Adverse Incident Report for Planned Out-of-Hospital Births rvices Florida Department of Health 003% a: ?ner . Submit form toDepartment of Health. Consumer Services Unit 4052 Bald Cypress Way, Bin C-75 Tallahassee. Florida 32399-3275 Part I: Practitioner Information Section 456. 0495, Florida Statutes, requires an adverse incident, defined as an event associated with a planned out-of- hospital birth over which a physician licensed under Chapter 458 or Chapter459, a nurse midwife certified under part I of Chapter 464, or a midwife licensed under chapter 467 could exercise control, to be reported to the Department of Health within 15 days of the incident. Adverse incidents include maternal death; maternal hemorrhagic shock or transfusion; fetal or newborn death including a stillbirth; certain traumatic physical or neurological birth injuries; or a transfer of a newborn to a neonatal intensive care unit under speci?c circumstances. This form does not replace any other adverse incident report required by the statutes and rules governing your specific profession. Practitioner Name: License Number: h? ML 3 Part II: Adverse Incident General Information Incident Date: '7 ii i i 0i Incident Time: Ruth Oil?; "Tangle Wu Address where incident ocurred: II to exinrg?lcn [ween Ln City: Saws/5; State: Ei/ ZIP: :19 ?l 3 i This address is a: CI Home/Private Residence El Physician's Office E/Birthing Center (specify nameOther (please specify): Please check all that apply: A maternal death occurred during delivery. 3/3 maternal death occurred within 42 days after delivery. The maternal patient was transferred to a hospital intensive care unit but rid/?r 5M 384 1 The maternal patient experienced hemorrhagic shock. The maternal patient required a transfusion of more than 4 units of blood or blood products. A fetal or newborn death occurred. i. at 3+ The fetal or newborn death was a stillbirth, The newborn was transferred to neonatal intensive care due to a traumatic physical or neurological birth injury. This transfer occurred due to a brachial plexus injury. DH5029-MQA (07MB) Page ?i of 2 Adverse Incident Report for Planned Out-of-Hospital Births (continued) CI The newborn was transferred to a neonatal intensive care unit within the first 72 hours after birth and remained in the unit for more than 72 hours. Part Iii: Adverse incident (Narrative Summary) Describe the circumstances of the incident; use additional sheets as necessary. ?61) (?inm 3W?m~? Ll) Awaiteweicwr' {Defomou WW - eii? 283/72 2 2? 222.2 #722 2 7? 0i? 0-2215, 2- Ave/1?3 at} [5 ?Tit ?V?K?i?tj'f?t Ebeiw?t 24AM ion: Tu wee sir 2222/52 153? 222.2 .. (Mew-V e-iw e2, IS IV he?) 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Mac-wag I 912020.06 outta, $194 'r?P?e MaiWWAH. 014a oar/E VML ?(Tu PObt??. Ha if vow/7.1+ H711 {3432 110; 3,0 3%;qu 55 MOM 9% What Race. RM 1AM WAC 0% PP Cam.- miw Z) CHLH ..- PM Cam 'j?LI-Ewi-i- ., HEART T0 HEART BIRTH 1110 LEXINGTON GREEN LANE .2223; Jun? 3:153:11}? LL SANFORD, FLORIDA 32771 PHONE: 407-322-9944 D6 40%9 Filld Cyprus WON. 8m Tallal/Lmree. F1 398961?? 659576 32399?32?599 02/21/2019 3:55 PM 19414043015 9 18504880796 pg 1 of 3 M. We; verse ncident Report nus for Planned Out-of-Hospital Births FEB 2 21119 Flonda Department of Health Submit form to: Department of Health. Consumer Services Unit 4052 Batd Cypress Way. Bin C-75 Tallahassee, Florida 32399-3275 Bart-1:1; Erac?tt'oner - Section 456. 0495. Florida Statutes, requires an adverse incident, de?ned as an event associated with a planned art-of- hospitat birth over which a physician licensed under Chapter 458 or Chapter 459, a nurse midwife certi?ed under part i of Chapter 464, or a midwife licensed under chapter 467 could exercise controt, to be reported to the Department of Health within 15 days of the incident. Adverse incidents include maternal death; maternal hemorrhagic shock or transfusion; fetal or newborn death inctudr'ng a stillbirth; certain traumatic physical or naurptogrcat birth injuries; or a transfer of a newborn to a neonatal intensive care unit under speci?c This form does not replace any other adverse incident report required by the stanrtes and rules governing your speci?c profession. Name: Jordan Shockley License Number: MW 374 ncidgm Date: January 30! 2019 Incident beBCh presentation1437 Address where incident ocurred: 800 Central Ave cw: Sarasota State: Florida ZIP: 34236 This address is a: Residence Physician's Of?ce E3 Center (specify name}: Rosemary Birthing Home Other (please specify): Ptease check all that apply: A maternal death occurred dining delivery. A maternat death occurred within 42 days after delivery. The maternal patient was transferred to a hospital intensive care unit. The maternal patient experienced hemorrhagic shock. The maternal patient required a transfusion of more than 4 units of blood or blood products. A fetal or nevnmm death occurred. d?N The fetal or newborn death was a stillbirth. The newborn was hansterred to neonatal intensive care due to a haumatic physical or neurological birth injury. BDDUDU 9 Cl This transter downed due to a brachial plexus iniury. OHM (urns) Page 1 on (B 02121/2019 3:55 PM 19414043015 18504880796 pg 2 of 3 Adverse Incident Report for Flamed Out-ot-Hoepitai Births (continued) 5 The newborn was transferred to a neonatal intensive care unit within the ?rst 72 hours after birth and remained in the unittor mm than 72 hows. Part Adverse Incident (Narrative Summary) Describe the circumstances of the incident; use additional sheets as necessary. At 0700 on 1130i2019 Pt