Ask an OB: What does that mean?

"Ask an OB" is a weekly series with Dr. Maude "Molly" Guerin, MC, FACOG. If you have a question for her, please share it with us here. 

I've heard people talk about pushing against a "cervical lip" during labor. What does this mean? Why does it happen? Are there any risks involved? - East Lansing Mom

“Cervical lip” refers to the nub of cervix that is left when the cervix is almost fully dilated. When the cervix is fully dilated it disappears and all you can feel is the baby’s head, with no little “cuff” of cervix around it. When the cervix is ALMOST fully dilated you can feel a little edge of cervix, usually right under the pubic bone, that puffs up because of the pressure of the baby coming down. Eventually this lip usually disappears, and then you can push. If the pelvis is too small this little “lip” never does go back around the head – so you never get fully dilated. If you start pushing before the lip is gone (in other words before you are fully dilated) one of 3 things will happen: 1) you will tear the cervix, deliver, but maybe have a weak cervix next time leading to premature delivery. 2) the lip will not go back, will swell up, and you will never deliver vaginally 3) the lip will go back over the head and all will be well. Pushing against a lip for a short time might be OK to see if it goes back easily, but if it doesn’t do that, you need a hospital.

What is "caput" and what does it indicate for a laboring mother/baby? - East Lansing Mom

Caput refers to the swelling that occurs on the top of the baby’s head in response to coming through the pelvis. The pelvic sidewalls form a tight “chute” and the baby helps fit through by “molding” the skull bones to make the head literally more pointy. The leading portion of the scalp gets swollen from all the pressure, and gives baby the “cone head” so characteristic of first labors (and completely normal). With subsequent labors, the baby spends very little time deep in the pelvis – some second babies come shooting out in one push!- so the swelling and molding are much less. When more and more caput forms, we worry that the baby is stuck – the bones can’t fit, but the contractions keep trying to force the baby through.

You can read more about Dr. Maude "Molly" Guerin, MD, FACOG, right here.

N.A.R.M. (No . Accountability . Renegade . Midwives)

NARM (North American Registry of Midwives) was founded as a branch of MANA (Midwives Alliance of North America) by none other than Ina May Gaskin. This is the private organization responsible for "educating" and "credentialing" what are now referred to as Certified Professional Midwives, formerly called lay midwives, Direct Entry Midwives or Certified Midwives.  If you've read previous posts you know how grossly undereducated these folks are in comparison to nurse midwives, who go to college to earn a degree and spend years in clinical study.

As the sole credentialing body for CPMs, NARM is also responsible for holding its members accountable when they act unprofessionally or negligently. At least, that is what they should do assuming that they are a professional, responsible and ethical organization (which is highly debatable). In my experience, however, filing a complaint with NARM is nothing short of a nightmare. Here, in brief, is what happens when you file a complaint with them:

1) First, submit your letter and complaint to Shannon Anton, CPM. She is, incidentally, the only person who handles allegations for the entire country.

2) Wait weeks, then months for a reply . . . and get none.

3) Email Shannon Anton, leave her several messages, then ask for her manager . . . wait a little longer and then finally get a reply.

4) Shannon Anton will proceed to graciously ask the accused midwives for your records and a statement of their practice.

5) While waiting months again for any further contact, you will anxiously anticipate the assembly of a "peer review panel" (peers meaning a local group of CPMs). In front of this panel, you are supposed to share your birth story/concerns verbally with the accused midwives present in the room.  Immediately following, your family would be asked to leave so the midwives can talk.

6) Instead of a panel being assembled, Shannon Anton will wait months and through persistent follow up on your part, will respond by telling you that she just now (3 months later) received the release to ask for records.  She'll also inform you that she kindly copied the letter of complaint and data so she could also send a copy to the accused midwives. (Wait...what??) 

7) When asking for reciprocal transparency, meaning a copy of any "birth records" sent in response, Shannon will inform you that their policy doesn't allow them to share anything the midwife sends them.

8) In the meantime, a simple google search will show that their entire review board is made of CPMs and that one was recently asked to step down over the death of a breech baby.  (Precisely the kind of birth in your complaint.)

9) The final straw will be learning that even after going through this assembled panel, which was never assembled, the outcome would be a letter of "recommended" changes in practice...not required, but recommended.  The accused midwives, even if found to be negligent are given suggestions.  But rest assured, if you are not satisfied, you can further file a grievance with the organization's board and engage in a conference call to request further actions. 

10) When you email Shannon Anton and tell her what a joke of a process this really is and how insulting it feels on the heels of your baby's preventable death, she won't bother to assemble a panel at all.  She will disappear into the unknown and unseen, never to be heard from again...almost like this never happened.

Due Process? Responsible? Accountable? You decide.  

PS.  If you are unsatisfied with the above stated process, you might think about asking the state to review your case.  In MI they cannot review it because CPMs are not licensed through our state (appropriately so), they are considered "a-legal" and free to practice unregulated, as they wish.  You then might think of reporting your baby's death to the police.  In MI they can't press criminal charges because there are no laws or regulations by which to hold them accountable.  The end result, CPMs walk away without so much as a reprimand.  

