what make a hb midwife "not safe" to you?

[carrieb26]

Reading through some other threads got me thinking about what makes a "safe" midwife.

I used a particular MW for my last birth, and am thinking to use her for my next, but some of the reasons that I liked her might be things that others would consider "not safe."  I guess I'm having some second thoughts, even though I prefer her over the other mw I interviewed. They are the only two that serve this area, AFAIK.

So, for you, what makes a MW "not safe"?

Carrie

[lisathena]

For me i thought my last MW was safe, but afterwards i think back and i dont like how she handled my PPH and she lied about it. That in my book makes her unsafe. I would not go back to her, in fact i am being forced into a birth center birth to avoid having her as my MW.... And now afterwards alot of ppl i have talked w/ say "oh yeah, i have heard that about her!" well thanks LOL I guess do research and really find out if others felt she was safe. And if you are comfy w/ her and like how she handled things then i dont see why you think she isnt safe....

[kcparker]

For me, a HB midwife is safe if she:

- she has received adequate training for doing OOH hospital deliveries and dealing with complications in this setting (this question of what constitutes "adequate training" can be so variable - a CNM might not have great prep. for an emergency in the home setting despite having attended 500 births, and an apprentice-trained midwife might have attended 500 births but still be crummy at suturing), is current on all her trainings (like neonatal resuscitation) AND has a commitment to doing continuing ed. and staying current in the field;

- carries emergency supplies (oxygen, pharmaceuticals for stopping a hemorrhage) AND knows how to use them;

- is honest with you in an interview about her training, skill set, past outcomes, and philosophy about care and homebirth;

- has a partner and/or back-up and a reputation for good clinical judgment in the local HB community (and if she is respected by local doctors, I think that also says a lot);

- is very clear with you about situations in which she would transfer care, either prenatally, or during labor. A philosophical commitment to homebirth should be tempered with a recognition that sometimes, the hospital and an OB's care really IS the appropriate choice. She should be willing to make that call and not worry about disappointing you, and she shouldn't have an antagonistic attitude towards hospitals;

- can give you references for clients who have had complications and can vouch for how she resolved them (PPH, dystocia, etc.);

- you feel on a gut level that you can trust her. She is the guardian of your birth. She will be in your space at a very intimate moment in your life. You need to feel that you can count on her not to cause harm through action, inaction, or attitude, to identify if something is going wrong, and to counsel you on appropriate action to take. Don't discount the 'vibe' you get, and if the 'vibe' isn't good, pay attention.

[carrieb26]

She wasn't actually at my last birth - was too fast, and she didn't make it, so I can't speak to her abilities while in labor.  Mostly my wondering of "safe" comes from thinking back on things in preparation for this birth.

Things like

- few prenatal check ups, no postpartum follow up

- comments like "I went to some seminars and read some about breech birth, and have now done a few, so I'm okay with them"

- I contacted an out of area mw I'd seen before about mw in my area, and she said that she would refer people to other mw's before my current one, since she felt others had more trainng and experience, and she'd heard other handle care with a little more attention.

It's just got me wondering.

[kcparker]

Lack of prenatals is a red flag for me. Part of being safe in her hands comes from her knowing your medical history and the course of this pregnancy so that she can see if it's deviating from normal. She ought to be following you with the same frequency as a family practice doc. or an OB. 1x/month for the first 7 months or so, then bi-weekly, then once a week for the last few weeks of pregnancy. If you are having issues with baby's weight gain or abnormal fluid levels, your blood pressure, gestational diabetes, etc., she should have the charting in place to have a clear picture of the course of your pregnancy. I think it's also normal that she ought to have you do a GBS culture (just in case you have to transfer care to the hospital, it is charted and if you are negative you don't have to get abx.). Plus, part of the beauty of homebirth care is that the midwife spends time geting to know you as a person - what are your strengths, fears, nutrition, lifestyle stuff that will affect the pregnancy or birth?

And, Say What!?! NO postpartum follow-up? She needed to come see you the next day, make sure the uterus and vagina are in good shape (esp. if you had any tears that she repaired), then again in the first 2-5 days at least once more to check in with you, particularly regarding baby's weight and nursing (especially for a first-time mom, she should have been really vigilant about making sure breastfeeding got off to a good start), then again for a 6 week visit to make sure you are healing properly, bleeding has ceased, etc. My HB midwife came to see me THREE times in the first week, and I wasn't even a 1st time mom.

