Friday, April 13, 2007

The Way We Give Birth, Part II

As promised, I want to talk about the (very little) I know about midwives and/or alternatives to the accepted medical standard of birth. My first thought is that there is very little consensus to the standard of birth and/or labor anyway. At my hospital, we do epidurals, pitocin, cut the cord immediately, term inductions, etc. At [county hospital], they get pitocin, but most of the ladies come in during the active phase of labor, if not delivering the baby on the stretcher, so there is much less "active management". At [froofroo private hospital], the third place students rotate, I think it's probably more common to induce electively; they probably do some elective c-sections, etc.

So if there's so much variation in the medical community, what is so different in a midwife birth? The following list comes from limited internet research, discussions with "the other med student on OB", and reading about midwives I've done over time. It is by no means all-inclusive, and I could be wrong on any point--I'm no expert.

  • Likely to be at home or in a birth center. Some midwives do have hospital privileges, and many (most?) will accompany a patient to the hospital if a home birth fails. Doulas may assist a laboring mother in a hospital setting or at home, with or without a midwife. If you give birth at home, you're surrounded by your own furniture and family. Birth centers tend to be better-decorated than hospital rooms (at least the ones in my hospital).
  • Depending on the midwife, there may be more focus on nutrition and/or herbs in prenatal care. Some, but not all, practice homeopathy.
  • Many midwives encourage water birth. Since the baby is still attached to the umbilical cord, they won't drown. From what I understand, the warm water relieves pain quite well.
  • There is a greater focus on immediate breast-feeding, mom/baby bonding, and father bonding with midwife-tended birth. There's no whisking the baby off to the nursery; instead, any labs to draw on mom and baby take second place to breast-feeding and bonding.
  • Many midwives believe in delaying the cutting of the umbilical cord. As Midwife With a Knife said in a comment, some neonatologists believe in the same thing, as the baby is still receiving precious oxygen via the umbilical cord until the placenta detaches from the uterus.
  • Most of the midwives I've checked out locally offer a full one hour initial visit, with as many prenatal visits as necessary. They're definitely more thorough than the 5-10 minute prenatal visit that is the medical standard.
  • Midwives aren't very likely to rupture a woman's membranes to "hurry the process along". Many of the stories I'm reading on midwife websites talk about the water breaking immediately before birth.
  • In our hospital, we constantly monitor all laboring mothers with a tocometer for contractions and an external fetal heart rate monitor for the baby. The monitors are held on the belly with tight elastic bands that aren't extremely comfortable; the only time they're off of most moms is if they're in the bathroom. Many midwives only monitor babies intermittently, especially if the pregnancy is low-risk, helping mother's comfort.
  • After a mom has an epidural, she can't really get up to go to the bathroom easily, so she either has to use a bedpan or have a straight catheter drain her bladder. If you have no epidural, you can walk around to go to the bathroom in privacy.
  • No ugly hospital gowns in a home or birth-center birth.
  • More focus on mom pushing on her side, propped on her back, in a bathtub, or even squatting, which should help with pain control and *help* prevent back labor. Pushing with gravity should help pushing be more efficient and take baby's weight off the back, rectum, and perineum.
  • Midwives and/or doulas stay with mom for longer during the labor process. In our hospital, the ob's check on laboring moms every 2 hours unless there's a reason to check on them. After the delivery, we leave shortly after everything is over. The midwife or doula is much more involved with labor than we are, and they stick around longer to help get everything squared away. Fortunately, we do have excellent L&D nurses at our hospital who kind of take on this role, but even they have multiple laboring patients at a time and other duties to attend, and cannot stay at a woman's bedside for long periods of time.

So, why doesn't everyone have a midwife birth? Why don't we all give birth in our hot tubs, surrounded by family, unhindered by medication, flowers in our hair, connecting with our instinctive inner mother? I will discuss my own pro and con list in Part III, coming soon. Keep the comments coming--I love hearing the different opinions! Also, if anyone could explain the difference between lay midwife and nurse midwife to me, I'd be grateful!


Midwife with a Knife said...

