- WHAT IS A CERTIFIED NURSE MIDWIFE (CNM), AND WHAT DO THEY DO?
- DO I HAVE TO HAVE NATURAL CHILDBIRTH IF I USE A MIDWIFE?
- WHY WOULD YOU RECOMMEND I HAVE A DOULA IF I AM ALREADY USING A MIDWIFE?
- ARE MIDWIVES SAFE?
- WHAT ARE THE OUTCOME STATISTICS FOR WOMEN USING MIDWIVES?
- HOW DO CESAREAN SECTION RATES DIFFER BETWEEN WOMEN USING DOCTORS VERSUS MIDWIVES WITH SAME RISK STATUS?
- WHAT HAPPENS IF MY BIRTH DOESN’T GO ACCORDING TO MY PLAN, SOMETHING GOES WONG, EITHER DURING PREGNANCY OR DURING THE BIRTH, OR I NEED TO HAVE A CESAREAN SECTION?
A Certified Nurse Midwife (CNM) is a Registered Nurse who has pursued advanced education to become an Advanced Practice Nurse who has specialized Master's degree level education and training in Midwifery, has passed a national certification exam administered by the American College of Nurse Midwives (ACNM), and is licensed to practice Midwifery by the state in which they practice (CNMs are licensed by the Board of Medical Examiners in the State of New Jersey). CNMs function as primary healthcare providers for women and specialize in the medical care of relatively healthy, low-risk women whose births and normal gynecological care are considered uncomplicated and not "high risk." We are independently licensed to provide medical care to women from puberty through menopause, including preconceptual care, taking care of them from the very beginning of their pregnancy and throughout their entire pregnancy, during the entire labor and birth of their baby, during their postpartum period, and continuing into their yearly well-woman nonsurgical gynecological care and meeting their family planning needs. We can prescribe medications and have admitting privileges at the hospital.
We focus on empowering the woman in her birth and making birth a safe and positive experience for her and her family. Midwives also incorporate a holistic approach to the pregnancy and birthing experience by integrating psychological, emotional, and alternative approaches that may impact progression in labor in addition to the standardized obstetrical care protocols. Midwives have time during prenatal visits to address the woman's concerns, educating her about her pregnancy and preparing her for childbirth. We focus on and discuss educational needs such as nutrition, exercise, self-care, childbirth preparation, optimal fetal positioning, and preparation for breastfeeding. We can answer questions about tests and procedures and can spend time addressing some of the psychological and emotional aspects of being pregnant and preparing for birth. We can help you to develop a birth plan and explain the birth process and ways to support you and your partner during that process.
Midwives are undisputed experts in normal pregnancy and birth and at helping women who are trying to have an unmedicated, natural childbirth. Midwives are typically present with the birthing woman throughout the duration of her active labor, in addition to performing the delivery and postpartum care. Midwives are very good at supporting and helping the normal processes of labor and birth with minimal intervention, unless such intervention is clearly indicated. We do not just “tolerate” natural childbirth; we actively promote, support and maintain birth as a normal, natural, physiological process. We help integrate the supportive family members and/or doulas into the support given. We encourage freedom of movement and walking during labor, unless it is contraindicated. We encourage alternative laboring and birthing positions to help promote optimal fetal positioning and descent of the baby with the use of birthing balls and birthing stools, and special safe midwifery maneuvers. We often encourage the use of water in the bathtub or shower to help with coping and comfort during labor. Midwives utilize massage, visualizations and aromatherapy to help promote relaxation during labor. Because we are present during your whole labor, we can diagnose and correct a malpositioned baby, and therefore help redirect a birth back towards a normal process, more likely resulting in a vaginal birth, instead of having the labor not progress and therefore needing to resort to a Cesarean Section to birth the baby (malpositioned babies account for many of the unnecessary Cesarean Sections that are performed nationally due to "failure to progress").
We have excellent medical training in childbirth procedures and are trained to handle complications if they arise. In addition to supporting the patient’s choices for her pregnancy and birth as long as it is safe for mother and baby, a midwife may need to use medical technology to assure a safe outcome for mother and baby. We are able to continue to manage a labor if medical intervention becomes necessary for the safety of either the baby or mother, including administering medications as needed, induction or augmentation of labor, continuous fetal monitoring if indicated, and delivering a woman if she either chooses or needs to have an epidural. Midwives are trained to help keep a woman’s perineal tissues as intact as possible during birth, although they can perform and repair episiotomies if they are medically necessary (rarely), as well as repair spontaneous lacerations that may occur during birth.
The midwife is expertly trained to recognize the signs of problems during pregnancy, labor, birth, and postpartum, and will consult the physician if necessary. If a Cesarean section becomes necessary, an obstetrician with whom we have consulted will perform the surgery. In the postpartum period, the midwife will stay and assist your initial breastfeeding and bonding experience with your baby, and get you acquainted with what to expect in the immediate post-partum period.
