Name: Rose, Adele
License type and number: DEM LD 10117447
Areas served: Portland metro
Letter to OHLA from doctors and CNMs involved in the care of a woman when her infant died and she required a hysterectomy after a homebirth attempt attended by Adele. For a .pdf of the original, go here.
January 29, 2008
Oregon Health Licensing AgencyBoard of Direct Entry Midwifery700 Summer St. SE Suite 320Salem, OR 97301-1287RE: Complaint against Ms. Adele Rose, CPM, LMD, in the case of ***********
Dear Board Members:We are requesting a forma review of the case of patient ********, who attempted a home birth on *********, after two previous cesareans. Ms. ****** suffered a uterine rupture, and her unborn infant son died. She was under the care of a Direct Entry Midwife, Adele Rose, CPM, LDM, and two midwifery students from Seattle Midwifery School, Kristin Effland and Rebecca Egbert. She was transported from her home to Willamette Falls Hospital on *********, where she underwent emergent surgery to deliver her deceased son. It was also necessary to perform a hysterectomy and blood transfusions due to her ruptured uterus.We contend that Adele Rose and the two midwifery students showed a lack of competency in the services they provided, and committed a serious violations in the standards of practice. AS a result of their irresponsibility and incompetence, an infant died unnecessarily, and his mother suffered a life-threatening complication.Our specific concerns related to this case are as follows:
- There is no evidence that the operatives reports of the two previous cesarean sections, or other relevant history, were requested or critically reviewed for the appropriateness of attempting an out-of-hospital birth.
- There is no evidence of an ultrasound to evaluate the placenta for placenta previa and/or appropriate placental attachment site.
- There is no written documentation of a signed, detailed informed consent regarding the risks involved with an attempted VBAC.
- There is obvious evidence of a protracted first stage of labor, and an arrested second stage of labor, including the notation that “no ctx” were noted at 8:40 p.m. These are clear violations of standards of practice requiring immediate transfer to a higher level of care, particularly for a high-risk multiparous patient whose labor deviated so far from the normal labor curve.
- Ms. Rose and the students left the patient’s home during the labor for a time of approximately 2 hours, during which time the labor became more active and the patient dilated from 3 to 9 cm. There is no evidence of fetal heart rate monitoring during this time frame; again, a grave violation of practice standards for a patient with two previous cesareans.
- After examining the labor records from the home birth midwife and midwifery students, we observed similarities between the documented fetal and maternal heart rates. We question the accuracy of the fetal heart rate determinations. This suggests that the maternal heart rate was the only heart rate being detected and monitored by Ms. Rose and the students. The infant was dead upon admission, and the patient’s pulse on admission was approximately what the home birth midwife had been recording as the fetal heart rate during the labor at home. Additionally, the fetal heart rate was documented at rates of 80 to 100 beats per minute with no notations of corrective actions taken, and no evidence of recovery of the fetal heart rate to normal ranges. This occurred hours before the midwife considered transferring the patient to the hospital.
- When the plan was made for transfer to a high level of care due to the development of “abdominal pain with movement,” the patient was transported by private vehicle instead of by ambulance.
- Several notations in the labor record indicated findings that responsible providers would have considered serious “red flags” during an attempted VBAC, and should have prompted Ms. Rose to transfer the patient to a higher level of care. These include the notation of “thready, both pulse and BP,” patient was asleep with “no ctx” after reaching complete dilation, and the low fetal heart rate on more than one occasion.
- We have noted the fact that two midwifery students from Seattle Midwifery School, Kristin Effland and Rebecca Egbert, were also involved in the care of this patient. While these two students are not yet finished with their training, and are thus not licensed in Oregon or any other state, we believe it is important for them to understand the tragic consequence of the poor decision-making of the provider in this case. We request the the Seattle Midwifery School be notified of this event, so their faculty can discuss the case directly with the students. It is our sincere hope that these two students have learned an important lesson, and will not ever make a mistake of this nature in their own professional careers.
- Finally, as a general concern for patient and infant safety, we request that attempted vaginal birth after cesarean be removed from the scope of practice for out-of-hospital direct-entry midwives. Home birth midwives, by definition, attend low-risk births. There is no continuous fetal heart rate monitoring and immediate surgical intervention available, as there is in a hospital setting. This case has made it painfully clear that a home-birth midwife cannot adequately monitor both mother and fetus during labor, and cannot rapidly and safely respond to an emergent VBAC complication. On *******, a full-term baby boy unnecessarily lost his life. His mother lost her uterus and her future fertility, and spent several days in the ICU; she is fortunate that she did not lose her life as well. A VBAC attempt after 2 previous cesarean surgeries is considered high risk by most obstetricians due to the concern for uterine rupture, and is thus not done by most hospital-based obstetric practices in Oregon. That an obstetrician in a hospital setting would consider this to be too high of risk to attempt should make it patently obvious that it is completely inappropriate for a home-birth setting with a direct-entry midwife.The Board of Direct Entry Midwifery has a responsibility to the people of Oregon to protect them from potential and actual injury. We noted from reading previous Board meeting minutes that the subject of whether VBACs should be attempted at home with a direct-entry midwife has been discussed at times in the past, and that it is a controversial subject. Your responsibility is to protect the mothers and babies in this state – not to “protect” the direct-entry midwives from the physicians. If the Board had made a decision to add VBAC to the contraindications list, then Ms. *******’s son likely would be alive today.This letter is being submitted to your review board with the full support of our physicians and nurse-midwives. We have been informed that we will not be able to attend the review board meeting to answer any direct questions about the care we provided to Ms. ****** after her transfer to us. Thus, please review this letter thoughtfully and request any information you need; we will promptly send it to you.We appreciate your attention to this serious matter, and we hope to avoid this type of tragedy from ever occurring in Oregon again.Sincerely,******, MD******, MD******, MD******, MD******, CNM******, CNM******, CNM******, DO******, MD******, CNM******, CNP
and two illegible signatures
Final order issued regarding death of infant and total hysterectomy for mother in a failed VBAC in 2008. Violation for maternal antepartum non-absolute risk criteria & assessment, transport plan, fetal heart tone evalution. Suspension of one month, during which Rose continued to practice.
Reported to OHLA for preventable severe maternal morbidity in 2010.
Reported to OHLA for the preventable death of an infant after prolonged labor, with additional significant maternal morbidity and delay of transfer in 2010. (Different incident from above.)
In the Media:
Red Flags: Three severe incidents reported to OHLA in as many years—this is a midwife who shows evidence of severe recklessness.
Stories around the web: