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Midwifery in America

Midwifery in America

I’ve gotten a lot of questions the last few months from fellow students and other midwives here in the UK about exactly what midwifery is like in America. There is a fair bit of confusion about the roles. Some people I’ve encountered think that midwives in the US don’t do any actual baby catching, but they’re confusing the role of US Labor & Delivery nurse with that of the US midwife.  It IS confusing because in the UK, L&D nurses don’t exist. Instead, the UK midwife does both the US L&D nurse’s job AND the US midwife’s job.  I also think the role of the midwife and scope of practice varies a great deal between the US and UK as well, and midwifery in general in the US is so confusing because there are two different standards of midwifery care there (CNM v. CPM). So in conclusion, a post to explain US midwifery and the differences I’ve noticed so far between the US and UK seems like a good idea!

First, here in the UK, a midwifery degree is an entry-level degree (i.e. a Bachelors degree) and the majority of midwives are direct-entry midwives (meaning that their degree is in Midwifery, without first having to obtain a nursing degree before becoming a midwife). Granted, there are some people here who come to midwifery after having obtained a nursing degree first (and there is a handy 18-month program which allows them to become midwives fairly easily), in which case they are both a nurse and a midwife after they qualify (and will have a Bachelors in Nursing and a Bachelors in Midwifery). Crucially, though, the practice of nursing and midwifery are separate fields of study here, and separate qualifications (although there is a lot of overlap in the subject matter, such as basic health skills). The labour wards here in the UK are staffed by midwives (and if there are staff members who are both midwives and nurses working there, they would be working on labour ward in their midwifery role and not in their nursing role). Labour & Delivery nurses do not exist in the UK (although there might be a few specialist nurses who do work on the labour ward occasionally in a nursing capacity) and the majority of the work done on the ward is done by midwives. After completing her midwifery education here, a midwife qualifies and joins the register through the Nurse and Midwifery Council (NMC) and has the title of Royal Midwife (RM). There is ONE standard for midwifery care here, which is defined, set and monitored by the NMC, and there is only one main professional organisation which supports midwives in this country (the Royal College of Midwives) versus two in the US (see below).

In contrast, in the US there are two different routes to midwifery, and three legally recognized titles that you can practice under as a midwife: Certified Nurse-Midwife (CNM), Certified Midwife (CM) and Certified Professional Midwife (CPM). Instead of one national accrediting body for midwifery educational programs, there are two: the American College of Nurse Midwives (ACNM) and the Midwifery Education and Accreditation Council (MEAC). Instead of one national board exam, there are two different exams administered by two different organizations: the American Midwifery Certification Board (AMCB), which administers the board exam to qualify as a CNM/CM, and the North American Registry of Midwives (NARM), which administers the board exam to qualify as a CPM. The acronyms alone are enough to make your head spin!

The ACNM (American College of Nurse Midwives) is the professional organization of Certified Nurse Midwives (CNMs) and Certified Midwives (CMs). Nearly all of the members of the ACNM have a Bachelors level nursing degree first, then go on to obtain an advanced degree in midwifery (usually a Masters degree), and are then credentialed through the ACNM. A very small subset of this group are “direct-entry” midwives, meaning that they don’t have any prior nursing education before beginning their midwifery training, although they do have a Bachelors already, usually in a related field like public health or sociology or biology or chemistry; a direct-entry student goes through the exact same program as her nursing compatriots, and when she graduates she takes the exact same board exam, and is credentialed as a CM, rather than CNM (both CNMs/CMs are credentialed through the American Midwifery Certification Board (AMCB)).  In this pathway, midwifery education is a Masters level degree, and when they graduate, a CNM/ CM is a a mid-level provider. They work autonomously are able to practice in all 50 states, prescribe medications in many of them, and are able to work independently as autonomous providers (although in some States they have to have a written practice agreement with a doctor in place in order to be able to practice legally).

In contrast, Certified Professional Midwives (CPMs) obtain certificates through midwifery-education programs which are accredited by the Midwifery Education and Accreditation Council (MEAC), and when they graduate, they are credentialed through the North American Registry of Midwives (NARM) and become CPMs. Like CMs, CPMs are direct-entry students, with no prior nursing education or experience. And because CPMs are not nurses, nor are they credentialed through the ACNM, they aren’t allowed to join the ACNM. The professional organization which represents the interests of CPMs is the Midwives Alliance of North America (MANA), which seeks to represent the interest of every type of midwife in North America, including CNMs/CMs (even though their interests are already being represented by the ACNM). While some midwives (well, CNMs/CMs) belong to both organizations, I think the majority of midwives tend to pick one or the other, if they even join at all (and just think how much further the profession as a whole could get if every midwife in the country actually joined their professional organization and paid dues, which could then be applied to projects and lobbying which actually benefits midwives and our profession. Sadly, of course, membership is never even close to 100%, which is really disheartening. Membership in the American Medical Association is much higher—I have never known a US doctor who was not also a member—and just look at what a powerful and influential organization the AMA is—i.e., look what happens when a professional organization actually has money! Ahem.)

Are you confused yet?

Now, there are so many problems with this I don’t even know where to start. Someone looking in from the outside could very sensibly say: well, don’t you think you’d have more power and more political clout and be better understood by the public and by other professions if all of you midwives just got together and decided on ONE standard definition, ONE standard credential and ONE professional organization to represent you? And of course, the answer to that would be a resounding YES! In countries around the world where midwifery has a very strong professional presence, and where midwives are not only highly respected but also deliver the majority of the babies in that country, invariably you will find that there is one unified professional organization for all of the midwives of that country, one standardized educational track and one credential. Here in the UK when you say “I’m a midwife”, no one needs to ask if you’re a nurse-midwife or a direct-entry midwife or if you have a Masters Degree or a Certificate. The profession of midwifery has one standardized definition of what midwifery entails, one credential, one professional organization and one standardized scope of practice. I’m sure this must really simplify things, and allow the profession of midwifery to move beyond issues of sorting out its own mess and instead tackle larger goals and issues and missions which are important to the entire profession, as a whole.

In America, because of all of the different credentials and the differing legal status of midwives from state to state, we’ve got an enormous range in our scope of practice. CNMs can legally practice in all 50 states. CMs are legally licensed in 5 states at the moment, and CPMs are legal in 33 states. CPMs most often work in birth centers or homes, while CNMs/CMs can work in hospitals, birthing centers and homes. Depending on what state you live in, a CNM/CM may or may not be able to prescribe drugs, or admit private patients to a hospital. In some states, CNMs/CMs are required to work with a collaborating physician in order to practice legally, in others they can practice autonomously (is this also true for CPMs? To be honest, I’m not sure. Any CPMs who are reading this, please let me know!). The scope of practice for CNMs/CMs can range from primary care to family planning to birth control to hormone replacement to basic gynaecology. To be honest, I’m not sure if CPMs can do all of this as well (CPMs who are reading this, can you? Or is that a state by state thing, too?). In other words, it’s a hodge-podge mess. And maybe that’s just the nature of the game, given that America is a conglomerate of states, and because each state wields so much independent power, laws vary considerably from state to state.

One of the biggest differences I’ve noticed, though, is the difference in power and influence that the profession holds in each country. Prior to the turn of the 19th century in America, there were thousands of traditional, apprentice-taught midwives practicing in America, and most births were still attended at home by midwives as they always had been. “Native American midwives continued to attend women in their tribal groups, as did colonial midwives among the white settlers, Hispanic midwives in their southwestern communities, immigrant midwives accompanying their ethnic groups, and black granny midwives in the American South” (Davis-Floyd & Johnson, 2006). However, starting in the early 1900s, doctors began to move into the lucrative birth business in droves and launched a comprehensive smear campaign against traditional midwives, stereotyping them as dirty, ignorant, uneducated and careless. This was happening at the same time that birth was moving out of homes and into the hospitals, which were portrayed as clean, modern, hygienic, progressive and cutting-edge. In this regard, patriarchy also played a part; it made sense to accept male dominance and authority in obstetrical matters when the cultural norm already viewed men in this role, and male inventors had ushered in the modern age through new technologies such as electricity, railways, cars, telephones, etc.–chloroform in hospitals and forceps deliveries felt like the future in this context (Davis-Floyd & Johnson, 2006).  Mainstream cultural pressure and assimilation also made giving birth with private physicians fashionable and trendy, while cultural, socioeconomic and language barriers made it nearly impossible for traditional midwives of different ethnic groups to join together to collectively fight the physician’s propaganda against them. The end results was a complete decimation of midwifery as a profession in the US; in the 1800s, midwives attended the majority of all births, but by the mid-1900s, midwives attended a tiny minority of births, often illegally (Davis-Floyd & Johnson, 2006).

