Grow Midwives Webinar Follow-up: Transitioning From Hospital Midwife to Birth Center Midwife

March 20, 2018

Grow Midwives transitioning from hospital to birth center

 

Join Lesley Rathbun and Ginger Breedlove for a thorough discussion on the difficulties, benefits, and drawbacks of transitioning from being a Hospital Midwife to a Birth Center Midwife. Lesley and Ginger have been involved with many midwives before, during and after their move to a birth center – including their own. Making such an important career choice is daunting to many, but Lesley and Ginger are here to clear up many of the misconceptions that surround the birth center model of care.

Interested in working with Lesley and Ginger one-on-one for career coaching, consulting on negotiations, or general Midwifery Consulting? Don’t hesitate to contact us and get something on the books!

IF YOU WOULD LIKE TO FOLLOW ALONG AT YOUR OWN PACE, YOU CAN USE LESLEY’S PREZI HERE.

Lesley: [00:00:01] Make sure you're all muted would be great. My name is Lesley. I am a certified nurse midwives and a family nurse practitioner. I'm in Charleston, South Carolina and I own Charleston Birth Place and I'm a recent past president of the American Association of Birth Centers. Ginger Breedlove, who is on mute currently, is the past president of the ACNM and has also birth center experience going back 40 years. So between the two of us, we should be able to give you a good idea of what it's like going from in-hospital midwife practice to a birth center practice.

Ginger: [00:00:49] Lesley, we still have somebody who's whose microphone is open. So for others, just so you know, we have these transcribed verbatim and also share these on our website. We would really like for you to take just a minute and make sure your phones or computers are on mute. Thanks so much.

Lesley: [00:01:15] I think that did it. Thank you. So the transcription will be ready, usually it's about a week to ten days after we finish this and then it will be on the website. And then you can re-watch or share. So we're going to start reviewing birth centers. So the American Association of Birth Centers is the membership organization for the birth center industry and the CABC is the Commission for the Accreditation of Birth Centers, that's who accredits first centers. So AABC writes standards for birth centers and then the CABC takes those standards and uses those to make indicators for birth centers who are seeking accreditation status.

You do not... Most states do not require accreditation. You don't have to be an accredited birth center to be a member of AABC either. We're getting more feedback again, so everybody check your mute. Some states have specific licensure for birth centers and some do not. It just varies and the licensure requirements also vary from state to state. For example, South Carolina does have birth center regulations. They're very old. They were written over 30 years ago, so they are quite out of date and they've caused us a bit of grief in the last couple of years legislatively. And then our neighbor, North Carolina, has no licensure for birth centers and we have about the same number of birth centers in each state. So the regulations for birth centers in the state are controlled usually through whoever it is that licenses health care facilities: hospitals nursing homes ambulatory care centers.

Those kind of facilities. And most of them will either have, like I said, no licensure requirements or they will be specific for birth centers. There's very few birth centers that are held to regulations that are not specific for birth centers in their state. So what is a birth center? There is a lot of confusion over that amongst everybody: midwives and regulators and payers, physicians and consumers, because the term birth center was not protected and it's too late to do that. It would be millions and millions of dollars and lots of lawyers and many years to try to now protect that term "birth center". So there are hospitals that call their maternity units "birth centers". Some of them are very birth center-like others are not at all. They just use the term birth center .

The AABC and the CABC is trying to change that by having it put into state licensure for birth centers, that they are not a hospital and it is in the AABC standards that and a birth center is not a hospital. The birth center is not a mini hospital. It's not a ambulatory care center. It's not a spa. It's a home-like facility where midwives practice midwifery and care for low-risk women who choose low-intervention birth. And there are a variety of models. There are ownerships by corporations there are ownerships by nonprofits there are for-profit ownerships and then there are FQHCs and then there are birth centers that are individually-owned, but either they're owned by midwives, but some of them or owned by nurses. Some of them are owned by doulas some of them are owned by the community that they serve.

So there's a wide range of the type and models for birth centers. But what's common for the majority of the birth centers is that they do closely reflect the community that they're serving. So if you're interested in a birth center and you're wanting to know, "Is this a quality birth center?" then you want to look for their accreditation standard which this is the picture here is the seal from the Commission for the Accreditation of Birth Centers, so accredited birth centers will usually will have this on the website. They also have it on the door of their birth center and it's not an easy thing to go through, so they're very proud of it and they're happy to share.

So what are the pros for working in a birth center? Full scope practices probably to me the number one and, because in a birth center you really do get to do every part of midwifery that you went to school for. Most centers do provide women's health services for non-pregnant women and provide contraception. They provide newborn care for the first month, breastfeeding support as well as pregnancy and birth. Some birth centers have models where they their midwives have hospital privileges so they sometimes will attend births both at a birth center and at a hospital. Some of those restrict that to only the mothers that they transfer, so they have privileges just for their transfer patients.

The autonomy for working in a birth center is another huge pro. When I asked my midwives this week as I was making his presentations, so tell me why did you like working in a birth center. And they all gave me this kind of, "Is this a trick question?" but the consensus was you just that you don't feel like you're being watched or that you're on the clock. You're free to do midwifery and that when they transfer a patient to the hospital they always feel like there's somebody looking over their shoulder.

