Midwives Rising

It was 2 a.m. on an August morning at Mount Sinai Roosevelt Hospital in New York City, and an exhausted Haydee Morgan, a teacher, had been struggling to push her baby out since midnight. She’d arrived at 11 p.m. the previous night, eager to deliver her second child. Her contractions were intense, but she coped by breathing and changing positions, often perched atop a giant rubber birthing ball. Although she’d been eight centimeters dilated when she was admitted, these painful hours had yielded scant progress.

Her previous delivery four years before had ended with the Caesarian birth of her beautiful daughter, Amina. But now, as an excellent candidate for a vaginal birth and with all signs positive for her and her baby, Morgan was determined to have a vaginal birth. “I grew up a midwife’s daughter,” she says. “You push your baby out.”

With her husband, her father, and her mother, Jennifer Dohrn, DNP, CNM, assistant professor, surrounding her, she agreed to the recommendations of her attending midwife, Laura Zeidenstein, DNP, CNM, the director of the Nurse Midwifery Program at Columbia Nursing. First she was given the drug Pitocin, which strengthens uterine contractions. But with little further progress, Zeidenstein suggested an epidural. The anesthesia would allow Morgan to rest and gather the strength she needed to finally push her baby out. The rest period could also permit her pelvic muscles to relax, Zeidenstein said, easing the baby’s descent into the ideal position for birth.

At 4 a.m., as a light rain was falling outside, Morgan’s bag of waters ruptured, and she felt her baby descending. She felt the urge to push and, at the same time, an anxiety about whether she could do it this time or would again need surgery. But in the hardest moments, she says, “Laura and my mom reminded me to trust my body and it would teach me how to birth. Their words were chosen and precise and just what I needed. ‘You’re doing beautifully,’” she recalls Zeidenstein saying. “‘You will soon meet your baby.’”

“Now that the baby’s head was descending in the pelvis,” Zeidenstein explains, “it was time for her to push the baby out. Her collaborating obstetrician, who was aware of her progress, was available for a repeat C-section, if necessary.”

“I started to push,” Morgan recounts, “but I wasn’t sure how to push. I was tensing my muscles.”

“‘Breathe,’ my mom said, ‘and only with the contractions.’”

Soon everyone was cheering, “I see the baby. It’s coming!”

“I pushed with everything I had,” Morgan says. “Out came my baby, who was immediately placed on my belly.”

She lay speechless, crying grateful tears. After a few moments, someone gently suggested her husband lift the baby’s leg. It was a boy! Already her son Maceo was nursing lustily at her breast.

Although VBACs (vaginal births after Caesarians) account for a mere 10 percent of births, it is not surprising that Haydee Morgan’s baby was delivered by a nurse-midwife. As more and more women are discovering, midwifery is dedicated to the principle that each woman and each woman’s body is unique. The expectant mother should be allowed, within the limits of safety for her and her baby—and backed up by or in collaboration with physicians and hospitals—to strive for the birth experience she wants rather than being treated as a member of a category subject to fixed rules and timetables. Midwifery aims to empower women who may feel powerless within the medical establishment. It seeks to give each woman a birth that feels respectful and nurturing, attuned to the nuances of her body and her labor. Moreover, as a wealth of evidence shows, a midwife-attended birth is overwhelmingly less likely to end with a Caesarian section and more likely to result in a multitude of physical and emotional benefits for mother and child.

Births by Caesarian section have increased in the United States, with nearly a third (32.8 percent in 2012 according to the Centers for Disease Control (CDC) of American mothers having such births, and a 90 percent rate following a previous Caesarian birth. These are costly surgeries fraught with far greater risks than vaginal births. Women having C-sections have significantly greater risk of infection, hemorrhage, and blood clots, and their babies face greater likelihood of respiratory distress. Future pregnancies can be more difficult because scar tissue may prevent the placenta from implanting properly.

Alarmed by these facts and the high Caesarian rate, physicians and health organizations worldwide have recently taken action. One step recommended by a consortium of researchers, clinicians, and others, as reported in The Lancet, is to move midwives more into the mainstream of medicine. Not only does midwifery reduce C-sections, they say, but it also reduces maternal and newborn mortality, perineal trauma, instrumental birth, anesthesia, severe blood loss, stillbirths, preterm births, and low birth weight. It has also been shown to increase spontaneous onset of labor and increased rates of successful breastfeeding.

In the U.S., the American College of Obstetricians and Gynecologists (ACOG) this year released new guidelines for events in labor that should trigger consideration of C-sections. ACOG recognizes the evidence that normal labor progresses more slowly than physicians had previously thought. Specifically, the new guidelines recommend that a cervical dilation of six centimeters rather than four centimeters should be considered the start of active labor, and that early-phase labor should be allowed to go longer. The guidelines permit women to push for at least two hours if they have delivered before and three hours if they have not, even longer with the use of an epidural. Finally, they recommend techniques to assist with vaginal delivery, which, the authors say, “is the preferred method when possible.”

