Should midwives assist in c-sections?

[jksmith]

I'm a student midwife writing a paper about midwives assisting OBs at sections. I am discussing the positive and negative sides and looking for your stories. I would especially like to hear from you are a midwife who assists in surgery, but I would also like opinions from those who did not. I am particularly examining the issues of continuity (is it better preserved by the mw being involved in the delivery or not), professional relations (how do the midwife and doctors work together, or not), and the promotion of natural childbirth (does it go against the midwifery ideals and goals, or not).

Please only post if you are ok with me quoting you in my paper.

[phathui5]

Not a midwife (mom and doula)- I'm not comfortable with the idea of a midwife assisting in a C-section. It seems wrong, out of place. I think that it would make sense for a midwife to sit in with a mom during a C-section, at the head of the table, for support, but not to be operating on her.

[HariB]

Maybe it would be good for you to clarify what you mean by 'assist' in csections...I mean, nurse-midwives are first, nurses, and it seems possible some if not all of them would be qualified to be one of the OR assists (no idea, though).  But did you mean actually assist with the surgery itself, or be onhand in OR for support, advocacy, etc? 

[HariB]

Maybe it would be good for you to clarify what you mean by 'assist' in csections...I mean, nurse-midwives are first, nurses, and it seems possible some if not all of them would be qualified to be one of the OR assists (no idea, though).  But did you mean actually assist with the surgery itself, or be onhand in OR for support, advocacy, etc? 

[jksmith]

Sorry, I will clarify:

some midwives in Canada and the US can become certified to be the first surgical assistant in a cesarean delivery (normally done by another physician or a surgical certified nurse)

[jengacnm]

 Hi jk-

I'm a CNM and have first assisted at c sections. Most of my patients appreciated knowing I was on the other side of the curtain. For some scheduled sections (placenta previa, breech), we actually bantered back and forth from over the curtain.

I can't speak much more to the experience of the patients, but I can speak for me. I was a CNM employee in an MD owned practice, and my boss sent me to a c section workshop. A year later I got let go, and another year after THAT I started a private home and hospital birth practice with another CNM.

I ABSOLUTELY loved being able to "do it all". I could help someone have her baby at home; if she needed a transfer I could continue to care for her and catch her baby; and if she needed a c section I could STILL help her baby out.

Speaking to a previous poster, I did some advocating as the first assistant. At one the doctor was going to close her uterus with a single layer, which we know increases the risk of uterine rupture in future pregnancies. It was a little tense, but the doctor did a double layer when I mentioned that she wanted more children.

Another piece of advocacy that may be a bit less "important" than a double layer uterine closure is that I ALWAYS asked the doctor to close the skin with a suture/technique that would minimize scarring.

Finally, once the surgeon told anesthesia to give an antibiotic after the baby was out, and I said, "She's allergic to that one". Chances are quite good that the anesthesia doctor would have noticed it, but wow, it's SO GREAT to know my patients as well as I do.

I understand another previous poster that it seems "wrong" and "against midwifery philosophy" to be a surgical first assistant. CNMs make complicated decisions for complicated reasons. In some academic medical center somewhere, CNMs learned how to do circumcisions because the residents were screwing them up. I'm ethically opposed to circs, so I don't see myself expanding my skill set in that way. In rural areas some CNMs do vacuum assisted births. I'd consider learning how if it were truly needed wherever I was working.

I'll admit, though, that I like first assisting because I like it. My former midwife partner teased me that I'd be going to med school soon. I think my wretching noises convinced her otherwise. :)

Oh, another thing: I'm a reiki master, so when we were closing I would sneak in some reiki during pauses. Who knows if the reiki energy could make it through the surgical gloves, but I like to think that that helped the healing process to some degree. 

Where in Canada are you? I'm applying to the bridging program at UBC. I'm done with the crap over here in the states.

I'm happy to share more if you like-pm me.

[jengacnm]

Oh, another thing-don't know if this important: my home to hospital transfer rate hovered around 15%, and my c section rate is about 7%.  

[Wittyone]

I am a CNM that also 1st assists for c-sections.  The midwives do at least 75% of the births in this hospital and our c-section rate is low.  When I trained for 1st assist I was a little intimidated, and my response to people who asked why I became a midwife instead of an OB has always been that I wasn't interested in being a surgeon.  However, the continuity of remaining with a family when a c-section is indicated, being able to reassure them that I will still be with them and that I will still be receiving their baby (one of the perks of the 1st assist!) is really nice.  I also feel that I am constantly learning during surgeries.  My relationship with our OBs is very collaborative and they are happy to answer my questions.  I think being present at the surgery also gives me information that I can review with the family and help answer their questions.  I'm not often in the OR, but it's a skill I am very happy to have. 

[LizD]

I'm a nurse in a small community hospital's Childbirth Center. I love that the midwives first assist. It preserves continuity of care and seems to uphold respect for the midwife as a medical professional. I see a far more collegial atmosphere betweeen OBs, midwives, nurses, techs in our practice than anywhere I worked as a doula, and I suspect this is a factor. 

[mclisa]

It would depend on if they have previously been trained to assist.

And the other thing to consider, does their malpractice insurance cover them during the c/s.  When lawsuits occur, they can sue anyone with their name on the OR record.  That might limit if they can officially scrub in or not.

I personally think they would be better with the patient where they can offer comfort (at the head of the bed)

[katelove]

In Australia a midwife *always* accompanies a couple to OT for a c/s. The midwife's role is to provide support during the preparation, epidural insertion, settling on the table etc. S/he then scrubs and receives the baby (is handed the baby by the surgeon). Sometimes the midwife is solely responsible for the initial baby check and sometimes there is a paed there as well. Once the check is done the midwife takes the baby to the mum for a cuddle and, in most places these days, stays with them both in recovery and accompanies them back to the ward.

It's a bit different here though I guess because all maternity units are fully staffed by midwives. We don't have L&D nurses and we don't have single certificate RNs in the wards.

I think it would be fine for a midwife to be the first assistant as long as there was another midwife to do the above.