No, breech birth, "I'm cool wit' it" doesn't cut it as an answer. Can she tell you protocols and techniques, can she walk you through a scenario? "Let's say you discover once I am fully dilated that baby is presenting breech. How do you handle this? How do you handle it if I am 6 cm. dilated and a foot comes down and is sticking out of my vagina?" She should have specific training and specific answers to these sorts of questions, and you should feel confident that these are the RIGHT answers, not just "it's all good, trust birth."

[kcparker]

Originally Posted by carrieb26 

She wasn't actually at my last birth ..

- few prenatal check ups, no postpartum follow up

What DID she do for you then?

[mwherbs]

What KC Parker has to say I pretty much agree with now maybe in a general discussion glossing ove things but if questioned further then detailed protocols emerge. For instance at an eary interview and you have a list of things you want to know about details about breech birth may be not elaborated on much unless you ask for specifics... Someone who can think on her feet. As far as meds for hemorrhage, humm not every state allows even licensed or legal midwives to carry meds... So what is the plan for managing a hemorrhage ? External or internal/ external bimanual compression - often even with drugs this kind of hand skill is needed and works fast while waiting for drugs to work , if herbs are used what are the additional protocols.

[carrieb26]

What you've said has given me a lot to think about.

And your last question actually made me laugh! What did she do for me... Not much really.  She came after the birth and helped with a bit of retained membrane - placenta was in the vagina, but the membrane was caught near the cervix from the uterus clamping down. She worked carefully to extract it, and the did a thorough check to make sure all of the placenta and membranes were present.  Did the newborn exam, but I don't know how extensive that was, as I was out of the room showering.

I guess at some level, I'm concerned about "what if" twins - there's a family history on both sides for twins, and the other midwife transfers care to hospital if she's aware of twins.  to my knowledge, there are no docs in this area that will vaginally deliver twins, and the docs don't do vbacs, either.

Wish I lived in a better area!

Originally Posted by kcparker 

What DID she do for you then?

[jeminijad]

To me, an 'unsafe' HB midwife is one who (1) knowingly attends women at home who have conditions which increase risk.

- multiples

- VBAMC

- postdates (past 42/43 weeks)

- premature (before 37 weeks)

- gestational diabetes

- breech

- other factors

Condition (1) would vary in a very rural area, or one where obstetric care was limited in general. If a cesarean, expert neonatal resus & a blood bank isn't available anyhow, you are much more justified (IMO) in staying home.

(2) who places little or no value in modern obstetrics, even when indicated [see above risk factors.] If I hear 'trust birth,' I am going to run.

(3) who I feel is inadequately trained [it would be a rare DE MW/CPM that I would be comfortable with.] Detecting problems, not dismissing everything as a variation of normal, is why they are there. If they can't suture, I don't want them either.

I am very conservative for this forum, obviously. But this is how I feel, and where reading has brought me.

[kcparker]

Originally Posted by carrieb26 I guess at some level, I'm concerned about "what if" twins - there's a family history on both sides for twins, and the other midwife transfers care to hospital if she's aware of twins.  to my knowledge, there are no docs in this area that will vaginally deliver twins, and the docs don't do vbacs, either.

If you have twins, do you want to know ahead of time? Technically, it is an indication for risking you out of a homebirth (per 'risk factor' guidelines). Also, this is a situation that I'd definitely want at least a few ultrasounds to make sure both babies were growing appropriately, bloodwork to monitor how my body is handling the pregnancy, and just a little closer eye on how everybody is doing. One of my circle of friends lost twins to TTTS, so I have just seen a case where close monitoring was warranted. I wouldn't want a c-section simply because nobody is trained to attend twin births (or breech, or because they are too chicken to attend VBACs), so I can understand that you wouldn't want to be forced into a situation that is anathema just because of lack of provider availability.

If you feel there is a chance of twins, I'd ask the Mennonite MW how she would assist you with a twin pregnancy (diet, rest guidelines, more frequent visits???) and what she'd do in a twin birth, past experiences, comfort level, etc. What does she consider risky and worthy of transferring for, either in pregnancy or during labor/birth. Make sure that her care and your philosophy and risk tolerances are in line.
 

