Expecting? The Process of Creating a Physiological Birth.

As I have reflected back on my own childbirth experiences, I remember the push to have an epidural, which I refused both times; instead, choosing on my own, less medicine to help me with the process. I also remember at the exact moment when I was pushing my daughter into the world glancing down and seeing my OB/GYN's hands up like he was going to catch a football and his head averted so he wouldn't miss a second of the University of Kentucky football game... another stellar moment.
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As an advocate for natural health, I hope to educate those of you who are pregnant, or may be thinking of starting or adding to your family, on the many benefits of working with a Certified Nurse-Midwife (CNM). In my quest to learn about the field of nurse-midwifery, I started researching Frontier Nursing University nearly three years ago. After speaking with dozens of Frontier grads and faculty members, I decided that, if I ever had another baby (which won't be happening as I'm in my mid-40s and currently in medicinally induced menopause! That's a whole other story), I would definitely use the services of a CNM.

CNMs have a master's and/or doctoral degree and, therefore, have the authority to perform examinations, order lab tests, prescribe medications, etc. In many parts of the world, CNMs are the main providers of care for childbearing women. Statistics from the U.S. Centers for Disease Control and Prevention show that about 12 percent of vaginal deliveries in the United States are attended by midwives.

The Cochrane Database of Systematic Reviews published a review showing that most women whose prenatal and childbirth care are led by a midwife have better outcomes compared with those whose care is led by a physician or shared among disciplines. More from the Cochrane research:

  • The main benefits of midwife-led care were a reduction in the use of epidurals, with fewer episiotomies or instrumental births.
  • Women's chances of being cared for in labor by a midwife she had gotten to know, and having a spontaneous vaginal birth, were also increased.
  • Women who received midwife-led continuity of care were less likely to experience preterm birth or lose their baby before 24 weeks' gestation.
  • The review concludes that most women should be offered midwife-led continuity models of care, although caution should be exercised in applying this advice to women with substantial medical or obstetric complications. (Source: Midwife-led continuity models versus other models of care for childbearing women (Review), The Cochrane Collaboration)

New guidelines released in December 2014 from the United-Kingdom-based National Institute for Health and Care Excellence (NICE) show similar findings. The guidelines assert that increased utilization of midwives and evidence-based physiologic birth practices most commonly associated with out-of-hospital birth settings are keys to improving maternity care in all settings within the U.K.

As such, the guidelines provide important opportunities for CNMs working to improve maternity care in the United States. The guidelines focus on healthy women with uncomplicated full term pregnancies entering labor at low risk of developing complications (i.e. the majority of women).

Overarching Points:
Care led by CNMs is considered safest for many women based on the following indicators:

  • Reduced neonatal and maternal morbidity and mortality;
  • Lower risk of preterm birth;
  • Fewer unnecessary interventions reduce the risks associated with the interventions;
  • Improved use of resources.

In addition, the guidelines stress that woman-centered care and careful communication are critical. All health care professionals are asked to ensure that there is a culture of respect for each woman as an individual undergoing a significant and emotionally intense life experience.

CNMs as Experts in Personalized Attention

As I have reflected back on my own childbirth experiences, I remember the push to have an epidural, which I refused both times; instead, choosing on my own, less medicine to help me with the process. I also remember at the exact moment when I was pushing my daughter into the world glancing down and seeing my OB/GYN's hands up like he was going to catch a football and his head averted so he wouldn't miss a second of the University of Kentucky football game... another stellar moment.

I'm certain the births attended by Tonya Nicholson are much smoother. Nicholson is a DNP, CNM, WHNP-BC, and CNE who graduated from Frontier Nursing University in 1999. She practiced in Florida and then returned to FNU, where she rose to the role of Program Director of Midwifery and Women's Health. Nicholson's well-earned advice to the moms with which she works is simple, "Your job is to grow a baby and take care of yourself. My job is to stand beside you, let you progress and watch for anything abnormal."

Nicholson has attended the births of approximately 2,700 babies: "I look at it as an opportunity to help women change their lives. Women are so open to change during their pregnancies as they grow into their role as mothers. Their whole life can be different because of their experience during pregnancy."

Creating a Setting for a Physiological Birth

Nicholson further explains the emphasis in nurse-midwifery is on the natural ability of women to experience birth with minimum intervention, which is called a physiological birth. She points out two key decisions for those who want to have a physiological birth:

1. Appropriate provider relationship -- Nicholson says the ideal situation is when women have access to nurse-midwifery care that functions within a system that also provides medical care. "As long as I'm working with a medical professional (physician), I am able to take care of most clients, even if they have some medical problems. For a low-risk pregnancy, I am able to provide all of the care." Nicholson explains that CNMs do a thorough assessment of a woman's history initially to determine if she is high risk or low risk. Based on the results, a plan is put together on who the woman will see. This may be the midwife, the physician or a combination of the two.

Assessing risk is about looking at the woman's situation, her current health and her preferences as to the best provider of care and birthplace. Risks might include advanced maternal age, which can cause genetic problems for the baby; high blood pressure; blood sugar levels; smoking; drug and alcohol abuse; and diabetes.

However, many risk factors change during the course of pregnancy. For example, all women are monitored for blood pressure problems. If they are detected, a plan is made to treat. "Being at risk for a problem does not mean that it will occur. The real risk to mom and baby occurs if a problem changes from a potential to an actual problem," adds Nicholson.

2. Appropriate birthplace -- Whether the mom wants to deliver at home, in a free-standing birth center, or in a hospital, this decision is important. "The midwifery practice is much wider and deeper than only delivering in a home. We can provide care for women in all birth settings, as well as those who might need some intervention. However, an inappropriate use of intervention increases risk and does not improve outcome. We feel the best solution for a woman in any birth setting is a physiological birth," adds Nicholson.

A common intervention in medical settings is an induction, which Nicholson says CNMs are less likely to use. "When a woman is induced, there's an increased requirement, rightly so, for monitoring the baby due to potential stress to them. This often means that mom has limited ability to move. Most women report more pain when induced, which increases the need for pain management. Inductions also often lead to C-sections. It's a slippery slope."

There's also the cost of giving birth. "When looking globally, we know that the costs of pregnancy and birth care with CNMs are less than it is with our physician colleagues. A lot of that is about the decreased use of intervention," adds Nicholson.

The CNM and Physician Partnership

I then asked Nicholson the difference between CNMs and physicians, "Midwives are the experts at normal and detecting abnormal. Physicians specialize in fixing problems. I like to reserve a physician's skills for problematic issues, and optimize CNMs to encourage and pursue normal, while detecting abnormal."

Nicholson sees patients two afternoons a week at a private office in her home state of Georgia. The physician with whom she works refers patients whom he feels are a better fit for Nicholson's skills as a CNM. "We partner to offer women what we believe to be the best of all worlds. It's about using our skills appropriately. All women, regardless of risk, need to have a partner who is educating, caring and a true partner in their care," urges Nicholson. "Midwife means 'with woman.' Women want to know that they are heard. Having a baby is a life-changing experience."

Nicholson's attention to helping moms have a positive, life-changing experience shows in the words of her patients, such as this quote, "I told my daughter that my visit with Tonya was the most relaxed and comfortable that I had ever experienced. I felt like I was chatting with a friend who happened to know everything that I didn't know, but should."

Resources to learn more:

  • To find a CNM in your area: Midwife.org
  • Consumer information: OurMomentOfTruth.com
  • Midwifery training information: Frontier.edu

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