Ideas for helping Midwives be more "hands off". [Archive]

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fourgrtkidos

10-07-2005, 10:17 PM

I am only one semester into my first year of Midwifery school. Yet, I am finding that the info given and the feeling that the teachers are projecting onto us is that we are going to "deliver" our clients babies and that we have to be there and hands on in order for the birth to go well.

This is soooo surprising to me. The Midwife community seems to despise that the medical system and Medical Doctors control birth, but it seems Midwives are also being very controling of the birth process, just in a more disguised way.

I am of the opinion that Midwives should only be at the birth as a kind of gaurdian. I want to help women become empowered, trudt their bodies and birth and work myself "out of a job." It would be my wish that mothers would have the confidence to go on to UC.

If not, if we as Midwives are Med-wives..... what is the point ? What is our role? We are cheating women out of the victory and accomplishment of their births....... we (Midwives) are stealing the credit for the new mother's hard work.

For now, I have to learn, I have to pass tests and prepare for liscensure...... But later, when I have a voice in the Midwifery community......... Is there a good way to share my ideas of "hands off" Midwifery? Are there strong, respected Midwives with this same opinion, speaking out and influencing our generation of Midwives?

bradley method mom

10-07-2005, 11:07 PM

I know what you mean. but even the midwives who I respect the most...I found out that they get in there and do things I would not do.
after asking them WHY WHY WHY? I found out it was because of fear. things that they went though at a birth. like giving oral vit K to EVERY infant. NO WAY, I thought to myself , but that is what they do. its not what they always did, but they do it now, because of past tramatic events with clients. it makes them feel safe.

I think there are different reasons that midwives act the way they do. some are ego driven, others a fearful, others are driven by protocol, others a teaching students and want to show them every way to do this and that. the list goes on.

write a book when you are done with school .that is a good way to share ideas and thought. also teach students how to be more trusting in the nature.
thats my 2 cents on the matter

mwherbs

10-08-2005, 12:24 AM

so I am not quite sure what you are asking-- as a student asking questions will usually serve 2 purposes 1 to inform you of anything you may not be aware of and to question the midwife. this may bring something to a teacher's attention and bring about a change.

homemademomma

10-08-2005, 10:02 AM

this is such a hard issue to deal with as a student, especially when you are learning in a state with such strict laws. one the one hand, it is SO important for us to learn and read and question and come to our own conclusions. but on the other hand, we have to defer to the knowledge and experience of our preceptors. i have learned SO MUCH in my student career. i have had wonderful, wise, amazing preceptors- and many of them have been way way way more hands on than i am comfortable with. they were all loving an respectful and gave great care, but their background (2 of my preceptors used to be l&d nurses) or their training (cnm), really colored the type of care they gave. it is hard, because i am doing births as a primary now, and with my old preceptors, if i didnt do things the way they did (akay kept my fingers out of their vaginas when they were pushing or whatever) they would jump in and take over. my current preceptor is not like that AT ALL, though. she rocks.

i think the best way, as a practicing midwife, to share your ideas is to be a preceptor or a midwifery teacher, and to attend conferences and meetings. being friends with the other midwives and having monthly peer reviews helps to keep communication open as well.

NavelgazingMidwife

10-08-2005, 10:17 AM

I have worked hard to learn to be a "hands-off" midwife. It's taken over 20 years, but I am getting my better at it.

I totally understand the OP... absolutely. I learned in much the same way - at Casa, apprenticing with other homebirth midwives, watching and learning from CNMs in the hospital and birth centers. I learned by doing 6-10 vaginal exams during a labor, rupturing membranes with fingers or amniohook, putting E-mycin in the baby's eyes, Vit K injections... all the things that now seem so strange and out of place in my practice.

I have done one vaginal exam in the last 5 births, including pregnancy.

