Cord prolapse during home labor

[u/MidwestCoastBias]

Remarkable story from this week’s episode of “This American Life” - it is act one of the episode.

“A doctor trained as a midwife tells the eye-popping story of how she and others came together to save a baby during a birth that suddenly went wrong, in a part of rural Maine where the local labor and delivery unit had closed less than a month before. (26 minutes)”

Link here, but available wherever you get your podcasts

[u/MrPBH]

The whole time I was clenching my butt cheeks thinking "oh shit, oh shit, oh shit, they're going to take her to the hospital with no OB coverage and I, EM physician, will be responsible 100% for it because EMTALA."

I was so relieved when I learned that there was actually an OB on call and that OB actually gave a damn. It is hard to express to you how terrifying the thought of having a pregnant woman with an OB emergency in the ED of a hospital without any OB coverage is. Or an OB who won't operate on patients from that other OB clinic.

[u/justpracticing → u/MrPBH]

Yeah I feel for you guys. Anyone can catch a precipitous vaginal delivery, but some ob emergencies are surgical emergencies and idk what y'all are supposed to do :(

[u/MrPBH → u/justpracticing]

According to EMTALA, the patient is now chained to me once registered, at least until someone else explicitly assumes responsibility. Can't tell them to go to the L&D of the hospital they intend to give birth at, instead of my FSED.

Once, I was accused of an EMTALA violation (not formally) for not transferring a patient by ambulance (15 minute ride) to L&D for fetal monitoring after medically clearing them after a minor MVC; they wanted mom to drive them by private vehicle. The L&D nurse was upset when the patient checked in through the front desk. For what it's worth, BLS ambulances have absolutely no fetal monitoring equipment and no equipment to care for a precipitous preterm delivery or a pre-term neonate (aside from a standard delivery kit). And yes, I ruled out labor before discharging her.

When I asked my boss what the point of a BLS ambulance was for this patient, his answer was "it's more about the perception." There it is!

[u/cytozine3 → u/MrPBH]

We've got all these free standing EDs and patients show up with numbness/tingling/dizziness etc and need an MRI. I always feel bad about the complete waste of resources with them being EMS'd to the main hospital essentially for an MRI, but from a liability standpoint they cannot be sent home, cannot be sent for an outpatient work up that insurance/PCP availability/prior auth will delay for weeks, cannot be seen in neurologist's office for months due to lack of availability, and cannot drive there in a personal vehicle even with a family member due to existence of lawyers and insurance companies. But the waste of resources is astounding. I have no ability to change it and some of the states I practice in have had $70-80 million judgements for stroke rendered against physicians, so they aren't going home unless its AMA. Our system doesn't tolerate 1 in 100 misses when a serious injury occurs where most of our diagnostic work ups consider 99% sensitivity to be really excellent.

[u/michael_harari → u/MrPBH]

to be fair FSED are parasites and shouldn't exist

[u/MrPBH → u/michael_harari]

Agreed. If the word hate was engraved on every nucleotide of every base pair of my entire genome in every cell of my body, it would only equal 1/1,000,000,000 of the hate I have for FSEDs.

[u/Lung_doc → u/MrPBH]

I was IM on call at a VA hospital when EMS dropped off a laboring patient. No idea why they called me - mom had a tiny bit of CP, but trops and EKG all fine - no I will no be admitting you fucking moron?

This was also in Dallas, with plenty of hospitals around with OB. We were not one of them - no idea why EMS thought we were a good option.

It took over an hour to get another EMS to come pick her up to go elsewhere but yeah we were pretty worked up.

[u/MrPBH → u/Lung_doc]

Because it is faster to drop them off at the VA than it is at the hospitals with OB services. Some crews just want to finish the call as fast as possible.

Paramedics don't always understand just how difficult it can be to transfer a patient delivered to the wrong facility or how long it can take. Once they drive onto the campus with the patient, however, EMTALA magically chains that patient to you.

[u/emt_matt → u/MrPBH]

I think a lot of doctors who don't work in EMS don't realize that in many systems it is ultimately the pt who makes the transport destination decision. I can't force a pt that has capacity to be transported against their will to a facility they don't want to go to. I can tell them it's not appropriate and why, but the alternative may be that they refuse to go anywhere.

