The Difference of a Midwife

So, with my first pregnancy, I wanted a midwife, but between bad information and some bad luck, I was unable to get away from the obstetrician (that I originally hired because I thought that was just what you did). It's something I really regret. On my first appointment, she made me cry by telling me that I had basically no control over who would be at my birth (or be putting their hands inside me).

I figured, okay, well, I guess that's how it is at OB practices. But appointment after appointment, she spent the time working on trying to make me afraid that this or that could happen. I was told not to read anything about pregnancy/birth or to participate in my Due Date Club (all of which I ignored, of course). She read my birth plan in front of me, told me everything was good, went over it and approved it.

Then, around 36 weeks, she freaked out over my use of the term 'emergency' to say that was the only time I would agree to a cesarean. Like most women who had never been to medical school, I had no clue that the obstetric definition of 'emergency' was a far cry from the average person's. And rather than just try to explain, she blew up and went on a rant and when my husband tried to calm her down by asking what the risks of an actual emergency cesarean were, she announced that it was basically guaranteed with "someone like [me]."

She continued with ignoring the whole agreement we had that we would not discuss induction before 42 weeks--she started pressuring me to induce at 38 weeks. I agreed to a sizing ultrasound and she was disappointed to see that it did not agree with her assertion that I'd have some gargantuan giant (with no medical reason to believe that I would). She was frustrated that I wouldn't let her control my birth and she took it out on me and tried to frighten me into it as much as she could (all the while trying to sound reasonable, kind and caring). If I hadn't had the awesome, supportive community of natural mama friends that I had, I might have been beaten down.

So, I think you can understand why I was wary in my second pregnancy and going to an OB, even if it was a new one. Due to insurance issues (screw ups in the administration part of it), it was 20 weeks before my first appointment. Every appointment, I was stressed and worried and sure that the First OB from Hell would reappear in the skin of my new OB. But time and time again, he was a great doctor, involved my daughter in appointments and was quite a CNM in OB clothing.

I had my VBAC with him and while I have some complaints about how I was treated by the staff, I don't have any complaints about my doctor. But I didn't want to birth in a hospital again. I didn't want to do the whole cycle of fear all over.

While I was recovering from trauma from my second daughter's labor and postpartum period, a friend had a wonderful announcement: a new birth center was being opened in my city. I was so excited. As people talked about the midwife who worked there, my excitement just climbed. No one had anything negative to say about her and really, she sounded too good to be true.

Still, I sent her an e-mail asking some questions about insurance, VBAC, etc. and was even more excited by her answers. She took my insurance, she was planning to take VBACs, it was all a go! Honestly, that was the last bit that I needed to heal and be prepared to get pregnant again.

Fast forward to my first appointment. I felt no fear as I approached the building. No trepidation, no sense of 'this person is going to hurt me, take my autonomy and make me cry.' It was an amazing feeling. I'm sure that the birth center being in an old house really helped--no sterile, cold office to make me feel separate and subject to someone else's will.

First, there was a living room for a waiting room. Not that there was much waiting--it was more to give the kids a place to play and my husband somewhere to sit comfortably with them where he didn't have to feel like he was dodging around being in the way (a constant concern of his).

The kids immediately connected with the midwife and her assistant and frankly, so did I. There were these magical words coming out of her mouth--it was like I was in Bizarro world. "You'll be expected to eat and drink to comfort in labor." "We don't cut the cord until it's done pulsing." "No one's going to be telling you when to push, we want you to listen to your body." "You'll be catching your own baby." (This was after I mentioned how much that meant to me with my VBAC)

There was a birthing pool in the room where the appointment took place. I sat on a real bed, not some table-bed thing. Normal sphygmomanometer, normal doppler (although the assistant was amazingly gentle with it--I'm used to the doppler wand making me kind of sore--and she found my baby's heartbeat at 10 weeks, which I didn't think would be possible!), O2 tank hidden off but available, etc. The safety measures available, but not obvious (and I don't mean not obvious by how they are kept in cabinets in the hospital, etc. -- actually not obvious).

My kids were included in what was going on. At my last appointment, my oldest was taught how to pump the sphygnomanometer and today, she and her sister both got to pump it up most of the way before the assistant needed to take over and get the actual reading.

Then everyone took turns listening to my heart.

And each other's:

Seriously, a picture is worth a thousand words. When are you ever going to see the scenes above at an OB's office? And an appointment isn't the same either. Today was my glucose test and it was probably the longest I ever waited--about ten minutes--while I paced around, letting my grape juice burn off (as being stationary is bad for the test!) and poked around the rooms (which is when I saw the O2 tank for the first time, actually) curiously. I've had the pleasure of watching the birth center be turned into the lovely building that it is now, since it was so new when I first started coming.

While my daughter shot darts at the door under the encouragement of my midwife and her sister laughed, stealing them and running back to Daddy, we talked about diet (protein, protein, protein!), concerns, where I'd want to transfer if I had preterm issues (my concern I brought up today), how to effectively communicate in labor and dealing with trauma from previous births.

At our last appointment, we talked about music and their available equipment for listening to it and the variety that mamas brought in. She also talked about my birth stories (which she read here on the blog) and how we could most effectively get me the birth I wanted (and she met my doula).

It's such a huge difference--I feel like a person, not a patient. My kids feel welcome and I'm really looking forward to birthing there. I don't feel like I have to make a plan to protect myself from staff--I know the 'staff.' It's my midwife, her assistant and my doula. It won't be whoever's on call at the time with mostly nurses taking care of me with the luck of the draw.

