Midwives are the guardians of normal birth; obstetricians are the guardians of mothers’ and babies’ lives.


Midwives love to claim they are the “guardians of normal birth.”

Type “guardians of normal birth” into Google and you get page after page of midwives declaring their commitment to a specific vision of birth.

I’m not sure why they’re boasting because it’s actually an unwitting indictment of the moral rot at the heart of contemporary midwifery theory. It highlights the difference in ethics between midwives and obstetricians. Midwives are the “guardians of normal birth,” while obstetrians are the guardians of the health and lives of mothers and babies.

It is fundamentally unethical for any health provider to pose as a guardian of a procedure. It would be wrong for a surgeon to pose as a guardian of appendectomy; it would call into question his or her ability to successfully and ethically treat abdominal pain when he had a clear bias toward removing appendices. It wouldn’t matter if the surgeon claimed to believe that appendectomy was the appropriate treatment for abdominal pain, and we would quite rightly suspect that the surgeon has his own self-interest (the surgical fee, the opportunity to hone skills, the enjoyment of performing surgery) at heart.

Similarly, if a dermatologist claimed that she was a guardian of Botox, it would call into question his her ability to recommend appropriate treatment for her patients. It wouldn’t matter if the dermatologist claimed to believe that every patient could benefit from an injection of Botox. We would quite rightly suspect that the dermatologist had her own self-interest (her fee, gifts from the drug company, opportunity to serve as a paid consultant for Botox)at heart.

When a midwife claims to be a guardian of normal birth, it calls into question her ability to successfully and ethically care for pregnant women. It doesn’t matter if the midwife claims to believe that normal birth is beneficial for nearly every women. We would quite rightly suspect that she had her own self-interest (her fee, professional autonomy, the enjoyment of assisting an unmedicated vaginal delivery) at heart.

Obstetricians, in contrast, are the guardians of the health and lives of mothers and babies. Their commitment is to the patients they treat, not to a particular method of treatment. Their commitment is to delivering healthy babies to healthy mothers, regardless of what it takes to make that happen. Their commitment is to people, not process.

Over the past few decades we have come to understand the pernicious influence that outside forces can exert on providers. Even something as simple and trivial as small gifts to doctors from pharmaceutical companies can affect a doctor’s choice of therapy (which is why pharmaceutical companies engage in the practice in the first place). Ideology is a far more powerful source of influence than pens and calendars. It, too, can sway a provider’s judgment to use decision making criteria other than the best interest of the patient. That’s why ideology has no place in medical care.

The central questions in caring for pregnant women should be: how can I help each individual women to remain healthy during pregnancy and childbirth and what can I do to ensure the health of her baby?

Midwives, as guardians of normal birth, view the central question as: what can I do to make this woman’s birth conform to my ideal of unmedicated vaginal delivery?

Not surprisingly the different approaches lead to different responses in the event of complications. Since the obstetrician is committed to health, complications are acknowledged, treatments instituted based on specific circumstances, with all options avaiable to achieve the desired outcome.

Midwives’ commitment to unmedicated vaginal birth means that complications are more likely to be ignored or denied (a “variation of normal). Treatment options are rated by whether or not they are compatible with normal birth, not based on their likelihood of ensuring the health of mothers and babies. A particularly distasteful consequence of privileging unmedicated vaginal birth is that failure to achieve a live baby is often unacknowledged, dismissed with the callous words “some babies are meant to die.” Instead of investigation, root cause analysis and questioning of the approach taken, midwives committed to normal birth may supress investigations and root cause analysis and to ban questioning of the approach taken since that would call the commitment to normal birth into question, which is intolerable.

Midwives need to take a long hard look at the moral rot of a philosophy that privileges birth process over healthy mothers and healthy babies. Rather than patting themselves on the back for being guardians of normal birth, they should be embarrassed to be caught out promoting a philosophy that places how a baby is born on an equal or greater footing than whether that baby lives or dies.

287 Responses to “Midwives are the guardians of normal birth; obstetricians are the guardians of mothers’ and babies’ lives.”

  1. elle
    April 1, 2015 at 5:06 am #

    Twisting words to turn midwifery into an ugly thing so that obgyns can have the spotlight once again. Midwives dont withhold care or call complications a variation of normal to support natural birth. They however support low risk average pregnancies and the mothers choice to wish for an u medicated labor. Not at the expense of safety. They are liable for decisions being made. If something goes wrong they certainly defer to medical experts not withhold care. Midwives dont want babies and mothers to die or be injured at the expense of an ideal. They just know that many bodies are perfectly capable of doing something biologically natural all on its own like its happened in every mammal species since the dawn of time. If anything is a damn shame its the medicalization of low risk births and the risks and negative outcomes caused by ridiculous insurance policies that force women to birth within such rigid boundaries like a plastic mold. Obgyns just cant keep their hands to themselves when they dont even need to interfere. And I’ve had a lot of experience with them. I changed providers several times with my first pregnancy and saw two with my second before birthing with a midwife. The first one gave me a pelvic after I told him no. My first birth was ruined by obgyns and I was nearly killed and both my baby and I ended up with a lengthy hospital stay due to the drugs they push on you to keep you within the boundaries of policy. Ridiculous and far sadder than midwives realizing this is a problem.

    • Amy Tuteur, MD
      April 1, 2015 at 6:00 am #

      No, MIDWIVES have turned midwifery into an ugly thing by pledging their allegiance to unmedicated vaginal birth instead of to the mothers and babies they serve.

    • moto_librarian
      April 1, 2015 at 10:29 am #

      Nature kills. Midwives increasingly value ideology over safety.

  2. fiftyfifty1
    March 31, 2015 at 8:41 am #

    Midwives are the Guardians of their Turf.

  3. KarenJJ
    March 31, 2015 at 5:28 am #

    This is Australia’s most populous state and their policy “Towards Normal Birth” authored by Hannah Dahlen – a midwife in academia and homebirth practising midwife that was (still is?) spokesperson for the national midwifery organisation here.

    Some Highlights:

    4.3 Percentage of spontaneous vaginal births
    (target >70% by 2015)
    4.4 Percentage of vaginal births (target >80% by

    5.3 All maternity services offer access to water
    immersion in labour (target 100% by 2015)

    7.2 Percentage of women who have a vaginal
    birth after one previous pregnancy delivered
    by caesarean section operation, i.e. primary
    caesarean section operation (targets >30% by
    2012 and >60% by 2015)

    NSW Department of Health will:
    • develop a leaflet for women talking positively
    about the use of water for pain relief and citing the


    Some of the graphics are hilarious too (hilarious to me because I’m not affected by this policy) with large green arrows showing “Normal Birth” being a destination.

    From what I can tell, all this is targeting process and not outcomes. Measures are not to do with health outcomes, or even patient satisfaction, but “normal” births and midwifery involvement.

    • Sarah
      March 31, 2015 at 8:02 am #


    • The Computer Ate My Nym
      March 31, 2015 at 9:13 am #

      develop a leaflet for women talking positively
      about the use of water for pain relief and citing the

      Simultaneously? That could be tricky.


      (The link is not wholely negative about water as a pain relief measure in the first stage of labor, but it’s not anywhere near as positive as I expect the NCB advocates want it to be.)

      • Ceridwen
        March 31, 2015 at 11:27 am #

        I absolutely adore baths and swimming and really expected to enjoy laboring (not birthing) in the water. When the day came? I hated it. It did absolutely nothing for me despite my positive expectations. Color me unimpressed.

        • KarenJJ
          March 31, 2015 at 10:58 pm #

          I tried googling to see if I could find whether such a leaflet has been produced and couldn’t find it. Maybe they’re having trouble finding enough women to speak positively about it?

  4. Ob in OZ
    March 31, 2015 at 12:03 am #

    So well written. This is it in a nutshell

  5. Sue
    March 30, 2015 at 10:57 pm #

    Imagine a Guardian of Normal Ageing:

    “Yes, we know you can’t read without glasses, bit it’s NACHERAL. Big Optica is just trying to sell you glasses to make money.”

    • araikwao
      March 31, 2015 at 1:25 am #

      I’m glad they’re not guardians of normal periods

      • fiftyfifty1
        March 31, 2015 at 8:06 am #

        Oh don’t think that they don’t have plans for LOTS of areas of your life. They know what’s best for you, missy!

      • Amy M
        March 31, 2015 at 8:24 am #

        The midwives also seem to be guardians of normal infant feeding (aka: breastfeeding), which should, of course, follow normal birth. You’d think those poor sad women who had abnormal births could be left alone to feed their babies as abnormally as they want, since they are already a lost cause, no? 😉

  6. KBCme
    March 30, 2015 at 5:06 pm #

    Instead of ” Guardians of Normal Birth”, they should call themselves “Guardians of Our (Midwives’) Paychecks/Jobs”.

  7. Hannah
    March 30, 2015 at 5:05 pm #

    Another obstetric lawsuit from the UK:


    This one feels a bit “hindsight is 20:20” but it would be interesting to have some input from people with more knowledge.

    • Daleth
      March 30, 2015 at 6:10 pm #

      It doesn’t seem any more “hindsight is 20:20” than any other medical negligence suit. In related news, I’m glad to see that UK doctors are now required to share information on the risks of vaginal birth with expectant moms, instead of just sharing info on the risks of c-section:


    • Mattie
      March 30, 2015 at 7:02 pm #

      I think they have a good case, and yeh I feel that risks of shoulder dystocia should definitely have been discussed. What I will say is that if according to Mrs Middleton the birth of her second baby was uneventful, that is likely what went in to her notes at her booking appointment. Her first baby was an assisted delivery and although her baby was big, it didn’t mention shoulder dystocia.

      Now in the UK the booking appointment usually takes place in the community, and relies on women telling the midwife about their obstetric history. So if nobody told Mrs Middleton about the shoulder dystocia during her second labour (a failing IMO) and there was none present in her first labour, then there wouldn’t have been an apparently greatly increased risk of a shoulder dystocia with her third baby. Her babies weren’t especially big, although we don’t know her stature of anything. I think that had she known about her previous shoulder dystocia, and noting that her babies were on the larger side and second baby was bigger than first she would have been consultant led care, or shared care.

      Now, IMO there are several issues present. First, is that community midwives rely on women telling them about their obstetric history, and ASAIK don’t often get to see hospital notes from previous labours. Secondly, there was a problem during Mrs Middleton’s second birth that was not discussed with her so she was not aware. Finally, even when women plan on having vaginal births and have no risk factors, risks and possible complications (and what is done in those situations) should be discussed. So no, I don’t think it’s a hindsight issue, I think it’s a series of failings, although it’s difficult to know if there was a failure in clinical care during labour as well as during pregnancy.

    • CanDoc
      March 30, 2015 at 7:39 pm #

      This is a fascinating case. Unclear to me that there is compelling evidence that there was any significant shoulder dystocia in the 2nd delivery at all… if you delivery the baby WITHOUT any manoeuvres (e.g. McRoberts, etc), then BY DEFINITION it isn’t a shoulder dystocia. Which is in fact irrelevant, because when you’re carting around a 5000 g baby (11 lbs), that’s a massive risk factor for shouder dystocia and in a woman of normal weight, a drastically advanced fundal height (40 cm at 37 weeks with a baby that subjectively “feels large”) should be a red flag to at least be cognizant of the possibility of significant fetal macrosomia.
      Additionally, when we suspect a large baby, our general mantra is “you push the baby out, or we cut it out” – i.e. avoidance of operative deliveries. ESPECIALLY in a woman with TWO prior vaginal deliveries – typically she would reach fully dilated then be delivered within an hour. A 3 hour second stage for a 3rd baby? Preposterous, and again, another reason NOT to do a forceps for vacuum.
      For a woman with prior shoulder dystocia, I wouldn’t usually advice a CS for future pregnancy – but I would discuss it and offer an ultrasound to at least guess at weight at 38 weeks-39 weeks.

      • Hannah
        March 31, 2015 at 8:09 am #

        Yeah, I was a bit “hmm” about the first shoulder dystopia (where the mother delivered standing up and was completely unaware of anything untoward happening), as well. I don’t have the chance to go back and check at the moment, but iirc she had a ventouse delivery (or I may be getting confused with the first birth). At the point where you’re attempting a ventouse delivery, is a caesarean still possible/advisable?

        • Medwife
          March 31, 2015 at 10:10 pm #

          If the baby’s head is still inside and there have been three “pop-offs” (vacuum comes off the baby’s head during a pull), as a rule, you need to go to section. Or if the baby can’t tolerate the delivery. It usually means a lot of effort in the OR to push the baby’s head out of the pelvis when that happens.

    • Medwife
      March 31, 2015 at 10:29 pm #

      That’s a sobering read. Poor kid. The stakes are so high in this field!

  8. Therese
    March 30, 2015 at 4:23 pm #

    A midwife is a “guardian” of normal birth because anytime a birth turns “abnormal” aka high risk, it is out of the scope of their practice and they should generally transfer to an OB. If someone is the guardian of a child, that means they’re legally responsible for taking care of that child. So to me a guardian of normal birth would mean a midwife is legally responsible for taking care of normal births, not that there job is to make sure the woman has a normal birth at whatever possible cost. This language makes the most sense in systems like the NHS where midwives are the default unless you are high risk. I don’t think CPMs ever use it, right? I certainly haven’t heard it if they do.

    • Amy Tuteur, MD
      March 30, 2015 at 4:37 pm #

      It unethical to guard normal birth. The only thing midwives should be guarding are the health and well being of mothers and babies. Anything else is self-interest.

      • Mattie
        March 30, 2015 at 4:56 pm #

        I think there’s a complication of language happening, or rather there has been a muddying of the waters with regard to what people mean by ‘normal’ birth.

        Normal birth shouldn’t refer to ‘natural’ unmedicated vaginal birth, it should refer to any birth without complications. So a normal vaginal birth progresses from latent to active labour, the second stage and the third stage, with or without induction, augmentation or pain relief.

        The need for augmentation with synthetic oxytocin is a complication…a deviation from ‘normal’ and as such the decision to augment, and the augmentation schedule is done by a doctor, the placement of the IV and administration of the medication is done by a midwife, The continuing assessment of labour progression and the need for further intervention due to failure to progress, or fetal distress, maternal fatigue etc… is done by the midwife but the decision on what to do in response to those complications is done by a doctor.

        A woman with a synto drip may give birth ‘normally’ following the progression of cervical dilatation to 10cm and a time of pushing where fetal heart rate remains stable. The third stage may progress normally either managed or physiologically or there may be complications. Midwives are trained to respond to emergency situations so that they can do something while also calling for support from doctors, but they’re not trained to perform surgery etc… So a normal c-section birth is one where no complications of birth take place, but midwives are trained to deal with ‘normal’ vaginal birth and ‘normal’ labour.

        The problem is when midwives do not ‘stay in their lane’ and attempt to blur their scope of practice, which goes against the NMC Code of Practice and Midwives’ Rules and Standards, and if the midwife is found to have breached these there are sanctions in place. This seems to happen a lot with CPMs in the US, but as there are no/few licensing laws or sanctions they can do it. Doesn’t make it right. Also doesn’t mean all midwives do it. Some midwives see anything that isn’t unmedicated vaginal birth as abnormal, but they are trained to deal with a lot of it (inserting an IV, administering pain relief, managing an epidural, managing a PPH etc…) so they don’t transfer for those things, which then leads to them not transferring when they really should, when things are truly ‘abnormal’.