And when it comes to a low risk healthy mom, they don't want to have to prove that what they're doing is appropriate. There's a slower pace to work in a birth center. The prenatal visits generally are 30 minutes to an hour. So you're not going to be expected to see 30 patients in a day prenatally. The birth center work you rarely have more than one or two moms in labor at a time and if you do they call in more staff. So you're not managing four or five women in labor, just one or two. You have less of the busy work.

So there's not as much of the red tape and the minutia that comes with working in a big hospital or in a large practice or a corporation where the charting in birth centers is very simple. We do have a EMRs that are specific for birth centers and it's the difference between just the computer work and the charting the midwives that come from the hospital practice to birth center they're just ecstatic with what little red tape that they have to go through at the end of a birth. It can it can take them 15 to 30 minutes. It's not going to be hours of work.

The personal relationship you develop with the clients, because you do have these long prenatal visits. And our birth center has five midwives and the patients rotate through them, but they all get to know us each a little bit before the birth, but then when you're laboring somebody one-on-one through natural childbirth for several hours you become very close to that client. And you know one of our biggest problems with the strong personal relationship that they can develop is then when the midwife wants to special that patient when she comes back in then that can cause havoc with your schedule.

But it is nice to see that our midwives make friends and you see them going to these children's birthday parties and they become a social network with them too. You really do have a huge sense of that community, not just the community of the midwives where you're working, but that community includes your clients and there's a huge, rapid response to change. If you want something to change, you change it today and it's implemented that minute. You don't have to go through lots of committees and approvals and corporate approvals and, you know, all of the change that you do in a hospital can take sometimes months, if not years, to make even incremental, small changes.

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And I'll give you an example of that here in just a minute. One thing that the nurses like is we mix our own ampicillin when it's time to hang antibiotics for [noise] so we don't have to wait for the patient to get admitted and then the orders to get in the computer and then that order to get to the pharmacy and the pharmacy to get it to the floor and in the Pyxis. You know sometimes you can waste a couple hours before you can even get the antibiotic. We just go in the work room and spike the bag and add the antibiotic and hang it, it takes two minutes.

Innovative new treatments are welcomed, so we'd like to see new things that can help a mom through labour and birth that has a very low risk to benefit ratio. So that's what I was going to talk about some examples. So this is a very blurry picture. But it's like a picture of a picture that I took. But this is actually a student of mine who when I opened the birth center it was the two of us and them when she had her baby she came back to the birth center and we had she was in labor when we happened to have an acupuncturist coming to talk to us about acupuncture and she was you know typical pregnancy having kind of a long prodromal labor. And he was lecturing how it could help, so I went in there and like you want to try this because he's here. She's like,"Let's do it." And so we just did it and it worked beautifully for her. Within 30 minutes she transitioned from that long prodromal into active labor and had a baby very quickly.

So it was, you know, when you, when you present things like this in a smaller birth center type, you have a little bit more wiggle room into trying things without, you know, waiting for all the different departments of the hospital to approve.

Another one is nitrous oxide. So we were either the first or within the first one or two birth centers in the country to offer nitrous. I'd been watching it and I'd been a huge fan following Judith Brooks' works. Tried forever at the hospital I worked out to get it into practice and I had several physicians, nurses that were really on board with it. That hospital still doesn't have it.

And that's, you know, 12 years later. But soon as the Nitronox became available on the market, we bought our machines got our nitrous render policy and procedure, got it approved through our advisory committee and had it up and going within just a day or two of getting at it and being able to offer it to our patients. And so that's another huge example of how you can get something started really quickly as opposed to having to go through all the stuff of the approval of all the various departments and then when you add in getting being the change agent to get, you know, all the players on the team on board. As you all know that can be an even bigger challenge.

So what are the cons? Salary and benefits. But what I want to say with that is don't be scared off from that. There is a wrong assumption that if you work at a birth center you're going to be grossly underpaid and get no benefits and that's generally not true depending on the size of birth center and I'll show you some charts with that in a few minutes, but you also got to look at your job satisfaction and your time on-call versus off-call and you know there's another webinar that we did talking about benefits and salary.

And a lot of the things that you can't put a dollar sign on are where birth centers really excel in, so when you look at the salaries don't get too discouraged, but they also are going up for birth centers as we see more insurance payers covering and seeing the value in what we do in getting higher reimbursement rates. And I personally see that getting bigger and bigger.

But the majority of birth centers do provide benefits. The same basic benefits you would get working in a large position type practice. You do take call, which many midwives who work in practices that do hospital birth also take call. But some of that as a shorter shift like a 12-hour shift. Most birth centers do 24-hour shifts. The smaller birth centers do longer call shifts, but the likelihood of coming in on call with the birth is much, much lower.

So when I first opened I did it by myself. So I was on call 24-7 for ten months. But the first month I did seven births and to a home birth midwife that sounds like wow that's a ton, but to midwives who work in the hospital, they're like well that's one day's work. So those seven births meant that I really only got called in seven times.

Now that's not counting, you know, office hours and when you take call, if you go from a practice where it was more shift work like doing 12-hour shifts or maybe you're working in a clinic where it's a Monday through Friday nine-to-five type position. When you take call you can't carry call around like a backpack on your back full of bricks. You need to enjoy your life when you're not being called in. Most birth centers, you can take call from home as long as you live within, you know, a certain distance to be able to get to the birth center. So you just need to remain sober and rested and available to come in.

But that doesn't mean that you have to sit with your hand on your cell phone waiting for the call to come. You have to learn to kind of let that anxiety about being on call go. There are definitely fewer job openings because there are fewer birth centers. But we're seeing that change. And I really do and Ginger will have her turn when she's not muted later and can give her opinion on this, but I think I'm safe to say we both think that birth centers are really going to start exploding very soon in the very near future. So that's going to be a big change.

