Dr. Jones: "I don't know nothin' about birthin' babies, Miss Scarlett." That is something no mother should ever hear, except on the big screen. Trained midwives have helped women and their babies safely through birth for a long time here in the West. This is Dr. Kirtly Jones from Obstetrics and Gynecology at University Utah Health. No, it's not "Gone With The Wind."
Announcer: Covering all aspects of women's health, this is the Seven Domains of Women's Health with Dr. Kirtly Jones on The Scope.
Dr. Jones: Building on the rich tradition of midwifery in the intermountain west, the Certified Nurse Midwifery program at the University of Utah is one of the top 10 programs in the U.S. Certified nurse midwives at the University of Utah help women with their choices in their birthing experience. Today in the Scope studio we're talking with Celeste Thomas, a certified nurse midwife and Clinical Director of Birth Care Healthcare at the University of Utah College of Nursing. Welcome, Celeste.
Celeste: Thank you so much.
Dr. Jones: So are there other kinds of midwives who practice in Utah?
Celeste: Yeah, so there are three types of midwives here in Utah. I am a certified nurse midwife, so I have gone through a master's or doctoral program after becoming a registered nurse to become a certified nurse midwife, and that's similar to a nurse practitioner.
And there are also midwives who are licensed by the state of Utah that are called licensed direct entry midwives. These are midwives that primarily do out of hospital births, so that would be home and birth center births. And they are also licensed by the State of Utah, and they usually go through an educational program but can also do a portfolio-based apprentice program as well in order to sit for their board exams. And then there are midwives who are not licensed in the state of Utah, and Utah allows midwives to practice even if they are not licensed. It's one of the few states that does that.
Dr. Jones: So your training, as you mentioned, was you had an undergraduate degree and then you got a nursing, an RN.
Celeste: I got an RN.
Dr. Jones: And then a special extra three or four or five or however many years it might be with a lot of hands-on training. I'd see the midwives in our program on labor and delivery at the U pretty frequently.
Celeste: Yeah, and a lot of their training is hands on. About half, 50% of their training is hands on and the other 50% is didactic or in the classroom.
Dr. Jones: Well, let's talk about that hands-on part. There are some aspects of the natural birth experience that women are kind of afraid of. Many women are worried about their bottoms. Getting a baby through there's no small task, and they might be choosing a midwife for many reasons, but one might be that they don't want an episiotomy, a cut that makes their vaginal opening a little larger. Now as we OBs don't commonly do episiotomy for a normal vaginal birth, but even we think that midwives might have a knack for getting the baby out without a tear. What is your magic?
Celeste: Oh, well, it's not magic. It's research.
Dr. Jones: Okay. Tell me about the research. You mean, you don't pass it down from midwife to midwife for the last 300 years?
Celeste: Well, it is very interesting. Maybe 20 years ago a lot of OBs were still doing episiotomies, and as the research came around to show that that was really not helpful to keeping that perineum, which is that skin between the vagina and the anus intact, that really has fallen out of favor and it's pretty rare to find an OB nowadays who does an episiotomy. Now as midwives, we rarely did episitomies, so we just kept rarely doing them and that's worked for us.
Dr. Jones: Oh. That was your knack?
Celeste: But the other things that we know about keeping the perineum intact, there are some things that we know in the research do work. So one is perineal massage. So this sounds really lovely, like massage.
Dr. Jones: Well, it sounds a little X-rated.
Celeste: It might. It really is gentle stretching. And doing that before you go into labor in the studies has been shown to decrease the number of tears, especially for moms who are having a baby for the first time.
Dr. Jones: So moms do it at home?
Celeste: Moms do it at home and with their partner. This does not have to be done by a health provider. So starting at 35 weeks and they only have to do it about once or twice a week. It doesn't have to be all the time in order for it to have the benefit.
Dr. Jones: Oh, well, that's good news.
Celeste: Yeah, so that's something kind of easy they can do.
Dr. Jones: Well, when you think about how much stretching actually, and often it happens over a period of just maybe 15 or 20 minutes. And for someone who hasn't had a baby to see where they are before and then see what has to happen, you're amazed that that tissue can stretch so easily and then come back to its almost before state.
