Confessions of a “medwife”

true confessions

“Medwife” is a term of derision typically applied by lay midwives (CPMs, LMs, DEMs) to real midwives, certified nurse midwives (CNMs), to signify disgust with using actual medical knowledge in the care of pregnant women. This “medwife” wrote to me in the wake of baby Gavin’s death to express her sorrow at such a needless, senseless loss of life. During the course of our correspondence, she explained her philosophy to me so eloquently that I asked for permission to publish it as a guest post.


On being a Medwife:

I do not believe babies know when to be born at either end of the spectrum. I am certain no baby intends to die in his mother’s arms on the verge of viability or in her womb pushing well beyond the dates. I use tocolytics to provide steroid administration and provide neuroprotection, 17P to prevent a subsequent premature birth. I believe frequent antenatal testing provides a level of reassurance beyond 40weeks, but will nudge your baby along at 41 weeks with little left to gain from conservative management regardless of the reassurance.

I believe our bodies do grow a baby too big for us and I believe shoulder dystocia is a sentinel event even in the hands of the most experienced providers. It is not a situation caused by poor maternal positioning or relieved by Gaskin maneuver and certainly not in a bathtub of your living room. Watching a healthy baby die on the perineum is a vision to haunt your nightmares for a lifetime.

I don’t believe in the 39 week rule. It will prevent some early term birth admission to a NICU, but will also cause hesitation by providers to act for fear of statistical outliers and repercussions. I will play within the rules, but will not ignore the soft indicators or the intuition to act upon them.

I believe babies have a due date, placentas expire and not much good comes after 41weeks. I do not believe waiting for a baby to display signs of decompensation is the time to act. Perhaps a poor tracing, MSAF and a neonatologist fit into your 41 week plan, but then again perhaps you didn’t really want the intermittent monitoring, minimal attendants and delayed cord clamping.

I believe in preeclampsia. I respect its etiology, pathology and spectrum of progression. No diet, herb or pressure point will prevent the sequence of severity. If you argue or ignore the recommendation to move towards immediate delivery and days later your ICU admission or eclampsia means crash carts and ventilators…your partner has officially forfeited his right to ask “wasn’t there anything you could have done to have prevented this?” I will just walk away.

I believe GBS treatment does not include garlic or tea tree oil. Protecting your baby’s gut flora may seem so important now, but means so little in light of GBS meningitis and seizures or the dopamine drip in the midst of septic shock should it be your baby that becomes the statistic.

I believe in VBAC with a heplock, continuous EFM and my OR team within feet of your room. I will not push the limits. As wonderous a window into the womb as your translucent uterine serosa may be, its presence means this OR is just where you needed to be.

I believe twin births in a dimly lit room with hushed voices can be safe, but that room is best located as an OR and behind those dim lights and hushed voices lies the wonder and safety net of an OB, anesthesiologist and neonatologist.

I believe in Vitamin K. Your fears should lie not in the process of administration or theoretical risk of preservatives, but in the absence of its existence. The process or risk will be far from thought if your child is the child flown to tertiary care with ever expanding head circumference and abnormal neurologic exam.

I believe in Rhogam, its safety and its efficacy. Your unfamiliarity with hydrops fetalis in an era of rare sensitization does not lessen its impact on your baby when undergoing MCA Doppler flows, premature delivery and multiple blood transfusions. Your decision to ignore the real risks and let fear based blogs will not prevent this from being your baby or your regrets.

I believe in breastfeeding, BUT I refuse to allow a mother to feel any less a mother for how she chooses to feed her baby. You may never know what lies behind her decision to bottle feed, but you have an obligation to respect and honor it. Just as labor and birth is one miniscule step in the process of mothering, so is feeding method. In several years no one will know who was born how or who was fed what. It really is that simple.

I believe in the wonder of birth. An unmedicated natural birth and it still leaves me in awe of its beauty, but I also comprehend its functionality. Your coconut water, lavender and doula make you no stronger a woman than the woman next door with a continuous epidural catheter or the mother down the hall lying on the OR table laughing and smiling at her baby’s first cry. Birth is amazing, but it isn’t how we determine our strength.

I believe in interventions from AROM to EFM to Pitocin to forceps to cesarean birth. My responsibility is to observe for progress and wellbeing, as well as to utilize the interventions at modern medicine’s disposal to ensure the safest path and highest outcome. Although I cherish and find reward in the intimate relationship we develop over the course of your care, my responsibility is to the health and well-being of you and your baby. Do not confuse my caring and compassion as a desire to become your friend. I will hold your hand, I will be compassionate…but I will not be afraid to use my ‘dead baby card’ or alter my care to avoid ‘hurt feelings”. If that is what it takes to make you realize these evil interventions stand between the health of you and your baby or the risk to disability or death, I will play my ‘card’.

I believe in doulas by definition, not as adjunct providers. The security and support of a doula can be a positive contribution to your birth experience, but so can your labor and delivery nurse. Please don’t discount the skill and support of your nurse and don’t use a doula to make medical decisions. She has not the training or authority to do so. Your doula is there to support you through labor, not create an atmosphere of animosity.

I will listen to the woo and my office schedule will fall behind, but I will gain the trust that keeps you here and not in the hands of an unregulated, unaccountable and uneducated CPM or lay midwife . I will listen to words of concern, because I believe every mother inherently seeks to protect and desires the very best for her baby. I will seek to clarify, educate and empower in order for others to comprehend the science behind the care I provide and the recommendations I make. My care and recommendations will be based upon guidelines, developed and supported by the highest level of scientific evidence; not chat rooms or anecdotes. I will do this because it is my responsibility as a health care provider and is not intended to cause fear or to disillusion ignorant bliss.

I am saddened by the liberal application of the title ‘Midwife’. I am disheartened when my years of formal education and commitment to continuing professional growth are soiled by the unprofessional and unregulated ranks of others who feel it is their right to share this title. As much as I looked forward to holding the title of “Midwife” I feel relegated to distinguish myself from it.

As others attend Blessingways, perfect the art of holding space and call themselves midwives… I will sit here and read my Green and Grey journals, among RN’s, CNM’s and Physicians. For I am the Medwife and I will be here alongside my colleagues, our resources and interventions keeping birth safe…ready, willing and able to identify and intervene when it’s not. If in so doing I am less the Midwife and more the Medwife, there are no regrets.