(this comment is not a criticism. Just my thoughts. :) )

The things I worry about with home births is cord prolapse or unexpected breech presentation or fetal distress during labor* and neonatal invasive GBS disease. All of which are fairly rare. And we all take risks in life. From my point of view, for those reasons, a midwife-managed birth in a hospital is better than a midwife-managed birth at home. For completely uncomplicated, low risk pregnancies, I will say that I suspect that a midwife-managed birth in the hospital is actually less risky than an obstetrician managed birth. Heck, you put a doctor in charge of anything, and we'll find a way to intervene or do a c-section and muck things up! Midwives, in general tend to be more patient. I worked with awesome midwives while I was a resident.

I, personally, would feel uncomfortable with a planned home birth (for me), and I suspect that if we were able to do the study well, there'd be a _small_ excess risk for home births. But heck, it's not like there's no risk of something happening at the hospital. The doc gets impatient and orders pitocin... you can get uterine hyperstimulation, and then a c-section. There's ORSA/MRSA/VRE floating around hospitals. You could get into a fatal car accident on the way to the hospital. (Also, if you're at the hospital, you don't get your own bed all yucky!)

There are very few things that can go wrong in home births that would cause catastrophe before the mom could get to the hospital. But as a resident I had a patient who had a baby die as a result of a cord prolapse during an attempted home birth, so maybe I'm not super objective on this issue. I don't think people who choose or perform home births are bad, it just isn't what would be right for me. I do think that if I ever have a kid, I'd like to be taken care of by a midwife (Besides, I'll probably have severe preeclampsia at 32 weeks and end up in the hospital anyway).

* The literature says that continuous fetal monitoring doesn't change any long term outcomes in low risk patients. So... I'm not quite sure how I feel about this one either.

Midwife with a Knife said...

Oh, one other thing. It's fun to deliver babies en caul if you can avoid the temptation to rupture the membranes (snag the bag?). Then the baby's still swimming in it's own little sac! How cute. :) It's also fun to do with multiples at a c-section. Um...just don't had them to peds that way, they'll freak out. ;)

Tiny Surgeon said...

oh my goodness, you totally just wrote my next post! that's almost exactly what i was going to say (all that stuff about home birth being scary, and what if something goes wrong, and why can't more midwives deliver babies in the hospital). hmph. ;)

Midwife with a Knife said...

Hah! Sorry! I didn't mean to steal your next post. (Great minds run in the same gutter!)

Diane said...

Hello! Some comments from a homebirth midwife who found you through "midwife with a knife"...

I was amazed at how accurate most of your bullet points were. So many people are way off base with their assumptions about midwifery.

A few corrections....

I wouldn't say that "labs take second place to bonding and breastfeeding.." Depends on which labs we're talking about. We're trained to do all the initial assessments with baby in Mom's arms, so there is a lot more focus on the bonding. But if cord blood needs to be obtained or any other clinical procedure where timing is important, it is done as soon as necessary.

Not a correction, but more of an addition - the intermittent monitoring is done to ACOG standards - or at least, it should be :)

'tis very rare for a doula to attend a mother without a midwife. And roundly condemned by almost every midwife and doula I know. A doula's training consists of a three day workshop and all of the international Doula orgs have a code of ethics that forbid it.

Otherwise, everything you wrote is right on.

As for the difference between a lay and nurse midwife.... that's a big one. Typically, "lay" means no formal training at all. Some of these women are highly skilled and have been "self-taught" by other "granny" midwives or perhaps at birth centers in other countries. They may be very competent, or a menace to their communities. They are completely unregulated. There are a couple of lay midwives in California without formal training who serve religious communities and are well respected by other birth professionals.

And then the third layer is "Licensed" or "Certified" or "Documented" midwives. All basically the same thing, just different terms in different states. These are midwives who have not gone through basic nursing first, but who have completed a formal, state approved training program. In most states, like California, Florida and Texas, their licensing is considered equivalent to a nurse-midwife and they are required to have the same skill level in midwifery as nurse-midwives.

I am licensed in California and attend a peer review group consisting of nurse and licensed midwives. We answer to different licensing boards (the Medical Board for me), but our protocols are identical.

Hope that helps! I love your blog.


"MWWAK" mentioned a little about the risks of homebirth above. All of them are true. And very rare. We go over these risks with patients when they sign up. And they are mitigated, a LOT I believe, by the low intervention rate at home. If you're not giving pitocin to speed up a slow labor, you're so much less likely to see fetal distress. If you're not rupturing membranes, less likely to see a prolapse. I don't think I've ever transported for true fetal distress... but I'll happily transport for a slow labor curve that I think might END in fetal distress...