But, that isn't the point. What I know is that I *had* to learn how to do those things. There is, absolutely, a place for every single skill. Some are far, far-reaching in finding their necessity, but during my "awakening," I kept seeing that there was indeed a reason for learning how to do all of these interventions. I am sooooooooo thankful I know them! They are merely a part of my catalogue of skills I am so glad I have at my disposal.

Learning on women is a huge hot button for me. Learning on women without their full consent, I should add. But, I know that with consent and their understanding, many women are very lovingly offering up of their bodies so we can learn so we are able to utilize the knowledge in our future *when needed*. (The key that is discussed in a sec.) Shoot, I've had about 50 million pelvics so my sister midwives could learn how to do Paps and such on morbidly obese women! I know because I have seen it; some women, if not most, are perfectly comfortable with the learning that has to be done. (I have a REAL hard time with rupturing membranes, just so you know... not physically, but it is one of the things that makes me crazy, when there is AROM... have not done that in YEARS and would probably practice on a balloon with a student. Some things... many things... are absolutely sacred and DO-ing them just to do them is ethically wrong, I agree. But I digress.)

So, I have been the perpetrator the OP speaks about. I have worked with women who have been birthraped and birth abused and realized how horrible I have hurt some women. Now, I am a loving and gentle woman who has always had a gift for supporting and midwifing women, but the subtle things - asking permission to touch *every single time*, stopping *anything* the second the woman says to stop, removing my hand when she says "Get out!" whatever it might be... remembering who is in control - she, not I. I have apologized to the women I have contact (when appropriate) and have offered prayers of apologies and asking for forgiveness to the women I will never see again but shall carry my pain with them in their hearts and minds and bodies forever.

And I was not evil... please don't get me wrong. I was a perpetrator in that I would coerce women to open their legs, not remove my hand from their vaginas when asked to, using coercion again. I never threatened or physically, purposefully hurt someone, but know, from talking to these moms, that they *were* hurt and I am acknowledging that and decided to change my behaviors because of that.

So, why learn at all? Why do we need to do 40 hundred million vag exams? Or learn to start an IV? Or <<insert intervention of your choice>>. Because you are a midwife. A lifeguard. If you were overseeing the pool, you would be expected to know how to swim and swim darn well. While you say the goal is for women to feel comfortable enough to UC... or, powerful enough... I gently remind you that birth is extremely unpredictable - and I am not saying that like a med-wife sort of way. I am saying that because I have seen a lot in 23 years. Including maternal and fetal death. (Mom died in the hospital from an amniotic embolism.) I know that there are absolutely reasons to have a midwife at a birth. My own UC with my second child resulted in a serious shoulder dystocia that required a decent amount of resuscitation.

I really, really am not trying to be a scare-monger. Really. I have been hired to sit and "be" at more than one birth. One birth, we set-up outside the room, sat quietly on our haunches, and the baby was born and we never touched mom or baby the entire time. They delivered the placenta, cut the cord, weighed the baby, etc. all in their own time (I left stuff for them if they wanted/needed it).

I also was hired to sit and watch and the baby, over 11 pounds we soon found out, needed guidance to get out... we had mom change positions several times (she said she never would have considered moving)... and we were so hands off, the baby fell on the floor (dad missed); *that* will never happen again. But, she was born and we utilized every skill we know to save a baby's life including prayer and oxygen. It was quiet and gentle, to the point that mom didn't know until dayssssss later that things were so scary. Apgars of 2/5/7/9. Mom hemorrhaged, so we got to use the other half of the emergency skills and meds we have at our disposal. Then they transported, so we got to use other skills... negotiation, comforting, preparation, love.

And just as a point of interest, a UC friend of mine (we became friends after the birth) recently lost her baby with a shoulder dystocia (8 pounder). Now, of course no one knows if another pair of hands might have saved the child, but she sure wishes she had had a set there.

