A tale of two midwives

It was the best of times

A new guest post from the “Medwife“:

The case

A 42 year old mother of one presents in the first trimester of her pregnancy to begin prenatal care. Her first pregnancy was uncomplicated at 26 years old with a spontaneous vaginal delivery of a 7ib 4 oz infant in a rural community hospital at 41.6 weeks after three days of prodromal labor. The mother presents for current pregnancy feeling overwhelmed, but excited. She expresses her desire for low intervention care because she ‘trusts birth.’

Homebirth midwife

The mother begins prenatal care with midwife, advised against dating ultrasound after being informed of risks of autism. Trust birth philosophy reinforced, Advanced maternal age is just a variation of normal. Prior postdates pregnancy discussed; midwife concurs ‘babies know when to be born’ and mother is excited to avoid pressure to deliver prior to 42 weeks. Extensive discussion of kale diet, yoga and pelvic rocks. The midwife does not accept Medicaid and an out of pocket cost negotiated and contract signed.

An intimate relationship develops over the course of hour long prenatal appointments at which plans for her doula, birthing pool and birth kit are discussed. Fundal heights are measured as normal, however blood pressures tend to trend up at the end of the 3rd trimester. She is reassured it’s just a little elevated and the mother is thrilled her midwife doesn’t use fear mongering or scare tactics like she reads about on BabyCenter. In the meantime, her midwife crowd sources Facebook and receives recommendations to ‘trust birth’, ‘babies don’t have expiration dates’, ‘Epsom salt baths’, ‘kale smoothies’ and to ‘explore her emotional acceptance of pregnancy’ as measures to respond to increasing blood pressure.

At 38 weeks, contractions begin and labor progresses rapidly as the mother is surrounded by family and birth team. A limp apneic infant is brought to the surface of the water and the mother is encouraged to speak to her baby to ‘bring her earthside’. After several minutes, resuscitative efforts are initiated and eventually EMS is notified. Efforts to resuscitate the infant fail and as the mother is consoled by the midwife she is reminded ‘some babies just aren’t meant to live.’

For an additional fee the placenta is encapsulated.

A year later, a mother sits alone in her living room where her birthing pool had been. Empty arms and a heavy heart, wondering if she just didn’t ‘trust birth’ enough.

Medwife

At the first prenatal appointment, a thorough history and physical exam is completed. Dating u/s confirms the estimated due date. The medwife counseled the patient on folic acid, diet and exercise, weight gain and initial prenatal labs. The risks of advanced maternal age were discussed including increased risk premature birth, preeclampsia, diabetes, intrauterine fetal demise (stillbirth) and chromosome disorders. The medwife offered amniocentesis to the mother and explained the planned increased antepartum surveillance at 36 weeks with recommended delivery at 39 weeks in light of advanced maternal age.

Amniocentesis reveals an unusual chromosome disorder (mosaic) with elevated risk of stillbirth, intrauterine growth restriction and cardiac defects. After counseling provided, the patient desires to continue pregnancy. Medwife arranges maternal-fetal medicine consult, genetic counseling consult, Level II ultrasound and fetal cardiac ultrasound. Antepartum surveillance plan developed between MFM, OB and Medwife. Patient agrees to the plan, but expresses a desire to avoid induction of labor. Medwife acknowledges and discusses concerns at length while balancing risk status and emotional needs of the mother.

At 36.6 weeks, EFW (estimate fetal weight) percentile decreased from 36% to 5% with normal amniotic fluid, BPP 6/8 (absent fetal breathing movements) mildly elevated systolic/diastolic umbilical artery waveforms (an possible indication of decreased placental blood flow) and reactive NST (non-stress test) after prolonged monitoring. Blood pressure elevated at 140’s/80-90’s. Medwife consults OB and maternal-fetal medicine specialist, and the decision is made to proceed with delivery. Labor & Delivery is notified and the neonatologist is aware of genetic diagnosis. Extensive discussion regarding risks and benefits of induction, concerns regarding genetic diagnosis, onset growth restriction and elevated blood pressures. She initially declines with concerns regarding the danger of delivering prior to 39weeks according to the March of Dimes. Risk factors and concerns are discussed at length; patient agrees to proceed with cervical ripening, heplock and continuous electronic fetal monitoring. Pain management options discussed. Mother is disappointed she is no longer a candidate for labor tub and expresses concerns regarding ‘cascade of interventions.

She presents to Labor & Delivery for cervical ripening with onset of uterine contractions 6 hours after dinoprostone placed and nonrecurrent variable decelerations responding to position changes. Over course of several hours she progresses to 5cm, SROM (spontaneous rupture of membranes) and variable decelerations becoming recurrent. OB and neonatologist remain on the unit, anesthesia is in house and aware of patient status.

She rapidly progresses to fully dilated/+1 with urge to push. Minimal descent is noted with pushing efforts accompanied by prolonged decelerations, intrauterine resuscitation initiated with position changes, intravenous fluids, oxygen and terbutaline. OB present in room, Medwife and OB discuss vacuum assisted delivery with plan to proceed to the OR if not immediately successful. Patient agrees. Shortly thereafter, bradycardia ensues and OB applies vacuum and a 2300 gm female infant is delivered with Apgars 8-9. A small, thin placenta is delivered with velamentous insertion and sent to pathology. Pathology report reveals a 284 gm placenta (50% for 25-26wk gestation) with variable thickness of 0.5cm-1.25cm, maximum width 7cm and multiple succenturiate lobes.

After an uneventful 24 hour course, mother and baby are discharge to home. A year later, a developmentally appropriate and stubborn little girl toddles into the clinic with her mother, a pink tiara in one hand and a sucker in the other.

The Medwife reports:

Lost many nights of sleep during this woman’s pregnancy and barely made it to my call room to vomit after a thorough evaluation of the placenta and days away from stillbirth. I’m still not sure how that placenta managed to sustain a fetus as long as it did. I keep a copy of the placental report with the end of the EFM tracing and a first birthday photo stapled to it on a corner of my desk. Reminds me just how much birth can’t be trusted, risk factors can’t be ignored and safe midwifery care cannot be practiced in isolation.

The Medwife counsels other midwives:

This is the essence of evidence-based medicine, availability of resources and collaborative care. This is NOT ignorance of risk factors in favor of touchy feely goodness, birth teams and spectator stunt birthing and this most certainly WAS NOT a baby who wasn’t meant to live.

To homebirth midwives: this isn’t about politics. If you cannot find OB backup or have a rapport with your local hospital … perhaps you need to reevaluate why that is. You have found a way to manipulate mothers, ignore risks, bury your heads in the sand, get paid for it and walk away without remorse or liability … only to do it again. If your philosophy involves taking risks, avoiding interventions at all costs and vilifying the obstetrics community, perhaps the only politics at stake here are those you have created for yourselves. To waive the ‘politics’ card is insulting to the midwives who work endlessly to support pregnancy and birth, maintain a high level of professional collaboration within the medical community and are at all times aware of their resources. Why? Because that is the true value of Midwifery.

So the next time you leave a mother with empty arms and a broken heart, don’t you dare whisper “some babies aren’t meant to live” or “she would have died in the hospital too”. It’s not true and I’ve got the tiara to prove it!

  • Lisa the Raptor

    Am I right in thinking that all those years between babies makes her medically nulliparous?

    • Young CC Prof

      It’s not like her bony pelvis shrank in the intervening years. As I understand it, the worst danger for first time mothers at home birth is simply that there’s no way to know whether babies will fit through her pelvis or not until it’s been attempted at least once.

      • Lisa the Raptor

        Ok. I wasn’t sure why it was so.

  • Allie

    Crying now.

  • Stacie

    Dear Dr Amy, thank you so much for this post! I am a “medwife” offering in hospital birth only. I am so sick of patients/families/society assuming I am an uneducated, hippie lay midwife. I do support natural birth but also know there is a great need for our interventions. Thank you again for clarifying that not all midwifes are risky, dangerous and suspicious of medicine!

    • CrownedMedwife

      My daughter-in-law is a nursing student. During her OB rotation, she shared that I am a CNM. She was stunned by the responses from her classmates who in summary presumed a midwife to be a birkenstock wearing, grey haired woman donning a prairie skirt with a trunk full of herbs who showed up at laboring mothers homes expecting complimentary meals, accommodations and cash payouts. In reality, I’ve never been to a store that sells birkenstocks, do my best to keep greys colored at all times, never owned a prairie skirt, imbibe in the occasional herbal tea to clear tight sinuses, rather like the complimentary meals as a member of the medical staff and would never presume to expect a cash payout. Poor girl didn’t know just how to respond as her only definition of a midwife happens to be a medwife!

      We have a long way to go to define our profession to the public and set the expectations of what a CNM really does.

    • Spamamander

      I loved my CNM who delivered my first, and all the other “medwives” at the clinic. That is all.