Nurse-midwifery in its modern incarnation first appeared in the US in the mid 1920s, after Mary Breckenridge, a public health nurse, travelled to the UK and trained there as a midwife, returning to rural Kentucky to found the Frontier Nursing Service (FNS), which brought the UK midwifery model of care to isolated and deeply impoverished Appalachian communities. This model of care was also adopted in New York City through the establishment of the Lobenstine Clinic in 1930, which began to train nurse-midwives to care for the underserved communities in Harlem, Hell’s Kitchen and the Bronx, tending to “populations in dire need that physicians were not attending [to], and did not wish to attend [to]” (Davis-Floyd & Johnson, 2006). During the World Wars, nursing had established itself as a profession and organised itself as a professional body, and America’s earliest modern midwives were able to use the legitimacy of the nursing profession to overcome the negative stereotypes surrounding midwifery; in this way, modern midwifery in the US has been associated with nursing from the very beginning, despite the fact that midwifery is its own profession, separate from nursing. The growth of nurse-midwifery was very slow through the fist half of the 20th century as nurse-midwives still had to fight against the negative stereotypes of ignorance and unprofessionalism, but little by little, gains were made. The first graduate-level midwifery education program was opened in 1956 in Yale’s Department of Nursing (again linking midwifery to nursing in the US), and the ACNM was formed in 1955 after nurse-midwives were unable to create their own niche within the newly created American Nurses Association (ANA). The post-war baby boom also opened up new opportunities for nurse-midwives as over-stretched hospitals in New York and Baltimore began to rely on them to cope with the increasing numbers of women giving birth (Davis-Floyd & Johnson, 2006). This resulted in nurse-midwives moving into hospital-based practices in greater numbers, which decreased their autonomy but increased their knowledge base and ability to deliver care to a larger number of women. However, nurse-midwives’ adaptation to hospitals and adoption of hospital norms was so complete that by 1973 the ACNM actually issued a Statement on Home Birth which declared that giving birth in a hospital was the preferred location due to increased safety (in 1980, ACNM retracted it’s original statement on homebirth and instead endorsed nurse-midwifery practice in all settings, but to this day, the majority of CNMs still practice in hospitals) (Davis-Floyd & Johnson, 2006). The ACNM continued to develop a national certification process and education programs, and by the end of the 1970s there were 19 nurse-midwifery education programs, nurse-midwives could legally practice in 41 states, and combined they attended a little bit more than 1% of all births in the US (Davis-Floyd & Johnson, 2006).

And then along came a midwifery renaissance in the US, spear-headed by one of the world’s most famous midwives, Ina May Gaskin. This renaissance was fueled by the turbulent cultural changes occurring in the 1960s and 1970s through the counterculture and feminist movements, as well as in response to the rampant over-medicalization of birth. Hospital birth from the 1930s – 1960s was increasingly restrictive and technocratic, with women disempowered recipients of authoritarian care, where the doctor was the “expert” and the woman was the”patient”, combined with restrictive practices like routine pubic hair shaving and enemas, routine episiotomies, routine use of forceps and common use of twilight sleep, which was a combination of morphine and scopolamine, a psychedelic amnesiac designed to take away the memory of the birth–which it did in spades, but it also transformed women into wild animals during the delivery (Davis-Floyd, 2003). Women receiving twilight sleep were often out of their minds and hallucinatory, strapped down to beds, left alone to scream, or put in padded rooms, only to wake up afterwards with a baby in their arms and no true memory of the birth experience except for scary flashbacks and nightmares which would haunt them for the rest of their lives (the TV series Mad Men did an excellent job of portraying this in Season 3 when Betty Draper gives birth to their third child). In the 1970s, giving birth became a feminist issue, with women clamoring to reclaim birth and humanise and personalise the birth process (NEWSFLASH–respecting basic human rights during birth is STILL an issue we’re battling today!) and midwifery care became a hallmark of this movement away from a disempowered, technocratic birth experience towards a more natural, woman-centered birth experience (Davis-Floyd, 2003). In the hospitals, the use of twilight sleep died out, routine shaves and enemas were no longer performed, and nurse-midwives in the 1970s and ’80s worked to include partners at births and to begin to remove barriers to natural childbirth like routine lithotomy position, routine forceps and episiotomy, and sterile drapes separating moms and babies, as well as promoting unmedicated birth and breastfeeding (Davis-Floyd & Johnson, 2006). But there was also an increase in the popularity of home births during this time, and more women became interested in providing and receiving midwifery care outside of the hospital paradigm, which increased the number of grassroots direct-entry midwives practicing in the country. These direct entry midwives (also called “lay midwives”), like Ina May Gaskin, Raven Lang and Anne Frye, were apprentice-trained and not formally educated like nurse-midwives, and by the end of the 1970s were also attending approximately 1% of all US births.

At first, these small clusters of lay midwives were unaware of each other, but because of growing interest in their counterculture message, the publication of books like Spiritual Midwifery and The Birth Book, and the media attention this brought, lay midwives began to band together and organise themselves. According to Robbie Davis-Floyd’s (2006) anthropological documentation of midwifery in the United States, there was probably a period of time when direct-entry lay midwives could have been folded into the ACNM, if the ACNM had been willing to drop the nursing requirement from its educational pathway and addressed some of the philosophical concerns of the lay midwives. But instead the ACNM affirmed its belief  that midwifery in the US required formal education and a nursing background (the ACNM later changed its mind about the nursing requirement, and went on to develop its own direct-entry pathway for non-nurses to become midwives, hence the credential of Certified Midwives (CMs)). Therefore, since lay midwives were not welcomed into the ACNM, in 1982 they decided to form their own professional organisation, the Midwives Alliance of North America (MANA), later going on to create the credential Certified Professional Midwife (CPM). As CPMs and MANA continued to evolve, they began to develop their own knowledge base, values and philosophy of care based on their greater understanding of unmedicated birth in homes, and went on to create an educational pathway that would teach and support this knowledge base without being incorporated into the more “medicalised” hospital environment. As it stands right now, CPMs can legally practice in 33 states, and The Big Push for Midwives continues to advocate and lobby for further legalisation in the remaining states (whereas CNMs can practice in all 50 states).

Thus through the history of modern midwifery in the US, we can see why there are two midwifery organisations, two educational pathways, two accreditation programs, and three different midwifery credentials you can obtain! And unfortunately, it seems like the chances of MANA and the ACNM actually getting together and coming up with one unified plan for midwifery in the US are very slim. There have been many attempts in the past to align both groups, most notably during the Carnegie Meetings sponsored by the Carnegie Foundation in the late ’80s through the mid-’90s, and subsequent MANA/ACNM Bridge Committees continue to keep a dialogue open between the two organizations (Davis-Floyd & Johnson, 2006). However, it seems unlikely these two organisations will be joining together any time soon (and I’m sure there are many midwives who would argue that that’s a good thing). Part of the problem is that the interests of these two groups are now quite distinct and it’s hard to find common ground. Many CPMs who are trained through apprenticeship view apprenticeship as a key component of their education, and therefore MANA is unwilling to give up apprenticeship training as a viable route to midwifery, whereas the ACNM has a long history of valuing graduate-level university education and is unwilling to accept apprenticeship as an equal educational pathway. There’s also an undercurrent of disdain between some members of both groups, unfortunately. I think that *some* CNMs/CMs (certainly not all!) have a tendency to look down on CPMs as being under-educated, unacademic, tradition-based rather than evidence-based, and not very clinically well-informed, while *some* CPMs have a tendency to look down on CNMs/CMs as being too interventionist and technocratic (“medwife” v. “midwife”), too quick to view pregnancy from an medical/obstetrical lens, too eager to suck up to the American Medical Association (AMA) and/or the American Nursing Association, and having lost touch with the heart and soul of midwifery. There’s really no point in arguing which point of view is right; they’re both flawed, and so long as this continues, the profession of midwifery in America will continue to struggle. The bigger picture is that right now midwives (of whatever credential!) in the US only attend 8% of all births, while in the UK midwives attend over 50% of all births!

In the UK midwifery took a much different route. Midwives in the UK were able to organise as a profession as early as 1881, and the first legislation legalising the profession was passed in 1902 through the Midwifery Act for England and Wales. Therefore in the UK, midwifery has always been its own profession, separate from nursing, and midwives have consolidated and maintained their position as the primary caretakers for pregnant women. In fact, the power of midwifery is so strong in this country that even in high risk cases, where women are very much being cared for and managed by obstetricians, they are still collaboratively managed and still have visits with midwives as well os OBs during their pregnancy in order to preserve some pregnancy normality for them. At the hospital where I am currently doing my clinical placements, midwives manage the majority of labours (doing both the US equivalent midwifery role AND the US equivalent Labor & Delivery nurse role combined) and call the OBs in for assistance when needed, but are very much autonomous practitioners. It’s true that the scope of midwifery practice is more limited here in the UK than my scope was as a CNM in New York (and as you can see from above, my experience in New York was quite specific to that state, and by no means an similar to other states). For example, I was trained in gynaecology as well as primary care and midwifery; many of the women I saw in the clinic weren’t even pregnant, but were coming for routine gynaecology appointments, such as contraception (in NY state I could prescribe all forms of contraception, as well as insert intrauterine devices/ coils), STI screening and treatment, fibroids, or abnormal uterine bleeding; I would often order initial work-ups such PCOS lab tests or basic fertility lab tests and then refer them on to my physician colleagues for further care. I occasionally saw women who were menopausal or had issues with prolapses, and of course took care of pregnant women through their pregnancy, births and postpartum period. However, in my experience midwives enjoy a much greater degree of respect, recognition and empowerment here in the UK. There are often campaigns designed to thank and recognise the midwifery role, such as the Pampers ‘Thank You, Midwife’ campaign, and I still get such a kick out of not having to explain to people what a midwife IS when I tell them that I’m in midwifery school…here in the UK, everyone knows what a midwife is, and most people I talk to have a great deal of interest and admiration for the work midwives do.

