ve anything to do with midwives.

Obstetrical Distrust and Liability Insurance          

     Physicians in private practice were particularly concerned that working with midwives would raise their malpractice insurance, and it did. However, the anxiety that a nurse-midwife was going to draw innocent doctors into a vortex of career-ending malpractice claims just never played out. Despite this, it was very difficult to convince insurance companies and individual physicians that midwives would not destroy their professional standing. And yes, obstetricians continued to face more lawsuits than their non-OB colleagues, but the medical misdeeds that initiated the suits could be attributed to individual midwife malpractice only rarely. However, midwives continued to be considered malpractice liabilities.

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Unhealthy Cultures of Care          

     As more women entered the profession of Obstetrics, professional relationships between physicians and midwives became even more difficult.  On the labor deck, it was rare to have women OBs willing to even speak to, much less work with, a midwife. Their demeanor toward CNMs could be characterized as aggressive, condescending, or just rude. Women obstetricians, in contrast with men, were tired and frustrated, impatient and disdainful, straight out of residency. There were no efforts, from any of the doctors, to understand CNM scope of practice,  or standards of care.  They had developed their own opinions.**

Medical School Training and Nothing Else           

       In general, most women OBs were absolutely unwilling to accept that there was even the tiniest overlap in MD/CNM scope of practice related to normal obstetrics. Nothing short of a medical school education conferred the right to care for women experiencing normal pregnancies.  The concept of teamwork did not exist.  Decent working relationships, even now, can be problematic and might be entirely nonexistent in some settings. Consulting doctors can be angry if you call them, and angry if you don’t. It has been a confounding dynamic for decades.***

When You Need to Leave a Hospital Environment          

     If these statements appear as meritless characterizations, the intent is for CNMs to understand that this particular dynamic of woman-to-woman communication (or serious lack of) can invite inadvertent medical mistakes.  Working and associating with some women physicians (or nurses) who do not believe in the concept of midwifery, know nothing about midwifery scope of practice nor care to, or just think nurse-midwives are unworthy of regard, pose a significant legal threat.  Animosity of this tenor can produce extreme stress, miscommunication, and risk of malpractice for CNMs/CMs .

      Sooner or later, there is a risk of being drawn into a dysfunctional OB-CNM dynamic , whether or not there is any legal duty in a specific care situation. Once named in litigation, it is hard to be let out.  If attempts have been made to get along, no one has listened and the situation reflects a terminally ill culture of care, there are only a few options. Negative communications need to be reported to administration, along with personal documentation of events. If nothing is resolved, it is safer to leave this workplace. Making this difficult decision is, ultimately, for the benefit of your career, professional sanity, and patient welfare. ***Attempting to understand unfortunate relationships between midwives and OBs, particularly the doctors who are the most critical of midwifery, it is surprising that many of these individuals have never even met, much less worked with, a midwife. I also would like to think that OB attitudes against midwifery may, somehow, be connected with the intense pressures of OB practice, feeling burdened with responsibility for a co-worker midwife, or just the stress of medicine,  motherhood and family. This, however, does not explain the intense vitriol of some women physicians in OB.

              I am encouraged to hear of the growing number of private practices where midwives and women OBs are working together. One practice I am aware of seems to have created the best of all worlds for the women that they care for.  If this represents a growing trend in OB and Midwifery care, I sincerely hope that it prospers and becomes accepted practice in women’s healthcare.

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References/Footnotes:

          1. Judith P. Rooks, CNM,MPH,MS,FACNM. Professional Issues in Midwifery; Chpt. 1, p. 23. Relationships Between CNMs and CMs and Other Midwives, Nurses, and Physicians. Jones and Bartlett Publishers.

