Attending births with a CPM

[biggolp]

I am graduating with my BSN next month (yay!) and I was thinking of assisting a CPM to gain experience with homebirths.

Someone mentioned to me that it might not be a good idea because if there's a negative outcome I would be held responsible since I'm the highest license there (my nursing license would trump the midwife's).

Does anyone know anything about this?

I would love to be at births in the home setting but have worked too hard on my nursing license to do anything that would jeopardize it.

Thanks in advance for any information or opinions regarding this.

[NRSKarenRN, BSN, RN]

Philadelphia and Southern New Jersey area has limited Nurse Midwife practices; 15 hospitals have closed maternity units in Philadelphia 5 county area over past 10 years.

Midwifery Institute at Jefferson,Philadelphia PA, formally Philadelphia University has long established midwifery program that may be source of local contacts if in South Jersey

Thomas Jefferson University | Midwifery About the Programs

[diabetesmelissatus]

i have my bsn and am currently in a nurse-midwifery program. i also wanted to attend some home births and i've been shadowing a CPM. i was also worried about jeopardizing my license and spoke with the director of my CNM program about it. she said that as long as i'm mostly shadowing/assisting hands-off/taking on more of a doula role that i should be fine and that it would be worthwhile experience. and she suggested i not do any charting.

[Jory, MSN, APRN, CNM]

No. You are not there in the capacity of a nurse, you are there in the capacity of a birth assistant. The patient is the CPMs and her responsibility to manage.

Your license is not "higher" it is just different. If you want to know why people are losing their nursing licenses, go on your board of nursing website and look at disciplinary actions.

Drugs, alcohol, criminal arrests, false charting, that is what people are losing their licenses for.

[cayenne06, MSN, CNM]

No. You are not there in the capacity of a nurse, you are there in the capacity of a birth assistant. The patient is the CPMs and her responsibility to manage.

Your license is not "higher" it is just different. If you want to know why people are losing their nursing licenses, go on your board of nursing website and look at disciplinary actions.

Drugs, alcohol, criminal arrests, false charting, that is what people are losing their licenses for.

I had multiple RNs work as birth assistants for me when I was a CPM, because I was licensed. However most states do not license CPMs (for good reason IMO). So yes, the RN would be the licensed provider in that scenario and it would be inappropriate to act in a birth assistant role. Even doula is pushing it. I wouldn't do it if the midwife herself wasn't licensed, no way.

[Jory, MSN, APRN, CNM]

double post

[Jory, MSN, APRN, CNM]

I had multiple RNs work as birth assistants for me when I was a CPM, because I was licensed. However most states do not license CPMs (for good reason IMO). So yes, the RN would be the licensed provider in that scenario and it would be inappropriate to act in a birth assistant role. Even doula is pushing it. I wouldn't do it if the midwife herself wasn't licensed, no way.

But you do realize that if your state doesn't recognize the CPM credential and you are attending births as a "midwife" in a capacity not recognized by the state, that is practicing illegally don't you? Most states DO recognize the CPM credential, 28 of them. However, you can find yourself arrested if you work in the capacity of a "midwife" without proper credentials that is recognized by the state.

If you don't have a license as a CPM, you are not a CPM. Just like if you are not licensed as an RN, you are not an RN.

If you are an RN and work with a "midwife" that is not recognized by the state, the mother is essentially "free-birthing" because she doesn't have a qualified attendant. As an RN, you should not participate in that because you would be the only licensed caregiver. Would you work with a physician that isn't licensed? Of course you wouldn't. Nor should you work with any other unlicensed provider.

That role changes dramatically if she is a CPM, recognized by the state, and you are her birth assistant.

A doula is not a legally recognized entity.

[LibraSunCNM, BSN, MSN, CNM]

I had multiple RNs work as birth assistants for me when I was a CPM, because I was licensed. However most states do not license CPMs (for good reason IMO). So yes, the RN would be the licensed provider in that scenario and it would be inappropriate to act in a birth assistant role. Even doula is pushing it. I wouldn't do it if the midwife herself wasn't licensed, no way.