So perhaps this helps to clarify just a little bit the ways that midwifery is different in the US versus the UK? (And of course, if I’ve misrepresented anything, or gotten anything wrong, please let me know–especially with regards to CPM legislation and scope!)

 

Davis-Floyd, R. (2003) Birth as an American Rite of Passage. London: University of California Press.

Davis-Floyd, R. and Johnson, C.B. (2006) Mainstreaming Midwives: The Politics of Change. London: Routledge, Taylor and Francis Group.

 

Student Midwife Life: The Forest for the Trees

Student Midwife Life: The Forest for the Trees

I had other plans for my #70midwifebloggers post. Something better researched. More topical. Some lovely commentary or analysis on what’s currently happening in the world of midwifery today. Oh, and did you hear that there was a royal baby born recently too?

But no. Today, managing to write a blog post, ANY blog post, in my currently-overwhelmed student midwife existence is enough. More than enough.

So what I’m going to write about is the overwhelm. I don’t really have any answers for it, but for me, writing always helps.

It’s hard to be a student midwife. Having been on both sides of the equation before, both a student and qualified midwife, I can say with confidence that once you qualify, it’s easy to forget just how hard it is to be a student. There is a sort of misty, rose-tinted glass effect that happens once you qualify where you start to look back on your student existence fondly–you may even start to think that you had it easier as a student. I think that’s because once you qualify, the sudden weight of responsibility that sits so firmly on your newly-qualified shoulders feels so stressful that it’s only natural to want to return to your more familiar student existence before you had so much responsibility, and to therefore view your student existence as the easier of the two.

But being a student again, currently, reminds me of just how difficult student life is. Learning is hard. Becoming something new is hard. Being in a nascent, in-between place is always challenging–no longer a layperson, but not yet confident in your role and knowledge as a clinician, not yet fully-formed in your opinions or identity, not yet having acquired all of the skills and experiences you need to be competent. Uncertain in so many situations. Wobbly and tentative, and constantly being presented with new situations and new experiences you’ve never encountered before. It’s an uncomfortable place to be.

Then, add to it this the demands of student existence. Students work 12-hour shifts, sometimes with no lunch breaks (and sometimes not even a chance to wee), just like a qualified midwife does, except that once you return home from said shift, the expectation is that you’ll be studying and researching and writing papers during your down-time, instead of vegging on the sofa and watching Netflix all day. (And trust me, after some of these shifts, vegging on a sofa is all you want to do, and is just about all that you’re fit for!). Down-time when you’re a midwife is essential for replenishing your stores. There is endless research detailing exactly how important this is, especially in caring professions where you give so much of yourself at work. If you don’t recharge your batteries, you burn out, it’s as simple as that. And as students, we need this just as much as any qualified midwife does. EXCEPT we have even less time for it.

The to-do list is intimidating. I have a massive assessment due in 10 days which I should be writing right. in. this. moment (except I’m not, I’m blogging instead, to take a break and recharge said batteries). I have physiology modules to complete that I am WAY behind on. I have case study scenarios to be writing up. I have a presentation on varicella which I should be starting to think about at this point, but I’m not because I’m still too snowed under by my more pressing assignments. Oh, and don’t even get me started about the OSCEs, yet. I am an ostrich with my head in the sand about those–la la la la la! Year Two is seriously intense! (Brief shout out to all my fellow Year Two compatriots out there–man, I feel you!) And on top of this I am currently on-call for three women whom I have case-loaded and who are due any day now (and I have heard nary a peep from them yet), so I could be called to a birth at any moment. Just like qualified midwives, students also live their lives on tenterhooks, always thinking “maybe I should nap now, in case I’m up all night”. It’s always in the back of my mind, the maybe-I’ll-have-to-drop-everything-and-GO. And if you have kids, like I do, that feeling combined with the what-in-the-world-will-I-do-for-childcare-if-I-get-called-rightnow-? feeling is pretty stressful.

And then there are the mentors. Nearly all of whom are LOVELY. But even with the nicest and most supportive mentor in the world, it’s still exhausting to have to work with and prove yourself to new mentors again and again. To have to build a rapport, not just with the woman or couple that you’re caring for, but with your mentor as well. To have to build a rapport while simultaneously being evaluated and assessed by your mentor.  And to also have to constantly adjust yourself to different people’s approaches and philosophies and styles of care, while simultaneously trying to form your own, fledgeling philosophy and style of care in the process. And sometimes the mentors forget how hard it is to be a student. Sometimes their expectations are too high. Sometimes your personalities don’t quite mesh. Sometimes they’re having a bad day. Sometimes you’re not nearly as well supported as you were hoping to be.

Finally, let’s not forget the work itself. This is demanding, all-encompassing heart work. This is physical, 12-hours-on-your-feet work: lifting, pulling, stretching, leaning, walking, running, pushing gurneys work. This is emotions so big you sometimes think you’ll burst. This is balancing a myriad of conflicting demands, coursework and motherhood and busy schedules and shifts, hospital policies which don’t align with birth plans, feathers that need to be smoothed, bad news that has to delivered with such sensitivity and care, personalities that have to be carefully navigated, emergencies that are terrifying and heart-rending, beauty so raw that it will sometimes make you cry, and sometimes sadness so raw that it feels too heavy to even hold. Mothers who need more time and support than you have to give. Resources that aren’t available, so you cobble solutions together, piece together equipment with tape (literally and figuratively), think fast on your feet, and sometimes fill needs from your own stores (which then need replenishing).

It’s daunting. And yet, every day, from this scary, in-between, uncomfortable place, students bravely get up every morning and put themselves out there again. That’s what the course requires of you: dedication, commitment, time, energy, focus, love, and putting yourself out there again and again and again. Making mistakes, and picking yourself back up, again and again and again.

It’s easy to forget why you’re doing this. It’s easy to lose sight of the forest for the trees. The big picture is vast, and you get so bogged down with the minutiae–why does preeclampsia cause proteinuria, what are the warning signs of obstetric cholestasis, how many weeks into the pregnancy before you start to measure the symphysis to fundal height, why does diabetes increase the risk of macrosomia, what are the diameters of the pelvic inlet–that you lose sight of the horizon. You find yourself wondering why you’re away from your family SO MUCH. Why you’re so tired all the time. Why you thought this was a good idea. Most of the student midwives I meet are so passionate about midwifery care, about making positive change in people’s lives, about making midwifery care better. But if the candle flame isn’t fiercely protected, it’s easy to accidentally blow it out. This is why so many students midwives leave the course, and given how desperately the NHS, and the UK, need midwives right now, we honestly can’t afford to lose a single one.

So what helps you stay the course? What helps to keep from losing sight of the goal? What ensures that your flame continues to burn brightly? I don’t have all the answers, not by a long shot. But what helps me is community. Knowing that I’m not alone. Talking with my friends and student peers who are on the course with me, who totally get it. Being part of online student groups and Facebook groups and the chaotic, messy twitterverse.  Leaning on my family and friends. Having dinner out with my friends (who I really wish I got to see more often). Laughing. Watching Game of Thrones (even when I know I should be studying). Cutting myself some slack (easier said than done!). Exercising–even (and especially) on the days when I think to myself: I’m just too busy to go for a run today (those are the days I most need to run)! Hugging my kids, kissing my partner, sucking up oxytocin whenever I can, and reading an extra bedtime story to my kids just because I want to. Cooking good food for myself (and then eating said food)!

This pin board helps me as well. It’s a silly thing, I know, but it sits over my desk and I find myself looking at it a lot while I’m studying. When I forget why I’m doing this, these pictures are a visual representation of my answer. This is why. Women and their families deserve this type of care, and it’s my privilege to be able to provide it.

So, I’ve used up an hour that I should have been using to write my essay on HIV in pregnancy. But maybe this post will help other students remember that they’re not alone either. And if that’s the case, that’s an hour well spent, and a good reason to blog.

Deskilled

Deskilled

How has it gotten to October and I have published nothing for all of September on this site?!?  The time is flying, and to be perfectly honest, I am slightly overwhelmed. Being a student is HARD. Being a mom is HARD. Being both of those together is VERY hard. And let’s not forget trying to be a good spouse, friend, sister and all the rest…there’s too much to get done every day, and not enough hours in a day. We’re currently on placement again now, working in the clinical setting, but in two weeks I have an in-class debate to research and prep for, plus a research activity due which involves critiquing a research study and then sharing it with the class. The first week in November our second 15-page(-ish) assessment is due, which I have started researching but have not yet written a single word for. We also have our Year 1 exams in December, focusing on anatomy, physiology and the role of the midwife, which I have started studying for, but again…this is not something you can do in a single cram session the night before. So, yeah, that’s the homework front. Add to that 12 hour work-days, not seeing my kids for entire days at time (because if I’m doing a day shift, I leave in the morning before they’re awake and come home once they’re asleep) and using my days off to try to desperately make it up to them with quality time…and also using my days off to try to get on top of the mound of homework. This student midwife business is definitely not for the faint of heart!