Some people think that if they use a midwife, they cannot use pain medication or epidurals. This is not true for me. It is not my decision what you will want to use. It is my job to help you explore your pain relief options, give you an informed review of the risks and benefits associated with your options, and to keep you and your baby safe. Midwives are trained to and should support the birth experience you want to have, even if you had planned on natural childbirth but choose to use pain medication later on, or plan on using an epidural from the start. Quite often, with the extensive, multidisciplinary prenatal preparation that we do, the women who birth with midwives (and doulas) tend to need or use less pain medication, but that is not always the case. The midwife can provide medications and order epidurals for pain if the patient desires or needs it.
If you are planning a non-medicated birth, I strongly encourage you to consider hiring a doula in addition to using a midwife to assist you during labor.
The roles of a midwife and a doula are distinct. Although the midwife offers many supportive therapies during labor and may incorporate many doula–type care therapies into her practice, her primary responsibility is to manage the labor and birth to continually ensure safety of mother and baby, and to be responsible for the entire labor and delivery process. This may necessitate her not being physically at the bedside in a continuous way even though she is working on your care, or making objective decisions that draw her attention temporarily out of the subjective supportive role. The midwife may have more than one patient in labor at a time, or may need to rest if the labor is long so as to be appropriately alert during the actual birth. Having a doula will be able to ensure that the laboring woman has the continuous one-on-one support she needs by someone whose only role it is to comfort and assist with coping with labor without interruptions. Using a doula has been documented by several good quality research studies to decrease Cesarean section rates, decrease the use of pain medications and epidurals, and help to increase the birthing mother's experience of birth as a positive one and achieve healthier birth outcomes. Partners are welcome and necessary as well, but they are usually not experts in childbirth, have a repertoire of comforting measures to draw upon from years of experience working with laboring women, and are themselves birthing parents, with all the emotions that accompany that process. We need the partners to do what they do best: be there in their loving and supporting role to the birthing mother of their baby!
YES! In fact, the Cochrane Library (which is a database of reviews and analysis of medical research, and is a key resource in determining evidence-based medicine) emphasizes the benefits of midwife-led care and supports the conclusion of a recent US Midwifery Care Study conducted by the American College of Nurse-Midwives that Says “All Evidence Points to Midwives as Excellent Maternity Care Providers for Moms, Their Babies.”
Studies have shown that birth outcomes for low-risk women are better for certified nurse midwife compared to physician-attended births in terms of the safety and health of the baby and the mother. Because of the way midwives attend women in pregnancy and labor, the women they care for tend to adopt healthier lifestyle habits that optimize the health of the mother and fetus. The birthing women are more prepared for childbirth, have less fear associated with giving birth, have lower rates of inductions of labor, have lower rates of unnecessary medical interventions that can cascade into a higher risk birth, have lower rates of small for gestational age babies, have less need for anesthesia and analgesia, have lower chances of undiagnosed fetal malpositions during labor, and generally have lower rates of cesarean sections.
Midwifery care of low-risk women improves the infant mortality rate in hospitals and birth centers compared to physicians caring for women of equally low risk: this is the conclusion stated in “Midwifery: Evidence-Based Practice: A Summary of Research on Midwifery Practice in the United States.” published by the American College of Nurse Midwives (ACNM), the professional organization of midwifery, April, 2012.
Decades of research and systematic reviews of scientific studies continually indicate that women cared for by CNMs compared to women of the same risk status cared for by physicians had
- Lower rates of cesarean birth,
- A significantly higher chance for a normal vaginal birth,
- Fewer technological and invasive interventions,
- Lower rates of labor induction and augmentation,
- Significant reduction in the incidence of third and fourth degree perineal tears,
- Lower use of regional anesthesia,
- Higher rates of successful initiation of breastfeeding and continued breastfeeding,
- Care during labor provided by a midwife that the woman knew,
- Increased sense of control during the labor and birth experience,
- Prenatal education focusing on health promotion risk reduction behaviors,
- A more hands on approach with a closer supportive relationship with their provider during labor and birth.
Midwifery care results in fewer cesarean births than physician care for equally low-risk women, and Midwifery Cesarean section rates are consistently lower than the national average for similar risk women:
Between 1970 and 2009, the cesarean rate in the United States increased dramatically from 5% to 33%.
Today, nationally, with the majority of births in the US being performed by physicians, the Cesarean Section rate is approximately 30%,(with some hospitals as high as 50%!), which means approximately one in three women nationally gives birth by Cesarean Section! However, to date, no published research demonstrates any improvement or benefit to either mothers or babies as a result of this increased C/S rate. In fact, both mother and baby become subject to the potential problems and risks stated below as a result of this major surgery.
The 2012 American College of Nurse Midwives statistics for New Jersey reveal:
- A primary C/S rate of only 9% for births attended by midwives.
- A total C/S rate of 13%, (combination of primary C/S’s with repeat C/S’s),
The World Health Organization states that the optimal Cesarean section rate for an average risk population should be between 10% -15%.
