That’s how long Lecye Doolen held her perfect baby boy for the first and last time while he took his final breath.
In the following weeks, she said, her midwife reassured Doolen her son’s death was unpreventable. She also said a trusted doctor not involved in the birth told her the same thing: It was unrelated to her attempted home birth. He would have died had she planned a hospital delivery, too.
Two years later, the Oklahoma mother read a newspaper account that told her something different.
‘A friendship formed’
Doolen and Allen Lippoldt met more than a decade ago at Nancy’s 57th Street Lighthouse in Midwest City, a restaurant owned by Lippoldt’s mother and where Doolen worked as a waitress.
The couple, now both 36, bought their northwest Oklahoma City home in 2009 and got married the next year.
Doolen and Lippoldt always wanted a baby. They tried for years before they had their first son, Dutch. He felt like a miracle.
When Doolen hired then-certified nurse midwife Dawn Karlin for Dutch’s birth, she had planned to deliver at home. But Dutch began showing signs of distress during labor, and Doolen was transferred to the hospital for an emergency cesarean section.
Dutch was delivered, healthy and pink, in July 2015, at OU Medical Center Edmond by OBGYN Michelle Brunnabend.
When Doolen learned she was pregnant again eight months later, she said, she wanted to try for another home birth.
“You ready to start hanging out again?” Doolen texted Karlin in April 2016.
Doolen was among some 39,000 U.S. women who planned a home birth with a midwife that year, according to data from the Centers for Disease Control and Prevention. She viewed documentaries and videos about home birth. Her neighbor raved about her own experience. And when the mother watched her best friend’s delivery in a hospital, she knew it wasn’t ideal. It felt impersonal, and she wanted more control over her own birth.
“I wanted a voice in this really profound experience in my life,” Doolen said.
Many women who opt for home births form close relationships with their midwives, and Doolen was no exception.
“The thing with midwives is you genuinely feel as if there is a friendship formed,” Doolen said. “And you cannot imagine that a friend would not tell you or be there for you if something’s wrong.”
Because Doolen’s first delivery resulted in a C-section, her second attempted home birth carried extra risk.
The infant mortality rate for attempted out-of-hospital vaginal births after previous C-sections — or VBACs — is more than double that of those attempted in a hospital, according to a 2017 American College of Obstetricians and Gynecologists opinion advising against the practice.
Doolen said she didn’t know the risks despite having signed a “consent/waiver for vaginal birth after cesarean” acknowledging out-of-hospital VBACs are not recommended for those whose C-sections occurred less than two years prior.
Doolen said she signed several forms at the same time and doesn’t recall seeing that document nor does she remember Karlin explaining any of it to her.
Karlin declined to comment on Doolen’s case, citing client privacy, but she told GateHouse Media that all clients get a full explanation of the risks.
“It’s my responsibility to give informed consent,” Karlin said. “And it’s the consumer’s responsibility to ask the questions that they have and to make sure that they understand before they make the choice for their own care.”
Karlin’s records of her care of Doolen, which GateHouse Media obtained from the state Board of Nursing, also state that she recommended Doolen transfer to the hospital five days before her son’s birth and that Doolen declined.
Doolen disputed this, saying she was never advised to transfer and never would have declined doing so.
‘The worst thing that ever happened’
More than three weeks before her anticipated due date, Doolen said, she couldn’t shake the feeling that something was wrong. She had a fever. She was contracting. And she noticed fewer movements from her baby, whom she planned to name Shepherd.
Karlin and her assistant, Brandy Harris, took turns visiting the mother at home — three times during a four-day period — according to text messages and midwife records GateHouse Media obtained from the Board of Nursing.
Each time, Doolen said, they told her everything was fine and that she needn’t worry. Just rest, she said they told her. Drink more water. Take an Epsom salt bath.
One day before Shepherd was born, Doolen said, she wondered if she should go to the hospital.
“I need to have a real conversation,” she wrote in a group text to Harris and Karlin. “I just had my fourth night of not sleeping and dealing with 10+ hours of mild to moderate contractions. I just don’t know how much longer I can do this.”
Doolen asked if she had the option of giving up.
“Since I don’t have insurance, will the hospital even see me since my water hasn’t broken?”
Karlin offered to check on the mother again and suggested she take some herbal supplements, text messages show.
“The hospital will see you, but they won’t keep you if you aren’t in labor, and your water hasn’t broken,” Karlin replied.
So Doolen didn’t go.
When her water broke on the morning of Nov. 7, Doolen was the only one awake in the house. She texted her midwife at 4 a.m. Her amniotic fluid was the color of Pepsi, she told Karlin.
