Part 6: Obstetricians are unfairly handicapped by being legally defined as a surgical specialty
Unfortunately for all of us (especially those who pay the bills for maternity care), the current legal ‘standard’ for the surgical specialty of obstetrics is a medical-surgical model of care. Physiologically-based principles of care have not been a legitimate part of obstetrical practice since being defined as medically inferior in 1910.
At that time, Dr. J. Whitridge Williams gave voice to the low esteem that physiological care had in the scheme of obstetrical practice when he said; “That word ‘physiological’ has all along stood as a barrier in the way of progress.” [Twilight Sleep: Simple Discoveries in Painless Childbirth, Dr. H. Smith Williams; 1914, p. 90] The theory and skills of physiologically-based care were never incorporated into the 20th century medical curriculum and are not taught in 21st century medical schools.
Practically speaking, this means the use of physiological management, which is primarily non-medical in nature, is legally a‘substandard’ form of care when provided by an surgically-trained specialist such as an obstetrician. Currently, the principles and practices of physiological management are only taught in midwifery training programs. Until that changes, midwives will continue to be the sole providers of maternity care based on physiological principles.
In far too many places, PHB is the only situation where true physiological management is legally able to be employed. This artificially forces us into a proxy state of mind that appears to pit hospital against PHB. But in a rational evidence-based system, no healthy women should ever have to choose between a midwife and a physician or between home and hospital in order to receive physiologically-based care for a normal birth.
In such a system, the individual management of pregnancy and childbirth would always be determined by the health status of the childbearing woman and her unborn baby, in conjunction with the mother’s stated preferences, rather than the occupational status of the birth attendant or the planned location of care.
Responsible Midwifery for the 21st Century
Responsible midwifery is an integrated model of care. It is able to meet its social obligation to serve and protect mothers and babies while simultaneously protecting the professional capacity of midwives and preserving the reputation of midwifery. In order to meet the biological, psychological, educational and social needs of childbearing families, excellent maternity care needs to be based on the highest level of art and the most comprehensive level of science. It must also be an ever-evolving discipline as new knowledge, new technologies and new thinking come to the healthcare field.
Physiological care as a ‘subtle’ system and independent form of ‘expertise’: Regardless of a midwife’s formal education, responsible midwifery for healthy women rests on the incontrovertible principles of physiological management as the universal standard of care. This ‘whole cloth’ model is organized around pregnancy and birth as a healthy function of normal biology. Obviously, this designation includes ‘first-responder’ emergency skills and equipment, as well as timely access to comprehensive medical care as the back-up plan (Plan B), However, the foundation of physiologically-based, non-medical care –“Plan A”, if you like — is best understood as a ‘subtle’ system.
In regard to healthcare, the word ‘subtle’ describes a supportive structure of normal (non-medical) care. Subtle systems are at one end of the healthcare continuum, while the pathology-focused, macro-level of intervention that defines the practice of medicine are at the other end. In the middle of this caregiver spectrum are integrated types of care and different types of careproviders who creatively blend the best of both (the subtle and the interventive) to suit the circumstances.
The practice of medicine is organized around diagnosing pathology in physical or biological function and implementing a predetermined set of interventions. There is nothing ‘subtle’ about a patient who is unconsciousness, in a coma, hemorrhaging or having seizures. Nor is there anything subtle in the treatment of these dramatic physical symptoms and other evident pathologies, all of which requires the use of diagnostic procedures, medical treatments, drugs or surgery.
This is not to say that some level of subtly is not an aspect of the diagnostic process or provision of good medical care — such subtly is often the mark of true expertise and makes one an “expert” in his or her field. Its just that subtle observations and subtle responses are not the core of the medical process. They are a minor part, or an expression of extraordinary fineness, but not the macro or basic unit of activity.
In direct contrast to the medical model of care, normal physiologic needs are typically detected and responded to via a subtle or ‘micro’ level of patient indicators and caregiver reactions. Physical and psychological needs are, for the most part, detected by subtle visual or auditory clues — the fleeting look of anxiety, pain or surprise that momentarily passes over the mother’s face, a faint hint of perspiration on her upper lip, her hands gripping the bedstead, a moan or low grunty sound that escapes her lips. Depending on the stage of labor, these subtle clues are likely to indicate the beginning of painful contractions in early active labor, the onset of transition labor accompanied by the mother’s feeling of panic or the very first urge to push early in 2nd stage.
A word picture for the subtle nature of supportive care comes from the world of parenting. The mothers and fathers of infants and small children naturally develop the ability to detect the smallest tell-tale sign that a child is about the up-chuck. Since the beginning of time, parents (and nurses) all over the world over have instantly responded by quickly moving the child or turning the baby’s head so it won’t choke and the mess will be easier to clean up. Breastfeeding mothers also respond to a variety of subtle clues that their babies is are either hungry or ready to quit nursing because they are full.
It’s this kind of watchfulness that is at the heart of physiological management as a subtle, non-medical system of care for an essentially healthy population of childbearing women and their newborns. As with parenting and the profession of nursing (as well as driving a car or piloting a plane), one must be present and paying attention in order to see and hear and respond to these subtle indicators — hence the descriptive (as well as legal implications) in the word “birth attendant”. Older medical and midwifery textbooks refer to this quality of waiting and watching as “patience with nature”.
Birth attendants and other caregivers respond to the subtle physiological and psychological needs of the laboring woman by watching carefully, asking the mother about her sensations (what are you feeling now?) and how she feels about what is happening (her emotions). After assessing the situation to be within the normal range for the stage or phase of labor, caregivers provide practical, non-medical support (physical or psychological) as appropriate. Often this nothing more than an a hand laid reassuringly on her shoulder, a word or two of encouragement or explanation, a suggestion that she change positions, get up or move around. These subtle reactions communicate that she and her baby are OK, that she is making progress and it won’t be too much longer before her baby is born.