“Midwives have always thought these things,” says Zeidenstein, director of Columbia’s graduate Nurse Midwifery Program, which is the oldest graduate nurse-midwifery program in the United States and about to celebrate its 60th anniversary in 2015. In all other developed countries, where midwives do 80 percent of births, she says, the Caesarian rate is closer to 12 percent, the percentage recommended by the World Health Organization.

In the early 20th century, when obstetrics became a specialty in the U.S., says Zeidenstein, midwives, who had attended most deliveries, were essentially eliminated. In the U.S. today, she says, the majority of providers now are surgeons. “They are excellent surgeons,” she says, “but surgery is normalized for them. Moreover, the health care system loads physicians with too many patients and too little time, making it easier for them to do C-sections.”

Time pressures also push physicians into quicker use of interventions to alleviate pain and speed labor or delivery, but these interventions also increase the likelihood that the birth will end as a C-section. Pitocin, for example, can put extra stress on mother and baby. The same is true of using an epidural for pain. Breaking the bag of waters too early, which physicians are quicker to do than midwives, can lead to possible infection.

Midwives also use these interventions but very carefully. “I can’t over-emphasize,” says Zeidenstein, “the importance of going slowly and mindfully.”

One of things midwives excel at—as The Lancet’s research confirms— is helping mothers manage the often agonizing pain of labor in order to avoid the use of an epidural or delay it as long as possible. Letting the mother move freely is key. Walking, squatting, or getting on hands and knees can help her cope. Perching on a birthing ball, which Haydee Morgan found “magical,” or sitting in a rocking chair are among the other options.

In many hospital settings, however, letting the mother move is either not possible or not encouraged because the woman in labor is strapped into an electronic fetal monitor (EFM) to continuously check her baby’s heartbeat. When possible, midwives instead employ a hand-held Doppler at frequent intervals to monitor fetal heart rate. “All the studies show,” says Sylvie Blaustein ’88, CNM, owner and director of Midwifery of Manhattan, “that intermittent auscultation is just as good as continuous EFM.”

Requiring women to lie on their backs in the bed originated long before EFM, says Jessica Lynn ’97 ’00, CNM, CDE. “It originates from the traditional obstetrical delivery. The position, called the lithotomy position, is based on the deliverer sitting on a chair at the end of the bed in order to have control over the delivery.” It was also, she notes, useful for women who had anesthesia and for convenience when using forceps. EFM, which is far more recent, further restricts the woman’s mobility. “Yet lying on your back is the least comfortable position for labor pain,” says Lynn, who worked as a midwife for 11 years at Brooklyn’s Woodhull Hospital before becoming a diabetes educator for pregnant women at the Naomi Berrie Diabetes Center at Columbia University Medical Center.

At Woodhull, a large public hospital with a significant and well respected midwifery program, continuous EFM is required. Nevertheless, midwives there encourage laboring mothers to walk and change position within the length of the electrical cord while the midwives reposition the device to pick up the heartbeat.

If, however, none of these pain-relief strategies has been sufficient over the hours, and the mother is exhausted, an epidural, timed correctly, as in Haydee Morgan’s case, can allow a period of rest so the laboring woman can then push her baby out vaginally. An anesthesiologist would administer the epidural, but the midwife would continue to care for the patient.

Women often choose midwifery for their birth because they feel that it empowers them. “They worry about being trapped in a hospital,” says Blaustein, “and having things done to them against their wishes.”

Maria Corsaro, CNM, MPH DNP, a Nurse Midwifery faculty member at Columbia Nursing who practices at Hudson River Hospital Center, tells of a recent patient who came to her practice for a second birth after what she experienced as a “traumatic” first delivery, including an episiotomy that did not heal well. “She felt she wasn’t listened to,” Corsaro relates. “She didn’t want an episiotomy or an epidural, although she did want pain relief.”

Early in her pregnancy the patient saw the rooms at Hudson River Hospital Center with their tubs of water, varieties of lighting that she could direct, and television if she wanted it. She told Corsaro that she would like a water birth, and she requested that her husband cut the cord and be able to hold their baby immediately. She also asked about options for pain medication. Screaming for help with pain does not necessarily mean patients want an epidural, Corsaro explains. They may have trouble communicating clearly exactly what they want, so she prepares them with a “safe word.” “If she says that word,” Corsaro notes, “I know she really wants an epidural.”

