Why do we need the docs for delivery?

SmilingBluEyes · Feb 26, 2005

Because even though most deliveries are fine, there are those really scary ones where I don't want to be the one responsible. The physician has been well-trained to take care of babies in distress and I'd rather not be responsible. In fact one of the reasons OB is not my favorite place to practice is just that - I've been in one too many deliveries where things turn on a dime and a baby is in distress.
We are a rural hospital. In order to get a sick baby to a NICU, it takes getting a crew together and they have to fly up here - the flight itself takes about 20 minutes but then the ambulance has to go over to the airport to get the NICU crew. We are sooo happy when they show up and take over . . . .
I didn't go into nursing to be a L&D nurse . . . I work at a rural hospital where we do a little bit of everything. I do L&D .. . it just isn't my first choice. I don't want a brain damaged baby or dead baby on my conscience if, as the nurse, I was all alone with a delivery and the doc was no where to be seen. I'm grateful that our docs have their roles to play and I have mine. I don't want to be a doctor. I want to be a nurse.
steph

OHHHHHHHHHHHH I so relate to you here Steph. I did the rural hospital thing.....it was a GREAT learning experience. It was where I cut my teeth in nursing. But it was also way too "out there" for me.I would prefer not to go back now.

snowfreeze, BSN, RN · Feb 26, 2005

Maybe midwives as a part of the OB docs practices. Work together for the perfect outcome.

Ok I know, I am living in a bubble LOL.

But wouldn't that be nice, educate first. Lessen the anxiety and stress. And how can a man really understand pregnancy and birth and being a mother, he has the wrong hormones and body parts.

JaneyW · Feb 26, 2005

I know that the drs that are at the ob/cnm practice I go to have the same mentality towards childbirth as the mw's. However, there are some bad ones out there.
I think handwashing (or lack of it) and not the care provider was often the cause of mom's dying. I know that at one hospital (maybe more) way back when the drs had higher death rates than the mw's because the drs would go from autopsy to delivery w/o washing their hands. One dr did experiments with having his residents wash in a aseptic solution before examining women and that it cut down on the deaths. I think it took a while to catch on. Not sure if the mw's were washing their hands or not.

I think that was part of why there used to be such mortality in medical care in general--not just in OB. However, a lot of the deaths were from the baby being too big to push out (or the mom too small). Postpartum hemorrhage was also very common. Or maybe failure to progress to the point of a deadly infection. Not all babies are going to come out lady partslly with a good outcome for mom and baby. I believe the death rate for childbirth was 20% at the turn of the last century. That is one in five. I agree that CNMs can be very valuable for those with uncomplicated pregnancies and all women who need education for their birthing experience, but you are being naive to think that it would be best to return to the days when they were in charge. MDs have their place.

I had my babies with a perinatologist/OB doc and was glad for the peace of mind. My birthing experiences were all at the same hospital with the same doc but quite different due to the different labor nurses on those particular days. I try to keep that in mind when providing care to my moms. We can clearly make a big difference for the better for our moms without being the one to actually deliver the baby.

ER1010 · Feb 26, 2005

Just to clarify, I don't mean that obstetricians are not useful, just supposing that they are overused. I don't quite get why a highly qualified physician needs to run in to "catch" the baby on a normal delivery....seems to me like anyone with minimal training could catch, and certainly a highly trained obstetrical nurse. I am surprised that it (normal vag delivery) is still a task a physician wants to take on. I realize that some nurses don't want to catch, I am just saying that the ones who want too theoretically could.

On another note, however, in the event of an emergency, I am surprised that there isn't always an OB on the floor. Or two for that matter. Most of the time the nurses are left completely alone until near crowning, and knowing that an OB wasn't there just in case would freak me out.

Makes me wonder if OB nurses are given too much or too little credit in what they are permitted to do?

jrring1019 · Feb 26, 2005

Just to clarify, I don't mean that obstetricians are not useful, just supposing that they are overused. I don't quite get why a highly qualified physician needs to run in to "catch" the baby on a normal delivery....seems to me like anyone with minimal training could catch, and certainly a highly trained obstetrical nurse. I am surprised that it (normal vag delivery) is still a task a physician wants to take on. I realize that some nurses don't want to catch, I am just saying that the ones who want too theoretically could.
On another note, however, in the event of an emergency, I am surprised that there isn't always an OB on the floor. Or two for that matter. Most of the time the nurses are left completely alone until near crowning, and knowing that an OB wasn't there just in case would freak me out.
Makes me wonder if OB nurses are given too much or too little credit in what they are permitted to do?