Birth and Failure

Women are known for placing high expectations upon themselves.  We take care of everything and everyone, often neglecting ourselves in the process.  Setting high expectations for ourselves is no different when it comes to birth.  We spend months preparing for birth, educating ourselves, reading books, writing birth plans, and creating a “vision” for what we hope it will be like.   We try to wrap our heads around what we can’t possibly ever know…how our labor and delivery will go.  

I’ve met women who have birthed in and out of hospitals who have felt dissatisfied with the experience of giving birth, or more importantly the outcome.  These questions keep occurring to me, “Can we fail as mothers at giving birth?  Did I fail when my healthy baby didn't survive child birth?  Did my friend fail who transferred from birth center to hospital?  Did my sister fail when she had a cesarean?  How and why do so many women feel they have failed in some way?” 

After experiencing both a hospital birth (with which we brought home a healthy baby boy) and a freestanding birth center birth (with which our baby did not survive the traumatic delivery), I’ve come to see the ways in which the Natural Childbirth (NCB) advocates are actually setting women up for failure.  When we are taught first to “trust birth and our bodies” and that “birth works”, what then are we to think when birth doesn’t work?  When we are taught that “birth is as safe as life gets”, how do we make sense of that when our babies are injured or die as a result?  When we are taught that the hospitals are ill-intended, for profit, will strap you to a bed, will withhold food, and full of unnecessary interventions that will ultimately harm us and our babies, how can we feel good about having to transfer to the hospital or worse, have a cesarean?  Did our births not go “right” because we weren’t strong enough…didn’t push the right way…didn’t tolerate the pain…weren’t patient enough…that it just wasn’t meant to be?  Was it because we didn’t “trust birth” enough? 

Conversely, I’ve met women who have experienced labor and delivery in the hospital setting who also felt this sense of failure too, because the birth they hoped and planned for had too many interventions or ended with cesarean.  In preparing for hospital birth, many women write birth plans (as we were encouraged to do by our Natural Childbirth educator) to communicate their “vision” for what they hope their labor and delivery will be like to the hospital staff.  In a way this prepares women to be disappointed too, when things don’t go the way they had hoped or envisioned.  Some women are so dissatisfied that they seek out-of-hospital birth for their next pregnancy.   These mothers didn’t like the feeling like they weren’t in control or that they weren’t a part of the decision making process.  They didn’t like what seemed like an endless array of interventions or the way their OB talked to them.  They wonder if they really needed Pitocin or if their birth needed to result in a cesarean.  These women have questions too, and they are turning toward the world of unregulated, out-of-hospital birth proponents for the answers they want to hear.  

While I empathize with the disappointment hospital birth can bring, isn't the bottom line taking your baby home alive?  Isn't the point keeping mother and baby safe before it is about creating an experience?  Doesn’t safety trump any vision or birth plan we hold going into the unknown?  The priority has to be safety for every mother and those who attend their births.  Speaking from experience, I’d much rather bring my baby home alive then have had a picture perfect, intervention free, birth in a candle-lit room.  

This isn't to say that there isn't a great deal of room for improvement in the hospital setting or that interventions couldn't be used less often, but sometimes (more often than credit is given) these interventions are absolutely necessary.  We should not fear them, nor should we feel anything like a failure when they become necessary.  Sure hospitals and OB care could do a better job educating women about birth and appreciating that some women really want to be a part of it, to be fully present.  Some women do aim for un-medicated birth and deserve a staff that can support that effort well, while maintaining that mom and baby are within safe guidelines for doing so.  The truth is we can't control birth, no matter how much we'd like to, and in no way is a mother failing for being unable to control the way things go. Women shouldn't feel like accepting or asking for pain relief will somehow cause her child to be a drug addict later in life (as Natural Childbirth advocates teach) or that having a cesarean will prevent her baby from breastfeeding. We have to find an element of trust with the care we are receiving that allows for professional judgment on our behalf, and we have the right to expect that professional judgment to be honest, ethical, current, and responsible.     

With so many women walking away from the experience of birth feeling like they somehow failed, we need to consider why and how to address this as a culture.  First, birth isn’t always about the “experience”, it’s about the mom and baby coming out alive and well when it’s said and done.  I do think there is value in thinking through an upcoming birth and in talking about hopes for labor and delivery with a care provider.  The two keys here are honesty on the part of your care provider about the realities of birth and coming to a mutual agreement that safety is the ultimate priority, even if it deviates from the original “vision”.  Women need to appreciate everything our obstetricians and responsible midwives are doing to keep us safe, and our care providers need to work hard to understand a mother’s goals, both knowing they may not be met if it means an alternate plan will ensure safety.  In addition, I wonder how much we could learn about each other if we sat down with our care providers for an honest follow up conversation about client satisfaction, disappointment, and how/why decisions were made during their labor and delivery?  