Could you consider traveling and staying near a birthing center/MW/mother-friendly hospital? I know it's not always an option for many reasons, but if you have a life that can go on without you for a few weeks, it might be an option to look into also.

[mwherbs]

Licensed midwives in New Mexico did a study on home vbac and the stats were good under certain protocols, within 30 minutes from a hospital that can put together a team in those 30 minutes. 1 previous csection so the study lead to home vbacs being legal if following certain protocols.
Additionally acnm did a stratified risk assessment quite a while ago on vbac, the highest risk of rupture is in Induction using pit or prostaglandins...

[Midwife Scottie]

Originally Posted by kcparker 

If you have twins, do you want to know ahead of time? Technically, it is an indication for risking you out of a homebirth (per 'risk factor' guidelines). Also, this is a situation that I'd definitely want at least a few ultrasounds to make sure both babies were growing appropriately, bloodwork to monitor how my body is handling the pregnancy, and just a little closer eye on how everybody is doing. One of my circle of friends lost twins to TTTS, so I have just seen a case where close monitoring was warranted. I wouldn't want a c-section simply because nobody is trained to attend twin births (or breech, or because they are too chicken to attend VBACs), so I can understand that you wouldn't want to be forced into a situation that is anathema just because of lack of provider availability.

If you feel there is a chance of twins, I'd ask the Mennonite MW how she would assist you with a twin pregnancy (diet, rest guidelines, more frequent visits???) and what she'd do in a twin birth, past experiences, comfort level, etc. What does she consider risky and worthy of transferring for, either in pregnancy or during labor/birth. Make sure that her care and your philosophy and risk tolerances are in line.
 

Could you consider traveling and staying near a birthing center/MW/mother-friendly hospital? I know it's not always an option for many reasons, but if you have a life that can go on without you for a few weeks, it might be an option to look into also.

In terms of twins, breeches, gestational diabetes, and few other things there is wide opinion as to the safety of these things at a homebirth (as you can see). A lot depends on where you live; the laws governing midwives in the area, what the atmosphere that midwives are practicing in. Personally I feel twins are safe at home as long as you have met certain criteria (Such as nonidentical twins, first baby should be vertex, ect). I would highly recommend finding out if you have twins (trust me your midwife is looking for them even if you haven discussed this possibility with her) because there are many risks for an unmonitored multiple pregnancy.

In terms of knowing if your midwife is safe I have to say there is a lot of trust involved but I will give you a few pointers:

-look for detailed information on her training and birth experience, this should be written down not just told you verbally (makes it very clear so there are no misunderstandings)

- she may not discuss her protocols for breech birth with you at the first visit but if you have a breech baby and are in your third trimester she should discuss her protocols, all the risks of a homebirth with a breech and all the risks of a hospital breech birth (this applies to any variation/ complication)

-with each lab test she does she should be asking your consent to preform it and be informing you about the risks and benefits of each test.

-you should feel safe with her

- she should be present (in the room) at every prenatal and postpartum visit even if she has apprentices. I know some midwives who use their apprentices to do some of their work for them. If you have given consent to apprentice care the midwife should still be supervising and double checking what she does.

-I have found that lots of paperwork (though a pain and kills trees) helps to make sure that everyone has all the information they need and there are no misunderstandings so I would consider that a good sign.

[CBEmomma]

An unsafe MW to me is -

* Only read books and/or went to seminars for training

* Doesn't carry any emergency supplies (oxygen, pitocin, etc.)

* Doesn't know how to use emergency supplies

* Isn't honest with her training, philosophy, birth experiences, etc.

* Doesn't have a back up OBGYN and/or clinic. Unless the MW is traveling more than an hour away, then I could see why they wouldn't have one in your area, but may have one back in their area, that is something that needs to be addressed (for example, I had my own back up  OBGYN)

There are more, but can't think of them at the moment. I want to say less than x amount of births, but that is iffy to me because my back up OBGYN who had been practising for 30 years had less than 1,000 births, which to many would make someone think they aren't qualified or haven't had enough training.

[labortrials]

I'd say follow your instinct.  Your last birth was satisfactory, right?  If so, then that might be a good reason to continue with her.  If you have concerns about some of the other stuff, maybe address those issues with her?  Personally, I think you need to know for yourself what is safe or not.  It's a tricky question b/c other folks' experiences can help you clarify your questions/concerns or just feed your fear.