Clinical placements have been challenging for lots of reasons. The work is fabulous, and it has been such a joy to be attending births again, and particularly births in the lovely midwifery-led unit/ birth center that is part of the hospital where I’m at. But it’s been painful to realise how many of my skills I have lost during the long break I took over the last 4 years where I wasn’t working as a midwife. Things that used to come very easily to me are now things that I am grappling with again. Is that really the right position of the baby I’m feeling on abdominal palpation? Is the baby vertex or breech? Is that the baby’s back? Are those the feet and hands? Is that cervix 7 cm dilated, or 8? What is the estimated fetal weight? I used to be really good at this stuff…now I find myself in the dark with it a lot more, much like I was during my first student experience. Muscle memories that have been forgotten and need to be retrained into hands again. How to press just so on the doppler to be able to angle it upwards into just the right position to find the fetal heart. How to get the monitor straps to be able to hold the tocometer/CTG in the right place. (Annoyingly, the straps are very new to me; in the US the women wore an elastic band over their bellies and you just had to slip the monitors underneath the band and they were magically held in place, without too much fiddling involved. We did have straps, too, for occasional use, but again, they were a different design and not at all like the straps in my new trust, which I think require some fancy angling and folding and tying tricks to get them to be angled/ placed correctly, of which I have by no means mastered yet!)  And don’t even get me started on the hospital policies, the documentation, the pro formas that have to be filled out. The new computer system.  There are even things that I murmur and say during deliveries: “Good job”, “you’re doing great”, “you’ve got this” which sound so American to my ears now. My mentor more often says “well done” instead of “good job”. Tiny things like this which I wonder about, and I wonder if my American-ness is helpful in labour, or if I was speaking better British-English, would that be more reassuring? It’s all new. So in SO MANY ways I feel like a complete novice at this again.

But that’s the part that sits uncomfortably with me. I had gotten used to feeling competent after years as a midwife in the US. I knew the system, I knew how my hospital’s policies worked. I knew exactly what documents needed to be filled out, and how to document correctly.  Feeling competent had become part of my identity. Feeling incompetent again is painful. I have to keep reminding myself that I am a first year student, because I AM. There is so much I don’t know. And in fact, there is a term for what’s been happening to me. It’s called being deskilled, or deskilling: losing skills which I had had in the States and had taken for granted, and needing to re-learn these skills again from scratch. Not fun in any way whatsoever! And in some regards, there are even bad habits I had picked up which I need to un-learn as well. And completely new skills which I never had in the first place, like using a Pinard’s stethoscope or estimating how many fifth’s palpable the baby’s head is in abdominal exam. In the States we would say the baby was engaged or floating, but never had to document exactly how engaged (3/5ths engaged, 1/5th engaged etc.) the baby was.

I was painfully reminded of this awhile ago when I experienced my first true emergency as a student on labour ward. A woman had been brought in by ambulance in booming labour, and was barely into a side-room before the baby had been delivered. And then she began to seize afterwards. The emergency bell was pushed in her room, everyone ran in to help (including my mentor), and I was out on the fringes trying to be helpful but not actually able to do very much. Whatever was called for from inside the room, I was one of the task-rabbits running to get it. I put out the overhead hospital-wide emergency call to bring the larger team to the room, which I had never done before, and didn’t even know what room the patient was in without asking another midwife about it. I got a screen to cover the door for privacy. I brought a table and emergency trolley to the room.  Which is helpful, a bit, but that was about as much as I could do, and I was conscious that if this had happened in my old hospital in the States, I would have been in the room, in the thick of it, being a lot more helpful.  And it was scary. In my 6 year career in the US, I had never seen a full-blown seizure like that. I hope I never do again, any time soon.

Midwifery is a highly-skilled job. It takes years to master the skills necessary to do it well. And years of training and experience in a particular setting to know all of the ins and outs of the job. And I am just at the very start of this journey again, deskilling and re-skilling again.

Private Midwives in the NHS

Private Midwives in the NHS

The Sunday Times published an article recently about private midwives attending births at NHS hospitals: “Mothers Take Own Midwives Into NHS Hospitals”. This is definitely becoming more common, especially now that NHS trusts are inviting it to happen by contracting with companies like Neighbourhood Midwives and Private Midwives:

Ten NHS trusts have signed partnership deals allowing one private company to book rooms in their hospitals and centres for women to give birth helped by a private midwife. The mother then pays the company.

I can understand why this is happening, but I have mixed feelings about it. On the one hand, many trusts are under severe financial pressure, with midwifery shortages and hiring freezes, and literally not enough staff to care for the number of pregnant women in their trust. Creating an option for some of that responsibility of care to be taken up by private midwives helps to ease the burden on their over-stretched service. Renting out rooms and equipment to private midwifery companies also generates more money for cash-strapped trusts, so you can see the appeal. We also know, by overwhelming evidence, that continuity of carer produces better outcomes across the board, from shorter labours to fewer cesareans to better neonatal outcomes, as well as increased satisfaction reported by both women and midwives alike. At the moment, though, continuity of carer is hard to come by in the NHS, but is something that private midwives are much better at providing, so it makes a lot of sense that women who are able to are choosing private midwives because this is the type of care they desire.

In 2016, in response to the Kirkup Report which investigated the tragic failures at the Morecambe Bay NHS Trust, NHS England announced a new scheme to give women more options in choosing their maternity care provider, ostensibly as a way to address the shortfalls which led to the Morecambe Bay tragedies, as well as increasing women’s ability to have a named midwife or case-loading midwife (i.e. to have continuity of care and continuity of carer). This scheme is currently being tested in several NHS trusts, called “Maternity Choice and Personalisation Pioneers”, and basically amounts to women being given a £3000 “birth budget” and then allowing them to choose where and how to spend their money–either on NHS services or private services which contract with the NHS, exactly as described in the Times article above. Which all sounds very good on the surface, but I’m worried that this is just a way to privatise the NHS through the back door.

As soon as you begin to allocate personal budgets to women, you’re pulling funds away from the general NHS pot, which is already operating on a shoestring and severely underfunded. If more money is diverted to private midwives and organisations providing private care, there will be less and less available for NHS, which has expenses (such as providing and maintaining actual physical hospitals) not accrued by private companies, who would be using the NHS facilities.  Also, it runs the risk of pulling low risk women (and their funding) out of the NHS pot, which leaves less money available for women with more complicated pregnancies, who would have to rely on NHS services if they weren’t a good candidate for low-risk private midwifery care.  There is a lot of thoughtful commentary out there on why a £3000 birth budget might not be such a good idea. For one thing, in some areas (such as London), £3000 wouldn’t fully cover the costs of hiring a private midwife, and my understanding is that the NHS has put provisions in place which would prevent women from taking the NHS budget and then supplementing it with their own money in order to purchase more expensive care. Also, women using these birth budgets can only use them on private midwives who have been contracted by the NHS, which means that they couldn’t use the budget to help pay for the services of a self-employed independent midwife working outside of the NHS. And in fact, the fate of the self-employed independent midwife (i.e. a private midwife who works outside of the NHS, and works for herself rather than being employed by a private company, such as Neighbourhood Midwives) is very uncertain at the moment anyway, thanks to an incredibly obtuse decision by the NMC (but that’s a conversation for a different day, certainly).

In my mind (and on my wish-list) is the option where the NHS is fully funded, the shortage of 5,000 midwives in the NHS is filled, and women are given true informed choice about the type of care and services they would like to have, including case-loading and one-to-one midwifery care, i.e. continuity of care and carer.  This is something the NHS has struggled to provide, and something that women are clamoring for.  When there is a shortage of midwives and a budget crisis, I suspect there isn’t enough staff to truly provide that kind of care in numbers that aren’t overwhelming to the individual midwife. I’ve already spoken to many NHS midwives in my very brief tenure so far who have discussed how they used to case-load, but over time found it to be too exhausting, so they switched to a different modality. Or about how home birth services that provided case-loading care gradually disappeared when the core midwives who were part of the team became burned out or fed up or too exhausted to continue, and no new midwives wanted to take on the role. Imagine how different a service like that would look if it was staffed in such a way that a midwife could personally attend…I dunno…20-35 births per year, tops, and truly give each woman the fullness of her time and energy and attention through their entire antenatal/ labour/ postnatal journey, while still feeling like she had down-time and time for self-care and time to see her family. Imagine what maternity care in a world like that would look like!

But I know well enough that this is wishful thinking. I’m not sure what the right solution is here. Women want (and absolutely deserve) individualised, unhurried care from the same midwife throughout their pregnancy, birth and postnatal period–and rightly so! If this can’t be provided by the NHS, I understand why women would try to seek out that type of care privately, and also why the beleaguered NHS might think that contracting private midwives to provide it is a good idea. But I also know that there are thousands and thousands of excellent NHS midwives who also long to be able to provide that type of care in the first place, and if they could work in a system that allowed for case-loading and continuity of carer in a humane model that didn’t require each individual midwife to completely drain herself dry, there would be no need to contract private midwives in the first place.  Where do we go from here? It will be very interesting to see how these birth budgets are working out in the pioneer trusts, and whether they can actually create the kind of change their creators are hoping for.

 

 

Holding Space

Holding Space

Recently, a good friend of mine, Elizabeth Purvis, who works in a magical, nurturing, life-coaching space (she would term it manifesting, I’m pretty sure) posed a very simple, but pithy, question: “What does it mean to hold space?”  And just this very evening, I was tagged in a post giving compliments and shout-outs to beloved midwives, and the idea of holding space bubbled to the surface again in my response. I’m taking it as a sign that the Universe is telling me I really need to write a thing or two about this idea of holding space, so here goes!