arrived at Rosemary Birthing Home in labor. with plans for a birth center birth. Uncomplicated pregnancy and labor, she appeared well with no signs of distress. all vital signs WNL. Baby galgated to be in vertex gosition, FHT clean! auscu ted on lower abdom care and her Part IV: Patient Identi?cation Manta-me: Patient Address: Olly: State: ZIP: Part V: Practitioner Signature C\g{leiiLi 1W1 (9 as Signature DateMme Report Completed ensues-mummy Pagezotz (9 02/21l2019 3:55 PM 19414043015 -) 18504880796 pg 3 of 3 HELLOFAX To view a High Resolution Color cepy of this. fax: 1. Go to 2. Login or create a HelloFax account 3. Enter Access Code: bcd99fa1Be (B 04/06/2019 6:44 AM 19414043015 18504880796 pg 1 of 4 1 i} Fax saawasJaLunSUOJ Hog From To Harmony Miller LM, Attn Gerry Neilson Rosemary Birthing Home DOHbConsumer Services Number of.,pages 3 - Message Please find attached the Adverse Event Report for infant Please confirm receipt . 0 04/05/2019 6:44 AM 19414043015 -) 18504880796 I pg 2 of 4 Adverse Incident Report for Planned Out-of-Hospital Births Florida Department of Health Submit form to: Department of Heath). Consumer Services Unit 4052 Beid Cypress Way. Bin 0-75 Tallahassee. 32389-3275 4 Section 456.0495. Florida Stahrtes, requires an adverse incident, de?ned as an event emaciated with a planned ord-di? hospital birth overwhich a physician licensed under Chapter458 or Chepter459, a nurse midwife certi?ed under part of Chapter 464, or a midwife licensed under chapter 467 couid exercise control, to be reported to the Department or? Health within 15 days of the incident. Adverse incidents include metemal death; maternal hemorrhagic shock or transfusion; total or newborn death including a dilibr?rth; certain traumatic physical or neurological birth injuries: or a transfer of a newbom to a neonatal intensive care unit under speci?c circumstances. This form does not replace any other adverse incident report required by the statutes and rules governing your speci?c profession. License Number: MW195 vmcincldem?enerallnf' Incident Date: 3129i19 Incident Time: Address where Incident ocumed: 3920 Bee Ridge Rd A Suite CSarasota Children's Clinic City: 53'3?? State: Pl 211:: __34233 This address is a: HomeiPrivale Residence EX Physician's Of?ce El Birthing Center (specify name): El Other (please specify): Please check all that apply: A maternal death owned during delivery. A maternal death occurred within 42 days after delivery. The maternal patient was transferred to a hospital intensive care unit. The maternal patient experienced hemonhagic shock. The maternal patient required a lranstirsion of more than 4 units of blood or blood products. A fetal or newborn death occurred. The total or newborn death-was stillbirth. El The newborn was transferred to neonatal intensive are due to a traumatic physical or neurological birth 'miury. This transfer downed due to a brachial plexus Injury. onseza-uonrorne) Page 1 ol'2 (B 04/06/2019 6:44 AM 19414043015 18504880796 pg 3 of 4 theunitiormoretbennhoms. Part HI: Adverse hcident (Narrative Summary) thmd?nmumamondMum. NSVD of viabie male. 39+1 WGA at delivery. APGARS 9.9. Baby breathed spontaneously. No sis of RES. Breastfeedirgnoma? Normal postpartum course. Motherffamily received postpartum and newborn care instruction. ?tstructed to cell pediatrician A written agreement with pad on file to see baby within 24 hours of birth. SP02 at disch1r99 from birth center 98 99 Baby was dischagao to carseat Fam?y I .. -. . . Part IV: Pattontldontl?catlon sm- ZIP: PertV: 1 ?5?19 0822 (Jammie Report Completed NM (07118) Page 2 of 2 A dv e or f T Pl an n e d 躍聽 S io n 4 5 6 0 4 . 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Bin 6-75 Tallahassee, Florida 32399-3275 Part I: Practitioner Information Section 456.0495, Florida Statutes, requires an adverse incident, de?ned as an event associated with a planned out-of- hospital birth over which a physician licensed under Chapter 458 or Chapter 459, a nurse midwife certi?ed under part I of Chapter 464, or a midwife licensed under chapter 467 could exercise control, to be reported to the Department of Health within 15 days of the incident. Adverse incidents include maternal death; maternal hemorrhagic shock- or transfusion; fetal or newbom-death including a-stillbirth; certain traumatic physical?or" neurological birth injuries; or a transfer of a newborn to' a neonatal intensive care unit under Speci?c circumstances. This form does not replace any other adverse incident report required by the statutes and rates governing your speci?c fession. Practitioner Name: License Number: 0 3361 OZ 2 Part II: Adverse Incident General Information . Incident Date: to, Z0 lot Incident Time: 0 3? 00 Address where Incident ocurred: [000 36754 8+ U%&m City: \1 9/0 ?Pgeaua State: FL -. ZIP: 3 29 (0 This address is a: El Home/Private Residence El Physician's Of?ce El Birthing Center(5pecify na Other (please specify): Please check all that apply: A maternal death occurred during delivery. A maternal death occurred within 42 days after delivery. The maternal patient was transferred to a hospital intensive care unit. El The maternal patient experienced hemorrhagic shock. The maternal patient required a transfusion of more than 4 units of blood or blood products. 