Hi there. This blog has been growing in my mind for several months with about a half dozen posts already in the works. I wasn’t sure how to start, then yesterday I saw this:
For those who have never heard the word “medwife” before, it’s a term of contempt that’s used to refer to midwives whose practice style is more interventive than the person using the term would prefer. For some, this means the midwife practices under a “medical model” (topic for another post) with little regard to the mother as an individual. For others, it means the midwife has actual skills and training and uses those to provide evidence-based care. Regardless, it’s a term of derision, and it’s ugly and stupid.
Enter “meggf” at Whole Woman. I’d never heard of this site before, but there are a lot of lovely little gems that I’m sure you’ll be hearing about later.
meggf opens by explaining what she believes a “medwife” is: a practitioner who by rights can call herself a midwife, but is unfortunately using that title to pull a bait-and-switch on unsuspecting mothers. She goes on to offer six questions by which one can identify the nefarious medwife. Let’s see how I score.
1. Do you recommend any routine testing in pregnancy?
A midwife will offer testing, based on risk factors, when the results may alter the choices for pregnancy and birth. A medwife will recommend routine testing regardless of risk factors and regardless of the effectiveness of the testing (including but not limited to GBS swabbing, and GD testing).
Oh, wow. So right off the bat, I’m firmly in the “medwife” category. I offer ALL the testing. Some I recommend, some I require, and some I don’t really care as long as I’m sure you are giving informed refusal in declining them. GBS swabbing is strongly recommended. I won’t drop you from care if you refuse, but there’s really no good reason to not do it. If you don’t want to have IV antibiotics in labor if the result is positive, let’s cross that bridge if we come to it. Only about 10% of my clients are GBS positive. That’s a 10% chance I’ll have to recommend antibiotics, versus a 100% chance they’ll force them on you at the hospital if we have to transport. Think about that. 100% chance that you’ll have antibiotics for a bacteria you only had 10% chance of testing positive for. I also recommend gestational diabetes screening. I still offer the 50 gram 1 hour screen simply because I don’t want anyone fasting until my office opens at 10:00 am, though they can go to the lab for the new 75 gram 2 hour with fasting screen. If the glucose drink is really a problem, I’ll go with the jelly beans or even grape juice. At the least, let’s get a 2 hour post-normal meal reading. Do you want to talk about risk factors for gestational diabetes? Unless you’re under 25, you’re at risk. And carefully monitoring for signs and symptoms of diabetes in lieu of testing? Good luck distinguishing those from symptoms of being pregnant. There are some very serious things that could happen to your baby if you have gestational diabetes, one of which being a gianormous baby with fat padded around the chest and shoulders that make it difficult for the rest of the baby to be born after the head is delivered. Remember, you are planning to have your baby at HOME, not in the hospital with an OR down the hall. And if you have gestational diabetes, and we can know that NOW, and modify your diet NOW, that can save us a lot of grief later. Again, I’m not going to drop you from care if you refuse routine diabetes testing, but I want to be sure you understand all of what I just said.
2. How do you assess progress during labour?
A midwife will watch your behaviour, she might talk about knowing where a birth is at by the smell in the room (yes really!) or the sounds you are making. She will recommend a vaginal exam to test for dilation in the unlikely event that it will give information that may alter choices but the majority of the births she attends will never have a vaginal exam. A medwife will do vaginal exams routinely.
Well, nuts. But what does “routinely” mean? Behavior is definitely the biggest clue I use to assess labor progress, but labor is defined by contractions that effect cervical change. I’ve been at too many labors that dragged on way too long when a simple vaginal exam hours ago would have identified a problem that we could have been working to fix instead of transporting now because you’re too exhausted to try anything else at home. Maybe I’ve just seen more than my share of malpositioned babies and dysfunctional labors. Limiting vaginal exams to prevent transmission of infection is evidence-based medicine, but letting mothers labor hard for hours before discovering they’re not getting the baby any closer to delivery is not. It’s a judgment call. I would never force anyone to have a vaginal exam. That’s called sexual assault. But I’ve rarely had anyone refuse an exam when offered, either. I would say the majority of my births have one vaginal exam. So 2-0 for medwife.
3. What if labour is progressing slowly? A medwife will have a certain time in which they need labour to conclude, they may offer drugs to reach that limit. A midwife will recommend food, water, rest, maybe some movement. She will want you to be healthy rather than to give birth in a certain time frame.
Sounds like I may be a midwife. There is no deadline, as long as progress is being made. If progress stops, I do my best to figure out why and make changes to fix it. But if there comes a time when my experience leads me to recognize it’s just not working, I see no valor in rubbing your shoulders and telling you to relax and visualize your body opening like a flower and that your body is doing what it’s supposed to do when I KNOW it’s not. And the truth is in those situations, the earlier we can go in and get some pain relief and/or some Pitocin to make your contractions more organized, the more likely you will be to have this baby vaginally than to go on until you’re too exhausted and the baby is too stuck in a bad position to push out. And also, the supposition that a “medwife” cares more about the clock than a mother’s health is gag-worthy. Seriously?
4. How do you feel about breech birth? A medwife will recommend surgery, listing the risks of bottom first babies.. A midwife will offer you facts and figures, the risks and benefits to both birthing and having surgery for breech. She will make recommendations but give you decisional power.
I can’t recommend surgery, I’m not a surgeon and that would be entirely inappropriate for me to suppose I knew when surgery would be best for a mother. I don’t do breech births. I know how. I have done them outside of the US. They were easy. That’s the thing though: I have experience with easy breech birth, but if they were all easy then we wouldn’t be talking about this. I believe in vaginal breech birth, but I would prefer they take place in the hospital. It’s a shame that physicians and hospitals aren’t allowing women that option, which is forcing them to seek midwives to attend their breeches out of hospital. Women should ALWAYS have decisional power when it comes to surgery performed on their bodies. So I wonder if meggf would call me a medwife when I support vaginal breech but don’t personally do them, and think they would probably be best done in the hospital (according to evidence-based practice)?
5. How do you view VBAC / VBAMC? A midwife will offer a balanced view of both options. A medwife will give you more information about the risks of birth.
I don’t do HBACs (home birth after cesarean), so I’m at a loss on this one too. I support VBAC. I think it’s probably safer to have them in the hospital, but again, doctors and hospitals aren’t giving women that option, thereby forcing them to seek home birth in order to avoid unnecessary surgery. And when mothers are allowed a trial of labor, it’s under heavy restrictions that hamper the odds of a vaginal birth. If I were a CNM I personally would have no problem attending VBACs in the hospital, so maybe “midwife” on this one.
6. When would you recommend induction? A medwife will give you a date by which you must give birth, be induced or transfer care to a surgeon. A midwife will say that her recommendations are to remain pregnant unless there is some health factor that requires action.
HOLY SHITSNACKS. After the Christy Collins Facebook crowd-sourcing tragedy I can’t believe I’m even addressing this. (WordPress is having fits trying to format a link so you can Google it if you feel you must). I would recommend an induction any time it’s safer for the baby to be growing on the outside than on the inside. Many people think that a due date is an expiration date. In fact, a pregnancy is not post-term until 42 weeks. However, just like having a pre-term baby, there are risks to having a post-term baby that put management of pregnancy past 42 weeks outside the scope of midwife care. At that time I will transfer your care to someone qualified to manage your high risk pregnancy, and it just so happens that he or she is a surgeon. Yes, they are going to want to induce you. Yes, you have the right to refuse. Yes, that may be an unfortunate struggle between you and your physician, but that’s just it. It’s between you and your physician, because I’m no longer a factor here. Because I’m a medwife.
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