In this discussion I would like you to explore the various types of practice setting that midwives may practice in.
1. Home birth
2. Free standing Birth Center
3. Low risk in hospital setting.
4. Tertiary care/ high risk setting
Reflect on how midwifery practice is shaped by the setting.
Reflect on the relationship between midwife and community.
What is the midwife's role in promoting the "normalcy of birth" especially in challenging environments?
I look forward to your thoughts.
Deb
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Along with my teaching responsibilities for NM students I also work closely with residents and am responsible for "teaching" the 1st year residents about "normal" labor and birth. It is a difficult task at best. We are a level III tertiary care center that does close to 4000 births a year. "Normal" can be hard to spot.
ReplyDeleteI have found the best way to teach normal is to let normal be. Residents are under such pressure to master the skill they often lose sight of the woman in front of them - like the first time you start an IV! They have never been given the opportunity or support to trust the process.
I had three births last night with an R1 (1st year resident) and it was a lovely sight to see her NOT break the bed, support the woman in spontaneous, non-directed pushing efforts, and do a superb somersault maneuver due to a tight nuchal cord! There IS hope!
Trust the process and lead by example.
Deb
I have been incredibly fortunate so far in this process to be able to witness birth in a free standing birth center as well as the hospital setting with the same midwife. The approach taken with each birth is different although the practitioner is the same. The births which take place in the birth center are family centered, low risk, often include the father catching the baby when he wishes to and all is "normal" with the birth. The births at the hospital mostly all end up with a woman who has planned a natural birth being unable to labor comfortably in the environment and obtaining an epidural at 7 or 8 cm dilation.
ReplyDeleteThe intervention of the epidural then changes the entire dynamic in the room. The mother's relax (which is good)but then need to be told when to push, must remain in bed, have an IV placed, remain on the monitor, and labor usually slows considerably.
I did have one natural birth at the hospital last week where the mother subsequently hemorrhaged and I was quite glad we were in the hospital. We have all of the same things to manage a hemorrhage at the birth center but I still found myself relieved to be there as this happened. This "normal" birth quickly became complicated and high risk due to complications.
The birth center is being closed this week due to pressures from the OB/Gyn groups in town and the hospital privileges for the midwives have been stripped. This is not due to anything the midwives have done but mostly the fact that the OB's have decided they didn't much like the competition.
The preceptor I have been working with now has 3/4 of her previous birth center clients who have decided to birth at home with-in the city limits and close to the hospital. They refuse to birth in the restrictive environments of the hospital and instead trust their bodies to do what comes naturally.
For a high risk pregnancy, a tertiary care setting is really the only place to be to protect mother and baby. There really are so many unknowns in any pregnancy and birth it may be hard at times to determine what may end up being high risk. By in large, however the place doesn't matter quite as much as the actual environment in the room.
Faith - I am so sorry to hear the birth center is closing. Those women have lost a valuable resource. Unfortunately medicine holds great power in our society and has the ability to control access in many ways. There will be other opportunities to support the normalcy of birth. I am glad you had this opportunity. for as long as you did.
ReplyDeleteDeb
I too practice in a Level III tertiary center, so I understand how difficult it can be to have a "normal" experience. There are times when I find it hard to believe that any women is able to have a successful vaginal birth without Pitocin. But every once in a while I am honored to participate in a truly inspirational birth, and I am reminded why I decided to become a midwife.
ReplyDeleteBut what I am really struggling with right now is how to balance my need to learn with what is best for the patient. For example, one of the skills we learn as midwives (and the one I am finding most challenging) is how to repair lacerations. And yet my goal is to help the patient deliver with her perineum intact so that I don't need to repair it. I need to know how to cut an episiotomy when the time comes, but I don't want to compromise a woman's perineal integrity just so I can learn. I need to be able to handle a shoulder dystocia (in practice, not just in theory), but I would never wish for someone's baby to get stuck. I could go on and on, but I'm sure you get the point.
I admire anyone who can comfortably participate in a home birth, either as a patient or as the midwife. Especially after watching The Business of Being Born, it could inspire anyone to try it. But having worked in a hospital L&D unit for ten years, it is my comfort zone.
With all that being said though, I am still able to offer my patients a natural birth environment. My hospital has jacuzzi tubs, rocking chairs, squat bars and mirrors in every L&D room. We also have birth balls and offer intermittent EFM to low risk patients, where they are able to be off the monitor for up to an hour at a time. It just depends on the provider, nurse, and patient all working together in order to help the patient achieve her optimal birth experience.