Not having ancillary services: most midwives who work in hospital practices don't give housekeeping and laundry and food service, janitors environmental services, any of the maintenance guys, security. You don't give them much thought. They become a luxury you realize when you work in a birth center, because you're doing that, you're doing the laundry. You may be mopping the floor. You may be heating up soup for your client.

So you have to be the kind of person that doesn't feel that they're above or below any, any duty. It definitely takes a team and I've had grandmothers waiting for baby saying, "Is there something I can help you with?" when we were busy and it's like, "Yeah, you can rotate the laundry and fold these towels" So you just, everybody pitches in and helps get the work done.

Less in-house support is probably the biggest thing for that transition is getting comfortable with not having that button on the wall that you push and the NICU shows up or being able to just stick your head out the door and say, "I've got a shoulder in here." And you know people are going to show up to help you and know what to do.

So you have to be able to screen very carefully the patients you accept into your birth center care and continue that screening all the way to the point that she's discharged home. That's always something that's in the front of your mind. You know, if she's starting to develop issues that is making her lean more toward needing medical intervention than not and when they start going toward they might need more medical intervention. That's when you start thinking of going over to the hospital. You should have very, very few emergency transports.

A vast majority of our patients that are transported to the hospital driving their own car and walk up to labor and delivery. So we're not talking big ambulance lights and sirens code type situations. In 10 years and 2500 births. We've only had a handful of those. Only two that I would say were true stat code c-section type situation- a prolapse cord and a abruption, but then we had trained for that. We had a plan in place. We had good relationships with our doctors and our hospital.

So from the prolapsed cord or the moment the woman walked in bleeding that was obvious she was well beyond normal bloody show. We just text our doctor 911 and from the cord prolapsed to the birth was 15 minutes and from the abruption to the birth was 12 minutes, so that included getting her over to the hospital, getting her in the OR, getting the IV in and getting anesthesia on board. So you have to practice for these things, so that when they happen they happen quickly and smoothly and know that you're, we're going to tog over this in the pearls. But you're you're not alone. You're just a phone call away from advice and help.

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Lesley: Covering two facilities. So when a birth center does have hospital privileges even if it's just transport privileges, you could have somebody in labor at the birth and somebody in labor at the hospital. So you have to plan a backup call for in case you have two births going into separate facilities. So sometimes there's a little more call even though that second call you are much less likely to be called in.

Anybody who's ever worked covering two facilities when I was a hospital midwife, we had a sister hospital and you know the docs never told the patients that if it was nights or weekends we most likely would ask you to come to whichever facility we were at, so that we didn't have to go back and forth and there was a train track in between that could take forever and you know just trying to run back and forth between births is never a good thing so that's why we always have a second person on call to cover the hospital or the birth center.

Usually what happens is they decide when to call in. It's like, “Okay, I've been with this mom for 14 hours. I want to go with her to the hospital.” That's almost always what it is. The midwife who cared for the mom usually wants to go with her to the hospital. It's like reading a book and not getting the last chapter and then maybe she had a postpartum mom in the birth center, so the second midwife comes in, takes care of the postpartum mom, and then gets to go on go back home so they rarely work a full shift.

The lack of awareness and I almost put lack of consumer awareness, but it's really lack of awareness from everybody. Many people don't, have never heard the term birth center. And if they have they, they have this strange idea of what a birth center is and I think most midwives are used to that, because we get the same thing when you tell people you’re a midwife.

That's changing a ton and it's the same thing is changing with birth centers. I don't have to explain what I do and I don't get as many “huh?” kind of looks as I did 10 years ago when I open, but they're still out there and there's definitely a lot of education that needs to be done for everybody: for nurses and physicians and consumers, payers, everybody on exactly what a birth center is.

Any time we've had somebody that was very skeptical - a mother in law, you know, the grandmother of the baby and we'll tell the mom just bring her in, bring her during your next visit. And any skeptical person, they always say the same thing. “This is not what I thought it was going to be.” So, not sure what people imagined it to be, but we always tend to be a little bit better than that.

The physical labor part can be tough. Remember you're doing the laundry, you're likely to be mopping a floor or cleaning a tub. Now we can't just push a button then housekeeping shows up with their cart to turn a room over.

Our birth center, we do now have a janitor that will come in and clean the rooms for us when we're gone. But there are times when we have to turn a room over pretty fast, so we're still doing quite a bit of the cleaning, but most birth centers do water births and if they're not water births they are bed births. So you don't have a bed to break down. There's no stirrups to hold her legs.

One of the physicians that was a maternal fetal medicine doctor. He toured our birth center and he looked at the bed and he was like looking under it and I was like, "What are you looking for?" He goes,"How does it break down? You know, where are the stirrups?” And I said, “We don't have stirrups.” and he said, “Well, what do you do with their legs?” and I said, “Well, sometimes they're right here on my shoulder.” He had a look of horror on his face like that is nothing that he would ever even consider doing.

So you know your arms and legs and back and you have to be very cautious of your own body mechanics and things like that because it can get pretty physically tough. And then there's also emotional fatigue when you're laboring somebody one-on-one through unmedicated childbirth. It's exhausting at the end of it, but it's a satisfying exhaustion.