*Attributable to DeLee: “the evils natural to labor” and . . .” If the profession (obstetrics) would realize that parturition (childbirth) viewed with modern eyes is no longer a normal function, but has imposing pathological dignity, the midwife would be impossible even to mention.” In re Williams: Williams was a lead professor at Johns Hopkins (and first author of Williams Obstetrics). It was his opinion, based on The Flexner Report on Medical Education and his own survey in 1911, that most women were safer with midwives than general physicians. To improve the training of obstetricians, Dr. Williams advocated for hospitalization for all deliveries and “gradual abolition” of midwives, who should be replaced by obstetrical charities that would serve as “training sites” for budding obstetricians.

          ** It is a common joke among midwives that there must be a class in medical school for women students entering obstetrics, warning them of the evil and incompetence of midwives that they may encounter in practice.  I’m sure there’s a syllabus out there, somewhere. But, if it weren’t for a few wonderful, supporting, and brilliant women OBs I have known and considered friends, I would have left midwifery sooner than planned.  I consider myself fortunate to have concluded my career with an obstetrical hospitalist group that I will never forget.  The doctors, midwives, nurses, and amazing young residents were some of the best people I’ve known in practice.  I was fortunate to conclude a long career, overwhelmed with gratitude for the opportunity to work with them.

            ***Attempting to understand unfortunate relationships between midwives and OBs, particularly the doctors who are the most critical of midwifery, it is surprising that many of these individuals have never even met, much less worked with, a midwife. I also would like to think that OB attitudes against midwifery may, somehow, be connected with the intense pressures of OB practice, feeling burdened with responsibility for a co-worker midwife, or just the stress of medicine,  motherhood, and family. This, however, does not explain the intense vitriol of some women physicians in OB.

              IRelevance For Practice

Situation

There are published and unpublished legal cases involving physicians who have failed to respond when a midwife has asked for consultation or referral. These failures appeared deliberate and the result of refusing to collaborate with an unfamiliar midwife.  Failures such as these occur most often when the midwife’s established consultant is unavailable or has signed out to hospital laborists or hospitalists. 

          Certain details cannot be disclosed due to confidential settlement agreements, but failures by contractual consultants have resulted in bad outcomes for mothers and/or babies. It appears that the majority of the failed/delayed responses involved non-reassuring fetal monitor tracings, placental abruption, fetal cord prolapse, or malpresentations. In these cases, both midwives and physicians were named in lawsuits.

Vulnerability

          Unfortunately, cases exist where the midwife has appropriately consulted, and a consultant physician has either delayed or refused to respond.  In one case, the midwife’s back-up physician could not be reached, and the laborist on deck declined to get involved. The midwife acted appropriately, and a laborist was responsible for an unacceptable delay in responding to the obstetrical emergency. Both the midwife and consultant were named in the personal injury lawsuit. Infants involved in these types of cases were injured as a result of a delay in treatment, deprived of oxygen, which resulted in hypoxic-ischemic encephalopathy, leading to cerebral palsy and a need for life-long supportive care.

Expectation/Duty

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          Some form of contingency planning, prior to any emergency in OB, is essential. This is especially true in situations involving rural hospitals or birth centers where a consultant may not be on-site.   In these instances, consultation/collaborative agreements must include contingency planning for alternative assistance in unexpected emergencies.  Communications between the midwife and consultant must be undertaken in accordance with pre-approved written plans, with both individuals understanding their roles in emergency situations. 

         Naturally, in the midst of an emergency, you cannot be at the computer.  Take whatever notes you can (on scrubs, glove packages, random pieces of paper, etc.) so you can more accurately transcribe events later. Providing real-time information will be helpful if a claim is filed against you. Time passes, and memories fade. Documenting conversations and events as close in time as you can manage will be helpful in case of unexpected problems.

Remedies/Protection

          Discuss the issue of back-up availability with your consultant and reach an understanding regarding other options for times when he/she may not be available. Work these details out in advance and have it in writing. If the hospital where you deliver has laborists, determine whether any of them may have problems stepping in to assist a midwife.  From a legal standpoint, hospitalists and laborists do have a duty to respond to requests for medical assistance, whether from an MD or CNM.

https://www.midwivesontrial.com