A guest post from a registered nurse (RN):
I used to be an assistant to a lay midwife who delivered babies in her own home. I was so ignorant, and I didn’t KNOW I was ignorant! The midwife didn’t recognize her ignorance either.
I really had no idea of the difference in education between CNM, CPM, and DEM. This particular midwife is completely self-taught, a “granny” midwife with no medical background. When I was assisting her, she delivered approx. 200 babies a year. She did not have OB back-up, but she did have a certain amount of respect from the local doctors and hospital, who accepted her transfers without hassle. That respect was probably because she at least didn’t try to do vaginal births at all cost and she did not wait too long to transfer. Also some respect simply because of her persona. She makes you feel like she is in charge, and just knows things. I’ve heard local medical personnel make remarks like “K really has a knack and intuition for midwifery, doesn’t she?” This persona is what makes the mothers feel safe with her. At first I thought she “knew” everything too. But as I worked with her, I began realizing that it wasn’t true. I tried to change how some things were done, but the lay midwife became upset. No one was allowed to threaten her little kingdom! So I left.
I became a registered nurse, and got a job working in a Labor and Delivery unit. Then I began to understand how little I really knew, and how deficient and downright dangerous the lay midwives are! As has been pointed out on your blog so often, when you are ignorant you don’t KNOW you are ignorant!
I used to believe what the midwife said, that the apprenticeship model is just as valid as formal education. She used to say “I would much rather have an experienced midwife (DEM) attend me than a CNM just out of school.” I, of course, thought that made complete sense. But that is complete BS, because you have no idea how the DEM practices or how accountable she is. The new CNM has real medical professionals looking over her shoulder until she has the necessary experience to practice safely.
This is why there should be uniform standards of education and practice for ALL midwives. The following paragraphs are very specific examples of direct entry midwifery practices as I experienced them.
She accepts anyone who wants to VBAC, regardless of the client’s history. I never heard her asking anyone what type of uterine incision she had. It wasn’t until I became an RN that I learned a woman should never TOLAC after a classical incision, I doubt she even knows that. Now I’m amazed that we never had a rupture that I know of (during the time I assisted her at least).
There’s no understanding of hemodynamics, and what acute blood loss can do to the body. What are signs of too much blood loss? Um, we didn’t know. We took one blood pressure after delivery and that was it. No pulse, no O2 sat. I didn’t know what a dangerously low blood pressure was until I was in nursing school. I knew how to take vital signs, but I had no idea how to interpret them. I didn’t know what they would look like when a woman was hemorrhaging. I don’t think the midwife knew either because she never took vital signs. So when did we transfer for hemorrhage? When the woman was lying in a pool of blood and passing out. Estimated blood loss? No idea. We estimated it in terms of a little, medium, a lot. No idea how many mLs. This is why it is easy for me to believe that the midwives in Australia didn’t recognize the signs of acute blood loss in Caroline Lovell’s case. Lay midwives are not trained professionals, they don’t know!!!
She didn’t know how to do perineal repairs. She always told the women to “keep their legs together for several weeks” and the lacerations would heal just fine. Once or twice I saw her put several random stitches in the perineum, but never any vaginal repair. She had no idea how to do it; therefore it would heal “just fine”. Not enough education!!
Prenatal visits consisted of a blood pressure check, FHT with doppler, manual palpation of fundal height and estimation (no actual measurement), and external position check. No weight check. Cervical exams were done close to term. A primip was sent to her PCP for a blood type to check RH. No other blood work was ever done, unless a mom specifically asked for it. Most moms were routinely given oral iron to cover any potential anemia, and they all got calcium and a prenatal vitamin. There were no urine checks for protein, no GBS testing, and no testing for gestational diabetes. No ultrasounds, unless the midwife had a question about position or the woman had a prior infant with an anomaly. Of course she had mostly low-risk women. They were “low-risk” because she didn’t check for any conditions that might make them high-risk, or really even know what conditions are high-risk. Not enough education!
So we didn’t have any gestational diabetics (because we didn’t test for it), of course we didn’t have to follow any newborn glucoses either. But of course, we had no idea that newborns might have a problem with their glucose because we had never learned about that!
She did no newborn exams, no newborn vital signs. She never laid a stethoscope on the newborns at all, nor checked their temperatures. And even if she had, she didn’t know normal parameters for newborn respiratory rates. Most babies got apgars of 9/10, some even 10/10. No babies got any eye prophylaxis or Vit K. There was no breastfeeding support offered.
There was no continuous fetal monitoring during labor, only doppler checks every once in a while. She did no charting at all, so there were no scheduled time intervals by which checks must be done, just when she happened to think about it. I had no idea about decels or fetal distress. I thought if you put a Doppler on the belly and the FHT are below 120, the baby is in distress. I didn’t know there was such a thing as late decels or what they meant. In second stage the baby was monitored once or twice. When we had a baby with low apgars, it was always “with no warning”, and “the baby was fine all through labor”.
She was not NRP certified nor was she even CPR certified. She carries oxygen and an infant bag with mask, and attempts resuscitation if needed. It impresses the parents, but isn’t much good actually. Now I have a NICU resuscitation team 30 seconds away from each delivery and I realize how inadequate our efforts were. Not enough training and education! Her assistants now are not required to have even CPR training and have no idea how newborn resuscitation is done.
She attempted external versions for breech and transverse lie. She delivered breech and twins. She had no idea of whether twins are di/di or not, nor any idea of the significance of that.
She used “black market” Pitocin for postpartum hemorrhages. But she didn’t stick to postpartum use. She gave it to augment stalled labor. How could she do that, without IV access? Simple, she gave it subcutaneously, in small amounts. And it worked. Now I’m appalled, aghast, at how recklessly dangerous that is without CEFM. I had no idea! Not enough education!!! There are many other OOH midwives doing the same thing.
She never used sterile gloves, or set up a sterile field for deliveries. Sterilization of instruments consisted of wiping them off with alcohol.
This midwife’s clientele is almost exclusively Amish. She practices near one of the largest Amish communities in the US in a state where lay midwives operate in a “gray area” legally. She likes it that way because the Amish women don’t question her, trust her implicitly, and will not pursue litigation or repercussions of any kind. They call her for any kind of medical questions they have, even outside of women’s health, and she freely dispenses medical advice over the phone without seeing the patient in question. Sometimes her advice even contradicts a doctor’s advice. . .guess whose opinion carries the most weight?
The only way to make homebirths safer is abolish the CPM and DEM, and require all midwives to be CNMs. I do think the Amish should be able to have an OOH birth option, as this is more compatible with their lifestyle. They are not doing homebirths to be crunchy or because they believe in vaginal births at all costs. They have never even heard of the “Business of being Born”. But they do deserve better care than they are getting. Every woman deserves professional medical care!!