It seems in today's society of technology and intervention that it takes us getting further away from a hospital setting to get closer to our patients. I say this because as midwives practicing in settings guided by protocol we are prone to do more interventions than if allowed to birth in a home setting. Working as an L&D nurse I have grown accustomed to many interventions in the birth process. However, I am also very comfortable with advocating for my patients to have as little or as much intervention as they would like. It is our job as the provider to educate our patients on the birth experience and provide them with options that correlate with their risk level. The midwife that practices at our hospital takes care of high-risk patients and, therefore, must plan their care accordingly. I think normal is what you make it. I hope that I can liken normal to a wonderful birth experience for all of my patients. Normal doesn't have to be associated with risk level or un/complicated. I think it can just be associated with a birth experience that is satisfying and has a positive outcome for the patient and family.
ReplyDeleteI have to agree with the repairing of lacerations. Thus far...knock on wood....I have only had a few 2nd degree lacs to repair. They are going well, but I feel like I don't have the experience there and all I can do is paractice on some chicken to improve my skills.
ReplyDeleteI work at a level II, but not a real hub for midwifery care. Idaho is not as progressive or midwife friendly as all the other states that are all around us. The nurses at the hospital are of the motto if the women doesn't want an epidural...keep working on her, she just hasn't made the "right choice" yet. The nursery nurses glare at us when we don't cut the coard with a slow to get going baby, and make no bones to say so in front of patients and most of all the amount of times that staff will "write up" the midwife staff for something that has no validity and is not based on evidence based practice. They are stuck in a time warp of the 80's! Thank God the midwives are knowlegable and have doctors that are supportive of their practices.
When I went from an L&D nurse to a nurse at a birthing center I too found it very disconcerting and almost out of control feeling with normal. It took a while to see what the big picture was. I remember my first delivery I felt like tunnel vision. All I could focus on was that head crowning. Same with my first repair. I had to have my preceptor hold my shaking hand...telling her don't you let go for fear I would poke the gal right in the thigh. That's how hard my hands shook.
ReplyDeleteI have had the honor and privilege of having my own homebirth practice and busy birth center for 26 years and now working in a Level III hospital with nearly every client being labeled as high risk. It has been a huge transition for me and I still feel like a fish out of water most of the time. In my own practice it was quite easy to respect and guard the normal process of birth. There were basically no "rules" to break as long as the client and I had an understanding of what low risk and normal mean in relation to birth and that we strived to maintain low risk and normal in every aspect of care. I absolutely love, respect, and treasure each mom's "labor dance" as she listens to her body teach her how to have her baby. In the hospital, there are so many policies to follow. I feel like instead of guarding the normal process of birth, I am guarding and protecting the hospital many times. I am blessed to have wonderful preceptors who do trust the normal process of birth although neither of them has had the opportunity to experience a totally "un -tinkered-with" birth. I have learned how important it is to support women in their choices regarding childbirth whether it lines up with my way of thinking or not. There is no right or wrong way to have a baby - just a safe way and each of our definitions of safe may contain different things. I have learned that it doesn't matter where the place of birth is as long as you can support your mom and make her feel that she is important to you and that her birth is important to you as well - this support will empower her to complete the hardest work she will ever do. Allowing a birth to unfold naturally will teach a client to trust the process, trust her body, and to always listen to her body as it tells her and shows her what it needs.
ReplyDeleteRegarding suturing: I have never had to suture too many tears - I just never have tears, sometimes some skid marks but not a lot to suture. During my clinical training I have still not had a lot of tears but have had lots of opportunity to do repairs. Of all of my skills that I have sharpened during clinicals, I am most proud of my ability to suture now. I feel like I can fix anything. My preceptors, both the CNM and the Doc have sat with me, watched the Anne Frye video, taught me to tie excellent and fast knots, and schooled me on every aspect of suturing. I feel like I could repair the Grand Canyon (hopefully I won't ever have to! lol). As much as I have learned about suturing, I have been able to share withe them how to guard the perineum and prevent tears. It has been great!
Deb, you said that we need to trust the process and lead by example. You are so right. I was thinking about this blog a lot last night and realized that the way I approach my clients and their care leads my nurses to follow suit. Even as a student, the nurses are looking to me to find out what they need to do to help the client, help me, and make the birth the best it can be. I realized that they are beginning to trust my faith in birth and the decisions that I make (although they know these decisions are supervised by my preceptors). This is a great realization for me since I will be working there after graduation.
ReplyDeleteLeading by example is a huge responsibility. Even every word that is spoken can affect the mother's attitude, the nurses and their attitudes, and ultimately the outcome.
I have worked as a L&D RN for 17 years. I have worked in two hospitals. We had a midwife at the first hospital I worked at for a total of 6 months. The group she was working with insisted on being there and watching everything she was doing. That was my first exposure to midwifery.
