What's the Difference Between Doctors and Midwives?

This is a question I get asked a lot by patients or potential patients seeking an obstetric provider. The answer consists of many things and some different philosophies in general. Of course, there are some midwives who practice differently, and some obstetricians who practice differently, so you can't put everyone into the same nutshell, but here are the main differences. Doctors have been to medical school and have done a residency in their specialty area which includes surgery and management of high risk medical conditions. Certified Nurse Midwives (CNM's) have received Bachelor's degrees in nursing and have most have gone to graduate schools for Master's degrees in nurse midwifery. We do clinical hours and deliveries over about 2 yrs of school which consists of clinic time managing pregnancy, primary care, and gynecologic care. We also deliver babies and assist c/sections in many hospitals. Some do deliveries in birth centers and a small portion about 4% in this country do home births. Direct Entry Midwives are midwives who have had some training usually about 1 yr and perform most deliveries at home or in birth centers. There are also lay midwives who learn the trade from experience and time with other lay midwives. They perform home births.

The general philosophy of midwives is that pregnancy and childbirth is a natural and normal process that requires care of the woman, but that less intervention usually leads to better outcomes-such as a lower c/section rate. We also focus on educating our patients about things to watch for and do during pregnancy to encourage a healthy mom and baby and vaginal birth. We offer more time during prenatal visits to educate our patients and to really take time to know them and care for them. Most of us, myself included want our patients to feel that their desires are being addressed and that we are giving our patients educated options to choose from to meet their desires for childbirth. I personally don't think there is just one way that is the best way. I think natural births are wonderful, but there are some women that do not desire this and just because you choose a midwife doesn't mean you can't use medication or an epidural if desired. We/I just want you to be comfortable and safe and feel like you had a great experience. We never put your safety on the back burner either. We do intervene when necessary and consult or manage your care with an obstetrician if things are varying from a normal safe path. That being said, most midwives have lower c/section rates, bigger babies, and less preterm delivery. Part of the latter is likely because of the education time we try to take with our patients.

Last but not least, midwives usually spend more time with you during your labor offering labor support or emotional support and advocating with the nurses and other care providers on your behalf to help you get the birth experience you want. So, if you are

considering a midwife, come on in, you won't be disappointed!

HPV AND CERVICAL CANCER

HPV or human papillomavirus has 100+ strains, a few of which are considered "high risk" meaning they can cause cervical cancer. HPV is sexually transmitted, and because it is a virus, it is not curable. However, like flu virus, there is a vaccine to protect young women (and men now) against the dangerous strains of HPV. Not all HPV infections will turn into cervical cancer. In many cases, your body will take care of the virus and you will not require treatment for abnormal pap tests or cancer. However, your body may not treat all of the strains, and some of them may mutate and cause changes in the cervical cells which may lead to cancer down the road. Most abnormal cervical tests take 5+ years before they would be considered as full blown cancer requiring hysterectomy, etc. However, there are some cases that move faster and therefore, it is important to follow up with regular screenings, colposcopy, or other treatment as recommended by your provider. Further, there are other types of cancer that are not caused by HPV and that is why all women must be screened, not just women with muliple partners.
Gardisil and Cervarix are vaccines that are available to prevent cervical cancer. The vaccines are recommended for women aged 14-27. It must be given in three separate doses and most insurance does cover this vaccine, so if you fall in this age group, check with your insurance and your provider and get vaccinated! Gardisil also prevents certain types of HPV that cause genital warts as well, so if this vaccine is right for you, you may be "killing two birds with one stone!"
So....don't skip out on those yearly exams or vaccines!

Preeclampsia or (Toxemia, the old fashioned term)

I just realized I've never posted on preeclampsia which is one of the number reasons why it is important to get prenatal care. The cause of preeclampsia is unknown, yet its damaging effects are well known. Preeclampsia is diagnosed by an elevation of blood pressure and protein in urine. Thus the reason for regular urine samples and blood pressure checks during your prenatal visits. There is no cure for preeclampsia besides delivery, and so the goal of treatment is to hopefully get you to term 37+ weeks gestation and then deliver. However, if it becomes severe and begins to involve other organs such as your liver, then delivery prior to term becomes mandatory. Signs and symptoms of preeclampsia are elevated blood pressure, protein in the urine, abnormal labs typically low platelets, and elevated liver tests, spots in vision and/or blurry vision, headaches unrelieved with medication, and swelling of extremities and face. It is important to note however, that swelling by itself is not diagnositic of preeclampsia as many patients believe. You must have the elevation of blood pressure and protein in urine to truly have preeclampsia. If you believe you may be having these symptoms it is important to see your provider as soon as possible or go to labor and delivery for evaluation. The worst case scenario if this is left untreated is seizures in the mother (eclampsia), stroke, or even death. In the fetus, there is risk of growth restriction, morbidity and mortality associated with preterm delivery, and death as well from vasospasm and constriction of blood flow to the placenta and therefore to the baby. So, moral of the story, be sure to keep your regular prenatal appointments, and pay attention to symptoms that could be worrisome. Hopefully, the majority of you out there will not experience this!

Glimpse of my Lake Powell vacation

For those of you who want to see the good times had at lake powell last week-here you go! And yes I know it doesn't have to do with midwifery, but since I don't have a separate personal blog, I figured my friends would like to see that I do dare to go on vacation even if it's only about every 3 years!