  • ngozi

    I like how the medwife was willing to discuss and answer questions at length. I personally think more women would be more willing to accept necessary tests and interventions if more care providers treated their patients the way this medwife treated her patient.
    Of course, if someone wants to be stubbornly crunchy, then there is no amount of explaining you can do…

  • Hurricanewarningdc

    That pretty much says it all. I’m at a loss for words – and more words really aren’t needed. How anyone chooses the first version is mind-boggling, More women need to see this… They need to know. (can’t get the log in to work. hurricanewarningdc)

  • Deena Chamlee

    Yes you go gurl!

  • anh

    OT: so…American recently relocated to the UK. My daughter is 19 months and tomorrow a home health visitor is coming. this sounds so scary to me (likely because in the US anyone coming to your home already suspects you are a terrible parent) This person isn’t coming to judge my parenting, are they?

    • Wren

      Fellow American in the UK here. I had my kids here, so that home visit with the health visitor was when they were tiny both times. These visits were pretty quick and largely about checking off items on a form.

      We moved when my kids were 3 1/2 years and 22 months, so we got another visit then. Really, they are just looking for a healthy child and a normal home, or for what help you might need to have those. A truly unclean home might lead to concern, but a few things out of place or dishes that need washing won’t earn a second glance. After I moved, I still had boxes all over that hadn’t been fully unpacked and she didn’t care. I was asked about stair gates, but when I pointed out my youngest handled stairs well and climbed stair gates, making them more of a hazard than a safety device, she was fine with that. The majority of the visit was about the kids’ development, the youngest in particular, and whether I had any concerns.

      It really wasn’t scary and I didn’t feel judged.

    • The Bofa on the Sofa

      Consider it an opportunity to discover things where you can improve. Remember, she is focusing on helping you have a healthy child.

      Don’t take anything personally. It’s medical advice, not personal judgement.

    • Mattie

      Hi anh :) Don’t be worried, HVs are just there for when your baby is over a month old, they will provide you with a ‘red book’ that has growth charts, vaccine records and other bits in, they also have information about local mother and baby groups and nurseries. They talk about how you are feeding baby and whether you have any concerns, generally they won’t be ‘involved’ as such and it is definitely not a judgement of your parenting skills! Home visits are quite usual in the UK and most of the maternity care is done by midwives (much more like the medwife description in the above post).

      HVs are registered nurses or midwives who have done extra training on child development/nutrition/illnesses and just form part of the local healthcare team. Hope this helps you a bit.

    • Dr Kitty

      Nope.
      Just to check your child is developmentally appropriate, ask you about vaccines and make sure you have a GP.

      HVs are usually the ones who are the first to spot child protection issues.

      Their role is a wonderful mix of paediatric nurse, lactation consultant and social worker. They usually have great local knowledge and will give advice on everything from child proofing your home to post natal depression

      Everyone gets seen by a HV at home for newborns, the 8week check, the routine vaccination visits, a 2 year home visit and the preschool vaccination visit.
      If the HV identifies concerns (domestic violence, neglect, developmental concerns) they visit more often.

      • Dr Kitty

        So…don’t freak out.
        They’re not picking on you, everyone gets the minimum number of visits, if all is well it will be a formality.

        HVs are used to dealing with EVERY family- they don’t judge particular parenting styles unless there is obvious abuse.

        They often run drop in baby clinics out of HP surgeries, where you can have your baby weighed and ask them any queries you have about child rearing, feeding, development or whatever.

        They are involved until your child is school aged (5 or 6), and will often liaise with your GP.

        They are really great for first time parents, who don’t always need advice from a Dr, but do have a lot of “Is this normal?” questions.

        Really, they’re nice.
        Ask them about childcare in the area, or how you apply to school,

      • Jessica S.

        Wow, that sounds really convenient! Better than schlepping across town, that’s for sure.

      • Medwife

        Man, we need this in the US.

      • Joyous76

        Ha! Vaccines. My council has been sending me warning letters with no contact info about my baby needing her 1st injections. We have finished with the third set. The nurse said they never update their database. Useless.

        • Dr Kitty

          Really?
          Ours are totally up to date. We send them records weekly after every baby clinic.

          I got my vaccine history (dating back to 1988) from my local school health dept.

          My HV was…not so helpful about breastfeeding, but otherwise totally fine. And she was only unhelpful because she had no personal experience (less than 5% of mothers are breastfeeding at a year here, “how do I wean my toddler” wasn’t exactly in her wheelhouse).

          • Joyous76

            My surgery sends the records, but apparently the council doesn’t update them. Also, my area doesn’t have a weekly clinic, only a monthly one (for weigh-ins and the like. Injections are just done at the surgery.) So when my baby kept falling down the centiles, everyone was shocked I bought a baby scale. Well, I thought waiting a month for a weight check was a bad idea.

    • KarenJJ

      I had one in Australia. Don’t get too put off if they ask you something like “is there someone that you don’t feel safe around?”. They ask it for domestic violence reasons. I found the question a bit strange and didn’t realise what it was about, but knowing more about domestic violence I’m glad they ask it. Mine also got me to do an depression scale (passed with flying colours but in retrospect some of the questions didn’t really apply for post-partum and I definitely had some anxiety stuff going on).

    • Joyous76

      Another American in the UK. Do people actually get useful advice from their HV? I have had two different ones, because one left. They both seem nice. They all ask to use the bathroom to nose around. They give totally conflicting advice and as for improving my parenting, neither has spent more than ten minutes here and the new one seems to think 1. My husband took no time off when he took 6 weeks and B. We have other children, which no she is my first. So, in general, nice but pretty useless.

      • Joyous76

        Oh and they forgot the three month visit because of the hand over and I was asked why I didn’t follow up when she didn’t turn up. I didn’t even remember there was an appointment.

  • staceyjw

    I just had to tear up after reading this:

    “After an uneventful 24 hour course, mother and baby are discharge to home. A year later, a developmentally appropriate and stubborn little girl toddles into the clinic with her mother, a pink tiara in one hand and a sucker in the other.”

    SHE MADE IT, and this is so very, very, beautiful.

    I am looking at my own little toddler, also a stubborn daughter, and marvel of evidence based medicine. She was not meant to die either, and thanks to ROUTINE care, she survived and thrived.

    People say “what a miracle” but I disagree. This is the result of proper care, practiced rigorously by the best docs out there, honed by skilled professionals, over a century of medical advances. The only miraculous thing is that we were lucky enough to live in a time, and a place, where this was possible.

    As awesome as it was, nothing my OB and MFM did was particularly remarkable, though their excellent skills did make the difference. Indeed, it was a boring old 2nd trimester anatomy scan that found the problem, a common procedure that kept her from being a 2nd trimester loss, and a typical course of progesterone shots, US, BPPs and NSTs, that kept her in until almost 34 Weeks. All the typical LnD protocols were followed, a VBAC commenced, ending in a healthy baby.

    The mom in this story WAS luckier than most, but it was her CNM, MFM team that made it all possible. And for that, I am thrilled.

    • KarenJJ

      Isn’t it better to perform “miracles” rather than shrug your shoulders and say “some babies weren’t meant to live”?

      I know what sort of health care I prefer to seek out.

  • Paloma

    This is a great post. Thank you for writing it!! My grandmother was a nurse midwife too, and she is the one who inspired me to become an OB/GYN.
    PS: If someone told me that my baby was not meant to live I would probably strangle them.

  • Sue

    Beautiful post – thank you! An ideal combination of sensitivity and rationality. That’s what makes a real professional.

  • MacArthur Obgyn

    Does Medwife have a website or her own blog? I’d like to read more.

    • CrownedMedwife

      Seeing upwards of 30 patients a day, 96 hours call/week and attending an average of 20 births a month, keeping up with countless journals, while still being a wife and mother is enough, but thank your for your inquiry. I appreciate Dr. Amy’s willingness to share guest posts. As she and the commenters here provide an excellent platform, it seems worthwhile to share here. If I can contribute in a productive way, it’s my little way of thanking Dr. Amy for maintaining this blog and her never ending commitment to what it represents. Unfortunately for my family, motivation to write seems to come on my day off when I am supposed to be cleaning or grocery shopping!

      • ngozi

        I like the way you were willing to answer questions and have discussions with your patient. In my local area, a doctor says something, and everyone is just supposed to say “yassuh massa.”

  • meglo91

    I love this. I am thankful every day for the medwives who recognized that my hugely elevated BP (160/100-ish) and the protein in my urine meant that I should not spend any more time pregnant and who induced me at 38 weeks with my second daughter. I wasn’t thrilled to have to be induced, but I recognized their expertise. I delivered a healthy 8-pounder who is a mischievous little peanut today. If they had waited to call it, I don’t know what might have happened — to her OR to me. Thank you, medwives.

  • yentavegan

    The Icing on the cake is the toddler in her tiara!

