I work at a teaching hospital with nursing students, medical students, and Residents. As a midwife, my work and responsibilities tend to overlap most with the Residents, at all stages in their Residency, from intern year to the final Chief rotations. At times working with Residents is fun, eye-opening, collaborative, and enjoyable. For me, unfortunately, the majority of times are incredibly frustrating, demeaning to myself as a midwife or midwifery as a profession, disempowering, a bleak look into the future of reproductive healthcare, and validation that the medical education system is broken right along with our healthcare system. I am still navigating this terrain of Residents and Midwives: trying to offer support, laying a foundation with a heavy focus on evidence, and interjecting midwifery mantras and knowledge of normal birth and holistic care. I also experience the Resident’s confusion regarding the similarities and differences in our roles, especially since we both interact directly with the same Attendings, though in different ways. Additionally, our setting is incredibly high volume and high risk, so there is great effort on getting people “delivered” and upstairs to postpartum, and minimal Resident support to acknowledge the birth process. I know many midwives are internalized into medical student and Resident education in some settings, and I would love to hear about what you think works and does not. I attended a session at last year’s ACNM meeting on this specific topic, but found little help in the discussion. For me, for now, as I have experienced it thus far, here are some things that I want talk with Residents about, and often do.
1. You are doing great. I never hear the Attendings say it, I never hear MFM say it, and I never hear Residents say it to each other. I have watched you over the past two years, and your work and learning and struggling is a process, and you’re doing great. Find ways to compliment yourself, focus on what went well, and compliment each other. (I just said “You did great!” to a Resident after a birth she managed completely differently than I would have, but she was always kind to the woman, affirmative, and agreed to skin-to-skin when I prompted it.) Midwives, say this to a Resident you know if you haven’t recently, even if they haven’t seemed to be doing great, and really even if they’re doing terribly. It’s all about growth and process and collaboration, and midwives can do a lot to support Residents in positive ways.
2. You and I are not here doing the same work at the same level. There are actually very important differences to our roles, including our responsibilities, expectations, licensure, and abilities. I work here as an independently licensed provider with completion of my own education and certification, with my own opinions about what might work best in each individual labor. Contrary to you, I do not follow orders given to me by Attendings. Rather, I consult, collaborate, and transfer care as needed.
3. As a midwife, I am not here to make your complicated and busy work as a Resident either easier or more difficult. We are different types of providers with different educational backgrounds: see #2 again as needed. I know that your job is to “run” the board, and my midwife-y practices are confusing to the approach of “get ’em delivered and to postpartum.” Perhaps this makes more work for you, but let’s break this down. No, I cannot do your work in triage when it’s not an emergency, because my hospital credentialing here does not allow it. Yes, I may act as the supervising provider/Attending during your births, and yes, what I say goes during that point in time, just like when an MD is your Attending. No, I am not able to do bedside ultrasounds because my training and added skill set does not include that (yet), so sometimes I will ask you to confirm presentation. Yes, I may have approaches and opinions on how to manage labors and births differently than you have heard before: there is strength in our differences, not weakness in midwifery care. No, just because you have heard an Attending speak down to me does it mean that you can also – it was unprofessional and disrespectful and inappropriate the first time. Yes, I am a fully licensed, independent provider and you are not, so my license is on the line in a way that your education and growth experience just isn’t. No, I will not do something differently because you think my management plan is bad and not moving things along quickly enough – we manage things differently, mostly because of different mantras and educational backgrounds related to pregnancy and birth, and, importantly and respectfully, my next point of contact is my Attending, not you.
4. Many things occur simultaneously when birth happens. Empowerment. Love. Growth. Fear. PTSD. Connection. Disempowerment. Understanding. Pain. Power. Pleasure. Joy. Generations. Adoption. Family. Culture. Happiness. Out-of-body experiences. Panic. Sadness. Relief. Death. Life. Each one of these can be honored and loved and respected. Allow yourself to see and feel and acknowledge these for the people in the room, for yourself as a provider, and for yourself as a person. Even taking a few seconds to validate any or many of these experiences can make all the difference for the individual having a baby, their family, and for yourself. Such is the beauty and struggle of the provider relationship with those we have the privilege to serve.
5. Your practice does not have to be an exact copy of one Attending or Midwife. Each of us practices differently due to style, history, and evidence-informed care, and you get to start developing that for yourself whenever you are comfortable doing so, as long as it is within the realm of safety. The sensitive ways in which we navigate difficult conversations with our patients can also be negotiated in conversations with Attendings and Midwives around why or how you would like to try something differently. The most we/they will do is say “No,” and from what I hear that happens pretty often anyway, so give it a try.
6. I became a midwife for a reason. For many midwives, it is a purposeful decision to study midwifery. I, in fact, like many other new midwives I’ve met, started out studying pre-medicine, and actively switched my focus. I am proud to be a midwife, and believe the reasons for our different types of education and approaches give strength to our specialty. I do not view myself as having become a mini-OB with less skills, versions of which I’ve heard you say. I specialize in normal birth, and am proud to do so. And, despite your comments, I am proud to work as part of your education and integrate midwifery into your obstetrical education care.
7. Just like all doctors are not the same, neither are all midwives. I find generalizations about our different modalities of care important from a macro perspective (see #13 and references to education and practice styles) in being able to discuss ways to improve both types of care. However, from a micro-perspective, any midwife will tell you she has met doctors who practice more like midwives, and vice versa. Personality and approach factor just as much into care as our certification does. I (try not to) generalize to a point of “midwives are great and doctors are bad,” and the most I can ask is that you try to not generalize the same. However, I recognize that we are each practicing within a culture of “me versus you” instead of “us as a team,” so I understand when this is difficult for either of us to grasp. Let’s keep working on that.