        • The Bofa on the Sofa
          March 30, 2015 at 5:08 pm #

          I think there’s a complication of language happening, or rather there
          has been a muddying of the waters with regard to what people mean by
          ‘normal’ birth.

          Then perhaps midwives should actually use language that better conveys what they mean?

          Personally, I think the reason they haven’t is because it is intentional, they are absolutely conveying the message they want to send. See the graphic Ash has posted, created by the midwives themselves, where they define normal birth. It absolutely contradicts your claim that “Normal birth shouldn’t refer to ‘natural’ unmedicated vaginal birth,” I agree with you, it shouldn’t, but that is EXACTLY how they are using it.

          So like I said to nata, if you have a problem with it, take it up with the midwives who are saying it.

          • Mattie
            March 30, 2015 at 5:31 pm #

            There actually are a lot of people taking it up with midwives, also a large proportion of the Nursing and Midwifery Council doing this very thing, that’s why there are all the cases on the NMC website of nurses and midwives being sanctioned for not following the regulations. Obviously that doesn’t exist in the US, but then you should take it up with the government that allows unlicensed providers to work as healthcare professionals.

          • The Bofa on the Sofa
            March 30, 2015 at 5:34 pm #

            There actually are a lot of people taking it up with midwives,

            Yet, here is the RCM using this deceitful message….

            Apparently, those people are failing, too

          • Mattie
            March 30, 2015 at 5:41 pm #

            Well the RCM is a trade union and pressure group, their aim is literally to promote what their members want, midwives don’t have to join the RCM and many don’t so they are likely to be biased. When looking at what midwifery is required to be in the UK don’t look at the RCM look at the NMC. While the RCM is perhaps more influential than other trade unions (debatable) it doesn’t actually have any power. They run campaigns, true, and they may be the most vocal, but the NMC still makes the rules and all registered midwives are required to follow the rules or face consequences, do some still do their own thing? Of course. Some people are terrible people, but they also have to show their practice regularly and can be denied registration.

          • Amy Tuteur, MD
            March 30, 2015 at 5:43 pm #

            Show me any midwife in a position of authority who questions the claim that midwives should be the guardians of normal birth?

          • Mattie
            March 30, 2015 at 5:58 pm #

            I won’t be able to, because that claim is not wrong. I could likely find many that question the claim that midwives should be the guardians of unmedicated vaginal birth.

          • Amy Tuteur, MD
            March 30, 2015 at 5:42 pm #

            Obviously, “taking it up” with midwives has been useless. They and their professional organizations are aggressively promoting “normal birth” and that’s wrong.

        • Amy Tuteur, MD
          March 30, 2015 at 5:09 pm #

          Well, that’s my point. It shouldn’t refer to unmedicated birth but it DOES. Hence being a guardian of normal birth is unethical.

          • Mattie
            March 30, 2015 at 5:28 pm #

            But that isn’t it, it’s unethical to claim you are a guardian of normal birth and only be a guardian of unmedicated vaginal birth. It isn’t in any way unethical to claim you are a guardian of normal birth if you actually are…that’s pretty offensive to the many many excellent midwives who put the lives of women and babies first and do an incredible job working in their scope of practice and caring for women by the book regardless of what painkillers they are on or what drugs they may need, or what medical conditions they are dealing with, or even if they are having an unmedicated vaginal birth with candles and whale music.

            Out of a cohort of 25 student midwives, there was maybe 1 who was a bit woo-y but she still worked within the confines of her scope of practice, and is still required to comply with the NMC Code and Midwives’ Rules and has to prove that every time she wants to renew her registration.

            I totally accept that there are hella loads of crazy midwives in the US (and some in the UK) but the answer is in requiring them to have proper training and licensing and sanctions, not in berating all midwives because of the warped way a few think.

          • Amy Tuteur, MD
            March 30, 2015 at 5:40 pm #

            It is fundamentally unethical because it betrays midwives focus on THEIR preferred process. They have no business prefering any mode of birth over any other. Their ethical commitment should be to healthy outcomes, not to any specific method of birth.

            Midwives claiming to be guardians of normal birth is a mainstream view within midwifery, not the product of warped thinking of a few.

          • Mattie
            March 30, 2015 at 5:57 pm #

            Like I said, it isn’t unethical to facilitate a birth without complications, that is what everybody wants. It’s unethical to claim to facilitate a birth without complications when really you are encouraging unmedicated vaginal birth. Unmedicated vaginal birth is not ‘normal birth’ it can be a normal birth if it ends with the safe birth of a baby and a well mother, but so can a birth with an epidural, or synto, or a kiwi. Midwives are guardians of normal birth in that they care for women having normal births, and that is their scope of practice. They are trained to manage normal births, as well as detecting when the birth deviates from normal and handing care over to a doctor in that instance. They can then have care handed back (like to manage a synto drip) and return to their role of assessing the labour and watching for deviations from normal. That is not preferring a method of birth, that is managing various labours where the progression remains normal, or returns to normal after an intervention.

            In fact there are some midwives (one a close friend of mine, many others who I worked with) who prefer the more complicated cases, and who find they enjoy working with doctors and with synto, epidurals, continuous fetal monitoring etc… and some who prefer the unmedicated vaginal births, in water, or who love working the c-section lists. But the care they give to all women, whatever their birth choices, is the same and is at a high level regardless of what kinds of birth they ‘like’ the most. I actually find it incredibly unethical to lambaste an entire profession based on your own country’s/government’s failing to regulate it.

          • nata
            March 30, 2015 at 6:01 pm #

            could not agree more x

          • Mattie
            March 30, 2015 at 6:12 pm #

            Thanks, I hope it made sense, also it’s hard because the UK is regulated and so the NMC makes rules and requirements for registration, in the US crackpots can call themselves midwives and quote things they don’t understand or that they got from crackpots over here and do what they want and women and babies die because of it.

          • Amy Tuteur, MD
            March 30, 2015 at 6:18 pm #

            But babies are dying at the hands of UK midwives BECAUSE they consider themselves guardians of normal birth. What do you propose to do about that?

          • nata
            March 30, 2015 at 6:23 pm #

            I think everyone here went mental about the morecambe report. Most midwives I know are shocked about the idea that a group of natural birth midwives could actually behave like this and for a long time. This is NOT what is normally happening here. The idea of guarding normal birth is more about things like encouraging mobility, nutrition hydration, privacy to reduce psychological stress factors. Also, taking some preventative measures, not withholding care!

          • Mattie
            March 30, 2015 at 6:46 pm #

            Yes, some midwives (how many was it, out of all the midwives in the UK?) are terrible, but other failings in that hospital led to a situation where those few midwives were able to do what they wanted without fear of reprisal. That, fortunately, is incredibly rare. It will also lead to various preventative measures at other Trusts to prevent it happening again. Is it acceptable that those women and babies died, of course it isn’t, it’s disgusting, and it’s also against the NMC Code and the Midwives’ Rules, which means the midwives were practicing illegally. They did not consider themselves guardians of normal births, they considered themselves guardians of any birth regardless of their real scope of practice, they decided what their scope of practice was and acted accordingly. That is not what the quote means, that is like saying that if someone twists your words and does something unspeakable, it’s your fault for saying the thing you said.

          • Amazed
            March 30, 2015 at 6:53 pm #

            Mattie, what do you make of the horrifying attitude of the midwives (including leading ones) from WeMidwives towards James Titcombe who lost his son as a direct result of midwives failing in their jobs? Those leading midwives were terribly quick to align themselves with “those few midwives” by disparaging James’ loss and showing horrifying indifference to both the horrors of the past and their own colleagues’ part in them.

            Because it sure looks more than “those few midwives” to me. “Those few midwives” were the ones who did the deed. The other midwives are probably those who would have done the same given the chance. Fortunately, the defences that didn’t stop the first midwives seemed to be working in other hospitals. The mindset of “those few midwives” doesn’t look limited to them alone.

            Those midwives aren’t so few, after all.

          • Mattie
            March 30, 2015 at 7:25 pm #

            Awful, I can’t actually believe those people can call themselves health care professionals, and actually what they are doing does go against the regulations. I don’t know if they have been reported but they should be. The more people that complain, and complain direct to the NMC, the more bad midwives, or ideologically driven ‘mad’wives we will weed out. I actually read a book a little while ago, called Friday’s Child, it is heartbreaking.

            Not only in the appalling care that led to the preventable death of a young mother, but in the revolting treatment of the father by the hospital and courts. It’s an incredibly difficult book to read, and I don’t know what happened to the midwife who failed that family, I hope she was struck off but google didn’t give me any answers.

            I mention this book, not just because it’s an interesting insight into something usually hushed up, but because the author and now single father of two is so brave and so strong, and he deserved so much better. I hope that by standing up and refusing to be bullied, victims and their families can help improve maternity services for everyone. The NMC have the power to strike midwives and nurses from the register, they have the power to investigate and implement change, and I sincerely hope they do, Because currently the far too vocal few (and it is a few) – from what I could find and the numbers are from 2008, from the NMC website which is really out of date there were over 35000 midwives practicing in the UK. This doesn’t include nurse-midwives currently working as nurses (I don’t think) – are harming patients and that is unacceptable.

          • Amazed
            March 31, 2015 at 4:41 am #

            Mattie, while I agree that their behavior is appaling, that was not what I asked. I asked what you think of the fact that there are definitely more midwives of the sort of “those few midwives” that you consider to be a bizarre accident. And some of them are quite high in the ranks.

            That rings the alarm bell for me because I take it as a sign that this attitude is more widely spread than you’d like to see. And because some of them are high in the ranks. It’s like fraud. Sure, we don’t like fraud in general, a fraud is a fraud is a fraud but while we might be displeased and revolted if your John Smith commits one, we’ll be far more displeased, revolted, and furious if the president is caught committing one, along with half the government. The higher you rise, the greater responsibility you bear. Midwives neglected that and those high in the ranks are the ones giving the tune. That’s extremely troubling.

            THAT was what I was asking you about. What do you make of this?

          • Mattie
            March 31, 2015 at 4:51 am #

            Well I don’t think there’s that many, like I said it’s a case of over 35000 midwives in the UK and a small percentage being dangerously ideological in their care. It’s going to look like more in situations like twitter, or even with the RCM because they are all in one place. That was the problem with morecambe bay, there were a lot of midwives in the team that thought the same, which meant that the care was altered by their dangerous ideologies. I’m not entirely sure what you mean by ‘higher in the ranks’ midwives are all on the same pay-scale, then you have midwifery managers that are paid more etc… if you mean for example the RCM it’s not a powerful organisation in the sense that it can punish or not punish midwives who do wrong, it’s the NMC who does that are they have been very clear that this behaviour is unacceptable.

          • Amy Tuteur, MD
            March 31, 2015 at 8:14 am #

            It’s the OFFICIAL POLICY of their organization. Please stop desperately trying the obvious.

          • Mattie
            March 31, 2015 at 8:20 am #

            But so what if it’s the policy of one organisation, they don’t control all midwives, or government policy, or midwives rules and standards or midwifery training or anything else…they have no power, they’re not in charge. The NMC are, and they do not listen to the RCM. They listen to the government reports and make changes based on them,

          • Amy Tuteur, MD
            March 31, 2015 at 8:23 am #

            Mattie, there’s nothing to discuss if you won’t accept reality.

          • Mattie
            March 31, 2015 at 8:48 am #

            Ok, then help me to understand your reality by explaining why you believe that the RCM as a pressure group/union have so much power, what power they have, and how they have more power over midwifery than the governing body for nurses and midwives. You can’t state your opinion as fact, if you can’t actually provide evidence showing it as fact.

            I am not disagreeing with you that the RCM are bad, that their campaigns are questionable at best and harmful and lead to the kinds of ideology that led to the ‘Musketeer’ midwives at Morecambe at worst, however they are not in charge of midwifery. The NMC are not on board with their campaigns or the idea of ‘normal’ birth meaning unmedicated birth.

            If it was the NMC’s campaign for normal birth, or that ideology being part of midwifery education then I would 100% agree with you, as would many good, skilled, midwives all over the UK. Personally I wish the RCM would shut up and go away, but they have the right to form a pressure group and campaign as that is how our political system works.

          • nata
            March 31, 2015 at 11:18 am #

            it’s so strange – you are over the pond and we are here witnessing midwifery care every working day of our lives. And of course you know better about our country and practices, attitudes of midwives through your internet reading 🙂

          • moto_librarian
            March 31, 2015 at 12:14 pm #

            Do you know why we are so interested in the UK model of midwifery care? Because it’s constantly cited (along with the Netherlands) as proof that midwifery-led care is superior to obstetric-led care and as proof that home birth is “safer than hospital birth.” Turns out that the leaders for midwifery in the UK are ideologues, just like so many midwives in the States. In case you haven’t read them, CrownedMedwife noted that her own professional organization in the States, the ACNM, holds similar ideological positions. While she herself refuses to privilege ideology over safety, she knows that too many of her colleagues do not. Given the complete lack of professionalism displayed on social media and blogs by a number of UK midwives, why shouldn’t we conclude that the profession is in serious trouble? I’m not convinced that you haven’t absorbed some of the Kool-Aid too, nata. You can’t cite a single reputable study about the impact of stress and privacy on labor, yet you claim that it is important. I care about what’s going on “over the pond” because it’s being used to push dangerous practices over here. 🙂

          • CrownedMedwife
            March 31, 2015 at 8:47 am #

            I’ve watched with interest at your futile attempts to rationalize Midwives as ‘guardians or normal birth’ and claims that Morecambe Bay was the result of ‘rogue’ Midwives.

            I challenge you to remove yourself from the midwifery viewpoint and reread the comments here, reread the proclamations by the RCM, ACNM and other organizations and academia to protect, guard or encourage their ‘construct’ of normal birth. Take a moment to drop the defense of other Midwives and stop claiming we’re all not like that. In truth, Midwifery organizations have created this warped view of “Normal Birth” avoiding interventions, pain management and hospital-based birth; therefore they have removed maternal autonomy through manipulation and ideology at the expense of safety to the birth process.

            That may not be your interpretation or your motivation, but is the stark reality of what Midwifery organizations are promoting. It is disgusting, it is foul and it is lethal. I refuse to allow such ideology to impact my practice and I will not waste a moment defending Midwifery when our very own leadership has made a blatant attempt to distort the true purpose of our profession. I am a Midwife, but I will not come to the defense of our profession in an attempt to rationalize their ideological stance. Nor can I find the wherewithal to declare we’re not all like that, because if Midwifery colleagues support the tenets of Normal Birth continue, it will not be long before our we are all like that.

          • KarenJJ
            March 31, 2015 at 9:03 am #

            Oh wow. This is a fantastic comment Crowned Medwife (sorry got your name wrong originally). Fact is “normal birth” as an end goal for midwifery has reached much further than a few rogue midwives and much further then a couple of rare hospitals and a nutty organisation or two. Mattie should take a read of what the NSW government health department policy is for maternity care I posted above. It’s shocking and it’s targets and requirements are not in women and children’s best interests.