She did state she's in NJ, where CPMs are licensed. Still kind of a thorny scenario, but less so than in a state where CPMs aren't recognized.

[rac1, ASN, BSN, RN]

Speaking as a former CPM, I would tread cautiously here. In some states (like in FL where I practiced), CPMs are licensed. If that's the case you could legally assist them in a nursing role. In most states they are unregulated, which means you would potentially open yourself up to liability in a bad outcome.

More importantly however, the training and expertise of CPMs is incredibly variable. The requirements for entry level competency are... substandard to say the least. There is also a lot of pseudoscience and medical distrust in the CPM community. Of course, some CPMs are highly competent and science based. But the entry level standard for CPMs does not meet IFM guidelines, which I find deeply troubling.

I just don't want you to go work with a CPM and come out of it thinking that Vit K is not really necessary for normal deliveries, or that routine vaccination is dangerous. Or that homeopathy is anything but complete and utter bullhockey. These are just a few examples of the things I LEARNED IN MIDWIFERY SCHOOL.

All midwives should be held to the same, science-based standard of care. I clearly feel strongly about this issue haha.

Anyway. If the CPM is licensed you could legally assist her. If she's not, then you shouldn't. Assisting women in unmedicated childbirth is a really important skill and CPMs do tend to be very very good at that. Which is great. But the medical expertise is often sketchy and ill informed.

Sorry, but you don't want her to "come out thinking that Vit K is not really necessary," or that "routine vaccination is dangerous,"..? It is really sad that nursing school teaches that Vitamin K is 100% necessary and that vaccines are PERFECTLY safe. Both assumptions are false. This is one huge problem with our standard education, and it is a much larger problem of an unthinking population. I am not over here to say no one needs vaccines or Vit K - but please do not ever say they are completely without ill effect because it is not true.

Vitamin K and vaccines are choices just like taking any drug is a choice, and parents should be made understood all the implications of the drugs they and their infants/children are prescribed. THAT is what we were taught in nursing school. Do patients refuse medications? Yes they do. Do we as nurses always agree? No we do not. Are we our patients' advocate? Yes, yes we are. We teach them, and explain and educate again. We explain what we know - but yes, we tell them side effects, and there are side effects and poor outcomes for every single drug available. In the end, it is a parent decision. Not a nurses or a CPMs.

CPMs do not need "medical experience" because they are experts in normal/healthy pregnancy and birth. Once the norm has left the room, the midwife should leave the room too (i.e.: transfer to hospital). CPMs are trained in "standard science-based care." Not sure why you think they are not. OB/GYNs have a different scope than CNMs, and CNMs have a different scope than CPMs, in that, each expertise is different. Some skills and knowledge overlaps, and some does not.

The training of CPMs is widely variable just like the training of a CNM is widely variable, just like the training of a OB/GYN is widely variable. Do all professionals have boxes to check, numbers to meet and hours to accrue? Yes. Do all CPMs have the same boxes to check, numbers to meet? Yes. Do all CNMs? Probably not - there is probably a minimum number of clinical hours for the national examination, but schools all have different requirements here. Same for OB/GYN. BUt all CPMs take the same test and have the same minimum hour requirement and experience requirements. So - maybe their preceptors could be good or bad but that is the same for doctors and CNMs too. Allll that to say.....all medical professionals go through similar processes to learn their expertise, and they all come out with variable education. CPMs are not unique in that. I just graduated nursing school with 29 other people and I am certain that we are not all qualified equally, yet we all went through the same process.

I also want to say that it is legal to practice midwifery as a CPM in 33 states (because you said they are unregulated in "most states"). 5 states currently have legislation for legality happening now, and 6 more are in planning stages. So really - in MOST states, CPMs are regulated. Some states "license" CPMs, some do not, but the CPM cert is usually what is used to "license" the midwife anyway (in my state) without other contingencies. So I am curious as to what the difference is to you - that "CPMs are not licensed"? I do not understand why you say they are unregulated - CPMs are regulated - in the states that regulate them.

To Original Poster:

That being said - I do not disagree that you should be very careful and contact your state board of nursing before you do observe (even if you are ONLY observing). Read your state Nurse Practice Acts. I would also familiarize yourself with all the CPM bylaws for your state. But thats just me and I tend to be very thorough.

