You’re pregnant. Congratulations! Now is the time to start sorting through some potentially tough questions related to delivering a healthy baby. One of the major decisions you will make is whether to utilize a midwife instead of an OB/GYN physician.
This Q&A with Laurie Roberts, CNM, MSN, a certified nurse midwife and the clinical director of community benefits at St. Joseph Hospital, Eureka, will help you understand your options.
Should I consider using a certified nurse midwife over an OB/GYN? What’s the difference between a midwife and a doula?
Choosing whether to have an obstetrician or a certified nurse midwife (CNM) deliver your baby is a highly personal decision. Women with a normal pregnancy can use either. An OB/GYN has completed medical school and residency, while a CNM is a registered nurse who has received additional training, most often a master’s degree, in women’s health. Midwifery is a recognized health profession with deep historical roots which treats women across their entire lifespan, through pregnancy and the postpartum period, along with general well-woman care and family planning. A CNM is defined under federal law as a primary care provider and can provide general women’s health care, prescribe medications and order tests, admit you to the hospital, and manage your labor and birth. Additionally, a CNM can create an individualized wellness education plan for you that includes disease prevention and emotional counseling, among other services. For women, this means having a primary care provider with something “extra”-- extensive experience with women’s health issues, combined with a wellness-centered approach that takes the whole woman into account.
A board-certified OB/GYN can manage high-risk pregnancies, perform surgeries and use forceps or a vacuum to assist delivery--things which a midwife cannot do. While we are technically clinicians, we are not strictly “clinical” when it comes to our patients. We understand that anything that concerns you, also concerns us. Talk to both an OB/GYN and midwife, ask them about your pregnancy and your preferences, and see whether one--or both--is the better choice for you.
I wanted to also mention doulas, another type of childbirth service provider you may have heard about. A doula can be of great help to women, but there are distinct differences in what they provide during childbirth. Unlike a CNM, a doula doesn’t perform any medical or clinical tasks, such as diagnosing illness, taking blood pressure, performing pelvic exams, or providing postpartum clinical care. Rather, while doulas are trained professionals, their primary mission is to provide physical, emotional and educational support to you before, during and just after childbirth. Doulas can be thought of as skilled pregnancy or childbirth “coaches.” Both midwives and doulas can play important roles in a woman’s physical, emotional and spiritual health.
Where can I find a trusted, expert midwife?
You can find midwives working in a wide variety of health settings, from private offices, outpatient clinics and hospitals, to birth centers, community health centers and private homes. A good place to start your search would be at the American College of Nurse-Midwives. If you are in the Humboldt County region like I am, contact St. Joseph Hospital, Eureka, or Redwood Memorial Hospital for more information --the OB physicians, midwives, nurses and staff at these hospitals have years of experience and have attended to thousands of newborn babies, their mothers and families.
What do you do at midwife prenatal visits, and when do you recommend that I have my first midwife appointment?
I recommend that you schedule your first prenatal appointment as soon as you suspect you might be pregnant. Once you’re scheduled, you can expect your first appointment to take the longest, approximately one hour.
I generally start with a women’s health exam, which consists of breast and cervical cancer screening, along with a “pregnancy orientation” and an overview of our practice. Later appointments are more focused on your pregnancy specifically, and what we work on depends on how far along you are in your pregnancy. During each subsequent visit, you can expect me to evaluate the following:
- Your blood pressure
- Your weight gain
- The babies’ growth by measuring your abdomen or “fundal height”
- The babies’ heart rate
- Your legs and feet for swelling
- The position of the baby, especially as you get closer to birth
- Order blood tests as needed
Finally, I will complete any other evaluations as they arise – for example, I’ll check whether you have cold symptoms, investigate early contractions, or help with managing back pain, just to name a few. And of course, I am here to answer all questions you may have about pregnancy, birth, the recovery or postpartum period. I typically see mothers every four weeks up to the 28-weeks gestation; then, they come in every two weeks up to the 36-weeks gestation. After that, I see the mothers every week until delivery. This is the basic schedule – you may schedule appointments more often if you need to. I’m always here to help.
What is your role as a midwife in the hospital’s pregnancy/delivery team? What will the interaction between you, me, physicians and other caregivers look like?
Midwives are critical members of the labor and delivery team. We work closely with the delivery nurses to manage labor, helping to ensure the safety of both you and your baby. Midwives are often educators as well, and act as role models for staff – which is another very rewarding aspect of our hospital life.
Most midwives are independent practitioners, though, working with lower-risk women. Midwives can independently manage your labor, perform vaginal deliveries, and repair episiotomies and lacerations. Sometimes the help of a physician is required, such as when there are complications during labor or birth. In these situations, we consult with one of our physicians and co-manage your case. Sometimes, we may directly refer you to the doctor who will then take over your case. These referrals happen only about 5 to 10 percent of the time, however. Quite often, a family will be admitted for labor, deliver and recover during the immediate postpartum period without ever seeing a physician.
