Hi Everyone! My name is Melissa Hatter and I will presenting my experiences during pregnancy and birth, viewed from both sides of the midwifery relationship—as a mother-to-be and as a midwife-to-be. I hope that you enjoy hearing about my delivery as much as I enjoyed experiencing it and telling about it! I also hope that you are better prepared to provide a positive experience for your clients, or that you are able to have a positive experience during your own childbirth.
Here is a little background information about me, to get us better acquainted. I thought it would be appropriate to share something about myself before giving you the dirty (and beautiful) details about my childbirth experience! As you can see, I’m married and my son is 18 months old next week. This picture is of him feeding himself oatmeal about two months ago. My husband and I were married in June, 2004, and we lived in Alabama, where we were both raised, until I completed my undergraduate degree in nursing. We then moved to North Carolina so that I could study nurse-midwifery and had plans to stay there for a while, but having a grandchild incited many pleas to return back to Alabama, so home we came. We are back in our hometown, near both sets of grandparents and many aunts, uncles, cousins, and distant relatives! Now that I’ve shared, I want to know a little about you. Please raise your hand if you are a midwife….Thank you….a student midwife….Thank you….other health care providers or educators....Thank you for your responses.
As I mentioned on the previous slide, I graduated with my undergraduate degree in Alabama, at the Capstone College of Nursing of the University of Alabama. I’m currently enrolled in the Nurse-Midwifery master’s program at East Carolina University and just took my finals last week and yesterday, so I’m on cloud nine this morning because I passed pharmacology by more than the skin of my teeth! Yea! I am officially in my Senior Year!
Some of you may have seen in the news that Tuscaloosa, Alabama, was recently struck with a devastating tornado. I live about 10 miles outside of Tuscaloosa, and the tornado passed about 2 miles north of my house. Needless to say, when the call came out for health care professionals to volunteer, I showed up, even though I had those aforementioned finals looming over my head. While out on a nursing team, I had the opportunity to practice this part of my presentation: one of the other nurses asked me about my choice to go into midwifery after she confessed that she hadn’t known that there were many of them around any more. So, here’s what I told her. Women have unique health care needs, many of which aren’t even recognized because of the paucity of historical research regarding women’s health. In addition to the differences in disease processes and drug effects that women experience when compared with men, women also must be concerned with the effects of their health on their offspring in a way that most men don’t have to consider. A woman’s health is directly related to the health of her fetus and children. In addition, the woman is often the one who makes health care decisions for her family; therefore, a woman in poor health is more likely to have an unhealthy family, particularly when it comes to nutrition and exercise. The medical model of care is based on the presence of disease and the practitioner’s attempts to cure disease. Women require holistic care that provides for their wellness needs as well as their health care needs; that is what midwifery offers to women. Midwifery gives women the choice to be cared for in a way that respects the integration of their spiritual, emotional, physical, and social needs. Women have the right to choose their form of health care and midwifery offered to me the opportunity to be with women throughout their lives, in whatever state of wellness they found themselves. Finally, family planning is so much more than prescribing birth control and performing pelvic exams. Often, physicians have limited time to provide for women’s counseling and educational needs regarding their bodies and fertility control; midwives are able to reach women on a deeper level by guiding them through their decision-making process for contraception and conception. These are just some of the reasons that I was drawn to nurse-midwifery as I was going through my undergraduate program. I saw the need for practitioners who could make a personal difference in women’s health in this region of the country.