I also would not want anyone at the birth to know I am a nurse. I also would be careful not to perform any nursing specific skills (IV placement for example).

I (obviously) am a CPM sympathetic. I am not against them in any way. I fully believe people can and should choose with whom they give birth and how they give birth. I believe we should all have freedom to choose our way of life - including birth to death - and everything in between. Sometimes that means we hire a crappy midwife - but you know what? Sometimes that means we hire a crappy doctor that spent 10 years in school. Crappy birth professionals are not limited to licensed midwives. Far from it. I have been a doula for 17 years, and I have seen so many really unprofessional doctors and even unprofessional CNMs. I have also seen unprofessional CPMs, but I've seen way more poor ob's.

Do your research, cover your tail, be professional, and you'll be good to go. Birth is beautiful and homebirth is an amazing experience.

[LibraSunCNM, BSN, MSN, CNM]

Sorry, but you don't want her to "come out thinking that Vit K is not really necessary," or that "routine vaccination is dangerous,"..? It is really sad that nursing school teaches that Vitamin K is 100% necessary and that vaccines are PERFECTLY safe. Both assumptions are false. This is one huge problem with our standard education, and it is a much larger problem of an unthinking population. I am not over here to say no one needs vaccines or Vit K - but please do not ever say they are completely without ill effect because it is not true.

Vitamin K and vaccines are choices just like taking any drug is a choice, and parents should be made understood all the implications of the drugs they and their infants/children are prescribed. THAT is what we were taught in nursing school. Do patients refuse medications? Yes they do. Do we as nurses always agree? No we do not. Are we our patients' advocate? Yes, yes we are. We teach them, and explain and educate again. We explain what we know - but yes, we tell them side effects, and there are side effects and poor outcomes for every single drug available. In the end, it is a parent decision. Not a nurses or a CPMs.

CPMs do not need "medical experience" because they are experts in normal/healthy pregnancy and birth. Once the norm has left the room, the midwife should leave the room too (i.e.: transfer to hospital). CPMs are trained in "standard science-based care." Not sure why you think they are not. OB/GYNs have a different scope than CNMs, and CNMs have a different scope than CPMs, in that, each expertise is different. Some skills and knowledge overlaps, and some does not.

The training of CPMs is widely variable just like the training of a CNM is widely variable, just like the training of a OB/GYN is widely variable. Do all professionals have boxes to check, numbers to meet and hours to accrue? Yes. Do all CPMs have the same boxes to check, numbers to meet? Yes. Do all CNMs? Probably not - there is probably a minimum number of clinical hours for the national examination, but schools all have different requirements here. Same for OB/GYN. BUt all CPMs take the same test and have the same minimum hour requirement and experience requirements. So - maybe their preceptors could be good or bad but that is the same for doctors and CNMs too. Allll that to say.....all medical professionals go through similar processes to learn their expertise, and they all come out with variable education. CPMs are not unique in that. I just graduated nursing school with 29 other people and I am certain that we are not all qualified equally, yet we all went through the same process.

I also want to say that it is legal to practice midwifery as a CPM in 33 states (because you said they are unregulated in "most states"). 5 states currently have legislation for legality happening now, and 6 more are in planning stages. So really - in MOST states, CPMs are regulated. Some states "license" CPMs, some do not, but the CPM cert is usually what is used to "license" the midwife anyway (in my state) without other contingencies. So I am curious as to what the difference is to you - that "CPMs are not licensed"? I do not understand why you say they are unregulated - CPMs are regulated - in the states that regulate them.

To Original Poster:

That being said - I do not disagree that you should be very careful and contact your state board of nursing before you do observe (even if you are ONLY observing). Read your state Nurse Practice Acts. I would also familiarize yourself with all the CPM bylaws for your state. But thats just me and I tend to be very thorough.

I also would not want anyone at the birth to know I am a nurse. I also would be careful not to perform any nursing specific skills (IV placement for example).