I had twins last time and that disqualified me - in my state - from homebirth.  I'm glad I knew that I had twins because we were able to rule out many potential complications early on and keep an eye out for other complications along the way.  For some folks what I did would have been way too interventive.  I ended up having a c/s because both babies flipped breech in the 3rd trimester . . . Baby A at 37 weeks, the stinker.

This time I'm planning a homebirth, and I'm HBA2C.  Some folks perceive this as unsafe, both here and IRL.

So I've definitely been on both sides of the spectrum.  I think of a midwife as a birth guardian.  She's there in case a complication arises.  I'm trying to figure out how to deal with my own need to accept responsibility for my birth and still allow for intervention should that need arise. 

Good luck!!

[homebirthing]

Wow! I must be an unsafe midwife. As someone who also birthed her twins at home as well. Been to twin homebirths, HBA2C, postdates (carried one myself to 17 days past EDD) and a breech!
 

Originally Posted by jeminijad 

To me, an 'unsafe' HB midwife is one who (1) knowingly attends women at home who have conditions which increase risk.

- multiples

- VBAMC

- postdates (past 42/43 weeks)

- premature (before 37 weeks)

- gestational diabetes

- breech

- other factors

Condition (1) would vary in a very rural area, or one where obstetric care was limited in general. If a cesarean, expert neonatal resus & a blood bank isn't available anyhow, you are much more justified (IMO) in staying home.

(2) who places little or no value in modern obstetrics, even when indicated [see above risk factors.] If I hear 'trust birth,' I am going to run.

(3) who I feel is inadequately trained [it would be a rare DE MW/CPM that I would be comfortable with.] Detecting problems, not dismissing everything as a variation of normal, is why they are there. If they can't suture, I don't want them either.

I am very conservative for this forum, obviously. But this is how I feel, and where reading has brought me.

[rajahkat]

Honesty would be the most important factor for me.  Does she realize her limitations and is she honest about them?  It isn't so much whether a midwife knows how to suture, or has vast experience with breech, VBAC etc that are important to me, but will she say, "no I've only attended 2 breech births so far, and you may be more comfortable having so and so midwife attend you instead."

Oxygen and Pitocin don't matter to me.  As long as she knows how to resus with room air and knows how to do bimanual compression for a bleed.  I would prefer someone who has had the experience of needing to do these things, as I really don't want to be someone's first emergency. 

[~~Sarah~~]

Originally Posted by jeminijad 

To me, an 'unsafe' HB midwife is one who (1) knowingly attends women at home who have conditions which increase risk.

- multiples

- VBAMC

- postdates (past 42/43 weeks)

- premature (before 37 weeks)

- gestational diabetes

- breech

- other factors

I am very conservative for this forum, obviously. But this is how I feel, and where reading has brought me.

There are a lot of things that can elevate risk, for example a c/section or episiotomy. That's why these things (and some of the ones posted above) are at the discretion of the experienced provider, and should be in consultation with the client. keywords: experienced and consultation. 

It doesn't make a care-provider unsafe to provide a homebirth for a client with one of the risk factors listed in the above quote so long as the client and care-provider are aware and educated on the topic (and in the case of the provider - experienced).

Originally Posted by rajahkat 

Honesty would be the most important factor for me.  Does she realize her limitations and is she honest about them?  It isn't so much whether a midwife knows how to suture, or has vast experience with breech, VBAC etc that are important to me, but will she say, "no I've only attended 2 breech births so far, and you may be more comfortable having so and so midwife attend you instead."

Oxygen and Pitocin don't matter to me.  As long as she knows how to resus with room air and knows how to do bimanual compression for a bleed.  I would prefer someone who has had the experience of needing to do these things, as I really don't want to be someone's first emergency. 

 yeah, this exactly. Well, I'd be more comfortable with Pit though... but nonetheless. Honesty. But always remember to ask the right questions! "How many births have you attended?" can bring an answer of "500", but upon further (and more precise) questioning you may realize that 490 of them have been doula births in hospital setting where the person in question had no clinical expertise and "do you carry medications" can be answered "yes" and only refer to the tylenol in her pocket. "Are you comfortable doing breech home births?" is a very different question from "how many times have you been the primary care provider for a breech home birth?"

[carrieb26]

I didn't mean to abandon my own thread - I need to figure out how to automatically subscribe to the threads I start!

