Why do we need the docs for delivery?

mitchsmom · May 5, 2005

I didnt say that they were certified. In the Proud State of Texas, anyone can advertise that they are a midwife. Unfortunately only the ones who are certified can be censored by the state if some unfortunate event happens.

I don't know what you mean by "anyone can advertise that they are a midwife" but just to clarify, midwives do have to be documented in Texas.

In order to be documented they must have completed one of certain education options outlined in this link:

http://www.tdh.state.tx.us/hcqs/plc/mwdoc.htm

It reads in part:

"Before someone can apply for documentation as a midwife in Texas, an individual must:

1. Successfully complete a course on midwifery (either on-site or correspondence course) approved by the Texas Midwifery Board AND successfully pass the state approved comprehensive written exam;

OR

2. Successfully complete a MEAC-accredited course on midwifery AND successfully pass the state approved comprehensive written exam AND successfully complete a continuing education course on the current Texas Midwifery Basic Information and Instructor Manual;

OR

3. Qualify for certification by NARM and complete the NARM certification process, thereby becoming a Certified Professional Midwife (CPM) AND successfully complete a continuing education course on the current Texas Midwifery Basic Information and Instructor Manual."

Further:

"It is illegal to practice as a midwife in Texas without documentation. The Texas Midwifery Board is authorized by the Texas Midwifery Act to take disciplinary action against persons who violate the Act, including the imposition of administrative penalties (monetary fines). Practicing without documentation may also subject a person to civil or criminal penalties. "

shukry · May 5, 2005

My mother had a donzen children all at home, with a midwife who did not go to school. We all turned out alright. A doc. delivered my 1st and 2nd children, and midwife the 3rd. I recommend a midwive, they are more patient and explain things more clearly. Doc's visit is in and out, and if you ask questions, you are wasting their time($$$$). I would like to be a midwife someday, and put women in charge in this field. When I had my second one the doc. just came in to catch the baby, after the midwife did everything else (I actually never so the doc. until the next day when she introduced herself, since I had my eyes closed during the delivery) haaa!!.

FrumDoula · May 8, 2005

In the UK the midwives do the"Normal" deliveries at hospitals, birthing units and at home. That is what we are trained to do, as well as look after abnormal pregnancies. It is very rewarding and very good experience/practice, you do enhance your skills(ie. suturing, water births etc)! The Drs would always be called if there are abnormalities in the pregnancy or labour. I think midwives from the UK would become very de-skilled working on a L&D unit in the US!!

And it must be noted that England has better outcomes than the US in terms of infant and maternal mortality and morbidity than the US.

In countries where midwives handle the low risk births, and docs handle the high risk stuff you tend to get far better outcomes. The US spends the most dollars per capita on pregnant women, and yet our stats suck. It's very sad, and more reflective of politics, money and power than true concern over women's health.

Hey, is that a soapbox under me, or am I just dreamin'? :)

Alison

BENNETTRN · May 9, 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?

I am in my 4th of 5 month orientation on labor and delivery. L&D has always been my dream and I love almost every minute of it. My preceptor is the most wonderful and skilled nurse with a wealth of experience and knowledge, some docs she would rather not call but she always calls them, and I know others that dont call on purpose. But she has seen so many bad situations in delivery that what would have happened if she didnt call the doc, many times you dont know until the you have minutes to intervene, interventions that only a MD can perform. What happens when you have a shoulder dystocia and only minutes?, or a bleeder? or the thousands of other things that go wrong in delivery. I know I am such a scared young nurse and will one day after years not cringe at the thought the doc doesnt make it like I do now, but the liability is out of this world. My preceptor has been sued two times, both of which were deemed not her fault, one was a mother who had a amniotic fluid embolism (I know not currently used term anymore) and another for what was a very uneventful labor and delivery but the baby had some deficits in its 6 month and so of course the doc and RN were sued. It just doesnt seem worth it too me, and I know it doesnt to my very seasoned preceptor (23 yrs as a labor RN). In only 4 mo's I have seen probably 15 deliveries go to H#$LL in a handbasket in minutes. Our hospital delivers the most babies in our city, so there is quite a variety of things to see and learn and go wrong everyday! If I wanted to deliver babies and deal with that end of the job I would go to med school or become a CNM. Just being a L&D nurse comes with enough liability, I want no more than that. If every attempt and honest effort was made to get the doc to the delivery in time thats one thing but if on purpose you didnt ensure that happened, could you live with yourself if a bad outcome occured?

sbic56, BSN, RN · May 9, 2005

Hey, steph...it's me, agreeing with you! :chuckle

Seriously, though...I work in a rural setting like yours where we are already the nurses of all trades of the dept. It takes NICU 45 minutes to arrive, so you can be bagging for that long, assisting peds with U/V lines, drawing blood, starting periperals. Yes, the arrival of the team is sweet!

We are also the PP nurse, lactation nurse, nursery nurse...