  • wookie130

    OT:

    I’m apologize for bringing this in here, but I know that many of you are medical professionals, OB’s, nurses, etc. I had my 20 week anatomy scan/ultrasound today, and although everything looked “fine” with my son, it was discovered that I have a 2 vessel cord, or SUA, as I’ve seen it referred to. Because of this, I’m now being referred to U of I hospital next week for a Level 2 ultrasound, to have a more in-depth look at the baby. I am terrified, although no one in my OB practice that I spoke with today said that I had any reason to be…I was reassured that it’s not uncommon, and that the vast majority of babies with SUA are fine. Well, I got home, and of course consulted Dr. Google…and then read over and over again about stillbirths, VADER syndrome, and a host of other issues. Being that I’m 35, I have had the MaterniT21 screening done at 12 weeks, and that test came back normal for genetic abnormalities. Does anyone in here have experience with this? Again, I’m sorry, and realize that this very well may not be a good place to be addressing this, but I really trust the level of expertise that’s brought to the table on this blog, and I’d appreciate any response anyone could offer. Thank you!

    • Jessica S.

      I have no advice, but as a 25wk pregnant lady, I wanted to offer a virtual *hug*. Your in my thoughts. I know you’ll get some great responses here.

      • wookie130

        Thank you everyone, for your replies! I appreciate it. My level 2 ultrasound has been scheduled for next week, so I hope to find out more then.

        • hurricanewarningdc

          Don’t know anything about this, but wishing you luck, I hope that the rest of your pregnancy is uneventful and plain old dull! :) Be well.

    • CanDoc

      Super common, usually completely normal pregnancy but needs some surveillance. See it frequently in practice. With normal chromosomes, if 18 weeks scan normal major follow-up will be to recheck growth in early 3rd trimester, and closer surveillance if any growth concerns. Although babies with SUA are a little more likely to have growth issues, the last one I delivered was 9 lb 14 oz (non diabetic). Stop consulting Dr. Google. :)

      • CanDoc

        Grammatical edit: if 18 week scan is normal, then the only major follow-up will be to recheck growth in early 3rd trimester. (Depending on your centre, at 28 and 32 and 36 weeks, or 30 and 34 weeks, or just at 32 weeks, or some variation thereof.)

      • Ob in OZ

        Agree with above and below. If your morphology scan was done at a high quality place, then nothing to worry about. I would add an u/s at 32 weeks for growth , maybe an extra one or two if clinically you were measuring small.

    • guest

      Like you I had a two-vessel cord. My doc also told me it was no big deal. Then I went home and googled it, and I promptly freaked the hell out. Fast-forward a-ways, next ultrasound showed he was growing fine. Fast-forward some more, and kiddo was perfectly healthy. My doctor was right all along. :) I know it is easy to panic, but it is more than likely that everything is absolutely fine. Hugs to you!

    • Captain Obvious

      Actually has a significant higher risk for congenital heart disease and slighter higher risk for IUGR. Need a feto echo and serial sono for growth in third trimester.

    • fiftyfifty1

      Happened to my cousin. They watched her extra close and had her come in at first sign of labor rather than wait. Had her on continuous monitoring. Recommended an epidural because intolerance of labor is a little more common and they wanted pain relief on board in case they needed to hurry up and do a vacuum or c-section etc. Everything went very well, baby tolerated labor without problem. Gorgeous normal healthy pre-schooler now.

      Also, good friend of mine with son with VATER syndrome (don’t know how his cord was). Did need some surgeries as baby. Now all grown up and normal health. Just made her a grandma last year.

  • Cold Steel

    It was a very well-written piece and a nice case report, but I too am curious why the patient was continued to be seen by the CNM. What role did she play or value did she add to a case which became increasingly high-risk as the pregnancy wore on, for both maternal and fetal reasons? Did the patient simply refuse transfer of care?

    • Amy Tuteur, MD

      I worked for a large HMO for 5 years and our practice included more than 20 CNMs. I collaborated with them every day and found they almost always added value. Why shouldn’t a CNM continue to follow a patient as long as she is consulting with an obstetrician? As a physician I often collaborated with other specialty physicians and neither of us felt the need to “own” the patient. It can work the same way with CNMs.

      • Young CC Prof

        I agree. I started out my pregnancy with a regular obstetrician, and I felt comfortable with her. Later, when a problem appeared, I wound up seeing MFM several times. They communicated about my care, and the regular OB did my delivery at the date recommended by MFM. It worked out pretty well.

        Sub-specialists can’t handle everything. For one thing, they wouldn’t have time!

        • http://www.antigonos.blogspot.com/ Antigonos CNM

          The thing about CNMs is that they have the knowledge base and the expertise to know when to consult with, or refer to, an OB. it isn’t an either-or, or adversarial relationship, but rather a collaborative effort, unlike the non-CNM midwife model, which at times seems quite paranoid about any form of assistance at all.

        • Ob in OZ

          For another,MFM rarely is interested in delivering a baby! They are happy to advise and exit.

        • Mominoma

          Zackly! With my daughter, I originally saw a CNM. Transferred care to an OB when I moved, and *he* sent me to see a peri. My CNM was already talking about sending me to an OB since I was already spilling protein at +2 at 24 weeks. They worked together to take care of us, and it worked out great. I saw the OB on Tuesdays and the peri on Thursdays. They consulted and collaborated and together they helped me deliver my healthy daughter at 38 weeks and prevented any further damage to my kidneys. I am grateful to all of them!

      • Laura

        This comment should be repeated for all those who say, “Dr. Amy hates midwives.” Clearly, you don’t! And you have positive experiences working with them in a collaborative way. My concern is that many NCB folks, midwives included, will say, “Well that’s only care for those with risk factors.” As we have evidenced, there are women with risk factors who aren’t risked out! And professionals who “own” their patients are ones who have crossed unprofessional emotional boundaries with their patients, compromising care and safety. This, too, we have seen in radical NCB circles.

      • Deena Chamlee

        Yes Dr. Tuteur yes indeed.

      • Cold Steel

        I’m only a resident as you know, but it seems inefficient or even dangerous for two people to manage the same patient for the same problem. Once a generalist refers to a specialist, s/he no longer attempts to manage the condition for which the specialist has been consulted. FPs don’t whip up their own heart failure cocktail in addition to the cardiologist’s; general surgeons don’t pop into the OR for an advanced biliary tree reconstruction they referred to the hepatobiliary specialist, etc. So why would the primary caregiver, in this case the midwife, still manage the pregnancy? Even if the two were in the same building and each saw the patient at each prenatal visit, it seems inefficient.

        • LadyLuck777

          Just because you consult cardiology and leave the cardiac issues to them doesn’t mean you transfer care of the entire patient. The CNM can still monitor issues like GBS, routine labs, gestational diabetes, etc.

          I work in Palliative Care, and more often than not when I get consulted for terminal issues, the rest of the caregivers bail and I become the primary provider. That is hugely harmful to the patient’s emotional well-being and really constitutes patient abandonment. I am thrilled that this CNM chose to remain a part of this care team.

        • Young CC Prof

          In Britain, they call specialists “consultants,” and sometimes, that’s how it works here too. Generalist or slightly specialized doctor is treating a condition that is normally well within his area of expertise. Patient isn’t improving or condition is more complicated than usual. First doctor sends patient to a specialist or sub-specialist for another opinion.

          Now, sometimes the sub-specialist might do surgery or something, and then it’s all his business. But for a chronic condition, often the sub-specialist examines the patient, maybe does more tests, and then sends him back to the first doctor with some new treatment recommendations. And maybe the patient continues to see the family doctor once a month and the specialist once a year.

        • Amy Tuteur, MD

          The obstetrician is the one with ultimate responsibiity for the patient, of course. But there’s no reason why some visits can’t be done with the midwife and there’s no reason why the midwife can’t catch the baby if everything is fine.

          The same thing happens with attendings. If I had a patient with thyroid issues, I’d consult an endocrinologist and take all of his or her suggestions, but I still managed the patient.

        • Medwife

          In the case study, the plan of care is decided by the OB (and patient). The CNM wouldn’t be tinkering with that but can be involved in patient care- the routine assessment, ordering labs, etc.

          It requires trust between the care providers and good communication.

      • ModerneTheophanu

        I am being seen by a large practice that has numerous CNMs and OBs, but the CNMs are not allowed to see anyone who is labeled high risk for any reason. Was that similar to what your practice was like at the HMO? At my current practice, as soon as the patient is labeled high risk, she is transferred to the OB side of the house. The OBs and the CNMs don’t share patients where I am. I’m just curious if this is common or not the rule in most large practices.

    • fiftyfifty1

      Good question. I can see the value of continuity of care for emotional reasons. Or, as is sometimes the case, when a patient has transportation issues. But I would be concerned about the risk of “the telephone game”. What if some detail were inadvertently left out or communicated but misunderstood? It doesn’t serve the patient and it puts the OB or MFM doc on the hook.

      As a primary care physician there are some things that I co-manage with a specialist, but there are other cases when it is better that I stay out entirely. Too many cooks can spoil the broth.

      • Medwife

        It’s different when you’re in a small practice together. It sounds like crownedmedwife and I are in similar practice environments. Really smooths out the whole consultation/referral process and patients sometimes really want to continue to see midwives as well as the OB. I do have some patients that I just absolutely won’t see and write “md only” in all caps on their problem list. For example, a patient with severe, active autoimmune disease.