3 A fetal or newborn death occurred. . The fetal or newborn death was a stillbirth. The newborn was transferred to neonatal intensive care due- to a traumatic physical or neurological birth' Injury. Cl This transfer occurred due to a brachial plexus Injury. oI-Isdzs-MQA (07113) Page 1 of 2 Adverse incident Report for Planned Out-of?HospitalBirths (continued) CI The newborn was transferred to a neonatal intensive care unit within the ?rst 72 hours after birth and remained' In the unit for more than 72 hours. [Part Adverse Incident (Narrative Summary) Describe the circumstances of the incident; use additional sheets as necessary. Semi MSW .. lPartl'lV: Patient Identification [Part V: Practitioner Signature, 0W s/droi Izw Practitioner Signature Dat?fl'im? Report Completed (07H 8) Page 2 of 2 Adverse incident (Narrative Summary) 4/29/19-had prenatal visit in the office at 41.2 weeks pregnant. Fetal movement wasgreat. All vital signs 'normal. Cervix was closed/SO/O. Discussed risks of being overdue. She signed informed consent/refusal sheet about post-dates. She did not want induction of labor. 5/2/19-had an ultrasound at 41.5 weeks pregnant. Fetal biophysical pro?le was SIS-Perfect. Included normal amniotic fluid. weeks pregnant. ent to work. She w?orked a half day and stopped when she started having mild contractions every 6 minutes. She called me on her way home andtold me she hadn?t felt her baby move since last night. I went to her house and could not hear. any fetal heart tones. I immediately called 911, and then rode in the ambulance with her. I called ahead to the hospital and sent records. When we arrived the ultrasound performed immediately at bedside showed no cardiac . activity. After a while the doctor broke her water bag and got labor going. She labored all _day and pushed for 3 hours. Baby was born vaginally? The placenta and cord looked normal. The baby girl did not have any visible defects. The parents refused autopsy. am ., 1:th BEBE QTUL um I) m: 0311.00 1?10103- SS-BECIGV- N11013: EHJ. :30 INDIE Eli-(J. OJ. HdDj?l?Na :10 1V HEMOIJS: 33TH ?Jib-1.43 r? I . .. H4 EU. ?h?hw Angela Love NAME Vero Beach. FL 39988 . -. - U.S. POSTAGE STREET $51.15 ?in" ?339.30 9023 cm! STATE ZIP Lu- .1513; Orlg: 32968 5 05/17/19 -- 11032299 . IF NEWADDRESS ?1 L- a: a 525555555 55555555555 #353 85553559 OF 405th (?[032 Mdawm 75" ?Macaw a; ?333 329 m: I Adverse Incident Report for Planned Out?of?Hospital Births Florida Department of Health Submit form to: Department of Health, Consumer Services Unit I . i ., 4052 Bald Cypress Way, Bin c?75 Tallahassee, Florida 32399-3275 Part I: Practitioner Information Section 456.0495, Florida Statutes, requires an adverse incident, de?ned as an event associated with a planned out-of- hospital birth over which a physician licensed under Chapter 458 or Chapter 459, a nurse midwife certi?ed under part I of Chapter 464, or a midwife licensed under chapter 467 could exercise control, to be reported to the Department of Health within 15 days of the incident. Adverse incidents include maternal death; maternal hemorrhagic shock or transfusion; fetal or newborn death including a stillbirth; certain traumatic physical or neurological birth injuries; or a transfer of a newborn to a neonatal intensive care unit under speci?c circumstances. This form does not replace any other adverse incident report required by the statutes and rules governing your specific profession. Practitioner Name: Wt Cl {Di 0 Elli/la? License Number: {Yuk} 3?4 Part ll: Adverse Incident General Information incident Date: 0 /20l I Home/Private Residence Physician's Of?ce Birthing Center (specify name): El Other (please specify): Please check all that apply: A maternal death occurred during deiivery. A maternal death occurred within 42 days after delivery. The maternal patient was transferred to a hospital intensive care unit. The maternal patient experienced hemorrhagic shock. The maternal patient required a transfusion of more than 4 units of blood or blood products. A fetal or newborn death occurred. UBXUDD El The fetal or newborn death was a stillbirth. The newborn was transferred to neonatal intensive care due to a traumatic physical or neurological birth injury. El This transfer occurred due to a brachial plexus injury. DH5029-MQA (07H 8) Page 1 of 2 Adverse incident Report for Planned Out-of?Hospital Births (continued) El The newborn was transferred to a neonatal intensive care unit within the ?rst 72 hours after birth and remained in the unit for more than 72 hours. Part Adverse Incident (Narrative Summary) Describe the circumstances of the incident; use additional sheets as necessary. 0A a named )2 r?ik . AcQ'wrgdAAJr w. - - . ?it; to 0 tom :dlbf'miamiaa .l m. x- . a ~i ,i?i 5mm 906 cm as AM tale in5m?: \lfM I?t?buusst? '1 - L. ?t . ?2400 I g- u. hst' - t- ?v u. 4. 4'0; AL 0.34(ismst?t? Wotan/Ame ?aces ?69?qu 6.va (at; mus We aimed \uwoti ems. box/Qt mc? Part IV: Patient Identi?cation Patient Name Patient Addr City: Part V. Practitioner Signature 05/5/19, [1:06 Practitibner SI 8 Date/Time R?eport Completed DH5029-MQ 7! 18) Page 2 of 2 was Vuy?r m-V (?stula Hoe; gawk. IV 1560a? was 6mm owA kid-5 max-Lona! our) Azsa?oqs?? \o?o?m H05 3 U6 Jf?w?r 6Le bee/w Mm? \Ofg? $55155 <39 lec Suww. DN- c. .k \Adp [All-W 0x spatmt; wrisjr ukxck Probabk, Vog??lrww 004:; We Ohw41me? as worm? TO SEAL PRESS FIRML TO SEAL ITY . Ls}? 11mm?0191mmunwumnmu CUSTOMER USE ONLY IN THE U.5. - FROM: (PLEASE PRINT- PHONE PRIORITY MAIL UNITED STATES POSTAL SERVICE 00 PAYMENT BY ACCOUNT (if appiicable) SIGNATURE REQUIRED N019 DELIVERY 0PT10NS (Customer Use Only) The mallet mus-1 check Ihe ?Signature Required? box h? the mailer: 1) ON HARD SURFACE TO MAKE ALL COPIES LEGIBLE. Requues the amresseo's ygnalura'. OR 2) Purchases msurance: OR 3} Purchases COD service: OR 4] I Purchases Rmum Recaxplsanrica. the boxisnm chucked. mePosta! Service Ieavethe nemm ms uddressee's I i 1 man} racopiacla or other mum locatnon w?hom lo oblatn the addlessee's sngnaluro on dolwery. Delivery Optlons I No Saturday Delwery [delivered next busmess day} I Sundanyoliday Delivery Heqmrad (addllional fee. where available10.30 AM Delivery Required {additional 1'09. where avanable?] 