Okay, I have to run to school (I'm working on a Master's in Psychology with a concentration in birth trauma because I have been a magnet for women to share their pain with and I thought I might should get some formal training and letters after my name), but I have two blogs that might interest you (politics aside, possibly). (And this was not to advertise, but there is wayyyyyyyy too much to share in one post - I write extensively about this very topic... NO, YOU ARE NOT ALONE!)

20 Years of Birth Stories - http://navelgazingbirthstories.blogspot.com/

and

Navelgazing Midwife - http://observantmidwife.blogspot.com/

Please also feel absolutely free to email anytime. But, let's continue the thread, too!

(not remembering if I have a signature here, sorry if it repeats.)

Barb Herrera, LM, CPM
San Diego, CA

homemademomma

10-08-2005, 10:25 AM

But, I know that with consent and their understanding, many women are very lovingly offering up of their bodies so we can learn so we are able to utilize the knowledge in our future *when needed*. (The key that is discussed in a sec.) Shoot, I've had about 50 million pelvics so my sister midwives could learn how to do Paps and such on morbidly obese women! I know because I have seen it; some women, if not most, are perfectly comfortable with the learning that has to be done.

I have been hired to sit and "be" at more than one birth. One birth, we set-up outside the room, sat quietly on our haunches, and the baby was born and we never touched mom or baby the entire time. They delivered the placenta, cut the cord, weighed the baby, etc. all in their own time (I left stuff for them if they wanted/needed it).

AMEN mama!

mwherbs

10-08-2005, 12:28 PM

I haven't been to a school and i just really don't know what all is taught and how. who I am as a midwife has been over 20 years in the making as well. Many of the things I started out thinking that I would never do or use I have used and done -- even coached pushing and flat on-the-back pushing, using a doppler all the time, referring a mom for an ultrasound. What does a birthing woman want, how do I best serve her and her family? sometimes it is knowing how to change what is going on-- before she is too exhausted, or the baby is sick , yes asking a mom to change position does happen -- I am thinking of one particular fairly recent birth where mom had told us how she did not want to be told to eat honey like in her first birth- but after a time she stopped drinking in labor and both her and dh said no- we did not force her to drink or nourish herself but at a point it becomes unhealthy- so when I started smelling ketones on her breath I said so- and she instantly decided to drink some juice, but it had already taken it's tole she was in a lot of pain and was becoming exhausted - she took up a position and did not want to move because she was afraid it would hurt more to move-- her baby was nearly crowning but was not moving any further down- so after quite a while in that position (more than an hr) , baby was fine, but her legs were numb and cold to the touch I said to her she needed to move , no no no , and we rubbed her legs and then rocked her sideways a bit and it didn't hurt she felt better, and the baby shifted she got up and went to the bathroom, I sat near her in the bathroom and she said catch the baby it's coming-.
as for other things it takes some research and awareness vitamin K shots- are the "standard of care" a refusal is client driven not midwife driven- this is not my family and not my choice to make- I can offer alternatives and information- my preference is on researched information , but your position is to offer and provide.
things like vaginal exams- probably in 23 years I have done around 100, but in recent years there are things to think about depending on your scope of practice- if you are able to provide pap smears and std screening as well as dx infections , then you would be offering at least one exam to everywoman -- and for treating infections you will probably be doing a follow-up or several follow-ups
On changing what you are taught I really don't know other than to question or carefully question what you are taught- but I have long ago given up changing a care provider's style- I have provided information or in the past brought in a "famous" speaker to talk to the subject and this has helped some, but carefully so it isn't an ego battle or in someway the care provider is shamed for changing or learning -- at this point I am having as much trouble with the midwives who practice to personal preference ( ie.. never offering vitamin K, rhogram, eye ointment, or only offering biased literature on the subject ) as I have with the other more obviously bossy gals ,both of these types of midwives have clients who adore their style and this is what that family/mom wants from a provider, I just prefer to have clients make choices- not make choices for them.

fourgrtkidos

10-08-2005, 12:50 PM

PapayaVagina

10-08-2005, 01:02 PM

So, I have been the perpetrator the OP speaks about. I have worked with women who have been birthraped and birth abused and realized how horrible I have hurt some women. Now, I am a loving and gentle woman who has always had a gift for supporting and midwifing women, but the subtle things - asking permission to touch *every single time*, stopping *anything* the second the woman says to stop, removing my hand when she says "Get out!" whatever it might be... remembering who is in control - she, not I. I have apologized to the women I have contact (when appropriate) and have offered prayers of apologies and asking for forgiveness to the women I will never see again but shall carry my pain with them in their hearts and minds and bodies forever.