        In my type of practice, I find myself having to work actively to define my scope and punt the patients that really must see the OB. It’s the opposite of the “turf battles” in always hearing about.

        • fiftyfifty1

          Ah, that makes sense if you are in the same practice and physically together.

          • CrownedMediwife

            Yes, Medwife said it exactly.

  • attitude devant

    Terrific. Thank you.

  • Guest

    There has been much discussion recently regarding CNM’s only practicing within their scope of practice due to restraints, the unwillingless of CNM’s to recognize and risk out risk factors and their failure to come together to take a stand against others in this profession who provide substandard or pseudo care. Where does it go from here? How exactly do the accountable CNMs acting within their scope of practice and as members of a health care team move forward? If ACNM doesn’t distinguish these providers from others, how is this accomplished?

    • fiftyfifty1

      “Where does it go from here? How exactly do the accountable CNMs acting within their scope of practice and as members of a health care team move forward? If ACNM doesn’t distinguish these providers from others, how is this accomplished?”

      This is the $1,000,000 question. If the ACNM doesn’t distinguish the good CNMs from the crazies, how can the general public? How can I, as a family doctor, recommend CNM care to my pregnant patients when this element of woo exists and seems to be growing stronger? I would love to be able to recommend CNM care without reservation to my patients. As it sits now, I can’t. Medwife may be great, but what if on the night my patient delivers, her colleague “I -Changed -My-Name-To-A-Fake-Native-American-Word-And-I-Trust-Birth” is on call?

      • The Bofa on the Sofa

        And this is why it is imperative on the good midwives to get the rest of the house in order. They are going to suffer from the influx of crap.

        • CrownedMedwife

          Million dollar question and no answer. The house of ACNM isn’t in order and that’s why I left without looking back years ago.

          Years ago as a graduate student, I listened to the ideals from classmates with few years of experience under their belts or their experiences were in a university hospital setting. They didn’t have the time put in or hadn’t experienced practice in an institution with limited resource (in house OB, anesthesia, pediatrics). Decades of night shift in a community hospital teaches a L&D RN a lot…labor support and early intuition and action to anticipate a step ahead of calling in the resources. I am sure I seemed a bit jaded (sometimes a bit flabbergasted and other times a bit bored) in those classes and didn’t hesitate to share that with the students if I felt there was a learning opportunity. While I hope their outcomes have been good, I wonder if their volume has provided the opportunity to now understand where I was coming from. If we’re lucky, they did. If we’re not…they are the ones left out their supporting ACNM and or/woo.That’s what we midwifery is up against.

          Hearing from other CNM’s here, they seem to share similar practice environments and management styles. How do these types of CNMs come together to make a change? How do we really even know what our percentage is? How can we get our house in order if we don’t even know who is in it? If the majority of CNMs are hospital based, how rampant does it range. I truly don’t know where it starts, but it’s overdue. I look forward to the day we can call ourselves CNMs and the public knows just what the expectation of that title is. Without a starting point, I don’t know that day will happen.

          • Medwife

            I’ll be honest, I was a student without the RN experience. I was woo-ish. I went into a great practice with excellent mentors, both OB and CNM, and that plus feeling the full weight of responsibility for two lives straightened me right out.

            The most important thing we can do is precept. I strongly believe that. Reach out to the students.

          • CrownedMedwife

            I have spent a bit of time feeling as though I have somehow let down my profession by not being more active in taking a stand for midwifery standards. ( I honestly where to start!) In hindsight I think lapsing my ACNM membership may not have accomplished much. Thank you for reminding me that serving as a preceptor is one way to make a difference. Over the years the majority of my students have been WHNP and FNP in clinic, with the usual rotation of EMT and first year med students in OB. In a way it may have helped define their expectations of CNMs as they move into practice or have brought back to courses shared with CNM students???

          • Medwife

            I am sure precepting students in other specialties and med students was hugely beneficial for them and for nurse-midwifery. I have met many OBs who were precepted by midwives and they are a pleasure to work with and learn from. But if they’re expecting cnms to be more like you and less like Ina May, we’ve got to get precepting! I’m talking to myself, too, but I want to get more years of practice under my belt before I step into that role.

      • CrownedMedwife

        It’s true, unless you specifically know the practice or philosophy of a particular CNM, you can’t refer and assume an element of the woo pervades. As a Family Physician, I’m sure there are certain surgeons you don’t necessarily refer to either. We all refer our patients based upon previous knowledge of that providers competence. For instance, I discourage a certain pediatric provider just because he plays in woo-land and encourages antivax.

        And as it stands, I wouldn’t ever practice in a group tolerant of substandard care so you wouldn’t need to worry the backup CNM would walk in dressed in woo. I may be a CNM, but I play by ACOG’s rules. I wouldn’t tolerate having a colleague who doesn’t like the rules of that game.

  • Mishimoo

    This was a beautiful rebuttal to the “some babies aren’t meant to live” card, and just an altogether wonderful story. So glad that mum and bub both survived and are doing well.

  • Ellen Mary

    Just one point of contention, just offering Amnio is like 2 generations behind. She would be offered MaternitI21 or VerifI or in some places still Quad Screen & Nuchal Fold & and then CVS. Amnio is only indicated after ALL of these less invasive steps now.

    • LMS1953

      That is a very good point!

    • CrownedMedwife

      No point of contention. The patient declined referral for 1st trimester NTT. The CffDNA tests were just being introduced at the time of her pregnancy and not widely available or used. At risk patients are counseled on CffDNA versus amniocentesis. Due to limited chromosome analysis of CffDNA, the patient requested amniocentesis. This baby’s specific chromosome disorder would not have been detected on the CffDNA panel available at that time, although that has changed with the expansion of testing panels. As groundbreaking as CffDNA has been for at risk pregnancies, it still has its limitations.

    • Captain Obvious

      Amniocentesis is still the diagnostic test and can still be offered first for at risk patients. ACOG’s statement on NIPT states ccfDNA is only for at risk patients (therefore not necessary for low risks patients). Some insurance companies are declining reimbursement for ccfDNA screening for low risk patients. Even if NIPT was performed and positive for risk, amniocentesis is still recommended for diagnosis.

      • LMS1953

        Why don’t insurance companies do something useful and decline reimbursement for the experimental procedure called waterbirth?

        • Captain Obvious

          I am unaware of any ICD or CPT code that specifies waterbirth. I wonder if insurance companies “knew” the NSVD code their using meant waterbirth if they might reconsider.

          • LMS1953

            ICD-10 has something like 80,000 codes versus 15,000 for ICD-9. Included are bizarre things like death by surfboard. But I’d be willing to BET that there is still not a code for ROUND LIGAMENT SYNDROME (the most common reason for ER visits for pelvic pain between 12 and 20 weeks. Nor will there be a code for BACTERIAL VAGINOSIS – the most common vaginal discharge with vaginal discharge being the most common gynecological complaint.

            I catch your drift, but if Medicaid can recoup payments for < 39 week deliveries upon further retrospective review, I think waterbirths can be tracked.

          • Captain Obvious

            625.9 RL pain. 616.10 BV

          • LMS1953

            You made my point. 625.9 is a very catch-all code for all female pain from the labia to the umbilicus. I would really like a number (there is only like an INFINITY of those) to attach one-on-one to the diagnosis ROUND LIGAMENT SYNDROME. Likewise with 616.10 which is “bacterial infection of the vajay” and can range from vulvo-vaginal GANGRENE to little old stinky bacterial VAGINOSIS. Kinda broad, don’t cha think? In thirty years I have not had a single case of vulvar gangrene come into the office. Bacterial vaginosis – several thousand. Now, if she had leishmaniasis, I’d be golden. But the MOST EFFIN COMMON VAGINITIS? Nope, can’t track that – it’ll get all buggered up with gangrene and drooling pus and whatnot. But if she suffers death by surfboard, by golly, we’ve got her covered.

          • Medwife

            Patient struck by an object falling from space? They’ve got it down to whether it was natural or man made. But BV vs gangrene? Now you expect too much.

          • Dr Kitty

            I give up on our coding system sometimes.
            A lot of my consultations are either “chat with patient” or “patient reviewed” or “supportive chat” because I just can’t code all the things we talked about.

            We use Read Codes.
            http://en.wikipedia.org/wiki/Read_code

            There are codes for BV and Round ligament pain.
            And also lots of odd and occasionally useful things.
            “Declines to state alcohol consumption”:XaZqd
            “Victim of human trafficking”: Xaa0i
            “Good parenting skills”: XaaGp
            “Provision of weighted vaginal codes”: Xaa0w
            We have it all.

          • Captain Obvious

            Why do you wan to track it? Just bill it, and be done with it.

          • staceyjw

            Ugh, Medicaid. I love having it, but loathe how they seem to want to cheat docs and force them out with ridiculous reimbursement.
            I get they need to make spending cuts, but that is not the place to do it. Maybe we could use some of the immense war budget to pay docs what they are worth, and cover more people, instead? Just a thought.