So, as I look back on my life at what prepared me to pursue a passion such as midwifery, I come across my first midwifery experience. I was six years old and in kindergarten. We had a lot of cats at my house, because as you know, they reproduce rapidly if they’re not spayed or neutered. One cat in particular was my favorite. She was a calico cat, so naturally I named her Calico. She was pregnant with her first litter, and she might have fallen in the adolescent pregnancy category if I’d have paid attention to her age. I was determined that she not have her kittens under the shed like most other cats in our family. I wanted her to have a comfortable place to deliver, especially a place that I could see her. So I got a paper box and a towel and made a little labor room for her in my closet. Every day after school, I would go in the yard and collect my patient and take her to her room for delivery. There she’d stay until dinner, at which time my mother insisted that she be released back into the yard for the night. One day, when I got home from school, Calico was at the back door, crying. I let her in and she went straight to her safe labor box. There, I attended the delivery of her five kittens, three of whom are pictured here. I watched as she delivered each one, and marveled that she knew to break the amniotic sac and lick her babies dry. I mean, it was her first time, and her body just knew what to do. As a future nurse-midwife, I did not intervene, except when she rolled over on one of the kittens. Then, I thought it appropriate to move it out of the way while it’s sister or brother was being born. Little did I know then, but that experience would shape my life in the now-not-so-distant future.
After graduating with my BSN, my husband and I moved to North Carolina, as I mentioned earlier. I was working as a labor and delivery nurse at a small hospital when I found out that I needed a physical before starting midwifery school. I searched the Internet for midwives nearby, since there weren’t any at my hospital. I found two practices within reasonable driving distance and chose one over the other because it was new and I thought that they probably needed patients more than an established practice. In August, 2008, I had my first actual midwifery patient experience! I was thrilled! It was everything I had expected! The nurse-midwife came in and talked to me, found out that I was getting ready to start school and planning a pregnancy. She offered advice about both, performed my physical without any distress on my part, and sent me off feeling like someone special. When I had a positive home pregnancy test in March of the following Spring, my husband and I immediately decided to see the nurse-midwives, even though that meant passing up free obstetrical services at my hospital of employment. For Women’s Health was 1 hour away, and we made the trip with pleasure, knowing that we were getting family-centered care from our midwives. I’ll share more about our experiences in the next slide, but along the same line as our decision to use nurse-midwives instead of physicians, is the consequence of our choice. After delivery, I received a bill for the full cost of our hospital stay, about $10,000. When I contacted my insurance company to find out why they didn’t cover 80% like I expected, they replied that I received services that my hospital provided outside of the company that I worked for. When I replied that midwifery care was not provided by my company and that I required midwifery care during my pregnancy and delivery, they requested a letter to this effect from my CFO. Long story short, I was able to get such a letter, and the insurance company paid their part of the bill. Although I didn’t make my choice for midwifery care based on wanting to take a stand for midwifery, I felt like I’d made a victory within that organization, that I’d demonstrated that midwifery care is unique from medical obstetrical care, and that women should have the option of choosing midwifery care if that is their desire.
As you can see, the nurse-midwives that provided our care during pregnancy and delivery were Becky Yates and Rebecca Hunnycutt. I was excited to see that their clinic was used as a site for student nurse-midwives to gain experience. There were three students who rotated through For Women’s Health during the time that Aaron and I were patients. You may have noticed that I use the plural when describing my status as patient: Becky and Rebecca always ensured that my husband was a part of the pregnancy team. They answered his questions and asked him some, too. Even with me working night shifts and Aaron in school most mornings, we were always able to get appointments that met our scheduling needs. We really felt like our midwives cared about us as people, as a couple, and as new parents. We received individualized care that was both personal and modern.