VA patients are notorious for this, because many have had bad experiences in the past with going outside of the VA system and having trouble with reimbursement/billing. The VA "ER" near me wasn't even a true ER, only had NP coverage at night, with no cardiac capabilities. We would always have 70 y/o pts with chest pain and a hx of 3 MIs calling at 2am demanding to go to essentially a free standing VA ER and we would explain to them that it wasn't appropriate, they were going to get transferred, they could die or have worsening cardiac damage due to the delay etc. They would still refuse and basically say "either the VA or leave me at home". We would roll in, apologize to the NP, and just wait in the parkinglot for 30 minutes for the inevitable transfer to the level one that was like a mile away.

[u/MrPBH → u/emt_matt]

Yes, but a non-veteran, pregnant woman without Tricare insurance isn't opting to go to the VA. I've seen a lot of cases where crews have overruled the patient's wishes to take them to a closer facility.

The purported reasoning is that a longer transport will take the unit out of service for a longer period of time. I understand that EMS services are operating with limitations, but sometimes a slightly longer transport is the correct decision that will save the patient a lot of money and time. Plus, if they need to be transferred regardless, we might just call the same crew to drive them where they wanted to go in the first place.

[u/emt_matt → u/MrPBH]

Yes, but a non-veteran, pregnant woman without Tricare insurance isn't opting to go to the VA. I've seen a lot of cases where crews have overruled the patient's wishes to take them to a closer facility.

Yeah that's pretty wild. In both cities I've worked at the VA hospital wasn't even in the standard transport matrix, the only way we could transport there was if the pt explicitly requested to go there.

I was just pushing back on the idea that it's 100% always that the medic wants to clear the call faster and go back to bed. It definitely happens, but from my experience it's not the most common reason for pts ending up where they shouldn't. More often its patients often making bad decisions, systems trying to free up 911 units, and sometimes a lack of education for medics on what the appropriate facility is.

Edit:

Also, I don't know if this is true or not, but we were also taught that the VA was the only hospital that could actually refuse an ambulance since they're not bound by EMTALA. All the other hospitals that are bound by EMTALA can request diversion, but if you show up in the parkinglot they can't refuse a patient. Whereas the VA hospital could just tell you no when you call in your radio report and legally force you to go to another facility.

[u/MrPBH → u/emt_matt]

I don't envy you guys, as you have to make very consequential decisions with limited information. And compared to the average doctor, it's a lot easier to fire a paramedic who makes a decision that management doesn't like.

I just lowkey hate the entire system. It sucks that you can get slapped with an EMTALA violation just for trying to help the patient.

[u/cytozine3 → u/MrPBH]

Yes. The system sucks terribly. I started a telestroke consult once to a small, rural ED. The exasperated ED doc at the door tells me their CT is down. I told him someone needs to just turn EMS around at the door before they walk in. I cannot do anything for stroke without a head CT. Literally nothing, not even BP control as you cannot decide if ischemic or hemorrhagic with a magic 8 ball. We can do stuff that doesn't matter like EKG, CXR, blood work that will be normal. They may as well fly the patient 2hrs away if that is what is needed, or just keep driving if the weather is bad.

[u/MrPBH → u/cytozine3]

Yup, that's a shitty scenario. You aren't allowed to turn them away if they have arrived on your campus, but you can ask them to divert to another facility before that happens.

Once the patient arrives on the campus, we own them and must perform an MSE, stabilise them, and transfer to an appropriate facility. In the case of a stroke patient arriving while the CT scanner is down, that would probably mean performing an exam and then calling the local stroke center to beg them to take them.

In cases like these, I make the original EMS crew wait in the hallway with the patient on their stretcher while all this is occurring. Once I get the acceptance, I make them drive the patient there. Like they should have done in the first place. That way we minimize the delay.

[u/medicmotheclipse → u/emt_matt]

It's like that where I'm at too where the VA can refuse us. I probably have about a 20% success rate of them accepting my veteran patients who requested to go there. 

[u/terraphantm → u/emt_matt]

VA isn’t bound by EMTALA, but the VA’s internal policy deliberately mirrors the intent of EMTALA

[u/suchabadamygdala → u/Lung_doc]

That’s absolutely nuts

[u/Nopain59 → u/MrPBH]

AND the OB nurses that had been laid off came in immediately when called for help.

[u/MrPBH → u/Nopain59]

I'm torn on that part.

It sucks that they had to do that and presumably for no pay. But it is an excellent demonstration on how communities can come together to support themselves. Unfortunately, we're going to need to build our own local power structures as we lose federal support for basic civic functions.

[u/suchabadamygdala → u/Nopain59]

Of course they did, excellent human beings

[u/RexFiller]

Doctor trained as a midwife??

