The Midwifery Perspective of Normal Childbirth: part 3

by faithgibson on March 3, 2013

in Info ~ Medical Board Members, Mfry Student Issues, Physician Supervision Issues

Link back to part 2: How to tell the difference between midwifery care & the idea of ‘performing a delivery’ ~ background & context: part 2

The customary care of a midwife begins by providing prenatal care over the many months of pregnancy and developing a personal relationship with the mother-to-be. During the intrapartum (labor, birth of the baby, postpartum & neonatal period) the midwife’s supportive role is that of guardian, guide and “educated observer with emergency response capacity”, which is consistent with the role of a lifeguard.

The seamless progression of official duties by the midwife during the three stage of labor includes on-going monitoring of maternal-fetal-neonatal wellbeing and many other specific tasks. These duties are NOT perceived by either the midwife or the family as a series of separate services that in the medical model* would be called “billable units” and result in a series of separate charges. [*see March 4, 2013 TIME Magazine’s article by Steven Brill titled “Bitter Pill”]

In the midwifery model, all the services provided during the intrapartum period are simply part of a basic professional fee for midwife’s childbirth-related assistance. This global reimbursement covers the midwife’s prenatal care, the entire intrapartum irrespective of its length or complexity (including hospital transfers), follow-up house calls after the birth, and on-going care of  both mother and new baby during the following six weeks.

For the midwife, the intrapartum is an eventful period of time with a set of activities engaged in by both midwife and mother-to-be. The midwife’s responsibilities include supporting and managing the entire spectrum of active labor and perineal phase, which is technically last part of 2nd stage, during the few minutes just before the baby is born. This phase of labor culminates spontaneously when mother gives that last big push and voila! — the baby comes out.

It should be noted that it is the mother (not the midwife) who labors and gives birth, and gets to personally take the credit for all that hard work. This is why the mother (and not the midwife) gets to keep the fruit of her hard labor — her lovely new baby!

For the midwife, this last push by the mother and the spontaneous arrival of the baby is is just one of many biological events that have or will occur during the intrapartum period. It is very clear to midwives that normal childbirth is not the result of any special medical skills or surgical techniques used by us.

As soon as the baby makes his or her appearance, the midwife’s attention turns to the newborn and her responsibility to make sure the neonate takes its first breath and subsequently establishes regular respiration with stable cardiac-pulmonary function (pink and pretty!).

After placing this new bundle of joy in its mother’s arms, the midwife’s caregiver duties continue on as the normal biological process rolls seamlessly into the third stage. This is the 6 to 20 minutes between the birth of baby and when the mother spontaneously expels the placenta. After the placenta is out, the midwife must check the mother for excessive bleeding, and the placenta for its completeness.

Anytime during any of these stages that labor is not progressing as expected, or if other medical issues arise for mother or newborn, the midwife will initiated a timely hospital transfer.

This is to emphasis again that midwives do not ‘perform deliveries’. Under the California Licensed Midwifery Practice Act of 1993, it is an illegal practice of medicine for professional midwives to provide any type of care that requires the use of ‘artificial, forcible or mechanical means’ — no Pitocin during 1st stage to speed up labor and no use of forceps or vacuum extraction during second stage to ‘deliver’ the baby. Midwives do not ‘deliver’ babies — mother push, midwives catch, that is how midwifery works.

The good news is that over 80% of women in the care of California licensed midwives do not require  anything that falls in the category of “artificial, forcible or mechanical” help. This means they have a normal labor and continue under midwifery care after a spontaneous birth. For their midwife, her duties do not end simply because the baby is born and the placenta has come, as she is directly responsible for both mother and baby until both are in a stable and satisfactory condition or unless medical assistance has been arranged.

To personally assess the on-going physical well-being of the new mother and baby during the first hour after the birth, the primary midwife, second-call midwife and whoever is assisting (mfry student or other helpers) generally remain in the room.

These professional midwives and mfry assistants are able to directly watch, assess wellbeing and meet the evident needs of mom and neonate. This includes monitoring vital signs of both, providing warm dry blankets for the new baby as needed, encouraging the new mother to drink fluids, and helping the baby to latch on to its mother’s breast for the first time.

During the second hour after the birth, more attention is paid to establishing breastfeeding and explaining how to manage the baby’s nursing. Later on the mother will be helped to the bathroom to shower and use the toilet. While she is in the bathroom, the midwife or one of the assistants will put fresh linens on the mother’s bed.

Next on the primary midwife’s duty roster is to do a complete (systems specific) physical exam on the newborn. This includes making a separate chart for the baby, and then gathering statistics on its head and body measurements, weight, length, vital signs, and Ballard gestational-age assessment.

