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Apgar Score of Zero at Five Minutes - Page 2

post #21 of 129

I have read the full text (NavelGazingMidwife has it if anyone is interested) and I will say with absolute firmness that if this data had been available when I chose home birth for three of my children, I would not have made that choice.  

 

The 18-19x higher relative risk for home birth midwife vs hospital based midwife is absolutely stunning.  And we know that that is an underestimate, because every responsible midwife who correctly identified fetal distress and transferred appropriately is not counted in the home birth population.  This could be quite a bit higher relative risk if operating under "intent to treat" instead of actual place of birth.  Higher than an almost 20x relative risk is astounding.  Absolutely astounding, and it needs to be addressed.

 

And this doesn't count any of the kids who had Apgars that were bad enough to cause damage but not at Apgar of 0 at 5 minutes.  Where are the major midwifery and home birth organizations in evaluating this evidence?  If we are proponents of evidence based care, this absolutely needs to be dealt with and it most certainly needs to be part of the informed consent offered to every home birth parent.

post #22 of 129
Thread Starter 

I agree that these numbers are very concerning, and I would like to hear a response from the major midwife and home birth organizations. These numbers are a really big deal to me - a 10x higher chance of an Apgar score of 0? Higher chances of seizures and serious neurologic dysfunction?

 

Here's Table 3 from the study, which shows the relative risk of neonatal seizures or serious neurologic dysfunction. Hospital Midwives had only 0.75x the amount that Hospital MDs had. Freestanding birth center midwives had 1.88x the amount that Hospital MDs had. Homebirth Midwives had 3.8x the amount that Hospital MDs had. (You can see all those numbers in row 1, column 2). 

 

Comparing hospital midwives and home midwives, home midwives had about 5.1x the number of infants with neonatal seizures or serious neurologic dysfunction.

 

That's hugely concerning to me. 

 

post #23 of 129

I still can't find a single thing from any major midwifery or home birth organization.  If anyone finds any response, please post it to this thread.

post #24 of 129

That may be because this is not yet a published article. It is only an accepted manuscript. There will probably more said about it when it is published.

post #25 of 129

If it's only an accepted manuscript, how do so many people have a copy of it already?  I'm just a regular, run of the mill mom and I got it last week.  

post #26 of 129

All it takes is one person who has access, and a paper that is a hot topic.

Word spreads and that single copy starts getting sent to people and they promote it and send it on to others.

 

I would like to know who got their hands on the accepted manuscript. Usually only the authors and the publisher have copies, and they guard those copies until publication.
 

post #27 of 129

The abstract on the AJOG website says it was published online on June 21st.  I'm not sure why it's termed both "accepted manuscript" and "published online" but I got it through a friend who had access through her academic place of employment.  

post #28 of 129
Subbing
post #29 of 129

I don't have time to look at the article now, but is there any distinction between CNMs vs. LPMs vs. DEMs? I would guess the CNMs don't have the low Apgar scores at the same rate as say, a DEM. I also think a DEM is more likely to take on a mother who should've risked out for a home birth as opposed to a CNM

post #30 of 129

The general response to this article is indicative of some of my concerns with the community that surrounds homebirth.

 

When articles appear to show benefits to homebirth, even rather negligable ones, they are praised and shouted from the rooftops for the entire world to hear.  When articles appear to show negative consequences, even severe ones such as an apgar score of zero at five minutes, they are ignored and swept under the rug.  It's like no one dares to talk about the things that go wrong, even though we know that sometimes things DO go wrong.  Rather than using the information to explore ways to make things safer, it's disregarded without further thought.

 

Granted, no one likes to hear the bad things.  All industries, groups, philosophies, etc.like praise more than criticism.  But the unwillingness to even acknowledge or discuss things that run contrary to popular belief within the homebirth community has me a bit unnerved.

post #31 of 129
Yours has not been my experience, rnra. Neither here on this thread or the HB forum (have you seen the Safety of HB thread?) or IRL. How in touch with HB communities are you?
post #32 of 129
Quote:
Originally Posted by rnra View Post

The general response to this article is indicative of some of my concerns with the community that surrounds homebirth.

 

When articles appear to show benefits to homebirth, even rather negligable ones, they are praised and shouted from the rooftops for the entire world to hear.  When articles appear to show negative consequences, even severe ones such as an apgar score of zero at five minutes, they are ignored and swept under the rug.  It's like no one dares to talk about the things that go wrong, even though we know that sometimes things DO go wrong.  Rather than using the information to explore ways to make things safer, it's disregarded without further thought.

