Midwives, Modern Medicine, and the Search for a Happy Medium

After the week I’ve had, I need to say something that should be obvious at first blush, but still comes as a surprise to many of  my patients: OBGYNs are surgeons.

There.  There it is.  Now, why is this awkward?  Lately, I’ve had a rash of patients who had bad experiences on their first go-round with physicians.   To their credit, these ladies are the few astute ones who seem to come out of their initial L&D experience with a better grasp on the status quo in obstetrics.  However, my statement above, while no secret, often comes as a revelation.  I’ll say it again: OBGYNs are surgeons.  And to be more specific, many of them prefer surgery.

Now, I’m not saying that every OBGYN heads into the on-call room at night, hops into bed and would provide you with an aerial view resembling this:

Surgeons

But think about it: if you were trained primarily in surgery and minimally in how to perform a vaginal delivery (case in point: most OBs no longer know how to safely deliver breech infants, unlike their predecessors), you would probably prefer what you’ve been most thoroughly trained to do.  It’s only natural.

Now certainly, this is a broad generalization.  I have met and currently work with many incredible OBs whose preferences are stayed by what’s best for their patient, and 9 times out of 10, this means a vaginal birth.  Often, these docs have picked up a few tricks along the way and they are rock stars when it comes to assisting women to birth vaginally.  However, unless you have some inside scoop on your doc (see: you know an L&D nurse!), choosing to go with a physician as your main OB provider may carry with it some inherent risk.

That’s where midwives come in.  Midwives, you say?  What are midwives?  What is this, the renaissance?

Thankfully for all of us, no.  We have not stumbled across some Medieval worm hole.  But midwives, who have been around since ancient times, are still around even today, serving as critical a role in L&D as they ever have, though now with far less recognition.  In the US, we have two types of midwives.

First, let me tell you about my favorite kind of midwife.  They are called CNMs, or certified nurse midwives.  CNMs are impressive for several reasons.  First, they are registered nurses.  That means they are trained professionals to start with, even before they are midwives.  Many CNMs start out their careers as L&D nurses and eventually choose to further their education to become CNMs.  Indeed, there’s no need to hop the nursing model if you want to further your education beyond a bachelor’s degree–CNMs are minimally master’s degree-prepared and trained to handle many of the same types of patients as their physician counterparts, including those requiring/desiring induction of labor, artificial rupture of membranes, emergency episiotomies, and a plethora of drug administration, including epidurals.  Yes, folks–you can have a midwife as your provider and get an epidural (assuming you’re in a hospital setting)!  In the US, CNMs work with physicians who oversee their practice and are available to step in if surgical intervention is needed.  The major difference between OBs and CNMs? I’ll bet you can guess it, but I’ll tell you anyway–CNMs aren’t surgeons!

The second kind of midwife is a CPM, or a certified professional midwife.  This particular type of midwife is somewhat controversial in my profession these days, and for good reason.  CPMs are apprentice-trained lay persons who do not have (or at least, do not require) anything close to the kind of formal training undergone by CNMs and OBGYNs.  While most are required to be certified in adult CPR, many states do not require that CPMs be required in NRP–which means that a CPM attending a home birth may or may not know how to save your baby if she has difficulty after birth.   The types of drugs they are able to administer are limited, though many of them remain high-risk drugs due to the nature of the field (methergine, oxytocin, etc.).  Conversely, some CPMs, such as those practicing in Minnesota, are unable to administer anything beyond vitamin K–so if you’re birthing at home and you begin to hemorrhage, good luck to you.  Again, it is not my intent to rail against all CPMs in this post as the requirements for education vary widely by state.  However, due to the unpredictability of labor and birth, it is not unreasonable to point out the vast differences in qualifications between CNMs and CPMs, both from the theoretical and the practical standpoint. As a result, I strongly encourage any woman looking for a midwife to go with the master’s-prepared nursing professional, no matter how comfortable you may feel with a given CPM’s personality or acquired skills.
To give you an idea of the range of skills contained in the CPM title, take a look at the link below:
https://www.ama-assn.org/sites/default/files/media-browser/specialty%20group/arc/direct-entry-midwife-state-chart-practice-information-2016.pdf

Why choose a midwife, you ask?  Specifically, why a CNM?  If you can get an epidural and a CNM can induce your labor, what makes a CNM so different from an OB?  Oh, where to begin…