8. Language is important. Everything we say matters. “Open your legs” versus “Let me know when you’re ready.” “You’re pushing wrong” versus “Could we try something different with the next contraction?” Additionally, take the time to practice explaining complex things to elementary age children, because if you practice in a low resource population, health literacy will play a big factor in your care provision, and sentences like “Because the baby’s station is so high, and you have polyhydramnios, the MFM is going to consult on how to proceed with your induction” won’t make sense to even to people with advanced degrees.
9. The baby’s head will stretch the vagina as much as is needed, and in the right places. Your fingers pressing down on the perineum or on the side walls does very little to change the speed of labor, and actually research shows it does little in the way of preventing tearing. Try a hands-off approach every so often just to see how it goes. Haven’t heard of the hands-off approach? This means that if she is completely dilated and pushing, don’t touch anything until you push for flexion on the baby’s head. So don’t check inside for the baby’s head again. Do not stretch open the labia. Do not press down the perineum. Do not demonstrate where you’d put an episiotomy just in case you need to. Just wait until the baby’s head needs flexion. Try it. Or watch us.
10. Here is the hierarchy of labor and birth knowledge: Women > the rest of us. Listen when she tells you something is wrong, and consider all possibilities other than “that’s normal, don’t worry”: there might be something going on that her intuition recognizes before our own kicks in. Listen when she tries to change positions while pushing: there might be a reason that her body is communicating. Listen when she says she feels like she needs to push, even if her cervix was 2cm an hour ago: labor is a surprise at every turn.
11. Anything you are thinking of “doing” during labor is an intervention, and there should be a reason before “doing” anything. This includes breaking the water bag, internalized monitoring, pitocin, induction, amnioinfusion, episiotomy, etc. Really think about why to do something before doing it, not just to speed things along and clear the rooms.
12. Episiotomies should be rare. This applies to all labors, including for primips. It’s borne out in research that women heal better, have less chronic pain, and will have fewer deeper laceration extensions with a natural tear. See also: research. See also: midwife episiotomy rates. I understand that certain Attendings prefer an episiotomy, and always instruct you to do so: see #6.
13. This hospital is an island, and our field is small. The provider culture here is unique. The way you witness doctors publicly degrading midwives here is not how midwives and collaborators interact everywhere. You may not stay at this hospital once your training is finished, and think that your experience here is a one-off and you won’t have to worry about our relationship again, but know that the OBGYN field is a small one. How you made your co-workers feel during your Residency will not be forgotten, and will be discussed when your name comes up in the future: by other doctors, by midwives, by nurses, and by medical students. Develop good relationships within our weird culture, even with people with whom you disagree.
14. Consent is a complex and ongoing process. Just because another provider has been assessing cervical change with vaginal exams through the night, the woman consents or does not each and every time someone needs to examine her. Ask every time. Declining medical advice or treatment is always an option and the woman’s prerogative, even after consenting at the beginning of a process (example: labor induction; example: VTOL; example: elective cesarean). Her declining to continue is the opposite of consent, and to do something against her will without medical reason on the logistical end of the spectrum is illegal and on the blatant end of the spectrum is violence.
15. Nipple stimulation is a method of labor induction. No, really it is. Really. Yes, really. (Orgasmic birth also exists, as do many other things unknown to you in the world of normal birth, but I sense that you’re not ready for that yet, so we’ll take this one step at a time).
16. Talk with, not at. Encouraging her to push during a contraction, and then speaking with her in between to compliment her work, to encourage her effort by describing how much progress she’s making, by engaging in thoughts about how soon the baby will be there, is to honor her process as well as complete your task as her provider. To only speak at her while pushing and instructing what she does is not a relationship, it’s a command post. There’s a big difference. So when you hear me speak during the silences, it is because I have looked to see her exhaustion level, have felt her depletion and known that my words and support could bring her back like a tour de force, and that the task will not only be achieved but also be achieved with an atmosphere and intention of woman-centered care.
17. Your opinion matters. You work in this setting more than any of the rest of us. Day in and day out, you already know most of the women who are here, you know the ins and outs of each Attending and Provider’s styles, you know the nurses strengths and support systems. To me, your opinion is invaluable in many regards, and when I ask for it, I really mean it. I consider you knowledgeable not only in the field of obstetrics (while I also am clearly emphasizing my need for you to know #s 1-16), but also an expert on where we work and the culture within our practice. Your opinion does matter to me.
18. Soon you will be interacting with midwives in an independent, collaborative way. I am more than willing to discuss the ups and downs of collaborative relationships between midwives and docs, to critique our work culture, and to encourage your relationships with myself and other midwives. We are already working together, but like with anything, effort is needed to improve our relationship. You and I have many years together, and I want our growth during your learning years to provide you with a foundation when you represent the place from which you were grown.
19. I respect your specialization in surgical birth, and respectfully remind you that midwives are specialists in normal birth.. There is a reason both midwifery and obstetrics exists: the normal deserves honoring and expertise, and the abnormal deserves speed and knowledge. I am thankful to work alongside you, even though I have never heard the same sentiment from any of the MDs working alongside me.
20. Birth is beautiful. It really truly is. Stop and take a moment, when you aren’t doing the million of other things required of you, so that you can remind yourself of that. And if you’re incredibly busy and need a second to enjoy a birth with a favorite patient, let me know: I would be more than happy to help so that you can have that experience. As providers we deserve that, as do all of the women we serve.
I am thankful for our work together. I am thankful that you continue to teach me about relationships between docs and midwives, and especially about the difficulties of Residency and ways in which I can support you. I am a midwife who works with Residents, and however messy and difficult and frustrating it is for both of us sometimes, I love it.