 

Granted, no one likes to hear the bad things.  All industries, groups, philosophies, etc.like praise more than criticism.  But the unwillingness to even acknowledge or discuss things that run contrary to popular belief within the homebirth community has me a bit unnerved.

I agree that that is an issue with the natural birth community. HOWEVER, pointing out that there seems to be no differentiation between the different certifications of midwives, and whether high risk groups (who should not have been birthing @ home) were included in the study does not mean we are sweeping it under the rug. I would expect a vast difference in outcomes between a hospital birth with a head down baby w/a CNM vs. a breech twin homebirth w/a DEM, kwim? I know that I read some birth stories here sometimes that leave me wondering WTF the mother/care provider are thinking risk wise. I think it's only logical to ask if situations, in which a mother certainly should have risked out, were included, and also the education level of the midwife listed. I now for myself, I would only use a CNM for a home birth, so the DEM outcomes wouldn't concern me.

post #33 of 129
I'd just like to ask... As with any study you have to question the integrity of the underlying data.

I do data analysis (technical data) and this makes me wonder - who reports these apgars? How are they collected? Apgar itself isn't very scientific since it is somewhat up to someone's opinion.

I can't but help but wonder if non-reported stats (typically an issue with hb data) could interfere with this. So- in our state, the parent fills in the 5 minute apgar score when applying for a birth certificate. If you had no idea, you could leave it blank, put in a zero, whatever. Those might seem minor- but I just don't trust the integrity of the data enough to feel like the study is worth reading.

I don't disagree with the statement that hb carries different risks than hospital birth. I just don't feel that this study is very interesting since it is based on such a non-scientific measure (up for interpretation) such as apgar and I question the hardness and actualness of the reporting of that particular metric.
post #34 of 129
Curious, I googled this and found this article from 2012. http://www.examiner.com/article/home-births-linked-to-seizures-low-apgar-scores

Can someone break Dow what a zero 5 minute apgar is? Is that a still birth? What are thoughts on apgar scores and transfers? That's not something I recall being discussed all that often. MC do you have a set apgar upon which you always transfer?
post #35 of 129

Here is a good explanation Identity... http://www.babycenter.com/0_the-apgar-score_3074.bc

 

Basically they are looking for five different things and each one gets a 0, 1, or 2, so the highest score would be a 10. I am not remembering for certain, but based on criteria, I would say that all but one of my babies has probably been in the 9-10 range at 5 minutes. I did have one baby, who we had at the hospital, who probably scored lower as she was having a hard time starting to breath. We knew before labor that she was probably going to have some trouble and had a full pediatric team in the room at birth.


Edited by fruitfulmomma - 7/6/13 at 2:12pm
post #36 of 129
Thread Starter 
Quote:
Originally Posted by ~Caitlyn~ View Post

I'd just like to ask... As with any study you have to question the integrity of the underlying data.

I do data analysis (technical data) and this makes me wonder - who reports these apgars? How are they collected? Apgar itself isn't very scientific since it is somewhat up to someone's opinion.

I can't but help but wonder if non-reported stats (typically an issue with hb data) could interfere with this. So- in our state, the parent fills in the 5 minute apgar score when applying for a birth certificate. If you had no idea, you could leave it blank, put in a zero, whatever. Those might seem minor- but I just don't trust the integrity of the data enough to feel like the study is worth reading.

I don't disagree with the statement that hb carries different risks than hospital birth. I just don't feel that this study is very interesting since it is based on such a non-scientific measure (up for interpretation) such as apgar and I question the hardness and actualness of the reporting of that particular metric.

 

I disagree with your statement that Apgar scores are a "non-scientific measure (up for interpretation)." Apgar scores have pretty strict standards for evaluation, recording, and reporting (at least in hospitals). And everyone follows the same chart - both doctors and midwives. An Apgar score of 0 is both clear and unwanted - I seriously doubt anyone would say that it was 0 if it wasn't 0.

 

And if the parents were the ones filling out the birth certificate, I can see five scenarios:

1. The parents know their child had an Apgar score of 0 (or other low scores), and they report them as such. 

2. Their child had good Apgar scores, they know the exact Apgar scores, and write them down.

3. Their child had good Apgar scores, but they don't know the exact numbers, so they estimate. If that were the case, they wouldn't write down a 0; they would estimate pretty good numbers.

4. Their child had low Apgar scores, but they don't know the exact numbers, so they estimate. Again, in this case, they would probably not put down a 0 - especially for the 5 minute Apgar. They would choose the more hopeful estimation.

