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.

[LibraSunCNM, BSN, MSN, CNM]

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.

Really not trying to get into an argument with you, I'm just offering my perspective as a CNM on your comments. I appreciate that you have a passion for being with women and are working your way down the CNM pathway. My two main points to your reply are these, and then I'll leave the thread to get back to its original discussion:

-I fundamentally disagree that CPM education is adequate, even for its sole scope in OOH birth, and that NARM does an adequate job of regulating CPM programs. This is based on information I have gotten firsthand from former CPMs, including cayenne, as well as interactions I've had with them in real life, and I'm sad to say you will never be able to convince me otherwise.

-my impression that you have somewhat of a closed mind about the world of OB stems not just from your prior comment in this thread but your recent comment in another thread about how you will possibly survive OB clinicals in a hospital without becoming so discouraged you will give up on midwifery. I'm glad from your last comment that you have clarified a little that this is not the case.

Peace and good luck in school!

[rac1, ASN, BSN, RN]

Really not trying to get into an argument with you, I'm just offering my perspective as a CNM on your comments. I appreciate that you have a passion for being with women and are working your way down the CNM pathway. My two main points to your reply are these, and then I'll leave the thread to get back to its original discussion:

-I fundamentally disagree that CPM education is adequate, even for its sole scope in OOH birth, and that NARM does an adequate job of regulating CPM programs. This is based on information I have gotten firsthand from former CPMs, including cayenne, as well as interactions I've had with them in real life, and I'm sad to say you will never be able to convince me otherwise.

-my impression that you have somewhat of a closed mind about the world of OB stems not just from your prior comment in this thread but your recent comment in another thread about how you will possibly survive OB clinicals in a hospital without becoming so discouraged you will give up on midwifery. I'm glad from your last comment that you have clarified a little that this is not the case.

Peace and good luck in school!

Thanks for the clarification. Your words came across strongly to me, and it's rough hearing such negativity when I do not feel that I embody such negativity in that way.

Anyway - I don't remember stating anything about giving up on midwifery because of ob rotation. But I recently did reply to someone else that spoke that way and my response was very positive.

[LibraSunCNM, BSN, MSN, CNM]

Thanks for the clarification. Your words came across strongly to me, and it's rough hearing such negativity when I do not feel that I embody such negativity in that way.

Anyway - I don't remember stating anything about giving up on midwifery because of ob rotation. But I recently did reply to someone else that spoke that way and my response was very positive.

I'm sorry you felt my comments were rough to hear. They are just one CNM's opinions. In healthcare, and OB in particular, it's vital to grow a thick skin. For what it's worth, here is the thread I was referencing: https://allnurses.com/certified-nurse-midwives/l-amp-d-893517-page2.html. Again, good luck and take care.

[klone, MSN, RN]

My second child was a homebirth with 2 CPMs, and they did a fabulous job. I would not hesitate to choose a well-qualified CPM for a homebirth in the hypothetical situation of having another child.

[Leader25, ASN, BSN, RN]

CPM????

[queenanneslace, ADN, MSN, APRN, CNM]

I attended births with CPMs, and at one point was apprenticing to become a CPM. I had chosen that route because I felt pulled toward that model of care, and wanted to provide midwifery services in out-of-hospital settings.

I concur with the other posters here who have concerns about the education and training of CPMs. So I won't repeat myself.

I will say that the last birth I attended with a CPM (in a home setting) was during nursing school. Once I had my RN license, I was very reluctant (resistant) to jeopardizing my license by even being present with a CPM at a home birth. And they ask me... because I think it lends legitimacy to what they're doing: "My birth assistant is an RN!"

I know how the board of nursing regulates nursing in my state, and I know how midwifery is *not* really regulated in my state (despite CPMs being licensed), I do not want to take the chance of being present at a home birth gone wrong.

No question in my mind that I would be subject to scrutiny for my professional actions (or inactions), and held to a higher standard than the CPM.

[rac1, ASN, BSN, RN]

I'm sorry you felt my comments were rough to hear. They are just one CNM's opinions. In healthcare, and OB in particular, it's vital to grow a thick skin. For what it's worth, here is the thread I was referencing: https://allnurses.com/certified-nurse-midwives/l-amp-d-893517-page2.html. Again, good luck and take care.

You don't have to be sorry for your comments. It's good to hear things like that, I was just looking for your perspective and trying to figure out why you were saying what you were. The thread you referenced doesn't have me saying anything about giving up because of my OB rotation..? So I don't know what you are talking about. I had a wonderful OB rotation, and I have been to countless hospital births as a doula. Again, I did recently see someone else post about the OB rotation in nursing...not sure if that is what you're referring to because I did respond to that one....

[Jory, MSN, APRN, CNM]

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.

I'm sorry, talk to any licensed CNM and you'll discover you are absolutely incorrect on this issue. There are tons of CNMs taking a break or looking for jobs that work as RNs and I challenge you to find ONE case where a CNM was working in the capacity of an RN at a hospital and was held legally responsible when a physician wasn't in attendance.

One. No, your Google search of your interpretation doesn't count. Find an actual case.

This happens all the time in hospitals and where are all the lawsuits? Well, there isn't any. If you seek more education on this matter, I would suggest you contact the American College of Nurse Midwives. It's not even a gray area.