          • Young CC Prof

            There are several ICD codes related to neonatal aspiration, but none obviously specifically water birth related.

          • Captain Obvious

            Search waterbirth…

          • Young CC Prof

            Again, lots of those things could be related to water birth, but they could also happen in a “dry land” birth, right?

          • Captain Obvious

            Of course, but was appropriate search answers for “waterbirth”.

      • Ellen Mary

        So indication for Amnio would also be indication for ccfDNA, so still confused why a provider would offer that first, instead of a screening test that is highly accurate & exponentially less invasive & performed way earlier in gestation.

        • Captain Obvious

          CcfDNA is a great SCREENING test. Amniocentesis is a DIAGNOSTIC test. Just like a Pap smear is a screening test and a cervical biopsy is a diagnostic test. Or a mammo is a screening test, and a breast biopsy is a diagnostic test. ACOG’s statement on ccfDNA is that it is for high patients. ACOG also stated in 2007 that amniocentesis can be offered to any woman wanting diagnostic testing even if you are not high risk or over 35. I know, doesn’t make sense. Well, some insurance companies are taking ACOG’s statement verbatim and not covering ccfDNA for low risk women even though Harmony will let any risk woman have the test done (for no more than $250). If your insurance company doesn’t cover the ccfDNA test, you may be stuck with a quad test and a 5% FPR for a 79-81% DR.
          CcfDNA does not detect all trisomies or aneuploidies or other specific genetic defects. CcfDNA does not detect spina bifida. You still have to do a second trimester MSAFP for that, and the MSAFP surely doesn’t have the same detection rate for SB that CcfDNA has for T21. Obesity has a higher redraw rate with ccfDNA, and it cannot be done on twins or egg donors.
          So amnio is still an effective diagnostic test and not ” like 2 generations behind”, if you have an abnormal ccfDNA, guess what you will be offered next? Yes ccfDNA has decreased the number of amnios done for “false positive” quad screens, but it is still the gold standard.

          • Guestll

            CO, can ccfDNA test for hemophilia? As a carrier and AMA mother, I skipped the screening and went straight to CVS. Just curious if it can screen for hemophilia?

          • Captain Obvious

            Must be tired, should be typing cffDNA ( cell free fetal DNA) instead of ccfDNA :( I don’t know if it can detect hemophilia specifically, I’ll have to look that one up. But since hemophilia is X linked, you can determine the sex of the baby as early as 7 weeks and know if you have a girl the worse you can have is a carrier. And if it is a boy, you have 50% chance.

          • Guestll

            Thanks for your reply. Once we learned 46XX, we didn’t pursue any further testing (other than MSAFP screen).

            Thanks again.

          • Ellen Mary

            I understand the difference I just didn’t understand the logic if skipping it in the above case study. As a mother, I want the test with a miscarriage rate of 0.0% first.

            As a personal anecdote, I skipped both @ 9 weeks because I didn’t personally want a temptation to terminate. But then they found an heart atypicality that needed further observation (upon Echo, turned out to be normal). I got so tired of hearing ‘we don’t know’ that I went for the DNA screen. I never got a bill. I got an EOB from my insurance company stating that I owed 1200 & a check for 200. The MFM clinic said if my insurance company rejected it, it would just be 250, but I have never received a bill @ all. Tracking that down tomorrow.

          • Medwife

            My state Medicaid does not cover it at all, under any circumstance. The integrated screening (1st and 2nd tri blood draws plus nuchal translucency) gives results weeks later than 16wk amnio and they are screening, not diagnostic. This delay in results greatly complicated the termination option.

          • staceyjw

            I am sure that is why they don’t cover it, though the excuse may be money. Anti choicers DO have their fingers in everywhere, all over health care. This is my main reservation to the USA ever getting a national healthcare system. If the government is the payer, than they can institute all manner of gross, inappropriate, religious based practices. Scares the crap out of me.
            HOPE I AM WRONG

          • Medwife

            I hope so, too. I’m already struggling with religious barriers to my practice; I deliver at a catholic hospital. I don’t have words for how frustrating it can be. And I’m in a rural area, so it’s their way or the highway.

      • drsquid

        i opted for amnio. i tried to get the maternt21 test but they wouldnt do it for twins. i declined the screening labs and NT

  • The Computer Ate My Nym

    Stubborn, developmentally appropriate toddlers are some of the best things in the world.

    • Jessica S.

      I need to post this on my fridge, for the moments I want to lock myself in the bathroom until my husband gets home. :) I kid. My 3.5 year old is really a good kid. And not so much a toddler. But boy, it’s crazy how something so miniature can drive me stark-raving mad. :)

      • The Computer Ate My Nym

        Heh. I say this now that mine is 10…but a stubborn toddler will, with some luck, grow up to be a determined adult some day…

  • The Bofa on the Sofa

    I’m not sure I understand. Is the first part (from a HB midwife) a narrative from your experience when you used to be a HB midwife? Or is it what you project a HB midwife to be doing?

    • CrownedMedwife

      Yes, this is a projection of HB midwife care based upon the premise (based upon recent cases discussed here and elsewhere) of ignoring risk factors and what can missed by ignoring standards of care in favor of ‘trusting birth’. Never attended a homebirth and never will; an ethical decision, having nothing to do with constraints or politics.

      • http://www.antigonos.blogspot.com/ Antigonos CNM

        I HAVE done homebirths as part of my British midwifery training, and it was nothing like the crunchy, back to nature experience in the first part of the article. BTW, the patient would not have been accepted for a home birth in the UK when I was there; too many risk factors present.

        • CrownedMedwife

          Unfortunately, the points in the first part have been discussed here, with prior HB woman I see for well woman care and have heard from the doulas as well. While the first part is purely anecdotal, an otherwise healthy AMA mother would easily be swept into HB assuming low risk and await spontaneous onset of labor. The crunchy runs rampant in the underground here, when things go wrong (risk factors known and all) they’re at the ED door.

          • CrownedMedwife

            …and the purpose is to demonstrate how well CNMs CAN identify and manage risk factors, known when to consult or refer and welcome collaboration.

          • Sue

            You have to wonder about clinicians who choose practice styles that avoid team-work and collaboration.

          • Guestll

            I was accepted into midwifery care/homebirth in Ontario, despite being a month shy of 40 at delivery. Three previous losses in a little over a year, ART pregnancy, android pelvis, OP baby, and postdates. 5 cms and 100% effaced for a week prior to delivery. At 41+4, the senior RM played the dead baby card, and my daughter was born the following day at 41+5 in the hospital after AROM.

            I believe you, is what I’m saying.

          • LMS1953

            That is extremely substandard care.

          • Guestll

            I know. I still carry the guilt.

            Three years on, and with my records, I’ve finally mustered up the courage to write the college.

            For the record, the secondary RM and senior RM were evidence-based and terrific. My primary was as woo as can be. One bad apple etc. etc…

          • LMS1953

            Why should you feel guilt? The appropriate emotion would be anger/resentment. I pray there were no long term sequela:

          • Guestll

            My daughter was fine, though long, skinny, dry skin, long nails, and a placenta that was probably not going to last much longer.

            I feel guilt because I knew better, just as I suspect Elizabeth Heineman did. I knew better, but I chose (with a lot of woo cheerleading/manipulation) to believe differently, and there but for the grace of God…one of your primary “jobs” as a parent is to be your child’s advocate. I was not acting in her best interests, only mine.

          • http://Www.awaitingjuno.blogspot.com/ Mrs. W

            From what I’ve heard, I would not be surprised if this is also happening in BC.

  • Stacy Knuth

    Beautiful! Thanks for sharing. I’m so thankful for the great “medwives” I had supporting me during my two pregnancies and for my two healthy children.

  • http://www.mamabean.ca Mama Bean

    I really liked this post, thank you so much :)

  • araikwao

    Small edit (in an excellent piece, btw): 2nd paragraph of the Medwife section states”Patient to plan..” – is this missing an “agrees” in the sentence?

    • Amy Tuteur, MD

      Thanks.

  • Susan

    Needs a get your Kleenex out before reading. One of your best ever posts I think.

  • Captain Obvious

    How about payment ethics? The only thing I agree with about paying the midwife anyway is to eliminate the motivation to not transfer so as to get paid. But pregnancy is global care. CPT codes for pregnancy include…

    CODE. Discription. WRVU. charge
    59400. NSVD/AP/PP. 32.16. $4000
    59409. NSVD. 14.37. $2300
    59410. NSVD/PP. 18.01. $2610
    59430. PP. 2.47. $375
    59426. AP 7-13 visits. 11.16. $1517

    So if another doctor from another practice delivers my patient, she bills for what she does and I bill for what I do. Why do midwifes expect no refunds?

    http://community.babycenter.com/post/a48875983/midwife_refund

    • http://www.pcosra.com/ PCOSRa

      Not only is it no-refunds, many of them expect full payment prior to 37 weeks. So, even if you had a last minute change of heart before labor started and decided to go to a hospital–you’ve still paid the midwife in full.