ReplyDeleteI was then lucky enough to work with a 50'ish year old male OB who had been trained by midwives. This man had the most beautiful births. He never cut episiotomies, knew how to sit on his hands, and had a bediseide manner that was as far from patriarchal as one could get. Interestingly enough, I have never seen anyone do such a beautiful forcep delivery either. One would think that those two things are in direct conflict. But, he understand the mechanics of birth and used forceps so well that a vacuum delivery seemed more traumatic to both mother and baby. This ability of his prevented many Cesareans that would have been due to second stage bradycardias or maternal exhaustion. After years of working with him, I began to look at midwifery in a different way and it became my goal. So here, in a hospital where midwives were chased out, the midwifery care that was taught to an obstetrician who brought that care to the women who birthed with us, showed me midwifery. He inspired a couple of nurses, including me, to think about pursuing midwifery. Now, this was many years ago but the desire stuck with me and ultimately here I am.
So, ironically a midwife that I will never know who trained an obstetrician who worked in a hospital setting is the midwife that is responisble for setting me on this path. How does this relate to setting? Any setting we work in presents us with opportunities to make a difference. That difference can be how we present ourselves to the community, the care we give to a woman who is high-risk (just means she needs high-touch, too!), the support we give to those learning---nurses, midwives, doulas, physicians. The opportunities for midwives to advance the profession is available in every setting.
My work in hospitals as a bedside nurse, nurse educator and participating in many administrative committees have taught me--learn the politics. Learning to navigate the minefield of the nursing department, the obstetric department, risk management, QI committees doesn't mean that you compromise your values and goals it just means that you will be better equipped to achieve them if you are working in a hospital setting. Make "friends" with those who make change or have the ability to make change--department chairs, marketing, medical staff, nursing staff, community stake-holders, etc. Over the years I have learned that "playing nice" in multiple sandboxes has earned me a bank account of respect that has given me the ability to make changes in practice and attitudes.
This fall (if I'm still sane by that time) I will be working with an Ob that I have worked with for ten years. She recognizes that having no midwives at the hospital means we are losing women to other hospitals. She recognizes that a midwife caring for her normal patients allows her to do more high-risk and surgery, what she is trained for. She also comes from a country where midiwves do the majority of births. She is losing those women who may need medical gyn care at some point. I sold midwifery to the CEO, CFO and medical director from a marketing standpoint. Midwives need to be savvy in business, politcs,and psychology to have half a chance at promoting birth as normal in our current system. Doesn't mean our system is right and that we should just "go with the flow" either but one must have an understanding of the current culture and be able to function in it if you want to have half a shot at improving it.
I too worked in L&D for about 16yrs and now this is the hospital where I am performing my clinical. Many things have changed, it truly has become very medicalized. But for those nurses that are more seasoned that are still around continue to try to hold on to the days when laboring a patient meant staying at the bedside, coaching a patient without an epidural.
ReplyDeleteMy journey through this midwifery program as been much like the process of labor itself. Nothing before this has ever brought such pain, fear, anguish and yet at the same time such an exhilarating joy to my life since the birth of my children.
I have had the awesome opportunity to work with 3 midwives, all of which differed in their practice and philosophies. My first preceptor was a very old school traditional midwife that reminisced of riding horseback to deliver babies in the Appalachian Mtns. Yet, she would forget my clinical days or leave me to work with other staff members.
My second preceptor, worked in a small family owned community level II hospital. While she was dedicated to her art she practiced with a more medical approach. Unfortunately, due to an incident that occurred to her during a delivery she was in that compromised her being able to precept me so I was forced to find another.
My third preceptor, is the only midwife in a practice of 7 OBs. She is extremely talented, very evidence based, a great teacher and has the tremendous ability to balance traditional/holistic midwifery with personal life and her political aspirations. She is everything I could ever hope to be as a midwife. Unfortunately for me again, I have been informed that she will no longer be able to precept me due to an incident in the office on last week. Last Thursday,I had 31wk G3P1 with a hx a 24wk abruption and hx of a hemolytic disorder that requires her to take Lovenox injections daily. The patient came into the office for her routine OB visit but had complaints of right upper quadrant pain. My preceptor sent me in to assess her, although this was the first time I had ever seen this person without my preceptor.Her B/P was 110/90(last weeks 120/80), no protein, no ketones and no glucose on dipstick. She stated that the pain was intermittent and that it had only occurred maybe 4-5 times over the last week and she associated it with the baby moving. She further added that the baby seemed to stay over in her right side. I palpated the area and questioned her about other symptoms such as tenderness, nausea, vomiting, dizziness, headache, blurred vision or SOB all of which she denied. I then discussed with her symptoms to watch and report asked her about her last US, measured her fundal height and listened to the baby. I rescheduled her appointment for the next week and encouraged her to call if the symptoms persisted or worsened. When my preceptor asked me about what I had assessed I told her what I had done and she felt that I had inappropriately assessed the patient and told me "that is why I sent you in to trip you up". Now we had discussed that she would challenge me this quarter and I have dealt with her drilling me in front of office and hospital staff, bu this felt very different. I felt confused and almost betrayed and I asked her not to set me up. She replied that perhaps she miss-worded her response but that it was my error in judgment and that I was responsible for assessing the entire situation and the chart and she thought that I should have ordered a PIH panel on the patient. At this point I understood what she meant and realized my blunder. At the end of the day, I was still very disappointed in myself and apparently my face showed my disappointment also. She said that I seemed stressed, I told her that I was always stressed and that that was nothing new but I would be alright. She remarked that I just needed to think. I replied to her that that was just it, when I thought I was thinking it just seemed to be wrong. In the meantime, a videography crew had arrived in the office to refilm the offices website pictures and we were finished for the day so I was getting ready to leave. The office administrator was standing outside of her office and overheard her asking me about my being stressed and apparently was disturbed because I did appear stressed and later from what I was told by my preceptor that she could no longer have students in the office. But even worse my preceptor wrote a letter stating that my behavior was unprofessional and that I was not ready for integration. I was in no way, unprofessional, at no time did I ever raise my voice or utter an angry word or gesture, but yes I was clearly disappointed in my own performance that day with that patient. We had been on call the night before and neither of us had gotten more than an hour or two of sleep. However, I know that my perception is not what was paramount at that moment it was hers.