So, for me, there's been a huge difference and definitely a greater happiness and satisfaction with my care in this pregnancy. Not just the difference of a midwife, but the right midwife. And that's something I wouldn't trade for anything right now.

What do Midwives do if something goes wrong?

This is one of the biggest questions people ask about homebirth. It's based on the fear that is instilled into people from childhood that birth is painful and dangerous and that most women need rescuing from it.

Well, first, that's just not true. True emergencies only occur in about 5%-15% of births where a cesarean is required. I couldn't find an exact statistic for post-birth emergencies, but it's pretty low in general.

Now we're going to disregard pain control in this blog because that's not a part of the question. Women choosing homebirth in the US have already accepted that they wish to give birth without pain medications in most cases. They know that if they need them, a short trip to their nearest hospital can provide them. In the UK, mothers are provided with 'gas and air' (nitrous oxide) that they can control themselves. This option is currently not available to US mothers (despite many women "wishing" for it to be).

So, what happens if something goes wrong in a homebirth?

Now, midwives are not doctors. They are not surgeons. They cannot perform surgery and do not take high risk patients. Only normal pregnancies are taken on in the first place. Midwives watch for the pregnancy to continue normally and if something isn't right (such as placenta previa, pre-eclampsia, toxemia, etc.) then the mother's care will be transferred to an OB.

This works smoothly in countries where midwives are the default caretakers of mothers and homebirth is an easily obtained option. In the US, many midwives do work with OBs as backup to mimic the better model.

Midwives do not induce women with pitocin, artificially rupture their membranes and put them on a clock, either. These are some of the highest risk factors leading to cesarean births. (Some midwives do induce with herbs and sweep membranes, even though the second is shown not to be particularly effective and the first can be nearly as dangerous as pitocin induction.)

So, first, we've eliminated about 4-10% of necessary cesareans right there (approximately).

Now, that does leave some risk to homebirth (studies have shown that the risk of homebirth is no different from hospital birth, except those studies that did not eliminate accidental homebirth and those that included all births occurring outside of a hospital setting--some have even shown that homebirths are actually safer in 90% of normal pregnancies) as to ANY birth. So what happens if one of those risks occurs?

A midwife is there in labor specifically for that (in addition to catching the baby and some postpartum care). She watches the mother and baby for any sign that there is a need to transfer and in the event that she becomes concerned (and the reasons for this do vary by midwife--for type of midwife as well as her personal experience), then mother is transferred to the hospital as quickly as possible. If the hospital is not close by, the midwife may call it sooner than if the hospital is nearby.

Now, many people are afraid of the time that that takes. However, it is not significantly longer than the time it takes for a hospital to call in an anesthesiologist, back-up obstetrician and a neonatologist if necessary. That's right--not all hospitals have all of these staff members available at all times. Any woman in labor is at risk of needing an emergency cesarean when the anesthesiologist has stepped out for lunch (or gone to bed) or her OB doesn't have a second to assist (or no OB is even present in the hospital at the time--why do you think the nurses often page them frantically to get there while urging the woman not to push?).

In the event of an emergency, an ambulance will be called to stabilize mom (and baby if needed) and will call ahead to the hospital to make sure everyone is in place that is needed.

So, basically, the midwife does the same thing at home as she would in a hospital or birth center--only in the comfort of the mother's home.

In the end, homebirth is a safe and should be a valid, legal option for any woman who wishes to have one (just as birth centers and hospitals should be). Making them illegal is what puts women at risk, because they may wait longer to call for help when they need it, for fear of medical bullying or legal reprisal. And midwives are fully capable of recognizing the need to transfer care even during birth or after.

And yes, many midwives are capable of repairing tears and stopping bleeding as well and CNMs usually come with oxygen tanks in the even of the baby needing to be resuscitated or mother needing oxygen. They are also trained to deal with shoulder dystocia, cord prolapse, unresponsive newborns, hemorrhage and nuchal chords (where it's wrapped around the neck). Many are trained in breech birth as well. They are trained to handle most complications that arise and don't require an operating room or specialized equipment.

And finally, the difference between OBs and midwives:

An Obstetrician is a surgeon and a fully licensed doctor. Decades ago, they were taught to handle many more births vaginally than they now know how. Many forms of breech babies could be birthed vaginally and women would transfer to an OB for this service. Now, most OBs are no longer trained in this and are primarily trained in surgery.

There are different types of midwives.

First is the DEM or Direct Entry Midwife. "An independent practitioner who has learned midwifery through study, apprenticeship, a midwifery school, or a college program that is not a nursing program."

Then there are Licensed Midwives. "Midwives licensed to practice midwifery in a particular area. Normally a state. "

Next is the CPM or Certified Professional Midwife. "A midwife who has passed rigorous competency testing by the North American Registry of Midwives (NARM) is awarded a CPM certificate."

Finally, we have the CNM or Certified Nurse Midwife. "These women are trained as nurses and have done additional study in midwifery. Many are graduate students. They often offer complete prenatal care as well as attending births. "

CPMs and DEMs typically attend homebirth and though CNMs can, most work in hospital settings. CPMs also attend birth center births, as do CNMs.

So now you know a little more about what happens in a real emergency during a homebirth. It's still very rare, but protocols are in place and most women don't die even if they require a transfer, any more than they do in a hospital.