Paris Bean checked into Rosemary Birthing Home before the sun rose on the last Wednesday in January, excited to deliver her first child.
Two weeks past her original due date and plump from pregnancy, the 23-year-old lumbered into the freestanding birth center with her longtime partner, Jason Fisher.
The couple carried a load of clothes and blankets for the baby, a birthing kit for the midwife, several bags of ice and two homemade casseroles — enough for 25 people — to feed the entire birthing team that they expected to rally around them.
But just one person was there at the time, Bean and Fisher said.
Newly licensed midwife Jordan Shockley welcomed the couple and ushered them into a private birthing room on the first floor of the converted, historic home.
It was just past 7 a.m.
Outside, the sun cast its first light on what would be their son’s birthday. A day that turned to horror after the baby went into cardiac arrest, respiratory failure and ultimately severe brain damage from which he may never fully recover, according to the midwife’s notes and records, an EMS report, and interviews with the family and a hospital official.
Brenden Charles Fisher is still alive.
He is at Johns Hopkins All Children’s Hospital in St. Petersburg. He has a tube in his nose delivering a steady flow of oxygen. A tube in his leg administers fluids, nutrients and anti-seizure medication. Another tube in his throat provides tiny doses of breast milk in an attempt to wake up his digestive system.
He cannot swallow. His parents and nurses take turns suctioning saliva from his throat and mucous from his nose.
He doesn’t cry. His only sounds so far came from a bout of hiccups.
His long-term prognosis is unclear.
It is the latest incident at Rosemary Birthing Home, profiled last year as part of a nine-month investigation by GateHouse Media and the Herald-Tribune into the dangers of out-of-hospital births.
One of the area’s two birth centers, Rosemary has a troubled history that includes at least three deaths and a rash of hospital transfers. At least one of the deaths was due to a congenital heart defect and not preventable, according to the child’s mother.
The owner of Rosemary did not respond to an email seeking comment for this story.
“I have chills from all these moms that went through a similar situation,” she said. “This can’t happen to anyone ever again.”
‘So many things were done incorrectly’
Brenden Charles Fisher was a foot-first breech baby.
Most babies flip into a head-down position in the last weeks of pregnancy. But a small fraction do not flip and either their buttocks or feet point toward the birth canal instead. Most breech babies are delivered by cesarean section.
Shockley did not know the baby was breech when Bean checked into the birthing home that morning in active labor.
Nor did she know one hour later when she performed a vaginal exam and said she felt the baby’s head, Bean said.
Shockley was reached by phone Thursday morning but said she was not able to immediately comment despite receiving Bean’s written consent to disclose client information. She said would call back but did not do so. She did not respond to two additional attempts to reach her.
The midwife’s own notes reflect she did not follow several state midwifery regulations prior to the baby’s traumatic delivery.
Florida regulations require midwives to perform an initial assessment at the onset of labor, including a vaginal examination to assess the baby’s presentation and position. Shockley’s notes show she did not do this. She said the exam was “declined.”
Florida regulations require midwives to refer their clients to a physician with hospital privileges if the baby has not flipped to the head down position after the 37th week of gestation. Shockley did not do this, according to her prenatal notes. There’s no mention of the baby’s position at the post-37-week appointments.
Florida regulations require midwives to refer their clients to a physician with hospital privileges if the baby’s gestational age is between 41 and 42 weeks. Shockley did not do this, according to her prenatal notes. She altered the due date instead, pushing it back by nine days less than a week before Bean was projected to give birth.
Florida regulations require midwives to consult with or transfer their clients to a physician with hospital privileges if the baby is breech during labor. Shockley did not do this, according to her labor notes. She attempted to deliver the baby herself at the birthing center.
“So many things were done incorrectly with this birth,” said Paris Bean’s mother, Nikki Bean.
‘I just can’t believe this all happened’
When Shockley felt the foot and told Bean the baby was breech, the laboring mother said she cried because she was scared. But Shockley reassured her that it wasn’t a problem, Bean recalled.
“She told me to push, and we could have the baby, and everything would be OK,” Bean said. “I just can’t believe this all happened. We were sold on this beautiful experience. I trusted her.”
Shockley noted in her report that she had an “urgent discussion” with Bean about going to the hospital at that point, but that Bean refused. Both Bean and Fisher dispute that account. They said they never refused hospitalization and would have willingly gone then if their midwife advised them to do so.