I have never doubted my calling to be a midwife, I have however, faced challenges with the role transition from being a nurse of twenty plus years to being an independent practitioner. This journey of mine has truly epitomized the quote "the race is not given to the swift, neither to the strong but to him hat endures to the end". I can only prayer that one day I will be able to see this dream come to pass.
Shawne-
ReplyDeleteI am so sorry you have had to go through this experience. The ability to teach, nurtue and grow someone into a competent practitioner is a gift. In my previous position as nurse educator for an OB unit I selected preceptors for new hires and new grads. I would meet with both throughout orientation. I began to learn that some people understood how to encourage someone, groom their confidence safely and know when to guide and when to sit back and let them fly. I am a firm believer that however awful a situation may seem there are lessons to be learnes and opportunities to be taken advantage of. I believe for you this is an opportunity to find a preceptor that has those qualities and wants to walk with you to your goal. Best of luck!
I definitely think that our practice is shaped by the setting, and the client situation. I think that all four settings can result in a beautiful birth experience, as long as the mom is kept involved and believes that she has a part in her care.
ReplyDeleteA good example of this that I was a part of happened one night I was on call and a birth cottage patient transferred to the hospital for a prolonged rupture. She was 42+1 weeks and the birth cottage midwife had ruptured her membranes at 4cm in the hopes of getting her labor going because she was postdates. However, after almost 24 hours of no cervical change, the birth cottage midwife brought her to our hospital for further care. The patient and her husband were hoping for an out-of-hospital birth, and their plans had come to a halt now. My preceptor and I sat and discussed our plan of care at length, speaking of the need for Pitocin and close monitoring, but still allowing freedom of movement as much as possible and a medication-free birth as desired. We stressed the final outcome: a healthy mom and a healthy baby, and after our talk our patient and her husband seemed reassured and comfortable to proceed. Well, she just needed a "whiff of Pit" (as we like to say), and her labor took off. With some coaching and much encouragement, she delivered a healthy baby girl a few hours later with no medication and felt empowered by her experience, with a renewed belief in her body that she thought had failed her earlier.
I would say half of my patients get epidurals and half of them do not. I enjoy each birth though, because it is the birth the mother has chosen. If a woman comes in wanting an epidural, or wanting a medication-free birth, I support them in their endeavor. I do agree with Denise in that the normalcy of birth begins with the mother and her partner. When I explain to the mother about being induced and hooked up to monitors and limiting her movement and forcing labor and the risks involved as opposed to laboring naturally with little intervention and lower risk, most of them opt out of the induction. Knowledge is power, and they just don't realize the complications we see occur every day from unnecessary interventions. Then there are couples who don't understand the need for intervention when necessary, and forget the big picture. It can go both ways.
One thing I enjoy about hospital births is the range of women I get to work with, from low risk, low intervention couples to high risk, complicated situations. They challenge me to give these women a positive experience despite the areas that we can't control. I recently had a postpartum mom that had just birthed full-term twins vaginally, but had developed preeclampsia at the end of her pregnancy and was still and was on bedrest. She was upset that she could not get up and take care of the babies like she had envisioned. I reassured her that she could do everything she wanted from her bed, such as feed them, change their diapers, hold and cuddle with them and bond as much as she wanted. This new perspective gave her renewed energy and she became much more content with the situation, knowing that this was temporary and that she would be chasing these babies around soon enough, wishing for a day of bedrest in the future. :-)
It's great that we have the chance to be involved and make a difference in so many different practice settings. Giving these women positive experiences encouarges them to go out and spread the word in the community that a midwife birth is the way to go.
