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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

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She had been laboring for three days, and twice they sent her home without an idea that she was suffering from an OP baby, you know, the kind that give you a pain in the back, and meet the world face up?

When I finally arrived at the hospital my young mother was a wreck. She lay out stretched on the hospital bed, wired and hosed like an old T.V from the 80’s. Her left arm held the Iv, her right was the pulse ox, the BP cuff,and strapped across her large round protruding belly was the beast.
The fetal monitor.

I sighed, disheartened, this was to be my first. My very FIRST birth on my own, with no mentor, no guide, no soothing gentle well worn hand of the Doulas who had seen a thousand births before me.

She was my first, and she already had an epidural.

DAMN.

She was sweet, young and exhausted. her partner, nervous as a march hare listened to each word I said, each reassuring, honest, fact based, science proven word. I saw his shoulders ease as did hers when I gently rested my hand on her belly and felt her first son respond to my ginger touch. Like a flutter of a hundred butterfly wings, I felt his feet.

But soon the quiet of our meeting and the soothing of my words was thrown to the way side my a noisy, blustering OB who insisted on checking my sleepy mom’s cervix at that moment, in her first moment of sleeping peace.

Damn. I wanted to chase them out.

I wanted to let her relax and start this on her own.He insisted on breaking her bag of waters, touting …”Now don’t worry, this will get the birth started no time…” But little did he mention the devisating fact that nearly 99% of premature babies comes from an idle OB insisting that the time is now rather then natures hand.

DAMN.

But I was the alien visitor, along side with the relaxed dressed father, and the poor institutionalized mother. I stood out against their familiar pale green, my own brilliant blue shirt, and earth toned pants made me a site for their sharp eyes.

The OB eyed my speculatively as he watched the Mother’s partner turn to me for a nod, or shake of the head. He had broken the sac before my tired eyed father had a chance to argue otherwise, while his partner watched on with confusion, after she rejected the offer. But it was done.

My heart sank as he then mentioned the risks, post bag breaking. Now he tells her that if she doesn’t deliver in 24 hours she will be subject to a Cesarean section. I  saw the fear swallow my mother, the easing and patients of the hours before gone in a single flush of carelessly placed words. With his task done, and waters dripping from the bed, he left us, soaking in our thoughts.

My mind reeled as I came to sit beside them while the nurse pushed a towel around my mothers back side. She clasped my hands and asked if what he said was true.

I smiled again, but she was no fool and read my face. Leaning back on her pillow, hand in mine, she turned with her clipped Spanish accent.

“Then, we must be the clock!” With a firm squeeze I replied…”There are NO clocks in birth, no time, no hours. Only moments, let us not worry about that ‘moment’ until we get there.”

Part I. END

*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)

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.