Getting Qualified Care: Titles and Education

13 01 2012

This is part of a series called Getting Qualified Care, where we examine the anti natural birther movement of storming the internet to dispel what participants within feel are lies and misinformation about birth. We are discussing just what constitutes quality care from qualified providers, the subtext being “who gets to decide this” — mainly, would you allow other individuals from a movement with their own set of biases choose for you what your standard of care should be?

What makes one “qualified”? Is it a prestigious educational background?

 Maybe it’s a rank or a title, like “Doctor”.

Amy is Harvard educated AND a doctor. Impressive.

Amy informs someone that college and medical background means you cannot disagree with them and possibly know what you're talking about. Interesting. Only a fool would disagree with a doctor!

Here is Amy telling us a Doctor is wrong.

Here is Amy telling us a Doctor is wrong.

Here is Amy telling us a Doctor is wrong.

Here is Amy beginning to tell us that yet another Doctor is wrong.

Don't want to ruin it for you, but, another wrong Doctor, according to Amy.

I could go on, but I think you get the point– Dr. Amy, 5, Other Doctors, 0.

It can’t be the Doctor credential and the years of medical training and background that is making people credible or qualified. Then again, I guess any glance at My OB Said What?! could have shown us that:

Just one example of real-life anecdotes submitted to popular website My OB Said What.

All doctors come to the table and present their “evidence”. How do you know who is telling the truth, especially in a world where we’ve considered that doctors are capable of being flawed?

Maybe it’s in the licensing of that title, to validate it.

Most of the “Fed Uppers” are on a(n in)quest to end midwifery that does not belong to the CNM (certified nurse midwife) category. They believe that all other forms of midwife (usually designated as CPM, or certified professional midwife) are a joke and disservice to women. It needs to be noted here that a lot of this stems from personal bias and bad experiences or trauma the women have faced with natural birth. Differing regions (particularly in the States) have varied regulation in terms of education and practice standards, but in general, much training and years of education are required for one to become a licensed midwife of any title. Yet, one of the main purposes this group claims to promote is eradication of what they deem less qualified midwifery in favor solely of the CNM model. Unfortunately, CNM’s largely practice in birthing centers and in hospitals. What I see as the real goal in mind is the eradication of home birth.

Is a midwife more qualified just for having gone to nursing school beforehand? Is a midwife more qualified for taking a more medical approach to birth? If no other midwife licensing is allowed or considered “qualified”, will that ensure everyone has more qualified care, or will it eliminate options and force women to choose between clinical birth and freebirth? Who gets to decide what kind of care a woman must receive, if not the woman herself? Who gets to mandate which one and only kind of education is valid and acceptable? What if midwifery as we know it became illegal?

Maybe it’s in the current state of practice.

Some argue that a midwife who refuses to renew her license recently is no longer a midwife and shouldn’t be allowed to practice. It doesn’t matter that her skills are still fresh in her memory, and that her choice to not renew is believed to be a political statement against mandating with whom and where women may give birth. To add controversy, suppose this midwife was unafraid of taking cases labeled “high risk” in order to give women more options for their labor, understanding the high risk cases could potentially result in a loss whether or not she presided over the care? If you knew a tragedy could be inevitable regardless, would you choose to stand by your patient, or would you CYA?

Others would argue that an out-of-practice OB/GYN who’s been retired for almost 20 years now, although still given the title “Dr.”, is no longer up to date enough to be giving accurate medical advice, opinions, nor to be weighing in on birth today and facts presented by others who are more current and active in the field. Indeed, birth has changed a lot since the 1990’s. For better or for worse, the skills, policies, drugs, and technology would be greatly different. A doctor who stopped practicing back then, in this fast-paced profession, would undoubtedly be considered old school or maybe obsolete to the hospital crowd.

Being fair, we could say that neither one has “lost” their skill set. Are either of them any less of a doctor or a midwife? Only in technicality. In our own minds, it’s up to our own judgment to ascertain this wisely. Who would you rather have– the latter, or the former– look after you? What would seem more “qualified” to you?

I think education is nice, licenses, degrees, and titles are all very nice… but at the end of the day, it isn’t any one thing that promises to provide you with “qualified care”. Everyone is equally capable of incompetence. Truly understanding this leads to resigned acceptance of freedom to choose the care you think is best, without harsh judgment or scorn.