I started my journey to midwifery after fourteen years of hospital labor and delivery nursing. Most often in a very medical management style, however, I had the great opportunity to work with several midwifes in this time frame that have helped to develop my impression of birth. The challenges that I currently face our simply being the advocate for the patients desires. I currently do my clinical in a low risk hospital setting. We provide prenatal care to whoever is scheduled in the office or at the hospital. We work with OB residents (who are often unsupervised) and OB doctors that believe in the medical model. The hospital is a Department of Defense facility and all of our patients are covered under a “socialized” insurance. This is great in many aspects however, it does not support home birth, or water birth. We are currently providing perinatal care to a patient that desires a home birth. She has a midwife and MD that she sees but has to pay out of pocket for. We provide modified prenatal visits with lab work. However, the other day she had an episode of acute gastritis and needed IV fluids et some palliative care. The Chief of the department came to my preceptor and told her that if this patient tried to deliver at home and needed to be hospitalized that her care would not be covered. He kept saying how unsafe home birth was. So we pulled out several articles and left them on his desk. Additionally, my preceptor has already supported several other women in the same manner. She herself is not able to provide home birth but if the patient requires hospitalization she would be there for them.
ReplyDeleteWater birth is another matter. Currently we are working on providing the information and evidenced based research to promote for our patients a tub for birthing. We are one step closer to getting a tub in our hospital. The residents that rotate through our facility (many active duty) are now required to do water birth at the local birth center. So as this relates to setting I think as midwife student and future midwife to practice in this setting it will be even more important for me to promote normalcy.
try once again
ReplyDeleteThis is the most painful thing I have had to try and figure out. I hate blogging, but here goes.
ReplyDeleteI have been a labor and delivery nurse for 17 years mostly in tertiary centers. I have seen how high tech can interfere with normal in many ways. Our residents and physicians do not trust that a woman's body can labor and do it effectively. There premise is that medicine can do better than what mother nature invented. I am looking forward to empowering women to do labor in ways that work well for their bodies.
My preceptorship is taking place in a Family practice clinic in which residents are trained. The midwives teach the OB clinical rotations and I am lucky to work with the residents also. This has been a great experience. What a change from OB medicine. Women still get epidurals which is great if that is what they want and what works best for them. I am glad not to be hearing "Yea wait till she gets in labor and then she'll want and epidural". I enjoy teaching the girls I am caring for about labor and what to realistically expect. I think that is the major role of midwives. Education is the key. We are in the process of starting a Centering Pregnancy program that will give more information to the OB patients that come through our clinic. This is a great program and if you have not heard of it I highly recommend at least reading some information on it.
We also have nursing students that follow the midwives and there have been 2 that did not have any idea what a midwife was or did. It is great to educate our new nurses about the roles of APN's.
Well I finally got some help with this and figured out how to post to this blog site. I will no be more participatory. Thank everyone who has tried to help this computer dummy with some of these new sites we are working with.
Liz
I have always worked in the same tertiary setting. Working with the midwives in Asheville NC gives me another outlook on how "real midwives practice." The midwives at my Hospital practice as MDs. They do not stay around and support the patient in the labor process and most patients refer to them as MD's because they practice as such. Being in Asheville also gives me a view of how a teaching hospital operates with Midwives. The hospital that I work in is not a teaching hospital and a teaching environment is more acceptable to all students including midwives. So I have been exposed to the differences in care in the low risk and high risk settings but not in a birthing center or home births. Home births are illegal in NC except in some rural areas of Asheville home births are allowed, however this is with a practice other than the one I am affiliated with. The setting does directly influence the practice. In the tertiary setting the practice of midwives is allowed but they practice as MD's and in the low risk setting midwives are allowed to practice more freely under direct management of the hospital with step by step collaboration with MD's .In Asheville the community respects and seeks midwives, but in the tertiary setting the community is not aware of midwives or feel they are incapable of giving them adequate care. I have viewed how consistent the care given by midwives to patients has been in trying to make the delivery normal despite an other factors that may be taking place. There was a vaginal delivery of vertex/vertex twins and although mom wanted to natural birth the MD's( including anesthesia insisted that she receive an epidural in case the second twin flipped after delivery of the first. They came to a compromise to place epidural and not to have a continuous infusion. This helped maintain the environment for the patient and even though we delivered in the ER in case of emergency, the patient was pleased with her control over the situations. Telicia
ReplyDeleteDenise-Thanks for the support. I am not sure at this stage of the game more computer savviness is what I am looking for, but... Have not choice. Liz
ReplyDeleteI am going to be working with another midwife for the next 2 weeks-at least- that does not do any OB. She only does GYN and I am looking forward to getting that piece also. The MD she works for does not want her to do OB. That is the norm for the St. Louis area. The OB's do not allow Midwives to practice in a hospital setting. And it is illegal for them to do home deliveries. I will be working in Southern Illinois when I get finished (again, illegal to do home deliveries).
I have worked in the hospital for so many years, I do not have any desire to do deliveries in a home. I have seen things go bad so fast and I know I do not want to take that chance at home.
