Dilemma Upon Delivery.

Byline: Andrea Damewood The Register-Guard

The call to paramedics came at 8:10 p.m., the instant midwife Anita Rojas realized the head of the breech baby she was delivering was stuck.

Twenty-one-year-old Kelsie Koberstein was swept up by medics in a blur of pain and fear.

Rojas rode in the front of the ambulance, with Koberstein's mother and best friend rushing behind in their car.

"I felt kind of halfway outside myself," Koberstein recalled. "That was the only way I could cope with the pain, which was so bad, it was beyond pain.

"My nerves were shooting pain out of my toes."

On her back, her legs pushed up as high as they could go, she clutched the hand of a paramedic as if he were her only anchor to reality.

Those minutes, so frantic for so many, ticked by slowly for her. As paramedics tried to wrest the baby out, Koberstein said she could sense the small life, still partially within her, beginning to fade. She began "letting him go, in a way."

At Sacred Heart Medical Center, the on-call emergency room obstetrician-gynecologists, Drs. Elizabeth McCorkle and Brant Cooper, wasted no time.

As they instructed paramedics over the hospital radio, they learned this birth was going to be as difficult as they come: It wasn't just a breech birth, but a "footling" - where a foot emerges first.

Just a few centimeters in width, a tiny foot might not open the cervix wide enough to allow the baby's head and umbilical cord to pass through. If the head becomes trapped, the baby could quickly suffocate.

When medics pulled up to the doors, the doctors leapt into the back, refusing to squander precious seconds bringing Koberstein inside. The doctors had to turn Lucian's head 180 degrees in order to free him, a move that took at least 20 minutes.

By then it was too late.

The infant was dead.

"Everybody was just deflated," said McCorkle, an OB-GYN with 11 years of experience. "Everybody was sad, and kind of shocked. I didn't know what to do."

Differences in perspectives

Koberstein named her boy Lucian Blaize - a name that means illumination. And in his death, he has cast a spotlight on the mistrust between many doctors and midwives.

Lucian's breech birth was so risky that most doctors and midwives would have insisted he be delivered by Caesarean section. But Koberstein's midwife attempted a vaginal delivery, a move that the two emergency room doctors believe killed him.

The Lane County district attorney's office investigated whether Rojas was criminally responsible for the failed June 15 birth, but the case was not prosecuted because the baby was born dead. Cooper filed a complaint against her with the state Board of Direct Entry Midwifery, which oversees licensed midwives.

Koberstein stands by her midwife. Also lining up behind Rojas are experienced midwives who believe the decision about how to bring a child into the world rests solely with the mother and her care provider.

What doctors and midwives do agree on is that low-risk labor - generally defined as a head-first birth with no foreseeable complications - is equally safe when performed in a hospital or in a home.

The consensus ends there.

A mother-to-be's options

Koberstein, a mellow woman with short, choppy strawberry-blond hair, discovered the pregnancy two weeks after missing her period last September.

"I was freaking out, and I was really scared because I didn't have a partner," she said.

Her panic led her to a Eugene abortion clinic.

Her instinct made her walk out five minutes before the surgery.

"Whoa, this is not who I am," she recalled thinking. "I really didn't know that about myself until I got there."

What she did know was that she needed more support than what she believed a busy obstetrician could provide.

Because she wanted a water birth, an option not available at the Nurse Midwifery Birth Center, a downtown clinic affiliated with Sacred Heart, she was referred to Rojas, owner of Sacred Waters Birthing Center in west Eugene.

Rojas, through her attorney, Dan Holland, declined to comment for this story, saying she was uncomfortable discussing her client's medical information.

Rojas has been licensed by the state since 1994 and has never been censured by the Oregon Health Licensing Agency.

She was featured in March as a "Happening Person" in the Eugene Weekly, and told the paper that she grew up in the Sierra Madre Mountains in Mexico. Her grandmother had been a midwife, she said, and she began her career in midwifery in 1986. She opened Sacred Waters Birthing Center two years ago with two other midwives.

"I just met her, and I trusted her, and I just went with it," Koberstein said. "It's kind of how I live my life, I go with my gut and listen to my heart."

Her visits to Sacred Waters would last for hours. She would talk with Rojas and other employees not just about her pregnancy, but about her life: her diet, what she was dreaming about, how relationships were progressing.

"It was like going and hanging out with girlfriends," she said. "It really put me at ease, meeting these women. I felt embraced."