If I were having twins, I would want to know ahead of time.  Where I am, to my knowledge, there are no docs that will vag birth twins, breach, or vbac. I called last year, just for info from the local hospitals, and all of them within an hour or so of me are the same way. Rural area, not many options.  The concern over a potentially unnecessary c-sec is one that worries me.

I do have the possibility of traveling to a larger city on the other side of the state, but that would absolutely be the last preference, for many reasons. 
 

Originally Posted by kcparker 

If you have twins, do you want to know ahead of time? Technically, it is an indication for risking you out of a homebirth (per 'risk factor' guidelines). Also, this is a situation that I'd definitely want at least a few ultrasounds to make sure both babies were growing appropriately, bloodwork to monitor how my body is handling the pregnancy, and just a little closer eye on how everybody is doing. One of my circle of friends lost twins to TTTS, so I have just seen a case where close monitoring was warranted. I wouldn't want a c-section simply because nobody is trained to attend twin births (or breech, or because they are too chicken to attend VBACs), so I can understand that you wouldn't want to be forced into a situation that is anathema just because of lack of provider availability.

If you feel there is a chance of twins, I'd ask the Mennonite MW how she would assist you with a twin pregnancy (diet, rest guidelines, more frequent visits???) and what she'd do in a twin birth, past experiences, comfort level, etc. What does she consider risky and worthy of transferring for, either in pregnancy or during labor/birth. Make sure that her care and your philosophy and risk tolerances are in line.
 

Could you consider traveling and staying near a birthing center/MW/mother-friendly hospital? I know it's not always an option for many reasons, but if you have a life that can go on without you for a few weeks, it might be an option to look into also.

[msmiranda]

Originally Posted by jeminijad 

To me, an 'unsafe' HB midwife is one who (1) knowingly attends women at home who have conditions which increase risk.

- multiples

- VBAMC

- postdates (past 42/43 weeks)

- premature (before 37 weeks)

- gestational diabetes

- breech

- other factors

Condition (1) would vary in a very rural area, or one where obstetric care was limited in general. If a cesarean, expert neonatal resus & a blood bank isn't available anyhow, you are much more justified (IMO) in staying home.

(2) who places little or no value in modern obstetrics, even when indicated [see above risk factors.] If I hear 'trust birth,' I am going to run.

(3) who I feel is inadequately trained [it would be a rare DE MW/CPM that I would be comfortable with.] Detecting problems, not dismissing everything as a variation of normal, is why they are there. If they can't suture, I don't want them either.

I am very conservative for this forum, obviously. But this is how I feel, and where reading has brought me.

I agree with you on most of this, but not on an absolute risking out of women who have gestational diabetes (obviously, since I had a home birth BECAUSE I had gestational diabetes).  Whether GD elevates risk absolutely depends on whether or not it is controlled.  If your sugars are well controlled, you are at no higher risk than the average woman.  Now, maybe preexisting type 2 and certainly type 1 are risk factors that would need to be monitored by an OB/endocrinologist.  But mild GD that is easily controlled by diet and exercise, I just don't see a problem with that for home birth.  

And for the other things, I mean I agree in the sense that that would also be *my* comfort level with birthing at home ... but I also think women who have different comfort levels should be able to choose home birth for themselves even if they have the factors you mentioned. 
 

[Mama Metis]

For me, a midwife is UNsafe if:

1. She doesn't at least *offer* what is considered to be "standard of care" in this country (i.e. screening, regular prenatal checkups, post-partum follow-up, oxygen and emergency pharmaceuticals at homebirth, etc.) Of course, these should be reasonably negotiable, in that clients should be able to discuss the risks and benefits of each offering honestly and candidly and arrive at an informed decision. It doesn't sound like your midwife offered the minimum standard of care. 

2. She takes on home births of higher risk without a thorough discussion of risks and benefits with the client. It's not that twins or breech at home should *never* be done, but the client should know exactly what the increased risks are, and exactly what would happen in the event of a transfer. Sounds like she did not fully discuss this with you. 

Finally, *for me* I would consider a midwife unsafe if she could not commit to my uninterrupted care in the event of a transfer. Meaning, if transfer becomes necessary or desireable at any time, I would want her to be responsible for my care in the hospital (jointly with her backup OB, as needed). Of course, in the US, only a CNM can offer this, which is why I chose a homebirth CNM. I realize others may not have this option.