What an amazing post!!

I am a strong supporter of UC though. But I greatly appreciate the insight about being the perpetrator. There are so many out there that don't apologize, and don't own the things that they do. I work hard at always apologizing if I overstepped or said something inappropriate. It is something that I think about a lot.

mwherbs

10-08-2005, 01:13 PM

homemademomma

10-08-2005, 01:15 PM

I am just trying to process....... I know that there are things/skills I have to learn in order to be competant especially in a case of an emergency. I just see that some clients are not given a choice by the Midwife preceptors about whether their bodies and births will be used as living models for students and it is INFURIATING to me. I never would have called it birthrape, but since that term has been used I can see that it is an accurate description.

I know I need to learn. However, informed consent is a big pet peeve of mine.

i think navelgazer said it great-most women are more than happy to have a student attend to them. i always asked a woman if it was okay for me to "practice" on them- ie "can i feel your belly?", or whatever. things like vag exams, when i was first learning i did them at less crucial times, like if mom wants to know her dilation during labor or if she is post dates and getting close to our legal cutoff and we are discussing natural induction. i would NEVER check if the mw was going to check after me as a matter of course.

as far as informed consent, i think it is really important for parents to be informed and to make decisions about their care, BUT at the same time, it is really hard for a parent to have all the info that we as midwives have, whether or not that is a good thing. they have hired us because they trust us, and while we can impart as much info as possible to them, really there can never be true informed consent for everything, because as professionals people rely on us to make good choices. thats why it totally sucks that a lot of the medical profession (mw included) are not trustworthy. its ridiculous to expect parents to know everything about midwifery/pediatrics. its impossible. they should be able to trust their care providers. :(

also i think it is really really important for women to understand the necessity of the apprentice- i hear women say on this board that they dont want to be practiced on- but how do you expect new midwives to learn? and really a student should be a legitimate part of a woman's birth team- she should have a role to play, and if she isnt doing anything useful she should be a fly on the wall. no woman should be getting multipla vag exams or whatever just so we can practice.

Apricot

10-08-2005, 01:48 PM

I have worked hard to learn to be a "hands-off" midwife. Hi Barb! I read your blog almost every day. Just letting you know you have a fan in this student.

One thing that I am grateful for is that I have been able to learn from the writings of Mary Cronk, Pamamidwife (here at MDC!), and from Barb on her blog. I'm the "lowly" student - I can't/don't do vag exams, so I practice my observational skills. I am trying with every birth to really learn the emotional signposts of labor, the non-invasive ways to intuit dilation, to be with-woman. I am hands-off because I lack the hands-on skills, but I am gaining skills. When else will I be forced to rely on non-intervention but as a new student?

mwherbs

10-08-2005, 02:21 PM

NavelgazingMidwife
I also want to say yes. birth rape and recovery is what had lead me to midwifery.
I recently read over your 2 blogs and they are great, recommended reads for anyone interested in birth and the life of a midwife. As for regrets and apologies yes , no matter how hard i try to do my best I make mistakes - I think that all midwives feel like this as well-- Susan Arms had a session at the Portland midwifery conference 16 years ago and the first thing she did was have all the midwives in attendance turn to their neighbor and confess and apologize for mistakes they had made out loud-- the room was not quiet, instead it was a loud hum, there was not a silent person in the group. it was very surprising to me because I had already formed opinions about many of the midwives and thought that they would not have noticed or cared that they had done things-I was wrong.