When, at 37 weeks, Rojas felt Lucian may have settled into a breech position, the pair discussed their options.

Koberstein said Rojas first tried external version, a method of manipulation to flip the baby.

After that proved ineffective, Rojas told Koberstein of the potential dangers of having a breech birth and those involved with a Caesarean section.

Rojas also told her about her good track record of freeing other breech babies that became stuck during labor. Koberstein and Rojas decided to go forward with home delivery, against what many doctors and midwives would recommend: A July 2006 study by the American College of Obstetricians and Gynecologists found that C-section is the "preferred mode for most physicians because of the diminishing expertise in vaginal breech delivery."

"A Caesarean section was my other option. I didn't want to do it, and I didn't ask a lot of questions about it," Koberstein said. "I was born to do this; every woman was."

Vaginal breech births are not performed at the Nurse Midwifery Birth Center, and they rarely occur at Sacred Heart or McKenzie-Willamette medical centers, where C-sections are encouraged because of the enormous risks involved, officials say.

"The Catch-22 in this community is you can't get a (natural) breech birth in the hospital," said Janie Akerlund, a registered nurse, who formerly worked at the Nurse Midwifery Center. "It would be a safer thing to try in the hospital, but it's not allowed. So then you leave parents saying either get a mandated C-section or try this at home."

A turn for the worse

By Lucian's due date, Koberstein felt ready.

"I knew when I was pregnant that I wasn't ready to be a mother," she said. "It took a long, hard journey to reach a place where I felt ready."

She prepared a bassinet, the same one that she used as an infant. She bought cloth diapers and clothing. She had a baby shower.

And she had faith - a faith so strong that she said she knew without an ultrasound that her child would be a boy. She gave him his name one week before he was born.

She also had faith that she and Rojas would deliver Lucian the natural way.

As her contractions began, she went for a two-hour walk by the Willamette River with Rojas and others. They laughed and joked between contractions.

They returned home as her active labor began. Surrounded by the people she loved, Koberstein crawled into the birthing tub, got on her hands and knees, and asked for everyone to be quiet, so she could concentrate.

Everyone was calm as the delivery progressed.

But then Koberstein reached down and touched what felt like a tiny heel emerging. It popped out. Stunned, she asked Rojas if everything would be OK.

In about a half-hour, Lucian's entire body was out. But his head remained stuck.

She left the decision of when and if to call an ambulance up to Rojas, who, as a licensed midwife for 13 years, had the experience, Koberstein said.

Rojas encouraged her to keep pushing, and had her climb out of the tub to try another position. Koberstein continued her labor.

Koberstein's mother grew more nervous, hanging back.

They wrapped Lucian's body in a towel, and tried to deliver him as she stood, then again as she lay down.

Rojas asked Koberstein to keep pushing, but she could not feel anything behind her thrusts.

It was then she heard what seemed like a hint of panic sneak into her midwife's voice.

"Anita said, `Call the ambulance,' ' to an assistant midwife, Koberstein said.

She felt totally helpless.

Finally, the ambulance arrived.

At the hospital, the awaiting doctors worked frantically to save Lucian. At one point, at least seven people - doctors, nurses, paramedics - were crammed into the ambulance, working in full sight of passers-by on East 13th Avenue.

"It was horrible," Cooper said. "You've got a baby that's all but delivered. You've got 15 people standing there watching these two doctors sweating, trying to deliver this baby."

"You're watching a baby die in front of your eyes."

Anger and complaints

Eventually, the doctors' shock turned to anger and frustration.

"No one would ever consider trying to perform (a footling breech) vaginally," McCorkle said. "At that point, the social experience of being home in your own house, that goes out the window."

Rojas, in McCorkle and Cooper's opinion, had gone too far.

Cooper said he had seen other patients with licensed midwives come to the ER with unexpected breeches, and even some footling breeches in early stages.

He had never seen anyone carry a footling birth as far as Rojas had.

McCorkle agreed:

"Without a sliver of doubt in my mind, if (Koberstein) had been seeing an OB-GYN or nurse midwife practitioner, (Lucian) would be alive," she said.

In his complaint to the midwifery board, Cooper outlined a number of points throughout the birth where Rojas could have saved Lucian.

In speaking with Koberstein after the failed delivery, he believed that she was uninformed about the risks involved with every step of the birth - including how hazardous a footling breech is. The fact that she was a first-time mother also upped the danger, Cooper said in the complaint.