I (obviously) am a CPM sympathetic. I am not against them in any way. I fully believe people can and should choose with whom they give birth and how they give birth. I believe we should all have freedom to choose our way of life - including birth to death - and everything in between. Sometimes that means we hire a crappy midwife - but you know what? Sometimes that means we hire a crappy doctor that spent 10 years in school. Crappy birth professionals are not limited to licensed midwives. Far from it. I have been a doula for 17 years, and I have seen so many really unprofessional doctors and even unprofessional CNMs. I have also seen unprofessional CPMs, but I've seen way more poor ob's.

Do your research, cover your tail, be professional, and you'll be good to go. Birth is beautiful and homebirth is an amazing experience.

Sidestepping the vaccine conversation, which will likely get us exactly nowhere, and apologizing for getting off topic a little, here are my thoughts on your little manifesto...Cayenne was a CPM for years, so she would probably know the ins and outs of CPM education better than any of the rest of us. Their education, as I have learned from her as well as from researching the curriculum, is sub-par to that of a certified nurse-midwife. They are not simply different types of midwives, or different in that CPMs only work out of hospital, and CNMs mainly work in hospital---the two designations have VASTLY different levels of rigor in their training. This truly is not a matter of opinion, it is fact. That is the reason that the two types of midwives can't come together and merge under one, simplified title---the Midwives Alliance of North America, which oversees the title of CPM, refuses to adhere to the guidelines that MEAC, which accredits CNM programs, requires CNM programs to uphold.

To state that all CNM programs are different other than requiring the same number of clinical hours to take the certification exam is blatantly false---all CNM programs must meet the same requirements set forth by MEAC, meaning they are all teaching the same core competencies. Sure, all programs teach the material a little differently, and many may focus more on certain topics than others (Frontier, for example, does a nice job of incorporating out-of-hospital birth in their curriculum, while other programs don't), but compared to, say, nurse practitioner programs, CNM education, I'm proud to say, is strictly regulated and as a result, produces providers with a level of excellence that isn't matched by CPM programs.

Now...does this mean there are not crappy CNMs? Of course not. Does this mean that there aren't excellent CPMs? Of course not. I also completely agree that women have the absolute right to choose with whom they give birth, and where, after being completely informed of all their options and the risks and benefits of each. But to try to defend CPMs as different but completely equal to CNMs in their education is pretty laughable, and if you're going into nursing school with the goal of becoming a midwife, I'd encourage you to start keeping a more open mind about the world of OB---specifically, not viewing anything remotely medicalized as somehow the enemy of women.

[Jory, MSN, APRN, CNM]

I'm a little curious why you think midwives are against Vitamin K and other vaccinations. That's a little bit of a stereotype, don't you think? Just because you have some ultra-granola anti-medicine midwives doesn't mean that's the norm. CNMs are advanced practice nurses, same level as a CRNA, CNS, or NP. Their education and certification is highly regulated.

I disagree that this is even a slippery slope, assuming the CPM the OP wants to assist is certified and recognized in her state. Just because you are an RN doesn't mean that you function as an RN in every capacity.

As I stated before, there are many CNMs in between jobs that work as L&D nurses. They are not held more accountable than any other RN if they are functioning in an RN role. For example, if a physician cannot make it to a delivery and the baby is coming and there is a licensed CNM on the floor that is employed as an RN, she would be violating policies of the hospital if she attempted to step in and manage the patient as a CNM even though she had the skills to do so. If something went wrong the hospital's Liability Insurance won't cover it either.

We really need to stop with the liability myths. I told a whole classroom of students once I would give the first person to bring me ONE case where the nurse was formally disciplined for a med error would receive $100 from me in our state. I even gave them a week to search. They could go back as far as they wanted.

I kept my $100. i did the exercise because I was sick and tired of all of the nurses at the hospital constantly telling students how they would "lose their license" over a med error.

[elkpark]

I disagree that this is even a slippery slope, assuming the CPM the OP wants to assist is certified and recognized in her state. Just because you are an RN doesn't mean that you function as an RN in every capacity.