1' I vn- w- .1 'Referto or local Post Of?ce" lor . I a. T01m5asevanm PHONE 3 . 7? I .TIONALLY. -. .RATION IUIRED. _l .2 . 4 51.. . ?mu-ADDRESSES $100.00 insurance Included. 3 .12-5X9.5 3 1 . ?ll LABEL 1 2015 F's-ii 7690020003900 66,57, guts no 0006 VISIT US AT ORDER FREE SUPPLIES ONLINE It INHIQS a UNITED STATES POSTAL SERVICE. To Consumer Servroes Unit Pa 1 of 59 2019-05-08 19:40 00 GMT FAX COVER SHEET TO ConsumerServicesUnit COMPANY FL Dept of Health FAX NUMBER 18504880796 FROM Suzanne Hudey DATE 2019-05-08 19:26:08 GMT RE Incident Report filed by Valentina Babinsky APRN CNM COVER MESSAGE Attachedare: 1)Adverse Incident Report for Ptanned Out-of~Hospital Births and 2) Exhibits to the Report. Thank you. MYFAX COM To: Consumer Services Unit Page 2 of 59 2019-05-08 1 9:40:00 (GMT) 18133543318 From: Suzanne Hurley Adverse Incident Report for Pianned Out-of-Hospital Births Florida Department of Heatth Submit form to: Department of Health. Conswner Services Unit 4052 Bald Cypress Way, Bin (>75 Tallahassee, Florida 32399-3275 Section 456.0495. Florida Statutes, requires an adverse incident. de?ned as an event associated with a planned out-of? hospital birth over which a physician licensed under Chapter 458 or Chapter 459, a nurse midwife certi?ed under part I of Chapter 464, or a midwife licensed under chapter .467 could exercise control, to be reportedto. the Department of Health within 15 days of the incident. Adverse incidents include maternal death; ma'temai hemorrhagic shock or transfusion; fetal or newborn death including a stilibirth; certain traumatic physical or neurological birth injuries; or a transfer of a newborn to a neonatal intensive care unit under specific circumstances. This form does not replace any other adverse incident report required by the statutes and rules governing your speci?c profession Valentina Jude Babinski, Practitioner Name: License Number: APRN 9268374 ti: Incidentuate; April 23, 2019 Address where Incident econ-ed: City: This address is a: HomeiPrivate Residence E1 Physician's Of?ce El Birthing Center (specify name): ll Other (please specify): Please check all that apply: A maternal death occurred during delivery. A maternal death occurred within 42 days after delivery. The maternal patient was transferred to a hospital intensive care unit. The maternal patient experienced hemorrhagic shock. The maternal patient required a transfusion of more-than 4 units of blood or blood products. A fetal or newborn death occurred. KDUDUD Cl The fate! or newborn death was a stillbirth. The newborn was transferred to neonatal intensive care due to a traumatic physical or neurological birth injury. [3 El This transfer occurred due to a brachial plexus injury. DH5029-MQA (07nd) Page 1 of 2 To: Consumer Sewices Unit Page 4 of 59 2019-05-08 19:40:00 (GMT) 18133543318 From: Suzanne Hurley with sea ?tment R?p?l?l for Planned Gut?Jain nHuspital Births {mmwi 95 was; :e a measly :ntenswa care um! within the ?rst 72 hours after birth and rammed; it? The MC: 9mm 32. haters. - to Day Irradmr Repair . 3.: 3: en Babimh. APRN ?les this Report pmuant In Section 456 0495(llfd} Fla Sta. . .. "1?81 This Report as ?led under subsection GM) of the Statue: because -CHM. Reliant as the nurse midwife fer a planned home bird: that ?Suited a fetal deam However CHM Bahinski was net present when the dentin deem-ted The death . - . MCHITL n?ex she. handed ovu?fu? responsibility of the laboring mother EMS ?611 a. 77. - :0 suhseq den: death 3559de with delivery cfthe hnby hythe licensee Fm 0123mm 2819 38 were -- Babinsh . - nedland 15Max26Apr22019mdApr112019$h? mar my mfmfumamandm To: Consumer Services Unit Page 6 of 59 2019-05-08 19:40:00 (GMT) 18133543318 From: Suzanne Hurley On April 21, 2019, patien was in early labor. Fetal Health Tones (F HTS) were assessed at 146. a normal 3. went into active labor at 7:47 PM on April 22, at which time FHTs were measure 148. The fetus was in normal position (vertex) throughout the labor. A abored, CNM Babinslci continued to monitor the Fetal Heart Tones (PHI 5) and the well-being of the laboring mother. birth environment. [The midwife] provides physical and labor support, as well as attemion to comfort md progress using simple interventions when necessary. The woman depends on the midwife?s ability to assess for continued normalcy. . . . Vamey?sMx?dm?m Chap. 32, Birth in the Home and Birth Center, p. 1076 (2015).? On 04 21 2019 at 6:45 PM FHTs were 146 04 22 2019 at 7:47 PM 148 at 8:30 PM 145 at 10:00 PM 140 04 23 2019 at 1:30 AM 138 at 2:41 AM 151 at 140 at 3:47 AM 148 at 4:35 AM 148 at 6:24 AM 138 at 7:05 AM 138 at 7:48 AM 140 at 9:00 AM 132 at 8:37 AM 134 at 10:06 AM 148 at 10:33 AM 154 at 11:03 AM 130 at 11:34 AM 140 at 12:13 PM 80 Vamey?s Midm?ry is an authoritative text used to train certi?ed nurse midwives. 