Can a mother fail at giving birth?  I believe the answer is no, a mother cannot fail at giving birth.  She can feel dissatisfied, disappointed, manipulated, but she cannot fail.  Rather the failure comes in the care givers who choose not to recognize that birth doesn’t always work and that sometimes we need help.  The failure rests on the shoulders of care givers who don’t appreciate that birth can be inherently dangerous.  A great disservice is being imposed on women everywhere to paint birth as this peaceful, perfect, painless (orgasmic if you're into Ina May) image that ultimately is false for many of us, and not because we chose it or didn’t do our part.  I believe our society has a responsibility to be honest about birth, its dangers and its beauties alike, and a responsibility to remove judgment of each other for the way in which our births have gone.  Success should be defined by improving practices across the board and celebrating every baby that is born safely, regardless whether it was “natural” or not.      

Funding Renegade Midwives

Renegade:

1. a rebellious individual who rejects conventions or laws of a group  

2. an individual who rejects lawful or conventional behavior

I have met in recent years, several midwives who work hard to serve their clients with a great deal of ethical responsibility.  They are educated, licensed, insured, transparent, cautious, and appreciate that sometime birth falls outside their scope of practice.  They know when and how to seek transfer of care and appreciate that at any moment "normal" birth can deviate.   These midwives build healthy relationships with and within hospitals and work to hold safety of mom and baby in the highest regard. 

Let's consider the question, What is a "renegade midwife"?  A renegade midwife is someone who prides herself on making a statement through her work, one who "trusts birth" at all costs and believes that when things go wrong it's just the way it's meant to be.  Renegade midwives are those to often put their clients in danger by taking on known high risk situations to better advance their own movement or to prove a point.  A renegade midwife will tell you that any risk factor is, "just a variation of normal", that moms know how to give birth and babies know how to be born, and fill their clients with fear about the hospital instead of building a healthy relationship with them (and yes, that effort goes both ways).  A renegade midwife doesn't report her outcomes, nor is she accountable to anyone.  She is uninsured, unlicensed, and unafraid to practice even when it's against the law.  These midwives "fly under the radar" and pretend their work is serving women, empowering them.  These are the midwives that put philosophy above safety and pose great danger to any mother seeking their care. 

With families speaking out more and more about their less than perfect experiences in the hands of renegade midwives during home birth and at freestanding birth centers, the question of support comes into play.  The trend appears to be that the Natural Childbirth advocates instantaneously jump on the bandwagon of support to protect their “choice”, their pleasant outcomes, their “movement”, and ultimately themselves without any real analysis of what may have gone wrong and why.  What ever happened to the responsibility to review adverse outcomes and improve practice?  Why are these “communities” so quick to dismiss the experiences of families who do find the strength to come forward and talk about what happened to them? Perhaps the very "advisory boards" that support them should offer advice that includes careful analysis of adverse events aimed at improving practice instead of asking for donations to support legal fees. 

For those who criticize the action of a lawsuit I ask them this…What other choice do these families have but to turn to lawsuits when there are no regulations or laws by which to hold midwives accountable?  Would they suggest discussing it over dinner and cookies and accepting that, “some babies just aren’t meant to live?”  When we experience something we knows to be reckless, unethical, and dangerous, is it socially responsible to say and do nothing? Is it acceptable for those people responsible to walk away without so much as a reprimand? Certainly not.

Even further, many of these “supporters” are throwing their money behind renegade midwives to support them financially due to the burden of legal fees, never mind the fact that if they had been responsible in having liability insurance in the first place, the “burdens” wouldn’t hit their pocketbooks so hard.  

A friend of mine brilliantly drew this analogy:

“Imagine you are sitting on an airplane, about to take off, when the flight attendant comes on the speaker and says this: "Hello ladies and gentlemen, before we take off we will be passing a collection plate around the cabin. You see, your captain and co-captain had a crash last year and a few people died. The settlements to the survivors and families are really steep and so they are hoping that you will consider making a donation to help them out. They love flying and can't wait to get you up in the air today! Thank you!

Seriously . . . would anyone on the flight put money in the plate? I doubt it. Moreover, would anyone stay on the airplane? I for one would grab my stuff and get the hell off. “

I’m growing weary of the folks that can’t see outside their own good outcome and recognize that something is very wrong for many of us - and it’s no coincidence.  How can people blindly support individual midwives knowing that their actions are at the very least questionable, to the point of costing babies and mothers their lives?  How about working toward improving out-of-hospital birth instead of ignoring and vilifying the outcries of families across the country while the midwives act like martyrs?  Recognizing the problem is the first step. The next is doing the hard work necessary to improve outcomes for all of us. 
 
For the moment, I hope that families in the Natural Childbirth community will choose to spend their money wisely and, in the meantime, have the sense to get off any plane that is piloted by irresponsible captains.

Ask an OB: Hospital worries

Thank you for your questions! Dr. Molly will answer them as they come in and we'll post a couple to share here on the blog every Monday. Here are two to start us off . . . 

What are three common misconceptions that the NCB (Natural Child Birth) culture promotes about hospitals that you would like to dispel? - Mom of three

1. “You will be strapped into bed flat on your back the whole time you are there”. 

Actually . . . .we don’t want you flat on your back! Please walk, go in the shower, crouch on your haunches, rock on all 4s, roll on our birthing ball, etc.

2.  “The chance for a c section is 40 – 50%”.