      • LMS1953

        That is an extortionary, manipulative and coercive billing practice that amounts to fraud and theft when payment is kept for a service not rendered. It would be no different if a Pedi demanded payment for a circumcision by 37 weeks and then refused to give a refund when the “boy” on ultrasound turned out to be a girl. Or if an anesthesiologist demanded prepayment for an epidural and refused to give a refund after mom pre-cip’ed in the ambulance on the way to the hospital.

        • Elaine

          I believe they see it as paying for their availability around the time of your birth because they only take a few moms due at any given time to have the best chance of being able to actually make your birth. And then if you don’t end up using them, that doesn’t change the fact that they held their schedule open. If you pay to rent a cabin, and then back out two days prior, they probably won’t be able to find another renter and will probably keep at least some of your fee to compensate for this. Hospital-based practitioners don’t have to have so few patients on their caseload because if two of their patients are in labor at the same time, both are in the hospital and being tended to by somebody, even if it’s not that practitioner personally. The reasoning makes a certain amount of sense from a certain standpoint. Not saying I am a fan though.

          • LMS1953

            So by this “logic” there is a HUGE financial incentive to put the baby in harm’s way. There is absolutely no justification for this. Medical ethics are different from cabin rental although that is about all CPM attendance is worth. A patient should not be restricted or coerced in any way about her choice of attending provider during her pregnancy. Doing so falls well out of the boundary of ethical behavior into the realm of fraud and theft.

          • Elaine

            Correct. But CPMs aren’t medical providers. Ask them and they’ll tell you so. Heck, check out the MANA ethics statement and see where it says that the patient is the care provider for her own birth. So, according to them, that justifies all their crap. There are probably plenty of categories of people who could justifiably charge a fee for their own attendance at an event and not refund if the client backed out on the grounds that they lost out on revenue they could have gotten from other clients. Medical providers, of course, are not in that category, nor should they be, but CPMs aren’t medical providers (except when it suits them, like trying to get insurance reimbursements).

        • Elle Bee

          My OBGYN requires payment in full of my portion of the delivery fee by 28 weeks gestation. She also requires payment in full of the circumcision fee for a boy by 32 weeks.

          • LMS1953

            That is pretty well standard. But if you transfer care or deliver unexpectedly while visiting Grandma in Peoria, your account will be adjusted and refunded accordingly. There are specific CPT codes that cover those situations. And if she doesn’t do a circumcision or have a covering physician do it, that fee will be refunded as well.

          • Captain Obvious

            Are you self pay? Then yes. But as LMS said, money would have to be refunded if you transfer.

          • Elle Bee

            No, I am not self-pay; I have insurance. And of course there would be a refund if I transferred. But when I had my daughter in 2012 I had to prepay my deductible to my OBGYN, but the hospital billed first and therefore the deductible was assigned to the hospital. I barely got the refund from my OBGYN in time to pay the hospital before they sent me to collections.

        • birthbuddy

          Goose and gander ethics?

    • mamaellie

      My midwife didn’t get paid if I didn’t start labor in the birth center. That was in the contract. I’m pretty sure that is why she didn’t risk me out.

    • LMS1953

      In 30 years of private practice I have NEVER had a third party payer allow $4000 global 59400 fee. About 48% of all deliveries in the US are covered by Medicaid. In most of my service areas it has been at least 75%. Most state Mecicaid programs pay “a la carte” per service rendered rather than a global fee. The Medicaid payment for the 59410 is around $750 to $850. The chump change they pay you for the office visits barely covers the overhead for the pro rata share of office rent and a nurse to chaperone the visit. The table paper and KY is gratis.

      • Jessica

        Just out of curiosity I had to look up the EOB from when I gave birth in June 2012. My OB billed $4,676 for the 59400 global fee; insurance allowed $3,624.45.

        I’m an attorney and occasionally work on insurance defense cases, and I hate how much they slash my hourly rate. Thank God it’s not my bread and butter.

        • Captain Obvious

          And you can charge for telephone calls, and work time on a case. Not me. I can research info for an hour about a patient and cannot charge her for it.

          • Carolina

            Which absolutely should change. I wish doctors could charge for certain emails/phone calls. It would be so much more efficient than going into the office all the the time.

      • LMS1953

        Now with the AFFORDABLE, I said Affordable, Affordable, I said Affordable Care Act (did I say “affordable”?) – patients who used to have affordable health insurance now have a $2500 deductible to go along with $1000 per month premiums – that is about $15000 out of pocket before the insurance company sends the first cent to the OB for things like ultrasounds, biophysical profiles and NSTs (somebody has to cough up the dough to cover ever expanding welfare roll of the entitled). The global fee will not even be considered for payment until 6 weeks postpartum. Hospitals, with their endowments and staff are notorious for not submitting their bill until the less well endowed physicians submit THEIR bills so THEY get stuck with the deductible. Often an OB ends up with more from a Medicaid delivery than a deductibly beleaguered private patient.

        • Luba Petrusha

          I bought insurance on the exchange, and if you pay a high premium (mine was $700) you have a low maximum out of pocket ($1500 for me) and deductible ($500). I played with the numbers a lot, and when you added up the premiums and MOOP for all the plans, the total was pretty much the same. I knew I’d need surgery this year, so decided to pay more in premiums and spread my costs out.

          Lower income individuals get subsidies, not only for the premiums but also for the MOOP. Higher income (e.g. me) individuals don’t.

          Oh, and I have prescription coverage for the first time in 15 years, and my cost for prescriptions is rolled into the MOOP. (This is a good thing, because the #@&%$ pharmaceutical companies have raised the cost of simple asthma inhalers to over $50; they used to be $2-3. And no generics.)

          What were your patients paying before? I suspect the same, although weighted towards premiums. And with no guarantees that their insurance would be there for them when they needed it (rescission, lifetime maximums).

          Insurance costs have decreased for the working poor, and many are insured for the first time in decades. Some higher income individual (e.g. me) may be paying a bit more, but I would have been anyway. It’s not like insurance costs were trending down under the old system. 5-10% annual hikes were pretty much standard.

          And with no lifetime caps on care, and no more rescission, medical bankruptcy should soon be a thing of the past.

          Some people are making stupid choices, going for lower premiums rather than properly assessing total costs. Maybe they won’t next year. But I suppose you never had patients cash an insurance check instead of giving it to you in the past? Or ever had patients not pay their bills in the past?

          • The Bofa on the Sofa

            Our place switched to an HSA plan this year. It was irrespective of the ACA.

            With this HSA plan, we would have paid about the same as we did in the past with our co-pay coverage. A pre-signup analysis indicated that, given our pattern of usage in the past, this plan would cost the same. However, with the kids growing up and past the ear infection stage, we will have fewer “routine” sick kid visits, so, in fact, we expect less than our historical pattern, so we will be paying less.

            Yeah, we are paying a lot more out of pocket (or out of the HSA) but our premiums are a lot, lot less, too.

            And the cap on total expenses is not all that much more than what our old plan was. Moreover, we can apply our HSA funds to non-covered dental costs, for example.

            That being said, I’m not a fan of the HSA model, and it would be easier if it was just all covered, but not necessarily cheaper, and likely more expensive for us overall.

          • staceyjw

            And thats the problem- low wage people FINALLY GET SOMETHING! We are benefitting from government for the first time in, ever really. Others cannot stand that we actually have something they don’t for the first time in history. And we would love for them to have it too.

            I am covered for the first time since I lost my high paying job, and my husband is covered for the FIRST time as an adult! My kids are covered, and I guarantee the ability to go into a pediatrician as needed has kept us out of the ER, racking up bills we would never have a hope of paying.

          • Luba Petrusha

            And therein lies the rub. Poor people getting benefits? Unnatural! Only the rich (i.e. the 1%) deserve good medical care–they’ve earned it. The rest of us are just cluttering up hospitals and waiting rooms, and making the masters of the universe WAIT LONGER!

        • staceyjw

          I am SO amazingly tired of hearing your whining crap, and this is a blood boiler:
          ” ever expanding welfare roll of the entitled”

          YOU are ANGRY with the WRONG PEOPLE.
          Why not hate on those that are cutting your reimbursements, and those that screw you with billing? I guarantee that the poor and working classes are not the ones doing this to you. We are out there making pennies providing services and products YOU need, and the profits YOU need to fund YOUR retirement portfolio. We aren’t the ones screwing YOU.

          Still, I am very sorry you are getting screwed, along with all the poor, working class, and middle class people. WE work for less these days- now YOU get to too! Join the club, the view is ugly from down here isn’t it? I am also very sorry we live in a nation that puts its citizens dead last, and cannot figure out how to do what every other advanced nation has.

          And, YES, we ARE entitled to first world care!

          Maybe you could get your head out of your ass and contemplate this one: Why there are so many poor people without coverage, and why is the number ever expanding? Hint: it’s not because we are lazy layabouts. Nope, we work more hours, for less money, and less/no benefits, than ever before.