NavelgazingMidwife

10-08-2005, 02:53 PM

[QUOTE=mwherbs]
Many of the things I started out thinking that I would never do or use I have used and done -- even coached pushing and flat on-the-back pushing, using a doppler all the time, referring a mom for an ultrasound.

I reply (now that I have a tad more time):

Yes! Yes! Yes! I don't think I was entirely clear with that and you clarify it perfectly. I did say there is a place for EVERYTHING we learn, even those situations mentioned above. I know that students and newer midwives wig out over the thought of putting a woman on her back, but lemme tell ya, when lunging, squatting, NOTHING is working to get that baby's body out, you'd put her hard into McRobert's, too.

Still, even then... there are ways to tend to the heart (snippets, not entire dialogues).

In pregnancy: So, if things happen that are emergent, words will be at a premium. I might have to say, "turn over now" and it might not be the most polite way to say it, but if I do, know that it is something urgent and somewhere, please hear "I need you to turn over now because something is going on with the baby."

And women get that - or tell me HOW to say it if it is obviously not sitting well (they were yelled at like that by a parent or former partner or whatever) and then I note to myself: DO NOT SAY TURN OVER TO MOM! and formulate another phrase instead, perhaps "on your butt" or something... ride test it with mom and go where she want you (me) to go.

In labor and birth, if unforeseen things happen (bruising on the baby, a broken clavicle, mom's BP extraordinarily high with other serious signs, etc.), expediency is crucial, but so is her permission and understanding. Even bi-manual compression for uncontrollable hemorrhage - "I need to hold your uterus NOW" as she stares at you or says yes or whatever - and as you are doing your "job," letting her know what is happening as best as you can, even if all that is is saying, "I'll explain later." She (and those around her) deserve to have even the tiniest fragment of an explanation.

Doing CPR is a separate issue and I tell women in pregnancy, if I am not talking (to them, because of counting usually), I am saving a life. They totally understand and in that instant of my explanation... just that little bit... they consent. They can always *remove* consent and I tell them that, too (not that I am talking about not doing CPR or hemorrhage control... WHOLE different issues), but they "get" that if I am unable to speak because I am working, I am working to save a life and will answer any question they have... for years.

MWHerbs continues:

What does a birthing woman want, how do I best serve her and her family? sometimes it is knowing how to change what is going on-- before she is too exhausted, or the baby is sick...

Again, absolutely!

A birth 2 weeks ago - first birth a painless hypnobirth in the hospital. This birth, baby rotated from ROA to OP on her way to LOA, but hung out in OP for quite awhile. Mom *howled* in pain... "agony" were words from her family. Neighbors several houses away heard her contractions that went from 0 to 180 and back to 0 in 25 seconds (typical OP contractions). This was going to be a very hands-off birth, but mom would not get out of the bed. Dad tried to get her out, I gave him ideas and phrases to use and she would not do it.

It's always interesting that so many believe instinct will take a woman where she needs to go to birth. I wonder if that was true in the wild, but in my world, if there is a bed around, women will nearly-instinctively be drawn to it.

Anyway, so after a few hours of this and she was in the bed, nauseated from not eating (serious hypoglycemic issues anyway), and in pain, I went to her and told her she was going to eat and go pee. I gave her choices of what to eat; she chose. I gave her choices of where to pee; she chose the toilet. When finished with those tasks, we talked about positioning (as her husband had for the past few hours already) and I'd already suggested hands and knees about a dozen times, but she chose to rock and sway and walk a little around the room. I also felt a vaginal exam was in order (she had had none during the pregnancy or labor) but it took consulting with the other midwives there, talking to mom and dad, and explaining my thinking that just to be sure there isn't a forehead or ear there, it would be a good idea. She was perfectly fine with it and I was very gentle, not wanting to disturb her membranes, and she had a contraction (I stopped moving) and I could feel this posterior girl come down so beautifully, I removed my hand and reminded mom that even if she chose to remain posterior, she could do it! Plenty of room and how powerful she is. She continued swaying.