So, as far as delivering the baby? Sure, it's doable at a normal vag delivery, but I prefer to get the doc there. I have "caught" 11 and counting, as the docs don't arrive too promptly at 3 am when called at home. Then there are those who get off the elevator grunting, "I gotta puuush!" Still, unless I have midwifery training and the little bump up in pay to go with it, I'd rather only do the "as needed" type catch deliveries, thanks. Dystocias, cervical tears...that's CNM/doc territory. Actually, I worry more about delivering the placenta than the baby; that's when the problems come! I'll never forget that inverted uterus that came right after the baby...yes, the doc was there, but that is the type of "suprises" that can come with that "normal" vag delivery. :eek: I suppose if there really was a doc in the area, I'd be OK doing most deliveries, but geez, in an LDRP, with no NICU, we do enough!

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

FrumDoula · May 9, 2005

Shoulder dystocias seem to frighten everyone. However, there are ways to educate yourself so you at least have a clue as to how to handle the problem. I figure that if something scares the piss out of ya, it's worth researching a little so it doesn't scare you as much. :)

I was always taught (in case, God forbid, a mother gave birth precipitously at home while I attended her as a doula) that you can do the Gaskin maneuver. You simply flip mom into an all fours position and this can unstick the baby (and in my case, while simultaneously dialing 911 and popping a Xanax :) ). The maneuver was popularized by Ina May Gaskin, a lay midwife and author of Spiritual Midwifery. At her birth center on The Farm, in Tennesee, they have something like a 2% c-section rate, and they do breech births and twin births. Incredible stuff. Anyway, she learned the maneuver from midwives overseas, and she trains other midwives and docs in this procedure. It's slowly catching on and appears to be highly effective in preventing both maternal and fetal complications.

The more standard one is McRoberts, which I've seen a couple of times, though you can really hurt a woman if you overextend her, so you have to be careful. If the mom is unmedicated or has a light epidural in, the Gaskin maneuver is certainly worth a try, and even women with heavier epidurals can potentially be flipped over. Any of the experienced L&D nurses have familiarity with this?

A doula friend of mine was laboring at a birth center with a client in the middle of the night, the doc and assistant had been called, but mom was speeding along. As the baby was coming out, shoulder dystocia happened. So DeeDee, who deserves the Doula of the Year Award for keeping her head on straight, flipped mom into the Gaskin maneuver. And waited for a moment. And nothing. She then had to corkscrew the baby out, which worked fine. In fact, she had seen a similar case the week before when she assisted at a homebirth with a CNM. The CNM showed her exactly what to do in such a case.

The point is that the docs aren't the only ones who hold the secret info about shoulder dystocia. Traditional midwives, CNM's and others have passed down great wisdom as well through the ages.

Here's a good article, with accompanying research, on the Gaskin Maneuver - the first obstetrical maneuver to be named after a midwife:

http://www.inamay.com/gaskin_maneuver.php

Alison

mitchsmom · May 9, 2005

That link is very interesting. I had read before that getting on all fours was very effective for shoulder dystocia.

As I read it now, I wonder if other confounding factors would make a difference in the comparison. Meaning, I wonder if the mothers in the hospital dystocias had other risk factors & the Gaskin babies were from very low risk mothers that would make manuevers more successful in general for them (as generally homebirth moms are lower risk in general than hospital birth moms on average).

I just wonder if aside from the fact that they all had shoulder dystocia, if other related facts were the same- is it comparing apples to apples? A healthier, lower risk mom birthing at home or at the Farm may lend herself/her baby to easier resolution of shoulder dystocia in general. Does that make sense? Just pondering here - anyone can throw in their ideas.

Not to put the all fours thing down, anything that is promising for relieving shoulder dystocia sounds great to me (my third baby was a shoulder dystocia baby (relieved w/ McRoberts & suprapubic pressure- I had none of the commonly listed risk factors & it was a med free birth that I moved around in freely the whole time).

SmilingBluEyes · May 9, 2005

I am well aware of Ina May's works and her manuever. It's great and it does work. Problem is, so many of our moms have prohibitive epidurals. Knowing ALL The manuevers and tricks to relieve shoulder dystocia are necessary in the hospital environment, just as they would be at Farm or in the home. I agree, educating ourselves is so important. All it takes is one BAD shoulder dystocia to make you want to learn MUCH MORE, which I have taken upon myself to do.

Mermaid4 · May 9, 2005

You know, I was and am never frustrated that a doctor is either there or readily available when it is time to deliver. I have delivered many babies (some were in a very big hurry), including some shoulder dystocias when the doc wasn't there. I still would rather have the doc there since that is what they do AND I prefer being up there coaching the patient. I don't think there is a simple answer to the question in that my frustration sometimes centers around disaggreements in the way the delivery is handled by the physcian and I am enough of an advocate and experienced enough to intelligently and professionally voice any concerns I may have. I agree with Smiling Blue Eyes....Not such a simple question as it seems...Liability these days makes me HAPPY to have the doc there.....

Mermaid4 · May 9, 2005

The old knee chest maneuver you speak of does NOT always unstick a baby....Attend a few of these deliveries when the doc has to break the clavicle...You will never forget it...

SmilingBluEyes · May 10, 2005

The old knee chest maneuver you speak of does NOT always unstick a baby....Attend a few of these deliveries when the doc has to break the clavicle...You will never forget it...

A-men. Thank goodness this is not too common.

URO-RN · May 10, 2005

I had an OB rotation in nursing school. So I agree that most nurses run the show and the doc is there to "catch" the baby.

I admire and respect OB nurses. They really do care for the patients and give it their all.