Nurse midwife suspended over homebirths

Evelyn Muhlhan, CNM was suspended by the Maryland Board of Nursing on October 7. According to the story in the Catonsville Patch:

The Maryland Board of Nursing has suspended the license of Catonsville-based midwife Evelyn D. Muhlhan, citing multiple complaints in recent years alleging she performed home births without a physician backup or an approved medical plan.

It seems that Muhlhan was too busy trusting birth to pay attention to the standards of practice. The suspension order is chilling reading, recounting as it does the various complaints made against Mulhan:

Case #1 (baby requiring expert resucitation):

On or about July 16, 2008, the Board received a complaint regarding Respondent from MD l, a neonatologist at Hospital-A.

According to the complaint, on June 7, 2008, Respondent performed a vaginal home delivery and the patient ("Patient A") was reported to have experienced a pregnancy with contraindications for a home vaginal delivery, including, a previous c-section, Factor V Leiden deficiency and maternal obesity...

On arrival at Hospital A, the baby was described as cyanotic and apneic with no respiratory effort and was intubated and admitted to the NICU. with diagnoses of respiratory distress and perinatal depression. The baby was discharged home on June 27, 2008.

When interviewed by the Board's investigator regarding the complaint, Respondent indicated that Collaborating MD-2 was her collaborating physician for home births.

During his interview with the Board's investigator, Collaborating MD-2 was adamant that he does not cover Respondent for home births and that he "never has covered and never will" and has made this clear to Respondent on several occasions.

Patient #2 (baby with hypoxic ischemic encephalopathy and seizure disorder):

On or about April 14,2010, the Board received a complaint from ... Director of Labor and Delivery and ... Director of Gynecology and Obstetrics, at Hospital B. According to the complaint, between March 25th and 26th, 2010, Respondent failed to follow the standard of care in her management of an attempted home birth by:

I. Utilizing Intramuscular Oxytocin to stimulate labor in a term pregnancy;
II. Using fundal pressure in the second stage of labor to attempt to cause descent of
the fetus;
III. Using vaginal chlorhexadrine, rather than intravenous penicillin, in labor to treata known group B beta hemolytic strep vaginal carrier to prevent early onset GBS neonatal sepsis;
IV. Misdiagnosing fetal station resulting in an unnecessary episiotomy. The physical exam on admission to Hospital B was a fetus impacted in the vagina at + 1 station which was incompatible with the report that the fetus had been crowning when the episiotomy was performed...

... Patient B delivered a male infant ("Baby B") by LSTCS, with a vertex fetal presentation and occiput posterior ("OP") position at birth. The APGAR scores were 1 at 1 minute and 5 at 5 minutes and cord/Initial blood gas was ph 7.1; pC02 63; p02 10; BE -13. Baby B was limp and cyanotic on delivery with nuchal cord x 1, required PPV for 3 minutes before being transitioned to CPAP. Baby B was transported to the NICU on CPAP with diagnoses of Hypoxic Ischemic Encephalopathy and Seizure disorder.

Baby B was transferred to a pediatric rehabilitation hospital on April 21, 2010.

Patient #3 (attempted homebirth of 11 pound baby):

On May 31, 2011, the Board received a complaint from ... Hospital C. The complaint alleged that on January 5,2011, Patient C presented to Hospital C after a failed home delivery by Respondent...

The complaint expressed concerns regarding: an attempted home birth when an estimated fetal weight of 11 lbs. was identified two weeks prior to labor; an attempted home birth with a mother with gestational hypertension; continued assistance of a patient at home with a protracted labor pattern.

...[O]n admission, Patient C was in active labor, dilated at 5 cm, 100% effaced and the fetal vertex was at - 4 station. The fetal heart rate was reassuring and the mother's vital signs were stable. A plan of care was discussed with the patient and a decision was made to proceed with a cesarean section due to arrest of labor and a ultrasound estimated fetal weight of greater than eleven pounds.

On January 6, 2011 at 0147, a live male infant was delivered by primary c-section. APGAR scores were 1 and 8 at 1 and 5 minutes respectively, and the infant weighed 10 lbs and 9.6 ounces.