          • Mattie
            March 31, 2015 at 9:03 am #

            Thank you for this response, it was detailed and polite. Although once again I would like to point out that the RCM are a pressure group trade union and as such don’t have any say in the policy that governs midwifery registration, midwifery education, midwifery supervision or any of the things that governmentally legislate nursing and midwifery. I don’t know what the ACNM is, is it a professional organisation or a licensing board? I totally agree that many campaigners who seem to favour vaginal birth at all costs do encourage this construct of normal birth. However I don’t think the response to that is to redefine what midwives do, but to reiterate it and make it explicitly clear what a midwife can and cannot do. Morecambe bay was the result of multiple failings by multiple agencies, safe-guards and guidelines. That needs to change, however, if the midwives had stuck to their scope of practice, if they were ‘good’ midwives they would not have been trying to achieve vaginal birth at all costs, they would have been transferring cases that needed it and working with women as well as a team of other HCPs to ensure safe outcomes. Those midwives were not following the guidelines, or working within their registration. Scope of practice is literally in the midwives’ rules, as is supporting the woman’s choice which includes her choice of pain relief, birth location, and AFAIK care provider.

            Undoubtedly following the Kirkup report, the NMC will make changes. The most obvious change for me would be a change in the way midwifery supervision takes place, as well as risk management within hospital maternity units. But it may extend to changes to the midwifery education requirements, assessment and fitness to practice declarations. This is necessary, and generally will not be a negative thing. Those who believe it will impede their practice are those who likely are not practicing as they should be, and those midwives need to go for the safety of women and babies first and foremost, but also for the safety of future midwives who might be being mentored by them.

          • Amy Tuteur, MD
            March 31, 2015 at 9:08 am #

            The NMC has officially adopted the international definition of a midwife, which includes the promotion of normal birth. So the NMC does promote normal birth.


          • Mattie
            March 31, 2015 at 9:53 am #

            So, internation confederation of midwives definition of a midwife is

            “The midwife is recognised as a responsible and accountable professional who works in partnership with women to give the necessary support, care and advice during pregnancy, labour and the postpartum period, to conduct births on the midwife’s own responsibility and to provide care for the newborn and the infant. This care includes preventative measures, the promotion of normal birth, the detection of complications in mother and child, the accessing of medical care or other appropriate assistance and the carrying out of emergency measures.” (my emphasis)

            I put the definition here because it makes for a more streamlined discussion. The promotion of normal birth just means physiological birth, and I do agree that you can’t or at least shouldn’t encourage one method of birth while simultaneously respecting maternal choice. However, physiological (vaginal) birth does not mean birth without pain relief, or even birth without augmentation. It just means not instrumental or c-section.

            While I didn’t write the definition and so don’t know, midwives promote normal birth in their scope of practice by not performing instrumental births or c-sections. So, a woman having an elective c-section would not have a midwife as her lead carer, she would be under consultant-led or shared care, and a woman who needed a forceps delivery would perhaps have a midwife as lead carer up to the delivery, but then the doctor would be the lead and the midwife would assist.

            There are certain things a midwife does to try and ensure a vaginal birth (if that is what a woman chooses) like encouraging a woman to mobilise, ensuring she is sufficiently nourished and hydrated, that interventions are decided upon appropriately based on the individual case, and that she is comfortable and her choices are respected. That is promotion of normal birth, and is likely what an obstetrician would do except their scope of practice extends to instrumental delivery and c-section, so they wouldn’t need to transfer care in those situations.

            At least that is what we as student midwives were taught about promoting normal birth, and remaining in our scope of practice. We were never taught to ignore women requesting pain management, or to aim for a vaginal birth at all costs, we worked with women to facilitate their births and make sure they were as safe as possible.

          • CrownedMedwife
            March 31, 2015 at 11:27 am #

            “Morecambe bay was the result of multiple failings by multiple agencies, safe-guards and guidelines.”

            No. Have you read the report? It was the fault of Midwives who subscribed to the ideological values of “Normal Birth’. The same ideological values professional and trade organizations have put forth.

            “The most obvious change for me would be a change in the way midwifery supervision takes place, as well as risk management within hospital maternity units.”

            Supervision? A change in supervision is not an answer to what happened at Morebambe. To put forth supervision as a preventative action seems a cover up of the original ideology at fault. By summation, physician supervision of Midwifery practice is a bit like suggesting physicians must be the ‘guardians of mothers’ from the ‘guardians of normal birth’. If you truly believe this rogue behavior occurred at Morecambe Bay and there alone, you are most likely mistaken. If not for the efforts driven by Mr. Titcombe, the details of the dangerous culture would not have come to light in time to raise awareness of the issue.

            You have repeatedly suggested RCM is a trade organization and does not influence practice, yet between NMC and RCM, I’ve only been able to obtain practice guidelines implicit specifically to Midwifery practice. From what I can tell NMC is a licensing agency with a basic code of conduct applicable to any health care provider.

            You can keep denying the influence of professional or trade organizations and ideologic behavior within the profession of Midwifery. However, I have seen no evidence to the contrary. No matter how often you choose to reinforce your belief that ‘we’re not all like that’, the simple fact is that Midwifery is infected. I’m not happy to admit that about my own profession, but I care too much about the well-being of women and babies to deny that.

          • moto_librarian
            March 31, 2015 at 10:25 am #

            No, I don’t think it’s incredibly rare. Your leadership (RCM) makes it patently clear that physiologic birth is the priority, and to hell with the consequences.

          • Mattie
            March 31, 2015 at 10:30 am #

            I will accept it is probably more common than I want to believe, but again, the RCM are not the midwifery leadership, they are a trade union than midwives are not required to join.

          • Sue
            April 1, 2015 at 12:22 am #

            Mattie – if the RCM are not the “midwifery leadership”, then who is, and what are their policies?

          • Mattie
            April 1, 2015 at 4:47 am #

            The NMC, in the sense that they regulate midwifery (and nursing) education, create standards for midwifery registration, are in charge of disciplining midwives who fail to adhere to those standards, work with government health regulations to update and alter those standards, train Supervisors of Midwives and create standards for the role etc… as for policies it’s most easily shown in the code (which is the document of rules for practice, and must be followed in order to maintain registration) http://www.nmc-uk.org/The-Code/Whats-changed-in-the-Code/

            but also they have changed (are changing) their process for renewal of registration/fit to practice requirements: http://www.nmc-uk.org/Nurses-and-midwives/Revalidation/

            These are all the standards, including midwifery and nursing education programs (all programs in the UK must meet these standards as minimum) http://www.nmc-uk.org/Publications/Standards/

            Guidance: http://www.nmc-uk.org/Publications/Guidance/

            NMC Hearings (open to the public, so schedules and outcomes are all on the website) http://www.nmc-uk.org/Hearings/Hearings-and-outcomes/

          • Amy Tuteur, MD
            March 30, 2015 at 7:09 pm #

            Kirkup, author of the report, has publicly declared that midwives have basically ignored it, dismissing it as midwife-bashing and using social media to accuse loss parents demanding accountability of “negativity.”

          • moto_librarian
            March 31, 2015 at 10:24 am #

            I am really tired of reading all of this bullshit about “encouraging mobility, nutrition, hydration, privacy,” etc. None of that did squat for me once I hit transition. I was in significant pain that became excruciating once I started pushing. By telling women that “pushing will feel good” and other such nonsense, you are setting up unrealistic expectations. You know what works best for severe pain? Anesthesia. Perhaps its time to start promoting epidurals rather than ideology?

          • March 31, 2015 at 12:45 am #

            Rather obviously, since my time in the UK, regulations and standards have become too relaxed. The rogue midwives need to be put out of business, by removing their licensure if they cannot work within the proper regulation. Just as in the food industry, a restaurant will be closed down if it doesn’t adhere to sanitary regulations.

          • Amy Tuteur, MD
            March 30, 2015 at 6:13 pm #

            No, it is NOT what everyone wants. It’s what midwives want.

            No one is needed to “facilitate” a birth without complications. Birth attendants are need to prevent, predict, manage and treat complications. Most complications are NOT iatrogenic, so a provider who wants to “guard” births without complications is unethical. Their ethical mandate is to guard safe outcomes, without regard to process.

            It is NOT about what midwives enjoy. No one cares, nor should care about what midwives enjoy. It it about what patients have a moral right to expect from providers.

          • Mattie
            March 30, 2015 at 6:41 pm #

            So there are some women who want births with complications? Or some providers who want births with complications? Or anyone who wants births with complications…because if not, then yes births without complications are what everyone wants. Not talking interventions, interventions prevent complications.

            Of course someone needs to facilitate a birth without complications, the prevention, treatment and management of complications is facilitating birth without complications/further complications/poor outcome. Did you actually read what I said, I said that while some midwives may enjoy working a certain type of birth better, it is irrelevant to the quality of care they give women. A midwife who likes working with water births will still give appropriate and effective care to a labouring woman who has a synto drip, a midwife who enjoys the different challenge of working with women with epidurals will still give appropriate and effective care to a woman who is labouring with no pain relief. They are all trained to the same standard and required to follow the same rules, their personal preference does not come into it.

            You seem to be using complications as synonymous with intervention, which is what you claim the worst NCBers do. Again, normal birth does not mean birth without intervention, it means birth within the scope of practice of the midwife. Midwives are ‘guardians of normal birth’ because they are the ones who protect and care for women having births within their scope of practice. They protect women having normal births by charting labour progression, monitoring the mother and baby and using their clinical judgement of the normal progression of labour to attempt to prevent potential complications. So, they may suggest a change of position to see the effect on a sub-optimal fetal heart trace, if that doesn’t work they will transfer care to an obstetrician because they can no longer protect the mother and baby within their scope of practice.

            That change of position is an intervention, midwives can and do perform interventions, and they do it to save lives not to save vaginal births. If a birth is heading south rapidly then sometimes a vaginal birth is quicker than a section, sometimes a section is the best option, sometimes an instrumental delivery. In situations where the birth is no longer normal (within the scope of practice of the midwife) the midwife’s role is to support the mother and offer assistance to the doctor. The lead professional is the OB as they are the most qualified to deal with an abnormal birth.

            In the case of an augmented labour with synto, the decision to start synto is made by the doctor, as the labour is no longer normal and all the options within the midwife’s scope of practice have failed. Once synto is running, labour may return to normal, in that the cervix is dilating at an appropriate rate and mother and baby are stable. In this case the labour is once again in the scope of practice of the midwife and the care continues until the placenta is delivered or another deviation from normal occurs when the doctor again makes a clinical decision. That is what it means to guard normal birth, it does not mean guard unmedicated vaginal birth at all costs.

          • fiftyfifty1
            March 31, 2015 at 8:24 am #

            “So there are some women who want births with complications?”

            No woman wants a birth with complications. The point is that WE DON’T GET TO CHOOSE. And since we don’t get to choose, I would like to be cared for by somebody who had MY best interests and the best interests of my BABY in mind, not preserving their damn autonomy.

            And don’t come back with some bullshit about complications being due to “psychological factors” or any other self-serving lies to justify your unethical priorities.

          • Mattie
            March 31, 2015 at 8:42 am #

            No, I didn’t think people wanted births with complications which is why I said that births without complications are what everyone wants. Of course we don’t get to choose, I don’t believe I ever said we did. I in fact stated repeatedly that interventions are what prevent and treat complications, they are essential and life-saving. Some interventions are also within the midwife’s scope of practice, that is the same for any HCP. A GP’s scope of practice wouldn’t include a heart transplant, but would include management of stable angina (for example).

            If a GP went outside their scope of practice that would be malpractice, same with a midwife. So a midwife can assess a pregnant/labouring woman and make clinical decisions, as well as perform duties that fall within her scope of practice…if it’s in a midwife’s scope of practice it is ‘normal’. When it is not in a midwife’s scope of practice it is a deviation from normal and care is transferred to a doctor. I also don’t know what you mean by complications being caused by psychological factors, they are physiological. Although there is evidence showing that the physiological stress response does interfere with labour, but that stress can be caused by pain as well as legitimate fear, and ensuring adequate pain management and a supportive, attentive and present birth attendant can often reduce stress…which may or may not help all that much, but it would be the first thing to try before moving to the next intervention.

            There’s also no need to swear, just because I disagree with you does not mean you have to be rude.

          • fiftyfifty1
            March 31, 2015 at 8:58 am #

            “Although there is evidence showing that the physiological stress response does interfere with labour,”

            I would love a link to that.

          • Mattie
            March 31, 2015 at 9:27 am #

            I’ll see what I can find, that isn’t on a NCB blog, because we did learn about it in our physiology of labour module but referring to the importance of properly managing pain and trying to reduce fear in the woman and by making sure she is comfortable and supported by an attendant in her choices, and understands what is happening and why. Which also extended to debriefing with women after a traumatic birth or fast emergency procedure so that she understood what had happened, the reasons for it, and could ask questions and get answers. Occasionally in emergency situations women or partners would not understand what was happening, or why so many people were doing things, and that can actually be traumatic. In the same way that being in any emergency situation where you are scared and don’t know what is happening can be traumatic. It might have been a load of rubbish, but it was focussed on why it’s important women are treated as individuals with different pain thresholds and fears etc… and that they are listened to because it’s their body and their birth and they should not be forced to suffer by a care provider.

          • fiftyfifty1
            March 31, 2015 at 9:34 am #

            tl;dr Basically I have no evidence to provide to back up my assertions.

          • nata
            March 31, 2015 at 9:48 am #

            How do you imagine an ethical RCT on the topic. Let’s divide all women into two groups. One will be constantly stressed by a number of boogy men in and out of the group. Another will enjoy quiet security of a private delivery room. Let see the birth outcomes. 🙂

            There some observational studies, anecdotal, observation of animals (a study done with mice), but doing this with humans would be unethical. However, we can see what happens when women in labor have psychological one to one support (say your comfort measure):

            Women who received continuous labour support were more likely to give birth ‘spontaneously’, i.e. give birth with neither caesarean nor vacuum nor forceps. In addition, women were less likely to use pain medications, were more likely to be satisfied, and had slightly shorter labours. Their babies were less likely to have low five-minute Apgar scores. No adverse effects were identified.
            Continuous support for women during childbirth. Cochrane library.

            It is fare to suggest, that continuous support have given the women psychological comfort and this improved their birth outcomes. This at least indirectly support the statement that psychological factors do indeed influence the flow of labour.

          • fiftyfifty1
            March 31, 2015 at 1:42 pm #

            Actually a RCT would be ethical and easy. Divide women into 2 groups: lights low in one, good room soundproofing, limit number of personnel. Other room lights up full, regular walls, regular ins and outs of workers. Midwifery philosophy says these things are ever so important. So do the study! No boogy men needed.

          • moto_librarian
            March 31, 2015 at 10:21 am #

            Mattie, I find the term “normal birth” to be problematic in general. By stating that vaginal birth is “normal,” it adds to the stigma associated with c-sections, because if vaginal birth is “normal,” all other births are by definition “abnormal.” And while I understand that not all midwives are ideologues, there are far too many, particularly in leadership roles, who are. You really need to start following WeMidwives on Twitter if you don’t believe me. I cannot believe the shit that they post, and it is indicative that there are some major problems in your field right now. It is also extremely clear that midwives in leadership positions do indeed define “normal” birth as unmedicated vaginal birth.