What DOES it mean to hold space for someone?

In one of the best articles I’ve read about this to date, the author, Heather Plett, defines it in this way:

[Holding space] means that we are willing to walk alongside another person in whatever journey they’re on without judging them, making them feel inadequate, trying to fix them, or trying to impact the outcome. When we hold space for other people, we open our hearts, offer unconditional support, and let go of judgement and control.

Heather then goes on to explain eight things which a person does when they’re “holding space” for someone, including giving people permission to trust their own intuition and wisdom, only giving as much information as the person can handle, ensuring that they keep their power through the process (or in other words, not taking their power away from them), keeping our own ego out of it, making them feel safe enough to fail, giving guidance and help with humility and thoughtfulness, creating a container for complex emotions, fear, trauma etc., and allowing people to make different decisions and have different experiences than we would choose for ourselves.

Which means, to my way of thinking, that midwives are the original space holders! (And, for the record, although I am writing this post with midwives in mind, holding space at a birth is in no way the sole purview of midwives! Doulas, nurses, doctors, partners and family members can also be exemplary space holders! The pictures for this post are taken from my first labour, and the woman seen in each of these photos–watching, murmuring, encouraging, pouring water over me, massaging hour after endless hour–was my good friend and beloved doula, Kristen, who held space for me like no one’s business through fifty. six. hours. of labour. I would have been lost without her, and still to this day cannot thank her enough for what she did for me.)

Holding space is what midwives do, day in and day out. When I read a woman’s birth plan, I’m always very conscious of the fact that I’m holding a woman’s hopes and dreams in my hand, which is no small thing to be entrusted with. We all know that birth plans don’t always go according to plan, but as a midwife you’re a facilitator, keeping the woman’s desires and expectations foremost in your mind while helping her to navigate the journey that she’s on. You’re the guide, the translator, the sherpa. You can read the environment and terrain, you have a map, and as you’re traveling with her, your job can include any of the following: reassurance, support, course correction, managing expectations, cheerleading, nonverbal cues, preventing interruptions, creating silence, actively listening, validating, explaining, teaching and demonstrating.  If the birth veers away from the hopes and dreams and expectations, the manner in which you support a woman through the transition has a resounding, life-long impact on her. Research has demonstrated this again and again: if care is delivered in a compassionate and respectful way, if a woman feels like she was listened to and was part of the decision making, if true informed consent is given, then the woman can come away from a birth still feeling empowered and whole even if none of it went according to “plan”. If respect is lacking, if imbalanced power-dynamics are at play, if decisions are made without input, if actions occur without explanation afterwards (not to mention thorough, supportive debriefing), then a woman often comes away from her birth feeling disappointed (at best) or traumatised (at worst). And we know these feelings carry into the immediate postpartum period, which not only increases the risk of postnatal depression, but also shapes the woman’s identity as a mother, and impacts her agency and her belief in herself, which in turn has a knock-on effect on her children as well. Again, no small thing to be entrusted with! Doing this well means choosing your words very carefully. Planting seeds without being proscriptive. Breaking news at just the right moment, in just the right way, without overwhelming the couple. It’s constantly walking a tight-rope, a balancing act of myriad pushes and pulls–energy levels, personalities, non-reassuring fetal heart tracings, medical realities, hospital policies, staffing levels. It’s knowing that every room in the birthing center is full, so best not to mention the birthing tub that she can’t have. When you start to think about the complexities, it all begins to feel quite daunting, and yet the best midwives I know feel like their work is a calling rather than a job, and love their work so fiercely that (almost) they would do the work for free (and to be honest, I think this is something the NHS is well aware of, and takes advantage of to the fullest, which is not a good thing by any means).

And you’re holding space not just for the woman, but for the partner as well, who is on their own journey from partner to parent, and often needs encouragement and guidance on how to better hold space for the woman too.  It’s hard to watch someone you love going through pain and doing something so difficult, and this can sometimes make partners feel helpless, scared and even guilty.  I’m sure many other birth workers can speak about births they’ve been at where the partner wasn’t holding space in a helpful way, and how a simple word–maybe try rubbing her like this…I don’t think she can answer those questions right now…why don’t you sit here and then she can lean back against you in between contractions…would she like a sip of water [handing water bottle to partner, so that they can then offer it to the woman]…speaking in whispers if peace and quiet is called for…demonstrating through your own example how best to support her–can make a big difference in a partner’s ability to more optimally support their loved one. And then, of course, there are those moments when the love is so beautiful and present in the room that you feel privileged just to be able to witness it, and no input from you is even needed. I can think of many such moments at births which even now can bring tears to my eyes when I recall them. A toddler telling her mother that she’s doing great. A partner making his girlfriend laugh in between contractions which otherwise have her crying in pain.  A husband telling his wife that her vulva is every bit as beautiful now as it was before the difficult repair she just had (I kid you not, this is actually something I overheard at a birth; talk about knowing just the right thing to say at just the right moment!).

Holding space as a midwife means creating an environment where the woman in labour feels safe, able to do or say whatever she wants, growl or pace or moan in whatever way feels right, but also an environment where she feels protected and contained (and hopefully in such a way that this protection and containment is invisible and completely non-intrusive). If I’m doing my job well, I’m the safety net, the life-guard on duty, watching and observing but for the most part doing very little.  If I’m doing my job well, I can create an environment where the woman feels free to listen to her body, to follow her own instincts and labour in the way that seems best to her, ideally supported by her partner and support team more than by me.

Holding space also means seeing the big picture for the woman. She is lost in her labour, moving from one contraction to the next, unable to see in front of her, or behind her. It means supporting her in the moment when she is convinced that she can’t do it–even when you know she still has a long way ahead of her, and things are only going to get harder. It means telling her, sometimes again and again, after every contraction, that yes, she can do it. Yes, she IS doing it. Yes, she can. Yes, she IS. It means having faith–faith in the woman’s body, faith in normal birth, faith in her strength, in her perseverance, in her ability to push her baby out–and holding that faith for her even in the moments she she has lost her faith. It’s like shining a torch for her, a light in the distance that she can walk towards, a voice calling her when she’s lost in the maze of labour. It’s knowing that YES, she can do it, and never wavering in that belief, even when she is convinced that she can’t. You can’t do the work for her, but you know that she can do the work for herself. You give her the gift of that faith, and when the woman does climb the impossible mountain that she was convinced she couldn’t climb, afterwards she feels like she can do anything. The faith you held for her becomes a truth that she believes about herself. That is what you’re holding.

Holding space is also protective. Birth is wildly unpredictable, and uncontrollable. Birth plans don’t always go to plan. Hopes and desires for specific outcomes can be trampled. The baby sometimes has very different ideas about the manner in which s/he would like to be born! And sometimes there are true emergencies which require quick, focused action with very little time for communication until after the fact. Sometimes holding space is about preserving a woman’s dignity through the chaos. Sometimes it’s about literally giving her something to hold onto–a hand as you race back for an emergency cesarean, a familiar voice that she can hear through the beeping machines and commotion. Holding space means giving a woman time to grieve and process (after the fact) and a warm, non-judgemental listening ear to allow her to debrief. Postnatal listening and letting a woman tell you her birth story (and sometimes she needs to tell it over and over) can help her to understand and contain the experience.

Which brings me back to two of my favourite quotes about midwifery (and about holding space), from the Tao te Ching, written by Lao Tzu in 5th Century BC China:

The midwife completes her work by doing nothing. She teaches without saying a word. Things arise and she lets them come. Things leave and she lets them go. Creating, not possessing. Working, yet laying no claim. And when her work is done she forgets about it, and it lasts forever.

 

Imagine that you are a midwife.  You are assisting at someone else’s birth.  Do good without show or fuss.  Facilitate what is happening rather than what you think ought to be happening.

If you must take the lead, lead so that the woman is helped yet still free and in charge.  When the baby is born, the woman will rightly say: “We did it ourselves”.

What does holding space mean to you?

 

The Pinard Stethoscope

The Pinard Stethoscope

So here’s something that will be pretty mind-boggling for my UK readers: in the US, the Pinard stethoscope doesn’t really exist, at least not in any of the midwifery circles I travelled in.  NO ONE used it.  I’d never seen one or even heard of it until I moved here and started midwifery school (in fact, the only mention I can find of it in any of my American midwifery books–including my American midwifery textbooks–is a brief mention of it on page 112 in Ina May Gaskin’s Birth Matters, where it’s called the Pinard Horn rather than the Pinard stethoscope).  So you can imagine my surprise when I discovered that here in the UK, the Pinard stethoscope is a beloved midwifery tool, so much so that it serves as the logo for the Association of Radical Midwives, and beautiful wooden models are often given to newly qualified midwives as graduation gifts. Nearly every UK midwife owns a Pinard stethoscope–many of them even own several–and if that doesn’t convince you of its importance, it’s one of the first things Jenny pulls out of her midwifery bag during her visits on Call the Midwife.