“Well that’s odd,” Karlin replied, text messages show. “Can you take a picture?”
Karlin identified meconium — the baby’s first stool — in the photo Doolen texted. Although it was a sign Shepherd could be in distress, Karlin didn’t suggest going to the hospital until 20 minutes later, text messages show.
Doolen and Lippoldt left within minutes of Karlin’s suggestion.
When the parents arrived at Mercy Hospital, the nurse couldn’t find the baby’s heartbeat. The on-call doctor, OBGYN Nancy Bishop, couldn’t find it either.
“It was the worst thing that had ever happened,” Lippoldt recalled.
Doolen was completely dilated, and Shepherd was malpositioned. Doolen needed an emergency C-section.
Bishop hopped on Doolen’s bed and rode with her to the operating room. The mother made eye contact with Karlin, who had just arrived, as they her wheeled into surgery.
The minutes that followed were the worst of Doolen’s life, she said. “I wouldn’t wish the memory on my worst enemy.”
The room was loud. The clock was ticking. Machines were whirring. She could feel her heart racing. People were running.
But no one was speaking, and their silence was deafening.
That’s when Doolen knew she wouldn’t bring home a happy, healthy baby.
“I remember looking at the clock,” Doolen said, “and thinking, ‘There will never be a time in my life that I don’t remember this moment.’”
‘Nothing could have been done’
Shepherd Dean Lippoldt entered the world at 6:19 a.m. on Monday, Nov. 7, 2016. He was 7 pounds, 1.2 ounces and 20.3 inches long.
“Is there a heart rate?” the mother asked Bishop.
“No,” the doctor replied.
“Is he breathing?”
Shepherd suffered hypoxic-ischemic encephalopathy, records show. He had been deprived of oxygen for too long, and the umbilical cord was wrapped around his neck five times.
Medical staff were able to revive Shepherd. But his brain began swelling, and Doolen and her husband had to decide if they were going to let him go or transfer him to a different hospital in an attempt to save his life.
Shepherd was baptized and given his last rites before they transferred him to a different hospital, where he received cooling therapy.
Brain cooling — when a baby’s temperature is reduced to about 91.4 degrees for three days — is standard treatment for newborn brain damage caused by oxygen deprivation and limited blood flow.
The procedure didn’t help. The family removed him from life support after midnight, on Tuesday, Nov. 8, less than a day after he was born.
“I really loved his name,” Doolen said. “I was upset I didn’t get to meet who he was.”
Doolen got to hold Shepherd for only four minutes. He took his last breath in her arms.
Lippoldt held his son for an hour. He didn’t want to let him go.
“I remember everything,” Lippoldt said through tears. “But the thing I remember the most was just holding him.”
The only noise his son ever made, Lippoldt said, was when he was gasping for air.
In the days that followed, Doolen planned her baby’s funeral from her hospital bed. She was discharged on Wednesday, and the family celebrated his life at Nichols Hills United Methodist Church two days later.
Shepherd’s name was inspired by the “Good Shepherd” in the Bible. The first scripture reading at his funeral was Psalms 23.
“The Lord is my shepherd; I shall not want. … Though I walk through the valley of the shadow of death, I will fear no evil; for thou art with me; thy rod and thy staff they comfort me.”
Lippoldt had just one request for those who attended the funeral.
“To honor Shepherd, just do good,” Lippoldt said. “Just do something for somebody for no reason.”
Karlin and Harris both came, Doolen said, and a few days later, Karlin called to check in.
The grieving mother wanted answers. She didn’t understand how this happened.
“I got checked and you guys were doing the Doppler on me and telling me that his heart rate was fine, but then the instant that he was born, he was gone,” Doolen said she told her midwife.
But Karlin assured her that Shepherd’s death was a fluke, that it was unpreventable, that nothing could have been done, Doolen said.
So she did her best to move on, until two years later, when she found out that other experts believe Shepherd might have lived.
‘The baby would have lived’
It was Jan. 1, 2019.
Doolen, Lippoldt, and their son, Dutch, were sitting on the couch, eating pizza.
While scrolling through Facebook, Doolen said she saw an article about an Oklahoma midwife whose license was revoked. She clicked on the link. She started reading.
The story was about Karlin, whose nursing license was revoked after two babies died under her care. The article, written by GateHouse Media, also mentioned Shepherd’s birthday.
And it hit her: This was her story. Shepherd’s attempted home delivery was one of the cases that later led to the revocation of her midwife’s nursing license. Until this moment, Doolen didn’t even know Karlin was in trouble over the handling of Shepherd’s delivery.
The article included Bishop’s testimony, in which the doctor said that Shepherd might have lived had Karlin taken timely and appropriate actions.