Vitamins

I am a huge believer in vitamins. Here are just a few thoughts on what I think are the most important vitamins to take on a daily basis. First-a multivitamin. These have all the basic vitamins and minerals you need to meet the majority of the daily recommendations. Second-calcium. The reason for the calcium is that most women will suffer some degree of osteopenia later in life which leads to osteoporosis. Most of us (men included even though they won't admit this) don't get enough milk or other dairy products to make up the amount of calcium and vitamin D that you need. Multivitamins have some calcium (usually about 400 mg/day) but not enough to prevent osteopenia. The recommendation is that we get 1200-1500 mg/day of calcium and that those supplements need to have Vitamin D. Researchers are finding we are very deficient in vitamin D and taking extra in these supplements will not lead to overdose (even though Vit D is fat soluble). Further many mood disorders such as depression can be helped somewhat with vitamin D supplements. If you are worried about your vitamin D levels, come in and we can draw blood to test this if you desire. The third daily supplement I recommend is fish oil. I think 2-3 capsules/day is recommended. These can promote normal cholesterol levels to prevent heart disease. It also helps the neurons or neurotransmitters in the brain so you can think and process information better and helps your nerves (I'm not sure the exact etiology of this off hand, but you can research this further if you desire).

I usually take this little cocktail at night all at once because this is the only time I remember, but it is probably better to take at least 1 or 2 capsules of the calcium in the morning and a fish oil in the morning and the other capsules and vitamin at night. I'm sure as long as long as you are getting the amounts in your system though, it is better than not at all.

I also recommend an extra folic acid pill if you are trying to conceive. They are finding more neural tube defects and perhaps if we get people taking closer to 1 gm of folic acid prior to conception this rate might be lower. Folic acid is water soluble so don't worry about overdosing on this if you are taking it with a multivitamin.

There are other herbs, etc available too that I take at times including garlic, and echinacea. These are not FDA approved but I think in small amounts can have some reasonable benefits. Well, happy vitamin taking!

To ultrasound or not, that is the ?

Our office offers ultrasound every visit. We have found this to be a very satisfying thing for patients to see their baby and have a better idea of their baby's growth, amniotic fluid, position, and even facial pictures via our 4D scan. I do have patients question the safety of this now and then though, so I thought I'd address this. Doing ultrasounds every visit (if desired) is not necessary, and doesn't necessarily mean your care is better than another office that doesn't do them. Years ago, some research suggested that too frequent of ultrasounds may result in growth restriction in the fetus or left handedness (oh no!) in the fetus. It also suggested that there is an increase in cesarean section in those with frequent ultrasounds. Further evidence later refuted that and said this could not be proven (besides the increase in cesarean section during labor from continuous monitoring-which is another story). So, because ultrasound has been around for so long and there is no good research to prove it is doing harm, we offer them regularly. However, you do not have to have them every visit. I still have the good old tape measure for your belly and doppler to check fetal heart beat if you would rather do this method. I do believe ultrasound is nice to have at least one per trimester for the following reasons. First trimester-to accurately assess your due date by your baby's size. Second trimester-to make sure your baby is anatomically normal with no lethal defects. Third trimester-to check fetal position to verify your baby is head down for delivery and to assess amniotic fluid levels. All the other in between ultrasounds unless specified for other follow up reasons, are basically for some growth assessment and for fun. Ultrasounds are also good for some situations too such as the overweight patient who a normal fundal height measurement is not as accurate. This is especially true for them because obese patients are more at risk for a fetal death so I think more regular ultrasounds to check for growth and blood flow in the cord is not a bad idea.

Now for the reason why continuous fetal monitoring in labor is an increased risk for c/section. Babies in labor typically have some decelerations in the heartbeat from umbilical cord compression or from head compression coming down the birth canal. Sometimes, we (providers and nurses included) interpret these decelerations to be more harmful than they might actually be, and we jump to do c/sections in the hopes of saving your baby or preventing cerebral palsy. Oddly enough, despite all these c/sections and continuous ultrasonic monitoring in labor, the cerebral palsy rates have not declined and the c/section rates have only increased. Thus, it may be better to have intermittent monitoring. Of course, this is only possible if you are not on pitocin and an epidural as these may increase your risk of having more or worse decelerations in the fetal heart rate necessitating a c/section. C/sections are not all bad of course. There are definite reasons to have a c/section such as a prolonged deceleration, or other more serious types of decelerations (that are not all caused by pitocin use:). Anyway, just more blah blah blah for you on ultrasound usage and the pros/cons. Hopefully, I'm not boring everyone to death.

Home Birth??

Since the last reader inquired about home birth, I've been giving this idea some thought. This is not something that I've done before but I'm starting to consider the idea of doing a few maybe. I would have to talk to my malpractice insurance company and my back up obstetrician and see if these are things that they would cover. One of the problems is if I have a patient at home and at the hospital in labor at the same time. I think the situation would depend on the time and the risk involved in any particular pregnancy. I still believe it is safer in most situations I'm delivering in, to be in the hospital. That being said, most low risk pregnancies that deliver at home (approximately 90%) are free of complications. However, that 10% or so still makes me a little nervous. To date, I have had no intrapartum fetal deaths, still births, major maternal complications, etc. and I'd really like to keep that record. Of course I've had hemorrhages and other more minor complications, but they've all been fairly treatable because I've had help for the baby and medications, etc. right there in the hospital with extra staff available to assist. That being said, I do believe in a women's right to choose her birth experience and that she has intuition about her own abilities and situation, and if home birth is something she is adamant about, maybe I should look into this? I'm just wondering how many patients or readers out there in the Weber County area would genuinely be interested in home birth if I offered this to certain patients who met a certain criteria?...ie very low risk! Please send me your thoughts, I'd be interested:)