Now here is my favorite part to tell. Our pregnancy had gone perfectly, no indications of any health problems at all. Of course, I’d had sciatic nerve pain, for which I’d seen a chiropractor, but I’d not been sick or had to take off from work. I fully expected to continue to work until 39 or 40 weeks, at which time I’d start trying to go into labor. One nurse at work even teased me that I’d probably go to 41 weeks just because I was enjoying pregnancy so much! On November 11, 2009, Veteran’s Day, Aaron and I were scheduled to have “belly pictures” made, you know, the kind where daddy puts his hands around mommy’s belly and makes a heart with his fingers; or where mommy is draped so just her pregnant belly shows. I was a little dismayed when I woke up at 9:30 am to get ready and my lower abdomen was aching. It was a constant ache, so I just thought that it was round ligament pain. Here’s where the L&D nurse “slash” student nurse-midwife began to argue with the pregnant patient. The professional part of me said that there was nothing to worry about, that I was only 36 weeks, that I’d just been to the midwife the day before, that it was just round ligament pain. I took a warm bath, but the pain didn’t let up. Instead, it became intermittent, coming about every 4 minutes. The patient part of me started to freak out a little bit, thinking that I couldn’t handle this, not preterm, that I didn’t want to have a baby today because I’m getting my pictures made. I even decided not to tell Aaron that I was hurting until after the photo shoot, because I had to have my pictures! After about 4 hours, though, the decision was made for me: I went to tell Aaron to get ready for our pictures and had a contraction right there in front of him. There was no denying it, I was in labor. Aaron called the midwives and got instructions to bring me to the office for triage. Then comes the patient part again, I wanted my precious diaper bag and overnight bag, but they weren’t packed yet. After all, I was only 36 weeks. I still had a month to worry about packing. But pack I did. It took 30 minutes of packing between contractions to get ready to go. Then the hour long drive to the midwives’ office. We arrived around 3:00 pm and the midwife said that my cervix was 1 cm and 100% effaced. For those of you who might not know what that means, my effacement and contraction pattern made it look like I was in labor and there was no stopping it. We were admitted to the labor and delivery triage area at the hospital, where the nurses tried to monitor my baby and uterus. Again, the professional in me said that the nurses needed to trace my baby and contractions well before they could let me ambulate, but the patient in my screamed to get out of bed. Then, I heard the heart rate dropping and looked at the monitor strip. Variable decelerations were obvious. Needless to say, Aaron recognized that heart rate was no doing what it was supposed to do, and asked me what was happening. Although I’d decided to keep my identity confidential from the L&D nurses until after delivery, I couldn’t help but explain the decels to my husband. After that, it spread through the unit like wildfire that I was an L&D nurse and student nurse-midwife. I was grateful that the nurses weren’t offended by my credentials; they treated me like a patient having her first baby, not like someone who doesn’t need any help because I should know it all already! They respected my decision to attempt natural childbirth and not once did anyone try to persuade me to get an epidural or take IV pain medicine.
After one hour, my cervix was 5 cm, and I was moved to a labor room in preparation for imminent delivery. Aaron was present throughout my labor, holding my hands and letting me squeeze his during contractions. He encouraged me to be positive, which secretly I was, although I was screaming NO, NO, NO during the contractions. My mom tried to coach me over the phone to breathe through the contractions, but since she was 9 hours away, I ignored her and kept screaming. Rebecca, who was the on-call midwife that afternoon, encouraged me to sit on a birthing ball while she squeezed my hips to allow my baby to enter my pelvis and turn as he should. When I began to feel the need to push, I insisted on getting into the bed, squatting on my knees with my chest against the upright head of the bed. Between contractions, I was able to tell Rebecca what I was feeling and talk to the nurse prepping for Ayden’s arrival. I understood that natural endorphins were working inside of my body to ease the pain between contractions. I recognized when Ayden was crowning because I could feel the “ring of fire” that people describe. I knew that I was almost finished with my pregnancy, that any second my baby would be born. When he was delivered, Rebecca had me turn over slowly because Ayden’s cord was short and she needed me in a better position for Aaron to cut the cord. I understood that that was why he had been having variable decelerations.
After the umbilical cord was cut, I held Ayden for a few minutes before the nurse put him under the warmer. I understood that, even though I wanted to keep him in my arms, that he was preemie, and that white preemie males often need a little extra help at the beginning. Ayden must have forgotten what I’d learned, though, because he didn’t need any help after all. I got him back quickly and Aaron and I were able to bond with our son, unmedicated and uninhibited. We attempted to breastfeed, and although Ayden was interested in nuzzling, he couldn’t get latched on right away. After changing call at 7 that evening, Becky came around to visit and offered some tips to the new dyad. We got breastfeeding eventually, and I felt empowered by Becky and Rebecca to keep trying, even when I was frustrated. When we were alone, Aaron asked me, “Well are you ready to do this again?” I answered, “Absolutely, that was perfect!” I had enjoyed every minute of it, and I know that, in spite of what the insurance company thought, I required midwifery care, I had the right to choose it, and I had an awesome experience that has changed my life and will affect the care that I give to my future patients.