All of this was news to me, though, as the closest thing we have to the Pinard stethoscope in the US is a fetoscope, which looks like this:

And you can see America’s most famous midwife, Ina May Gaskin, using a fetoscope here:

However, when I brought my American-style fetoscope to antenatal visits to show to my mentor, she was rather shocked, as she’d never seen one before. We then spent the afternoon experimenting with the Pinard stethoscope v. the fetoscope for auscultation of the fetal heart. I found that I could hear the fetal heartbeat more clearly with the fetoscope, while she preferred the Pinard. Go figure! But it was a very interesting experiment, and generally the pregnant women who so graciously allowed us to practice auscultation on their beautiful bellies were amused by the whole thing.

Since I knew virtually nothing about the Pinard stethoscope, and since as a student here in the UK we’re required to become proficient with its use as per the standards for pre-registration midwifery education (NMC, 2009), I thought it would be a good topic to write about for my first midwifery school essay assignment (which, interestingly enough, are called “assessments” here, rather than “essays”, just for the record). So, having written 15 pages on the subject now, and having tried my hand at it multiple times in the clinical setting, I have a bit more of a clue with regards to this ancient and much-revered midwifery tool, which I’m going to share here (you lucky devils, you!).

The Pinard stethoscope is a small 6-8” hollow, funnel-shaped tube often made of wood, metal or plastic, with the larger end placed against the woman’s abdomen and the auscultator’s ear placed against the smaller end (Harrison, 2004). In pregnancy, the Pinard stethoscope can be used from approximately 24 weeks onwards to auscultate the fetal heart during antenatal visits, and can be used in labour as a tool for intermittent auscultation (Johnson & Taylor, 2016). The very first monoaural stethoscope was invented in 1819 René Laennec, and was basically a long wooden tube which the auscultator would place against the patient’s chest wall, with his/her ear placed against the other end (although who’re we kidding…in 1819, it was most likely a man’s ear on the listening end).  Prior to Laennec’s invention of the monoaural stethoscope, fetal auscultation was performed by the examiner placing his (or her) ear directly against the woman’s skin and listening through her abdomen, a practice which required a large degree of intimacy between patient and practitioner, and which (you can imagine) may have been particularly discomfiting to 19th Century sensibilities (Montagu, 2008; Blincoe, 2005). The Laennec stethoscope afforded a measure of distance between patient and practitioner, helping to preserve the dignity of both, and in 1821, Laennec’s colleague, Jacques Kergaradec, applied the newly invented stethoscope to fetal auscultation for the very first time (Pinkerton, 1969). John Creery Ferguson brought fetal auscultation to the British Isles after studying in Paris with Laennec and Kergaradec, where the practice quickly took root at the Rotunda Hospital in Dublin, gradually spreading to the rest of the UK from there (Pinkerton, 1980; Harrison, 2004). The Laennec stethoscope underwent modifications by Holh in 1834, and was finally refined by Adolfe Pinard in 1896 into the current model (Harrison, 2004; Dunn, 2006). The Pinard stethoscope transmits fetal heart sounds more clearly through the long bore of the tube than the more ubiquitous binaural stethoscope which we commonly see slung around practitioner’s necks, which is one of the reasons it still remains in use as a modern obstetric tool today (Montagu, 2008). And, since the advent of the Midwives Act in 1902 here in the UK, proficiency with the Pinard stethoscope been taught to midwives in the United Kingdom for over a century now.

So why use a Pinard stethoscope? What are the advantages to it, versus the more common doppler (which uses ultrasound technology)? And how does Pinard use slot into general antenatal and intrapartum care here in the UK? Good questions, and as luck would have it, this was exactly what I was writing about in my essay!

At its most basic level, the rationale underpinning fetal auscultation is to confirm the presence or absence of a fetal heart rate (FHR) and to assess fetal well-being (Johnson & Taylor, 2016). According to the National Institute of Health and Care Excellence (NICE) Guidelines (sort of the US’ NIH equivalent), there is limited benefit from routine FHR auscultation during antenatal visits, particularly in the presence of fetal movement, since “auscultation of the fetal heart may confirm that the fetus is alive but is unlikely to have any predictive value, and routine listening is therefore not recommended” (NICE, 2008). Nevertheless, NICE supports antenatal FHR auscultation if the mother requests it, and for better or worse, FHR auscultation has become an expected and routine part of antenatal care these days–I couldn’t imagine an antenatal visit in which a mother didn’t want to hear her baby’s heartbeat (once the pregnancy had advanced to the point that this is possible). In labour, FHR auscultation is recommended throughout in order to monitor fetal well-being and the fetal response to contractions (Johnson & Taylor, 2016). The NICE Intrapartum Care for Healthy Women and Babies Guideline (2014) recommends intermittent auscultation every fifteen minutes in the first stage and every five minutes in the second stage for all low-risk women in labour, with continuous cardiotocography (CTG–i.e. electronic fetal monitoring, in US speak) used only in high-risk women, or in situations where intermittent auscultation reveals a non-reassuring FHR pattern or other emerging risk factors (NICE, 2014).

The use of the Pinard stethoscope as a primary tool for fetal auscultation is supported by both NICE and the Royal College of Midwives (RCM). In its 2012 guideline on intermittent auscultation in labour, the RCM recommends that the Pinard stethoscope be used to initially auscultate the FHR before switching to hand-held Doppler or CTG (i.e. electronic fetal monitoring) in order to ensure that the fetal heart is being recorded accurately (RCM, 2012).  This is because unfortunately the Doppler is capable of picking up “artifact” and doubling or halving the maternal heart rate by mistake, and in many tragic situations Doppler ultrasound can falsely reassure both parents and practitioners that the baby is alive and well, when in fact that’s not the case (and many UK stores recently banned the sale of hand-held dopplers to customers because of this very thing).  Using a Pinard stethoscope first to confirm the presence of the fetal heart helps to limit this mistake, and in fact, the Medicines and Healthcare Products Regulatory Agency here in the UK has issued an advisory on CTG which calls for the Pinard stethoscope to be used initially and at any other point when a change in FHR or concern in labour arises, in order to prevent monitoring the wrong heart beat (MHRA, 2010).  NICE also specifies that either the Pinard stethoscope or Doppler ultrasound be used for the initial assessment of a woman in labour, rather than CTG, and that the Pinard is a valid tool for intermittent auscultation throughout labour (NICE, 2014).

There are many advantages to using the Pinard stethoscope. First of all, as mentioned above, the Pinard stethoscope allows the midwife to listen to the FHR directly, unlike Doppler technology which uses ultrasound technology “to evaluate changes in sound waves caused by the direction and velocity of blood flowing through vessels and the heart” (Blincoe, 2005) and which can sometimes get it wrong and pick up the maternal heart rate by mistake.  Many experienced practitioners also find that they are able to hear not only variability with a Pinard, but also differences in tone and rhythm which can be ascribed to differences in individual babies (ARM, 2000; Wickham, 2002a; Cronk, 2002), and in fact there have been reports of midwives being able to pick up congenital heart defects through the subtle changes in rate they were able to detect with the Pinard (ARM, 2000). The Pinard stethoscope may also help support the woman in her role as the expert on her baby (Young, 1999; Montagu, 2007). “The current fashion for selling Dopplers to pregnant women implies that artificial monitoring is in some way protective; instead, it disempowers women and casts implicit doubt on their ability to be conscious of their own baby’s well-being through …awareness of the baby’s movements” (Montagu, 2008, p. 3). In other words, we should all be working harder to support and empower women to feel like THEY are the experts on their babies (because they are) and reaffirming again and again that the biggest predictor of fetal well-being is fetal movement. If you can’t hear the FHR because the baby is moving too much–no problem! You know that the baby is absolutely fine, in that situation (although, unfortunately thanks the to the pressures of litigation, as a midwife these days you would still have to find and record the fetal heart rate, otherwise your care will be deemed sub-standard, and certainly wouldn’t hold up in a court of law).  The low-tech Pinard stethoscope exemplifies the art and essence of midwifery care, and is particularly valuable in the developing world where resources are more limited (Mahomed et. al., 1994). Similarly, there will always be women in the developed world who will decline ultrasound technology, and since it’s imperative that midwives respect a woman’s choices as per the NMC Code (2015) and the Better Births Initiative (National Maternity Review, 2016), the Pinard stethoscope offers a much needed alternative to the Doppler!

However, in practice, the Pinard stethoscope has several disadvantages as well.  First, it’s not easy to use in labour, particularly if the woman is moving around or assuming different positions, such as on hands and knees (Blake, 2008; Harrison, 2004). Second, the Pinard stethoscope can only be used from 24-28 weeks onward, whereas the Doppler can detect the FHR as early as 10 wks (Blake, 2008), which is a big advantage to the Doppler in many women’s books, since naturally many women want to hear their baby’s heart beat as early as possible. There is also concern that accurate FHR auscultation can only be achieved by a highly-skilled practitioner who is expert with the tool, and that the average user is not as accurate (Blake, 2008)–and I can certainly attest to that, as the Pinard stethoscope is quite tricky to use in the beginning.  Additionally, a randomised control trial (RCT) comparing Pinard stethoscope to Doppler or CTG found that the Pinard was the least successful in identifying abnormal FHR patterns (Mahomed et. al., 1994). You can’t use the Pinard stethoscope in the water, which means if you’re monitoring a woman with Pinards alone, she’d have to get out of her birth tub every time you needed to listen, which isn’t very practical.  Finally, women have reported that the use of the Pinard stethoscope in labour is more uncomfortable than the Doppler, particularly if you can only use the Pinard while she’s on her back; additionally, you sometimes have to press quite firmly with the Pinards in order to be able to hear the FHR, which again can be very uncomfortable in labour.  Overall, studies have shown that women tend to prefer Doppler or CTG monitoring instead of the Pinard stethoscope, as being able to hear the heart themselves provides them with more reassurance (Garcia et. al., 1985; ARM, 2000).