Choice for home birth

But midwives say that as the number of Caesarean sections skyrocket, their profession is essential for maintaining a mother's right to choose.

Parents in Lane County opt for a home birth more than anywhere else in the state: 5 percent of the more than 3,700 births in 2005 were performed out of a hospital, nearly double Benton County's second-highest home birth rate.

Parents who use midwives are more involved in making decisions, said Holly Scholles, vice chairwoman of the Board of Direct Entry Midwifery. They choose their care based on education from their midwives and their own research, she said.

"Sometimes that means consumers choose things that go against what the mainstream medical community would choose," said Scholles, who has more than 30 years of experience and is president of Birthingway College of Midwifery in Portland.

By talking with Koberstein about the risks and benefits of all options, Rojas would have been following the Board of Direct Entry's rule of "informed consent," she said, adding that she did not know the specifics of Koberstein's case.

Many doctors do not trust midwives because they rarely perform vaginal breeches, just as midwives are wary of doctors because they don't have experience in Caesarean sections.

Scholles bristles at claims that breech births delivered at home have a higher mortality rate. Hospitals' frantic pace, overtesting, overmedicating and concern for the bottom line rather than the mother are what is truly perilous, she said.

"It's a complicated thing. It's more about philosophy, ethics, faith and belief than it is about hard cold facts, because the facts can be very elusive, both ways," Scholles said. "We're a different paradigm, that's what makes us different: We have a very different standard of birth."

Those conflicting perspectives - coupled with a lack of communication and natural distrust - lead to tragedy when the professions refuse to work cooperatively with one another, said Polly Malby, a nurse midwife and assistant professor at Oregon Health and Science University in Portland.

"There are a number of licensed midwives who do a fabulous job," she said. "It's unfortunate that the only experience that many medical providers have with these individuals is when something goes wrong."

Midwives should have close relationships with doctors, she said, and many do. But there are midwives who dislike or fear hospitals, and doctors who refuse to work with midwives.

"The mistrust that happens between providers of out-of-hospital birth and in-hospital birth is tragic," Malby said. "We all have to ... get some sense of mutual respect and trust."

Otherwise, she said, midwives may resist going to the hospital in situations when seconds are crucial.

`Unnecessary' C-sections

For Malby and others, the issue is not home delivery, but the judgment of midwives who continue births they say are too risky.

Eugene holistic gynecologist Dr. Jan Stafl, who retired from obstetrics in 2005 after 25 years of delivering babies, has long been interested in bringing down the number of "unnecessary" Caesarean sections.

But in the cases of breech birth, research has proved surgery is the better option, he said.

"Personally, I think it's a mother's choice," Stafl said. "But I don't want to go back to the 19th century where 10 percent of babies and 1 percent of mothers died."

Midwives and doctors should perform breech births only in a hospital setting where forceps, surgery and medical assistance are readily available, Malby said.

"I've had a woman say to me, `The worst thing that I can possibly imagine is having a Caesarean section,' ' Malby said. "I looked the woman in the eye and said, `Having a C-section is not the worst thing that can happen.' '

"The worst thing that can happen is having a dead baby or a baby that cannot read in the first grade."

Grief and investigation

After Lucian died, Koberstein washed her baby, rubbed him in oil and dressed him in the clothes he was to wear on his trip home. She held him in a daze, her large blue eyes unable to meet his tiny closed ones, her ears listening for his cries that would never come.

A hospital staff member took Lucian, and told her she could pick him up Monday. They told her they would wrap him in warm blankets, she said.

Instead, she would spend the next days trying to reclaim her son's body. He arrived six days later at a funeral home. Naked. His clothes in a bag. Lucian had become part of a district attorney's investigation, and she was told that an autopsy might be performed, whether she consented or not.

"This is my baby, how ridiculous is this?" she said, placing her head in her hands as tears leaked through her fingers - crying for the first and only time in discussing her ordeal. "He's my flesh and blood, and now he's county property?"

An autopsy was never performed.

Koberstein's immense grief has been overshadowed by anger: She said she feels violated and abandoned by the authorities who are leading the charge against Rojas, whom she said bears no blame.

She said that while she was still recovering, she was forced to make phone call after phone call to the doctors, the district attorney and the medical examiner's office.

"They were treating it like a murder investigation, almost. It's kind of creepy," she said. "You can abort fetuses, but I can't take a risk?"