          • Mattie
            March 31, 2015 at 10:28 am #

            Yeh, I definitely agree, I haven’t been following them on twitter because it gives them attention, makes me angry and they don’t exactly listen to reason…and lash out horribly at other people, including victims and their families. But I will make sure to keep up to date with their rubbish without giving them a new follower. I do see what you mean about using normal, I prefer just saying vaginal birth or physiological birth. I think though that an emergency c-section isn’t ‘normal’ it’s a procedure to save a mother and/or baby. But then an elective section isn’t abnormal, it’s either a woman’s choice or a procedure to ensure a good outcome because problems are likely. TBH I find the word ‘normal’ to generally be problematic because it’s at the discretion of the person using it. Do you have a preferred term, like vaginal birth or physiological birth or other? I think if the NMC definition was clearer it would leave less room for interpretation by those with an agenda of natural whatever happens, and also be easier to see when midwives were working outside the guidelines.

          • moto_librarian
            March 31, 2015 at 11:11 am #

            I don’t see any reason not to simply call it birth, be it vaginal, operative, or c-section. It might be better for midwives to clarify that they are there to facilitate low-risk births, and that the moment that the process moves out of that category, they consult with obstetricians. Low-risk birth can be medicated or unmedicated – it gets rid of the baggage associated with “physiologic” birth.

          • sdsures
            April 5, 2015 at 1:37 pm #

            How do midwives have any choice in what patients they treat (i.e. one desiring a waterbirth)?

          • Somewhereinthemiddle
            April 5, 2015 at 2:49 pm #

            Not sure if this applies to midwives in the UK but an L&D (US) nurse shared with me a bit of how they sometimes decided in her hospital which nurse works with which patient. She said that some nurses had a stronger preference for unmedicated labors, water labors, medicated labors, cesareans, etc more than others. If they had the opportunity to do so and it worked out from a practical standpoint, they would assign patients based on nurse preference. I could see how this could work out well for patients and the medical staff. But I don’t have any clue on if that is applicable to midwives in the UK…

          • sdsures
            April 5, 2015 at 3:52 pm #

            I’m not sure, but if I find out, I’ll let you know. My impression was that, like doctors, nurses also need a “full rotation” in every department when they’re getting their nurse equivalent of internship. So I thought that at some time or another, every nurse-midwife would have had exposure to all different options that a patient might choose. Then that would help them decide which areas they preferred to practice in.

          • Mattie
            April 5, 2015 at 3:35 pm #

            Well at least in the UK they don’t, but if a woman was making a choice that was against medical advice then likely she would be assigned to a more experienced midwife, as well as have doctors present (if in hospital) or an extra midwife or Supervisor of Midwives present (at home). In regard to midwives ‘liking’ one birth over another, it makes absolutely no difference, literally nobody cares (other than maybe the midwife judging his/her own job satisfaction) and all midwives (I’m in the UK) will be trained to the same standard and have the same skills, waterbirth is a little different as it requires additional training or skills, so while all midwives will have the same basic level of training in waterbirth, one may have taken more study days or in depth skills training so may be assigned to a woman labouring in water over another midwife will less developed skills. The standard skills are sufficient to provide safe care, so it then becomes an issue of ‘well Molly midwife has done more water births than Milly Midwife, so it makes sense to have her in room 3 with the lady in the pool”

          • Daleth
            April 3, 2015 at 10:36 am #

            If it were just a few, I would completely agree with you. The problem is when **midwifery organizations** start publishing statements about such things (being the “guardians of normal birth,” valuing the ability to “let go” i.e. let babies die, etc.). Or when individual midwives post such things on midwifery forums and loads of others agree with them, and few if any disagree.

          • Mattie
            April 3, 2015 at 6:22 pm #

            Yeh I do agree, and I think midwifery organisations are doing a lot more harm than good, especially when the people in leadership within those organisations seem to be the worst kind of advocates, advocating not for safe birth by whatever means necessary, but natural birth at whatever cost. Other organisations (like the NMC in the UK) are working to maintain the standards of safe practice in midwifery, and act to protect the public from harmful ideological based care that is unpleasant at best and dangerous at worst. However, they need to do more, and do it louder and more fervently than the nutty groups.

          • Daleth
            April 5, 2015 at 8:13 am #

            I completely agree.

          • March 31, 2015 at 12:42 am #

            I’m not sure it is really UNETHICAL, but it sure isn’t APPROPRIATE to the situation, IMO. It’s a bit like being a “guardian of automatic gearshift” where cars are concerned. Some people prefer stick shift; nothing wrong with that. But driving any sort of a vehicle without a license, is.

          • fiftyfifty1
            March 31, 2015 at 8:18 am #

            Sure it’s unethical. It’s unethical for all the women who can’t have a normal birth. It’s unethical for all the women who don’t want a normal birth. It’s unethical even if a woman can have and does want a normal birth.

      • Therese
        March 30, 2015 at 5:21 pm #

        Did you even read my comment? They aren’t guarding anything in the sense you are using the word, they are guarding it in the sense of taking care of and watching over. Like how a guardian cares for a child if their parents are absent. But no one ever says that their job is to guard the child. That’s not how we use the word “guard” anymore. No one ever says, “I am guarding my grandchild because the parents are away.” But that person is still the guardian, even though we would never describe the action as guarding.

        • Amy Tuteur, MD
          March 30, 2015 at 5:36 pm #

          I read your comment and I think you are making excuses for the inexcusable focus of midwives. Unmedicated vaginal birth doesn’t need to be guarded because there’s nothing paticularly valuable about it. The health of mothers and babies, on the other hand, is very worthy of being guarded.

          • Therese
            March 30, 2015 at 7:31 pm #

            Women who are having unmedicated vaginal births still need an attendant to look out for them and take medical responsibility for them. That’s all it means to be a guardian. So basically, midwives can only be a “guardian” to women that are having unmedicated vaginal births. If the woman wants an epidural, that is out of the scope of a midwives practice and someone else must be called in who can take responsibility for that aspect of a woman’s care. A midwife being a “guardian of normal birth” is a GOOD THING because we sure as hell don’t want midwives being guardians of high risk births.

          • The Bofa on the Sofa
            March 30, 2015 at 7:35 pm #

            As far as I can tell, Therese is suggesting that midwives are basically doing the job of labor monitors. They are childbirth-sitters.

            So why not just use electronic monitoring? It can tell if if things get interesting or out of “normal.”

          • Therese
            March 30, 2015 at 7:53 pm #

            Don’t hospital midwives use electronic monitoring all the time? And when electronic monitors aren’t being used, isn’t the nurses that typically monitor with Dopplers?

          • The Bofa on the Sofa
            March 30, 2015 at 8:41 pm #

            Yeah, but nurses don’t go running around proclaiming how they are the “Guardians of Normal Birth” and pretending like it is something profound.

            I think you are trying to give them the benefit of the doubt, but if what you say is true, then they are nothing more than labor monitors. You really think that is what they are trying to say? “We sit and watch labor”?

            Nah, not at all.

          • March 31, 2015 at 12:39 am #

            I understand the phrase “guardian of normal birth” not to mean “guardian of those being delivered/delivering via normal birth” but that the process of the birth itself is what is being “guarded” i.e. that a non-interventionist, unmedicated birth is being “protected” from any sort of change. Which is silly. Birth isn’t a static process; not a factory where the same auto part is created over and over again a million times from the same basic material. Birth is an active process, which changes, and is altered by, a host of different factors. The midwife’s job is to react appropriately to those changes. It can mean back rubs or what medication she is permitted to give — or it can mean transfer to OB care [it can also mean not needing to do anything at all, but that really is very rare]. In birth, ANYTHING can happen; knowing how to respond correctly is the entire art of midwifery.

          • Daleth
            April 3, 2015 at 10:34 am #

            Wrong. A CNM in the hospital, or a British midwife in a hospital or maternity clinic, can call an anesthesiologist to administer the epidural and continue being a “guardian” of the woman and the baby, her patients.

            The fact that someone else (an anesthesiologist) is required to provide that aspect of her care does not prevent the midwife from continuing to be a guardian of the mother and child.

            The only thing it prevents the midwife from doing is continuing to be a guardian of “normal” (unmedicated vaginal) birth.

            Which was exactly our point: she should NOT consider herself the guardian of normal birth. The only thing she can ethically be the guardian of is her patients.

        • fiftyfifty1
          March 30, 2015 at 7:52 pm #

          If that is the sense they meant it in they would be the guardians *during* normal birth, not guardians of normal birth.

          • Therese
            March 30, 2015 at 7:58 pm #

            That just sounds awkward. In what other context would you ever say you are a guardian during something? “I am a guardian during Jimmy’s childhood.” ? Sounds a lot better to just say I am the guardian of Jimmy.

          • fiftyfifty1
            March 30, 2015 at 8:40 pm #

            And that’s Dr. Amy’s exact point! Midwives should be the guardians OF something. And that something needs to be mothers and babies. Not a process.

          • FormerPhysicist
            March 30, 2015 at 8:55 pm #

            I am guardian of the children during my cousin’s deployment. Not awkward, nor uncommonly said.

          • Daleth
            March 30, 2015 at 10:03 pm #

            Right–you have a duty to protect the children. And for some reason, some midwives seem to think they have a duty to “protect” what they call “normal birth” (unmedicated vaginal birth) from “interventions,” such as pain relief.

        • Daleth
          March 30, 2015 at 9:46 pm #

          To be the “guardian of X” means you’re supposed to protect and preserve X. That’s just what the word means. There isn’t some other sense of the word in which “guardian of X” means someone who protects and preserves something OTHER than X.

          Public schools are the guardians of democracy. (They protect and preserve democracy.)
          Bob and Jill are the guardians of their orphaned niece. (They protect and “preserve” her, i.e. feed her, house her, educate her, prudently manage any money she may have, etc.)
          These superheroes are the guardians of the galaxy. (They protect the galaxy.)
          The dragon is the guardian of its treasure. (It protects and preserves its treasure.)

          So a midwife has no business being the guardian of any particular type of birth; her job is to be the guardian of her patients.

        • lilin
          March 31, 2015 at 12:33 am #

          ” No one ever says, “I am guarding my grandchild because the parents are away.” But that person is still the guardian, even though we would never describe the action as guarding.”

          So . . . what are you even saying here? “Guardian of normal birth” actually means “guardian of women and children undergoing normal birth” itself the way “guardian of a child” means watching over a child, even thogh “we would never describe the action as guarding”.

          To me it looks like you’re making a logic-free word salad to try to get away from a straightforward interpretation of the phrase – a phrase that everyone can see means “midwives see themselves as preserving and fighting for a certain birth process.”

    • Hannah
      March 30, 2015 at 4:53 pm #

      Clearly you can parse that phrase in different ways, and it’s apparent that in practice midwives do, with some interpretations being more malign than others. Overall I don’t think that the phrase is particularly helpful or meaningful.

  9. nata
    March 30, 2015 at 1:20 pm #

    I think there is a total misunderstanding of notions. Guarding normal birth means preventing complications before medical intervention is needed, so that the birth happens as normally and smoothly as possible. It does not mean promoting one type of birth. The women and babies are always at the centre of the care, this is just the general notion of women centered care, promoted UK.

    • Ash
      March 30, 2015 at 1:33 pm #

      From the horse’s mouth:


      For example, why is promoting no epidurals woman centered care?

      • nata
        March 30, 2015 at 1:42 pm #

        Well, each intervention, even en epidural has its side effects, right? So supporting the woman through labour so she does not need/ask for an epidural could be a good thing? This said women are/should not be denied an epidural if/when requested. Any hospital’s policy as well as NICE guidelines are clear about that

        • The Computer Ate My Nym
          March 30, 2015 at 1:45 pm #

          It’s all good if that’s what she wants. Overstating the risks, denying or delaying the epidural, or trying to restrict access are not good.

          • nata
            March 30, 2015 at 1:59 pm #


        • KarenJJ
          March 30, 2015 at 1:45 pm #

          Heck, I even asked for a repeat c-section. Absolutely no interest in trying for a VBAC. Luckily my obgyn practised ‘woman centred care’, as well as good medicine, and let me choose that option.

          • nata
            March 30, 2015 at 1:59 pm #

            a woman can request a repeat c-section in UK as well. However, I actually witnessed an ob rejecting a frightened and stressed mom a repeat c-section although she had a full right to ask for it. She had a previous traumatic labour and emergency section. When I asked the doctor about it she said – “I am not giving her a section, she can have a baby naturally or with some synto” (British pit). So it is not a matter of being a midwife or an ob- we are talking about general humane qualities that some professionals lack. In the situation above I personally believe the role of the midwife would have been to advocate for the woman and challenge the doctor. I feel sorry I hadn’t at the time – I was very new.

          • KarenJJ
            March 30, 2015 at 2:03 pm #

            That sucks. So it’s not “guarding normal birth” but “advocating for women and baby’s health and mental well-being”?

            Why the heck is that not their motto then?

          • KarenJJ
            March 30, 2015 at 2:25 pm #

            “advocating for women and baby’s health and mental well-being”?

            Actually if midwifery were seriously to take on that motto or something similar and apply it consistently to women in all situations that come under their care I’d probably take my bat and ball and go home. Enough of this “supporting other midwives” and “guardian of normal birth”… Who the hell are they meant to be guarding it from? Midwives shouldn’t be guarding anything…

          • KarenJJ
            March 30, 2015 at 2:26 pm #

            Apologies for quoting myself it is wayy past my bedtime…

          • fiftyfifty1
            March 30, 2015 at 8:24 pm #

            “Who the hell are they meant to be guarding it from?”

            From the OBs, duh!

          • nata
            March 30, 2015 at 3:45 pm #

            it’s a campaign, it’s like taking one aspect of care and promoting it. It’s not the centre, core, essence of the midwifery care, but being with the woman, supporting her is. For example, the same rcm about intrapartum care: https://www.rcm.org.uk/sites/default/files/Supporting%20Women%20in%20Labour_1.pdf

            In addition, the professional expectations in midwifery are not by any means defined by the professional union (RCM) or its leaders (like Cathy Warwick). It’s opinion, campaigns, support is important, but it does not override the actual government expectations from the midwife. The registration body for midwifery is NMC. Most essential document is the NMC code and the points like: “Make the care of people your first concern, treating them as individuals and respecting their dignity” is way much more important than any philosophical, political or ideological ideas promoted by anyone else.

          • Amy Tuteur, MD
            March 30, 2015 at 4:20 pm #

            It’s unethical because normal is defined arbitrarily in reference to what midwives can do and what midwives value. It’s normal if a midwife can do it and “abnormal” if she can’t. It puts the beliefs of midwives ahead of the well being of patients. Obstetricians, in contrast, are guardians of the health and lives of mothers and babies, in keeping with ethical medical care.

          • KarenJJ
            March 30, 2015 at 10:07 pm #

            “it’s like taking one aspect of care and promoting it”

            But why choose “normal birth” to promote. Apart from using a value-laden term like “normal”, leaving the other mothers feeling like they have had “abnormal” births, why would a midwife care how the birth actually goes? If the baby and mother are happy and healthy afterwards, what would be the improvement made if they’d done it more “normally”?