Unexpected breech now.. that would be yucky. I'm lucky, I'm in a very urban area and could probably transport in time. GBS disease? Also lucky - very close to hospitals. And we screen for it and use abx prophylaxis if requested by the patient. And of course, with any sign of breathing difficulties we transport rapidly. Most midwives stay several hours after the birth to observe for GBS, instruct the parents what to look for and when to call, and follow up with another hour long visit within 24 hours.

You know something interesting I've noticed? In almost all labors that will become complicated, labor will slow down or stop. Incoordinate contractions, a plateau in dilation, contractions stopping for no apparent reason.... an excellent time to consider going to a hospital. It's as if the body/uterus/baby are waiting for a safer place.

Diane said...

oh, and a comment on cord prolapse. That one would be nasty. We're trained on how to transport if it happens (Mom in knees-chest, holding head off cord), but no one wants it to be them. We try to mitigate this by only going ahead with labors for patients with a well engaged and applied fetal head at term and referring polyhydramnios out of care. But sometimes you get someone stubborn and by law, we cannot refuse to care for them. But my heart sinks with primip at 41 weeks, a high, floating head and an AFI of 15... who refuses to entertain the idea of a hospital induction. Yikes.
Why invite disaster?

Barbie said...

unrelated to the post, but thought you would like this post.

the other med student on OB said...

The first OB I shadowed was at a hospital were a nurse midwife worked. She had her own rooms which looked much more homey then the sterile OB L&D rooms. If anything went suddenly wrong, then the OB was just a call away to section, or do whatever. I doubt they had the nice perks of water births or anything....but it seemed to be a good mix. You have the natural birth with the midwife, but you are in a hospital with an OB should anything go wrong.
I had a conversation with my father about this topic the other day. His comment was this: "I was born on a farm by a midwife because that was what my father thought was safest. I almost died because I wasn't getting enough air and no one knew what to do. My sisters were all born in a hospital after that." It sent a chill

Diane said...

It gives me chills too to think of birth being attended by someone unskilled and without all the amazing equipment we have at our disposal today.

Tiny Surgeon said...

Wow, this is great! Thanks for the corrections to my points--I get nervous posting about stuff I know so little about.

frectis said...

MWWAK: What do you think of this with regard to risk and outcomes: Outcomes of planned home births with certified professional midwives: large prospective study in North America? I am interested in your comments.

Other Med Student: My dad was the first of his family to be born in a hospital. His dad's union finally got insurance in the 40's and the hospital is where all the rich women went ot have their babies. Ironically, today one of the "complaints" about home birth is it's only for the "rich, white" women.


I'm a midwifery college graduate, a nationally accredited Certified Professional Midwife and am state licensed (whew!). I also belong to a mandatory, yet volunteer peer review. I am working on more school and apparently it won't be as an immunologist or urologist ;)

I'm NRP and CPR certified; have 02 and mask and know how to use it! I also carry anti-hemorrhagics and IV fluids. I suture. I have two lab accounts and will draw just about anything under the sun as it pertains to the woman and standard of care per ACOG and the state laws. Get and give RhoGAM, vit K, erythromycin, obtain newborn screens, file birth certificates, and on and on.

I'm totaly a pro-fession-al! ;) I am also the first responder; it's my job to stabilize for transfer if necessary. In a home birth emergency or complication that requires EMS help, they are just lights and siren. They don't have jack on their rig that I didn't already do. I was once applauded by an entire squad of fireman for delivering a placenta (precip birth and dad panicked and called them, not me!). They'd never seen it done without breaking a sweat-- and certainly never seen it done without the cord being cut first!

I get in the hospital and get twitchy. I only want to be there if I have to be and if I have to be, we ARE. I imagine that an OB would be rather twitchy at home.

Anyone who would like to come to a home birth rotation at my place, just say the word! ;) I'm pretty middle of the road.

frectis said...

ps: Also, if anyone could explain the difference between lay midwife and nurse midwife to me, I'd be grateful!