Actually . . .  the chance for a c section in a mom who is term, low-risk, and in spontaneous labor is about 15 – 20%. Most of these are done because either the baby won’t fit, or the baby’s heart rate doesn’t tolerate the strong contractions in late labor.

3. “Your baby will be taken away from you and given meds, formula, pacifiers, sugar water and vaccines you don’t want it to have”.

Actually . . .your baby will be plopped right up on your chest at birth, left there till you want him weighed, allowed to nurse as soon as she wants to, room in 24 hours a day, and go home whenever you are both ready to go.

What is the No. 1 fear that women come to the hospital with that they really DON'T need to worry about? -Mom of three

For some reason some women worry they will be a bystander to their labor and delivery – that all decisions will be made without their knowledge or consent, that nurses and doctors have an agenda that they don’t share, and that what the parents want will be disregarded. This is absolutely not true! Please talk with your provider about your hopes and dreams for your labor and delivery – it is our strongest desire to make you happy. If there is a mismatch between what you want and what we think is safe – we WILL discuss this in as much detail as you need.

You can read more about Dr. Maude "Molly" Guerin, MD, FACOG, right here.

Considering Out-of-Hospital Birth? Questions to Ask Your Midwife

Note: "Out of Hospital" birth is defined as home birth or birth at a freestanding birth center, one that is not within the walls of a hospital.)  

A note about pointed questions: If you are embarrassed to ask the questions lest you offend the midwife, don’t be. Any midwife who bristles about these questions needs to be left in the dust. She should have complete composure, no defensiveness and be clear and truthful in her answers. If she can’t act professional with you, how will she act with a doctor in front of her if you transport? It’s a midwife’s job to answer these questions; it’s your right to know the answers.

Are you licensed?  What are your credentials and experience?

Being licensed, regardless of state is critical.  Do not hire a midwife practicing without a license.  Know the laws in your state.  In all states CNMs have a license, but CPMs are licensed in some states, not in others, and illegal completely to practice in yet others.  Even if you find a CPM who is licensed, please thoroughly understand their credential because it is far less education, clinical practice, and experience than a CNM.  The philosophy of their credential is also something to be concerned about. 

How long have you been practicing as a primary midwife for out of hospital birth?  How many births have you attended as a doula? As an apprentice? A midwifery assistant? How many births have you been the primary midwife with supervision and then without supervision at a homebirth for? How many births did you experience in the hospital setting?  

I can’t stress this enough, asking the midwife more pointed questions will give the woman more information than just, “How many births have you been to?”  But, what should the answers be? Because there is no standardization in midwifery education or skills training, the answer depends a lot on the woman.  It’s difficult to evaluate philosophy and character, indicators for how this person would handle your care in the event of impending danger or crisis.  The more specific questions you ask, the more information you have.  At a minimum, you’re looking for someone who has experienced hospital births, complications, transfers as the primary caregiver, and doesn’t hesitate to describe circumstances that were out of her scope of practice whereby care was transferred.  

Do you carry malpractice/liability insurance? 

If your midwife does not carry malpractice insurance, find another care provider.  This is an enormous red flag as it says a great deal about the philosophy under which that midwife is practicing.  Malpractice insurance protects them as much as it protects you.  It establishes a consistent set of guidelines for scope of practice, safety measures, and professional development for the caregiver you are hiring.  Without this is place, they can function in whatever way they please…and if they do act negligently you have NO recourse.  Insurance is a mechanism to ensure your safety and to help families who suffer negligent circumstances like preventable birth injuries and preventable deaths.  Don’t hire a midwife who isn’t responsible enough to carry insurance.  

How do you evaluate risk? 

This is another critical aspect of your conversation.  How much is too much risk and how will it be determined?  I don’t know precisely the exact answer, but your potential midwife should be able to explain exactly what she monitors, looks for, when she might be concerned, when she would transfer your care. 

What defines your scope of practice?

In other words, what types of births do you take on and which would you consider too risky?  Who regulates or determines your scope of practice?  If a midwife is running the show by her own rules, there is a problem.  Ask for a copy of her scope of practice from whomever has issued her credentials…it could be a state board via public health code or ACNM, a national credentialing body for Nurse Midwives.  What are they permitted to take on in an out of hospital setting? 

How do you define “high-risk”? 

Some midwives don’t think anything is too high risk for them to handle.  Many claim to take on only low risk, normal pregnancies, but somehow end up delivering breech babies, twins, women with gestational diabetes, women with high blood pressure…and on and on.  Even low risk, normal pregnancies can go wrong in seconds, but at the very least, establish a boundary of low and high risk in your own mind and with your midwife.  Consult an OB and ask this question too. 

Do you think a hospital is ever necessary and under what circumstances?

Your midwife should be specific about this.   A general “of course they are” isn’t going to cut it.  This question will help you get a sense for her attitude toward hospitals.  Does it sound like a working relationship?  Her answer shouldn’t be about mothers who aren’t strong enough or who fatigue, they should be about specific concerns for the labor and delivery of your baby…prolonged labor (more than 3 hours of pushing with little to no progress), too much pain, meconium present, size of the baby as determined with ultrasound before labor, baby’s position, multiples, high blood pressure, VBAC, gestational diabetes, group B strep...etc.    