          • Realitybites100
            April 1, 2015 at 9:08 am #

            I wanted a repeat c section also. Was forced into an unmedicated VBAC (15 months after the surgery.) Wish I was more educated at the time so I could have advocated for myself. In hindsight I am grateful for the experience just because I enjoy knowing both sides of birth. It does however make me wonder about all these women who carry on about the experience, who feel they failed if they ended with a section, and who have staunch birth plans. I guess I feel they really hurt themselves with such high expectations. In my opinion… In the end it really didn’t matter how I gave birth. As long as everyone survived and was healthy it just didn’t matter to me. One wasn’t better then the other. Each were great and difficult in their own way.

        • Ash
          March 30, 2015 at 1:48 pm #

          Imagine you go to the hospital because you are having acute pain. The doctor tells you have kidney stones. It is the worst pain you have ever had in your life. It is relentless. You have been in pain for 12 hours. You have no idea when the pain will stop.

          Doctor tells you they have a campaign for normal kidney stones in women. They have a quality control measure in which they are trying to decrease the number of patients who receive pain relief for kidney stones. For patient centered care.

        • The Computer Ate My Nym
          March 30, 2015 at 1:48 pm #

          Another way of looking at it: Supporting a woman in labor so that she doesn’t need an epidural because she doesn’t want an epidural, doesn’t feel the pain is severe enough to justify one, etc seems like a good goal. Putting a quota on it and saying that most women should give birth without an epidural because someone other than the woman in labor in consultation with her providers thinks that most women should not have epidurals is not a worthy goal.

          • Daleth
            March 30, 2015 at 2:01 pm #

            All pain relief in all situations has possible side effects and complications. Why is it only women in labor who are urged to forego pain relief?

            I don’t see dentists warning patients against anesthesia for their root canals, emergency room doctors warning against it for broken legs, etc.

          • Sarah
            March 30, 2015 at 2:31 pm #

            Yeah but some of those patients are male.

          • The Computer Ate My Nym
            March 30, 2015 at 2:54 pm #

            Actually, you kind of do. My step mother came home with no prescription for pain meds after she fell and broke her ankle. It wasn’t a long bone fracture, but still…There is definitely a trend towards trying to minimize pain meds used. That being said, I agree that labor pain is minimized and trivialized because only women experience it. On the other hand (am I on my third hand now?), labor pain varies a lot and if a woman says, “Eh, I don’t feel like bothering with an epidural” I don’t see any need to try to talk her into one. (Of course, I’d say the same thing about someone with a fracture so I guess I’m firmly in both camps on this one.)

          • Daleth
            March 30, 2015 at 3:05 pm #

            Could it be that that type of fracture, once properly treated, is not so painful that you need prescription pain meds? Quite a lot of pain relief is available over the counter. None of it is remotely sufficient for labor, but it may be sufficient for very minor fractures.

          • Guest
            March 30, 2015 at 3:13 pm #

            A recent study just showed that ibuprofen provides BETTER analgesia in long bone fractures than narcotics.

          • The Computer Ate My Nym
            March 30, 2015 at 3:15 pm #

            Do you have a link? I haven’t seen it, though it would make sense given that the pain is at least partly inflammatory.

          • Somewhereinthemiddle
            March 30, 2015 at 4:38 pm #

            I’ve found that to be true for almost every pain I’ve experienced. Most of my pain has been post op stuff, from a burn, that sort of thing so nothing related to a major trauma but in almost every case it has been more effective that the prescribed pain meds.

          • Roadstergal
            March 30, 2015 at 6:45 pm #

            I’ve seen data suggesting that ibuprofen provides equivalent pain relief, and should therefore be preferred as it has less potential for addiction. However, there’s also animal and human data showing that ibuprofen can interfere with bone healing, so I avoided it when I was healing. In favor of ice, mostly. :p I used Norco for about three days after the initial plate and two days after the removal, after which the pain was tolerable.

          • Guest
            March 30, 2015 at 7:25 pm #

            The bone healing studies were in elderly patients and published decades ago. My hospital group did a journal club lit search on this subject in 2012. All but one of the orthopedic surgeons I know thinks that otherwise healthy kids to middle aged adults heal fine with NSAIDs.

        • LibrarianSarah
          March 30, 2015 at 1:49 pm #

          You can’t “support” away intense pain nata.

        • Sarah
          March 30, 2015 at 2:30 pm #

          Have you stopped to consider that denial of epidural also has side effects?

        • EmbraceYourInnerCrone
          March 30, 2015 at 2:47 pm #

          Why is “encouraging women not to ask for or not getting adequate pain relief, when you ask for it, something to strive for (pretty sure if you told a dental patient it wasn’t “really” painful, or to try breathing through the pain, they would have a few words for you) ?
          How would delaying or preventing me from getting ventouse extraction for my daughter due to late decels and meconium been at all helpful? Glad all the interventions were available for my daughter and she has all her brain cells…
          Yes epidural “may” have side effects (for the mother) but being in a LOT of unnecessary pain can have side effects too.
          Also not inducing in the case of non-productive labor can put the baby under more stress for longer, when it wasn’t necessary (especially if the membranes are already broken).

          • namaste863
            March 30, 2015 at 4:00 pm #

            As a matter of fact, I was in this very situation. My dentist wouldn’t give me Novocain, because the cavity “Wasn’t deep enugh.” and to try “Breathing techniques” to ease the “Mild discomfort.” Needless to say, I wasn’t breathing, because I was too busy writhing in pain. It took me five years after that to see a dentist, and needless to say, it was someone else. I told this new guy that I wanted every kind of dope he had, and he was more than happy to oblige.

          • EmbraceYourInnerCrone
            March 30, 2015 at 4:49 pm #

            I have met this type of dentist. I was tempted to borrow the little dental hook and poke him in the privates every time the pain was bad. I didn’t as I didn’t have bail money…

        • Amy Tuteur, MD
          March 30, 2015 at 4:09 pm #

          So you advocate supporting women through appendectomies to avoid the much larger risks of general anesthesia?

          • nata
            March 30, 2015 at 5:01 pm #

            During a surgery the patient is passive, the main aim for the patient is to survive it as painlessly as possible. The labour and birth does require woman’s participation. You trade relative comfort to mobility, more control, easier second stage. You are becoming a patient with an iv line and catheter, tied to the bed. That’s why not everyone opts for an epidural even when it’s readily available and noone considers a non medicalised surgery 🙂

          • Amy Tuteur, MD
            March 30, 2015 at 5:13 pm #

            No, childbirth does NOT require women’s participation. Women in comas can give birth.

            Your avoiding the issue. You claimed that epidurals should be avoided because of potential complications, yet you are perfectly happy to allow pain relief in settings where the risk of complications is higher. Isn’t that hypocritical?

          • Daleth
            March 30, 2015 at 5:24 pm #

            YOU might trade relative comfort for mobility, easier second stage, etc. That’s your choice. Many women would make a different choice.

            Not sure what you mean by “no one considers a non-medicalised surgery.” If you mean no one considers having a c-section when there are no medical indications for it, you’d be wrong.

          • Sue
            March 30, 2015 at 11:37 pm #

            AN interesting thought: is the pain of a quick laparoscopic appendicectomy any worse than a prolonged back labour? Maybe we should encourage the appendicitis patient to avoid the general anaesthetic and just allocate them a support person to reduce the anxiety and breathe through the pain. No post-anaesthetic recovery needed.

        • Who?
          March 30, 2015 at 6:11 pm #

          Isn’t it true though that deciding to not intervene also has side effects? That’s what ‘risk’ is. Risk assessment is about deciding whether the risk from not intervening is different from, and greater or less than, a particular intervention.

          It’s not the case that deciding to not intervene means things go well every time.

        • Nick Sanders
          March 30, 2015 at 11:57 pm #

          That depends, what are the relative risks of side effects from having an epidural versus the risks of not having one?

      • rh1985
        March 30, 2015 at 1:42 pm #

        Exactly what I was just thinking.

      • KarenJJ
        March 30, 2015 at 1:43 pm #

        And what medical complications are they trying to prevent by restricting inductions? Surely inductions would also be preventing issues…

        • nata
          March 30, 2015 at 2:03 pm #

          Are there no complications caused by medical induction? Hyperstimulation of uterus? Fetal distress?

          • KarenJJ
            March 30, 2015 at 2:04 pm #

            So it’s not about being a “guardian of normal birth” but preventing complications? Why don’t they just say that?

          • Daleth
            March 30, 2015 at 3:13 pm #

            Yes. I think they’re perfectly capable of saying what they mean, and they’ve done so here.

          • Sue
            April 1, 2015 at 12:41 am #

            Cos they might have to have their fingers crossed behind their backs?

          • Allie P
            March 30, 2015 at 2:38 pm #

            My induction was ABSOLUTELY preventative medicine. It prevented: stillbirth due to post-dates placental failure, oh yeah, and c-section. It also SOLVED issues, such as the fact that my cervix was not cooperating and I wasn’t going into labor.

          • The Computer Ate My Nym
            March 30, 2015 at 2:41 pm #

            Induction can lead to complications. So can waiting. Neither is innately superior or risk free. Therefore, I don’t see the point in saying that one should be the goal or that there’s a problem if a specific percentage of women do not give birth in that way. If OBs suddenly claimed that there should be a goal of at least X% of women being induced I’d think that pretty weird too unless they presented strong data showing that practices that worked that way had better outcomes.

          • Roadstergal
            March 30, 2015 at 2:44 pm #

            According to the most recent data, term inductions actually improve outcomes and reduce C-sections. So why are they considering reduction in inductions and reduction in C-sections parallel goals, when it seems there would be a trade-off between the two?

            And why are reduction of certain procedures considered goals, rather than goals relating to positive health outcomes for women and children?

          • Montserrat Blanco
            March 30, 2015 at 3:10 pm #

            If you get to the point to recommend an induction it is because those risks are less than the risk for mother or baby if the pregnancy continues. That is why you recommend a procedure in the first place. Sometimes I do recommend procedures and they are unlikely to be risk free, but I know the risk is less with than without the procedure.

            So no, inductions are no risk free but they are less risky than the alternative even if you take those risks into account.

          • Amy Tuteur, MD
            March 30, 2015 at 4:12 pm #

            Far preferable to the common complication of normal vaginal birth: a dead baby.

          • nata
            March 30, 2015 at 4:19 pm #

            so, the idea is to reduce the need for induction or augmentation, not deny the induction when it is needed.

          • Mariana Baca
            March 30, 2015 at 4:56 pm #

            Again, *how* do you reduce the need for induction or augmentation?

          • fiftyfifty1
            March 31, 2015 at 8:30 am #

            “Again, *how* do you reduce the need for induction or augmentation?”

            By helping women be less uptight I guess.

        • nata
          March 30, 2015 at 5:43 pm #

          How interesting. I have never participated in discussions, but have read a lot here. Doctor Amy has always emphasized that only natural birth junkies delete posts they don’t like. I replied here. The whole thread is gone 🙂 ha.

          • Amy Tuteur, MD
            March 30, 2015 at 5:47 pm #

            NOTHING has been deleted. There lots of comments and you may not have looked carefully to find the thread you are referring to.

          • nata
            March 30, 2015 at 5:51 pm #

            You are right, I got lost, sorry for that comment.

          • March 30, 2015 at 7:01 pm #

            You’ll note that she also won’t delete your comment accusing her of deleting comments.

      • The Computer Ate My Nym
        March 30, 2015 at 1:44 pm #

        Natural dentistry. Natural appendectomy. Really, why? We’ve got good drugs for acute pain. If they were trying to find alternate ways to deal with chronic pain, which is a real mess to treat medically, there might be some point, but acute pain? Just…why?

    • Daleth
      March 30, 2015 at 1:56 pm #

      What complications are prevented by denying women pain relief in labor? The graphic that Ash posted defines “normal birth” as ones in which the mother got no anesthetic. If you go on UK mothering forums, you’ll hear a lot of stories from women who repeatedly asked and even begged for an epidural but were denied it. Apparently the goal of getting to count a traumatized woman’s agonizing birth as “normal” because she was denied anesthetic is an important goal for the NHS?!

      • nata
        March 30, 2015 at 4:16 pm #

        The official policy is clear: women in labour should not be denied pain relief. What happens in real life is different from place to place, like in any other service.

        You can also read a number of stories when the women were “bullied” out of homebirth if they had a risk factor or into having a c section or induction. Level of care and women’s perception, hospitals differ. They also differ worldwide and even US wide. The difference is that the UK for some reason is quite transparent: the government reports can be found online and openly analysed and criticized.

        I personally agree, the poster above does look as a suggestion that the midwives are encouraged to improve amount of non-medicalised births, but keeping in mind the requirements for women centered care, it should not be done by declining pain relief. For example, women labouring (not necessarily birthing) in water in a homelike environment are less likely to ask for one than the woman left lying on her back (the most painful position) on her own in a cold brightly lit hospital ward. The idea behind promoting normal birth is to increase women’s own capacity to cope with pain, not to deny the pain relief when she needs it.

        • Amy Tuteur, MD
          March 30, 2015 at 4:24 pm #

          Claiming to be guardians of normal (ie unmedicated) birth is utterly incompatible with allowing easy access to epidurals.

          • Woolie
            March 30, 2015 at 6:10 pm #

            It seems that there is very little insight into the role of the midwife in the UK. The vast majority of midwives are employed by an NHS trust and tend to be either hospital or community based. Ideally a pregnant woman is booked for maternity care from about 8/40 and risks identified at this point as to whether care will be midwifery or obstetric led, and a schedule of care based upon this. At any point, antenatally, intrapartum or postnatally, care can be transferred to the appropriate caregiver. I currently work on a busy obsteric led labour ward, with an alongside midwife led unit. Women are given the option at booking (if they are considered to be low risk) of where they would like to give birth. Thresholds for transferring are very low. Maternal request for epidural, you transfer. Delay in first or second stage, you transfer. Any pv bleeding, you transfer. Mum wants to transfer, you transfer. I’m sure you get the idea. A typical scenario on my Labour Ward (at night or weekend) would be 7 midwives, 1 Registrar and a senior house officer caring for up to 14 labouring or immediately postpartum women. The Obstetricians have to rely heavily on mid wives for alerting them to any concerns or potential problems. Thankfully, we work very much as a team with our Obstetric colleagues, which is the way it should be to ensure the best outcomes for mums and babies. Apologies for my ramblings. Just finished a run of nights.

          • Daleth
            March 30, 2015 at 6:12 pm #

            Only 7 healthcare professionals for 28 patients (14 moms and their babies)?! That hardly seems sufficient, at least not if more than, say, 5 of the women are in labor.

          • Liz Leyden
            March 31, 2015 at 2:38 pm #

            That’s 2 couplets (mother and baby) per nurse.

          • Woolie
            March 30, 2015 at 6:25 pm #

            7 midwives plus a co-ordinating midwife and a neonatal team (based in the attached NICU). We also have 2 maternity support workers. One midwife is usually allocated to a 4 bedded observation bay, where there may be women on MgSO4, women in threatened in pre term labour or women post section. This is exactly why we have to have good working relationships with our obstetric colleagues and certainly no personal agendas.

