A sister midwife recently posted to an email to my discussion list. I really appreciated her honesty and openness as she shared her thoughts and feelings about being “conflicted” as a midwife. More specifically, she was referring to the sense of inner conflict she felt in deciding when to offer care to clients with a history of a c-section.

I could identify with her feelings, and I was pretty sure that most midwives on my list could too. And I suspect that such feelings of conflict are not limited to just VBAC issues. So, I decided to address the broader subject about being “conflicted,” rather than limiting my comments to only the VBAC issue.

This article was adapted from my posted response to our midwives email list. Hopefully, it will be of help to other midwives who face similar conflicts in their own practices. In this article I will share my own thoughts from personal experience. I still occasionally struggle with my own inner conflicts when I face some difficult decisions in my own practice. But I have also learned some things that are helpful to me, and I would like to share what I have learned.

Speaking from experience, I usually face times of inner conflict about a client’s case when I focus on how I feel about her situation. Of course, we can’t help what we feel, and our feelings can’t be completely divorced from our care, nor should they be. A large part of what makes us good professional care givers is that we do in fact “care.” Many if not most of us can not only sympathize but empathize with the feelings of pregnancy, labor and childbirth. And many of us can empathize too with what it is like to receive impersonal intrapartum care and unnecessary interventions in a hospital setting, and to have a disappointing birth experience.

Our inner conflict comes not from having feelings, but instead from focusing on those feelings. In determining whether we should refuse to provide care for someone, or to transfer a client out of our care, we should of course be in tune to the emotional impact of such a decision on the person in question. However, the moment we place our emphasis on that emotional factor, we run the risk of crossing a line. If we allow their feelings and/or ours to dictate our decisions, then we have sacrificed something of our professionalism.

As I see it, a key component to dealing with issues that can cause us inner conflict is balance. We should avoid focusing too exclusively on either the professional or the emotional aspects of our midwifery persona. Too much emphasis on professionalism, and we come across as doing midwifery by the numbers, as though midwifery is nothing more to us than just a job. On the other hand, too much emphasis on emotions, and we risk acquiescing to unreasonable expectations just because we don’t want the client to feel bad or have an unpleasant experience.

Of course, achieving and maintaining balance in life, in whatever aspect or endeavor, is easier said than done. And I have periodically and even recently struggled with this issue of balancing emotions and professionalism. I recently felt very conflicted over one repeat client in particular. If you will indulge me, I will set up the circumstances of her most recent birth in order to illustrate my point.

I became quite close to “Katie” (not her real name) after I delivered her fifth baby several years ago. Her four previous (hospital) births had been horrible experiences, including the birth of her first child, who has cerebral palsy as a result of her mishandled premature birth. By contrast to her first four births, baby #5, her first home birth with me, was a wonderful experience.

Katie had a second home birth while briefly living in central Texas. I suspect that this pregnancy had been an undiagnosed diabetic pregnancy. Katie was not tested for it by the midwife she saw in central Texas. Near the end of her pregnancy, she decided to have her baby unassisted (she was not comfortable with the other midwife). Baby #6 was 13 lbs., and got stuck at his shoulders for 5 minutes (they know because they videotaped the birth). But after he came out, he did not need resuscitation. Because it was an unassisted birth, we were never sure how badly he was actually stuck.

During her pregnancy with baby #7, Katie developed gestational diabetes. She did a fairly good job of controlling it with diet. At no time did I see the need to risk her out during her pregnancy. Baby #7 was not as big as #6. I believe that is because we were aware of her gestational diabetes and we monitored her diet. Baby #7 was only a little over 10 lbs at birth. Even so, we ended up having about a 2 minute shoulder dystocia that was really bad. Katie pushed so hard she got a nose bleed, and the baby had a 0 APGAR at one minute. Fortunately, we were able to revive her very quickly, and her 5 minute APGAR was something like an 8.

Katie came back to me again when she became pregnant with baby # 8. This time, she had gained a lot of weight since her previous pregnancy and I knew right away that she was in poor health. I tested her for diabetes immediately and discovered she was a diabetic (not just gestational diabetes). I really thought that I would have to risk her out right away and prepared her for that. But she promised to do anything I told her if I would just let her try for another home birth. So I agreed to keep her only if:

1) She saw a doctor, and he agreed for her to remain under my care

2) She stayed completely off all sugar, tested her blood sugar several times a day and kept the numbers within proper limits

3) The baby did not get as big as her 10 lb baby which got stuck so badly. (This meant the possibility of an early induction.)

She agreed to all my requirements. But I honestly thought no doctor would ever agree to this plan. To my surprise her family doctor not only agreed but was very impressed with the care she was receiving from me. He encouraged her to continue with me as long as she could keep her blood sugar under control with diet alone.

Katie did better than I expected. She lost a lot of weight at the beginning of her pregnancy without compromising her baby because she was eating right. She then gained about 23 lbs throughout the remainder of her pregnancy. But near the end she started spilling some sugar in her urine, and she was not testing her blood as regularly as she had at first. I suspected she was cheating more than she was telling me.

By 38 weeks we tried to induce naturally, because according to a sonogram the baby had reached 9 lbs. But no natural induction we tried would work. So, I faced a conflict. I knew that here in Corpus Christi, Katie would probably be treated as an automatic c-section (9 lb baby, a diabetic mother, a history of two shoulder dystocias, transferring care at term). But if I waited another week, the baby would likely be 10 lbs, a size that worried me because of her history.

