Nurse midwife or OB-GYN?

[brightness]

I am a junior in college and I have considered becoming an NP or maybe a physician. I am not a nursing student, so I would have to go back and get a one year accelerated degree in nursing, then work for a bit in L&D, then go back to become a CNM. On the other hand, I could complete the med school pre-reqs and do that instead.
I job shadowed some nurses at the local hospital today in L&D and I felt like working in this setting would be good for me. I don't feel particularly excited by the prospect of doing surgery, but for me, continuity of care is important and I don't want to leave my patients as a CNM if the birth becomes complicated and the OB needs to take over.
My main question for you all is about the roles of nurse midwives, how they function in your practice, how YOU feel their work is quality wise, and what an MD/DO OB-GYN can do that a nurse midwife cannot.

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[BBCatcherVA]

I am biased, of course. I chose to attend medical school and am now applying for residency, but that decision isn't for everyone. I knew that I always wanted to be a physician and developed an attraction for the childbirth process later. If things have happened differently for you, that's fine. I think that it really is up to you and what you think your role should be. There are multiple career paths to caring for pregnant patients - Ob/Gyn, CNM, certified professional midwife, lay midwife, Ob/Gyn Nurse Practitioner. All of them require a rather lengthy training commitment, though some are of course longer than others. Some questions to consider: Do you only want to take care of pregnant patients or would you rather take care of all women? Do you want to focus on only the childbirth process or would you rather have a more broad knowledge base? Where do you want to practice - office only, L&D only, or a combination? Will you feel comfortable with "handing off" patients to the Ob/Gyn if a case becomes high-risk or a delivery becomes complicated? Will you be comfortable trading some autonomy as a midwife or NP for decreased malpractice requirements (some states place restrictions on the scope of practice or require physician oversight)? How would you conduct your practice if you were to live in an area that allowed lay midwives? In the academic Ob/Gyn practice at my school they employ a CNM and an Ob/Gyn NP. The NP takes care of pregnant and non-pregnant patients but she works only in the office. Of course her schedule is great. The CNM works in clinic and on L&D. I feel that she is competent and seeks physician counsel when appropriate. However, I have interviewed at programs which range from never working with midwives to having a large staff of them that collaborates with the physicians. For me, one of the definite pluses of being a physician (beside the ability to perform surgery) is that the licensing requirements are more standardized. All states will grant you a medical license if you pass the 3 steps of the US Medical Licensing Exam that are required by most, if not all, US medical schools and residency programs prior to completion. Licensing requirements for the other practitioners can vary considerably from state to state. Many folks feel that midwives or NP provide more "holistic" care, but I think that a competent caring physician is just as capable of doing so. Unfortunately, in today's medical reimbursement environment, the midwife or NP probably has more time to spend with each patient. I could go on and on but I'm sure no one wants me to. In short, I would recommend examine your own career goals. It may not make sense to get a nursing degree if you never intend to practice as one. Likewise, it may not make sense to go to medical school if you are comfortable with a much more limited scope of practice and do not wish to do any of the more "generic" tasks that physicians can. Regardless of what you choose, I wish you the best of luck!

 

[OBGirlie]

Depends on what you do. In the English system, all deliveries except the complicated ones are handled by midwives, where the OB docs are primarily gyn surgeons who step in for complicated deliveries. One isn't better than the other, both have their place. You need to just decide what you like, how much time are you willing to put in, and what your goals are. We can give you advice and say this is the way to go b/c of blah blah blah, but at the end of the day, its your choice. You'll have a job regardless of which way you go.

 

[All4MyDaughter]

I don't feel particularly excited by the prospect of doing surgery, but for me, continuity of care is important and I don't want to leave my patients as a CNM if the birth becomes complicated and the OB needs to take over.

I used a CNM but ended up needing a C-Section. My midwife stayed with me and assisted the OB-GYN with the surgery.

 

[nykka3]

I used a CNM but ended up needing a C-Section. My midwife stayed with me and assisted the OB-GYN with the surgery.

i know you were behind the curtain getting some much needed anesthesia, but how exactly did your CNM "assist" the OB/GYN? Did the CNM function as a resident or a med student?

 

[brightness]

i know you were behind the curtain getting some much needed anesthesia, but how exactly did your CNM "assist" the OB/GYN? Did the CNM function as a resident or a med student?

Thats exactly what I am wondering! I don't mind calling in the physician when I need to, but I don't want to abandon the patient that I have established a rapport with and who is trusting me on such an important day! Otherwise, CNM is a great path...I'm really not sure if I want to do surgical interventions, anyway.
There is always a part of me that feels like having to defer to the doctor as a midlevel would hurt my pride a little bit. Still, I believe that as a midlevel it is important to not only defer but consult with your physician.