Prosecutors completed their investigation last month. Because Lucian was never alive under Oregon law, there was no crime to prosecute, District Attorney Doug Harcleroad said.

Scholles, of the Board of Direct Entry Midwifery, said this is the second fetal death in Oregon in the past few years in which she can recall law enforcement becoming involved.

The precedent such investigations set frightens her, she said. "Women make choices based on what they think is best for their baby, and to supersede that woman's choice is dangerously paternalistic," Scholles said.

Some doctors are frustrated because they say negligent midwives cannot be held accountable.

"If I mess you up, you know the system is going to take over and punish me," McCorkle said.

The Board of Direct Entry Midwifery will hear complaints and can suspend or revoke a midwife's license, and charge civil penalties, Scholles said.

But midwives don't need a license to practice in Oregon.

Focus on recuperation

Ultimately, the decision to deliver her breech baby outside a hospital was hers alone, Koberstein said.

"People need to make choices that are right for them, period," she said. "When it's a matter of your family, your body and your life, it should be your choice."

She is angry with the doctors, she said, but can understand their passion. "You gotta live your truth."

Despite the turmoil, she said her faith in humanity has only grown stronger.

She is taking her time to recuperate, moving slowly, and is thinking of returning to take dance, yoga and massage therapy classes at Lane Community College. She is looking into support groups for those who have lost their children.

"It's really hard to function because I was preparing for the opposite of this," she said. "I was preparing to pour all of my love out on the baby."

Spending time with friends and family has helped her come to a place where she has accepted that what happened was meant to happen.

Though she has moments where she goes to "dark places" of questioning her decision, she is at peace with what happened.

"I can't regret, or I can't heal," she said. "I have to be OK with the choices I made."

MIDWIFE OPTIONS

There are several categories of midwives, which denote different levels of supervision, knowledge and education.

Unlicensed midwives: Are not overseen by any governing board, and do not have any educational or experience requirements, but are legally allowed to practice in Oregon. It is difficult to estimate how many operate in the state.

Many traditional unlicensed midwives have years of birthing experience but choose not to be licensed or cannot afford the $1,500 fee for the license.

Licensed midwives: The Board of Direct Entry Midwifery supervises 47 licensed midwives in the state.

Licensing is based on passing tests and meeting standards set by the North American Registry of Midwives. Licensees, among other things, must prove that they have assisted in 25 births, have been the primary practitioner in another 25 births and have given 100 prenatal care examinations. Most midwives attend midwifery schools, but schooling is not required.

Licensed midwives fall under the Oregon Health Licensing Agency, which handles complaints against them. Midwives found to be negligent can face fines and either a suspension or revocation of their license. Without a license, midwives may continue to practice, but are not eligible for most insurance reimbursements.

Certified nurse midwives: Certified nurse midwives hold master's degrees in nursing and have passed a national certifying test.

In Oregon, they can legally deliver in hospitals, homes and in birthing centers. They are not required to carry malpractice insurance, but the majority do because they are affiliated with hospitals, which require it.

The state Board of Nursing oversees certified nurse midwives and handles complaints against them. Nurses found guilty of negligence or malpractice can lose their license to practice midwifery or lose their nursing license altogether.

MIDWIFERY COMPLAINTS

From 2001 to 2005, the Board of Direct Entry Midwifery, which oversees licensed midwives, received a total of 23 complaints. A quarter of the complaints involved twin births, breech births or women attempting natural birth after a previous Caesarian section.

Three resulted in fetal death.

Below is a sampling of cases, and what action the board took:

October 2002: A hospital physician filed a complaint alleging a midwife mismanaged a breech birth, which resulted in the fetus' death.

The board recommended the midwife be fined $9,000. In a settlement, she paid $900 and surrendered her license.

January 2003: A group of physicians filed a complaint stating they were concerned about the services a midwife was providing - including a case involving a twin birth, during which one of the twins died.

The board recommended a $2,000 fine and a suspension of her license. In a settlement, no fee was assessed. She was required to submit the records for her seven most recent births to the board for review.

September 2004: A patient's mother filed a complaint saying she felt the midwife's incompetent care during a breech birth caused the fetus' death.

The board recommended a $3,000 fine and revocation of her license. Her settlement required her to take 40 hours of instruction and provide the board information about her next 15 births, including the birth's date, the result and the name and license number of her assistant.

- Board of Direct Entry Midwifery