What is your relationship with the local hospital?  What privileges or practicing rights do you have at the local hospital?  Does the nearest hospital have a Neonatal Intensive Care Team/Unit? 

Only hire a midwife who has a good standing with your local hospital.  Don’t just take her word for it, ask the manager of the Neonatal Care Unit, Nurses, Doctors, local paramedics.  Ideally, hire a midwife who has practicing rights or privileges to work and transfer along side you as part of your continued care in the event of transfer.  If your nearest hospital doesn’t have a Neonatal Intensive Care Unit or staff, out of hospital birth is not for you. 

What hospital do you transfer to?  What records & personnel transfer with me?  What would happen in the event of transfer?

You need to know where the nearest hospital is that includes a neonatal unit.  It doesn’t really matter how many minutes away the hospital is if your midwife doesn’t catch danger signs soon enough or her fear/ego gets in the way of transferring you in the first place.  A hospital 10 minutes away won’t matter once the crisis has hit.  The key is someone skilled, equipped, and responsible enough to catch it before it gets to that point. 

Midwives are also notorious for taking less than detailed records or sending no records at all during transfer.  You need to know what they note during labor, how that compares to an OB or L&D nurse, and what a transfer would be like.  (See post about what transferring is like.) 

Who determines/decides when to transfer?  What would you say to a mom who asks to transfer during labor?  What complications warrant transfer?  What is your rate of transfer? 

You are hiring a midwife to attend your birth as a professional, a so-called expert on birth.  They need to be clear that they will tell you when you are in danger and be a leader in deciding to transfer.  The decision should never fall on you during labor, nor should you ever be pressured to stay.  If your midwife starts to tell you about how long it will take for transfer to take place, that you’re so close…just a little longer, or if it seems like your midwife is avoiding transfer, indecisive, or stalling, get to the hospital!  .  

The list of transportable reasons is endless and it’s the midwife’s professional responsibility to know what they are. The midwife will surely say something like, “Breeches, twins, high blood pressure, a fever, baby’s heart tones are questionable.” They are hired to know when to transfer (non-emergency) and transport (emergency), but sometimes egos, fear, and mantra get in the way.   

Some states now have an exhaustive list of complications during pregnancy and mandate which of those requires a consultation with an OB and which requires transfer altogether.  If your state does not have these guidelines in place, you are subject to the will of the midwife, making out of hospital birth far more subjective, dangerous, and unregulated.  (Essentially a midwife can do whatever she wants…low risk, high risk…etc.)  If during labor, you or your partner is questioning the situation at all, please be a self advocate and transfer.  

Regarding what the hospital transport rate is, this can be taken any number of ways. Low transfer rate? She only takes very low-risk women, maybe none who’re having their first baby. Or, maybe she stays home hoping complications will resolve or she’s afraid to transport…which directly puts you and your baby in danger.  (See this website if you question whether this happens and how often.) Maybe she has a lot of experience and takes appropriately low-risk women. How are you to know why she has a high or low rate of transfer? You can’t; it’s all in how she sells herself. 

Do you work in conjunction with an OB?  May I have a few visits to get to know him/her?  Under what circumstances might I consult with your OB?

A midwife should always have a working relationship with an OB.  Before hiring any midwife to attend your birth, schedule an appointment to interview the OB as well.  Meet with the OB at the beginning and at the end of your pregnancy (before labor) at minimum.  Talk with them about your plan for out of hospital birth and whether you are a good candidate for this kind of delivery.  Share with them who you have chosen as your midwife.  If there is no relationship with an OB or the two are not mutually agreeing on your plan of care, out of hospital birth should be reconsidered.  

Who is your midwife back-up? 

Some midwives take on more than 3 or 4 clients a month. Be sure to interview the back-up midwives, too, asking these same pointed questions.

How often will I see you during my pregnancy? How long will prenatal visits last?

I’ve never known a midwife to see clients on anything different than the standard monthly until 28 weeks, bi-weekly until 36-37 weeks and weekly until the birth. Plus, appointments are almost always 45-60 minutes long, most of the time being spent on social interaction… getting-to-know-you aspects. The actual medical/technical part lasts less than 15 minutes. When going to an OB, the social aspects are what is often what mothers see as missing. (Please see an important post about emotional attachment and personal relationships, the way they can adversely affect sound decision making and leave you vulnerable to manipulation.) 

What is your philosophy about prenatal testing (Gestational Diabetes, Ultrasound, Group B Strep)?

If your midwife tells you any of the listed tests are dangerous or that they are unnecessary, keep looking.  They do them for good reasons.  If you’re considering more advanced testing, please consult an OB. 

What (emergency) equipment do you use/carry?