When this patient arrived in active labor and in intense pain, Corsaro gave her choices at her each step. Did she want to enter the water, have pain medication, or an epidural? She chose the water. The patient chose to emerge because she wanted to be in bed when she was ready to push. At that point, she was nine centimeters dilated, and her midwife again gave her choices. To break her waters or not? The patient said yes. Her husband was on one side of her, giving sips of water, and her mother was on the other, wiping her brow, when Corsaro quietly encouraged her to push. “Then the head crowned,” relates Corsaro, “and then his shoulders and arms emerged. I said to her, ‘Reach down and take your baby out and onto your chest.’” She did. Her husband and mother were encouraged to gently touch this new life, with his umbilical cord still attached. The room, said the midwife, was suffused with “ a quiet joy.”

The midwife’s continuous presence (or as near as possible), confers significant benefits on mothers and infants, including less likelihood of epidurals, studies confirm. “The midwife’s physical and emotional presence in witnessing the woman’s pain and acknowledging it reduces her anxiety,” says Lynn. “It normalizes the pain and makes it more tolerable. I tell them it’s OK to make noise. I let them scream and don’t shut them up.”

In addition, says Zeidenstein, when the midwife is present, she can gauge the mother’s mood and sense of her progress. “It’s not a case of waiting two hours until the physician stops in to do something. We say, ‘Oh, she’s not coping well. Let’s help her calm down and ask what she’s afraid of.’” The mother’s emotional state, she explains, can affect her stress hormones, which can influence the progression of her labor.

In this and other ways, midwifery is holistic, practitioners say. It encompasses the whole woman, emotionally as well as physiologically. It also comprises the entire process of pregnancy, delivery, and the initiation of successful breastfeeding. Midwives learn who their patients are, their relationships with the important people in their lives and the people in the delivery room. “I see when they have tensions because of violence in their lives,” says Lynn, “or sadness because of the loss of a parent. I might ask, ‘Are you thinking about your mother now?’”

“Midwives tend to understand the complexities of the body mind connection,” Lynn says. Since most women think of their own mothers during delivery, she explains, sadness would be likely for a woman who’d lost her mother. A woman who suffered violence may feel especially vulnerable and “invaded.”

Midwifery is, by its nature, collaborative, both with patients and with physicians and hospitals. The collaboration of the private practice, Midwifery of Manhattan with The Birthing Center at Mount Sinai Roosevelt, says Zeidenstein, is an example of “seamless teamwork.” This hospital, she says, is unique in having allowed attending private midwives for 50 years. “The obstetricians and perinatologists recognize our expertise,” she says, noting, “Many of the physicians come to our practice to have their babies.”

Jocelyn Finger ’05 ’06, CNM, who practices at Midwifery of Manhattan, calls it “unique” and “ideal.” The ratio of midwives to patients frees midwives to be involved with them early and deeply and to be constantly present at deliveries, even as the occasional patient is wheeled into surgery for a C-section. “As a student at Columbia,” Finger says, “we’re taught what the ideals are and to work toward them. But we’re also taught to temper our ideals with the reality of the health care system.”

The Columbia Nursing educated midwives who work at Woodhull Hospital do just that, they say. The reality is that midwives cannot always be continuously present with their patient but they try to be, at least once active labor starts. Even without constant one-on-one attendance, women benefit from what midwives do, says Lynn, “touching, talking, advising, calming.” Sometimes this occurs with the assistance of a translator for those from Africa or Asia, for example.

Women at public hospitals are assigned to midwives rather than seeking them out, explains Zeidenstein, who trained at Woodhull. “The midwives are caught in a medical model,” she says. “Yet even there, midwives make an enormous difference.”

Woodhull and Mount Sinai Roosevelt, she says, are quite unusual in their support of midwifery. “The reality,” she says, “is that midwives in U.S. hospitals are completely vulnerable. We have not been fully integrated into the maternal and child health system.”

If it is a myth that only affluent or educated women give birth with midwives, it is also a myth that midwives do not attend complicated pregnancies like those of twins or when the mother has gestational diabetes. In deliveries of twins, Lynn says, midwives help with labor support, pain relief, and emotional support, and can even deliver the babies vaginally while an obstetrician assesses the babies’ well-being and is ready, if necessary, to perform a C-section.

With gestational diabetes as well as Type 1 and Type 2, says Lynn, midwives can be instrumental to women. They offer care focused on diet, blood glucose levels, and weight gain during pregnancy. Attention to these can result in healthier pregnancies, healthier babies, and less chance of macrosomia, a very large baby, common in mothers with uncontrolled diabetes, which increases the likelihood of a C-section.

Whatever the medical complications— or lack of them— says Finger, a chief role of the midwife is to make childbirth as natural, healthy, and emotionally satisfying as it can be. When she gave birth recently, for example, she and her husband told their midwives they wanted to be treated as a “pregnant couple.” They involved her husband at every step, she reports, even asking him how he was feeling when she had morning sickness.

“In our practice, we care for women all the time when things don’t go right,” Finger says. “But, above all, we know that what we are doing is facilitating the foundation of a new family.”