Liz
I love reading all the postings. It is very interesting to see the different parts of the country and the level of support for midwifery depending on where you are in the country. It will be interesting to see how health care reform effects midwifery. I think it will increase the usage of all midlevel providers. Health care dollars will have to be used wisely and normal births should be done by CNM's. Goes along with normal annual exams and contraception visits. WHNP's and CNM's should do the bulk of these and leave the problems to the OB/Gyn's. It will take health care reform to reward OB/Gyn's for providing the care needed to high risk, illness, and surgeries. Insurance and government should begin rewarding OB's for lower c/s rates, not enourage the rise in numbers by paying big bucks to do a c/s. If only there were big $$ in giving the woman a chance at VBAC.
ReplyDeleteUnfortunately, the only experiences I have had with midwives have been in the hospital setting--from community hospitals to tertiary care units. Unless the state of Alabama changes, I will never see a home birth. Hopefully, we will have a birthing center within the next decade if I have anything to do with it! I have seen midwives from one extreme to the other meaning they operate on a medical realm to the normalcy realm. I can do either, but I prefer the normalcy mode.
ReplyDeleteOne of the most beautiful deliveries I ever had a hand in was a G4P3003 that had delivered at home with 2 and in a free standing birth center with 1. As an Alabama resident with no birthing centers and a law against home birth, she was forced to deliver in a hospital. I tried to make her birthing experience as nice as possible. After it was all said and done, the midwife came to me and told her of the woman's compliments of my care. She said that of all her deliveries, this one was the best. I respected her wishes and she respected our policies. With a mutual agreement, we were able to give her and her family the birthing experience in a hospital that she could not have had in the setting that she wished for in ALabama. This was the deciding factor of my path to become a midwife.
If I cannot change laws in the state that I live in, at least I can help provide some normalcy to women's options in our great state! Although I alone cannot change those laws, I can make an earmark in the politics that guide them!
I also work in a level III unit. Our midwives really function off of a medical model. Most of out patients receive epidurals and deliver in the lithotomy position. I have had the pleasure of precepting in a level I facility. In clinicals, I have had the pleasure of learning how to do paracervical blocks which is unheard of where I work. I have also had the pleasure of seeing many natural labors and births. There is a menonite community in the area. These women choose not to have medical intervention due to personal beliefs and lack of money to pay for the services. They are very well prepared for childbirth and they have excellent support from friends and family. This support is often lacking with the patients that I care for at work.
ReplyDeleteWow, can I just say I have finished my first week of clinicals with my new preceptor in a new state, new hospital and boy is it different!!! We had three women deliver this week and two of them had IUPC's as well as amnioinfusions and epidurals and the one who was delivering naturally due to not having time for the epidural ended up with a physician consult and a forceps delivery. Far cry from the natural labors I was seeing in Montana but to each their own in this field I've come to realize. It is just so much more medical than I ever realized midwifery could be.
ReplyDeleteI think that many of us labor and delivery nurses fear of home birth may be because we only see the really bad outcomes. I currently will not be able to provide home births but I hope to someday. Until then I plan to help each woman through the birthing process her way.
ReplyDeleteI agree with you Ness. I am an old L&D nurse but I remember the days before epidurals and fetal monitors, but after working with them for so long it does become ingrained.However, I still believe that labor is a natural, safe life event that occurs with more good outcomes than bad and I believe that is where we as midwives truly make the difference for our patients.
ReplyDeleteYou're right Shawne- we are in the best position to help patients achieve their ideal birth. I know you must be really frustrated with your preceptor situation- I hope you are able to find a good one soon!
ReplyDeleteI have been working this week with a CMN that does not do any OB anymore. She has done deliveries in the past but is now only working in the office doing GYN. I have gotten some great info from her.
ReplyDeleteWhat I have found amazing through this whole education process is the number of women who do not realize all that a midwife does. They think that midwives only do OB and are surprised that they can also do well women. The other thing I have found is the public thinks that midwives only do deliveries in homes.
I am amazed by this and am wondering if this is more of a regional thing or if these ideas are spread around the country???
Liz
Liz,
ReplyDeleteI'm not sure if where I live in Ohio is considered a different region than where you are. We are both in the "midwest". But it seems that I have found that many of the people I talk to are under that mis-conception.
I think you guys are right. I have found through working in different parts of the country that the general public (those who haven't wanted or searched for any options aside from an MD) believe midwives to be either a "thing of the past" or only birthing in homes. I have found that the clients I've seen who have experienced both physician and CNM care overall prefer the care given them by a midwife.
ReplyDeleteLiz,
ReplyDeleteIt is primarily the same in Alabama all over. People do not realize the clincial expertise nor the differences in midwives. I am reading "Labor of Love" by Cara Muhlhan and she even states in her book that is the general concensus of the US.
Hopefully, the PEP program through ACNM will help change this nationwide.
Liz- I think your observations are universal- I meet the same misconceptions among my local community and from my friends and family across the country when I tell them about what I'm going to school for. Just goes to show that we need to be seen and heard from more!