Patient #4 (attempted VBAC, uterine rupture, intrapartum death):

On or about July 14, 2011, the Board received another complaint from ... Hospital C. The complaint alleged that on July 12, 2011, Patient D presented at Hospital C, after an aborted home birth, with uterine rupture, intra-partum fetal death and a history of a previous c-section...

On arrival at Hospital C, the patient was evaluated in the ER and taken immediately to the OR. Several unsuccessful attempts were made to obtain a fetal heart rate.

On July 12, 2011 , Patient D underwent a low transverse c-section. Operative Findings include: ... male infant in vertex presentation, occiput posterior with a tight nuchal cord. Mother had an area of uterine rupture from the scar from the midline to the right side going down toward the cervix and uterine vessels on the right side. Abundant thick meconium was noted in the patient's abdomen and pelvis with massive bowel edema and erythema, with meconium already stuck onto bowel walls.

Patient #5 (postpartum hemorrhage, attempted manual removal of placenta at home):

On September 8, 2011, the Board received a complaint from the Risk Manager at Hospital C regarding Patient E. According to the complaint, Patient E was admitted to Hospital C on September 7, 2011 after a home delivery and suspected manual extraction of the placenta.

EMS reported that on September 7, 2011 at 22:21 hours he responded to a call of "maternity with complications." Upon arrival, he reported one crew attending to the mother and another attending to the baby. The mother was observed to be lethargic, pale and bleeding from the vaginal area with a blood pressure of 90/50 and heart rate of 158...

... Respondent's assistant (name unknown) stated that that the baby had been born at 9:15pm, the placenta had failed to deliver, Respondent "pulled out the placenta" and at least "some of it had been removed."

The attending physician at Hospital C, documented that Patient E presented with PPH and Retained Placenta and an estimated blood loss at home of 1 liter.

... Patient E underwent a Dilatation and Curettage and Repair of deep 2nd degree perineal laceration with an estimated blood loss of 1500 ml...

The Maryland Board of Nursing suspended Muhlhan's license for, among other things:

• Practicing without required physician backup
• Attempting high risk deliveries at home.
• Use of intramuscular oxytocin to induce labor at home.
• Attempted unsuccessful manual removal of placenta at home
• Hypoxic ishcemic encephalopathy and seizure in one newborn
• Death of the baby during an attempted home VBAC

Mulhan's conduct is completely indefensible, but, you guessed it, homebirth advocates are nonetheless supporting her. According to the website Save Homebirth with Evelyn in Maryland:

There are several problems with the way the Board of Nursing has treated Evelyn. The first, and most severe, is the fact that they suspended her license before proof has been established. One of our rights as an American is that we are deemed innocent until proven guilty. This drastic act does not allow that right to Evelyn. The Board of Nursing has stripped Evelyn of her ability to serve women in any capacity. They did not just suspend her CNM license, they also suspended her Registered Nurse (RN) license, thus completely taking away her ability to work or make a living.

Secondly, none of these complaints came from one of Evelyn’s clients or a client’s family. The complaints were filed by hospital physicians after a client was transported to the hospital. In fact, three of the five complaints came from the same hospital...

Three of the five complaints came from one hospital? Well if that's not a conspiracy, I don't know what is? Just because Muhlhan sent them transports including a woman with a dead baby and ruptured uterus, and another woman with a postpartum hemorrhage during which Muhlhan attempted unsuccessfully to manually remove the placenta at home, they decided to victimize poor Evelyn.

Things are not going so well with the fund raising, however:

Our Goal Is To Raise $20,000. As of 12/01/11 we have raised $1355.00

The Maryland Board of Nursing reprimanded Muhlhan in the strongest possible terms:

... The complaints regarding her practice involve her incompetent, negligent practice during home deliveries resulting in serious complications for the mother and/or death or a poor prognosis for the infant. Her practice shows a blatant disregard for the laws and regulations governing her practice as a CRNM and a reckless disregard for the health, safety and welfare of her pregnant patients. Respondent's practice is a danger to the public health, safety and welfare.

Homebirth leaves babies dead or brain damaged. It is indeed a danger to public health.