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Midwife-led versus other models of care for childbearing women

Hatem M, Sandall J, Devane D, Soltani H, Gates S
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Summary
Midwife-led versus other models of care for childbearing women

Midwife-led care confers benefits for pregnant women and their babies and is recommended.

In many parts of the world, midwives are the primary providers of care for childbearing women. Elsewhere it may be medical doctors or family physicians who have the main responsibility for care, or the responsibility may be shared. The underpinning philosophy of midwife-led care is normality, continuity of care and being cared for by a known and trusted midwife during labour. There is an emphasis on the natural ability of women to experience birth with minimum intervention. Some models of midwife-led care provide a service through a team of midwives sharing a caseload, often called ‘team’ midwifery. Another model is ‘caseload midwifery’, where the aim is to offer greater continuity of caregiver throughout the episode of care. Caseload midwifery aims to ensure that the woman receives all her care from one midwife or her/his practice partner. All models of midwife-led care are provided in a multi-disciplinary network of consultation and referral with other care providers. By contrast, medical-led models of care are where an obstetrician or family physician is primarily responsible for care. In shared-care models, responsibility is shared between different healthcare professionals.

The review of midwife-led care covered midwives providing care antenatally, during labour and postnatally. This was compared with models of medical-led care and shared care, and identified 11 trials, involving 12,276 women. Midwife-led care was associated with several benefits for mothers and babies, and had no identified adverse effects.

The main benefits were a reduction in the use of regional analgesia, with fewer episiotomies or instrumental births. Midwife-led care also increased the woman’s chance of being cared for in labour by a midwife she had got to know, and the chance of feeling in control during labour, having a spontaneous vaginal birth and initiating breastfeeding. However, there was no difference in caesarean birth rates.

Women who were randomised to receive midwife-led care were less likely to lose their baby before 24 weeks’ gestation, although there were no differences in the risk of losing the baby after 24 weeks, or overall. In addition, babies of women who were randomised to receive midwife-led care were more likely to have a shorter length of hospital stay.

The review concluded that most women should be offered midwife-led models of care, although caution should be exercised in applying this advice to women with substantial medical or obstetric complications.

This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2010 Issue 3, Copyright © 2010 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in The Cochrane Library (ISSN 1464-780X).
This record should be cited as: Hatem M, Sandall J, Devane D, Soltani H, Gates S. Midwife-led versus other models of care for childbearing women. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD004667. DOI: 10.1002/14651858.CD004667.pub2.

This version first published online: October 08. 2008

http://www2.cochrane.org/reviews/en/ab004667.html

*The term epidural is often short for epidural anesthesia, a form of regional anesthesia involving injection of drugs through a catheter placed into the epidural space. The injection can cause both a loss of sensation (anaesthesia) and a loss of pain (analgesia), by blocking the transmission of signals through nerves in or near the spinal cord.

*Wikipedia.

Risks and common side effects of the epidural include:

1. Back pain at the site of injection. 100% of women experience localized tenderness. 10 -12% have back pain for up to three months post Birth. (However, it may last longer if their was a previous history of back issues.)

2.Maternal, and in turn baby, fever due to suppressed immune system.(Caused by the medication being administered via an open path directly to the spinal cord and the fact that most anesthetics are an immune suppressor, giving your body limited availability of healing white blood cells).

3.If develops fever, infant will spend more time in intensive care under observation. Which means: less bonding time, less skin to skin contact, more stress on breast feeding and returning to normality.

4. Incomplete pain relief- Epidural is subject to gravity, administering the medication through path of least resistance, causing random numbness with pain hot spots. Can affect only one side of body. ( Which in turn calls for more medication, increasing the usage and dosage, slowing the labor by increasing lack of feeling and an increase or lack of being able to ‘push’ with the rushes.)

5. Spinal Headache (1% of women get them)

Too often a woman with a normal delivery, is interrupted for the needs of the medical staff in a hospital.  They are woken from much needed naps for a blood pressure that could have waited, or woken, or roused from a deep meditative state in their labor to have their cervix checked to see if she is “progressing”, when the movement is obvious on her belly.

I’m trying to get a good figure for how much a woman really wants to be bothered.

1. They are not accurate.-many nurses have openly told me how often they fail and give false positive tracings.

2. Takes freedom away from mom’s movement in turn slows down the labor process.
3. Medical staff become too dependent upon it and look for clinical problems when there are none.

4. Constant sound of fetal heart beat- labor can last 4-48 hrs. Babies heart beats 145 times a minute. Imagine 145 beats a minute for 18 hrs next to your head. (Unless you like things that go “PING”)

5. Causes false alarms
6. Use of fetal monitor leads to other interventions.- Epidural because loss of free movement and bed restriction increases pain.
7. Detracts from the momentum of birth if a ‘ drop in heart rate is heard’ 12 people come into the room to find that monitor slipped out of place.
8. Loss of independence and makes mothers feel ‘ trapped and weak”
9. Belly binding for monitors itchy.
10. Increases stress in labor all around.

*Numerous studies have shown that the fetal monitor does not increase the safety of fetus or mother, in fact the clinical use of the monitor increases the likely hood of unnecessary intervention.