The midwife records all the neonate’s statistics, plus gender, parents names, Apgar scores and health status at and since the birth on the baby’s chart. A copy of this will be provided to the parents to give to the family doctor or pediatrician so he or she will have information about the birth, physical exam and other pertinent findings.

The next set of tasks is to prepare the family to take over the responsibility for the care of both new mother and new baby. The primary or second-call midwife spends considerable time describing normal newborn behavior and giving instructing to the parents on when to call the midwife relative to minor problems, and how to tell if emergent medical care becomes necessary for either mother or baby (i.e. calling 911).

Then the parents need additional information and tips on how to manage breastfeeding, monitor maternal bleeding, tracking the number and nature of changed diapers, what to do about breast engorgement, etc. “Best practices” also includes providing the parents with a chance to ask questions and get additional information about issues not covered or not understood.

The final arrangement before the mfry team packs up and head home is scheduling return house calls at 1 1/2 and 3 1/3 days, as well as information about arranging for newborn genetic testing, and directions for filling out the preliminary paperwork to register their baby’s birth.

This model of midwifery care includes the full-time presence of the primary midwife during all stages of active labor, and arranging for a second-call midwife to be present for the last 1-2 hours of second stage labor/perineal phase and the first 1 or 2 hours hours after the birth. Under California regulations, the standard of care for licensed midwives requires that at least one midwife remain with the new parents for a minimum of two hours after the birth, longer if necessary. Typically the midwives and assistants are present and helping the new family for 3 to 5 hours postpartum.

During this time the primary midwife is often responsible for the clinical training of a midwifery student enrolled in a program recognized by the MBC. While students do in the course of their clinical training ‘assist’ the midwife and the mother-baby, students are not primarily present at births as an assistant to the midwife.

Responsibilities of the primary midwives to students of midwifery and non-creditionaled helpers

The primary responsible of the midwife is to teach clinical judgement and clinical (hands-on) technical skills to her students. The primary goal of the student is to learn clinical skills and clinical judgement at a level consistent with her training, a joint decision by student and midwife that accounts for the needs and safety of the family as well as the stage of training for the student.

In other instances, the primary midwife may call on members of the family (ex., laboring woman’s mom), a professional labor attendant (or doula), or another lay person to provide some kind of non-medical help or do something for the mother-to-be, such as getting food or helping her to the bathroom. While these non-credentialed assistents are helpful to the midwife and the mother, they are never asked to provide clinical care such as a vaginal exam or managing maternal bleeding, or to perform a procedure such as suturing a perineal laceration.

However, when the midwife is gloved or otherwise physically unable to do something in a timely fashion, these non-medical helpers may occasionally be asked to hold the fetal heart doppler probe to the mother’s abdomen so the midwife can listen to the unborn baby’s heart rate and rhythm. They many also be asked to hold a light or open a sterile package while the midwife reaches in with a gloved hand to retrive an syringe, instrument or packet of suture.

To put this in perspective, one must remember that the legal issue in this instance is not the mechanics of gathering data (such as using an electronic blood-pressure cuff with a digital readout), but the clinical judgement for what action/non-action is appropriate based on that information. The clinical role and responsibility of the primary midwife lies in what she does with the information. Ultimately the midwife is the person responsible for making the correct clinical determination.

A licensed midwife’s professional responsibility also includes not asking those present to perform any careprovider acts or engage in clinical treatments or procedures that they are not trained for (i.e. students) or that would constitute an illegal practice of medicine (i.e, lay assistants).

Conclusion:

Midwives don’t perform deliveries as a medical-surgical activity. Those who assist the midwife and the mother during the intrapartum are not ‘assisting the midwife during a delivery’, but are instead helping the midwife to provide the physiologic care that is associated with labor, spontaneous birth and on-going care of the new mother and new baby.

After noting the extensive length of time and the sheer number of professional responsibilities and normal caregiver acts required over the course of a typical intrapartum (4 to 10 hours), it is obviously a labor-intensive activity for the midwives and her assistants and keeps all those present very busy. However, this never requires non-credentialed helpers to do anything that would be considered an unauthorized or illegal practice of medicine.

I hope this addresses the questions about ‘delivery’ vs. assisting during a normal birth. But let me leave you with this definition, which at least expresses our experience as midwives:

Birth is something the mother does, while being born is what happens to the baby.

The only ‘delivery’ associated with a midwife-attended normal birth and her mfry students or lay-helpers is when the pizza guy delivers a double cheese and pepporoni pie after it is all over.

Good bless the delivery guy, ’cause by that time we are all ravenous!

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