Do you perform episiotomies? What is your role during C-sections or VBACs?
Although it doesn't happen very often, I may perform and repair an episiotomy to expedite a delivery if needed. Mostly, I will coach you to simply push during childbirth, allowing the perineum to stretch naturally. If a laceration occurs, it’s usually smaller than an episiotomy incision; plus, it tends to bleed less and causes less pain for you.
While I am trained to assist surgeons during a Cesarean section (also called “first assisting”), midwives currently aren’t assisting at St. Joseph Hospital, Eureka. Other ministries within St. Joseph Health that employ nurse midwives, such as St. Joseph Health, St. Mary, allow their midwives to first assist during C-sections. It is important for the nurse midwife to continue in the care of the family, even if a Cesarean section is required, especially if he or she is the family’s primary health care provider. This maintains continuity of your care and also helps to decrease anxiety.
Currently, providers at St. Joseph Hospital, Eureka do not perform Vaginal Birth After Cesarean (VBAC), thus I personally don’t have a role in them. However, midwives do participate and encourage VBACs in many settings across the United States, such as at Redwood Memorial Hospital in Fortuna.
What type of education or training should I look for in a midwife?
When choosing a midwife, you should be familiar with his or her level of education, training and licensing. You should also find out who the back-up physician is, and know what backup plan is in place in case of emergency.
As far as training and qualifications, you should know that there are many educational tracks to become a midwife. CNMs are educated in two disciplines, midwifery and nursing. They earn graduate degrees, complete a midwifery education program accredited by the Accreditation Commission for Midwifery Education (ACME), and pass a national certification examination administered by the American Midwifery Certification Board (AMCB) to receive the professional designation of CNM.
Beyond training and certification, I always encourage families to choose someone they are comfortable with – whether it’s a physician or a nurse midwife. It’s very important that families have a trusting partnership with their health care provider.
What is the benefit of choosing a CNM?
I believe all families should consider midwifery care, because they benefit in so many ways. Families that use midwives typically experience lower Cesarean section rates, fewer preterm deliveries, fewer low birth weight babies, and better breastfeeding rates. But it all comes down to your preferences and what you’re most comfortable with.
What is your philosophy as a CNM?
My passion for this field comes from the good things I believe midwifery brings to the world. I truly believe the interactions we have with families during pregnancy and birth have the potential to impact the rest of their lives in an incredibly positive way.
A good pregnancy and birth experience is literally life-affirming. I have seen that midwifery can enhance maternal-infant bonding, improve the mother’s self-esteem and her sense of being a good mother, as well as enhance the mother-partner relationship. As healers, we have a responsibility to promote wellness and prevent traumatic birth experiences.
At its core, midwifery follows the philosophy of “physiologic birth” – that the natural process of labor and birth is powered by the innate human capabilities of the woman and her fetus. I think of birth as a normal, natural process to embrace, not a medical procedure to fear. In my experience, a birth supported by a midwife is more likely to be a safe and healthy one, simply because no disruptive or unnecessary interventions interfere with the normal physiologic processes.
I believe that the relationship between provider and patient is a sacred one. I am not here to judge, but to guide – with the goal of bringing more healing and wholeness to a family than they had before we met.
What do you find most challenging about your work? What is your favorite part of what you do?
I love my work, but if I had to pinpoint what is most challenging about it, it would probably be the office setting itself. Many hospitals feel very “clinical” and have fairly strict schedules for seeing patients. Ideally, I’d like to see patients in a more welcoming, supportive environment, as in the “centering pregnancy” model, where health assessment and education is bundled together in a personalized setting. Centering pregnancy visits are often done in a group, and can last for two or three hours – so women can get all their questions answered, and not feel that they are “alone” in their pregnancy journey. I think all women could appreciate having their health care providers spend more time with them, but especially when the all-important baby is on the way.
My favorite part of midwifery, by far, is in building relationships. I get a deep sense of satisfaction out of creating relationships with families, supporting women’s choices, and being a conduit for bringing new life into this world!
What is your role as a midwife with community health issues like teenage pregnancy, smoking cessation, drug abuse and domestic violence?
As a midwife, I play many roles. I am a clinician, educator, policy maker, administrator, community health worker, lactation specialist, counselor and much more. This is because pregnancy doesn’t happen in a vacuum; there are often other issues that need to be considered – some of them serious. When teenagers become pregnant, if a patient smokes or drug use is involved, or when domestic abuse comes to light – obviously these are important factors that must be addressed, too. And because these are also public health issues, midwives actually perform a broader role beyond just helping an individual. Additionally, most midwives participate in some level of the broader community – by working in local and national committees, or in task forces dedicated to women’s health. It seems we’re never satisfied with just bringing new life into the world; we want to be part of raising the whole world’s children, too!
This information is not intended as a substitute for professional medical care. Always follow your health care professional's instructions.
