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Hi Everyone,

I'm 4-6 weeks pregnant (that's another story all together) and interviewing HB midwives. I did my first interview this morning. I felt good about the midwife, and she was very straightforward with answering all of my questions, but now I'm not so sure what answers I wanted to hear for some of it.

Help me out with the more medical jargon here. Can someone give me a brief run down of the possible qualifications (LM, CPM, BSN, etc) - what do they really mean and why would that qualification be important to me?

What is a good transfer rate? What are some important factors for this?

How important is an official back up ob and hospital? Would a friendly relationship with an ob who has always helped when needed and can practice at the nearest hospital (that is actually pretty natural birth friendly) be enough for you?
 

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We didn't have an official backup. If we needed to we'd transfer to the hospital. We interviewed four midwives before we found one that we liked. The first three were okay but we really clicked with the fourth ones.
 

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Quote:

Originally Posted by Flower of Bliss View Post
What is a good transfer rate? What are some important factors for this?
Personally, I find transfer *rate* less important than reason for transfer. I would be wary of a mw who transferred many for "exhaustion, failure to progress, etc"

I would want to see transfers mostly for real reasons.

-Angela
 

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I agree that transfer rate is not as important as transfer reasons; any mw could have a run of transfers (or a run of anything--things in the midwifery world seem to come in batches) that impacted her overall rate but might not have much to do with her skill or protocols. Basically saying that there are various reasons a family might choose to transport that are about them, not the mw (family pressure, for instance).

Still--I would want to see a transport rate of no more than 10%--and all the better if it's lower. And oh yeah, along with knowing some reasons for transport, I would want to know how any of those related to her practice protocols or legal restrictions. For instance, her license may demand that she transport after a certain # of hrs after water breaks, or beyond so many weeks pregnant. Or even without legal restrictions, she may have adopted personal preferences about such things.

A solid connection with a hb-friendly doc who practices in a natural-friendly hospital would be a great plus for me in terms of choosing a mw. But not a requirement; I'd be more interested in the mw's skills, approach and protocols, and in how we got along with each other.

LM means Licensed Midwife--this means that the mw has completed any training/testing the State requires, to consider her adequately prepared to handle normal birth at home. Plus, it means she is hooked up into the State's Med Board/professional regulation system, meaning you can find out more info abuot her throught that agency, make complaints there, etc. If your state licenses mws, then there is probably a website that details req's and protocols of the State's midwfery laws.

CPM means Certified Professional Midwife--and refers to a mw who has been certified by North American Registry of Midwives to be adequately knowlegeable and skilled to assist normal birth at home. NARM is an independent organization (NOT State or Medically affiliated) composed of mws and other mw advocates; it has formulated a set of skills and body of knowledge that is considered a 'basic standard' of midwifery care (according to internationally accepted standards). NARM holds written exams and also requires that a mw-applicant show proof of clinical skills. A mw could have had her training through a school, through apprenticeship or even be self-taught--NARM does not distinguish as long as an applicant can both pass the written exam and show proof of clinical ('hands-on') skills. Some states use the CPM as a basis for licensing (if you're a CPM, you can be licensed), but being a CPM does not automatically mean you are licensed. It only means that you have demonstrated to NARM that you have the requisite standard knowledge and skills to assist normal birth at home (and to recognize medical complications so as to transfer care).

BSN is bachelor's of science in nursing. Some states use the BSN as a foundation for mw licensing, but a BSN is only a general nursing degree. Which means that any w/a BSN would have to show proof of specializing somehow in midwifery to get licensed. If a mw told me she was a BSN, it wouldn't mean anything to me really--I'd still want to know how/where she got her *midwifery* training.