My preceptor through school is a CNM with a BSN and MS plus certificate of midwifery education, who does not have hospital privileges by choice, opting for home and birth center birth attendance. We took a woman to the hospital once, don't remember why, and the charge nurse said, "Oh you're the lay midwives." The CNM said, "No, I'm the nurse-midwife and this is my student." The charge said, "But you said you do home births?" and the CNM confirmed. The charge said, "Like I said, you're the lay midwives" and then she went on with checking in our patient. So it doesn't matter to hospital personal who receive us what are degrees are, we're not "them".

Another time a nurse asked what I would be when I graduated. I said a "registered midwife" and she said, "Oh, a lay midwife." Um, no, not any more than she is a lay nurse after her education and registration! She wasn't pleased with my analogy ;)

"Lay midwife" speaks to uneducated, under experienced women doing a job they are ill equipped to do. As you can see it's often thrown back at us as an insult so I am not the only one who thinks this way. Then again some midwives who shun the medicalized model proudly wear their "lay midwife" badges.

Nurse-midwives, as Diane shared, are another category of advanced practice nurses (like FNPs, NNPs, CNAs as in nurse-anesthetists). Autonomous right down to DEA licenses in some states, but legal in all 50. Non-nurse midwives, on the other hand, are slowly being regulated around the nation and the standard that is being adopted comes from the North American Registry of Midwives. Schools are regulated by the Midwifery Education Accreditation Council.

Sorry to be the poster-who-ate-your-comments-section!


Tiny Surgeon said...

So the more appropriate terms are "certified midwife" and "nurse midwife", then?

frectis said...

Get ready for alphabet soup:

CNM: Certified Nurse-Midwife are "registered nurses who have graduated from a nurse-midwifery education program accredited by the American College of Nurse-Midwives (ACNM) Division of Accreditation (DOA) and have passed a national certification examination to receive the professional designation of certified nurse-midwife. Nurse-midwives have been practicing in the U.S. since the 1920s." (legally recognized and regulated in all states)

CM: Certified Midwives are "individuals who have or receive a background in a health related field other than nursing and graduate from a midwifery education program accredited by the ACNM DOA. Graduates of an ACNM accredited midwifery education program take the same national certification examination as CNMs but receive the professional designation of certified midwife." (As far as I know only recognized in the state of NY.)

CPM: Certified Professional Midwife is a "is a knowledgeable, skilled and professional independent midwifery practitioner who has met the standards for certification set by the North American Registry of Midwives and is qualified to provide the Midwives Model of Care. The CPM is the only international credential that requires knowledge about and experience in out-of-hospital settings."

Regarding CPMs: most all of the states that regulate non-nurse midwives require the CPM credential in order to obtain a license. Some states further require the midwife to have graduated from one of the MEAC schools, which in turn requires the CPM examination and credential as the final piece to earn the degree (I suppose it's somewhat analagous to a board exam or USMLE if I understand those right).

That being said, unless you're trying to get a license in a state that requires the CPM, it's a voluntary credential. There is a huge push to make the educational and exam process uniform across the nation, so it's heartening to see states adopt it. Missouri and Illinois are currently weighing it in their state legislatures. The major opposition is, as you might expect, local ACOG lobbyists.

So after that bit of education, the gist is either nurse-midwife (CNM) or direct-entry midwife the category in which CPMs and CMs fall into without the nursing degree. Two different exams and credentialing bodies, and 10 billion ways of getting to the license (legalization is a whole other kettle of grenades ;)


Question for you: A DO and a DC focus on the "holistic" approach to health care. DOs do surgery, DCs don't. Why, if you have an opinion, are DOs respected but DCs are quacks?

Tiny Surgeon said...

If we're talking chiropractors (DC?), I don't know a whole lot. I would say one difference is a DO attends medical school, even if it is osteopathic medical school, while I doubt many doctors think chiropractic school is the equivalent (we want to be the toughest). DO's do medical residency, often a traditional one; DC's do not. I would also say there is a distrust of ICAM practices such as homeopathy and spinal manipulation in the traditional medical community. We're not taught much about DC's other than that they are "quacks". However, most of us work with DO's all the time--they function as MD's for all intents and purposes.

Personally, I'm a little leery of someone throwing my spine around, but I'd have a similar mistrust of a neurosurgeon trying to cut it. That's about all I know.

I do think we need to learn more about ICAM so that doctors know a) which practices work b) which don't and c) what to tell a patient who asks about such things instead of just blowing them all off.