Well, it takes more than minimal training to deliver babies and you only know it was a normal lady partsl delivery after the fact. When all is said and done we all say "what a great birth blah, blah, blah" but ANYTHING can happen during the second stage and I for one want someone there who has delivered a shoulder etc... Have you ever seen a BAD dystocia ? I have, probably the worst kind and I was glad to have the MD make all the decisions. As someone stated earlier, the docs "catch" the babies because the patients WANT them to (or they would have a midwife and deliver at home)

allnurses Guide · Feb 26, 2005

Well, it takes more than minimal training to deliver babies and you only know it was a normal lady partsl delivery after the fact. When all is said and done we all say "what a great birth blah, blah, blah" but ANYTHING can happen during the second stage and I for one want someone there who has delivered a shoulder etc... Have you ever seen a BAD dystocia ? I have, probably the worst kind and I was glad to have the MD make all the decisions. As someone stated earlier, the docs "catch" the babies because the patients WANT them to (or they would have a midwife and deliver at home)

You are exactly right . .. .if nurses want to deliver babies than they can get more training and do just that. In my role as a nurse, I realize that there will be times I might actually "catch" a baby but for the most part these are the textbook normal cases thank you God. The physician has had specific training for whatevery ends up happening and besides Neonatal Resucitation, I have not.

I'm a nurse. He/she is a doc. Different roles . .even though sometimes a nurse catches a baby. Even though most deliveries are without problems. Regarding the comment about why a highly trained physician would need to run in to "catch" a baby . . . Why would a physician go into any field if the outcomes were only scary?

Don't the physicians enjoy the miracle of childbirth? Isn't that the reason they go into it .. .to see these positive outcomes?

They are highly trained so they can only do high-risk stuff?

That doesn't make any sense to me.

steph

ER1010 · Feb 26, 2005

I am sure they enjoy births, I just thought since the doc doesn't come in (usually) until the end, that it makes it less fulfilling. It seems to me like some OB's are more interested in special procedures, research, etc, but that is just my observation.

ayndim · Feb 26, 2005

Just to clarify, I don't mean that obstetricians are not useful, just supposing that they are overused. I don't quite get why a highly qualified physician needs to run in to "catch" the baby on a normal delivery....seems to me like anyone with minimal training could catch, and certainly a highly trained obstetrical nurse. I am surprised that it (normal vag delivery) is still a task a physician wants to take on. I realize that some nurses don't want to catch, I am just saying that the ones who want too theoretically could.
On another note, however, in the event of an emergency, I am surprised that there isn't always an OB on the floor. Or two for that matter. Most of the time the nurses are left completely alone until near crowning, and knowing that an OB wasn't there just in case would freak me out.
Makes me wonder if OB nurses are given too much or too little credit in what they are permitted to do?

Nurse do deliver babies. They are called Nurse-Midwives You probably knew that! But the training is anything but minimal. It is a two year Master's program. I don't think that every baby needs a dr and that in most instances a CNM will do just fine. However, I am, while not alone, quite rare in my thinking. Most women just don't use them. Which is weird when you think of it. They have the highest satisfaction rating of any provider when delivering babies and in their prenatal treatment of mom. I think the average is 5-7% of births where midwives (CNM or direct entry). Of course in the UK it is opposite and most women use a mw. I think New Zealand is the same. I heard (not sure if it is true) that in Germany a mw must be present at the birth even if a dr is the provider. I have wondered if my German friend was pulling my leg. Since I don't read German I have no way of verifying this.

expatnurse · Feb 27, 2005

Nurse do deliver babies. They are called Nurse-Midwives You probably knew that! But the training is anything but minimal. It is a two year Master's program. I don't think that every baby needs a dr and that in most instances a CNM will do just fine. However, I am, while not alone, quite rare in my thinking. Most women just don't use them. Which is weird when you think of it. They have the highest satisfaction rating of any provider when delivering babies and in their prenatal treatment of mom. I think the average is 5-7% of births where midwives (CNM or direct entry). Of course in the UK it is opposite and most women use a mw. I think New Zealand is the same. I heard (not sure if it is true) that in Germany a mw must be present at the birth even if a dr is the provider. I have wondered if my German friend was pulling my leg. Since I don't read German I have no way of verifying this.