The answer should be: Doppler (preferably waterproof) with extra batteries, blood pressure cuff (two sizes), thermometer, glucometer with in-date supplies, lancets, IV equipment with in-date fluids (Lactated Ringers, Sodium Chloride, Dextrose 5% Lactated Ringers are the most common types of fluids needed in birth), in-date Pitocin (which is supposed to be kept cool), Methergine (IM and tabs), Cytotec (for postpartum hemorrhage), in-date lidocaine, in-date sutures of at least two sizes (one smaller one for the labia), in-date Erythromycin eye ointment and Vitamin K for the baby, in-date antibiotics for GBS+ women, scissors, needle holders, forceps (not the kind that pull babies out), oxygen (I always carried two tanks… one for mom, one for baby), a bag and mask with new masks for each baby (they are marketed as disposable; most midwives I knew re-used the masks [after cleaning]), in-date blood draw supplies, in-date catheters, and a Sharps container.

It can be hard to know what answers you’re looking for when you ask a midwife about various complications.  The above list is a minimum and is no guarantee that they will have what they need when an emergency arises.  When emergencies come along they do so quickly, sometimes w/o warning on low-risk, normal pregnancies.  The best place to handle complications is in the hospital.  More important than any equipment is a midwife who appreciates and is skilled enough to spot trouble before it’s too late and has the respect for birth to get  you the help you need.  

If your midwife starts to use fear tactics, telling you the horrors of cesareans, that epidurals will lead your child to be a drug addict, that fetal heart monitoring is only so insurance companies can make a profit, or showing you disturbing videos about circumcision, find another care provider.

Please see our FAQ Page for more information.

Find your state’s public health code and determine what regulations there are for midwives in your state.  If there are none, that is a red flag.  

Nurse Midwives in MI are currently defined under "Nursing".  You will find next to no rules even for nurse midwives in our state.  CPMs, lay midwives, & birth centers are not regulated at all.  There are no safety guidelines for out of hospital birth in the state of Michigan, making standards of education, care, and practice inconsistent and making accountability nearly impossible.  Out of hospital birth in Michigan is an unregulated practice at present. Please see Michigan's Public Health Code  for more information. 

Written by Barbara E. Herrera, LM, CPM (aka Navelgazing Midwife) and augmented by Sara Snyder

Who do midwives protect?? (“From Calling to Courtroom”)

Ever been told how honorable, how noble a midwife’s role is during childbirth…to “be beside” a woman as she intuitively hears her instincts and births her child?  I always assumed that a midwife’s first and foremost concern was the safety of the mothers and babies they serve.  As more and more families come forward to share their alarming experiences with out of hospital birth, we are learning this isn’t always true…in fact it is often not true. 

Low and behold, midwives have even written a book about how to protect each other and themselves.  The title, “From Calling to Courtroom: A Survival Guide for Midwives”. 

“Knowledge is power and protection. This book strives to make a positive contribution to every midwifery practice and is dedicated with the intention that no midwife should ever again be unjustly prosecuted or persecuted.”

Knowledge is power and protection which is why EVERYONE should read this book to fully understand the warped efforts to “protect” themselves above all else.  No one should ever be unjustly prosecuted, midwives included…BUT those who are guilty of gross negligence, negligence, and wrong doing should absolutely be held accountable as is the rest of society.  Midwives should not be excluded on some pedestal of birth worship. 

“Too many midwives have been forced to expend too much of their energy, finances and sanity trying to defend the practice of midwifery. Too many midwives are serving jail time for providing appropriate midwifery care.” 

Nothing like playing the martyr and the victim with such dramatic conviction.  Really…defending the practice of midwifery OR more accurately defending their negligent, reckless, irresponsible, and unethical actions?  I’d further say that not enough midwives are serving jail time for inappropriate care.  Are midwives really so self-righteous that they can’t see that some members of their “profession” don’t act ethically?  Isn’t that true of every profession?  How sanctimonious to protect your own so loyally without really aiming to improve the practice, this is why the “profession” is in danger. 

Chapter 6 also mentions a progression of interest in protecting first mothers and babies, then “themselves, and their profession”.  The focus of the book is about the latter.    

The reality of the care that’s being distributed across this country speaks more accurately to serving themselves & their profession first and foremost...and forget about the moms and babies, "some of them just aren’t meant to live”.  If you question this reality, please visit the "Hurt by Homebirth" blog. 

Of particular interest on this blog would be Chapter 6 which specifically addresses the history and current state of lay midwifery in MI.  It details motivation and strategy for midwives to obtain licensing and seek “regulation” so they can both seek insurance reimbursement and make it so they are less likely to be prosecuted or sued.  It has nothing to do with improving practice, practicing in a safer way, or being more accountable.  In fact, in MI they want to follow their own rules set by their own board with a panel for review of only themselves.  Check out NARM's (North American Registry for Midwives) new statement about licensing.  Nothing like advocating for licensing and regulation but writing it so that no one can make any rules or have any oversight except for themselves.  Purposefully confusing politics, read it carefully.  Is this any different that what’s already happening???  Unaccountable and protecting themselves instead of the families they are supposed to be serving…No wonder ACNM (American College of Nurse Midwives) doesn’t support them. 