          • AllieFoyle
            March 31, 2015 at 3:17 pm #

            All that transferring seems like an inconvenience and waste of resources to me, especially in a system that is already understaffed and pressed for resources.

          • Woolie
            March 31, 2015 at 6:19 pm #

            You’d think so but the transfer rate is actually less than 10% and feedback from women using the birth centre is overwhelmingly positive.

        • The Bofa on the Sofa
          March 30, 2015 at 4:54 pm #

          The official policy is clear: women in labour should not be denied pain relief.

          The graphic posted by Ash includes the definition of “normal birth” as given by the self-proclaimed guardians of it. That is what THEY claim to be guarding, so who cares about any vague “official” policy.

          They claim that normal birth does not have an epidural. If you disagree with that assessment, you are most certainly invited to call them on it.

        • Mariana Baca
          March 31, 2015 at 12:11 pm #

          “You can also read a number of stories when the women were “bullied” out of homebirth if they had a risk factor ”

          If they have a risk factor, they should not be *eligible* for homebirth, that has nothing to do with bullying. Similarly, if they have a risk factor that recommends induction or c-section, that is not bullying but a medical recommendation.

        • Mariana Baca
          March 31, 2015 at 12:29 pm #

          “The idea behind promoting normal birth is to increase women’s own capacity to cope with pain, not to deny the pain relief when she needs it.”

          Ok, so… I have means of coping with the pain of migraine — a dark, silent room, an ice pack, a warm shower or bath, trying to sleep. I would do these things when Advil didn’t cut it for my migraines. Then I had a migraine that landed me in the ER because I was vomiting from the pain uncontrollably. Then I discovered Sumatriptan (and other triptans). And you know what? I don’t see the need to wait until I have a migraine “I can’t cope with” and “need” to take medication. I just take it as soon as I realize regular painkillers and hydration won’t do the trick (sometimes, if I feel it will be bad, I don’t even wait that long). Coping with the pain is pointless and wasteful.

          Now, are there unpleasant side effects to triptans that make me not want to take them? Sure, I don’t like the body feeling, weird sensory effects and it makes it feel like someone stuffed my head with cotton. If I feel the migraine is mild and have stuff to do I wait a bit sometimes. But only if the side effects outweigh the pain. As soon as the balance shifts, there is no reason for me to “cope”.

          For some women, pain in childbirth is tolerable and might be less of a hassle than needles, calling the anesthesiologist, catheters, risk of headache, etc. But if they start needing to do complicated things to “cope” like being immobilized in a bathtub, being alone in a dark room, it starts to sound a bit like “trying to cope with the pain of a migraine”. Yes, for some people, epidurals don’t work or they are allergic and it is good to have alternatives for them to cope. Similarly, triptans don’t cure some people’s migraines and they need to cope. But there is no reason to “cope with pain” if you don’t want to. Nor should women be convinced that this is in any way desirable.

          • Sue
            April 1, 2015 at 12:38 am #

            Snap! I was the same with migraine, having to lie down for a day or occasionally two, with vomiting, until I discovered the Triptans. Now – an hour or so, and the attack is aborted.

            How does it make sense to “increase women’s own capacity to cope with pain” rather than relieve it?

    • attitude devant
      March 30, 2015 at 3:20 pm #

      nata, you seem thoughtful and I appreciate your posting here. If I could gently say that the whole idea of one type of birth being more “normal” than another is philosophically suspect. What is ‘normal’? Is normal just what we would all hope for, a timely and spontaneous onset of labor with no augmentation needed, pain that is manageable, and no operative approach needed? What percentage of women fall ‘normally’ into that category? Those moms are fortunate, but certainly not any more ‘normal’ than others. And withholding needed treatment does not make other pregnancies ‘normal;’ it just leads to unnecessary pain and potentially worse outcomes. Therefore, why ‘guard’ birth at all? We don’t get to choose between an easy timely labor and a difficult labor—-these things happen or they don’t.

      • nata
        March 30, 2015 at 6:17 pm #

        Thank you for encouragement

        I guess I believe it is possible to manage some mainly psychological factors that can reduce chances of complications. If you look even at the RCM pages on supporting normal birth, it’s meraly about simple stuff like privacy, encouraging mobility, reducing anxiety. http://www.rcmnormalbirth.org.uk/ For a better chance of a nicer birth. Noone ever advocate for withholding treatment, even an epidural, this would be against the code. The midwives who did this are just wrong and would get in trouble with the NMC

        • attitude devant
          March 30, 2015 at 6:18 pm #

          Please provide evidence that psychological factors cause complications.

          • nata
            March 30, 2015 at 6:43 pm #

            I guess it’s too late for me to search for it now, may be tomorrow. What I can say from the head – there were a number of studies that one to one support say reduces length of labour and reduces likelihood for cs for failure of progress. So comfort measures can make a difference in progress. More tomorrow if I have time. Or maybe dr Amy ventures to write a post on it and then we could argue the points from all sides.

          • attitude devant
            March 30, 2015 at 8:09 pm #

            Saying that one-to-one support decreases c/s is not the same thing as saying psychological factors cause complications. Frankly I know the research, and there is no support for your claim. Barring such severe mental illness that a patient is a danger to herself or others, there is no data to suggest that psychological factors increase the c/s rate or the PPH rate. Women don’t cause these things by thinking negative thoughts, you know.

          • Laura
            March 30, 2015 at 10:02 pm #

            I understand and appreciate what you’re saying. I would be interested in reading more if you could elaborate more specifically on what you’re saying. My last OB who had been practicing over 20 years observed that mothers-in-laws in the delivery room seemed to complicate births in his experience. I didn’t ask specifics, but I was curious what he had actually seen. I also appreciate what others are saying as well and wonder if there’s room for both “sides” to have legitimate points.

          • Linden
            March 31, 2015 at 10:20 am #

            Also that “privacy” is a psychological factor that impedes birth, but somehow excruciating pain isn’t.

            Please do tell me that I gave two figs about who saw what, while I was in agony before I got my epidural.

        • Amy Tuteur, MD
          March 30, 2015 at 6:20 pm #

          But they’ve done it, babies have died and they haven’t gotten in trouble with the NMC or anyone else.

          • nata
            March 30, 2015 at 6:31 pm #

            how are you so sure?

          • Amy Tuteur, MD
            March 30, 2015 at 7:11 pm #

            Because I follow the blogs and social media accounts of the major midwifery figures and organizations, not to mention mainstream media publications.

          • nata
            March 31, 2015 at 9:30 am #

            There is no much information on the actual midwives on the case. I looked up Jeanette Parkinson, the manager mw involved – she is not practicing anymore. I think we will hear about the actions taken on those responsible. As I’ve mentioned before, it is interesting how British system is transparent and so much could be found online.

        • fiftyfifty1
          March 30, 2015 at 8:12 pm #

          Yep. The belief at the heart of today’s midwives: If your birth goes sideways it’s because you were uptight.

          How much longer are women going to have to put up with this misogynistic bullshit? And from other women!

    • Amy Tuteur, MD
      March 30, 2015 at 4:07 pm #

      How do midwives prevent pre-eclampsia, or breech, or a true knot in the cord, or abruption, or postpartum hemorrhage?

      • nata
        March 30, 2015 at 4:31 pm #

        The midwife can reduce the likelihood of pph or abruption if you manage to avoid augmentation when labour stalls due to simple reasons like stress. So the point of the campaign is to improve midwifery care to reduce some complications. Not to prevent them from happening altogether.

        • Mariana Baca
          March 30, 2015 at 4:38 pm #

          If labor stalls, wouldn’t things like pitocin or an epidural help reduce stress or move labor along? (Or I guess my question is, what tools do midwives use to move along stalled labor?)

          • nata
            March 30, 2015 at 4:44 pm #

            but is it better to avoid labor slowing down altogether?

          • Amy Tuteur, MD
            March 30, 2015 at 4:46 pm #

            You like to pretend that all complications are iatrogenic. They’re not.

          • nata
            March 30, 2015 at 4:48 pm #

            some, not all

          • Montserrat Blanco
            March 30, 2015 at 5:30 pm #

            Where is the peer reviewed paper that demonstrates that???? Please provide one recently citation, peer reviewed journal, impact factor higher than 5.

          • nata
            March 30, 2015 at 6:11 pm #

            I think everybody agreed above that use of pitocin sometimes can have adverse effects on the mother and the baby? Hopefully I get away without roaming journals and guidelines? 🙂

          • Amy Tuteur, MD
            March 30, 2015 at 6:16 pm #

            Again, you refuse to acknowlege that iatrogenic complications are only a small portion of complications and tend to be less dangerous than many other obstetric complications.

            The job of midwives is not to guard normal births; it is to guard the lives of mothers and babies. If their preference is to guard normal birth they should not be healthcare providers; they should find some other profession where they won’t kill people while attempting to satisfy their personal preferences.

          • SarahSD
            March 30, 2015 at 6:33 pm #

            Dr. Amy, I would love to see a post that lays out some of the research on iatrogenic complications in childbirth, as they are the cornerstone of the “cascade of interventions” narrative. Despite considering myself somewhat ‘reformed’ from the NCB model, I still harbor reservations about how liberally some interventions are used in certain contexts, and would like some insight into the decision-making process around when and how strongly an intervention is indicated. I’m sure this varies depending on provider and case/patient, but some generalizations are probably possible.

          • nata
            March 30, 2015 at 6:37 pm #

            May I join here – would be lovely to read a post on it, supported by literature of course :p

          • Laura
            March 30, 2015 at 9:56 pm #

            I would be very interested in reading that as well!

          • Sarah
            March 31, 2015 at 6:30 am #

            I can well believe that the cascade of interventions is sometimes a thing. It’s just that we don’t hear enough about the cascade of non-interventions. Which is also a thing. Additionally, sometimes earlier intervention prevents subsequent, more drastic intervention- ie in the UK, induction at 41 weeks reduces the EMCS wait.

          • Amy M
            March 31, 2015 at 8:13 am #

            Well, I know anecdotes aren’t data, but I can tell you that pitocin augmentation and an epidural prevented a C section in my case—and I had twins. (Usual disclaimer: I had/have no issues with Csections, but was reluctant to have surgery knowing I would have two infants to care for while recovering. Had anything been amiss, I would not have hesitated to agree to a Csection.)

          • SarahSD
            March 31, 2015 at 5:19 pm #

            I understand that, in principle, preventive medicine will catch and intervene in more pregnancies than it ‘needs’ to in order to prevent the complications or bad outcomes that it does catch and prevent. The question is, and I think this is the concern of many midwives and mothers seeking to “guard normal birth”, when will we know if we have passed the level of ‘just the right amount’ of intervention, and lose the possibility of childbirth without medical intervention? Is childbirth so inherently risky that a heavily interventive birth is always safer than a low- or no- intervention birth? Is a woman who comes out healthy with a healthy baby in a low or no-intervention birth (even in hospital) just getting lucky? Like with arguments about the ideal c-section rate, it can be hard to determine which interventions were necessary in hindsight, or to decide on what c-section/intervention rate is appropriate. And it’s problematic to assume that such a rate would hold in all contexts. But since interventions are not themselves risk-free, it makes sense to try to sort out how often they are really needed.

            I don’t think that “natural” childbirth is superior, but I do think that it’s reasonable to expect that some women would prefer that choice if the conditions allow. Many hospitals are working to keep this an option, sometimes by having CNMs and in-house birth centers, etc, but many women face a high likelihood of an interventive birth just because that is how their particular hospital tends to practice (hence being advised to stay home as long as possible in order to avoid medical interference). How does a particular hospital or practice’s ‘culture of risk’ dictate how widely they cast the preventive medicine net? And is the use of intervention in every case evidence-based or preventive? If not, what are the other factors that guide the use of intervention – maternal request? Workplace routine? And is it possible, through detailed analysis, to hone in on the line between indicated/necessary and unnecessary? We know about the outcomes of the extreme NCB approach, but what about the grey areas in between ultra-medicalized and less so?

          • Amy Tuteur, MD
            March 31, 2015 at 6:25 pm #

            Future technological developments should help us reduce interventions, but if we want to prevent complications, there will always be women who receive interventions who didn’t need them in retrospect.

            Technology may help in a variety of ways. Right now, the best method for determining whether a baby is tolerating labor is to monitor its heart rate; that is both indirect and relatively crude. What we really want to know if what the baby’s oxygen levels are and that will almost surely be possible in th future.

            Better imaging technology may allow us to make better predictions about which babies will fit and which babies will be born without injury from the breech position and it may help prevent shoulder dystocia.

            It is the nature of screening tests, however, that no matter how much they improve, they will always be balancing the risk of overdiagnosing problems vs. underdiagnosing them.

            The key point, in my judgment, is that there is nothing inherently valuable about “normal birrth.” In nature people didn’t eat with utensils. Does that mean we should feel guilty about using a spoon because it isn’t “normal” eating? I don’t think so and I suspect no one else thinks so either. The same thing applies to birth. There’s nothing valuable about recapitulating nature, which naturally leads to a great deal of death in childbirth.

          • SarahSD
            March 31, 2015 at 6:40 pm #

            Thanks for your response. Just as there’s nothing inherently good about “natural” childbirth, there’s nothing inherently bad about technology. It is a good reminder. And I think we both agree that human beings are characterized by our ability to create non-natural things – language, built environments, and technology.

          • Sue
            April 1, 2015 at 12:30 am #

            I’d also like to see the research on the role of “stress” or “emotional factors” on the progress and outcomes of labor.

          • toni
            April 1, 2015 at 1:06 am #

            extreme stress can bring about premature labour, right? http://download.bioon.com.cn/upload/201111/23175321_1439.pdf (search maternal-fetal stress) it seems plausible to me at least that being very frightened in labour could put the baby in distress as well but idk. if your blood pressure goes up really high maybe.

          • Roadstergal
            March 30, 2015 at 6:28 pm #

            Maybe it sometimes can, but it seems it generally doesn’t?
            “Pregnancies exposed to the regular use of preventive induction (n = 1153), as compared with pregnancies receiving the current standard approach (n = 1865), experienced a lower caesarean delivery rate (5.7% versus 14.4%; relative risk 0.39, 95% CI 0.31-0.50; I2 P = 0.21), a lower neonatal intensive care unit admission rate (2.9% versus 6.5%; relative risk 0.45, 95% CI 0.31-0.65; I2 P = 0.57), and a lower weighted adverse outcome index score (2.8 versus 6.1).”

            “There was a reduced risk of fetal death (RR 0.50, 95% CI 0.25-0.99; I(2) = 0%) and admission to a neonatal intensive care unit (RR 0.86, 95% CI 0.79-0.94), and no impact on maternal death (RR 1.00, 95% CI 0.10-9.57; I(2) = 0%) with labour induction.”

            “Compared to delivery at a later gestational age, those induced at 39 weeks had a lower risk of cesarean (adjusted odds ratio [aOR], 0.90; 95% confidence interval [CI], 0.88-0.91) and labor dystocia (aOR, 0.88; 95% CI, 0.84-0.94). Their neonates had lowered risk of having 5-minute Apgar <7 (aOR, 0.81; 95% CI, 0.72-0.92), meconium aspiration syndrome (aOR, 0.30; 95% CI, 0.19-0.48), and admission to neonatal intensive care unit (aOR, 0.87; 95% CI, 0.78-0.97)."