          I sure hope you either do not take Medicaid, or you at least keep your shitty ass attitude to yourself.

          Signed,
          Wife, and mother, of a hard working, low wage earner and a formerly a middle class, well insured, career woman.

      • Captain Obvious

        I must be one of the unusual ones, I am not credentialed with Medicaid.

      • Ceridwen

        For my daughter’s birth in May 2013 my relatively crappy student insurance (yay grad school) allowed global billing under 59400 for $3911.00 and paid out $3441.68 after the contract discount. I didn’t even have to pay a copay.

        Perhaps you need new billing people working for you?

        • LMS1953

          Due to Obamacare, many universities have had to discontinue their student Heath Insurance because it is no longer affordable.

          • An Actual Attorney

            Citation please?

          • Ceridwen

            Citation needed. I can only find evidence of one university dropping their plan because of the affordable care act and what they were offering their students is something they should have been ashamed of and certainly shouldn’t have been called insurance. Do you believe everything Fox news tells you?

            Furthermore, you completely avoided the actual point my comment. I shouldn’t have expected anything else though.

          • The Bofa on the Sofa

            Do you believe everything Fox news tells you?

            You really have to ask?

  • LMS1953

    I still have a problem with this. Once the amniocentesis showed a genetic defect, why is the patient not immediately referred to an OB? This is just another variation of the variation of normal crap every midwife is imbued with. You know, OBs know how to manage “normal” pregnancies too. And they are much better trained to be attuned to the harbingers of an ill wind before the shit hits the fan. You need a stable of monkeys on a leash to do the stat C-section when it does. Don’t be surprised if one day the midwife tugs on the leash and finds a General Surgeon on the other end. But I guess that is what is driving the movement to grant CNMs C-section privileges – without the 4 years of 100 hr work weeks in a residency, of course.

    • lawyer jane

      In this vignette I think it’s implied that an OB and MFM are co-managing the patient.

      • LMS1953

        I got the impression that she “collaborated” with them – gave a case presentation so they would be documented on the chart so they could get sued if anything went wrong. Probably just a phone call, nothing an OB can be reimbursed for, although I got the impression the midwife did all the visits. The MFM at least got to bill for a sonogram. Try pulling that free phone schtick with your CPA or attorney. She still expected the OB to jawjag with her about a vacuum in the presence of significant bradycardia – more wasted time. What is the CPT code for the OB to get compensated for standing around watching the midwife do her thing? – accumulating lots of liability but very little by way of billable service, especially if the patient/client is on Medicaid.

        • Medwife

          When I am co-managing a patient with the OB I am in practice with, he and I both see the patient, often we alternate. We are reimbursed the same. He performs the amnio. While I am on the unit with the laboring patient he is freed to be seeing patients in the office and doing procedures (the stuff that actually pays!). He is available to be at the hospital within 15 minutes. So actually it works just great for all concerned. If he takes over management completely at any point during this pregnancy, labor or delivery, I’m seeing 2 or 3 other patients who are complication-free. No way could he be seeing the volume/complexity of patients that he does without me and other cnms in the practice.

          (I’m not the author of the original piece)

        • CrownedMedwife

          Collaboration: working together towards same goal. You seem unfamiliar with the concept of CNM and OB working side by side provided shared care to patients. There isn’t any turf to protect, it’s a united goal. Arranging consult with MFM includes genetics, LII U/S, fetal echo and extensive discussion between CNM and MFM to determine management plan. Thereafter, CNM and OB discussed status and plan on a regular basis.

          Expected to jawjag with OB over vacuum? Are you serious? You have got to be kidding me. Waste precious moments? Initiate a turf battle? What purpose would that serve? What would be the point of OB being available for expertise and not utilize it when the situation dictates it. A thorough discussion before birth included CNM advising OB of her low threshold in the setting of IUGR, variable decelerations and chromosome disorder and proactively consenting patient for Cesarean Section. OB agrees, however in setting of bradycardia the OB feels a vacuum extraction was a viable option to avoid Cesarean Section. We work together to develop and agree upon a plan, but when a medical decision needs to be made…the OB’s expertise is immediately deferred to. Again, no turf war when you both share the same objective: a healthy mother and baby.

          • Captain Obvious

            Why is it when I hear collaboration I want to sing a vanilla ice song?

          • Susan

            I have seen it work it can be done. It doesn’t have to be a turf battle where there is mutual respect and skilled providers who know their scope of practice.

        • moto_librarian

          LMS1953 – people come here frequently and claim that Dr. Amy hates all midwives, but it’s pretty clear to me that you’re the one who really does. Do you not believe in collaborative care? Do you not refer patients to a MFM yet still keep them as your patient? How is anything that medwife did inappropriate?

    • CrownedMedwife

      This is a small OB/CNM practice and is set up with both OB and CNM providing care in the same office. While the patient saw the CNM the majority of the time, the OB was intimately involved in her care. No step of her care was performed in isolation, again it’s all about collaboration. Yes, I realize OB’s know how to manage normal pregnancies…who do you think was my mentor?

    • CrownedMedwife

      Just had to come back to your comment.

      “This is just another variation of the variation of normal crap every midwife is imbued with.”

      In what way was this medwife acting in ‘variation of variation of normal’? Variation of normal would have ignored the risks and failed to initiated an action plan. Appropriate AMA counseling provided, diagnosis obtained, management plan coordinated with MFM/OB/CNM. Where was the seemingly variation of normal? What wasn’t normal and frankly just damn frustrating, was the necessity of concurring with MFM to proceed with IOL at 36.6wk to avoid ‘elective induction’ battle. Sure, IUGR IOL is ok at 37wk per ACOG, but add in chromosome disorder, MILDLY elevated s/d ration, increasing BP’s (without severe features) and AMA….I’m not willing to wait 1 more day to achieve 37 wks.

  • Jessica S.

    Excellent. Thank the heavens for modern medicine!!

  • An Actual Attorney

    Damn you. I’m about to cry in this restaurant.

  • EmbraceYourInnerCrone

    I guess I’m just a sheeple because I absolutely DO NOT get the “I want to avoid all these interventions” attitude (and I absolutely hate going to the doctor, too many hospitalizations as a child).
    Would it have been nice to not have a heplock, sure although when I was vomiting during transition it was nice they could start IV fluids so I didn’t get dehydrated . Would it have been nice to not have an episiotomy/vacuum extraction, sure but with the scary late decels/meconium stained fluid I was glad they got my baby out before things got worse. Interventions usually happen so we can AVIOD the worst happening. That doesn’t mean if you have them and your baby and you are fine that they were not needed, it means you got lucky.
    And I know it makes me a mean person, but who in the hell thinks giving birth at 42 is low risk? Your eggs are older , your uterus is older and you have a higher probablity of pre-e, survivable(within a hospital!) birth defects and placental problems.
    I have a high school education and i know this….

    • anion

      I’m 40, and hubs and I are discussing whether we want one more before we close up shop for good. The one thing that gives us real pause is the increased risks for me and baby. You bet I’d want every intervention possible, if we end up doing it (no pun intended).

      & I have a GED, because I was too busy skipping school. :-)

    • Hannah

      I don’t understand it, either. It seems like the only issue with a ‘cascade of interventions’ is that it interferes with the mother’s ‘birth experience’ (if Business of Being Born is to believed). A live baby and live mother is apparently does not offset the horrific trauma of not getting to birth as you planned.

  • The Computer Ate My Nym

    A year later, a mother sits alone in her living room where her birthing
    pool had been. Empty arms and a heavy heart, wondering if she just
    didn’t ‘trust birth’ enough.

    These lines reflect one big emotional/non-rational reason that I didn’t want and would never want a home birth: If something goes wrong, ranging from blood stains on the floor to death of the baby, I will forever associate it with my house, the place I have to live every day. I’d much rather that crap got stuck to a hospital I may never have to enter again. As I said, this is an entirely emotional reaction on my part, not an argument against home birth for everyone, but I wish women thinking about home birth would consider every aspect before they do, including the fact that labor is PAINFUL and they may end up trembling with fear at the remembered pain every time they pass their bedroom if they deliver at home. Even if everything goes well. And if the worst happens…you’ll be living every day in the place your baby died. I can’t even imagine the horror. Well, I can, but I really don’t want to…

    • http://Www.awaitingjuno.blogspot.com/ Mrs. W

      I wonder how many move in response to that kind of trauma.

      • Hannah

        I would.

      • The Bofa on the Sofa

        I know people who have been unwilling to even set up their nursery before the baby was born (in the hospital) because they couldn’t bear the thought of coming home without a baby and seeing the nursery all set up.

        • 2boyz

          That’s a common Jewish custom. Some people say it’s a superstition, but I’ve always viewed it as facing that fact that bad outcomes are, God forbid, possible. I would not want to face a nursery in those circumstances either. I didn’t even have a baby shower.

          • Dr Kitty

            My husband left me at the hospital with the baby to go and pick up the pram and the car seat from the shop (who were more than happy to keep them for us). I wouldn’t have them in the house before the birth, and insisted that they weren’t fully paid for.
            The only things we had were a Moses basket and changing table our friends gave us and a basic layette.