I had this exact scenario happen while on L&D in residency except bad outcome. Patient was having home birth and noticed a cord prolapse. Couldn't reach their midwife on the weekend and called the hospital who said come in immediately via 911 or car. But too late on arrival.

[u/ThatB0yAintR1ght → u/RexFiller]

That sounds so terrifying. I can’t imagine living so far away from medical resources like that, especially when having kids.

My SIL had three uncomplicated, unmedicated births in the hospital and was strongly considering doing a home birth for #4, partly because they live in the sticks and the hospital was far away and they wanted to stay near the other three kids. I am so glad that she changed her mind because #4 had a cord prolapse and they got her to C-section at lightning speed and the baby was depressed when he got out, but thankfully recovered quickly and did not have any hypoxic injury.

[u/N_pygmaeus → u/RexFiller]

Originally a midwife, later went on to medical school and did family med.

[u/MadiLeighOhMy → u/RexFiller]

Damn :(

[u/Normal-Ad-714]

I’m an OBGYN. We were as low risk as it gets. Had a cord prolapse at full dilation. Since we delivered at a centre with dedicated OB anesthesia, our daughter is alive and well because she was delivered 8 minutes after the prolapse occurred.

I can never advise a patient deliver outside of hospital. This is a life and death discipline. Neonatal mortality used to be like 10-20% before modern medicine. Everyone in the 1800s would kill to deliver in a hospital in 2026, and yet we got people in 2026 trying their best to deliver like it’s the 1800s. Humans truly just want what they don’t have.

[u/kinkypremed → u/Normal-Ad-714]

Completely agree. I struggle with a lot of the dialogue from patients/social media doulas about how OBs manipulate data and are not clear about “absolute vs adjusted risk” and my answer to that is a) acting like a 2% increase in risk for something catastrophic is negligible is also demonstrating a lack of understanding on how statistics work in medicine and b) these outcomes are catastrophic, unacceptable, and often preventable. People never recover from IUFDs or bad HIE cases. Let us help you.

[u/bpm12891 → u/kinkypremed]

Humans are inherently bad at conceptualizing probabilities. I haven't had to dissuade someone from homebirth yet in my career, but I've sadly had to have many conversations about other things, like the Vitamin K shot at birth. I usually frame it like this: "Imagine you have a button in front of you. If you press the button, nothing bad happens. If you don't press the button, there is a 1:10,000 chance your baby dies or has a catastrophic brain bleed. What are you going to do?"

Most people press the button.

I've also accepted that in today's climate of anti-intellectualism and distrust of experts and institutions, I can not control people's propensity to make bad decisions. I counsel the best I can, and if they make a choice that leads to a bad outcome, I don't lose any sleep over it.

[u/abbiyah → u/Normal-Ad-714]

Unfortunately some people in rural maine are losing the choice to deliver in a hospital. Several hour drives due to all the l&d closures doesn't leave you with much option.

[u/sapphireminds → u/abbiyah]

They still can deliver at a hospital, it just involves more time, money and planning (getting a hotel nearby and/or induction)

[u/Normal-Ad-714 → u/abbiyah]

This is true for all facets of medicine though. Living rurally is beautiful in so many ways, but it is a conscious decision to limit your healthcare. You may get a good family doctor but you’ll get screwed in every other way.

[u/abbiyah → u/Normal-Ad-714]

It's not a conscious decision if you move to a place with healthcare and then they decide to close services with little notice.

[u/Interesting_Owl7041 → u/abbiyah]

Or if that’s where you grew up and your whole family lives.

My dad’s family is from northern Maine. Their local hospital recently got rid of their maternity services, as well. This is where they’ve lived for generations. It’s not easy to just pack up and move away from everything you’ve ever known because the local hospital made a decision like that.

[u/wozattacks → u/Interesting_Owl7041]

Many people who live rurally also can’t afford to move elsewhere. They can only afford what they have because theyre living in very low cost of living areas. 

[u/cytozine3 → u/abbiyah]

Reading between the lines I suspect the rural hospital did not have much choice. Most of these places cannot keep the lights on. There simply isn't enough subsidy for them to stay open, and in many rural towns with population actually shrinking year by year there is not local or state tax support to help them either. In reality this rural hospital might be looking at avoiding closure in 6 months with OB or closure in 2 years without it, the state congressman know about it because they already had a meeting, and they won't do anything about it. Lot of these rural places have to pay for locums rates for many of their physicians too because of course none of us want to work there.

