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.
We are celebrating my son’s 5th birthday this week! Merrick’s birth plays a large part in why I am where I am today.
Now bear with me… my mind may be a little fuzzy on all the events, and I hope I’m telling the story accurately and clearly, as this story is pieced together from past Social media posts. But of course, my birthing memory may be a bit skewed… I WAS IN LABOR LAND!
When I found out I was expecting in late August of 2010, I was utterly surprised. I had previously been diagnosed with PCOS, Polycystic Ovarian Syndrome, and had tried a gamut of medications to help my natural system take over, but was told that having biological children was nearly impossible and my insurance wouldn’t likely cover the next stages of medical intervention had I wanted to have children. I remember my mother vividly when she said, “Don’t cry. God gives us the truest desires of our hearts,” so it was common sense to call her first from the bathroom of my apartment at midnight, gripping the test in hand.
Is this real??
That’s also what I said when labor began.
5 years ago at 2 am, I looked up from my bed at my midwife and said,
" Tell me this is real."
I had been experiencing contractions since yesterday AM and was praying these were not Braxton Hicks as I had not noticed any previously in my pregnancy. She smiled and confirmed they were real labor contractions. My son’s “due date” was today. She tucked me in and said she’d be back around 10 am, but call if things changed.
She came back as promised and my home slowly filled with birth workers – Kim, Alexis – the other midwives – and Sarah, my doula. And even for a short time Angela, a doula I had met along my travels. I was excited, but I knew I had some time when my midwives went to lunch. I felt as if my contractions spaced and were not as strong, but my back hurt a bit more so my husband and I got in the “birth pool” which at that time was an Aquarium kiddie pool splashed with colorful fish all around it and a waterbed heating pad underneath which scorched my bottom if I sat too long.
The pool I LIKED! Leave me there for the duration of labor and I’d be one happy mama! My midwives returned and after a few more hours I began to hear little blips in my baby’s heart tones. I looked to read their faces, but they all held poker face – not one gave anything away. Joyce spent some extra time to listen the next time with the doppler. When I began presenting a low-grade fever, I went to labor in the living room, out of the warm air from the pool and onto my awesome birth ball. This is where the next heart tones were heard and my midwife laid it out; his heart tones were “fluky” and mine were beginning to mimic, along with an elevated temp.
She was talking transport, and it was previously set in my mind, if she ever considered it, I’d just go.
As the sun went down, we began preparing to transport from home to hospital. I set aside my desires for a home birth to be sure Merrick made his debut without incident. His heart had made some “wonky” blips of sound and it seemed my heart was conducting Heart Math with Merrick’s. I called my mom and told her it was just taking too long and we were transporting for a change of scenery — my little white fib to save her from worry.
We jumped, or rather slowly got in the car. I held on to the “oh sh*t” handle and I cringed while Brendon drove through the potholed streets of Worcester, following my midwife, and cracking jokes. I don’t really remember arriving – I mean, AT ALL. The next thing I really remember is my midwife-turned-doula, Joyce, saying, “I’m so sorry, I know it’s uncomfortable,” but it would be in my best interest to get on hands and knees. I remember thinking that meant Merrick was probably posterior… Boy, did I have a whole internal dialog!
Now I know I still had about 9 hrs ahead of me after arriving at the hospital, but then I assumed I’d be in labor for at least another 3 hours. I needed a break. However small it would be. I made the decision to have Nubain which gave me a 20 min “reprieve”. I remember trying to rest though the contractions in that 20-minute span. Brendon fell asleep in the cot next to me. Joyce had already been with me about 15 hrs and had seen me in the wee hrs earlier that morning… She laid her hand on me and gently rested her weary head beside me as I tried to snooze on my left side between contractions. Each time a contraction would envelop me, Joyce could feel me tense with her hand, would lift her head, and quietly remind me to relax. I remember thinking if she ONLY did THIS alone, she was worth her weight in Gold! But she did so much more! The contractions came and went and so did the 20 minutes rest! Somewhere around this time, I was told by the midwife on duty that they would break my amniotic sac. I don’t even remember consenting to it, but am pretty sure I did… I don’t know why they even suggested it. Suddenly, in my stupor, I felt the wetness and realization set in that it indeed had been broken.
Eventually, I couldn’t stay in bed any longer. I don’t remember getting naked, but I was. I don’t remember getting in the shower, but I had and was soaking wet. I sat on the toilet and remember being urged to my bed to be examined as I was feeling pressure. Low and behold, I was 10 cm dilated. It was time to push and meet my baby.
At some point in the early hours of April 23, 2011, my doula Sarah had returned and grabbed the camera – which I am so thankful for. For almost a full hour I fell asleep between contractions and pushed each time one came. I think I even SNORED! LOL!
When my baby crowned, I was reminded to touch his head, but I just couldn’t get the energy to lift my hand. Instead, I pulled it all together for one final push. “No, he’s coming out NOW!”
Finally! I met my son. “Vanessa, take your baby”. I was stunned…
My exact thought was, “Oh shit! There’s a baby!”
I looked down and lifted my son. And the realization that this little being was given to me to protect, love, and nurture changed my whole perspective on life.
I don’t remember hearing him cry. I don’t think he did much. But when I held him, I sang, “Around the world, I searched for you…” He just blinked and at that moment, my definition of love died and was reborn into something so much more magnificent!
My dear Merrick James is now in preschool and registering for Kindergarten. He breaks dances in our living room, adores listening to scores from The Lion Guard, tells me all about Professor Xavier and his X-Men, and gives me updates on his Batman video game. He’s a little obsessed with Minecraft and can do a hundred things on a tablet that I can’t. He loves digging in the yard and watering the flowers. He’s so proud to teach his swinging skills to his sister and that he can read a lot of words all on his own.
He’s everything I wished for and more!
He’s a boy through and through – dirt, dinosaurs, and DC Comics, but still a gentle and compassionate soul.
And today he is 5 years old.