            My husband and sister painted the nursery 2 weeks before my daughter was born. I helped by painting the skirting boards, because I could do it while sitting on the floor.

            I am not a superstitious person, but I just couldn’t totally let go and believe it would all be ok until after it was.

          • Susan

            I threw a baby shower for someone and many of the the Jewish relatives said that it was the first baby shower they had ever been to. It sounded to me like baby showers were seen as inviting bad luck?

        • Young CC Prof

          I did make a nursery in advance, but I didn’t even start setting it up or buying things until after my anatomy scan. In retrospect, doing it earlier would have saved a lot of stress, but I stand by my reasons.

          • The Computer Ate My Nym

            I didn’t tell anyone I was pregnant until I got the amnio back.

          • Young CC Prof

            I didn’t do an amnio, but I did wait until I’d had an ultrasound with a normal heartbeat and size matching what I knew was my due date.

    • Young CC Prof

      Is that why in the old days some larger houses had a little tiny room called the “birth and death” room? (intended for births, severe illness and definitely fatal illness.) Maybe it was so whatever happened there, once you shut the door it would be easier not to think about it every day?

  • lawyer jane

    Grateful to the “medwife” who made the call to induce me. Not so grateful to her colleagues, the woo-y midwives who seemed hell bent to get me as close to eclampsia as possible before doing anything; did not believe me when I said that Cervadil had sent me into active labor; and who gave me a guilt trip for getting an epidural.

  • Maria

    I am 42 years old and gave birth to my 2nd little girl 6 weeks ago. I can’t imagine how I would feel if I lost my baby due to negligence and substandard care. It would be devastating for my whole family. The “Medwife” shows you can provide excellent, evidence based care, in an integrated environment, while also maintaining the personal connection that women value in their midwives. I look at these two scenarios and the contrast in care is stark.

    • Dr Kitty

      Congratulations on your new baby!

    • araikwao

      Congratulations! So glad you and your daughter are safe :)

      • Maria

        Thanks! And the key word is safe. Being as old as I am I was not prepared to take anything for granted during my pregnancy or my birth. I wanted a baby, not an experience.

    • Mishimoo

      Congratulations on the safe arrival of your new addition!

    • Josephine

      Congratulations on a safe, healthy birth and a new baby girl!

  • http://kumquatwriter.wordpress.com/ Kumquatwriter

    Beautifully written. As I listen to my healthy, beautiful 3.5 year old son playing I am profoundly grateful I didn’t trust birth, so he could be here.

  • MichLaw

    Ten years ago I had a “medwife” for my delivery at Brigham and Women’s hospital in Boston. The hospital had a wonderful program for midwives who worked together with OBs. All of my prenatal and postnatal appointments were with a midwife but after a long, unproductive labor, the midwife suggested we call in the OB who recommended a C-section.
    Despite delivering in an OR, I remember my son’s birth as beautiful. My midwife stayed with me til the end. She photographed the surgery so that later I could see my son’s birth. I can still picture my husband seated beside me, his eyes beaming, his smile covered by a surgical mask as he held our newborn. Neither the baby nor I were dopey. Despite being numb from the chest down I still managed to breastfeed him (with the help of a nurse in recovery who held him for me). He became a champion nurser at the hospital despite staying part of the time in the nursery and my insistence on one bottle feeding so I could sleep after being awake for 30 straight hours. (You can probably guess what I think when I hear the claim that just about everything we did interferes with bonding.)
    I also still remember the look on the midwife’s face when I asked what would have happened to my son had we not been in a hospital. Thank God we were in that hospital.

    • Medwife

      We have a wonderful recovery nurse where I deliver who is just spectacular with getting babies skin to skin and nursing in the recovery room. She has no official L&D experience but she’s got a gift (and has worked hard for many years). Oh and at the same time she provides excellent care in making sure the mothers are stable, too!

      There are so many people working so hard in hospitals to do their jobs plus go the extra mile. I know not everyone shines all the time, but all in all the hospital is NOT the enemy.

      (I’m not the OP btw, although I wish I could take credit for that beautiful piece of writing!)

      • Dr Kitty

        I breast fed in recovery. The spinal block made my nipples numb, which was nice, because, as I found out once the spinal wore off, my kid had a latch like steel trap and sucked like a Dyson and breastfeeding HURT for six weeks until I got used to it!

        If I had actually been able to feel that first feed, it probably would have lasted a few seconds and I’d have been really pissed off. As it was she fed for a good 15 minutes and I was just able to enjoy it. Once it DID start hurting I’d already had such a good experience that I decided to persist on with it.

        So, THAT’S a possible benefit of regional analgesia…painless and enjoyable first breastfeed, possibly giving a motivation to continue breastfeeding.

        • Hannah

          Didn’t you know that motherhood is meant to be physically painful? If it doesn’t hurt, you aren’t doing it right.

          Seriously, though, can I ask them to numb my nipples?

  • Squillo

    Every time I look at my healthy, happy 12-year-old, I’m grateful for my “medwife” and her physician colleagues.

  • http://Www.awaitingjuno.blogspot.com/ Mrs. W

    A wonderful illustration of the power and promise of collaborative care with competant providers – and how the current environment makes it too easy for quacks to practice without recourse, and perhaps creates unneccessary barriers for qualified providers to provide competent care. Can you imagine if the second mother stuck to her guns and insisted upon a 39 week delivery? You can bet the march of dimes would not be left holding that bag.

    • http://Www.awaitingjuno.blogspot.com/ Mrs. W

      The only bit that is missing in the second story is where the care provider screens the mother for post-partum depression…

      • Squillo

        And refers her to a trusted lactation consultant for breastfeeding help, and counsels her on contraception.

        A year later, she places an IUD when the mother decides she’s done having babies and reminds mum of the importance of regular paps, as her prenatal tests revealed HPV infection.

        Two years later, when she performs the mother’s pap smear, it comes back with atypical cells. A follow-up reveals no change, and she refers the mother to a gynecologist, who performs a cone biopsy that removes a stage IA1 cancer. Mum is followed closely, and there is no recurrence.

        Twenty-five years later, mum dances at her daughter’s wedding. Thirty years later, she holds her first grandchild.

        • Elizabeth A

          Yes to both of these!

          It bugs me so much that midwifery care appears to discontinue completely at 6 weeks post-partum. Mothers have reproductive health concerns well past the childbearing year!

          • Medwife

            Which is why it’s awesome to be a nurse midwife. The vast majority of a woman’s life she is not pregnant. Antepartum, intrapartum, and postpartum care are a small piece of women’s needs.

        • CrownedMedwife

          To be honest, I was worried the post was too long too keep the reader engaged as it was as I was thinking of adding similar remarks. Well-woman care is all too lost in what is considered midwifery care. Antepartum through PP care may be monumental moments in the lifetime of a woman, but they are such a small component of care. I would estimate the actual antepartum care makes up only a third of my office schedule with rest being a spectrum of gyne care Thank you for adding the additional points, and lest we forget the transition to menopause and beyond.

          As if I haven’t shed enough tears of gratitude for this tiara wearing toddler, goosepimples and tears arise yet again at your last two sentences. Thank you for the mental image it gave me.

  • Elizabeth A

    I teared up too.

    I recognize myself in that mom, no matter that the relevant ages don’t match. I was the woman raising questions about the wisdom of pre-term delivery while a surgeon called for immediate section. I was the patient who tried to agitate back towards a peaceful, natural waterbirth while midwives referred me to doctors who said, basically, “too bad.” I was doing what patients with preferences do, and the doctors were doing what doctors with good information and training do.

    I sent my “medwived” baby, now 4.5, to preschool in a tiara this morning. That is the baby we all want – the thrilling, passionate, dancing in circles and driving us crazy, alive one.

  • Guestll

    You had me at 42 year old mother of one. Tears now. This is awesome, thank you for sharing.

  • Busbus

    I love this post.

  • DaisyGrrl

    I got shivers reading this story. What a testament to collaborative care!

  • Young CC Prof

    Yes. THIS is what a midwife should be.

  • Carolina

    I teared up reading this. Wonderful! I’d like to replace “Trust Birth” with “Trust a Competent Care Provider”

  • http://whatifsandfears.blogspot.com/2012/12/the-business-of-being-misled.html Doula Dani

    This is so powerful!! Brought tears to my eyes. I can’t wait to share.

  • Sullivan ThePoop

    I love this article! So well written it made me tear up a little.

  • Karen in SC

    Stupendous!! Standing ovation!!
    If Midwifery Today accepts case studies, I urge you to submit this testament to collaborative care. Please.

    • http://www.antigonos.blogspot.com/ Antigonos CNM

      I fear those reading Midwifery Today would probably find Medwife’s case notes virtually incomprehensible, since they reflect a level of knowledge far in excess of the average layperson.

      An excellent case, btw.

  • Mel

    Wow. Very well written, Medwife!