Let me remind everyone that CPMs, those fighting so hard to keep their unbelievably lax “rights” to practice in MI are the same thing as lay midwives who renamed themselves DEMs (Direct entry midwives), then changed that label to CMs (Certified midwives), then again to sound more official to CPMs (Certified Professional Midwives).  The history is all in Ch 6.  The book expresses how “fortunate” Michigan midwives are b/c they can function under the blanket of “alegal status” in our state, not regulated, but not illegal.  How lucky.  We are on an “island in the Midwest”, one that is costing babies and mothers their lives. 

These are NOT CNMs (Certified Nurse Midwives).  I contend that if CPMs would like a license and the right to deliver babies, perhaps they should consider a college education and practice as a professional like the rest of us.  Why should they be granted a license to protect themselves without earning one, and without being accountable?  The only legal “midwife” should be a Nurse Midwife and yes, they should be required to carry insurance as a measure of responsibility for practicing within parameters of safety guidelines, professional development, and as a responsible professional. 

Ask an OB: Meet Molly

We are excited to kick off a series of posts here on the blog called, Ask an OB. Our resident OB, Maude "Molly" Guerin, MD, FACOG, will field questions you have related to pregnancy, labor and hospital birth.  Wondering what it means to be post date? Worried about the so-called "cascade of interventions?" Curious about cord clamping philosophies? If you have a question for Molly, please share it with us here.

Before we get started with questions, let's meet Molly . . . 

"I made a big loop that started in Ann Arbor for undergrad, wound through Florida, Maine, New Hampshire, and then back to Michigan in 1989, with med school (1978), OBGYN residency (1982), marriage (1977), and three boys (1981, 1983, 1987) along the way. After my family, my biggest love is my work. I still love coming to work every day, because of the transformative power of the three “blood events” for women. Being a small part of the “becoming” (…a woman… a mother…a wise old lady) for my patients is a privilege I am grateful for every day. Birth is the most dramatic of the three transformations: the most physically challenging, and the most dangerous, the most rewarding. My job as an obstetrician (from obstare “to stand by”) is to be present, vigilant, and ready to intervene when necessary. Creating a strong bond of trust between parents and provider is a critical goal of prenatal care, so that, when necessary, interventions are done with understanding and consensus. Just because things usually go well doesn’t mean they always go well - my job is to anticipate, be prepared, and do what it takes to get a healthy mom and baby as often as is humanly possible."

We Need Strong Voices

Quick Background...Rep. Ed McBroom has drafted a bill (with, for, and funded by lay midwives) that proposes to license CPMs in the state of MI. (A CPM is a "Certified Professional Midwife, whose certification is held by NARM, a politically motivated, pro-lay midwife advocacy group).  This bill is dangerous for many reasons and will do MI families more harm than good if it is passed. ACNM (American College of Nurse Midwives) has publicly denounced this bill, saying that it does more to protect midwives than the families it serves. This bill is about licensing unqualified people into a profession that should require a great deal of competence. It is not about limiting practice of educated, responsible, licensed nurse midwives. We need your voice in writing to express your concern and tell your legislators MI can do better.

To learn more about why this bill is dangerous and incomplete, you can check out this recent post.

Here's what you can do:
Write letters. Legislators respond to consumer opinion. Send a letter to Rep. Gail Haines, the chair of the House Health Policy Committee, voicing your concerns for HB 5070.

If your legislator is a committee member of the above mentioned committee or is a co-sponsor of this bill, please write to him/her too.
http://house.michigan.gov/committeeinfo.asp?lstcommittees=health+policy

Prepare to attend the Committee Hearing. The hearing will be held in Lansing on a Thursday at 9 am. We probably won't get much notice. It will mean a lot if we can pack the room with concerned citizens. Watch for a post giving specific instructions when the hearing is announced.

Educational Standards of American Midwives: A Comparison

From Midwife(ology) blog:
"The term midwife is used frivolously in today's American society. When one refers to a midwife, most often it is thought of as someone who provides out of hospital care to a mother and her child. Unfortunately, many are not aware of the differences among the various types of midwives found in the US today. There are a variety of midwives in the US today - Certified Nurse Midwives, Certified Midwives, Certified Professional Midwives, Licensed Midwives, and Direct Entry Midwives. 

A CNM and CM are quite similar with the only real difference being a CNM is required to hold a nursing degree and a degree in midwifery, whereas the CM is only required to hold a midwifery degree (both on the master's level). CPMs, LMs, and DEMs are quite similar as well, with the main differences being the legal status which varies state to state, licensing status which also varies, as well as the mode of education.  Traditional midwives (CPM, DEM, LM) often learn through various methods of education such as traditional school of midwifery, distance learning, or by an apprenticeship. While all are referred to as midwives, there is a vast degree of educational standards separating them.

The two most well-known credentials are Certified Nurse Midwife, and Certified Professional Midwife. The educational differences between these two credentials are extreme."