I fully agree that women are happier when they have been with a midwife instead of a doctor. I am a third year nursing student at present I am considering applying to midwife training later on. Would someone tell me more about there training? How long do you pratice as a nurse before you trained as a midwife etc. I love your take on episiotomies. When I was with the midwives there were fewer episiotomies done. In the USA I wonder if women are not aware a midwife can be there.

James Huffman · Feb 27, 2005

It seems to me like the experienced nurses on this board could very easily deliver the normal healthy deliveries. Just wondering if the OB nurses get frustrated with having a doc do the delivery, when all he or she did was catch? In Europe aren't all the nurses also midwives, and they only call the doc for emergencies? Do you guys think this would be a better practice?

An interesting account of how birth centers operate in Germany:

"Birth Centres in Berlin

Apparently, the first autonomous birth centre in Europe was established in Berlin in 1987 by midwives, a sociologist and a social worker. The inspiration came from the United States (people like Kitty Ernst and Ruth Lubic through the National Association of Childbearing Centres) and Sheila Kitzinger. Once just an advice centre, it is now not just a birth centre, but has a shop, a contact and advice centre and a domiciliary care service. Four more birth centres have opened in Berlin, and more than forty throughout Germany.

What is a birth centre? In Germany, a birth centre is an independent, privately run 'birth house', an alternative to the hospital. Almost all are run by independent midwives and are completely autonomous, not in any way attached to a hospital. Of the five in Berlin, I've chosen to concentrate on the original one. It's called Geburtshaus fuer eine selbstbestimmte Geburt, that is, Birth House for a self determined birth - GfesG). They have a limit of twenty-eight births a month, and often turn people away.

This birth centre is in a wonderful old apartment building on the second floor; it's a 300 square metre apartment consisting of: two education rooms, two birth rooms, two bathrooms (one equipped for water births), a kitchen and an office; it has high ceilings, wooden floors and a lovely atmosphere. Twelve midwives offer courses, antenatal and postnatal care and are rostered (24 hours), so a woman choosing to have her baby there doesn't know which midwife will attend her for the birth, but she has usually met all of them before her due date through courses and antenatal care. In some of the other Berlin birth centres, the woman can choose which midwife she would like to attend her birth. Apart from the size - and individual staff of course - this appears to be the major difference between the five centres.

When a woman arrives at the centre in labour, the midwife on duty stays and will usually call a second midwife for the birth. Another midwife may do the postnatal care, perhaps the one who lives closest. The principle of the birth centre is minimal intervention and maximum, individualised and holistic support. Alternative therapies are offered including acupuncture, homeopathy, moxibustion and foot reflexology. The contact and advice centre offers counselling, legal advice, pregnancy advice and courses on pregnancy, childbirth and parenting topics at reasonable rates. It fulfils an important role in the holistic care model and facilitates contact between women, couples, and new parents.

For women to be eligible, it must be a low-risk pregnancy with a normal birth anticipated. Ineligible women are those having twins, with breech or other abnormal lies, with serious illnesses, those who have had an operation on the uterus (VBAC, or lady partsl birth after caesarean, is now allowed, provided it's only been one) or women experiencing complications after miscarriage. Women who develop problems such as pre-eclampsia or gestational diabetes are excluded, and births before 37 weeks or after 42 weeks must be referred to a hospital.