5. They don't know the scores at all, so they leave it blank. And non-reported stats (if people just left the spot blank on the birth certificate) were excluded in this study, and so that wouldn't bring the numbers down.

 

Again, practically no one would report an Apgar score of 0 if the Apgar score was not 0. I think the integrity of this data is pretty solid.

 

Quote:
Originally Posted by IdentityCrisisMama View Post

Curious, I googled this and found this article from 2012. http://www.examiner.com/article/home-births-linked-to-seizures-low-apgar-scores

Can someone break Dow what a zero 5 minute apgar is? Is that a still birth? What are thoughts on apgar scores and transfers? That's not something I recall being discussed all that often. MC do you have a set apgar upon which you always transfer?

 

The wikipedia on Apgar scores is pretty good - http://en.wikipedia.org/wiki/Apgar_score. Apgar scores are assigned out of a scale 0 to 10, based on five different criteria. Infants can score a 0, 1, or 2 on each of the five points (which are appearance/complexion, pulse rate, reflex irritability, activity, and respiratory effort). Scores are usually done at 1 minute after birth and 5 minutes after birth (and sometimes at 10 minutes after). 

 

An infant with a score of zero at 5 minutes means that, at five minutes old, that infant is blue or pale all over, has no pulse, no response to stimulation, no activity, and has no respiratory effort. In a nutshell, no signs of life. 

 

The wikipedia article says "Scores 7 and above are generally normal, 4 to 6 fairly low, and 3 and below are generally regarded as critically low. A low score on the one-minute test may show that the neonate requires medical attention, but is not necessarily an indication that there will be long-term problems, particularly is there is an improvement by the stage of the five-minute test. If the Apgar score remains below 3 at later times such as 10, 15, or 30 minutes, there is a chance that the child will suffer longer-term neurological damage."

 

An infant with an Apgar score of zero at five minutes isn't a still birth - it can still possibly be revived and survive (and most do). But, it seriously increases both the possibility of death or of long-term damage.

post #37 of 129
Quote:
An infant with an Apgar score of zero at five minutes isn't a still birth - it can still possibly be revived and survive (and most do). But, it seriously increases both the possibility of death or of long-term damage.

 

So if a child was stillborn, they would have been excluded from the study, correct?

 

Does anyone know if the study included any information on the outcome of the births?

post #38 of 129
Can someone link the entire study? The PDF link from the op requires a login. Did the article discuss whether transfer had been completed or initiated? Great conversation among our HB mamas! Wish I could participate more fully... On holiday ATM.
post #39 of 129
Thread Starter 
Quote:
Originally Posted by IdentityCrisisMama View Post

Can someone link the entire study? The PDF link from the op requires a login. Did the article discuss whether transfer had been completed or initiated? Great conversation among our HB mamas! Wish I could participate more fully... On holiday ATM.

 

I don't know if there's a PDF freely available that can be linked to, but NavelGazingMidwife will email you a copy of the PDF if you email her at NavelgazingMidwife@gmail.com.

post #40 of 129
Thread Starter 
Quote:
Originally Posted by fruitfulmomma View Post

 

So if a child was stillborn, they would have been excluded from the study, correct?

 

Does anyone know if the study included any information on the outcome of the births?

 

I looked at the study again to see if I could find the answer to your question, and from what I gather, if a child was stillborn they would have been included in the data. They're still assigned Apgar scores because since some babies have the possibility of being revived, they assign all babies Apgar scores. It isn't until the baby can't be revived that it's decided to be a still birth.

 

Here's what the researchers said about the still births in the study ("antepartum"= before labor; "intrapartum"=during labor):

 

"Another limitation is that it is not possible to know from the CDC data whether a 5-minute Apgar score of 0 was effectively a stillbirth that occurred antepartum or intrapartum. We do not believe that this limitation changes our major findings. This is because the vast majority of stillbirths delivered in the hospital are known to be antepartum and not intrapartum. On the other hand, in out-of-hospital settings, most antepartum deaths in planned home births would be transferred to the hospital. Moreover, in out-of-hospital settings, there is likely less antepartum testing and no continuous electronic intrapartum fetal monitoring, both of which may have affected adverse outcomes." 

 

And here's what they said about the outcomes of births:

 

"Data on long-term follow-up of neonates would be optimal, but the CDC database does not include such information. An Apgar score of 0 indicates that there are no signs of 
life (no heartbeat, no breathing or movements). Infants with a 5-minute Apgar score of 0 have a significantly increased risk of mortality and if they survive an increased risk of significant morbidity. Survival relates directly to the effectiveness of neonatal resuscitation which is severely limited in home births."
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