Shockley then dialed an unidentified person for advice, the couple said. When she hung up, she called 911. Her notes from the labor report state that she “activated EMS, gave report of fetal breech presentation with needs for urgent support.”
An audio recording of the 911 call sounds anything but urgent.
“I have a mom in labor, everything’s fine, but her baby is breech,” Shockley told the dispatcher. “We broke her water and found a foot, so we kinda want 911 on … she’ll have a baby by the time they get here, but just to have them here.”
Paramedics arrived three minutes later, according to the EMS report. Some gathered in the hallway, others in the birthing room, as Shockley instructed the mother to push, Bean and Fisher recalled.
“The main EMT said, ‘She shouldn’t push. We need to go right now,’” Fisher said. “But Jordan said, ‘No, just push.’ The arguing went on for it seems like forever.”
Neither the midwife’s labor notes nor the EMS record mentions an argument. The EMS record states simply: “Decision made to continue delivery at birthing center.”
“Licensed midwives attending childbirths at birthing centers or private residences are not healthcare professionals,” according to the Sarasota County EMS Handbook for Community Protocols. “Respond, assess, stabilize and transport the mother and/or newborn to an appropriate Resource Hospital. Staging at the birthing center and engaging in discussions with the midwife are not authorized.”
Sarasota Fire and EMS Chief Michael Regnier refused to answer questions directly related to that incident. He said each case is different.
The EMTs stayed at the birthing center for nearly 30 minutes, records show, while Shockley attempted to the deliver the baby herself.
According to her labor notes:
At 2:54 p.m., a foot emerged.
At 2:56 p.m., both feet and calves emerged.
At 2:59 p.m., Shockley claims she again advised her client of the need for urgent transport. Bean and Fisher strongly deny the midwife ever encouraged them to go to the hospital.
At 3 p.m., the buttocks emerged covered in meconium — the baby’s first stool.
At 3:02 p.m., the midsection emerged.
At 3:07 p.m., the arms emerged.
At 3:08 p.m., the head remained stuck and Shockley again claims she expressed an urgency to transport. Again, the couple denied this.
At 3:10 p.m., Bean is moved to the stretcher to begin transport to Sarasota Memorial Hospital.
‘There was a protocol, and I broke it’
Bean was on her back on the stretcher with a portion of her baby dangling from her vagina. Shockley got on the stretcher with her. Paramedics loaded them into the ambulance and left Rosemary at 3:13 p.m.
While en route to Sarasota Memorial Hospital, paramedics noticed the baby’s exposed umbilical cord stopped pulsing, the report states. This means it was no longer delivering blood and oxygen to the brain. They also discovered the mother’s placenta had detached.
They cut the cord and began chest compressions on the baby, with his head still lodged behind his mother’s pubic bone. Bean said she reached out and held her son’s hand.
The baby went into cardiac arrest at 3:18 p.m., according to the EMS report.
Back at the birth center, Fisher was standing in a daze on the street, he said. The ambulance had left him behind. He was covered in blood and meconium, unsure what to do. Eventually, someone took him to the hospital.
Mother and midwife arrived at Sarasota Memorial Hospital at 3:21 p.m., according to hospital spokeswoman Kim Savage, who had permission from the family to discuss their case with the media.
Shockley went into a waiting area while staff wheeled Bean into a room. After several attempts to have Bean push out the baby, the staff gave her a third-degree episiotomy — cutting her from the anus to the vagina — and pulled out her baby.
“He was in cardiac and respiratory failure at birth. His APGAR score at one minute after birth was zero,” Savage said in the email. “It increased to a 3 within five minutes and remained a 3 at 10 minutes.”
An APGAR score rates the baby’s condition at birth on a scale from 0-10, with 0 being lifeless and 10 being healthy. Midwives are required to submit that information to the state on their annual reports. Shockley noted in her labor report the baby’s 10-minute score was 4.
“His neurologic assessment was abnormal and consistent with severe hypoxic encephalopathy,” Savage added, referring to the brain damage that occurs when a person is deprived of oxygen.
The neonatal intensive care team resuscitated the baby and restored his heartbeat, but he was unable to breathe on his own and needed to be intubated, Savage said in the email. The team also began immediate cooling treatment, lowering his body temperature in an attempt to reduce brain damage. He was transferred three hours later to Johns Hopkins All Children’s Hospital in St. Petersburg.
“They told me before they took him,” Fisher said, ”If he makes it through the night, he will never wake up again. He’s totally brain dead.’”
While sitting in the hospital waiting room with Shockley, Fisher said he asked her what happened.