The normal procedure is that the woman has her antenatal check-ups (or at least three of them) at the birth centre, but her obstetrician would do ultrasounds or swabs. Antenatal

courses (including baby care) are also offered, but they are not obliged to attend. When the woman goes into labour, the midwife may visit her at home first to see if she needs to come in - she also has the option of a home birth (about ten percent of the planned birth centre births become home births). When mother and baby are well, they go home four hours after the birth and are seen daily (more if necessary) for the following ten days. This is standard in Germany and paid for by the health insurance - in fact up to another eight visits to eight weeks postpartum and breastfeeding advice for as long as the woman is breastfeeding are all covered - and more if the doctor requests it.

Should problems arise during the birth the nearest women's clinic is only a few blocks away and over the years they have developed a co-operative working relationship. Health insurance is compulsory in Germany, so even those on welfare will be covered. Health insurance companies don't always agree with the fees the birth centres charge and there may be a 'gap' of up to 600 marks (about $720) to be paid by the family. The challenge for recognition from the health insurance companies will no doubt continue for a while.

An ongoing study2 of all non-hospital births in Germany has shown that a birth centre birth does not entail greater risks for mother and child. Their rates of caesarean sections (2.5%), episiotomies (6%) and bad perineal tears (1%), are lower than in hospitals.

In Berlin, approximately 1000 babies (or 3.6%) are born each year in birth centres. Of the planned birth centre births, 94% are normal, with a transfer rate of 15% (from GfesG). Transfers are usually during labour and result from pathological CTG and/or meconium staining. Water births are increasing and are now 35%. Sitting or squatting birth positions are favoured (45%) or on all fours (31%), 'beetle' position (lying on her back) is only 8% and the remaining 16% give birth lying on their side, standing or in water. There are very few birth centres with a doctor on the team. This means that only normal births are allowed to occur in birth centres (no forceps or vacuum extractors, nor infusions are allowed if not under the supervision of a doctor).

There is now more tolerance towards birth centres and one midwife said doctors seem more open and accepting of the birth centre midwives (in general, if they transfer) than the clinic midwives.

Some hospitals are more accepting than others, with one in particular favoured. A midwife who used to work there started a birth centre around the corner and has established a good working relationship. The other birth centres benefit from this. The GfesG midwives have meetings once or twice a year with the senior obstetrician at the local women' s clinic to discuss transfers and resolve problems. They also have weekly team meetings and regular supervision sessions.

Why go to a birth centre and not have a home birth? One of the main considerations is probably consideration for neighbours, as most people in Berlin live in flats; or women choose one that's nearer to a clinic than their flat - the homebirth away from home."

Jim Huffman, RN

BETSRN · Feb 27, 2005

Just to clarify, I don't mean that obstetricians are not useful, just supposing that they are overused. I don't quite get why a highly qualified physician needs to run in to "catch" the baby on a normal delivery....seems to me like anyone with minimal training could catch, and certainly a highly trained obstetrical nurse. I am surprised that it (normal vag delivery) is still a task a physician wants to take on. I realize that some nurses don't want to catch, I am just saying that the ones who want too theoretically could.
On another note, however, in the event of an emergency, I am surprised that there isn't always an OB on the floor. Or two for that matter. Most of the time the nurses are left completely alone until near crowning, and knowing that an OB wasn't there just in case would freak me out.
Makes me wonder if OB nurses are given too much or too little credit in what they are permitted to do?

Actually, docs rarely just "catch". There is a lot of technique to this and many babies do not just slide out. Believe me, I want the doc or midwife there to take that responsibility. Sure, I can "Catch" if the baby comes shooting out but that is really a rarity. With malpractice rates where they are and in this litigious society, I want the doc there taking the responsibility he pays dearly for!

ayndim · Feb 27, 2005

For women to be eligible, it must be a low-risk pregnancy with a normal birth anticipated. Ineligible women are those having twins, with breech or other abnormal lies, with serious illnesses, those who have had an operation on the uterus (VBAC, or lady partsl birth after caesarean, is now allowed, provided it's only been one) or women experiencing complications after miscarriage. Women who develop problems such as pre-eclampsia or gestational diabetes are excluded, and births before 37 weeks or after 42 weeks must be referred to a hospital.
Jim Huffman, RN

Funny how they say breech are abnormal for a birthing center. I don't think most think you could even consider it because here it is usually an automatic c-section. Makes me wonder if women birth breech babies lady partslly over there.