“If it had been identified earlier that this baby was not vertex,” Bishop testified, referring to the baby’s position for delivery. “I feel like if she had been in a hospital setting, the baby would have lived.”
Until then, Doolen had no idea.
The Oklahoma Board of Nursing found that in Doolen’s case, Karlin failed to: timely perform assessments, perform compete assessments, timely document assessments and adequately and appropriately monitor.
Another certified nurse midwife, Melanie Ware, testified during the hearing that Doolen should not have been a VBAC candidate because she was older than 30, her previous baby weighed more than 10 pounds, she had evolving pre-eclampsia and she had a C-section less than 18 months prior.
Ware testified that it was Karlin’s responsibility to explain the potential risks in a way that would help Doolen to make the best decision for her and her baby.
Karlin’s care for Doolen and Shepherd fell below the minimum standard of care, and contributed to Shepherd’s death, Ware said.
Moments after she delivered Shepherd, Bishop also told the board, she went into the hallway to confront Karlin and Harris.
“I’m not throwing anyone under the bus, but I do want to let you know the head was not down,” Bishop testified having told the midwives. “There was an arm and a knee in the vagina.”
“Well, anyone could miss that,” Karlin replied, according to Bishop’s testimony.
Bishop also testified that in her conversation, she felt like Karlin showed no remorse.
“I did not talk to her long, but the interaction that I had with her was very disturbing,” Bishop said, adding that Karlin wore at the time a T-shirt with “VBAC No Fear” in large letters.
Bishop testified in the hearing that she struggled seeing that T-shirt, knowing the baby was going to die.
Karlin denied responsibility for Shepherd’s death, board documents show. She also testified that she had no concerns about her practice.
Karlin continues to practice midwifery, despite having her license revoked. In Oklahoma, non-nurse midwives can deliver babies outside the hospital without a license or oversight. So Karlin removed the word “nurse” from her title and continued practicing.
Two months after reading the article, Doolen and her husband unsuccessfully sued Karlin, her assistant and the other providers for medical negligence.
They also unsuccessfully sued the doctor who had delivered their first son, Michelle Brunnabend, whom they visited after Shepherd’s death at Karlin’s urging.
“I sat in that office as a completely broken person,” Doolen said. “And I’m begging her to tell me how did this happen? What could we have done?”
In Karlin’s Board of Nursing hearing, Brunnabend testified that “she has acted, unofficially, as a consulting physician” for the midwife, according to the summary of her testimony. Brunnabend was not involved in Shepherd’s delivery, however.
The reason Doolen sued Brunnabend is because, she claimed, the doctor assured her Shepherd’s death had been unpreventable.
Doolen also said in the lawsuit that Brunnabend led Doolen and Lippoldt “into believing that nothing could have been done to save their son’s life.”
Doolen alleged, that, in fact, Brunnabend concealed “negligent acts” which directly resulted in the death of Shepherd.
Because Brunnabend did not tell Doolen that when they met, Doolen missed the statute of limitations for suing Karlin, according to Doolen’s attorney.
Brunnabend acknowledged in a court document having seen Doolen one month after Shepherd’s delivery but denied providing any opinion about the circumstances of the baby’s birth or death.
Brunnabend also told the court that even if Doolen’s allegation were true, the doctor’s “opinion would not be wrong as Shepherd was taken to the hospital and Dr. Brunnabend believes everything was done that could have been done to save Shepherd from dying.”
The defendants denied the allegations and noted the family had filed the suit after the statutes of limitations had expired.
A judge dismissed the entire case against all parties, including Brunnabend and Karlin, Oct. 1.
Brunnabend declined to comment, referring GateHouse Media to her attorney, who reiterated the doctor “had nothing to do with the care and treatment at issue in this case.”
The family filed an appeal Oct. 16.
‘Voice of change’
Doolen and Lippoldt talk about Shepherd often with their oldest son, Dutch, now 4, who carries a photo of his baby brother in his pocket most of the time. He tells people Shepherd has tractors in heaven. Sometimes, Dutch even blames things on his brother.
“We just go with the fact that Dutch has used his imagination of what his brother does and who he is,” Lippoldt said.
For now, Doolen will continue to share Shepherd’s story. She now feels like she can do something for him that matters.
“For a long time, I felt like Shepherd’s death was this unbelievable tragedy because this precious soul never got to sort of make his mark on earth,” Doolen said. “And I’ve come to believe that Shepherd will end up being the voice of change, because I think that his story, and unfortunately, his death will hopefully lead to some people really rethinking how we look at midwives in the state of Oklahoma.”