          • nata
            March 31, 2015 at 8:57 am #

            So according to the evidence, usually the widespread statement that inductions increase c section rates compares inductions to spontaneous deliveries at the same gestation. So it has been proved the woman who does go into labour spontaneously at term is less likely to have a c-section than the one who is induced at the same time. ex:
            CONCLUSION: Labor induction is significantly associated with a cesarean delivery among nulliparous women at term for those with and without medical or obstetric complications. Reducing the use of elective labor induction may lead to decreased rates of cesarean delivery for a population. (Obstet Gynecol 2010;116:35-42)

            The newer studies you quote compare the induction to expectant management. According to these studies, the longer we wait, the more likely the woman might end with a section. However, according to the most recent publication in BJOG, the benefits of early term inductions are inconclusive:

            “Additionally, there has been no large modern trial of induction versus expectant management at 39 or 40 weeks of gestation, i.e. the equivalent of the Hannah trial of induction versus expectant management that was conducted at 41 and 42 weeks of gestation.[19] Until such a large modern trial is conducted, I would not routinely recommend induction of labour prior to 41 weeks of gestation”. Caughey A. Induction of labour: does it increase the risk of cesarean delivery? BJOG2014;121:658–661.

            In England the aim is to facilitate delivery before 42 weeks. The induction does start at 41wks by a sweep and progresses to prostaglandin, AROM and pit. Midwives are key people providing this care.

            I think if we talk about promoting normality and reducing inductions, like in the poster – again, the point is not in refusing intervention, but in reducing a need in one. The midwives cannot say magic words and make everyone go into labour at proper time. They do not encourage women to go overdue. However, if we promote maternal health – for example support the woman into improving lifestyle habits, this in turn might improve her chances of not getting conditions like gestational diabetes, high blood pressure. This in turn could reduce the necessity of early induction for these causes.

          • fiftyfifty1
            March 31, 2015 at 9:13 am #

            “In England the aim is to facilitate delivery before 42 weeks…[…]…Midwives are key people providing this care”

            But see, my aim as a mother was to get my baby out alive and me healthy. End of story. Avoiding induction was meaningless to me. It’s not about the process. It’s about my baby.

          • fiftyfifty1
            March 31, 2015 at 9:19 am #

            “According to these studies, the longer we wait, the more likely the woman might end with a section. ”

            AND the more likely she is to end with a dead baby (twice as likely) and meconium aspiration (3 times as likely).

            Avoiding dead and damaged babies? THESE are the goals that matter to women. Avoiding an IV? Avoiding pitocin? not so much.

          • Cobalt
            March 31, 2015 at 9:35 am #

            “However, if we promote maternal health – for example support the woman into improving lifestyle habits, this in turn might improve her chances of not getting conditions like gestational diabetes, high blood pressure. This in turn could reduce the necessity of early induction for these causes.”

            This really resonated with me, and I’d like to explain why.

            I am a healthy, physically fit person. I care for and ride horses for a living, along with general labor on our farm. We raise our own chickens, ducks, and eggs, along with most of our vegetables and some of our fruits.

            I gained a total of 13-15 pounds while pregnant, and started at a healthy weight. I stayed reasonably active, watched my nutrient and vitamin intake, did everything right.

            I still got gestational diabetes in two pregnancies (out of four). I still got high blood pressure in two pregnancies (one I had both!). And in my last pregnancy, my baby needed to come a little early, and when the placenta was delivered it was easy to see why. It was full of calcifications and clots. I had a manual evacuation of my uterus to get the parts that, having failed to kill my baby, were having a run at me.

            Waiting would likely have ended in a stillborn son, and there was no amount of diet that would have changed that.

          • Montserrat Blanco
            April 1, 2015 at 1:09 am #

            I would love to hear how you can support someone to do not deliver preeclampsia during pregnancy and how that would be different from an OB care. As I said again, paper published on a peer reviewed journal impact factor higher than 5.

            I would love to hear it because the midwife that I had two consultations with during my pregnancy was completely useless in that aspect. My OB was the one ordering tests and worrying about my blood pressure and prescribing me drugs in order to lower it.

          • Montserrat Blanco
            March 31, 2015 at 1:27 am #

            Well I assume you use pitocin as any other drug under the sun. When I prescribe a treatment I do it in the knowledge that it has (at least statistically speaking) less side effects than the condition I am treating. I include pain in this affirmation. Please do provide evidence that interventions have more side effects than doing nothing.

          • Mariana Baca
            March 30, 2015 at 4:50 pm #

            You aren’t answer *how* you would do this as a midwife. If a woman is having contractions for days, and is exhausted, and labor is not speeding up, an epidural might be just the thing to get her to sleep a bit and have energy to labor and give birth (true story!). Conversely, positive reinforcement and no pain relief will only make her more tired and more likely to need a c-section.

          • LibrarianSarah
            March 30, 2015 at 5:09 pm #

            You aren’t answer *how* you would do this as a midwife.

            By whispering sweet nothings into the laboring mothers ear obvious. Don’t you know that sweet nothings and unicorn sparkles solve everything.

          • nata
            March 30, 2015 at 5:28 pm #

            I agree with that. In a situation as you described it’s reasonable. On the other hand if labour progressed well, but slows down due to say lack of privacy (also true story) then restored privacy, understanding and support might be enough.

            Also, if we are speaking about UK, there are clear guidelines regarding prolonged active stage, it is not normal practice to delay necessary augmentation just for the sake of a tick of a box and pat on a shoulder.

          • Mariana Baca
            March 30, 2015 at 6:21 pm #

            So, midwives can advocate for women to get private laboring rooms in the UK? Fair enough. Seems like it should be standard policy, though, I know it isn’t in some places. Not sure how this prevents pph or abruption, though. It may prevent induction, but it doesn’t sound like a situation where induction was going to cause any problems because labor was so speedy.

          • nata
            March 30, 2015 at 6:33 pm #

            Is the privacy only about a private room?

          • Mariana Baca
            March 31, 2015 at 1:01 am #

            I assumed that is what you meant? If you meant not wanting friends and family in the room, while that might be a social problem, it is not really one that requires an official hospital worker to solve.

          • Sarah
            March 31, 2015 at 6:41 am #

            Or instrumental, as in my case.

          • Mariana Baca
            March 30, 2015 at 4:54 pm #

            Oh, are you asking if maybe sometimes stalled or slow labor isn’t good? No, contractions going on for ages or protracted active labor is painful and dangerous for mother and baby and doesn’t prevent PPH or abruptions.

          • nata
            March 30, 2015 at 5:36 pm #

            I answered in the other post. In addition, if it is necessary the midwives can use an epidural and pitocin as well, under the ob’s supervision of course. In an English hospital midwives work as midwives for low risk cases and in a way as ob nurses for high risk. However, the idea of promoting normality is to try and reduce likelihood of that happening.

        • Amy Tuteur, MD
          March 30, 2015 at 4:40 pm #

          You don’t seem to understand that deadly non-iatrogenic complications are far more common than deadly iatrogenic complications. The point is to save women and babies from injury and death, not iatrogenic complications.

          • nata
            March 30, 2015 at 4:47 pm #

            Well, in the ideal world we would aim into avoiding unnecessary iatrogenic complications while getting necessary treatment for non-iatrogenic ones. Wouldn’ we?

          • Amy Tuteur, MD
            March 30, 2015 at 5:07 pm #

            We aren’t discussing the ideal world, are we? Most complications AREN’T iatrogenic, but you don’t seem to have any idea what to do about those. That’s unethical.

        • Roadstergal
          March 30, 2015 at 6:57 pm #

          “The midwife can reduce the likelihood of pph or abruption if you manage to avoid augmentation when labour stalls due to simple reasons like stress.”

          Please see the citations below where term induction reduces negative outcomes across the board vs expectant management. Given that data, why are you advocating for avoiding induction?

  10. moto_librarian
    March 30, 2015 at 1:08 pm #

    You should all try following WeMidwives on Twitter (if you have the stomach for it). They actually tweeted about how a speaker at a conference for midwives described episiotomies as “an assault on women.” Another presenter called breech birth “unusual, not abnormal.” It is patently clear that they have learned nothing from Morecombe Bay, and that they don’t care about poor outcomes. I sincerely hope that th NHS finally does something about it.

    • newmom
      March 30, 2015 at 1:51 pm #

      Wow. Had an episiotomy during delivery and I am pretty sure my wonderful and experienced OB didn’t “assault” me with it but made an informed and experience based decision. healed fast and with zero complications. My sister-in-law gave natural birth and basically tore to pieces and is still having pain a year later. I know it’s all anecdotal evidence but still….

  11. B. B. Walsh
    March 30, 2015 at 12:59 pm #

    I wish that by “Guardian of Normal Birth,” these midwives really meant what I think they want people to perceive: that they want to give women
    who want to have a safe, “positive,” vaginal delivery to have every opportunity to do that. There are actual, safe things they could do to help make this possible. For instance, they could promote prenatal care for underserved women by conducting home visits even at odd hours of the
    night, and arranging for mobile clinics in business and industrial areas as
    well as low income neighborhoods to provide free bp and urine testing. They could help provide women struggling with addictions both common (cigarettes) and more stigmatized (alcohol, illicit drugs) with judgment free pre-natal counseling and healthcare. They could help create a friendly and safe hospital environment by presenting accurate, science based advice while providing comfort and gentle reassurance to patients that their safety and the safety of their child is a paramount concern—and that the team of midwives, nurses and OB is there to help, not push an agenda of any kind.
    All of these things help women and babies, and have the side effect of
    helping increase the likelihood of a live, vaginal delivery. Instead, they put the cart before the horse.

    • Amy M
      March 30, 2015 at 1:06 pm #

      They could work as team members with the OBs instead of engaging in a turf war, and they could recognize the scope of their practice.

      They could provide (and perhaps UK midwives already do this?) post-natal care that goes farther than 6wks pp, and includes mental health screenings. I guess that’s not really normal birth, or any kind of birth, but its still part of the process of new parenthood.

    • Liz Leyden
      March 30, 2015 at 1:11 pm #

      Normal Birth is a retrospective diagnosis. No one knows a birth will be normal until after the baby comes out.

    • MegaMechaMeg
      March 30, 2015 at 1:22 pm #

      There is a pro-life ultrasound truck that circles our planned parenthood with a bullhorn blasting fun facts about their baby having a heartbeat and
      I always thought that if only they were a mobile prenatal care van they could do so much good. They could travel to the mother at a conveniant time, perform standard screening and care and at the very least let the womal know if they need to go to a doctor.

      • The Computer Ate My Nym
        March 30, 2015 at 1:32 pm #

        The problem is that they aren’t doctors or ultrasound technicians and they have absolutely no clue how to read or really even how to perform an ultrasound. I’ve read cases where they tell women all about their “baby” when they’re looking at a (diseased) kidney or talk about the lovely heartbeat on a dead fetus or otherwise give out grossly incorrect information. So, no, they couldn’t do much good that way, unfortunately.

        • MegaMechaMeg
          March 30, 2015 at 1:51 pm #

          I know THEY are not qualified. Hell there is one who shakes a doll at me on the regular and says the abortion doctor wants to eat my baby. But in terms of cost the equipment and transport can’t be cheap, a couple qualified techs would be able to do some actual good in the world with the same equipment.

      • Medwife
        March 30, 2015 at 8:34 pm #

        40 days for life is over in less than a week! It can’t come soon enough. At least this year there is an absence of posters with dead 20 week fetuses on them, where I live anyway. They piss me off every morning (my office is next door to a Planned Parenthood).

        • MegaMechaMeg
          March 30, 2015 at 9:44 pm #

          Last year during our endless winter of polar vortex the protesters were bringing their babies and toddlers out and I just felt so terrible! Those poor shivering kids just broke my heart. Ithe dogs are just as bad too, once I crossed the line to let the family know their dog had ear mites and give them some inexpensive reunified if they couldn’t afford the vet. It was weirdly surreal.

          • Spamamander
            March 30, 2015 at 11:50 pm #

            Around here it was people out in the 95+ degree heat, on the blacktop, with their little ones in strollers. “We’ll make you complete your pregnancy- don’t mind us neglecting our born children!” Grrrr.

          • MegaMechaMeg
            March 31, 2015 at 9:50 am #

            I know it isn’t fair, but the families always creep me out. The kids look so scared and bored and the women are so weirdly silent and the men just glare at you in this weirdly posessive way like they want you to be pregnant RIGHT NOW… I could be projecting but it just gives me the worst sinking feeling like they are trying to implement some kind of Attwoodian horror fest.

          • The Computer Ate My Nym
            March 31, 2015 at 10:55 am #

            it just gives me the worst sinking feeling like they are trying to implement some kind of Attwoodian horror fest.

            They are. And it’s working. Look at the poor woman who was just sentenced to 20 years for having a miscarriage. Or the “religious freedom” laws in Indiana.

    • The Computer Ate My Nym
      March 30, 2015 at 1:37 pm #

      Again, assuming that they know what they’re doing well enough to be helpful and not harmful. For example, that they didn’t go out and tell pregnant women to cure their pre-eclampsia with diet or that gestational diabetes wasn’t real or any of the other things that people presenting themselves as midwives have been known to do.

  12. KarenJJ
    March 30, 2015 at 12:31 pm #

    The “guardians of normal birth” sound a lot like the “guardians of normal eye sight” or the “guardians of walking”… It just sounds like ableist bullshit to those of us on the “abnormal” spectrum…

    • MegaMechaMeg
      March 30, 2015 at 12:32 pm #

      It kind of sounds like Guardians of the Galaxy to me, but I am also kind of into Chris Pine.

      • iris
        March 30, 2015 at 12:57 pm #

        Chris Pine wasn’t in Guardians, that was Chris Pratt. Pine has not been in any of the Marvel movies, just Chris Evans and Chris Hemsworth.

        Sounds like you are confusing Star Trek and Guardians of the Galaxy 😉

        • MegaMechaMeg
          March 30, 2015 at 12:58 pm #

          I am terrible at everything 🙁

          • iris
            March 30, 2015 at 5:54 pm #

            No, there’s just too many ^$@& guys named Chris in Hollywood. They should all be forced to change their names to something different, or to only go by their surname.

            So…inquiring minds must know – is it Chris Pine or Chris Pratt you’re into? 😉

          • MegaMechaMeg
            March 30, 2015 at 9:48 pm #

            Oh god, do I have to choose? They each hold a piece of my heart.

            I actually googled to make sure I had the right name and was so blinded by pretty that I screwed it up.

      • Liz Leyden
        March 30, 2015 at 1:04 pm #

        Groot’s line would be “Variation of normal.”

        • MegaMechaMeg
          March 30, 2015 at 1:18 pm #

          A wall of space midwives stopping the evil world destroying birth intervention from reaching the plant/laboring woman.

  13. Laura
    March 30, 2015 at 12:25 pm #

    OT: March 30th is Doctor Appreciation Day. Thank you doctors who contribute to this site and inform and explain so many things to us lay people! I learn so much for the experiences you share as well. And thank you, Dr. Amy, for your tireless advocacy of patient safety in obstetrics.