Once I believed she wouldn't climb back in the bed, I got out of their space. Within an hour, she screamed her birth cry and we came in and her baby's head was in her hands. She tells us that not 5 contractions after getting on hands and knees, her water broke, the baby turned, and there she was.

Afterwards, I asked her about my "telling" her to do stuff. She said that's what she hired me for... for when she wasn't able to, or wouldn't, listen to her husband - and she said it was really good because I knew the tone and words to use to penetrate her LaborLand High. I liked that! I asked if I was too intrusive (she is aware, as all my clients are, of my evolution and striving for low-profile midwifery care) and she said not at all.

(This is getting so long, sorry.)

It has recently come up that perhaps ONE vaginal exam about 36 weeks is in order. Not a cervical exam, but an exam to check for yeasties. Over and over and over I am seeing moms and babies fighting systemic yeast when mom had zero clue she had it during the pregnancy (and I didn't either because I'm not doing exams!). Apparently, "self-reporting" isn't always the best way to gather information. I'm trying to figure this one out.

Me: Would you like me to check and see if you have yeast so we can tend to it now instead of later? *pondering*

MWHerbs says:

On changing what you are taught I really don't know other than to question or carefully question what you are taught- but I have long ago given up changing a care provider's style... but carefully so it isn't an ego battle or in someway the care provider is shamed for changing or learning...

I reply: Yeah, many midwives around me are not so happy with many aspects of my disclosing and speaking out about the inner workings of midwifery. My reesponsibility is to the woman... women... and until there are no more birth abused women, I'm gonna holler. Loud.

I'm reading Martin Luther King essays right now and he speaks about how painful change is for those who benefit from the status quo. His essays about civil rights are so aligned and appropriate for women in birth today. No change happened without pain and anger and isolation.

MWHerbs says:

- at this point I am having as much trouble with the midwives who practice to personal preference ( ie.. never offering vitamin K, rhogram, eye ointment, or only offering biased literature on the subject )...

Oh, yeah! Don't you love those that barely mention GBS because they don't do IVs (even though they legally can) or don't buy antibiotics only because they can't afford them? Now, I certainly don't do the standard GBS medical route... UNLESS the woman wants that! ALL of that is her decision (and partner, of course). I try to share both sides, explain when or why my thoughts might tilt sideways (fever in labor, abx at home instead of hospital, for example), but other than that, I give them Google words to explore on their own. And, lo and behold, they DO know how to make their own decisions. ;)

Okay, blessingway to attend now... more later, I am sure. Thanks for the kind words and patience with my processing and writing so much!

Barb Herrera, LM, CPM
San Diego

fourgrtkidos

10-10-2005, 09:37 AM

Very cool.

I am reminded that my opinion really does not count as much as the mother's and her family's. I can beat myself up for administering Vit K or IV antibiotics (because I believe there are better ways)...... or I can give the patients unbiased(thanks for bringing that up) info, that truely shows pros and cons of each...... the INFORMED CONSENT..... I was so adimately bitching about earlier...... and provide whatever service the woman and her partner decide is best for them! The problem is I sometimes feel guilty about doing such "medical" things, when I need to remember those actions are not my decision if the mother has adequate info and chooses them. I am unnecessarily feeling guilt when I am actually providing the services the parents want. :o ~Michelle

BTW, Some of this is left over from the years of hospital L/D and newborn nursery work I have done as a RN. I felt I was doing such a disservice to those women and babies. I felt if they knew better they would never set foot in a hospital. What I found this last year or so is.... that most of those women, once I began speaking up and informing them, do not want to know, they want all the medical crap and they want doctors to make their decisions for them. And so, I was in fact doing what they wanted and should never felt guilty for the medical procedues I was participating in.