As I stated before, there are many CNMs in between jobs that work as L&D nurses. They are not held more accountable than any other RN if they are functioning in an RN role. For example, if a physician cannot make it to a delivery and the baby is coming and there is a licensed CNM on the floor that is employed as an RN, she would be violating policies of the hospital if she attempted to step in and manage the patient as a CNM even though she had the skills to do so. If something went wrong the hospital's liability insurance won't cover it either.

We really need to stop with the liability myths. I told a whole classroom of students once I would give the first person to bring me ONE case where the nurse was formally disciplined for a med error would receive $100 from me in our state. I even gave them a week to search. They could go back as far as they wanted.

I kept my $100. i did the exercise because I was sick and tired of all of the nurses at the hospital constantly telling students how they would "lose their license" over a med error.

There is plenty of documentation on this issue. You can't "turn off" your nursing education or licensure. When nurses (including APNs) choose to work in a position below their highest level of licensure, the dilemma and risk are that, if anything goes seriously wrong, the BON and courts will hold them to the standards of their highest level of education and licensure, regardless of the job description under which they are currently working. In the scenario you give, a CNM would almost certainly be held responsible by the courts and the BON if s/he was aware of an emergency situation and failed to step in and function as a CNM, regardless of the hospital's requirements, if there was a bad outcome and the situation ended up in court or before the BON.

Here are some sample statements from various BONs on this topic that I was able to find in a quick Google search several years ago. There is no mystery or ambivalence about this issue. I did not do an exhaustive search, and check every state BON website for statements, but, in the sampling below, each BON is clear that nurses are held to their highest level of education and licensure regardless of the job title or hospital job description under which they may be working at a given time. Bolding is mine.

New York:Can a Registered Professional Nurse (RN) or Licensed Practical Nurse (LPN) work in a position that is below his/her level of licensure?

Answer: Yes. A licensed nurse may work in a position that he/she has the training to do and that is within his/her scope of practice. RNs have the training to perform LPN, Certified Nurses Aid and Home Care Aid functions and therefore could accept a work identified for these levels. An LPN has the training to perform Certified Nurses Aid and Home Care Aid functions, and could accept work identified for either of these positions. However, the nurse that does so would still be required to act prudently based on his/her educational preparation and would be held to that standard.

NYS Nursing:Practice Information:FAQ

Wisconsin:

IF I HAVE AN RN LICENSE, BUT CAN ONLY FIND WORK AS AN LPN OR CNA, IS IT ACCEPTABLE FOR ME TO WORK IN A POSITION BELOW MY LEVEL OF LICENSURE UNTIL I CAN FIND OTHER WORK? THE SAME WITH AN LPN WORKING AS A CNA?

The Board of Nursing does not regulate CNAs, so questions regarding the practice of CNAs should be addressed to the Wisconsin Department of Health Services. It is important to note that while working at a lower level, you may be held to a higher standard of care due to advanced education, training and experience. Also, you must hold the credential for the profession in which you work.

http://dsps.wi.gov/Documents/Board%20Services/Position%20Statements/Registered%20Nurse.pdf

　

North Carolina:Can a LPN or RN work in a position that is below his/her level of licensure?

A licensed nurse may accept and work in a position that he/she has the training to do and that is within his/her scope of practice. A RN has the training to perform LPN and NA functions and therefore could accept a position identified for either of these levels. However, the nurse that does so would still be required to act prudently based on his/her educational preparation and would be held to that standard.

Error | North Carolina Board of Nursing

Iowa:Q. Can a LPN or RN work in a position that is below the level of his/her licensure?

A. There are no laws or Iowa Board of Nursing rules that prohibit a licensed nurse from working in a position that is below the level of his or her licensure. However, the board has previously determined that the nurse who does so is held to the highest level of his or her education. If a nurse is working in a position lower than the nurse's licensure and fails to act prudently based on education preparation, the nurse's license would be subject to sanction by the board.

http://nursing.iowa.gov/faq/practice.html#b1

　

Maine:Practice Below Level of Licensure

A licensed person who agrees to be employed in a position which requires less knowledge and skill than that for which s/he is prepared may find several problems:

1. S/he may be expected to perform at the level for which s/he has been prepared even though classified at a lesser level; and

2. S/he will be held to the standard expected of the higher licensure level should legal problems occur in that health care facility, no matter what the job classification.