 

[midwife]

i know you were behind the curtain getting some much needed anesthesia, but how exactly did your CNM "assist" the OB/GYN? Did the CNM function as a resident or a med student?

I act as - and bill as - a first assist. I "assist" by holding retractors, delivering and stimulating the baby before handing off to NICU, manually extracting the placenta, and some suturing. I usually close, but sometimes I let the resident . When I'm not available, the doctors I work with will use a resident instead if we have one with us for the month, but our residents second assist if I am there. I assist on scheduled c/s, I am called in for stat c/s as well (before the resident), and I always go back with my labor patients if they end up needing a surgical birth. I will also assist on some GYN procedures, mostly tubals.

Does that help answer your question?

To the OP - CNM is a great path if you love birth and pregnant women and gyn care, but don't want to spend 4 years learning surgery. I hear you about turning your patients over to an OB, but I find that I can stay very involved in their care, and often co-manage complex patients with my doctors. I don't do just pregnancy and birth - as BBCatcherVA seems to be implying - CNMs can do a great deal of gyn care as well. I even have a few geriatric gyn patients.

 

[midwife]

Double posted - sorry

 

[mules05]

I act as - and bill as - a first assist. I "assist" by holding retractors, delivering and stimulating the baby before handing off to NICU, manually extracting the placenta, and some suturing. I usually close, but sometimes I let the resident . When I'm not available, the doctors I work with will use a resident instead if we have one with us for the month, but our residents second assist if I am there. I assist on scheduled c/s, I am called in for stat c/s as well (before the resident), and I always go back with my labor patients if they end up needing a surgical birth. I will also assist on some GYN procedures, mostly tubals.

Any chance you'd let us in on what hospital this is at? I would hesitate to apply to a program like this due to what seems like a lack of learning opportunity. As a med student I was allowed to second assist and even first assist on occasion, while our residents always first assist or act as the primary surgeon while the attending supervises and acts as first assist. I had assumed it was like this everywhere. Is this not the case?

**Please don't take this as anything meant to start an MD vs CNM debate, just worried about availablility of learning opportunity as a resident!

 

[midwife]

Any chance you'd let us in on what hospital this is at? I would hesitate to apply to a program like this due to what seems like a lack of learning opportunity. As a med student I was allowed to second assist and even first assist on occasion, while our residents always first assist or act as the primary surgeon while the attending supervises and acts as first assist. I had assumed it was like this everywhere. Is this not the case?

**Please don't take this as anything meant to start an MD vs CNM debate, just worried about availablility of learning opportunity as a resident!

It is a FP residency program. No OB residency at this hospital. I work in a private practice that takes one resident a month for an OB rotation at our practice. I haven't found that many of our residents even plan on doing OB after residency, let alone cesarean sections, so I don't know how upset they are at being second assist instead of first. Most residents give us excellent feedback on their experiences at our practice.

 

[mules05]

It is a FP residency program.

Ok, fair enough...that makes much more sense now! The FP residents at the hospital I did my OB rotation at weren't even allowed in the OR.

 

[brightness]

This is exactly what I want to do. Its perfect! I mean really perfect. I just want to be able to stay involved when and if my mamas need the MD to come in and help out!
How do you get to be first assist in a hospital that is full of residents, though?

I act as - and bill as - a first assist. I "assist" by holding retractors, delivering and stimulating the baby before handing off to NICU, manually extracting the placenta, and some suturing. I usually close, but sometimes I let the resident . When I'm not available, the doctors I work with will use a resident instead if we have one with us for the month, but our residents second assist if I am there. I assist on scheduled c/s, I am called in for stat c/s as well (before the resident), and I always go back with my labor patients if they end up needing a surgical birth. I will also assist on some GYN procedures, mostly tubals.

Does that help answer your question?

To the OP - CNM is a great path if you love birth and pregnant women and gyn care, but don't want to spend 4 years learning surgery. I hear you about turning your patients over to an OB, but I find that I can stay very involved in their care, and often co-manage complex patients with my doctors. I don't do just pregnancy and birth - as BBCatcherVA seems to be implying - CNMs can do a great deal of gyn care as well. I even have a few geriatric gyn patients.

 

[mules05]

Congratulations Ob/Gyn forum, you have now become a recruiting ground for your competitors.

Edit: Nevermind, not getting involved.





In response to the original poster, since this thread has kind of gotten off track... I would try to shadow someone in these professions (CNM, women's health NP, OB/gyn) and see what appeals to you. The advice I give people on med school is what my daddy once told me- don't be a doctor because you can see yourself doing it and think you'd like it; be a doctor because you can't see yourself doing anything else.

 

[nykka3]

This is exactly what I want to do. Its perfect! I mean really perfect. I just want to be able to stay involved when and if my mamas need the MD to come in and help out!
How do you get to be first assist in a hospital that is full of residents, though?

