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OB, Midwife, Doula – What Is the Difference?

Parents today have more options than ever before when deciding who will provide their prenatal care, who will attend their baby’s birth, and where the birth will take place. Many of these options indicate a positive shift in the way our culture views maternity care: Parents can (and should) be actively involved in selecting the type of birth they want for their family. Unfortunately, the overwhelming number of choices, combined with a lack of cultural familiarity with birth itself, sometimes leads parents to choose a “default” birth (read: OB-attended birth in a hospital with standard medical interventions) rather than thoroughly exploring their options.

The primary goal of Healing Hands Chiropractic’s pregnancy and childbirth workshops is to demystify the process of birth and the choices involved, allowing parents to choose the options that are best for them and for their baby. Understanding the difference between types of care providers is an essential part of planning the birth you want.

In the United States today, the vast majority of births are attended by an obstetrician (OB), a medical doctor who specializes in pregnancy and childbirth. Obstetricians are trained to manage low-risk pregnancies and deliveries, but are especially skilled at handling complications. They can attend vaginal births as well as perform cesareans. Among OBs, there may be a wide variety of attitudes toward pregnancy and birth. If you are considering care with an obstetrician, it is important to make sure that his or her philosophy on birth is similar to your own.

Midwives are extensively trained in providing care for low-risk pregnancies and deliveries. A midwife practicing in a hospital is usually a certified nurse-midwife, or CNM. CNMs are registered nurses who have additional training and experience with maternity care. CNMs in hospitals generally work in conjunction with one or more obstetricians, and can consult with them or even transfer patients to their care should complications arise. Many CNMs tend to have a more hands-off, holistic attitude toward pregnancy and birth, though this is not always the case. A CNM practicing in a hospital is often subject to institution policies, including standard procedures for length of labor after admission to the hospital, eating and drinking in labor, and management of complications.

Midwives who practice outside of the hospital have different credentials depending on licensing regulations in each state. (In New Hampshire, the designation is CPM, or Certified Professional Midwife.) Unlike hospital-based professionals, Direct Entry Midwives are trained in birth first, medicine second. Even more than a CNM, a CPM tends to regard pregnancy and birth as a natural, healthy process that requires little to no intervention. (Midwives have been known to say that they do not “deliver” babies, they just “catch” them.) Direct Entry Midwives attend births in free-standing birth centers and at home. They are trained to watch for and manage complications, and to transport clients to the hospital when necessary. Their labor bags include medical equipment to prevent or manage maternal hemorrhage, to provide sutures in the event of a perineal tear, and to resuscitate a newborn. An out-of-hospital birth for a healthy, low-risk mother is neither dangerous nor irresponsible. In several studies, home birth has actually been shown to be safer than hospital birth, because the mother is not subject to standard procedures that may lead to complications.1

Doulas are labor support professionals. They are not responsible for the medical aspects of birth, but provide emotional and psychological support for the mother and her birth partner. A doula is also trained to interact professionally with hospital staff, and can act as an advocate for the mother should the need arise. A doula generally arrives earlier in labor than other birth attendants, often supporting the mother while she labors at home and then traveling to the hospital with the parents. She can help with the initiation of breastfeeding and may also offer additional postpartum support. (For more information, including the distinction between labor doulas and postpartum doulas, please check out Doulas of North America: http://www.dona.org/mothers/index.php)

Practitioners at Healing Hands Chiropractic regard pregnancy and childbirth as natural processes in which both parents should be involved and educated. For more on birth choices, consider an upcoming childbirth series or early pregnancy workshop. Email jenny@healinghandsnh.com for schedule, rates, and registration information.

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Dominoes

An acquaintance shared her birth story with me. We’ll call her Shelley. Her child was born at a local hospital less than four years ago. Here’s a summary of the birth of Shelley’s first child:

Shelley’s water broke (also called “ruptured membranes”) a few days after her due date. As instructed during the last weeks of her pregnancy, she called the hospital, and was asked to come in for an evaluation. After a quick test, it was determined that her water had indeed broken, and she was admitted to the labor and delivery floor. Shelley was then asked to get in bed so that staff could check on her baby’s heart rate with an electronic monitor.

She stayed in bed for 13 hours.

Over the course of that long night, not much changed for Shelley or her baby, except that she got pretty darn sick of sitting in bed. When morning came, the birth of her baby did not appear to be any closer than it had been the night before. He doctor decided to administer Pitocin, a synthetic hormone used to cause or strengthen labor contractions. For the next 11 hours, Shelley sat in bed experiencing strong labor contractions with no pain relief. (Because her cervix had not dilated to at least 4 centimeters, she was not eligible for an epidural.)

After a full day of Pitocin-induced contractions, Shelley was exhausted, frustrated, and dilated to only 3 centimeters. By this time her water had been broken for over 24 hours, which many practitioners believe increases the chances of infection. Since Pitocin had not helped her labor to progress, her doctor diagnosed her with labor dystocia (also called “failure to progress”) and recommended a cesarean section. Shelley gave birth to her baby via cesarean a few hours later.

Shelley was left very disappointed with her birth experience. She had wanted a vaginal birth and couldn’t understand why her body had not cooperated. She was left to recover from major abdominal surgery while learning to care for a newborn.

Shelley’s story is a classic example of a concept childbirth educators call the “Domino Theory of Interventions.” Like dominoes falling, one medical intervention leads to another, and that one to another, and so on, often resulting in a disappointing birth experience overall.

Could Shelley’s cesarean birth and subsequent difficult recovery have been prevented? I believe so.