I knew we could have any number of possible outcomes from this point forward, depending on the choices we made. Of those possible outcomes, several were possible good outcomes, whether at home or in the hospital. But to help me make my decision, I decided to face what I thought were the three worst possible scenarios imaginable:

1) waiting for natural labor and having a vaginal birth at home, but ending up with a major shoulder dystocia and loosing the baby;

2) transferring care and having Katie treated like a bad mother just because she considered a homebirth with a midwife, seeing her sectioned immediately and the baby put through numerous invasive tests without being given a chance for other options;

3) transferring care, with the doctors choosing to induce her, only to have her still end up with a major shoulder dystocia and loosing the baby in the hospital.

By forcing myself to face these possible nightmares, I realized that the only scenario that I “could not live with” was number one. I had too many warning signs that Katie was at risk for a bad shoulder dystocia with a 10 lb baby. If I ignored those warning signs and then lost a baby just to give her a home birth, I could not live with that.

To be honest with you, I expected Katie to be very unhappy with my decision. But to my surprise, she had complete peace about it. I explained to her that I thought they would section her and not even consider an induction. She was even willing to accept this possible outcome under the circumstances.

To my surprise, the doctor decided to induce after another careful sonogram showing the baby to be about 9 1/2 lbs. Katie had no shoulder dystocia and she gave birth vaginally to a very healthy 9 1/2 lb baby with a huge 14 ½" head. In fact, this baby had a huge head and small shoulders. The previous baby had a smaller head and huge shoulders.

Katie and I still believe the best decision was made under the circumstances. We might have had a perfectly healthy outcome at home if we had waited for natural labor to begin. But we have no way of knowing that for sure. And I still believe I made the best decision as her midwife. I have no regrets and I would make the same decision all over again.

Would I have felt differently if Katie had ended up with an unnecessary c-section or worse? I would have felt really bad for her if the hospital experience had turned out bad. But I would not have regretted my decision to transfer care because I made my decision based upon my best professional judgment at the time. I did not let myself get distracted from making the best decision just because I wanted to also help my client avoid a bad hospital experience.

So what should we do for all the Katies out there? As midwives, it is our responsibility to determine whom to accept as a client, and when to transfer a client out of our care should complications arise. We feel conflicted in such cases because these duties are difficult ones, because the women coming to interview us often have strong feelings about what they want (and often what they don’t want) in a birth experience. And many times we really develop a bond with those we accept as clients. Because we care, we are sympathetic to those not wanting a hospital birth, and don’t really want to turn them away. And transferring a client out of our care can be a particularly painful duty.

All kinds of questions come to mind when I face the prospect of turning someone away or transferring care of a client. What kind of treatment will she receive at the hands of a doctor? How will she be treated at the hospital? Will she have a bad hospital experience? Or will she have an unnecessary c-section (which in Corpus Christi is quite likely)? And I know I am not alone in facing those questions, in coming to terms with my feelings about this. So, what should we do?

Ultimately, we must remember that we are not “saviors.” It is often tempting to think that we are in a position to save a client or prospective client from unnecessary medical interventions, abusive treatment or an unnecessary c-section. Such a perception may at times feel right, but this kind of thinking can be dangerous to us. In the final analysis, we must remember that it is not our responsibility to save women from disappointing (or even outright bad) birth experiences.

I referred earlier to two aspects of our midwifery persona, the emotional and the professional. A one-sided emphasis in either direction diminishes the quality of our care and could even put our clients or ourselves at risk. So no matter how we feel about a client or her prospects if she does not get to have a homebirth, we are flirting with trouble if we allow ourselves to think in terms of “saving” her.

What happens to that client after she is transferred out of our care is ultimately not our responsibility. Of course we care about what happens to her, but caring is not the same as being responsible. If we risk out a client because we have determined that it is no longer safe for her to have an out-of-hospital birth and she ends up with an unnecessary c-section or a bad hospital experience, that is not our fault. We will feel badly for her, certainly, but our feelings don’t mean that we made a wrong decision. We did our job; we transferred her care once we determined she was no longer a good candidate for an out-of-hospital birth. The subsequent response of doctors and/or hospital staff to her is their responsibility.

We all want to continue to respect the rights of our clients to make informed choices. But we should never decide to take on or continue care for a client just because she wants to have a homebirth or because she wants to avoid the hospital. We must evaluate each situation based upon our professional protocols and whether or not we think it is best for them to continue under our care.

There will be those situations where we agree to go the extra mile for a particular client in a particular situation. For example, we might recommend transfer of care, and the client refuses. However, if we agree to allow her to refuse transfer (which the law does allows for in Texas), we sure better be making an “informed professional choice” and not just giving into her wishes. We cannot ignore our legal, moral and professional obligation to make decisions which should be based upon our professional training and knowledge. If we disregard our training and experience just because a client objects to our recommendations, then as I said before we sacrifice something of our professionalism.

I have spoken in principle about facing difficult decisions with a balanced view of professionalism and emotional concern. Now I want to make it clear that I am speaking to myself as much as anyone. What I have been recommending for others in principle come from lessons I am learning, principles I apply to myself in my own practice.

This approach may sound cold-hearted to some, but I believe in the final analysis it goes a long way toward achieving balance in my practice. By learning to focus more on my duty and my scope of practice, by resisting the urge to let a fear of what might happen to my client if she leaves my care, I believe that I am making better decisions. I am also feeling less conflicted over the difficult choices I sometimes have to make. And, I believe this focus gives less opportunity for the medical community to point a finger of blame back at me if something does go wrong. In fact, ultimately it holds them more accountable to do their job right when I do transfer care.