Certified Professional Midwife (CPM)

• No High School diploma or GED required, there are no prerequisites for the Midwife to be Program 
• No college degree or accredited academic training is required
• Standards for certification are set forth by North American Registry of Midwives (NARM)
• Some states require a license, others do not and many states consider CPMs illegal 
• The "Midwife To Be" program is a completely distance learning program.  It is self-paced, and can be completed in as little as a few weeks if done extremely quickly, or as long as 60 years if so desired.   Average completion is 2-3 years.   
• The MTB program is a  self-study program with tests taken online on the honors system over birth and breastfeeding books, no tests over the textbooks or “units of study”, no classes, no lecture, and the ability to master the required "skills" by looking up You Tube videos 
• The “Midwife to be Program” through NARM is NOT accredited
  
  

** A CPM "certified" in the US would not be competent to practice in ANY other first world country!**

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Certified Nurse Midwife (CNM)

•  High School diploma or GED required, and acceptable scores for college entrance on the SAT or ACT   
• Requires a Bachelors degree in Nursing and a Masters degree in Nurse Midwifery
• CNMs must prove competency and evidence of certification through the American College of Nurse Midwives (ACNM), a rigorous, well respected, and accredited organization.  
• A license is required and every state recognizes/issues licenses for CNMs
• Takes a minimum of 6 years of higher education
• Requires an extensive list of college/graduate school classes with lectures, quizzes,  research, clinical studies/practice, tests, graded projects, case studies,  and more
• Degrees and licensing can only be obtained through accredited programs of study
  
  

Food for Thought:  What about CONSISTENCY in preparation, education, scope of practice, oversight, licensing, definition of "midwife" and on and on and on...?   Why are we accepting anything less when it can mean life or very possibly death?

Top 10 Reasons Why HB 5070 Will do More Harm Than Good for MI Families

1)      There is nothing in this bill that requires midwives practicing outside a hospital to report their outcomes for out of hospital birth.  There is no reliable data to evaluate safety or efficiency of out of hospital birth and NO way for families to reliably know the past record of outcomes for a midwife she hires.    

2)      There are no guidelines for safety measures, transfer of care protocols, or definition of what “low-risk” birth means.  This is critical in making out of hospital birth a safe option for women and ensuring that midwives only attend low risk births and have consistent guidelines to practice safely. 

3)      House Bill 5070 hands a license to CPMs who are grossly undereducated in comparison to their CNM counterparts.  (CPMs don’t need a high school diploma and CNMs require a minimum of a masters degree and years of supervised clinical practice.) In fact, the standard for certification in the US for CPMs is so low, that our CPMs would not be able to practice in ANY other first world county. 

4)      This bill proposes to have CNMs and CPMs call themselves “licensed midwives”, but does not render all other “midwives” illegal.  It does nothing to address consumer confusion about what the term “midwife” means in terms of preparation, standards of care, competency, or recourse in the event of a bad outcome.  In fact, it adds yet another term to an already confounding list of terms, increasing consumer confusion and putting them at greater risk.  Instead, only licensed midwives should be allowed to call themselves “midwives” in our state and all be held to a strict standard for education, standards for practice, and transparency.

5)      House Bill 5070 also proposes to establish a new board within LARA (Licensing & Regulatory Affairs), one made of only midwives and one citizen.  This is wildly inappropriate and will further add to the deeply rooted problems surrounding lacking oversight, disciplinary action, and review from third parties.  ALL other states that have adopted regulations for midwives have created a BALANCED board, including midwives, obstetricians, pediatricians, and nurses…all who have a vested interest in birth and the well being of babies no matter where they are being born. 

6)      This bill specifically states that the state licensing board would have NO authority in making rules to oversee the practice of midwifery, that instead it would be determined by NARM.  The only “regulations” or rules proposed in this bill come from NARM (North American Registry of Midwives, founded by MANA and Ina May Gaskin) as their source.  This is deplorable and extremely dangerous as NARM is a very politically biased and reckless group that works to protect their own.  They have NO viable system for accountability and absolutely should NOT be the source for any laws regarding midwives.  Instead, the BALANCED board should be responsible for collectively making decisions about educational standards, accredited programs of study, licensing, insurance, safety protocols for out of hospital birth, standards for transfer of care, a mechanism for oversight, and mandatory practices for reporting outcomes to evaluate safety/efficiency.   

7)      CPMs want to obtain licensure so they can seek reimbursement from insurance companies, yet they don’t want to carry any liability insurance themselves.  There is nothing in this bill that addresses the need for midwives, like all other health care professionals to carry malpractice insurance.  Having insurance would instantly implement a standard for education & licensing, guide practice more safely, and help families who end up paying enormous medical bills due to negligent circumstances.  It would also prevent midwives with a repeated history of negligence, injury, or death from continuing to practice if insurance was required.  This is a critical piece in improving the safety for out of hospital birth. 

8)      This bill has been publicly denounced by ACNM (American College of Nurse Midwives) because, “it does more to protect midwives that the people they are intending to serve.” 

9)      There is nothing in this bill that defines “birth center”.  There are NO guidelines nor is there any oversight for those who open a birth center in the state of MI.  In fact, I could open one tomorrow in my garage and call myself a midwife and it would be perfectly legal in our state.

10)  This bill is written by, supported by, and funded by lay midwives and CPMs in our state.  The sponsor of this bill, Ed McBroom is having his fourth baby with a lay midwife this summer.  Your legislators NEED to hear from you about why this bill is so dangerous.