ReplyDeleteI have often thought I would like to do home births after having a few years of experience under my belt, but I have seen such a negative reaction to this from the medical community. I wouldn't even know where to start in finding physician backup or how to approach the subject. Any one else thought of doing home births.
ReplyDeleteI never really thought much about doing home births because here in North Carolina it is so frown upon. The medical community here is still getting uses to the idea of Midwifery period let alone having home births. There is only one free standing birthing center in the entire state. Now that is where I would love to work in a birthing center.
ReplyDeleteYou guys know those Johnson & Johnson Ads they did a year or two ago saying "Be a nurse"? I would love to see ACNM put together some money for a national ad campaign about CNM's! It would be great to finally have a credible name. Nursing has notoriously done this to itself though with all of the different "levels" within our profession. I mean, we all know that a CNM is not the same as a lay midwife or that CNA, LPN, AD RN, and BSN RN are not all the same but the public just hears "nurse" or "midwife" they don't really know the difference on the whole. Also, with the whole push for advanced practice nurses to have their doctorate in the years up and coming, tell me that isn't just going to be even more confusing... Hi, I'm Dr. Faith Krull but no I'm not an MD although I practice in that rhelm. I mean why do we do this to ourselves as nurses?
ReplyDeleteBecause Faith until the ACNM requires that each state standardize the practice of Nurse Midwives and demand the recognition that our training,our expertise deserves we will continue to not be have the respect that this profession truly needs.
ReplyDeleteThe art of Midwifery dates back to biblical days probably even older than doctors and yet much of the public view of midwifery as Denise said still has the idea that midwives delivery in the woods, conjure spirits or mix up potions. When in essence if only the general public really knew just how natural and truly beautiful the professional is actually.
People still find it too difficult to believe that our bodies have the innate ability to heal itself.
Shawne,
ReplyDeleteI totally understand that portion of it. I was just saying that sometimes in the nursing world we hurt ourselves by not providing a set standard or definition which is separate from the other areas of nursing which makes it so difficult for the pubic to understand exactly what we do.
I think taking part in political matters related to our practice will help put our profession out there and get us the recognition we deserve. Here in FL we have something called Lobby Day, where meetings with legislators and senators are held to discuss changes that need to be made. For example, CNMs are not reimbursed the same as physicians for Medicare patients, and although there are few Medicare patients that are seen by CNMs, it is still an important trend setter for CNMs. At this time, CNMs are reimbursed at 60% and physicians are reimbursed at 100% for seeing Medicare patients. We have a very active lobbyist in town (who used to be a CNM!) that helps push for these changes and keeps us afloat of what we can do to help her in this cause. Every state needs someone like this, and I commend her for continuing to pursue equal reimbursement, and therefore equal standing, for midwives. I plan to be there for Lobby Day in March to see what else I can do to get involved in these types of processes that will give us more recognition. :-)
ReplyDeleteKaren and Shawne,
ReplyDeleteThere are several CNMs in Texas who do homebirths and I have spoken with them and found that they didn't have any trouble getting a doctor to support them. Of course they have to provide the doc with their practice guidelines and have frequent open communication regarding patient care. There are about 10 CNMs practicing in the East Texas area and approximately a dozen direct entry midwives who are practicing. At my hospital, there are many months that midwife attended births outweight the number of any of the practicing OBs. Yet with all of that, people in the community still think of midwives as outdated and don't even realize that midwives are out there for them. It is so sad to know that so many childbearing families do not know the option available to them through midwifery care that is so viable and so much better if they are low risk.
Another thing that I have come to realize is that regardless of the type of midwife you are, you will be frowned upon at some point for your profession. Many, Many people look down upon it. BUT, it doesn't matter if you know you that midwifery is your calling and you wholeheartedly believe in what you are doing. Every life that you touch will cascade over into other people's lives and they will be educated about midwifery care.
I think there is such polar feelings about midwifery. There are peers that either support midwifery model of care or those that are afraid of it or only see midwifery as risky, out of the box, radical care and thinking. Those people do not trust the natural process of birth. If any one had a chance have you seen the Cochran report on midwifery care? It shows with hard scientific data that low interventions and midwifery care improves outcomes and patient satisfaction. I love selecting articles to send to labor and delivery nurses, or others in maternal fetal health care to show how evidence based practice is very much a part of midwifery care.
ReplyDeleteI have been exploring the option of locum tenens and doing laborist work for a bit to get more births and experience in before I make a final descision about what type of practice or setting I want to work in.
Have any of you thought of locum tenens? what do you all think about travel assigments and midwifery care?
Karen,
ReplyDeleteI traveled for a few years as a nurse and LOVED it! However, I don't know that traveling and midwifery go all that well together. I think to gain the respect and the confidence in a provider during such an important time in their lives, many women would prefer a provider who was more permanent. Also, the laws are so very different from state to state I would think it would be difficult to be licensed and able to practice from one place to the next.