  1.  A CNM is a nurse and trained in the nursing model, not a medical model.  CNMs traditionally take a broader, more holistic view of the patient and as such, often allow mom more freedom, especially in labor (providing it is safe to do so).  Because of their holistic focus, many CNMs are more attentive and responsive to other pregnancy concerns–you know, those nagging little things like not having had a bowel movement in two weeks or morning sickness that isn’t bad enough to get you hospitalized but also has you pinned on your living room couch drinking ginger ale and utterly unable to do anything else, including watch your toddler…that kind of stuff.
  2. Having a CNM as your provider doesn’t preclude you from getting medication in labor.  Epidurals, nubain, fentanyl–CNMs are able to tend to your pain relief needs in the same way as their OB counterparts.
  3. Given that a CNM is expressly not a surgeon, most CNMs are extra dedicated to helping their patients experience good, safe vaginal births.  In short, CNMs are renowned for their patience with their patients.  That isn’t to say they won’t defer to the physician if need be, but a CNM cannot perform a C-section him- or herself, and as a result, CNMs are in it for the long haul, whereas your impatient OB may opt to CPD (cut prior to dinnertime!) for no great reason other than their convenience.
  4. Traditionally, midwives are less invasive than physicians.  And that isn’t just because they don’t do C-sections.  (Warning: generalization ahead!)  Many CNMs are both known and preferred for their gentler, hands-off approach to L&D.  For example, instead of invasive, painful perineal stretching practiced by many a physician to open the vaginal canal and speed delivery, many CNMs opt to monitor baby and allow mom to bring baby down at her own pace.  Often times, this means less tears and repairs, better control over pushing, and a slower delivery but with faster recovery time.
  5. Many CNMs are more involved in the labor process than their physician counterparts.  Now, this certainly ranges both on the OB and the midwife side, but generally speaking, CNMs tend to carry lower patient loads for the expressed purpose of being more involved in the labor and delivery process overall.  Some CNMs pick up their patients at some point in active labor and don’t leave their sides until hours after the baby is born.  Other check in at intervals and stick around when it’s time to push.  Barring unforeseen circumstances (for example, your CNM has two patients in labor at once!), the bottom line is this: you will probably see your CNM while you’re in labor much, much more often than you’d see your OB (especially considering many OBs prefer to wait until the baby is basically delivering itself, run in, catch, and run right back out as fast as possible!).
  6. Most CNMs make for great labor support partners.  Especially if yours is an uncomplicated labor and your CNM is planning to be present for the long haul, their experience with birth combined with their expertise in keeping you and baby safe is top-notch at relieving anxiety, which in turn, can often relieve pain in childbirth!  For a non-medicated woman, sometimes a CNM is the only drug they’ll need.
  7. CNMs usually let mom lead the way.  Again, this is assuming that your labor is low-risk, unmedicated (see: no epidural) and uncomplicated, most CNMs will allow mom to birth in her position of choice/comfort whereas most physicians prefer–nay, insist–that women deliver in a supine position (an archaic, outdated practice that is still in place solely for provider convenience!).  What’s the big deal, you ask, especially if you have an epidural?  The big deal is the long-term consequences for your bottom as you’re more likely to experience trauma in the supine position versus other positions (such as squatting or even side-lying) as well as the potential for a C-section as a result of lying supine and pushing, especially if this occurs over an extended period of time.
    (Think about it–we tell women to stop laying flat on their backs in the 2nd trimester of pregnancy due to the weight of the uterus on the abdominal aorta, the huge vessel that supplies blood to baby and mom’s lower extremities, but often, laboring women lay on their back for hours while pushing at the very end of pregnancy when the uterus is at its biggest and heaviest!)
  8. The big caveat to all the above: As always, CNMs and OBs range in their skill sets, preferences, personalities and personal beliefs, so be sure to do your research.  Look up what other patients have to say about the providers in your area.  Schedule meet and greets with OBs or CNMs that you’re considering and ask them questions about their practice and what they should expect.  Pay attention to their reactions to your questions as much as you listen for their answers.  And of course, if you don’t feel comfortable with something that your provider says or does at any time, always be prepared to stop the flow of events and respectfully seek answers before you allow any further treatment to occur or plans to be made.  If it’s a true emergency, you’ll know. If it isn’t, you can at least get an explanation in the wait-and-see meantime, that way you’re able to make an informed decision should something happen.

That just about covers the highlights I can think of offhand, so if any of that appeals to you and you’re looking for a different–perhaps less traumatic–L&D experience, check out your local CNMs.  You may very well be glad you did!

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