  14. Mel
    March 30, 2015 at 11:41 am #

    I prefer the term “birth junkie” to describe untrained midwives attending births.

    First, midwives write strangely poetic stories about “blissing out on oxytocin” and other hogwash while attending births.
    Second, the level of fear/caution present during labor/delivery is near zero. Just as a person addicted to meth doesn’t have the time to worry about the purity of the new batch of the drug, midwives don’t have time to worry about potential maternal-fetal dangers during labor and delivery.
    This was brought home to me when Jill Duggar was describing a birth she attended and was shown on TV. First-time mom was entering second stage (and she sounded miserable). Jill says “There was one thing that worried me at that point..” I thought “Maternal BP? The fact the baby is being “monitored” with a Doppler? Position of the baby? Potential hemorrhage?” as she finished “in the birth plan, the Dad was supposed to deliver the baby!” At that point, Mom was lying flat out on her back pushing while holding Dad’s head on her chest.
    Yes, during one of the more dangerous points of delivery, the (possibly teenaged) primary midwife was mainly concerned that the birth plan may not be followed.

  15. Amy
    March 30, 2015 at 11:23 am #

    Oh come on, obstetricians aren’t committed to their patients! They just want to get to their golf game (even in the middle of winter, even if they don’t actually play golf).

  16. Thea
    March 30, 2015 at 11:21 am #

    I read a study from the UK a few years back that concluded up to 75% of all cases of appendicitis could be treated with antibiotics instead of surgery. So why do 100% of patients with such diagnosis get appendectomies?

    It must be that doctors are greedy, want to make their tee-time, love interventions, or are ignorant of science right? We need a website dedicated to “unessiappendectomies” to educate to public right?

    Or, could it be that we currently lack tge technology to predict which group an individual patient belongs to beforehand. Since appendectomies are common, quick and have a short recovery period the surgery is not considered particularly risky and the consequence of being wrong are dire, the Doctor will perform one.

    • DaisyGrrl
      March 30, 2015 at 11:45 am #

      My appendectomy was 10 years ago. I was out of the hospital the next day, and fully recovered within a week. Compare that to the level of monitoring and resources that would be required for the antibiotic people (25% of whom would still end up with surgery, perhaps after developing peritonitis), and the costs (both in terms of healthcare and lost wages) probably still favour appendectomy.

      I’m amazed at how far medicine has come for appendicitis. My great-grandmother died in the 1920’s. My uncle spent 3 weeks in hospital in the 1960’s, my brother-in-law spent a week in hospital in the 1990’s, and here I am with no visible scars! Progress!

    • LovleAnjel
      March 30, 2015 at 1:46 pm #

      The main problem is, you can’t really tell if a case will require surgery until, well, it requires surgery. Doctors would rather catch it before the appendix explodes and fills the abdomen with fecal matter. Doing that means a very high rate of “unnecespendectomies”.

    • Sue
      March 30, 2015 at 11:47 pm #

      That’s a very pertinent example, since the ideological push to minimise procedures (retrospectively) assessed to have been “unnecessary” can lead to some bad practice.

      The concept of the “negative laparotomy” has changed – from being an acceptable part of surgical practice, it has come to be seen as a failure. Now routine abdominal CT scans are taking over, exposing many to unnecessary radiation and surgical delay. We also are losing the art of serial examination and observation due to the pressure to move patients through the system. Laparoscopy is a really good compromise – take a look, take out the appendix if needed. It’s especially good for young women who might have ovarian pain.

  17. namaste863
    March 30, 2015 at 11:00 am #

    I can’t fathom prioritizing some ridiculous notion of what constitutes “Normal” over the lives of human beings. As long as everybody goes home healthy at the end of the day, who cares what it takes to make that happen? It’s downight disgusting that these people believe “Interventions” must be avoided at all costs, but when babies and/or mothers die because the help they need is basically being withheld, these nut cases in essence shrug and say “Shit happens.” That attitude is fucked up beyond all belief.

  18. Cartman36
    March 30, 2015 at 10:49 am #

    What a great article! I love the comment “Their commitment is to the patients they treat, not to a particular method of treatment”. This is SO TRUE. Nurses and doctors (at least at my hospital) don’t care if you get an epidural or not. They only care about making sure mother and baby are safe.

  19. Ash
    March 30, 2015 at 10:39 am #

    An obsession with vaginal birth without medication is fetishistic. It’s gotten even to the point where you see some midwives claiming that women SHOULD NOT lie down on their backs if they want to. Honestly I was slightly amused that the “Born in the Wild” show had (gasp) women lying on their backs! If only they were more in touch with nature!

    Sheena Byrom, you may worship the vagina but stop pushing your religion on the women in your care.

    • Allie P
      March 30, 2015 at 1:04 pm #

      Yes, I recently read a birth story” about a woman who wanted NCB and couldn’t get there, and the amount of time she spent freaking out over the fact that she had to lie on her back for the CS was rather mindboggling.

      • Amy M
        March 30, 2015 at 1:07 pm #

        What position did she want to be in for the Csection? Hanging upside down from a tree?

        • Allie P
          March 30, 2015 at 2:41 pm #

          “I remember being very worried that I had to lie flat on my back, which you aren’t supposed to do in pregnancy, for risk of the baby resting on your aorta and compressing the blood flow to both of you. I imagined coming all this way only to have the baby die because I was lying flat on my back on the operating table.”


      • Ash
        March 30, 2015 at 1:08 pm #


        • Liz Leyden
          March 30, 2015 at 7:32 pm #

          WTF? Now beds are an intervention to be avoided?

          – Highlight the issue; take on a project to move the bed from birth rooms or run a fund raiser to buy alternative birth equipment. Either push the bed away or when you walk into a room with a woman or you sit on the bed so she can’t then you can talk to her about staying off it.”

          So the midwife, who I assume is not in labor, is going to sit on the bed and tell the laboring woman, who is probably in a lot of pain, that she’s not allowed to lie down on the bed? Somehow, I can’t see that going over well.

          “Tell the women when they walk through the door “the bed is only for emergencies, you are not an emergency are you?”

          At which point the woman or her support person will probably tell the midwife to bugger off, and the woman will lie down on the bed.

          • KarenJJ
            March 30, 2015 at 10:11 pm #

            Seriously? That’s fucked up. Midwives are the guardians of giving birth while standing up? Let the woman lie down if she wants to…

          • Melissa
            March 30, 2015 at 11:43 pm #

            It’s funny because when you watch homebirth videos on YouTube a majority of them are birthing on their back. You know, almost like that might have some sort of natural draw for someone who is in pain and tired.

            A family member who was big into the NCB woo had in her birth plan that under no circumstance would she be in a bed. She wanted to be standing or have a birth chair. 20 minutes in she was in so much pain and couldn’t find a comfortable position so the nurse asked her to just TRY the bed. What do you know, it was better! (Of course she ended up with a C-section after a stalled labor so she blames the hospital for letting her get on the bed).

  20. Alcharisi
    March 30, 2015 at 8:37 am #

    “It would be wrong for a surgeon tp posed as a guardian of appendectomy…” should be “TO POSE as a guardian…”

  21. Amy M
    March 30, 2015 at 8:16 am #

    And from working in Pharma, I can say that there are new laws in effect to reduce the bribery/gifting. They limit what can be given to clients (which includes doctors) and every employee here (even those of us in R&D who have never seen a patient or a client/customer) had to receive the training.

    I would hope that things like Morecambe Bay would lead to new legislation, at least within the hospital, in an effort to prevent future incidents. Certainly that has happened in hospitals before—if there was some error that led to injury or death, the hospital takes measures to try to ensure it isn’t repeated. I guess if the people in charge are the same midwives whose ideology led to the problem in the first place, nothing will change. Do those midwives have supervisors? If so, there is hope that things can change.

    • Cartman36
      March 30, 2015 at 10:50 am #

      Don’t take away the pre-natal vitamin samples! Those things are expensive. My OBs office gave me a bag full of samples and that is all I took during my pregnancy.

      • Amy M
        March 30, 2015 at 11:29 am #

        Ha! Yeah, I work in MS research, with mice and cells. I know absolutely nothing about sales, marketing, or bribing doctors to get their patients to take my company’s drugs. 🙂 Which is why I found it odd that I had to get the “no gifts, no samples, no bribes training.”

        • KarenJJ
          March 30, 2015 at 2:00 pm #

          Perhaps someone a bit higher up has had their knuckles rapped and as part of the settlement with the legislative/regulatory body the company has rolled out site-wide training…

          • The Computer Ate My Nym
            March 30, 2015 at 3:16 pm #

            That sounds entirely likely.

          • KarenJJ
            March 30, 2015 at 10:13 pm #

            Spoken from experience…

          • Roadstergal
            March 30, 2015 at 3:54 pm #

            Or it’s just easier to roll out the training to the whole company rather than trying to pick out who might see clinicians and who not, and possibly getting that wrong? Even someone in basic research can come across clinicians while presenting a poster or the like…

      • March 30, 2015 at 12:41 pm #

        And I’ve got enough pens to write at least 25 novels each the length of War and Peace…

        • The Computer Ate My Nym
          March 30, 2015 at 12:48 pm #

          They’ve stopped giving out pens, but I have a number of them left from earlier. Some of them I look at and say, “Now what the heck is DrugName and what is it supposed to be good for?”

          • Amy M
            March 30, 2015 at 12:57 pm #

            I’ll have to pay attention–even though I don’t deal with doctors, etc, I do have order lab materials, and sometimes deal with representatives from companies that make/service the machines we run assays on. I had a ton of pens/fidget toys/t-shirts/calendars/etc from them—I wonder if they have the same restrictions? One of the really awesome pens I got once had a data stick attached.

          • The Computer Ate My Nym
            March 30, 2015 at 1:42 pm #

            Yeah, I remember some of the antibody makers being quite aggressive back when I did mostly lab research. I don’t think that there are the same legal restrictions on PhDs, though I suppose the same potential ethical issues apply. Do you think it influences you?

          • Amy M
            March 30, 2015 at 2:11 pm #

            I don’t know…I suppose I am as susceptible as anyone else to marketing, but also, if I find a product that works, I’ll keep buying it, ’cause why fix what ain’t broke? I don’t have a PhD, but you do? Or you have an MD?

          • The Computer Ate My Nym
            March 30, 2015 at 2:47 pm #

            I’m an MD but I did lab research for about 5 years after finishing fellowship. I suffer from terminal indecision about what I want to do with myself.

          • The Computer Ate My Nym
            March 30, 2015 at 1:43 pm #

            BTW, totally off topic, how do you like working in pharma? I’m considering jumping ship from clinical medicine (again) and wondering about what it’s like on the other side…

          • Ash
            March 30, 2015 at 1:50 pm #

            Whatcha wanna do? Work as a research physician for a clinical trials unit?

          • The Computer Ate My Nym
            March 30, 2015 at 1:54 pm #

            I’m not sure, to tell the truth. Kind of flirting with the idea at this point. I think I’d prefer to work for a pharma firm rather than a CRO since I don’t get the impression that CROs get a lot of input into how trials get designed, at least not at the “the lab people said that drug X inhibits RAS in cells and mice, let’s see what it does to pancreatic cancer in humans” level of decision making.

          • Ash
            March 30, 2015 at 2:00 pm #

            You’re right about the CROs. Some pharma companies do operate their own research units (the big guns) and don’t just use CROs. Device companies are an option as well. Protocol development kinda depends on your CV.

          • Amy M
            March 30, 2015 at 2:00 pm #

            I think you are right about the CRO’s level of input, but unfortunately, the trend right now is to ditch in-house R&D in favor of CROs, because its cheaper for the company.

          • Roadstergal
            March 30, 2015 at 2:54 pm #

            Working for a CRO does suck if that’s your goal. It’s good for people who want the stability of a regular job, good pay, regular schedule, steady work. I have a friend who works for a CRO and likes it on those grounds. I couldn’t.

            I do work in sort of a dream job for my own desires – a friend once told me about a dude he knew who said, “I’m the & in R&D,” which doesn’t mean anything but sounds brilliant, so I appropriate that whenever possible. I work for a biotech company that really believes in biomarkers and has a sincere commitment to it, so I work in just that perfect space of translational medicine where I do have input in how things move from mice to humans, and have many opportunities to do good science all the way through late-stage. I’ve moved away from the bench, and I’m finding I’m happy with that (we have substantial in-house support as well as doing our fair bit of outsourcing). But every biotech has a different attitude towards biomarkers – I worked briefly at a company that seemed to expect us to just pull a perfect biomarker strategy out of our asses at Ph2, and I’ve had friends who worked at places where the balance was more on the other side – I’m finding the place I work, while not perfect, is a good balance of clinical and science for my own desires.

          • The Computer Ate My Nym
            March 30, 2015 at 2:58 pm #

            That does sound fun, though I’m personally more interested in working with drug therapy than biomarkers (except that, of course, at this point biomarkers are guiding therapy pretty much everywhere…which is cool both in and of itself and because it means actual useful therapy in some conditions where we used to have nada, nichts, and squat to offer people.)

          • Roadstergal
            March 30, 2015 at 3:33 pm #

            Yes, it’s all biomarkers, all the time. I hate buzzwords, but there they are – I work for personalized health care. :p The clinicians we talk to are increasingly interested in the full spectrum – prognostic biomarkers, Dx biomarkers, PD biomarkers, surrogate outcome biomarkers. If we can help them determine who will benefit most from the treatment (even if it’s not a cDx), if the drug is having the right effect, and to tell early on if there’s going to be a clinical benefit, it helps everyone…

            I don’t know how the cost analysis will work out. Biomarkers definitely help to kill bad programs early, which saves costs, and I’ve been on some very good kills. They also, I hope, can lead to better efficacy and better quality of life downstream. But they are indeed more expensive to develop and implement!

          • Amy M
            March 30, 2015 at 1:59 pm #

            It has its pros and cons. I worked in a couple of academic labs before this, as a lab tech. I have a lot more autonomy and this has been a fabulous career move for me, because I have learned a ton, and still have plenty of room to learn more. I like the work–I do not have a PhD, or even a master’s degree, but I get to do some hardcore science. I also get paid way better than in academia. I am in a good group–I like my coworkers and my boss is fair and generally a good manager.

            The major downside is the corporate atmosphere. When I started here, it was a smaller, stable,independent company that was more employee friendly and family friendly. The company got bought up by a larger pharma, and assimilated. Now there are layoffs every few years, stupid corporate hoops we have to jump through and its not as employee/family friendly. My impression, from friends in other pharma companies, is that it is same throughout the industry.

    • Roadstergal
      March 30, 2015 at 1:21 pm #

      It’s a good thing and it needs to keep happening. I would be a happy Big Pharma (or reasonably-sized-biotech) shill if I never saw another ad for the latest SMI for asthma or etanercept for everything under the sun…

      • KarenJJ
        March 30, 2015 at 2:21 pm #

        NO NO NO – keep throwing etanercept around – and some of the other biologics. If something else more common sticks they might get cheaper for the handful of us that find these drugs to be a miracle worker.

        That said I’ve currently got $8.5k of biologics crammed into my fridge after an ordering mixup at my new hospital… Surely that would earn me a magnet or something?

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