There is a specific reason Shelley’s labor did not progress: Her baby never “dropped,” which means his body never moved down far enough for the top of his head to press on her cervix. Especially in first pregnancies, without pressure from the baby’s head, a mother’s cervix can dilate the first few centimeters, but usually no further.  Mother and baby truly work together to make labor happen.

Why didn’t Shelley’s baby drop? The likely reason is that she was stuck in bed. Her body was not allowed to opportunity to work with gravity and move her baby deeper into her pelvis.  The most frustrating part of this story is that, according to Shelley, there was no medical reason for her to stay in bed for those 13 hours. She simply wasn’t offered other options. Once the Pitocin was administered, staying in bed was necessary, since Pitocin augmentation requires continuous monitoring of fetal heart tones.  (This is because Pitocin contractions can be more stressful on the baby than naturally-occurring contractions are.) As we know already, Shelley’s baby hadn’t had a chance to drop, so the 11 hours of painful and exhausting Pitocin contractions were relatively futile.  For Shelley, confinement to bed interfered with both her own body’s and her baby’s natural impulses, which resulted in Pitocin administration, which necessitated staying in bed and further stole the opportunity for Shelley to work with her contractions. In all likelihood, it was medical intervention that created the need for a cesarean.

So what to do if you find yourself in a situation like Shelley’s? If you give birth in a hospital, starting your labor in bed is highly probable, since most hospitals require 15 minutes of fetal monitoring upon admission. If this is your hospital’s policy, you still have options. You can sit upright in bed for 15 minutes, then get up and move around. Another option – one that works especially well if your situation requires continuous monitoring throughout labor, instead of just 15 minutes – is to labor near the machine but not in bed. You can stand or walk near the machine, or sit in a rocking chair or (my personal favorite) on a birth ball directly next to it. As long as the monitor stays in place on your abdomen, and you don’t move further than the wires can reach, there is no good medical reason for staying in bed.

Our weekly prenatal yoga classes incorporate many poses that can encourage your baby to “drop” and engage in your pelvis at the final weeks of pregnancy. The majority of the poses we practice are equally helpful during labor, and some can even be used for birth.  Any expectant mother who wants to learn more about helping to create the birth she wants for her baby is invited to join an upcoming prenatal yoga class or childbirth class series.

Healing Hands Chiropractic is a family wellness center located in Londonderry, NH. Also offered at Healing Hands: Prenatal and Family Chiropractic, Acupuncture, Pregnancy Massage and Reiki Therapy.  

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The Ecstasy of Birth

Quote: “There’s just no reason to do it any other way.” Said by many a new mother sitting in a hospital bed, following the virtually pain-free birth of her baby, thanks to the wonders of modern medicine. Years ago, when my sister-in-law and I had this conversation, I found myself at a loss. Having just delivered my own daughter without medication or other intervention, I felt conflicted. I disagreed with her logic, but could not seem to come up with an articulable counter argument, and that frustrated me.

Before we go any further, let me be clear: I count women who have chosen  medical birth among my dearest family and friends. I have no wish to offend them or anyone else. And for a minority of mothers, medically-oriented labor and delivery is the best option. But natural-birthing mothers have been silent too long, and it’s time we respond, “Yes, there absolutely is a reason to do it another way.” To more accurate, there are several reasons, and the evidence on the sheer physical benefit of physiologically normal birth is compelling. But let’s forget about the science for a moment and talk about one specific, albeit abstract, reason: Elective childbirth without medication just may be – no, will probably be – one of the greatest sensations of your life.

Is childbirth painful? You bet. It’s probably some of the most extreme discomfort many women will experience in their lives. Childbirth educators like myself often shy away from the word “pain,” because we don’t want to scare anyone. But let’s face it: “Discomfort” does not begin to describe the sensation of transition contractions. Birth hurts.

But that’s only half the story, and if that’s all you’ve heard, you’ve missed the best part. Yes, birth hurts. But birth also heals. Childbirth is not only one of the most physically painful things many women will experience; it is also one of the most physically and emotionally ecstatic.

I’m convinced that many mothers shy away from discussing this aspect of birth for two reasons: 1) It is highly personal, and 2) It is extremely difficult to articulate.

Describing to anyone your feelings at the birth of your child is to let them in on one of the most intimate experiences of your life. It requires a level of intimacy that most of us share with very few people. Even more challenging, the ecstasy of childbirth is nearly impossible to put into words. But its inarticulable nature does not mean it doesn’t exist. By way of contrast, consider some of the more intense experiences of your own life – moments that enveloped you physically, emotionally, and spiritually. And then ask yourself: Could anyone possibly put that experience into words? Poetry might be able to come close, but prose? Could a random, double-blind, controlled scientific study even begin to touch it?

For most people, the answer is no. There are experiences that cannot be put into words. Science may reflect the hormonal surges that lead to the feelings we experience, but science cannot describe the feeling itself. Now ask yourself: How do you normally respond to an experience that is “too good for words”? Doesn’t its inarticulable nature only make you want to try it more?

So here’s my suggestion: If you are expecting a baby and find yourself on the fence about natural childbirth, put down the research books. Instead, talk to a mother who chose to deliver her child without medical intervention.  Ask her about her experience. (Don’t be shy – most mothers love to tell their birth stories!) Notice her enthusiasm, her attitude towards labor pain, her level of confidence. Ask her if she would have chosen a different approach to her baby’s birth. I’ll wager that she’ll tell you: “There’s just no reason to do it any other way.”

 

Considering a natural birth? Want to learn more about your options? www.HealingHandsNH.com/childbirth.html