Neonatal Resuscitation

7 12 2011

One of the biggest fears when talking about UC (unassisted childbirth) is how to respond to emergency scenarios. A common fear is that the baby will not be breathing or responsive at birth. I believe that having some idea of what you would do in a crisis is extremely important. Not only is it a life saver in the rare event that you face danger, but it’s invaluable for instilling the confidence and peace of mind needed for a truly relaxing birth for you and baby. After all, panic will help no one, even if you are presented with a challenge. Be prepared!

So, here are a few things to remember on the topic of neonatal resuscitation. This is not to be construed as medical advice; please research all subjects independently before making any decisions with regard to the health of you and your baby.

  • Babies are instinctively stimulated by mother. You can read more about how mothers tend to do this to illicit a response here in Emergency Childbirth: A Manual, by Gregory J. White. Lisa Barrett (midwife) also remarks, “Rubbing a baby and gently blowing and talking is usually enough to ensure the baby opens her eyes to look and take a breath. There is usually no rush as with a cord pulsing the baby is normally getting plenty of oxygenation and will come into herself pretty soon.”   Keeping the baby warm and stimulating it are usually more than enough to achieve positive results.
  • There can be a delay in crying, pinking up, or drawing first breath– don’t panic! The two previously quoted sources also support this and provide elaboration.
  • Aggressive tactics for administering oxygen are no longer generally recommended, and are often not even used amongst the medical community/rescue services. The Lisa Barrett link as well as the Emergency Childbirth text will discuss this more, including how utilizing pure O2 has not been proven better for neonate resuscitation compared with blowing shallow breaths for the infant (this too can be instinctive). In fact, these days, using oxygen on a newborn is considered to do more harm than good and so is foregone in favor of the gentler revival techniques. The International Association for Maternal and Neonatal Health (IAMANEH) also state that an oxygen tank is NOT essential for neonatal resuscitation, that the mask and bag are more appropriate (which is equivalent to shallow mouth-mouth), and even warn against routine suctioning of mouth and nose of infants after delivery.
  • Take action first, dial for help afterward. In an infant CPR video, EMT and Captain Nathan McConnell warns that if your baby needs help, your time is best spent attempting to stimulate and resuscitate. He recommends giving at least 2 minutes of care before stopping to call 911. Precious time could be wasted if you choose to dial emergency services first. By the time they respond and arrive, it could be too late, and since every second counts, immediate attention is key. Since life saving resuscitation techniques tend to be the same both at home and in the hospital, knowing how pros handle it will be critical to making sure you’ve done just as they would, and that you’ve done all that you can do.
  •  IAMANEH details the appropriate steps to neonatal resuscitation and speak on it very practically. Basically the steps (see all the links and sources) involve stimulation of the infant, clearing the airways, breathing for the infant, gentle chest compressions, and repeating.
  • Signs the resuscitation was successful include pinking of the tongue (lips alone are not indicative), overall raised APGAR scores, good pulse and good breathing. Resuscitation efforts can go on for up to 10 minutes or more, and 10-20 minutes is usually the period where further attempts would prove futile.
  • Finally, understand that the majority of the time, everything is just fine. The odds of you having to do any of this are slim. Knowledge of neonatal resuscitation techniques can be there for you just in case. You need to learn them, know them, get familiar and comfortable with them, keep cheat sheets, and then put it out of your mind. Don’t dwell on a negative potential… focus your attention on the actual reality and remain calm and optimistic. You have every reason to believe that birth will go smoothly, so don’t worry yourself sick (it only distresses the baby and increases the chances for dilemmas).

Nothing beats taking a class. If you’re like me, you have taken a class several years back and even been certified, but keeping current could be beneficial for both increasing your confidence as well as hearing the updated recommendations (as these change from time to time). Hear what the pros have to say, and if possible, get certified. If you’re unsure of your ability to react quickly in an emergency, do drills. Include everyone you think will be present at the birth. Think of all possible scenarios and outcomes. Have Plans A, B, and C.

Like I usually say– even if you don’t plan on having a UC, being as prepared as you would need to be to have one is such a good idea, because you never know where you’ll find yourself and what will happen. Accidental UC’s happen all the time, and mothers who weren’t expecting it and were not prepared experience worse outcomes than intentional UCs that were thought out in advance. When it comes to birth and nerves, education is key. Never hesitate to transfer to a hospital if you suspect something is amiss with your neonate and they do not appear to be thriving. It’s always better safe than sorry.