So here's the thing probably everybody has been looking for. This is the from the AABC survey of their member birth centers and only a portion of those answered. So we're talking just a few. If you can you can see the numbers up here. So it's not representative of all birth centers across the country, but it's just what we got. So, as you can see, the smaller birth centers are going to have less salary. And they're also going to have much less work.

The majority of busy birth centers I would say range in that 150 to 350. Those two boxes there that's where you're going to see a lot of birth centers starting to pop up in that three to four room, instead of just the one or two room, which would be the smaller ones and then there's few that have more than 350. Those are usually four to six room birth centers. So they are much bigger, so birth centers can be all CNM centers staffed with all CNMs they could be staffed with CNM and CPM or licensed midwife combination or exclusively with CPMs and licensed midwives.

So the salary range is lower for the CPMs and the LMs. We did include CMs in here, because there are a few of those out there in birth centers mainly in the New York area. So these are the average, so if you look inexperienced in a 250 births or more birth center around 74,000 per year experience 85-to-89 thousand. So that means there are some below that and some that would be above that.

Where are the birth centers located? All over the United States. Alaska. None in Hawaii yet. There's a few states that don't have any, but they're few and far between. South Dakota is one of them and Ginger and I recently visited them and hopefully they'll get one soon. But in Alabama it's another one in Mississippi so there's a few that have none, but mostly they are scattered throughout the United States. And what I see when midwives are looking for a new job, two of the big priorities are salary benefits and location. So sometimes they will take a less salary to be in a more desirable location, than the other way around and the number of CNM to CPM birth centers that are members of the AABC are about 50/50. There is currently 350 birth centers in the United States and only about half of those are accredited.

So hospital birth, which is what many of you may be more familiar with. When you’re students, you tend to get more experience in hospital midwifery than in birth center or home birth just because there's not as many opportunities for preceptors in the out of hospital births. So there's a lot more job opportunity in that the hospital based midwives that familiarity, you knew about it when you were a student. Other people know about it. It's not anything you're going to have to necessarily explain to people that you're attending births in a hospital. They know how that works. Salary and benefits can be higher in larger corporations.

Ancillary support services, so you can call housekeeping to clean up the placenta that fell on the floor. You can order a tray from room service. If it's late at night you're walking to your car, you can have security walk you to your car or there's lots of people around to help you do your job and feel safe doing it.

You also have the in-house support. So there are other nurses on staff. There may be other midwives. There may be hospitalists, physicians, you know, there's a NICU team. You’ve got anesthesia. You've got all these other professionals that are there to help and support you depending on the size of the hospital, but at very minimum you have nurses that have NICU training and training in NRP and the equipment and skills that go along with that.

Generally we do have that in birth centers where you have at least two people for every birth and both of you trained in NRP, but it's not like you push a button and more people can come running it, so some very small rural hospitals do operate similarly to how a birth center does when it comes to staffing.

The public acceptance of the place of birth. So nobody's going to question that work. Well, you know, I take that back now. There are people who think midwives should not work in hospitals. That they should work out of hospital. But for the most part it is an accepted place to give birth, as in the hospital.

Developing client relationships, of course, you can develop very close client relationships with your hospital patients. I didn't want to make it sound like you can only do that if you if you work in a birth center. But depending on the type of model that you're in, if you're a laborist in the hospital, you may not have ever met this mom before. And if it's a busy night you're running catch a baby and move on to the next patient. So you might not get to feel like you develop much of a personal relationship with her.

It is exhausting. Of course, all midwifery work pretty much is exhausting, but you do have slightly less physical labor with hospital midwifery. You have other people to help you if you need to hold the patient, move the patient. You also generally when you're, if you have the opportunity to do water birth, you could still have the same problems as far as having to lean over the tub or midwives, you don't break the bed down, but you don't when you're done with all of that, you don't have to clean the room and mop the floor and do the laundry to go with it.

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So this is the picture of...I’ve tried to throw more pictures on here. I just don't have that many pictures of me working. Apparently just holding babies. But this is a picture a dad took of us going back to a c-section. That's our consulting physician Dr. Martin who's wonderful, so this is our hospital I'm headed back to the OR, so that's what you look like when you work in a hospital.

So the kinds of hospital work is lack of autonomy. You many times are dictated how you practice by the policy and procedures of the hospital or your policies and procedures and guidelines of the practice with you work and or both. RVUs, which is when you’re judged on your productivity.

So you may be required to see so many patients per day in the office and they may give you quotas to reach. So having to live up to that hurry up and get on to the next patient can be a stressor.

Sometimes you have to balance call and office where whether you're on call you're also covering the office and running back and forth. And there's definitely more busy type work in those types of settings. Depending on the size of the hospital you're in, the bigger the hospital, the bigger the corporation, teaching facilities, there can be all sorts of, you know, screens you have to go through to get even to the part where you want to put your orders in. And it can just take longer.

No sense of ownership in the decision making process. Many times midwives aren't even asked to serve on any of the committees. So you might not have as much voice in how things are done and any change is slow to occur.

So you've decided you're going to work in a birth center. So these are some things that would help, pearls to make it a little easier on you. And I've divided them into a newborn care, interment consultation, labor support and range of normal. Those are kind of the big things that can be a bump in the road or fear as you move from the hospital to the birth center.

And newborns I put number one because many times that's the thing that the midwives have the most aches over. Yes they have newborn education and training in school. But it might have been a while since they've used it, you know, in the hospital when the baby is born if there is a resuscitation it's handed off to a nurse and the resuscitation team is doing it. If a pediatrician is coming in and managing the baby and doing the newborn exam.