On the left, you can see Aaron cutting Ayden’s umbilical cord. Rebecca is on the far left and the nurse’s name was Jan. On the right, of course, are momma and baby! It was love at first sight!
Now that I’ve shared my birth experience, I’d like to let you know how this will affect my practice of nurse-midwifery. I know that there are audience members here from around the world and that the laws governing the practice of midwifery is highly variable. Even in the United States, there are different laws from state to state. I have experience with the laws of two states: North Carolina and Alabama. Both of these states are considered more restrictive than most other states in their practice laws. As you can see on the slide, certified nurse-midwives are licensed as registered nurses and are approved to practice midwifery after entering into a collaborative agreement with a physician involved in obstetrics. Neither of these states allows the practice of midwifery by any other person, certified or otherwise. There is a push in both states to allow the practice of midwifery by certified professional midwives and lay midwives; this can be viewed as positive or negative, depending on who you are. Unfortunately, midwives in both North Carolina and Alabama are entirely dependent on a physician’s willingness to collaborate before they are allowed to even apply for a license to practice. Because of the bias that many physicians hold against advanced practice nurses in general, some midwives may find it difficult to practice in this restrictive environment. This limits the care that can be provided in many of the rural areas of both states.
In order to make a difference in women’s health and in the provision of midwifery care in this country and around the world, each of you must educate yourselves and the public about the status of midwives where you live and practice. First, educating yourself is the most important; you cannot and should not attempt to tell your story without having all the facts on hand. Get a hold of your practice laws and find out what is being done to change problems in the laws. Then, take every opportunity to tell people about midwifery. As I mentioned earlier, I discussed midwifery care during a tornado recovery trip last week. I’m always surprised when people that I meet think that midwives don’t even exist in this state any more. There aren’t very many practicing in Alabama currently, but those who are here must take a stand and let our voices be heard. We must advertise midwifery services and explain what a midwife is and what a midwife does. One of the most important things to do is to reach out to underserved women, especially in rural areas where there may be no other health services provided. These women are desperate for care that midwives are trained to provide. Finally, you must attend midwifery events such as this one, where you can network with other midwives, find out what’s going on in the world of midwifery, and receive education and support from your peers.
I want to thank you all for coming to my session. You can see a conclusion here of what I discussed. Also, I’ll go to the next slide for my references in case anyone is interested in them. Are there any questions?
Melissa Hatter VIDM presentation
The View From Both Sides Midwifery-Assisted Birth Experience of a Student Nurse-Midwife Melissa Hatter, BSN, RNC-OB Virtual International Day of the Midwife May, 2011
Personal Background <ul><li>Married with 18-month old son </li></ul><ul><li>Lived in North Carolina for 3 ½ years </li></ul><ul><li>Raised and currently living in Alabama </li></ul>
Educational Background <ul><li>Bachelor’s of Science in Nursing at the University of Alabama, Capstone College of Nursing—Graduated in May, 2007 </li></ul><ul><li>Master’s of Science in Nursing, Nurse-Midwifery at East Carolina University, School of Nursing—Expected Graduation in May, 2012 </li></ul>