In specific cases a Cesarean Section can be life-saving for the baby, the mother, or both, and is therefore the safest way for a particular birth to proceed when the benefits of a surgical delivery outweigh the risks of this major surgery. There are, however, significant increases in maternal and infant morbidity and mortality associated with this surgery including:
- 3-4 times rate of maternal death
- 2-4 times the rate of amniotic fluid embolism
- Placental abnormalities in future pregnancies including placenta previa and placenta accreta (requiring post birth hysterectomy)
- 4 times the rate of infant respiratory morbidity and neonatal ICU admissions
- Post-operative deep vein thrombosis and pulmonary embolus
- Increased rate of stillbirth or emergency repeat Cesareans of subsequent pregnancies due to uterine rupture
WHAT HAPPENS IF MY BIRTH DOESN’T GO ACCORDING TO MY PLAN, SOMETHING GOES WRONG, EITHER DURING PREGNANCY OR DURING THE BIRTH, OR I NEED TO HAVE A CESAREAN SECTION?
Nurse-midwifery practice is the independent management of low risk women’s health care during pregnancy, birth, postpartum, within a health care system that provides for consultation, collaborative management, or referral as indicated by the health status of the patient. This involves assessment and detection of complications. During my care I continually and vigilantly monitor the birthing process to ensure safety. Despite all the ways in which we midwives help women to try to birth normally, the reality is that some women may need various levels of medical intervention in order to achieve a safe birthing outcome for their babies and themselves. Usually “Natural facilitates Safety, but Safety always trumps Natural.” Therefore it is possible that the best intentioned birth plans might need to be altered to keep everyone healthy and safe. Sometimes that means the use of pharmaceutical agents, the use of an epidural even if one had not been intended to be used, more continuous fetal monitoring than originally envisioned, an augmentation or an induction of a labor, or perhaps a vaginal surgical birth (vacuum or forceps) or a Cesarean Section.
Therefore, CNMs always work in collaboration with an OB/GYN should complications develop outside the scope of midwifery care. I have a collaborative agreement with a very midwifery-supportive physician, Dr. Charles Haddad and his OBGYN associates. I inform my backup physician of each patient admission, and alert him/her to potential predisposing risk factors already present or those that may develop during the labor. I also have access to the excellent Maternal Fetal Medicine specialists at Hackensack UMC at Pascack Valley who are always available to me for consultation, collaboration, or referral if you have risk factors during your pregnancy, develop conditions that may complicate your prenatal care or birth, or require a planned Cesarean Section. If problems develop during the prenatal period or birth outside the scope of midwifery care, I will, without hesitation, consult, collaborate or refer, as needed, with these excellent physicians.
There also is a level 2 Neonatal Intensive Care Unit at Hackensack UMC at Pascack Valley should issues arise with the baby after birth.
I am able to attend women with a history of prior Cesarean Sections who would like to birth as naturally as possible and have a VBAC (Vaginal Birth After Cesarean). My back-up physician, Dr. Haddad, is very supportive of VBAC birthing.
A benefit of being in the hospital in which your midwife works means that there is no need for transfer to a different facility if complications or the need for medical interventions develop, and I can continue to care for you seamlessly. Most complications declare themselves over a period of time, for which predisposing factors are usually present, while things are still safe, and for which my covering physician would already be aware. Even if your birth does become higher risk and involve various levels of medical intervention, I am always present to preserve and protect those components of your birthing care that remains normal. If your labor becomes more “medical” by necessity, I continue to care for you collaboratively with the physician, and usually can deliver the baby unless it requires a surgical birth. In the unlikely event that an unforeseen emergency would occur suddenly without predisposing factors, in addition to my personal back up physician covering for me being immediately available, there is always a ”house” OB/GYN physically present at the hospital at all times for true emergencies, which are rare.
If your birth deviates from your originally intended birth plan and becomes more “medical,” these deviations are not in any way regarded as “failures.” In fact, they are the components of the birth experience you had to have to have a healthy outcome. You have birthed your baby, albeit in a different fashion than originally intended. Your emotional reactions may be complicated, raw, and perhaps include various levels of disappointment, sadness, or grief. These feelings are not to be minimized, however, as we help you navigate through these unexpected scenarios, we like to help you reframe and celebrate your birth as a BIRTH of your baby and the brave and courageous choices you have made to keep your baby healthy.
If the birth is to be a Cesarean, I would accompany you and your partner into the operating room, continue to advocate for you to bond and touch and be with your baby as much as is clinically safe and appropriate during the surgery, and accompany you through your recovery period to preserve the parts of your birth that can still be normal, like breastfeeding and bonding and taking care of your baby.
I, as your midwife, would continue my care for you through the birth, the in-hospital post-partum period, and through the six week post-partum period that follows, as I would for any birth.
The care that I give is holistic and goes beyond the physical attributes of the birthing process. As a Cesarean and VBAC (Vaginal Birth After Cesarean) mom myself (see tab on “About Donna”), I can personally emphasize as well as sympathize with some of the journeys my Cesarean moms’ hearts and minds may take after a birth that was not the birth envisioned or planned or the outcome that was hoped for. I will midwife you through this postpartum journey in an individualistic way, and I will see to it that you have access to all resources that you may need to be helpful in your recovery.