So to be in charge of all that on your own you likely need to re-educate yourself and make yourself more familiar.

With the newborn resuscitation, like any other kind of resuscitation skill, the more you practice the better you're at it. So NRP now has these great little video modules for practicing on. And those are very helpful.

But also, when you're in the hospital ask how to bag that baby, you know, ask to participate in the codes and make sure you keep your NRP and all that very current, so that you're not going to be like a fish out of water when you have a stunned baby born.

Some of the things that are done in birth centers that might not be done in a hospital setting that are helpful. One it is called a placental transfusion. Some of your county hospitals may also do that. But it's just where you lower the baby lower than the placenta and then you get a dumping of placental blood into the baby.

As you know many of those stunned babies that come from relatively normal labor and birth can be so just from some cord compression there right at the very end, so you give them back that blood and they just magically wake up crying and get pink.

So at our center we have we purposely bought tubs that had a very wide lip. So we have a dry towel there, so when the baby's born or if it is stunned we will place the baby on the side of the tub and have mama stand up. And I would say at least 75 percent of the time that takes care of that stunned baby without having to grab for the bag and mask.

A fast cath is UV access without actually putting in an umbilical vein catheter. The NRP guidelines now say that you have to have the training and the ability to provide IV access on a newborn regardless of where you are or your credentials.

So this is something that's been developed for health care workers who are intimidated, not as familiar with umbilical vein catheter placement, so that you can get that rapid fast access. And you take an angiocath, and IV angiocath, a 14 or 16 gauge, tie off the umbilical stump, cleaning with the betadine. Cut it like you would for a UV line and take the needle out of the catheter. Place the catheter in the umbilical vein and you'll see flashback and then you can hook that up to an extension set with the stop cock.

And most of the time that would be used in a situation in a birth center was either to give Eppy or to give some volume in a baby that might have had a blood loss at birth, an abruption or Acorda bolster or for something like that. And it's a lot easier and more comfortable if you think of this fastcap method and I think you're going to hear more and more about this, because they're recognizing that not all babies are born in hospitals with NRP NICU teams that come rushing with their magic stuff. So they are starting to look at the out-of-hospital but it's very similar to where the LMAs were a few years ago.

You know, when they came out we were like, “Oh, I'm not going to be able to do this.” So much easier than intubating a baby. So now you can you can use an LMA to get an airway and you can use an angiocath to get IV access and be able to provide the same type of resuscitation that they would have in the hospital in the birth center which is very important.

You need suction you need oxygen you need the same emergency equipment and procedures that you would have. The baby shouldn't be at a disadvantage due to the place of birth. Newborn exams. You’re going to have to do your homework and go back to the books and study the normal newborn. There are some online things now that back, yeah, I graduated in 2004 everything was still you know in books, but we still have the books there at the birth center so people can go, “Hmmm, that looks funny and let me look that up and see you know that's a little bit different.”

Examine as many babies as you can. So every baby that you attend the birth of, you do a head to toe exam on that baby. Go to the nursery. Hang out in there. Get to know the nursery nurses. Make friends with everybody.

And one of the first things that I did when I decided for sure, you know, getting really serious about opening a birth center is make sure that I develop a relationship with a friendly pediatrician who is very helpful in helping me write our guidelines and policies on what to do with babies. And then she's on call just like the obstetrician is and we call her more for advice then actually needing to transport babies.

But I would say it's almost equal to the amount of consults that we do with our obstetrician. So common issues that newborn babies will have that you need to be familiar with is hyperbilirubinemia so knowing which babies are at risk. Knowing what the norms are for the hours of the age. There are apps now for these things, which are wonderful, but some are little better than others, so you'd want to check with your friendly pediatrician. Same thing with hypoglycemia. You can get the glucose gel and have that in the birth center to give a low blood sugar baby as opposed to having to give formula or something more fat.

And then as you're following these babies for the first few days or weeks after most birth centers do have parents, have a pediatrician that sees the baby within the first week. The birth centers continue to follow the baby and the mom together primarily with the breastfeeding, so many times we may pick up that slow to gain baby that pediatrician didn't, because the baby was fine when the pediatrician saw it on its three-day-old visit. They didn't make another visit for two to three weeks. And we see the baby at a week to ten days and we see that that baby has lost you know over 20 percent of its body weight and is really needing help. And then of course there's the breast feeding. Lactation support.

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Intermittent auscultation might not be something you're familiar with. You learn about it when you're in school, but having the opportunity to do it on a routine basis was rare. Hopefully that's changing now that we are promoting physiologic birth in all settings, not just birth centers and hospitals, but if you're not familiar with it, what you need to know what you're already doing it even if you don't know you're doing it.

And that's when you're sitting at the desk or you're in the patient's room, but you're not looking at the monitor and you hear something that causes you alarm. Then you go to look at the monitor and we've all done that. So you're already doing intermittent auscultation. You hear that cadence and you know what's good and what's maybe not so good.

A1 has the guidelines for intermittent auscultation, which is what most people use and that's generally what the standard that you'll be held to. You want to get a really good Doppler. Occasionally I have parents ask me about that $50  Doppler that you can buy at Target, is that is that any good?