Passion for Women <ul><li>Women’s unique health care needs </li></ul><ul><li>[See Brucker (2011)] </li></ul><ul><li>The role of women in the health of the family [See Welch et al. (2009)] </li></ul><ul><li>Women’s health care choices </li></ul><ul><li>Women’s rights </li></ul><ul><li>Family planning </li></ul>
“ Calico” <ul><li>My first “midwifery” experience! </li></ul><ul><li>Calico the Cat had her kittens in my closet </li></ul><ul><li>What nature intended </li></ul>
Midwifery or Medical? A Personal Choice <ul><li>Working as a labor and delivery nurse </li></ul><ul><li>No midwives in my hospital system </li></ul><ul><li>Passed up opportunity for free obstetrical services </li></ul><ul><li>Traveled 1 hour each way to For Women’s Health </li></ul><ul><li>After delivery, received hospital bill for full cost of services </li></ul><ul><li>Fought with BCBS-TN for payment for midwifery services in hospital </li></ul>
Prenatal Care <ul><li>Becky Yates, CNM and </li></ul><ul><li>Rebecca Hunnycutt, CNM </li></ul><ul><li>Student nurse-midwives in the clinic </li></ul><ul><li>Appointments available to fit husband’s school schedule </li></ul><ul><li>Time and attention provided by the midwives </li></ul><ul><li>Questions answered </li></ul>
Labor and Delivery Experience <ul><li>Preterm labor onset </li></ul><ul><li>Early labor at home </li></ul><ul><li>Decision to call midwives </li></ul><ul><li>Electronic fetal monitoring and variable decelerations </li></ul><ul><li>Desire for natural childbirth </li></ul>
Labor and Delivery Experience <ul><li>Coaching </li></ul><ul><ul><li>Husband </li></ul></ul><ul><ul><li>Family via telephone </li></ul></ul><ul><ul><li>Midwife </li></ul></ul><ul><ul><ul><li>Birthing ball </li></ul></ul></ul><ul><ul><ul><li>Positioning </li></ul></ul></ul><ul><li>Delivery </li></ul><ul><ul><li>Unmedicated </li></ul></ul><ul><ul><li>Hands and knees positioning </li></ul></ul><ul><ul><li>Awareness—”ring of fire” </li></ul></ul><ul><ul><li>Short umbilical cord </li></ul></ul>
Immediate Postpartum and Breastfeeding <ul><li>Premature infant, white male—required “extra” attention </li></ul><ul><li>Breastfeeding attempts </li></ul><ul><li>Husband’s response to birth experience </li></ul>
Nurse-M idwifery in the Southeast US <ul><li>North Carolina & Alabama </li></ul><ul><ul><li>CNMs are licensed as RNs and approved to practice midwifery </li></ul></ul><ul><ul><li>Must hold collaborative agreement with physician involved in obstetrics </li></ul></ul><ul><ul><li>[See Advanced practice (2004); FAQ (2005)] </li></ul></ul><ul><li>Dilemmas </li></ul><ul><ul><li>No CMs, CPMs, or other midwives in either state </li></ul></ul><ul><ul><li>Practice is not independent; must have physician approval to practice </li></ul></ul><ul><ul><li>Limited access to care in many rural areas </li></ul></ul>
Making a Difference <ul><li>Educate yourself </li></ul><ul><li>Educate the public </li></ul><ul><li>Advertise midwifery services </li></ul><ul><li>Reach out to underserved women </li></ul><ul><li>Attend events such as local, state, national conferences and VIDM </li></ul>
Conclusion <ul><li>Awareness during pregnancy, labor, delivery, and breastfeeding </li></ul><ul><li>Confirmation of choice to become nurse-midwife </li></ul><ul><li>Desire to make patient experiences as beautiful as mine </li></ul><ul><li>Make a difference!!! </li></ul>
References <ul><li>Brucker, M.C. (2011). Modern pharmacology. In T.L. King & M.C. Brucker (Eds.), Pharmacology for women’s health (pp. 3-24). Sudbury, MA: Jones and Bartlett. </li></ul><ul><li>Frequently asked questions (FAQ). (2005). American College of Nurse-Midwives, North Carolina Affiliate. Retrieved from http://www.ncmidwives.org/for_consumers/questions.html </li></ul><ul><li>Advanced practice nurses: Collaborative agreement, Alabama Board of Medical Examiners S 540-X-8-.17 (2004). Retrieved from http://www.alabamaadministrativecode.state.al.us/docs/mexam/8MEXAM.htm </li></ul><ul><li>Welch, N., Hunter, W., Butera, K., Willis, K., Cleland, V., Crawford, D., & Ball, K. (2009). Women’s work: Maintaining a healthy body weight. Appetite, 53 (1), 9-15. Retrieved from EBSCOhost. </li></ul>