CNM--Certified Nurse Mw. This woman has a BSN *plus* a master's degree in nurse-midwifery--the CNM is among the group of 'nurse-practitioners' in the med world, who have more responsibilities and privileges than plain nurses, but less than docs do (including your general practice NP, Nurse-Anesthetists, other). Some states req hb mw to be CNMs with some sort of physician collaboration arranged, before they are legal to practice out of hospital. All CNMs can practice in hospitals under MD supervision/collaboration--in some hospitals they are not allowed to attend birth, in some they are (they do labor triage instead, or only prenatal visits and well-woman gynie care)

hope this helps
 

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Discussion Starter · #6 ·
Thank you everyone. That helps plenty. MsBlack, that break down was just what I needed. Thank you.

The midwife I interviewed had a pretty high tranfer rate last year (10%) which she was very upfront about and said was because she's been taking LOTS of VBACs (the VBAC climate in the area has been pretty bad lately, so I'm glad she's taking them). I wasn't sure how uncomfortable I should be with that. I'm not a VBAC client.

Would you expect a midwife to be able to stitch a 3rd or 4th degree tear? I had a 4th degree tear with DD (FAST labor and compound presentation were mostly at fault, though I imagine not the only factors). I sure hope that doesn't happen again, especially with a midwife to help me with positioning and such, but I'm wondering about having the midwife unable to repair such a tear.
 

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Quote:

Originally Posted by Flower of Bliss View Post
Thank you everyone. That helps plenty. MsBlack, that break down was just what I needed. Thank you.

The midwife I interviewed had a pretty high tranfer rate last year (10%) which she was very upfront about and said was because she's been taking LOTS of VBACs (the VBAC climate in the area has been pretty bad lately, so I'm glad she's taking them). I wasn't sure how uncomfortable I should be with that. I'm not a VBAC client.

Would you expect a midwife to be able to stitch a 3rd or 4th degree tear? I had a 4th degree tear with DD (FAST labor and compound presentation were mostly at fault, though I imagine not the only factors). I sure hope that doesn't happen again, especially with a midwife to help me with positioning and such, but I'm wondering about having the midwife unable to repair such a tear.
I would think *most* midwives would transfer for a 3rd degree tear and I'd be pretty surprised at one trying a 4th at home.

-Angela
 

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NAK!
I think the backup OB relationship varies a lot depending on state/region. I live in WA, where HB MW's are licensed, and homebirth is relatively common. Neither midwife for my 2 births had a direct relationship with a back-up OB.

My 1st HB was near a hosp. that was extremely anti-HB (big baby factory in a big city), but that is where I would have transferred during labor for an emergency... so no back-up OB, just a lot of hostile care providers. I knew I'd only be able to transfer for a true emergency.

For my 2nd HB, I'm living in a small, very "crunchy" town. Again, no direct back-up b/c the hosp. is so small that you'd get whoever is on call/available... but all OB's know the midwife and allow her to attend in hosp. (not sure if this is official... but she has 2x the experience of every OB in town -- they're all young docs, she' been practicing 25 years). Also, doc's and nurses are reasonably HB friendly b/c of the community atmosphere.

So, 2 very different reasons why my midwives had no specific back-up as I had heard they "should" -- but I felt comfortable with the transfer plan both ways.
 

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I think it's quite important that your midwife be well respected at the local hospital. The midwife for my first birth - although I loved her - was, apparently, not. The local hospital hated her. And when I had to transfer after the baby's birth for a post partum hemmorhage, I believe it greatly affected the care I received in the ER. They fought with her, didn't want her to come in to be with me (although she did prevail), then gave me a mini lecture about choosing an out of hospital birth. When I was searching for my second midwife for baby # 2, I wanted to make sure she did have an excellent reputation and also a back up doctor who respected her. She did. Fortunately, a transfer wasn't needed.

If there isn't a back up doctor, then I would ask the midwife in the interview what she does during a transfer, how she works with the hospital staff, etc. If she has a friendly relationship with an OB and you have a natural birth friendly hospital, you're golden.
 

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Quote:

Originally Posted by Briannasmom View Post
If there isn't a back up doctor, then I would ask the midwife in the interview what she does during a transfer, how she works with the hospital staff, etc. If she has a friendly relationship with an OB and you have a natural birth friendly hospital, you're golden.
Again, this will vary GREATLY by location. Here our midwives really don't have any working relationships with the OBs. There are really 2 midwife-friendly OBs in town. They seem to do okay with any of the midwives, though they wouldn't recognize most of them in a dark alley.