Well if the fifty dollar Doppler was as good as mine, do you think I'd pay eight hundred dollars for mine? And the answer is no. So you want to get a Doppler that the probe can go into the water. You also want a Doppler that picks up the heart tones very easily, that doesn't have a lot of static in background. And what's ideal is it has a digital readout of the actual heart rate, so that you can be watching it and you can see the variability if it's going you know from 134 to 142. As you're listening over a minute or two you know you've seen that variability. You're hearing it as opposed to seeing it printed on on the strip.

You can also do intermittent consultation on stress tests where you listen. And then as the baby moves you count the heart rate. And for how long it goes up and is equal to doing a N S T on a strip.

Some birth centers tease or run a strip when mom is admitted in labor and there's pros and cons to doing that. Some of that is a legal liability issue. You have, you know documented strip that this was a baby that met criteria to be admitted for a play in birth center birth. But intermittent auscultation is accepted and has been defended in court cases as appropriate for a woman who meets criteria to give birth in a birth center. So you may see some that do run a strip and some who don't. But you cannot keep a mother on a monitor in labor.

If the mother needs monitoring, the mother needs in the hospital. So you transfer any. You wouldn't want to waste the time of transferring her by getting the monitor, putting her on it, watching it for longer. You're just wasting time. So then they need to go on to a hospital for continuous fetal monitoring.

Labor support - that's kind of one of the pearls of midwifery period. But some, depending on the type of private practice you are in. The practice I was in was very busy. We had seven physicians and five midwives and so we could have I think the most I ever had labouring at once was ten patients. I'm not providing labor support for 10 people. I'm barely being able to keep up without drowning in the work that you're doing. So I attended some of the local childbirth classes to brush up on it.

I worked with some of the doulas. You definitely want to network with your home birth community or other birth center midwives. And then, of course, there's lots of books and apps and youtube stuff on all the latest, but Penny Simpkin’s stuff is wonderful. The Birth Partner, if you haven't heard of that app called Ibirth. It's an app that some hospitals and practices give their clients as a benefit of using their practice.

We use it for our birth center patients, but you can also buy it individually. And it is literally like having a jewel in your pocket. It has videos that says if she's having back labor then you just push the video and it says, “This is how you do hip squeezes. This is how you do around the world. This is how you do a rebozo.” So it's like a cheat sheet for your pocket.

So the range of normal. What is normal? And I think you know abnormal when you see it, but you don't always know normal, because the terms normal and low risk don't have a set definition in medicine. It's more exclusion.

You don't have anything wrong, so therefore you're low risk or you're normal and everybody has their own comfort level in your community, where you're practice, how your birth centers set up how close it is to the hospital the relationship you have with your hospital and your physicians. You know there are certain criteria and standards that are going to be set for you.

The standards for AABC and the AABC accreditation indicators and your licensure in your state may say, you know, a common one is 37 to 42 weeks so anybody less than 37 weeks not a candidate for birth center anybody over 42, not a candidate. Other things like insulin dependant diabetics, multiple births, breaches. Those are pretty standard. But then when you look at things like a well controlled gestational diabetic with no other no risk factors, that may be individual birth center to birth center as to how they would handle that patient.

So you're going to have this huge range of normal. But when you're in a birth center, you're always thinking is this mom on the path of least likely needing medical intervention and once she starts heading to that more likely to need medical intervention. That's when you start to consult and think and talk to the mom about this may or may not be the best place for you. We all know that birth is a normal, healthy physiologic event that... my dad's calling.

Sorry about that I did not know that what happened.

So we know it's a normal, physiological event that has the potential to become a medical emergency. So as the likelihood for that potential to be a medical emergency starts going down that path, that's when you start thinking about, “Should we be delivering this baby and this mummy here in this building?”

With physiologic birth, the pace of it is a wide range and you can't predict. They always fool you. You know you can have this little prime app who comes in and she's 44 centimeter to 100 percent effaced 0 to plus station that her 38 week appointment and you tell her, “Oh, you're going to have this baby quick!” And she ends up with a hospital transfer in a forceps delivery or a c-section.

You know, not what you'd anticipated or the opposite of that. You know you have somebody and you think I don't know maybe we shouldn't have accepted her as a patient. You know, she seems like her BMI is right on the edge and she's gained a lot of weight and she's very needy and always calling and doesn't seem real sure that this was for her and then she comes in and, you know, has her baby super fast.

And, so, you have to be able to just live in the moment with that patient. Some of our multiples will have these labors that they labor really will get to eight centimeters and they get tired. And they say I'm going to go take a nap and their labor stops and they go take a nap for hours and you're like, you know, let's get the show on the road and they’ll wake up and have their baby.

We had a woman not long ago who got stuck at 8 centimeters and her contractions kept getting less intense further apart. And she said, “I'm hungry. I think I just want to eat.” And she had brought spaghetti and meatballs and she had a big plate of spaghetti and meatballs. And 30 minutes later had her baby. So, you know, she knew what she needed.

So as long as mom and baby are both well and things are moving along. We just have to have patience. And I think that's why a lot of midwives knit. It gives your mind and hands something to do so that you're not jumping in and intervening in a process that is at its own pace and not necessarily at your pace.

So I was going to stop and take some questions here. And then also we we can tell you our stories. I've told you a lot about mine, if you read the blog you saw how I got started with just frustration with the job I had and just decided to make my own job. So how do you want to do this, Ginger?  

Ginger: [00:51:46] We're sitting with about 16 people, so if people want to use their microphone, I think that would be OK.