2 To: Consumer Services Unit Page 8 of 59 2019-05-08 19:40:00 (GMT) 18133543318 From: Suzanne Hurley When the suddenly and to 80 beats per minute, CNM Babinslti immediately repositioned patien 11 her left side, administered oxygen, and called 911. This is exactly what (13 require. Abnormal fetal heart rate patterns may require emergency transport to the hospital. Variant fetal heart rate patterns that do not resolve with increased hydration, a change inmatemalposi?on andabn'efperiod ofoxygenbymask, indicatethatthe fetus is atina'easedrisk. . . Auansferto thehospitalisindicated. . . Vmeyis Midm?ry, Chap. 32, Management of Urgent Eancrgency Clinical Situations, p. 1088 (2015). See also: Dre Home Birth Pram'ce Manual, Third Ed., American College of Nurse Midwives (2016), page 178, Fetal D?stress listed in Conditions that May Require Collaboration or Referral,? attached as Exin'bitB. And see also Vamey?s (2015), Chapter 32, Birth in the Home and Birth Center at Evidence of?ral intolerance oftabor in Common Indications for a Change in Birth Site ?'cm Home or Birth Center to Hospital at Box 32-3, p. 1080, attached as Exhibit C. Once oxygen was being administered, the FHTs rose to 120 beats per minute. EMS arrived but did not allow CNM Babinski to attend her patient in the ambulance during the transiort. Instead, the nurse midwife was required by EMS to turn 0ch full care of patient her unborn child to EMTs who, unlike the CNM, were untrained in fetal mom mg and neonatal resuscitation. CNM Babinski stressed and EMS agreed to assure that oxygen would continue to be administered to the mother during the transport. The EMTs informed CNM Babinslci that she would have to follow them in a separate vehicle. The last FHTs recorded by CNM Babinski before pati as transferred were 118 and 126 so the nurse midwife Babinski believed that a sa tra or would ensue. As soon as safely loaded into the ambulance, CNM Babinski called Ft. Walto Center Labor and Delivery and pr Charge Nurse a full report so that the hospital could be prepared to a probable STAT caesarean section. However after arrival to the hospital, Nurse Midwife Babinski was informed that her client, Wham died in utero during the ambulance transfer. Babinski does not posse a copy of the EMS records so is without knowledge as to when the baby's heart tones ceased or where the fetal death occurred. Low Applicable law: Under Florida law, a nurse midwife may, to the extent authorized by physician protocol, a patient during labor and delivery. . . manage the medical care of the normal obstetric patient, manage medical problems, ?464. and initiate appropriate therapies for certain conditions. ?464. 012(3)(b) CNM Babinslci?s Protocols authorize all of these See APRN Protocol Agreement, attached as Exhibit D. During mtraparmm Babinsld?s Protocols speci?cally authorized s, which she did. It further To: Consumer Services Unit Page 10 of 59 2019-05-08 19:40:00 (GMT) 18133543318 From: Suzanne Hurley authorized Babinslri to diagnose indicators of deviations from normal, including complications and emergencies. The Florida Board of Nursing recognizes the American College of Nurse Midwives (ACNM) as the specialty Board that sets Standards and scape of practice statements applicable to Certi?ed Nurse lldidwives. Fla. Admin. Code When it comes to a transfer from planned home birth to hospital, ACNM Guidelines are specific that the nurse midwife should continue to provide routine or urgent care en route to the hospital in coordination with EMS. Best Practice Guidelines: Tmns?r?'om Planned Home Birth to Hospiml, Home Birth Summit 2013.2 See Best Practice Guidelines: Transfer from Planned Home Birth to Hospital, attached as Exhibit E. When the EMS receives a patient after being called but prohibits a nurse-midwife from accompanying and attending her patient during a transfer, then EMS assumes full responsibility for mother and baby. This is what happened here and is why CNM Babinski cannot fully ?ll out this form. She was not present at the time that the full-term fetus died. Other than the fact that the ambulance left for the hospital wi board, CNM Babinski does not have personal knowledge of what ha ce after she transferred we of her client into the hands of the EMS. Conclusion Nurse Midwife Babinski complied perfectly with all ACNM Standards (as required by Florida law and by her Protocols) and, as such, with all relevant standards of the Florida Board of Nursing. She did her best and made all decisions with the best interests of the mother and unborn baby in mind. She was very upset to learn what happened to patien her unborn baby after EMS took them without allowing her to awompany an momtor them. To date CNM Babinslti is unaware as to whether an autopsy was performed to determine causes or contributing factors that may have led to the unexpected fetal intolerance of labor (decelerations of the FHTs) and death in utero of the fetus. She is sad and grieving over the loss her client experienced. The Home Birth Summit?s Guidelines were endorsed by ACNM in its Number 61, November 2015 Clinical Bulletin, dez?ry Envision ofHome Birth Sem?ces, at p. 130, Tram?r??om the Home to a Hospital Setting, paragraph footnote 7. See ACNM Clinical Bulletin No. 61, Nov. 2015, attached as Exhibit F. 4 DOH Consumer Services for Planned Out-of-Hospital Births Florida Department of Health 1 2mg Submit form to: Department of Health, Consumer Services Unit 4052 Bald Cypress Way, Bin 0-75 Tallahassee, Florida 32399-3275 Section 456.0495, Florida Statutes, requires an adverse incident, de?ned as an event associated with a planned out-of- hospital birth over which a physician licensed under Chapter 458 or Chapter 459, a nurse midwife certi?ed under part I of Chapter 464, or a midwife licensed under chapter 467 could exercise control, to be reported to the Department of Health within 15 days of the incident. Adverse incidents include maternal death; maternal hemorrhagic shock or transfusion; fetal or newborn death including a stillbirth; certain traumatic physical or ?