And in practice, what is it actually like? Well, rather tricky. It took me several tries with it before I could finally hear the fetal heart. It’s often a very faint sound, and in many cases I don’t really “hear” it at all, but instead almost “feel” it against my ear as a vibration, something which Mary Cronk has written about as well (Cronk, 2002). It also requires that you’re SPOT ON with your abdominal palpation, as you really have to be right on top of the fetal heart in order to be able to hear it (whereas the Doppler is a bit more forgiving, and can allow you to pick up the heart rate even if you’re not exactly in the right location).  This means that the Pinard is a lot more difficult to use in situations where the baby is fully engaged, breech or posterior, as well as in situations where it’s difficult to determine the baby’s position due to the mum having a higher BMI. On the flip side, however, because precise abdominal palpation is a prerequisite skill for using the Pinard stethoscope, many midwives will use the Pinard to help confirm that their assessment of fetal position is correct, and sometimes see this as an advantage to its use (Cronk, 2002; Montague, 2008; Wickham, 2002a).

All in all, there’s something really special about the Pinard stethoscope, and I’m very glad that I’ve had the opportunity to learn how to use it.  I like it because of its historical significance, as well as its low-tech simplicity. I also like that there’s a real art to its use that only comes from experience and continued skill development. To me it represents a true skill that must be learned and practiced many, many times in order to attain mastery, and is something I’ll have to continue to practice and refine for the remaining years of my career.  Now that I’m on my rotation in the Birthing Center, I’ve been relying on the Doppler more, particularly as we’ve been using the pools a lot and it’s impossible to use the Pinard in a pool, but I would absolutely like try the Pinard in labour as well. I would like to someday be as comfortable and proficient with the Pinard as I am with the Doppler–it’s worth aspiring to, at any rate!

 

References:

Association of Radical Midwives (ARM). (2000) ‘Hearing Variability’, Midwifery Matters, (84) [no page numbers].

Blake, D. (2008) ‘Pinards: out of use and out of date?’, British Journal of Midwifery, 16(6), pp. 364-365.

Blincoe, A. J. (2005) ‘Fetal monitoring challengs and choices for midwives’, British Journal of Midwifery, 13(2), ppp. 108-111.

Cronk, M. (2002) Me and my Pinard’s. Midwifery Matters, (94), pp. 3-4.

Dunn, P.M. (2006) ‘Adolphe Pinard (1844-1934) of Paris and intrauterine paediatric care’, Archives of Disease in Childhood, Fetal & Neonatal Edition, 91(3), pp. 79-85.

Garcia, J. et al. (1985) ‘Mother’s Views of continuous electronic fetal heart monitoring and intermittent auscultation in a randomized controlled trial.’ Birth, 12(2), pp. 79-85.

Harrison, J. (2004) ‘Auscultation: the art of listening’, RCM Midwives, 7(2), pp. 64-69.

Johnson, R. and Taylor, W. (2016) Skills for Midwifery Practice. 4th Edition. London: Elsevier.

Mahomed, K., Nyoni, R., Mulambo, T., Kasule, J. and Jacobus, E. (1994) ‘Randomised controlled trial of intrapartum fetal heart rate monitoring’, British Medical Journal, 308(6927), pp. 497-500.

Medicines and Healthcare products Regulatory Agency (MHRA) (2010) Fetal Monitor/ Cardiotograph (CTG) – Adverse Outcomes Still Reported. Available at: https://www.gov.uk/drug-device-alerts/medical-device-alert-fetal-monitor-cardiotocograph-ctg-adverse-outcomes-still-reported (Accessed: 11 May 2017)

Montagu, S. (2008) In defense of the Pinard. Midwifery Matters, (118), pp. 3-4.

National Institute for Health and Care Excellence (NICE) (2008) Antenatal Care for Uncomplicated Pregnancies. (Clinical Guideline CG 62). Available at: https://www.nice.org.uk/guidance/cg62/chapter/1-Guidance (Accessed: 19 May 2017)

National Institute for Health and Care Excellence (NICE) (2014) Intrapartum Care for Healthy Women and Babies. (Clinical Guideline CG 190). Available at: https://www.nice.org.uk/guidance/cg190 (Accessed: 11 May 2017)

Nursing and Midwifery Council (NMC) (2009) Standards for pre-registration midwifery education. Available at: https://www.nmc.org.uk/globalassets/sitedocuments/standards/nmc-standards-for-preregistration-midwifery-education.pdf (Accessed: 11 May 2017)

Nursing and Midwifery Council (NMC) (2015) The Code. Available at: https://www.nmc.org.uk/standards/code/ (Accessed: 15 May 2017)

Pinkerton, J.H.M (1969) ‘Kergaradec, Friend of Laennec and Pioneer of Foetal Auscultation’, Proceedings of the Royal Society of Medicine, 62(5), pp. 477-483.

Pinkerton, J.H.M (1980) ‘John Creery Ferguson: Friend of William Stokes and pioneer of auscultation of hte fetal heart in the British Isles’, British Journal of Obstetrics and Gynaecology, 87(4), pp.257-260.

Royal College of Midwives (RCM) (2012) Evidence Based Guidelines for Midwifery-Led Care in Labour: Intermittent Auscultation. Available at: https://www.rcm.org.uk/sites/default/files/Intermittent%20Auscultation%20%28IA%29_0.pdf (Accessed: 11 May 2017)

Wickham, S. (2002a) ‘Pinard wisdom: tips and tricks from midwives (Part 1)’ Practising Midwife, 5(9), pp. 21.

Wickham, S. (2002b) ‘Pinard wisdom: tips and tricks from midwives (Part 2)’ Practising Midwife, 5(10), pp. 35.

Young, G. (1999) ‘The case for community-based maternity care’, in Marsh, G. and Renfrew, M. (eds.) Community-based Maternity Care. Oxford: Oxford University Press, pp. 7-26.

Notes to Self

Notes to Self

We’re beginning the clinical portion of our midwifery education now, after a very intense, action-packed 8 weeks of theory and classroom work. For the next 8 weeks, we’ll be in the clinical setting, on our placements, learning by doing, helping and shaping the antenatal, birth and postnatal experiences of the women we meet.  I’m SO EXCITED to begin actual midwifery work again! But on the eve of my clinical placement, it seemed like a good time to write a few notes to myself (and my fellow students on the eve of this exciting milestone):

Clinicals are going to challenge you in ways we can’t even imagine yet–even though you’ve done parts of this before, it’s still going to be challenging, and new. You’ll need your mind, your ability to think, your ability to feel, your ability to see clearly, to watch and wait, to put 2+2 together, to use all of this knowledge we’ve been working so hard to acquire.

But remember that birth isn’t in the textbook. It’s in the mother, sweating with exertion, it’s in the partner, whispering words to encourage her, it’s in the baby, liminal and waiting.

Remember that wherever you stand in that labour room, no matter how chaotic, you stand in a holy place. Your heart has called you to this profession, this path, this work. Let your heart shine–your wisdom, your strength, your love.

 

 

It’s ALL Happening: Midwifery Seminar, Timetables, Bursary Approved!

It’s ALL Happening: Midwifery Seminar, Timetables, Bursary Approved!

It’s all starting to get very, very real! I went to my new university on Friday to attend a midwifery seminar, which they hold every 6 months or so. It was a fantastic morning listening to some very interesting speakers and topics (I’ll give you a run-down below). I also received my student timetable for the first year of the course (let’s just say….lots and lots of work ahead, and very few holidays), and yesterday I also got a notice from the NHS that my fees-only bursary has been approved. What a huge relief that is! And for the record, I am an incredibly lucky student, as I am part of THE VERY LAST COHORT of incoming midwifery students who will be eligible to receive an NHS bursary. Starting in Aug. 2017, all incoming midwifery and nursing students will have to pay for their education (to the tune of 9,000 GBP per term), whereas if you are lucky enough to begin your education under the old scheme (as I am), your fees will be covered for your entire course (i.e. 3 years worth of education). As you can imagine, there are a lot of organizations (most notably, the RCM and RCN) which were quite distressed about this change, as it may limit the numbers of incoming student nurses and midwives and destabilize the future of maternity care in the UK. I am not entirely convinced about this, as midwifery and nursing education has ALWAYS been paid for by students in the US, without detrimental effects on the number of students choosing to enter these professions (but obviously coming out with lots and lots of student debt at the end of their education, which isn’t necessarily a good thing at all). In any case, though, as an American student approaching midwifery education here in the UK, I must admit that I am absolutely floored (flabbergasted! Amazed! Delighted!) that my education will be covered by the NHS, as I would never in a million years dream of free tuition in the States for any degree. It feels completely surreal to me, especially as I spent years and years paying off my student debt from my US midwifery and nursing education. And I am counting my lucky stars that I am slipping in just under the wire and will have my fees covered, but at the same time saddened that this incredible system–a system that values a student’s time and energy, and understands that properly educated professionals require investment–is being dismantled.