Celeste: It's pretty miraculous, but we like to help it out if you're a first-time mom. And the research is pretty strong on that one too.
Dr. Jones: Okay, now let's talk about water birth. What is that?
Celeste: Well, water birth, it has been getting more popular recently, and really women laboring in water is the thing that seems to be supported in the research. So we know from the research that women who labor in the water have shorter labors. They have less need for any medications or an epidural, and they have greater satisfaction and greater mobility to be able to move, because as you know when you have a baby inside you, it can be difficult to kind of get into certain positions, right? It's hard enough just tying your own shoe.
So being able to move in the water is really lovely. And for a lot of women who don't want to use medication, being in the water during labor is really beneficial. The question is then when the baby comes out, is there a benefit to being under water? And from what we can see in the research there is no benefit.
Dr. Jones: But there's no harm either?
Celeste: For low-risk women, we don't have a lot of evidence, but from what we have there doesn't seem to be a lot of harm. We have a study ongoing here at the University of Utah about water births specifically to look at potential harms. But yes, it is a good option as far as we know for low-risk women, and a lot of women just don't want to get out in that really intense moment when the baby's head is kind of maximally stretching things.
Dr. Jones: How deep is the tub?
Celeste: So the tub in order for it to have its benefit needs to be at least 27 inches deep.
Dr. Jones: I would think it'd have to be deeper if you really want to have some buoyancy.
Celeste: You have to at least be immersed usually up to your chest in order to have those benefits.
Dr. Jones: Okay. Now the next question is, do you have to come as the midwife in your bathing togs, or do you have to just get your scrubs right in there or you just bend over and get back pain? How do you get in there?
Celeste: This is a good question. So body mechanics is important. The thing to remember is that you don't have to support the baby's body in the same way as you do when baby's born with gravity. So when you have a woman who's delivering, it's important to be able to get to the baby if you need to, but you're watching for that baby and you really are not doing a lot of hands-on in that moment when the baby's coming out. You just need to be able to reach the baby and bring the baby up above the water when the baby comes out.
Dr. Jones: Well, I was thinking again, if we go back to the episiotomy question when we are delivering a woman in a bed, this is OBs, we're careful to kind of support the head and make sure it doesn't come out too fast and gentle the head out. But that's kind of a low position to be in in the tub.
Celeste: Which is why we don't get into that position in the tub. It's pretty hard to get there, and depending on the mom's position. We do try to coach her through that crowning process so that she does it nice and slowly.
Dr. Jones: Crowning, when the baby's head is just about to be born but isn't it quite born yet.
Celeste: Yes. But in general she is letting the baby out, and then we are bringing the baby up to the surface when baby comes out.
Dr. Jones: Okay. But you don't get to have an epidural in the tub?
Celeste: No epidurals in the tub, no.
Dr. Jones: Okay. No narcotics in the tub?
Celeste: No narcotics in the tub because of the risk of dizziness. And currently at the University of Utah we also don't allow people to have nitrous gas also in the tub because of that risk of dizziness.
Dr. Jones: Right, right. Well, we have tubs at the U.
Celeste: We do. We have four rooms with tubs, but only one of them is technically deep enough to push your baby out under water. But you can absolutely use them . . .
Dr. Jones: For laboring.
Celeste: . . . and sit in the tub for labor, and that really is where the benefits come from.
Dr. Jones: Right. So getting back briefly to certified nurse-midwives, you primarily practice inside the hospital but create an environment which we'll talk about a little bit more that you think is as homey as you can be, given that you're close to all the other things that a hospital can offer.
Celeste: Yeah, so the majority of certified nurse-midwives give birth in hospitals, but there are certified nurse-midwives who do home birth and birth center births as well. We can catch a baby anywhere.
Dr. Jones: Oh, you can catch a baby anywhere. I'm glad to hear that.
Well, so whether you choose a physician, a certified nurse midwife, or a team of both, because sometimes people have complications, they need the entire team to be with them. For your OB care and delivery, our goal is to provide the safest and most comfortable passage for moms and their babies through pregnancy and birth. And thanks for joining us on The Scope. Thanks, Celeste.
Celeste: Thank you.
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