-Wcal?bi?h?mriesfo?a?transfer pf a newborn to a neonatal intensive care unit under specific circumstances. This form does not replace any other adverse incident report required by the statutes and rules governing your specific profession. Practitioner Name: arcs L- ev?l?t??x . License Number: 431? I incident Date: Li i 0? Incident Time: I ?i 1 Addr City: This B/HomeIPrivate Residence El Physician?s Of?ce El Birthing Center (specify name): El Other (please specify): Please check all'that apply: 2/ A maternal death occurred during delivery. A maternal death occurred within 42 days after delivery. The maternal patient was transferred to a hospital intensive care unit. The maternal patient experienced hemorrhagic shock. The maternal patient required a transfusion of more than 4 units of blood or blood products. A fetal or newborn death occurred. I: The fetal or newborn death was a stillbirth. E/The newborn was transferred to neonatal intensive care due to a traumatic physical or neurological birth injury. El This transfer occurred due to a brachial plexus injury. (07718) Page 1 of 2 Adverse Incident Report for Planned Out-of-Hospital Births (continued) 12/ The newborn was transferred to a neonatal intensive care unit within the ?rst 72 hours after birth and remained in the unit for more than 72 hours. Describe the circumstances of the incident; use additional sheets as necessary 8/ war, \Gvbor-I?j on kMoLs Jr- b1 5700? Hall gar?5r? SQOM 0! ~90?9r"d epqp?tfl-H?W b: '??rV?LJ.axlr?- Wag-44 {19% wow-$4113 Lat 67ng its: wrvw. uf?r?gLJ-?r-c} AS C/mglp?p 0 A gimba\\g?n jag/aar? Practitioner Signature "1 5 lislle?i?tu Date/Time Report Completed DH5029-MQA (07MB) Page 2 of 2 FL. $11: 151 Ma??i? 2019 PM Bm$0191uMWuleJ? Pb 33>3q?s #39515 32333-32?5% 11111111 erse Incident Report for Planned Out?of?Hospital Births DOH Consumer Services Florida Department of Health . Submit form to: 5 MM 2 5 2019 Department of Health, Consumer Services Unit 4052 Bald Cypress Way. Bin Tallahassee, Florida 32399?3275 Part Section 456.0495, Florida Statutes, requires an adverse incident, defined as an event associated with a planned out-of- hospital birth over which a physician licensed under Chapter 458 or Chapter 459, a nurse midwife certified under part I of Chapter 464, or a midwife licensed under chapter 467 could exercise control, to be reported to the Department of Health within 15 days of the incident. Adverse incidents include maternal death; maternal hemorrhagic shock or transfusion; fetal or newborn death including a stillbirth; certain traumatic physical. or neurological birth injuries; or a transfer at a newborn to'a neonatal intensive care unit under specific circumstances. This form does not replace any other adverse incident report required by the statutes and rules governing your specific profession. Practitioner Name: Angela Love License Number: APRN 3390252 Incident Date: 5l5l2019? Incident Time: 15:22 Address where incident ?occurred: Home/Private Residence El Physician's Of?ce El Birthing Center, (specify name): El Other (please specify): Please check all that apply: A maternal death occurred during delivery. A maternal death occurred within 42 days after delivery. The maternal patient was transferred to a hospital intensive care unit. The maternal patient experienced hemorrhagic shock. The maternal patient required a transfusion of more than 4 units of blood or blood products. A fetal or newborn death occurred. l2] The fetal or newborn death was a stillbirth. The newborn was transferred to neonatal intensive care due to a traumatic physical or neurological birth injury. El El This" transfer occurred due to a brachial plexus injury. DH5029-MQA (0711 8) Page 1 of 2 3) Adverse incident Report for Planned Out-of-Hospital Births (continued) El The newborn was transferred to a neonatal intensive care unit within the ?rst 72 hours after birth and remained in the unit for more than 72 hours. ?Part In: Summary) Describe the circumstances of the incident; use additional sheets as necessary. 5/5/2019 15:55 Mat?rnal patient is 31Y gravida para 0 at 42w 1d gestation with estimated delivery date of April 20, 2019 brought to Cleveland Clinic Indian River Hospital via EMS by Midwife Love after being unable to auscultate fetal heart rate at home. Patient admits to fetal movement last night and states today she did not feel the baby move. Midwife antenatal record shows prenatal care starting at 11weeks gestation with approximately 15 visits. On arrival to hospital unit bedside ultrasound, performed by shows no fetal heart rate. Con?rmatory ultrasound shows estimated fetal weight of 3823 grams, AFI 8.7, fundal placenta, no signs of abruption and no fetal heart rate. Midwife notes date con?rming ultrasound 12/3/18 at 20 weeks. Last prenatal visit was 4/29/2019, A biophysical pro?le 5/2/2019, score 8/8. Patient reported she went to work and came home due to pain. Doula was present at home prior to Midwife arriving. Patient was in labor with contractions 2 minutes apart. On arrival to hospital contractions were noted, patient denied leakage of ?uid or bleeding, cervix was closed. After epidural placed, patient labored, IUFD was delivered with pea soup thick meconium ?uid 5/6/2019 at 02:10. Midwife prenatal record lists no supervising physician, no physician exams; no NST (Fetal Non-Stress Tests) recorded in the prenatal record. There is no maternal education documented. RNdiscussed