The practice of employing licensed individuals to work below their level of preparation, as defined in the LAW REGULATING THE PRACTICE OF NURSING, places that licensed nurse in potential legal jeopardy and is of serious concern to the Board. (1985)Maine.gov - Error - Page Not Found

While searching for my old post, I came across a post from you as recently as February 11 that seems to suggest the opposite of what you're posting now:

"You can work below your license but you can't be held liable below your license. You can't take your LPN knowledge away.

Example: RN tells a medical assistant to give a blood pressure medication to Patient A. The RN is responsible for knowing the blood pressure needs to be checked prior to administration. The medical assistant, in the strictest sense of their training, does not. So if they give it to a patient that has a BP of 98/54 prior to administration, guess who is liable? The RN.

Example #2: RN tells an LPN to give blood pressure medication to patient A. Patient A has a BP of 98/54. The LPN should know that if you give blood pressure medication when it's already low it can cause them to bottom out and the low BP should be reported to the RN. If the LPN gives the med anyway, the LPN will probably be held just as liable as the RN."

[rac1, ASN, BSN, RN]

Now...does this mean there are not crappy CNMs? Of course not. Does this mean that there aren't excellent CPMs? Of course not. I also completely agree that women have the absolute right to choose with whom they give birth, and where, after being completely informed of all their options and the risks and benefits of each. But to try to defend CPMs as different but completely equal to CNMs in their education is pretty laughable, and if you're going into nursing school with the goal of becoming a midwife, I'd encourage you to start keeping a more open mind about the world of OB---specifically, not viewing anything remotely medicalized as somehow the enemy of women.

I'm happy to side step the vaccine stuff, and I wasn't trying to start a debate of any kind at all. I am not against vaccines. Nor for them. They are a tool.

I did not mean to imply that I thought CPMs and CNMs were "completely equal in their education" and I do not really think that I did imply that. My point was that their scopes are different entirely. They are trained differently because their scopes are different. CPMs do not require the training that CNMs are required because their scope is not that of a CNMs, similarly, the scope of CNM does not require the hours/education of that of an OB. The message I was trying to put across is that a CPM isn't "less than" because her training is not the training of a CNM. She has a different scope and does not need the training - just like a CNM does not need the training of a OB/GYN. Different scope = different training requirements.

Speaking of training requirements. NARM regulates the CPM and the CPM requirements are all the same. If the candidate does not graduate from a MEAC accredited program then the process is different, but is (supposed to be) equal to a MEAC accredited schools education. I wasn't in any way trying to insinuate that CNM programs are not good enough or something. Not sure how I came across that way - possibly because I was trying to say that CPMs are a safe option - everything else was clouded up... I don't know. I felt that the response I was replying to was pretty negative toward CPMs and that is where I was coming from. Doctors and CNMs have poor outcomes too. CPMs aren't the lone ranger there. I believe their training is all adequate (between professions) - it is the responsibility of the patient to hire competent care. We place trust in the licensing bodies to have strict requirements, and we have trust that people that have passed their licensing exams are safe practitioners, but that is not always the case. I have trust in our licensing and accrediting agencies. I have less trust in the people that pass the exams, and that is where education, information and interviewing comes in. Women have the right to choose how they birth and with whom.

I also do not have a closed mind about the world of OB - what makes you think I do? I really would like to know, because I can't imagine what lead you to think/say that to me. I do NOT view "anything remotely medicalized as somehow the enemy of women." I do not believe that in any way whatsoever. I have been a doula for a long time. I have seen the most natural birth to the most medicalized. I stated plainly that I believe women most certainly have the right to choose how they birth, whatever that means to them. Do I want them to be informed? Yes, yes, yes. I wish all women could have amazing care providers that give them awesome information and education so they can make truly informed decisions for themselves. If that means in a hospital with an epidural and continuous monitoring, with induction, AROM, and anything else on top - so be it. We all have our own paths and choices to make in life and we do the best we can with what we have, and when we know better we do better.