-Angela
 

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As for stitching up tears...most midwives are REALLY good at preventing them. You can talk to your mw about it, but many are willing to support the perenium, guide you a bit in pushing to encourage you to push slower, etc if you are worried about tearing. So maybe you can prevent a bad tear. And most mws can stitch 2nd and 3rd degree tears and do a better job at it than OBs, IME.
 

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Quote:

Originally Posted by Flower of Bliss View Post
Thank you everyone. That helps plenty. MsBlack, that break down was just what I needed. Thank you.

The midwife I interviewed had a pretty high tranfer rate last year (10%) which she was very upfront about and said was because she's been taking LOTS of VBACs (the VBAC climate in the area has been pretty bad lately, so I'm glad she's taking them). I wasn't sure how uncomfortable I should be with that. I'm not a VBAC client.

Would you expect a midwife to be able to stitch a 3rd or 4th degree tear? I had a 4th degree tear with DD (FAST labor and compound presentation were mostly at fault, though I imagine not the only factors). I sure hope that doesn't happen again, especially with a midwife to help me with positioning and such, but I'm wondering about having the midwife unable to repair such a tear.
for a 4th degree you would want to transport. Most mws do not do a lot of suturing. They don't see many tears and do virtually no epis. They might call in another mw to do suturing if there is something really bad. While they have training in this you want someone who has done it many times over. This would not disqualify a mw for me.

I don't want a dr back up. Then the mws answer to the dr. Which means they don't do what the dr wants - dr drops the mw and the mw looses the back up. I did not find it important in case of emergency. In fact my dr was on vacation when I had ptl and his partner refused to see me. So I got who was on call anyway.

What you are looking for in a mw is what is important to you. Qualifications aside, if you she doesn't believe what you do about birth all those qualifications don't mean a thing. I had very specific criteria I was looking for when I interviewed. I did not want to be pressured about post dates despite state laws. I needed a mw comfortable with water birth. I wanted a mw who offered labor support (this one is very major to me). I wanted to be respected (this seems like a given but I hate being treated like they know it all because they are the mw/dr).

I really liked that my mw can call someone to come to the house to do ivs. MWs here can't do that so to have a relationship with a dr who does is wonderful. This alone could cut down on transfer rates.
 

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It originally looked like I had a 3rd degree tear (turned out to only be 2nd degree) and my MW was going to call a more experienced colleague to come and stitch me up. A 4th degree tear would definitely necessitate a transfer.
 

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definitely talk to your mw about her suturing experience before making a decision. I know mws who learned to suture, but tend to transport for any tear that may need it--because they simply don't have much experience with suturing, they don't feel their skills have been honed enough through frequency. Yes, they are generally better at helping to prevent tears--so, it is the OBs who have to see and stitch far more tears, have had a LOT of practice doing it, that I would want suturing me or a client if needed.

That said, even for a 3rd degree your mw might be willing/able to suture, you just have to see. This may depend on the tear--if it's straight and simple, maybe so; if it's compound in any way, she may want to defer to an OBs greater experience. Btw, if you do transport for sutures, DON'T let an ER doc sew you up! Make them send you to OB ward, where an OB/surgeon with particular experience with yonis will do the job.

Work now on prevention through nutrition and herbs. I would be using a good herbal/vit e salve on my scar throughout pregnancy, to help it to continue healing, breaking up scar tissue and promoting elasticity of those tissues. Even a long time later, herbs like comfrey and calendula and others, and/or vit e oil, can have a very beneficial impact on scars. Kegeling, with equal emphasis on toning AND releasing, may also help.

And of course, if possible your control of delivery would be best--no purple pushing, no reclining or semi-recline to push, try to breathe through burning pain of crowning rather than push....I'm sure your mw will be able to talk w/you about these things.
 
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