patient saying she did not know there were potential risks associated with late postdate delivery. Physician asked why she was waiting so long. Patient responded the midwife told her it was OK. I - Placental Pathology demonstrates: Third trimester placenta with small peripheral infarct and calci?cations, congested three-vessel cord, :chorioamnionic membranes with squamous metaplasia and pigmented macrophages consistent with meconium staining. American College of Obstetricians and Gynecologists acknowledge increased maternal and neonatal morbidity 8: mortality associated with late and post term pregnancy. Review with the State of Florida Nursing and Medical Boards have been unable to identify any participating/ supervising physician for APRN, Midwife Love. (07/18) Page 2 of 2 a1 Part IV: Patient Identification Patient Name: Patient Addres n- '1 . algnalure I 12% Wm; m? i game? Practitioner-Signature 27?) j; (07/18) Page 3 of 2 Datemm'e Report Completed [3 Cleveland Clinic lndian River Hospital DUUL 6553 Maine: Department ofHealth, Consumer Services Unit 4052 Bald Cypress Way, Bin (2-75 Tallahassee, FL 32399-3275 Enmndoxmapqqoao?golaig anim??.?u?ooa?n .. . .. y. Adverse Incident Report er Ser ?t?e . 7 DOH consum for Planned Out-of-Hospltal Births JUN 1 3 1019 Florida Department of Health Submit form to: Department of Health, Consumer Services Unit 4052 Bald Cypress Way, Bin C-75 Tallahassee. Florida 32399?3275 Part I: Practitioner Information Section 456. 0495, Florida Statutes, requires an adverse incident, defined as an event associated with a planned out-of- hospital birth over which a physician licensed under Chapter 458 or Chapter 459, a nurse midwife certified under part i of Chapter 464, or a midwife licensed under chapter 467 could exercise control, to be reported to the Department of Health within 15 days of the incident. Adverse incidents include maternal death; maternal hemorrhagic shock or transfusion; fetal or newborn death including a stillbirth; certain traumatic physical or neurological birth injuries; or a transfer of a newborn to a neonatal intensive care unit under speci?c circumstances. This form does not replace any other adverse incident report required by the statutes and rules governing your specific profession. Practitioner Name: CLO I I Z. License Number: LM 3 17/1 Part II: Adverse incident General information Incident Date: Lf/7l/l c? Incident Time: 7. '73 Address where incident ocurred: City: This a ress Is a: {Home/Private Residence El Physician?s Of?ce Birthing Center (specify name): El Other (please specify): Please check all that apply: A maternal death occurred during delivery. A maternal death occurred within 42 days after delivery. The maternal patient was transferred to a hospital intensive care unit. The maternal patient experienced hemorrhagic shock. The maternal patient required a transfusion of more than 4 units of blood or blood products. A fetal or newborn death occurred. El The fetal or newborn death was a stillbirth. CI The newborn was transferred to neonatal intensive care due to a traumatic physical or neurological birth injury. This transfer occurred due to a brachial plexus injury. DH5029-MQA (07M 8) Page 1 of 2 Adverse Incident Report for Planned Out-of?Hospital Births (continued) The newborn was transferred to a neonatal intensive care unit within the ?rst 72 hours after birth and remained in the unit for more than 72 hours. Part Adverse Incident (Narrative Summary) Describe the circumstances of the incident; use additional sheets as necessary. J/de/Jor/J j/e?rrgr/ 02 alga/P 04.22 710 HIN- don/66 0x. abort! and b/rf/I wen Baku War 70?4/2 9431de 740 GOASCMO 0/7/ 01th [Naomi an ?Me 5u000r+. brie support Mida??n?7? moier? dud 7?0 Emineu :lnilure, Iq-ian-l- ma: diagndse AVIWWQIWSIAIX. [pa 3 Part IV: Patient Identi?cation Part V: Practitioner Signature 22/0 grow/4m Practitioner Sign?ature Date/Tune Report Completed (07/18) Page 2 of 2 .. - '4 . ?i 11?I?ll .L Hag/1??) Stag-21:5 un?t Bald Nag} Bin Q79 Taudlm?aee FL 3239?1 -5?2'75323.345: . '4 a ears? :32?9?2399?3z?aasi? a: . . dverse Incident ?em anned Out-of-li-lospital Births Florida Department of Health Ol' Submit form to: Department of Health, Consumer Services Unit 4052 Bald Cypress Way. Bin C- 75 Tallahassee, Florida 32399-3275 Section 456.0495, Florida Statutes, requires an adverse incident, defined as an event associated with a planned out-of- hospital birth over which a physician licensed under Chapter 458 or Chapter 459, a nurse midwife certi?ed under part I of Chapter 464, or a midwife licensed under chapter 467 could exercise control, to be reported to the Department of Health within 15 days of the incident. Adverse incidents include maternal death; maternal hemorrhagic shock or transfusion; fetal or newborn death including a stillbirth; certain traumatic physical or neurological birth injuries; or a transfer of a newborn to a neonatal intensive care unit under specific circumstances. This form does not replace any other adverse incident report_ required by the statutes and rtrles governing your specific profession. 7' Practitioner Name: TANASHIA ROBERTS HUFF License Number: MW 362 Part II General Information:.:1I: . . .- .- . Incident Date: JULY 8. 