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Lesley: [00:52:03] You want to tell a little bit of your story. Ginger while people are thinking of their questions?

Ginger: [00:52:08] Sure. You know my story started back in 1979 when I had worked for a year, my first year right out of nursing school, as a charge nurse in labor and delivery on the evening shift. That's when we worked eight-hour shifts. I was sharing with an undergrad nursing program yesterday that I lectured at that I actually got in trouble towards the end of that year, because I started giving moms ice chips and letting them get out of bed go to the bathroom with their 1000CC enema we had to give them and shaving them from their navel to their knees and started breaking the rules enough that my charge nurse came down on me and said, “You know, if you can't follow the protocol then maybe you ought to leave.” And I said, “OK, maybe I do need to leave.” and was fortunate in that a family practice physician and a very good friend of hers who was also an RN in labor and delivery had began a private practice focusing on obstetrics and women's health. So I was literally hired to go sit in a building built in the late 1800's that eventually came a birthing center the first state license birth center in the nation in Topeka, KS. Two birth rooms on the first floor. Three exam rooms on the second floor. Big teaching area in the attic area. It's was a glorious pregnant looking building and that was the first 14 years of my career. So I really had the opportunity of knowing hospital based care well. I was a scrub tech in labor and delivery for two years while I was in nursing school then became a charge nurse, so I had three years of hospital... of hospital culture. I was going to say indoctrination, but I do believe hospital-based experience lends to one’s critical eye and intuition about what is normal and what is moving toward not normal. And that's a great intuition to have when you come into a birth center environment.

I think we know that when we graduate. That's one of the core expectations of minimal competency upon your graduation. But I do believe that the more you practice in a hospital environment, the greater the tendency is for one to develop more concern about how that range of normal is interpreted both in the biophysical markers of the mom, but in your observations.

So the first 14-years of my career after that, one year from nursing school in labor and delivery I was at a birth center and it really grounded me to go on and do the other things I did later. I guess what I see now in my more recent transitions in work I've done is that nurses and midwives, both, that I have hired over the past couple of years to go work in a birth center environment needed a greater deal of time to break down their fears and anxieties and sort of separate out how to manage a patient because of the loop that you have when you're in a hospital environment.

So I think there needs to be, for your expectation as well as those you work with, kind of an on-ramping period where you can feel free to perhaps transfer where maybe a colleague would not or be more willing to step forward and say, “Look I'm not sure about this. Can you give me feedback on what I see or feel or hear or believe?” And the other piece especially for the midwives is, “What is your relationship with the consulting physicians?” So both both the obstetrician or family practice doc and the pediatric side. What kind of relationship do you have with them as you start independently in your role? Have you had dinner or breakfast with them? Do they know who you are personally? Have they looked at your resume? Do you know who they are?

And the sooner you can establish a confidence in your self as a provider with who your collaborating physicians are, the more comfortable you're going to feel, as Lesley said, you're only a phone call away. Well, you're only a phone call away if you have the trust of the person on the other side.

So it's really really important you take the initiative or the facility you're going to takes the initiative to make that happen. And the other thing I'm just going to reiterate, because I think this is the most challenging for midwives especially those who have been out for a while working in hospitals, is taking care of that newborn.

It is like a deer with the headlights when you say, “OK now you're going to manage independently that baby and you're going to do the exam. You're going to discharge them to home and they're literally your responsibility until that baby sees a pediatric care provider.

That is terrifying to a lot of people. And, as Leslie said, there are a tremendous amount of resources online now. That may be a topic we should think about doing, Lesley, is is caring for the newborn just by itself. I can not under state how much of an issue that is and if it's not an issue and you haven't ever cared for a newborn, it should be.

Lesley: [00:58:18] In the majority of problems from birth centers, it's the baby that pays the price. So that's you know it's very important that you are familiar with resuscitating that baby and recognize if they’re distressed early.

We are at the top of that hour, but since we did offer questions we're going to stay on as long as you have questions and we'll keep it recording for those who are on a time constraint and need to hang up if you might want to listen later. So feel free to chime in with any questions.

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Ginger: [00:58:53] There is there is a couple of questions that have been typed in, Lesley. In your opinion, what is the best midwife-to-client ratio, in labor, in a birth center setting?

Lesley: [00:59:07] So, each mother needs one-on-one labor support. So, if you have more midwives and doulas that can come in and assist. I would say no more than three-to-one with a midwife and it should be an uncommon occurrence that there's a 3-to-1 situation going on. Usually that's, you know, one of those nights where everybody comes in at 8 centimeters at the same time. But that's when you do start calling in your extra help and, so like in our practice, we have an employee that we can...

We're starting a new medical position it's called a midwife technician, so she's a doula, she's a paramedic, so she can start IVs, she can draw blood, she can get vitals, but she also can do labor support. So sometimes you don't need the full RN, but you need some somebody to help with the labor support. No mother ever wants to feel like she's getting slighted.

Ginger: [01:00:09] I would just add here too that it also depends on how the center markets the model of care and you're going to tell your patients that you're going to have a midwife from the time you're admitted until birth or shortly after birth, then you better provide what you're marketing. It's a very important concept to understand. And there is not one model. One of the things I've been saying on the circuit for a couple of years is, we do not have staff ratios in the birth center world like exists in the hospital model. So it's still I think an evolution, but that's just my two cents.

Here's another question, “I'm interested in and in-hospital birth center I know Mercy in St. Louis is one. Do you know of others?”