I met a few of the students who will be in my course, though, as well as a few of the professors, and everyone was incredibly kind and welcoming. I even met a third year student who gave me her phone number (unprompted by me!) and told me that I could get in touch with her at any point if I needed help. What a kind thing to do, and such a wonderful example of mentoring.  All of it seems very encouraging, and is making me think (again!) that I’ve chosen the right university to study at. The atmosphere was warm, the students were engaged, and the questions being asked were perceptive, smart and on-point. I am very excited about learning here!

The first speaker at the seminar was the one and only Professor Cathy Warwick, CEO of the Royal College of Midwives (and how fantastic that she’s speaking at conferences at my university??). Her presentation was on the importance of challenging the status quo in order to better deliver personalised care to each woman, which is a core value reflected in the National Maternity Review’s Better Births policy, but is not always easy to implement when a woman’s desires for her birth clashes with the institutionalised norm. She discussed many of the common situations where care is provided based on ritual (i.e. we do it this way because we’ve always done it this way), rather than evidence of best practice (examples of these sorts of non-evidence based rituals include transferring women between wards in a wheelchair when they’re perfectly capable of walking, not allowing fathers to stay overnight in early labour, routine use of external fetal monitoring on admission, transferring women from birth settings in an ambulance regardless of the reasons for the transfer etc. etc.) Prof Warwick pointed out that delivering personalised care presents big challenges for midwives on a systemic level, but that in many situations massive system changes aren’t needed. She spoke, for example, about how you can begin as simply as removing the word “allowed” from your vocabulary (something I can 100% get behind). The woman in labour is the one in charge of her birth. As midwives, it’s our job to support and empower her, but ultimately she should be the one making decisions (in collaboration with her midwife and birthing team). Telling a woman she isn’t “allowed” to do something goes against this sentiment. Ideally, a woman should be able to do whatever she likes in labour and on the ward (within reason), so long as the risks and benefits of her choices have been fully explained to her and she has been given the opportunity to make an informed decision. It’s HER birth, after all. Prof Warwick also pointed out that in some cases, women are labeled as “birthing outside of guidelines” as if they are stubborn and intractable and taking unnecessary risks with their babies, when in fact they are successfully advocating and demanding the type of birth experience they want and are legally entitled to. A better question is: how do we support women who challenge birth conventions/ norms of institutions, and choose to birth outside of these norms? As a strong advocate for home birth, this is something I have encountered many times before, and something that independent midwives facilitate, as many women who choose independent midwifery care are doing so because the institutionalised care offered to them was not in sync with what they desired for their birth. (And I must admit, I found it incredibly encouraging to be hearing this from the CEO of the RCM, especially in light of the recent difficulties imposed on Independent Midwives by the NMC). Safety and risk is perceived differently by every woman, after all; what feels safe to one woman could feel like the definition of risk to another. Prof Warwick also spoke about the need for not only continuity of care, but continuity of carer, and was quite adamant that figuring out how to deliver this type of continuity is something that can only be done by midwives (and that most likely the way forward will be different for each individual midwife, in terms of case-loading v. shift work v. shared call), and that midwives need to be given the power and flexibility to find their own solutions.

The next speaker was Margaret Nyudzewira, a public health advocate and co-founder of the charity CAME Women and Girls Development Organisation (CAWOGIDO), who spoke to us about breast ironing. While I’ve been aware of the dangers of Female Genital Cutting (FGC, or Female Genital Mutilation, FGM) for years, and have encountered it a few times as a midwife in Brooklyn, the practice of breast ironing is fairly new to me. Strangely enough, I first learned about it just a few weeks ago when a midwife friend posted a link to a photographer’s riveting portraits of women and girls who’ve experienced breast ironing.  The practice involves using a tight elastic band, pestle, ladle, hot stone, shell, or even hot seeds or heated leaves, to massage and flatten developing breast tissue on young girls, and can lead to many serious medical complications, including chronic pain, scalding, burns, infections, cysts, abscesses, tissue damage, the inability to breastfeed, and of course psychological trauma. Breast ironing is most often done by the girl’s mother (but can also be done by a grandmother, aunt, or tribal practitioner), and comes from a place of love, or more specifically, fear for loved ones–fear of unwanted sexual attention directed towards their daughters, fear of rape or sexual assault, or fear that early marriage or teen pregnancy could education and curtail opportunities.  And similar to FGC, this practice doesn’t occur only in Central and West Africa, but in the UK (and the US) as well (although the numbers are difficult to track, and very few studies have been done on the rates of breast ironing in the UK). In Cameroon, 50% of girls on the coast, and 24% of girls nationwide, experience breast ironing.

But one of the things that struck me the most was when Ms. Nyuydzewira said quite emphatically: “It is NOT part of our [Cameroonian] culture to harm girls and young women.” And that is absolutely true. While the practice of breast ironing itself is brutal and debilitating, it’s really important to keep in mind that the practice and the culture are not exactly one and the same. As a (white) midwife approaching a cultural practice like this (which runs counter to my own beliefs, and feels very foreign to my own cultural upbringing), I think it’s crucial to come from a place of support rather than a place of judgement.  This is one of the reasons I have come to call it Female Genital Cutting over the years, rather than Female Genital Mutilation (which has our cultural judgement baked into the very name itself) or Female Genital Circumcision (which to me seems to condone the practice, on some level, and also equates it in the mind with male circumcision, which is a false equivalence), especially when I’m discussing it with women/ patients directly (I understand that more generally, in health policy and research, it is more often referred to as FGM). Some women brought up in cultures which practice female genital cutting, for example, may view FGC as no more strange to them than piercing bellybuttons or lips or eyebrows is to us, even if the implications, the actual act itself and the repercussions of it can be much more damaging to them than a bellybutton piercing.  When viewed within their culture, it may be seen as a mark of belonging and identity, a much anticipated rite of passage, a way of fitting in, a symbol of their womanhood, a manifestation of their virtue and honor, and on its most basic level, the way that vaginas are supposed to look–beautiful, even, to their eyes. On a personal level, I disagree with these assertions and find FGC abhorrent, but as an outsider to these cultures, I can’t approach a woman by telling her that she’s been mutilated as the starting point for any future conversations with her–that will immediately close her off to me and only serves to project my own cultural bias over her own.  Instead, gentleness and sensitivity is needed more than anything else. Rather than imposing my own viewpoint, I would have to elicit the woman’s own views on the topic first, and use that as the starting point for whatever would be most useful to her moving forward: education and resources if desired, medical care if needed, mental health referrals if she feels depressed or traumatised by her experience, or silence and non-judgement if she views it in a positive or neutral light (and should this viewpoint ever change, I can then step in at that point with whatever help or support is most appropriate at that time).  To me, this gets to the very heart of my own personal philosophy of midwifery care: LISTEN to women, and DON’T JUDGE. In any case, now that breast ironing is also on my radar, I will be more alert to it if/ when I ever encounter it, and in a much better place to offer sensitive care on this very complex issue. Overall, it was a difficult and disturbing presentation to listen to, but I’m glad that it was part of the seminar, as these things are really important to think about in advance of encountering them!

There were two other speakers at the seminar: Debra Sloam, Midwife and Infant Feeding Specialist from Frimley NHS Foundation Trust, who spoke about her MSc research on student midwives’ attitudes towards offering breastfeeding assistance (as suspected, I will most likely have a lot more time to help women breastfeed as a student than I will as a working midwife), and Dr. Kim Russell from the University of Nottingham, who discussed her action research on challenging midwifery barriers (real and perceived) to facilitating water births on the wards.  These were both interesting and engaging presentations, and I’m really glad I was able to attend the seminar.

Two more weeks until classes start!

 

Mission Statement

Mission Statement

Every new project and endeavor needs a Mission Statement. I wrote this 12 years ago, when I was attending midwifery school for the first time, but I have found that it sets a lovely tone for the inaugural post of this website. It is my hope that these goals will not only guide and shape my growth as a midwife, but also come to suffuse everything I do: my practice, my values, my beliefs and dreams and aspirations, what I fight for and work towards, and not least of all, this website!

My mission as a midwife is…

…to provide insightful and compassionate clinical care for women throughout their pregnancies.

…to educate women about their bodies and to foster a sense of trust in their bodies and themselves.

…to offer sound advice and ready emotional support.

…to respect a woman’s choices, background and culture.

…to view pregnancy and birth as a normal, healthy process–a state of wellness rather than a state of illness.

…to provide a birth alternative to women and their families which is non-invasive, holistic, and woman-centered while remaining evidence-based and clinically sound.

…to help women guide themselves through the labour process; to be an ally and an advocate, as needed.

…to never forget the rest of the family–the husbands, the wives, the significant others, the older children, the soon-to-be-new-grandparents–and to involve the family as much as possible; to encourage bonding and to support the family as a unit.

…to promote midwives and the practice of midwifery–to get the message out, to stir the pot, to educate the general public about how much we have to offer.

…to make the right call at the right time–to intervene when I must, but to be able to decide to do nothing, to watch and wait, to trust the woman’s body and instincts.

…to educate women about pregnancy and birth; to provide as much information as possible, so that women can make informed decisions.

…to never lose sight of the sacredness of birth.

…to welcome new babies into the world with gentle, competent hands.