2019 Incident Time: 0832 IS a ress IS a: Home/Private Residence El Physician's Of?ce El Birthing Center (specify name): Other (please specify): Please check all that apply: . A maternal death occurred during delivery. A maternal death occurred within 42 days after delivery. The maternal patient was transferred to a hospital intensive care unit. The maternal patient experienced hemorrhagic shock. The maternal patient required a transfusion of more than 4 units of blood or blood productsi A fetal or newborn death occurred. El El The fetal or newborn death was a stillbirth. El The newborn was transferred to neonatal intensive care due to a traumatic physical or neurological birth injury. El This transfer occurred due to a brachial plexus injury. 3 DH5029-MQA (07/18) Page 1 of 2 Adverse Incident Report for Planned Out-of-Hoshital Births (continued) The newborn was transferred to a neonatal intensive care unit within the first 72 hours aftertbirth and remained In the unit for more than 72 hours l. Describe the cirbumstances of the incident; use additional sheets .as necessary. CLIENT WAS A G7MI1I1I5. 37.4 WGA. GBS NEGATIVE. CLIENT CONTACTED MIDWIFE AT 0525 STATING THAT SHE THOUGHT- SHE IN EARLY LABOR. MIDWIFE ARRIVED AT CLIENTS HOME AT 0600. ASSESSMENT WAS COMPLETED. CERVIX WAS MEMBRANES INTACT. FETAL HEART TONES REASSURING. MATERNAL VITAL SIGNS WITHIN NORMAL LIMITS. CLIENT COPING WELL. CLIENT PLANNING WATER BIRTH. LABOR WITHOUT INCIDENT. AT 0?30 CLIENT REQUESTED VAGINAL EXAM BEFORE ENTERING BIRTH POOL. EXAM WAS SCIWSDW-L CLIENT ENTERED POOL. CONTINUED TO COPE WELL. FETAL HEART TONES REASSURING AND MATERNAL VITAL SIGNS WITHIN NORMAL LIMITS. AT 0815 CLIENT REQUESTED FOR ARTIFICIAL RUPTURE 0F MEMBRANES. MIDWIFE DISCUSSED RISKS AND BENEFITS. VERBAL CONESNT FOR AROM GIVEN. AROM: RETURN OF LARGE AMOUNTS OF CLEAR FLUID. FHTS WNL. EXAM WAS 0829: CLIENT EXITS BIRTH POOL FOR COMFORT AND LAYS 0N BED. BABY BOY SPONTANEOUSLY DELIVERS AT 0832. HE IS PLACED SKIN- TO-SKIN WITH MOM. DRIED. AND STIMULATED. BABY IS VIGOROUS WITH GOOD COLOR. TONE. AND SPONTANEOUS RESPIRATIONS. APGARS 9 9. AT 0845 BABY BEGINS TO HAVE MILD GRUNTING. NO RETRACTIONS OR NASAL FLARING. VITAL SIGNS WNL. MIDWIFE PERFORMS CHEST PERCUSSION THERAPY 8: POSTURAL DRAINAGE. MIDWIFE DISCUSSES WITH CLIENT WHAT IS HAPPENING AND POSSIBLE NEED FOR TRANSFER IF BABY DOES NOT TRANSITION. GRUNTING IMPROVES. BABY REMAINS SKIN-TO-SKIN WITH MOM. APPROXIMATELY AT 1000. GRUNTING INCREASES AND RESPIRATORY RATE INCREASES T0 603. MIDWIFE INFORMED CLIENT AND SPOUSE THAT BABY NEEDS EXTRA CARE AND NEEDS TRANSFER TO HOSPITAL. MOM AND BABY TALLAHASSEE MEMORIAL HOSPITAL VIA AMBULANCE. MIDWIFE MEETS THEM AT HOSPITAL TO GIVE REPORT AND PROVIDE RECORDS. EASY T0 NICU DIAGNOSIS OF PNEUMONIA. .IuIy14 2019at0925 /Practitioner Signature Date/Time Report Completed DHSOZQ-MQA (07718) Page 2 of 2 2% 5375 /g 375/ Mb (IL/Imam Ii @353 917i jar/w 17/0652 ?it/[Z Ida}? 11:17.. 75 fag/$148366; 5 JM 4415:2753 . 5: II: I: II: ?i?imIsmuig-rI-I-II-?I; Adverse Incident Report for Planned Out-of?Hospital Births Florida Department of Health Submit form to: Department of Health, Consumer Services Unit 4052 Bald Cypress Way, Bin Tallahassee, Florida 32399-3275 Part I: Practitioner Information Section 456. 0495, Florida Statutes, requires an adverse incident, defined as an event associated with a planned out-of- hospital birth over which a physician licensed under Chapter 458 or Chapter 459, a nurse midwife certi?ed under part i of Chapter 464, or a midwife licensed under chapter 467 could exercise control, to be reported to the Department of Health within 15 days of the incident. Adverse incidents include maternal death; maternal hemorrhagic shock or transfusion; fetal or newborn death including a stillbirth; certain traumatic physical or neurological birth injuries; or a transfer of a newborn to a neonatal intensive care unit under specific circumstances. This form does not replace any other adverse incident report required by the statutes and rules governing your specific profession. Practitioner Name: Mi License Number: l/ll/t 3141} Part II: Adverse Incident General Information Incident Date: Incident Time: 7 620 Home/Private Residence Physician?s Of?ce Birthing Center (specify name): CI Other (please specify): Please check all that apply: - A maternal death occurred during delivery. A maternal death occurred within 42 days after delivery. The maternal patient was transferred to a hospital intensive care unit. The maternal patient experienced hemorrhagic shock. The maternal patient required a transfusion of more than 4 units of blood or blood products. A fetal or newborn death occurred. The fetal or newborn death was a stillbirth. I The newborn was transferred to neonatal intensive care due to a traumatic physical or neurological birth injury. i El EKN This transfer occurred due to a brachial plexus injury. DH5029-MQA (07/18) Page 1 of 2 . Adverse Incident Report for Planned Out-of-Hospital Births (continued) El The newborn was transferred to a neonatal intensive care unit within the ?rst 72 hours after birth and remained in the unit for more than 72 hours. Part Adverse Incident (Narrative Summary) Describe the circumstances of the incident; use additional sheets as necessary. anc? {blow ertg?QWml due to bt?PPCl/x Ingn-Ji mam dE/lf/l/Crt?d Q76 6499.07747/ by (?lain/o2 a??er Ami/77:2 {?ack ?67er Cana/ 793/" #:3744516 Tri?m; mid/5 nor/2 no W650, (Io/m of? 1714917374 1,7625 war/sen] A7 mac/7 co/ ?at? ER @742? w/w Mf/f? d?/c 7?0 (21072 5?30 mm 76me Inv??mf M45 115? 77126 %n arenz?: disco/i/hap? ,7 to KUDOO MAFa??'Ml?ff Kim-(? ?7?0 [04 07L bmtri/l 05' Part IV: Patient Identi?cation Part V: Practitioner Signature 23 2/0 675/ 9 77m /0 02w? [Practitioner Signat?e Date/Time Report Completed (07/18) Page 2 of 2 -. I ZQR {1?4 ?30in! 2-. ?gamu- I I . H052 Edd MCV BHN ('75 FL 323% ?3175 323aa?32?5??