Lesley: [01:00:57] So according to the AABC standards, you cannot be an in-hospital birth center. It must be freestanding. That's fairly new in the last year. There are only and I'm not sure. St. Louis is one of them to be honest with you but there was only three accredited in-hospital birth centers. But there's a lot of physiologic birth units that have midwives that call themselves birth centers but they're not accredited and they may or may not hold to the standards for birth centers. So because we want more physiologic birth and we want more models of different types of birth centers, the AABC has a separate membership for alongside or midwife led units. I'm not sure what they're calling them. In Europe they're called alongside birth centers. They have free standing, alongside, in-hospital. And then the CAB is developing an accreditation for that which will be similar to Baby Friendly. And I think that's where a lot of those type units are going to fall in and it's a wonderful thing.

The more physiologic birth units availability for mothers the better. But there are a lot of hospitals that say they are centers, but they still do things like a vagina breech birth or some monitoring or the mother can decide she wants an epidural and she gets it in the same room. That would not be a birth center.

Ginger: [01:02:39] Yeah, I think one of the things that's going to start happening as birth centers explode, which Leslie and I know from our own current work is happening, is that the insurance industry is going to get smart. Right? They want to pay what they believe should be a lower cost for a freestanding facility than to pay the same amount they're going to pay for a woman laboring and birthing in a hospital L&D unit. So they're going to catch up sooner than later. And hospitals are going to realize pretty quick you cannot disguise a birth center by one definition and be asked to be paid three times higher than what the true birth center is going to be reimbursed at. So it's only a matter of time.

Lesley: [01:03:27] Right. And hospitals can still own free standing birth centers. They just won't be located within the hospital necessarily. It's much more expensive to have an in-hospital birth center, because every square foot in that building is having to help pay for the ICU, the NICU, respiratory therapy. All those services that these low-risk women that are coming in and having natural birth aren’t using.

Ginger: [01:03:54] Another question, Lesley do you have someone with you when you are laboring a patient: a nurse., B.A. etc. or do you only get a nurse when birth is imminent? .

Lesley: [01:04:07] So, B.A. is a birth assistant, so not all birth centers use registered nurses. It varies from state to state as to what your requirement and the model of the birth center may choose to have a specific licensed person. And for this birth center assistant which is different from being an L&D nurse we've had some L&D nurses that did not transition well to being birth assistants in the birth center that the AABC now is developing a birth center birth assistant accreditation. So if you're an RN with lots of L&D experience, you can test out of a lot of it and get your certification to help. And we're hoping that that's going to help make the transition to being an RN in a birth center a little bit easier as well as having the unlicensed people getting them what they need to be able to help you. But each birth center runs things a little differently, but an accredited birth center, once the mother is admitted in active labour, the midwife has to stay with her, so she can't leave and leave a nurse to labour that patient.

And it depends on the mother the, the midwife, and the pace of her labor. So some midwives, especially if you're new to birth center work, we would always anticipate when I have a newer midwife who's just starting doing call on her own who's just coming off from, you know, being shadowed with another midwife, she's going to call her RN birth assistant in way earlier and we're going to make sure we schedule an RN birth assistant that's very strong as well.

So most of the time the midwife will labour the mother longer than the nurse will be there. That the nurse won't come in until the birth gets closer or or she becomes very active, but it also depends on that mom. If that mom's needing a ton of labor support, you're going to need a second person who can help you.

Ginger: [01:06:06] There aren't any others typed in. I don't know if anybody has any they want to use some with an open mike or pitch out to us. We can wait a few minutes. We still have everybody on with us that started so...

Lesley: [01:06:24] One thing on that nurse thing, after the baby's born, some birth centers the midwife stays until the mother goes home. Generally for most birth centers that's a minimum of four hours, maximum of 12. Others, the midwife stays the first two or three hours and then the RN stays with them until discharge.

Ginger: [01:06:45] I would add one more thing as I think about, you know, what did I do in a hospital that I did that was different than being in the birth center and I would say that for those of you of work in systems with shared governance, that idea of sharing the work is very important to realize, so you're not going to have a quality of risk management team, you know, doing all that stuff that you rarely get your fingers on when you're working in a hospital that you will tangibly be participating in in a birth center.

You need to understand what the quality metrics are, what kind of quality improvement you're doing. Be very up to date on safety medication expirations. People have different jobs in the birth center environment that I think are unique to not having those responsibilities when you're in a hospital environment. That may sound sort of trivial, but that does add a little bit to the non-clinical work that you'll be a part of. And quite frankly I think it makes us all even better professionals by being more intimately involved.

Lesley: [01:07:59] And it's not for everybody. It's midwives who do birth center work become very passionate about what they do. And that's why they continue to do it, because it can be physically and emotionally and mentally more challenging than being in a hospital. But they really have a passion for it. They keep with it. I know when we have people come in and watch, like nurses, to come watch a birth. The first time, it's not unusual for them to either cry or applaud at the end of the birth.

Ginger: [01:08:38] Yeah, well, Leslie, I think we should end by saying you know that we're glad to help in any way we can. Leslie's presentation again will be put up on our website under the blog. We'll be pushing out another one in a couple of weeks, yet to be determined.

We love your feedback if you want to leave us any comments on the Facebook reviews or send us messages privately. We're here to help in a variety of ways and thank you so much. Leslie you want to end it.

Lesley: [01:09:09] Good night everybody and thanks for listening and good luck with all of you wherever you end up.

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