All of the literature available to pregnant women today encourages them to “talk to your doctor or midwife.” This is sound advice. A good relationship with a well-matched, compatible care provider is of utmost importance in your pregnancy and birth. Yet the fluidity of those terms being used together can give the impression that the two are one and the same. It seems to suggest that your care will be only slightly different with a midwife than it would be with a doctor.
The reality is much different. Doctors and midwives approach pregnancy, labor, and birth from two profoundly different foundations of training. When it comes to the actual labor and birth, their training drives their decision making, and the approaches they take could not be more different.
Doctors tend to practice what is known as “active management” of labor and midwives mostly practice “expectant management” of labor. Of course there are exceptions, but by and large, this is what you will find in your doctor or midwife. Your choice of care provider matters more than you may think – and it’s worth it to understand the difference between the two approaches before hiring a doctor or midwife.
“Active Management of Labor” was invented in Dublin during the 70’s. It was the first method used to define labor, determine what is “normal” for clinical purposes, and establish protocols to keep women’s labors within its defined set of “normal.” Active management of labor protocols was not based on evidence, yet they were fully embraced as such without question. Active management of labor made its way to the United States soon after it was invented in Dublin.
According to Midwifery Today: The basic [abbreviated] principles are: diagnosis of labor based either on painful contractions and complete cervical effacement or broken water; one hour after admission, progress is assessed and amniotomy (water broken) performed; cervical dilation must advance by at least 1 cm per hour or oxytocin is started and increased until mother has 5-7 contractions every 15 mins; maximum labor length is 12 hours; a midwife stays with each woman throughout labor; the midwives manage labor, senior staff consults; induction is rare; pain medication is available but discouraged.
Unfortunately, the only pieces of the program that survived the Atlantic crossing (from Dublin) were routine amniotomy (breaking the water), the liberal use of oxytocin, and the time limit on labor. Other parts–the continuous support of an experienced woman, that residents did not make decisions, the minimal use of epidurals (5%), the minimal use of induction (<10%), not using painful contractions as the sole diagnosis of labor–did not make it…. Moreover, the Dublin doctors expected women to give birth vaginally….
In short, active management of labor is committed to the defined process, and to keep a woman’s labor on track with the arbitrary definition of “normal”. It does not allow for the many variations of normal in labor, and the goal is for a woman to have her baby within a certain time frame, whatever the cost.
Expectant management of labor, by contrast, is the approach that midwives tend to take. In this approach, the attendant sees birth as a normal and uncomplicated process that only requires intervention in a small number of cases. In contrast to the active management approach, a midwife sees normal birth with a wide range of variation. Birth does not need to be confined to a set standard, especially so long as the mom and baby are both doing ok.
An expectant management approach can also be called the “wait and see” approach. Rather than jumping on the use of interventions right away, a care provider who practices expectant management may take a step back and allow the birth process to unfold the way it needs to, provided that safety is of utmost importance.
To demonstrate the difference between active management and expectant management, imagine a woman is in labor and the labor slows down. By definition of the active management approach, the woman’s labor is now “stalled” and requires synthetic oxytocin in order to stay on track per the definition of labor. She is given intravenous Pitocin, her cervix is checked every hour to ensure “proper” progress, and she has now become a high-risk case due to the use of medication. Furthermore, she has now started what can quickly become the snowball of interventions.
An expectant management provider, however, would see a slowed labor through a different lens. She may see it as the laboring body giving mom a rest. She may see that the labor has, up until this point, been working on positioning the baby properly, and she may just leave well alone. She approaches it from a respect for the birthing process rather than seeing or feeling the need to make the labor conform to a pre-set idea.
Not all care providers are the same, and certainly, there are going to be doctors with a more expectant approach and midwives with a more active approach. Active management of labor has been the standard used and taught to doctors and hospitals for so long that creating change toward a more expectant approach is slow, but change is fortunately happening.
Until then, make sure you know you are hiring the right provider for you. Interview them thoroughly. Understand the differences between the two approaches, and carefully decide which is right for you. Your choice of care provider is a crucial one, and as a doula, I’m always willing to help match you up with a provider whose values align with yours, whether that be expectant or active.
Care Providers in Pregnancy
Most women in pregnancy see one care and support provider, and in America that is usually an obstetrician. They attend their prenatal appointments, stay away from sushi and blue cheese and call it good. Unbeknownst to them, there is a whole world of additional care support available to women that they often times don’t even know about! They can see an OB, a Midwife or a Family Practitioner for their primary prenatal care. In addition, pregnant women can benefit from the services of a chiropractor, a prenatal massage therapist, a nutritionist, an acupuncturist, a naturopath, a monitrice, a doula or a prenatal yoga class. All specialists have something unique and valuable to offer women in their pregnancy.