The temperament required for this kind of ‘patience with nature’ is a large part of what makes a birth attendant good at providing normal care for normal childbirth. Unfortunately, these characteristics are the opposite of the personality traits associated with surgical specialties. Surgeons are trained and paid to make split-second decisions, take quick decisive action, finish up as efficiently as possible and move on to the next most urgent need. If surgery had an unofficial motto, it would be “lickity-split”. In addition, surgery is such a highly specialized field that most of us do not even have a right to voice an opinion about how its practiced. As a result surgeons do not take kindly to having their understanding or judgment questioned.
For professionals who spent hundreds of thousands of dollars and 12-15 years training in the surgical specialty of obstetrics, the idea of sitting in the room with a laboring woman and just watching and waiting for hours and hours is met with the same enthusiasm as watching paint dry. For this reason, physiologic care will likely remain the purvey of non-obstetricians for the foreseeable future.
The role of the midwife is to provide a supportive structure for the physical, mental, emotional, and social needs that accompany this normal (but extremely intense) aspect of reproduction. The goal of this integrated model is to serve the full spectrum of practical needs experienced by childbearing women. This includes guidance and counseling, as well as one-on-one, hands-on support and encouragement and spans the most mundane issues of newborn behavior and breastfeeding at one end to the appropriate utilization of obstetrical or neonatal services as desired by the mother or required by baby.
It should be noted here that community midwifery has far more in common with general practitioners than the specialty of obstetrics. The midwife who provides care in non-institutional setting is generally responsible for the entire ante-, intra-, and postpartum period as well as the immediate and on-going care of the newborn baby and all the issues this entails such as breastfeeding, weight gain, colic and concerns about newborn behavior for the first 6 weeks.
Reproductive biology not perfect: For healthy women with normal pregnancies, absolutely no routine medical or surgical treatment, drug, protocol or procedure can make normal labor and birth better than the process already provided by the normal biology of human reproduction. But reproductive biology is no more perfect that any other aspect of our physical body, which means the risk of complication and emergencies must remain ever-present in the minds and plans of all birth attendants. The incontrovertible principle of responsible midwifery is right relationship between midwives, mothers and the biological sciences, with critical thinking skills at the heart of it all. The invaluable contributions of modern medicine in responding to complications must be enthusiastically acknowledged, which includes appreciation for the vital role of obstetricians, perinatologists and hospital-based care.
To achieve a high level of preparedness, midwifery educators need to intellectually prepare their students to be fully competent in both the art and the science of midwifery. This includes adequate clinical experience in manual dexterity skills, development of clinical judgment skills and the mental toughness to make right use of appropriate interventions or initiate a timely transfer of care when indicated.
There is no shame or blame for either mother or midwife in necessary hospitalizations, but rather a recognition that each person involved in the situation has to deal, as best they can, with the cards dealt by Mother Nature. This is often the opposite of what the parents expected and the midwife hoped for. Nonetheless, a timely hospital transfer and use of comprehensive obstetrical services is not a “failed home birth” or failure of other aspects of the care-giving process. An appropriately timed hospital transfer is a marker of responsible midwifery, to be applauded and appreciated.
Since the birth attendants who provide normal care for normal birth are primarily midwives, the hundred-year history of prejudice by the medical community against physiological management is a burdensome legacy. Unfair as this hard-wired prejudice has been, non-nurse or direct-entry midwifery is sometimes endangered from within by a ‘soft prejudice’ of its own low expectations.
This describes a well-meaning but inappropriately defined role of intrapartum management that is a combination of ‘do-nothing’ and ‘feel-good’ care that parrots platitudes and responds to everything that happens with comments like “that’s normal” and “it’s OK”. But childbirth is no place for magical thinking. This idea of ‘midwifery-lite’ completely misses the crucial role that midwives take on as primary caregivers for childbearing women and their newborns.
Regrettably, Mother Nature presents us with potentially life-threatening situations in 1 out of 10 pregnancies. This number includes the entire spectrum of childbearing women, even those who are healthy and have low- and moderate-risk pregnancies. Midwives are statistically less likely to encounter an emergent situation than obstetricians providing care in an inner-city hospital but like the lifeguard at the beach, our mandate is still eternal vigilance.
A midwife is an educated observer with emergency response capacity. Watchfulness and well-timed access to intervention can make a huge difference for mothers or babies who need help. In the majority of cases, small well-timed actions will correct the problem and successfully circumvent the danger. That is not a place-of-birth issue, nor does it normally depend on high-end technology. But someone must be present and paying attention (hence the original of the phrase “birth attendant”).
In any labor, the midwife must be continually aware of the mother’s childbearing history, current pregnancy status, the size, position and gestational age of her baby, the psychological status of the parents, their religious beliefs, goals and values, as well as the real-time characteristics of her labor, the critical facts of the mother and baby’s immediate biological situation and any diminution of wellbeing for either mother or unborn baby. This is particularly an issue in planned home birth where transfer time must be factored in. This requires consideration of the geography, weather, traffic, distance, financial impact on the family and the level of cooperation (or lack thereof) that can be expected from the staff of the receiving hospital.
This sobering reality requires that all OOH birth attendants be both smart and capable – smart to recognize situations which have the potential to develop into a complication and capable of dealing with unusual or abnormal circumstances in ways that dramatically reduces the likelihood that a low level problem will become a complication that escalates into life-threatening emergency.
Part 7: Part III: Developing “Standard Characteristics” for OOH Studies of Intrapartum Care ~:~
Concluding chapter currently unpublished — link to original publication on the Healthcare 2.0 website
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