Karen,
ReplyDeleteWhen my husband and I traveled constantly for his work, I met lots of traveling midwives. The were mainly British midwives serving the middle eastern women. They all loved their jobs and loved getting to travel. If my husband was still working all over the world, I wouldn't hesitate to be a midwife without borders!
My church is building a hospital in Tanzania, as soon as I do finally become a midwife I want to go there for a while.
ReplyDeleteThe hospital is a women and children's hospital. The idea of the hospital was birthed out of tragedy. The pastor that we work with there sister died while in childbirth She was put on the back of a bicycle and had to ride 3hrs in labor, she was dead by the time they arrived. They were able to manage to save the baby.
Shawne, What a beautiful tribute to that women who died, but what a sad story. It reminds me of Monique and the Mango Rains. Such a great read and yet so sad at the end. I too would love to make enough money to take a month or so and work someplace in central america. In mexico there is a traditional midwife or partera who does immersion classes for spanish and midwifery. Midwives go down and spend one to two weeks practicing their spanish and then they work with her doing births. They get to see another cultures way of handling the process.
ReplyDeleteProject hope is another service that sends ships to latin america and asia with health care teams to go and assist communities in those area.
Just a couple of wonderful areas I would like to do before I die....But first the student loans need paying.
One of the preceptors I am working with here in Idaho is in Pakistan right now. She is teaching mdiwives there how to be safe in practice and when to refer. She said she had a "slow night" the other night and only delivered 12 babies! Something like 2/3 of all of the births there are unattended by anyone. It is amazing how different it can be in other countries.
ReplyDeleteFaith,
ReplyDeleteI bet your preceptor has a lot of stories and some great wisdom and insight to pass on. I really respect her for going there to teach and to serve those women AND the midwives there.
Faith,
ReplyDeleteThat would be a dream come true. I agree, I bet sh does have a lot of stories both happy and sad. But I also bet she is an incredible teacher.
Isn't it exciting that we are so close to being done and we will be the next midwives to make a difference and we will be the next preceptors, etc. These are huge responsibilities but I feel like our program has prepared us well. I personally feel like my precpetors have done an excellent job and it sounds like all of your preceptors have done the same. What are your biggest concerns about being out on your own?
ReplyDeleteMy biggest concern is providing that safe and effective level of care and continuing to stay up to date on evidence based care balanced with the art of "being with women" as a teacher, support person, advocate and clinician. The end of school is only the beginning of my career.
ReplyDeleteKaren,
ReplyDeleteI share those same concerns. It seems like an overwhelming task to accomplish when being a midwife almost means being everything to everyone. I have to keep reminding myself that I can't do everything......I'm sure that it just takes some time to get comfortable with being on our own and getting used to our new jobs and most of all getting our priorities in line.
In keeping with the view of birth being a natural process, I like the idea of delivering at a birth center. It gives the midwife a natural setting where normal process takes place. Unlike a hospital setting where the protocols require excessive intervention, the birthing center does not have IV insertion, continuous fetal monitoring, or anesthesia. The women are in control of their delivery and have made birthing plans with the expectations they want to achieve. Most women who decide to deliver in a birthing center are also believers in natural process. This includes breastfeeding, which is encouraged immediately after birth and the baby stays in the room with the mother to promote bonding. So many times in the hospital setting the baby is whisked away to the warmer by the nurse so that she can document her assessment, per protocol. I guess the main difference in the birthing center and the hospital is that there are no protocols in the birthing center, just to provide the expected midwifery care to produce a normal birth.
ReplyDeleteAllison said:
ReplyDelete1. Homebirth-Midwifery's beginnings were in the rural home, and having a midwife in the home birth completes the entire experience. A midwife is a mother's and family's liason between her safe home experience and medical care. A midwife is the safety net and resource on which to rely while the mother experiences childbirth.
2. A free standing birth center is the next best setting for a midwife to assist in childbirth. For those ladies who are unable to have a home birth, a free standing birth center allows them to have a similar experience as in the home. Thus, a midwife's presence in this setting fulfills the close-to-home birth experience. Also, some ladies may feel safer in this setting but with the amenities of home, which includes the midwife of course!
3. Low-risk in hospital setting: Some midwives may not have the luxury of practicing in a free standing birth center or assisting in home births. Thus, they must practice in a hospital setting. The OB/GYN clnic in which I work employs a CNM who assists with childbirth in the hospital setting. She also conducts all of the early labor evaluations in this same hospital for her group of physicians.
3. Tertiary care/Hi risk setting: A CNM can still play a significant and meaningful role in a mother's childbirth experience even in a hi-risk setting with appropriate medical supervision and support. Often, having a nurse midwife present for ladies who are hi-risk puts them at ease, increases their understanding of complications/abnormalities, and helps them feel supported with one-on-one attentive care. In this setting CNMs would function collaboratively with the physician (or in a teaching role with residents-as you do, Deb).