Obstetrician. Obstetrics is a surgical specialty of medicine. OB’s specialize in high risk, abnormal, and pathological pregnancy and birth. They are perfect care providers for women with preeclampsia, diabetes, autoimmune conditions, cancers or other complications.
Midwife. A midwife is an expert in normal pregnancy and birth. The World Health Organization recommends that all women who are experiencing a low-risk pregnancy seek the care of a midwife. This is because low-risk birth with a midwife is known to be safer and less complicated. It also frees up obstetricians to focus more energy on the high risk and complicated cases that they are specialists for. Midwives are known for developing relationships with their clients and for providing personalized care rather than standard care. There are options for midwives; Certified Nurse Midwives who work within hospital settings and Certified Professional Midwives who support families in home birth.
Family Practitioner. Many women will choose a family practitioner for their primary pregnancy care. FP’s who care for pregnancy will generally have rights at a hospital. The care they give will be similar to that of a midwife. They do not generally do surgery, but they can manage all other aspects of pregnancy and birth.
Chiropractor. Chiropractors are a must for pregnancy. Many people mistakenly believe that chiropractors only work on the back, when in reality chiropractors are specialists in the skeletal balance of all kinds. When the relaxin is flowing during pregnancy, it doesn’t take much for joints to become out of balance. This can lead to all sorts of discomfort, especially in the hips. A chiropractor can be a tremendous help in keeping women comfortable. Chiropractic care is safe through all of the pregnancy.
Prenatal Massage. A compliment to chiropractic, prenatal massage can help keep pregnancy comfortable. As joints stretch, muscles stretch and discomfort increases, prenatal massage can help loosen and balance all the growing parts of a woman’s body. When combined with chiropractic care, prenatal massage can really help women feel as normal as possible as they progress in pregnancy.
Nutritionist. A woman’s body is growing a human! It makes sense that the building blocks to accomplish this feat could use some gentle guidance. Proper pregnancy nutrition can help prevent a myriad of pregnancy related complications. Your body needs ongoing nourishment for itself as well as your baby! Furthermore, a pregnant woman’s physiology is different than that of a non-pregnant body. A nutritionist who is trained in pregnancy can help your pregnancy to be as healthy and uncomplicated as possible.
Acupuncturist. Acupuncture is a branch of eastern medicine that is not widely understood in the western world. Nonetheless, its effectiveness cannot be argued. Acupuncture is based on the theory that your Qi (pronounced chee) must be balanced for optimal health. We now understand Qi to be electromagnetic energy in a body, so it’s not all fantasy. Many health problems are thought to be the result of unbalanced Qi. Acupuncture is safe in pregnancy. At the end of pregnancy, it is a very effective form of natural induction.
Naturopath. A naturopath is a practitioner that uses many natural types of healing and nutrition to bring balance to the body. Their healing approach is generally holistic – seeing the body as one whole functioning organism where all parts are connected. Some naturopaths specialize in varying types of natural health. Some may include nutrition counseling, homeopathic remedies, herbal remedies, etc.
Doula. A birth doula is a specialist in pregnancy and birth support. A doula is an expert in connecting a pregnant woman with all the resources she may need in her pregnancy to be fully informed. During labor, a birth doula will stay with a laboring couple throughout the course of labor to provide physical and emotional support throughout the birth. A doula is not a medical care provider, so she does not use clinical skills that nurses, midwives, and OB’s employ.
Montrice. A monitrice is similar to a doula in the way she works to offer prenatal education, support, and physical comfort, but is also trained to perform a limited amount of clinical skills such as maternal blood pressure, fetal heart tones, cervical exams for dilation, and abdominal palpation to assess the position of your baby. A monitrice will offer these services while laboring at home, but once she accompanies you to the hospital, her role becomes strictly non-medical by offering doula support.
Prenatal Yoga. One of the best and most effective ways to prepare for labor is through prenatal yoga. While most forms of exercise tend to be safe throughout all of the pregnancy, yoga is particularly good for pregnancy because it combines deep focused concentration, relaxation, and physical exertion. A prenatal yoga instructor will usually do a mental and physical exercise as a practice for labor during their class. This practice is of tremendous benefit as a woman prepares for labor.
A pregnant woman has many options for pregnancy specialized care. Making use of the many available options can bring balance, comfort, health, and support to a pregnancy and birth.