I saw it. But the truth is, I will never know. Maybe it could have happened to me. To one of my clients. I will never stop being relieved that it didn’t.
I mean, that midwife was the most popular one at our birth center. She has a cult following. She is a registered nurse with L&D experience in addition to a licensed midwife. Do I really believe I was so much better at midwifery than her? Was I really so much more careful than she was? Realistically? I can’t sit here and tell you that I was.
I am tired and overwhelmed for now, but will share more details about this in the days to come. If you have questions, feel free to leave them in the comments.
Further honest midwife coverage on this case:
9 thoughts on “It Could Have Been Me”
Were the tracings recorded?
Jenny, if you mean the fetal heart tracings, the answer is that none were done. In a nonhospital birth center, heart tones are checked using a handheld doppler. The midwives listen to the heart rate, count it, and record a number (or a range) in the chart. This presents a problem for accountability, because bad hearttones could be left undocumented for the midwife’s benefit. The midwives did not report any decels during the entire labor until crowning, and then only down to 110, which is normal. They wish us to believe that this baby had stellar hearttones during the entire labor, and then was born either dead or nearly so. (The midwives claim he had a heartbeat when he was born, but considering everything else they wish us to believe, I have no reason to think that this is necessarily true.) By the time the paramedic got the baby hooked up to a monitor in the ambulance, there was no heartbeat.
This is very tragic for the baby/family and the providers. While I would never choose such a delivery scenario, people that do accept a certain amount of risk. The baby is not being monitored. That is the key point. I work in this field, as well, and know that neonatal rescusitation of a baby like that takes a team of qualified personel. That said, delivering in a free standing, likely unregulated birth center is almost like delivering at home. If something goes wrong your baby is more likely to die. I don’t know the percentage, but a 42 week delivery will most likely have meconium stained fluid. Most people who work in labor and delivery know this. However, I don’t think the midwives should be charged with homicide. I hope this doesn’t start a trend for seeking relief in the courts in the event of a poor outcome. Prayers to the all involved.
If you had gone for a tour of the facility, you would have been assured that the baby is carefully monitored using evidence-based intermittent monitoring. You would have been assured that this was very safe; safer, in fact, that what the hospital does. And since you would be being told this by a licensed professional in a licensed and accredited facility, you probably would have believed it.
You as a professional know that the risk of death in a birth center is much greater than in a hospital, but I refuse to blame the parents for not knowing that. We were very convincing as we sold our services.
Today I am releasing detailed summaries of the father’s and the midwife’s testimony. I hope that you’ll read it and give your opinion then.
Did the family film or photograph any of the birth? Just curious if they were able to use any video or photos to check the validity of some of the statements, such as; if the tub water was clear or how long the mother was truly actively pushing.
I feel certain that if there were any pictures or video they would have been presented as evidence to the jury, and none were.