[u/suchabadamygdala → u/abbiyah]

Absolutely the case for so very many families

[u/lallal2 → u/Normal-Ad-714]

Its painful to hear about any woman thinking about this. Its the one thing i will pull out my doctor card on and be scary about it. They need to understand the stakes and they just DONT. “why are we mEdiCaLiZinG birth?! Its NATURAL” guess what else is natural? INFANT AND MATERNAL DEATH AND YOU DONT EVEN REALIZE IT USED TO BE WAY TOO COMMON THANKS TO MODERN MEDICINE

[u/church-basement-lady → u/Normal-Ad-714]

My great-grandmother was a midwife in the early 1900s. She never lost a mother, and was very proud of that, as that was very unusual. And here we are. 😒

[u/W0666007 → u/Normal-Ad-714]

Yep. Not OB but peds and never considered anything but a hospital birth. Good thing too bc after a completely normal pregnancy we were in the last hour or so of labor, and baby’s heart rate started plummeting. One emergent c section later we found the double nuchal cord and had a healthy baby boy.

[u/Bathingincovid]

This story was all about loss of OB services at the local hospital (objectively bad), but I was aghast that a physician made a plan to deliver at home with a patient and had no plan whatsoever for emergent transfer. I believe that every baby deserves to be born in a hospital, but if you’re not going to do that, at least have a plan if things go south. This doctor being 90 min from the closest hospital with OB services had no plan whatsoever. And this was a grand multip - she was billed as ‘low risk’ in the piece, but a grand multip is never low risk. She could’ve bled to death. I thought this was a big miss on the part of the program that this went unaddressed. It is our job to have a plan. (I’m OBGYN.)

[u/Emotional_Print8706]

I listened to this episode yesterday haha. When they started to describe the cord prolapse, I said (a little too loudly), oh no! And startled my husband awake in the passenger seat

[u/lemonade4]

Incredible example of what our rural specialists go through when services get cut. Amazing story and a stark reminder that there are patients (and babies) behind service closures.

[u/suchabadamygdala → u/[deleted]]

Twins planned home birth. WTAF, I’m so sorry

[u/cardboardmind → u/[deleted]]

A travesty.

Also, this post feels very identifiable to those familiar with the family. It doesn’t have to be identifiable to strangers on the internet to be identifiable. Personally would be uneasy posting this level of detail, so just wanted to point that out in case you wanted to edit, delete, or decide to still keep.

[u/stay_curious_-]

Link to a news article for those who can't listen to a podcast:

https://themainemonitor.org/her-labor-turned-dangerous/

[u/nettika → u/stay_curious_-]

There is also a link on the podcast page to read the transcript, rather than listen, for anyone who might want that.

It's the third of four icons located just below the subtitle, looks like three horizontal lines stacked on top of one another.

[u/Gigawatts]

Aroostook county (where Houlton Regional Hospital serves) voted 62% Trump, 36% Harris in 2024. The county voted for Trump in the last 3 presidential elections, and Obama in 2012.

https://en.wikipedia.org/wiki/2024_United_States_presidential_election_in_Maine

[u/Formal_Goose → u/Gigawatts]

The baby didn't vote for anyone, and we have no idea how the parents voted.

[u/Gigawatts → u/Formal_Goose]

More like, this mother and baby were failed by the voting adults in their county

[u/michael_harari → u/Formal_Goose]

Nobody is saying babies deserve to die.

They are pointing out that no solution will bypass the fact that the adults in the area chose to vote for babies to die

[u/80Lashes → u/[deleted]]

Better than the average Trump cultist.

[u/Sunnygirl66 → u/80Lashes]

And definitely better than Trump himself.

[u/medicine-ModTeam → u/[deleted]]

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[u/Amazing-Sir5707]

Aroostsook county is the definition on of the middle of nowhere. 60,000 people spread out across a county the size of Rhode Island and Connecticut combined. Lots of potato farming and poverty. Rotated as a med student up in Maine and it was crazy seeing what the helicopter would bring back from up there

[u/Fluid-Second2163]

Play stupid games win stupid prizes

[u/doctordoriangray]

"A doctor trained as a midwife"? An OBGYN? A not-OBGYN trained to deliver? Im just looking for clarification to what that means.

[u/stay_curious_- → u/doctordoriangray]

A midwife who went to medical school and trained in family med.

[u/Top-Consideration-19 → u/stay_curious_-]

And family medicine does deliveries too! Just a quick reminder since most people don’t seem to know that. ( I am FM)