You are confusing W-2 employment with other APRN positions that typically require collaborative agreements and in some states a formal supervisory agreement before it's even legal for a CNM to practice. Nothing in your example addressed APRNs. What if I attended a delivery and the patient had a postpartum hemorrhage and the OB wasn't there? Do you honesty think I can order the nurses to go get 800 mg of cytotec or methergine? Uh no, I cannot.

Let me explain what performing to the "top of your license means", it means in your current capacity. At my hospital in L&D, per policy, ONLY THE CHARGE NURSE attends a delivery if the OB cannot get there. Let's say the bedside nurse was a CNM functioning as a RN. That CNM cannot step in, go against the policy of the hospital and tell the charge nurse to step aside. Even in the case of a shoulder dystocia, if the delivery was unattended, you actually think she could step in and cut an episiotomy? No, she cannot.

[babyNP., APRN]

I'm sorry, talk to any licensed CNM and you'll discover you are absolutely incorrect on this issue. There are tons of CNMs taking a break or looking for jobs that work as RNs and I challenge you to find ONE case where a CNM was working in the capacity of an RN at a hospital and was held legally responsible when a physician wasn't in attendance.

One. No, your Google search of your interpretation doesn't count. Find an actual case.

This happens all the time in hospitals and where are all the lawsuits? Well, there isn't any. If you seek more education on this matter, I would suggest you contact the American College of Nurse Midwives. It's not even a gray area.

You are confusing W-2 employment with other APRN positions that typically require collaborative agreements and in some states a formal supervisory agreement before it's even legal for a CNM to practice. Nothing in your example addressed APRNs. What if I attended a delivery and the patient had a postpartum hemorrhage and the OB wasn't there? Do you honesty think I can order the nurses to go get 800 mg of cytotec or methergine? Uh no, I cannot.

Let me explain what performing to the "top of your license means", it means in your current capacity. At my hospital in L&D, per policy, ONLY THE CHARGE NURSE attends a delivery if the OB cannot get there. Let's say the bedside nurse was a CNM functioning as a RN. That CNM cannot step in, go against the policy of the hospital and tell the charge nurse to step aside. Even in the case of a shoulder dystocia, if the delivery was unattended, you actually think she could step in and cut an episiotomy? No, she cannot.

yeah, I mean if she doesn't have privileges at that hospital, she really can't do any of those advanced procedures. I've always been curious how this would work as everyone says that you're expected to practice...if I was a RN attending a delivery and a baby needed to be intubated but I wasn't privileged for that, I don't see how I could be held liable for that. If I thought a baby needed a sepsis work up but the provider disagreed, I can't go over her head and order antibiotics...

[LibraSunCNM, BSN, MSN, CNM]

yeah, I mean if she doesn't have privileges at that hospital, she really can't do any of those advanced procedures. I've always been curious how this would work as everyone says that you're expected to practice...if I was a RN attending a delivery and a baby needed to be intubated but I wasn't privileged for that, I don't see how I could be held liable for that. If I thought a baby needed a sepsis work up but the provider disagreed, I can't go over her head and order antibiotics...

Agreed, I think that "you're held to the highest level of your licensure" stuff is somewhat urban legend. I know of no one who has actually faced consequences for not stepping in as an APRN when they were working in the staff RN role.

[Jory, MSN, APRN, CNM]

yeah, I mean if she doesn't have privileges at that hospital, she really can't do any of those advanced procedures. I've always been curious how this would work as everyone says that you're expected to practice...if I was a RN attending a delivery and a baby needed to be intubated but I wasn't privileged for that, I don't see how I could be held liable for that. If I thought a baby needed a sepsis work up but the provider disagreed, I can't go over her head and order antibiotics...

Nope, you cannot. It's a huge myth that exists when APRNs work in an RN role that needs to be squashed.

I'll give you an unlikely example, but a good one on a "top of your license scenario".

Let's say that I was an acute care nurse practitioner and my primary job was working in a hospital. Let's say that I had extensive training in intubating patients, performed tons of codes, etc.

Now, let's say I'm working as an RN (not as an APRN) and a patient codes and maybe RT is slow to respond because of other fires in the hospital. Let's say it's night shift and the ER is a train wreck, docs are tied up, etc. Most hospitals have policies that will allow a senior nurse, etc., to attempt an intubation in a life-or-death emergency especially if that RN is trained in transport.

Let's say I butcher the job. Badly. Cause all kinds of damage to the vocal cords, etc.

What standard am I going to be held to for that skill? An RN that may only perform one or two intubations a year (b/c there is not a true proficiency) or the skill that I can actually perform because I am also licensed as an acute care NP and perform them often, hundreds maybe even thousands of times.

One is just an unfortunate outcome because the patient was going to die anyway if someone didn't do something....now.

The last example can be viewed as negligence because once you have learned a skill...you can't unlearn it. If it's something you know how to do, you are expected to perform it to the highest level of which you have the ability.

Does that make sense?

[cayenne06, MSN, CNM]

My second child was a homebirth with 2 CPMs, and they did a fabulous job. I would not hesitate to choose a well-qualified CPM for a homebirth in the hypothetical situation of having another child.

And here's the problem. We as health care providers might have the know-how to research a potential CPM and determine if she is qualified and experienced. The lay public may not know how to vet a potential provider, nor should it be their responsibility.

As it stands right now, the CPM credential does not in ANY WAY guarantee that said midwife is trained to the entry level standard set by IFM. All midwives should be held to the same standard of care. Of course there are awesome CPMs, but the credential itself is shockingly subpar. Our patients deserve better than this double standard.