Congratulations Ob/Gyn forum, you have now become a recruiting ground for your competitors.

...does seem like it is going that way. maybe this thread can be moved to the allied health board. however, i do agree that it would be nice to have the CNM involved instead of ditching the pt. on another note, i have heard of "lay" midwives who bash MD's as being cold and barbaric in their care of pt's....sad.

 

[smq123]

The thing is, I don't think CNMs (or NPs in women's health) are our competitors. I think they're valuable colleagues in this profession. The ones I've worked with I've found to be very knowlegeable and good at what they do. I also don't think they're competition because their scope of practice is different from that of an ob/gyn.

CNMs and NPs could be valuable colleagues, but I think it's ingenuous to think that they're going to be that way forever. I'm sure family med doctors used to say the same things about PAs and NPs.

The problem is that when people claim that their "scope of practice is different," the message slowly changes into "our scope of practice is BETTER." "Practitioners" on the fringe of OB/gyn - such as some lay midwives and doulas - are already preaching that idea.

CNMs, as far as I know, don't perform gyn surgery, handle high-risk OB patients, or treat infertility patients. As far as some CNMs first assisting on C-sections (or other gyn surgeries), I'll just point out that any RN can become certified to do this by becoming an RN-first assist.

And there's always the question of how long CNMs and NPs are willing to have an entirely different scope of practice. In psychiatry, there are quite a few psychologists and NPs who are fighting for prescription rights. So I wonder how long it will be before CNMs start fighting for the ability to do c-hysts or BSOs.

 

[brightness]

The only thing I can say is that I have been looking at the CNM route specifically because I don't want to do those things. I started this thread because I was having a hard time deciding, but now that I know I wouldn't have to adandon my patients, I feel better about the CNM path. I want assistance in high risk situations, I want to consult with an MD- of course, in a civil way, but obviously with me as the less skilled clinician.
I guess MDs can feel how they want about it, but all I know is that I am considering NP over going to medical school because I am comfortable with that scope of practice, I'm about to be a senior and haven't taken any pre-med prereqs (so I'd be doing pre-reqs until I was 24 for something I'm not even 100% committed to...that just makes no sense).
If Tired and Co. had their way, no one except the people who were willing to go to school until they were 30 would have a hand in patient care. Maybe that will be the wave of the future, maybe midlevels will take over.

 

[midwife]

I personally have no interest in debating the value of CNMs, I thought I would merely answer the question of how CNMs assist with cesearean birth. If anyone wanted to ask a more general question, I would think the area for NPs/PAs is probably more appropriate.

And I will say that the day I have a desire to do a c-hyst or a BSO by myself, I'll sign myself up for med school.

 

[brightness]

Well, the reason why I didn't put this in the clinicians forum was because I really did want the input of people who work in the OB field specifically, MDs included, to know how they feel about the CNM scope of practice and how CNMs function where they work. So I had a reason for putting it here in the physician area of the forums.

 

[nykka3]

Maybe that will be the wave of the future, maybe midlevels will take over.

Are you being sarcastic or did I miss something here?

 

[brightness]

Are you being sarcastic or did I miss something here?

No, I was actually being very sincere- what I meant was- If Tired and Co. had their way, no one except the people who were willing to go to school until they were 30 would have a hand in patient care. Maybe that will be the wave of the future- only doctors will take care of patients- maybe midlevels will take over many aspects of patient care. I don't know the future of medicine, I just want a part in patient care.
Obviously I wasn't very clear.

 

[chrisisinnocent]

No, I was actually being very sincere- what I meant was- If Tired and Co. had their way, no one except the people who were willing to go to school until they were 30 would have a hand in patient care. Maybe that will be the wave of the future- only doctors will take care of patients- maybe midlevels will take over many aspects of patient care. I don't know the future of medicine, I just want a part in patient care.
Obviously I wasn't very clear.

What you are missing is that people who are not willing to go through the training want to assume higher levels of responsibility for the patients and over reach their training. The perfect example of that is mid levels in primary care and CRNAs in anesthesia. It always starts out with "our scope of practice is different" and ends up with "we provide so much better comprehensive care who needs those pesky doctors anyway we can follow an algorithm as well as anyone".

 

[brightness]

Yep, I've heard this argument. All I can say here is that I can only speak for myself. I want to deliver babies, I'm not interested in doing surgery. I would welcome physician oversight and input, especially in doing surgery. As an CNM, I want the birth process to be all about what the mother wants- whether thats a natural birth, lots of medical interventions- its up to her. As a CNM, your scope of practice is obviously different- the training of a nurse is so different from a physician. In many ways a CNM's knowledge is inferior to that of the OB physician- but that doesn't mean those CNMS don't offer a valuable service to their patients.

What you are missing is that people who are not willing to go through the training want to assume higher levels of responsibility for the patients and over reach their training. The perfect example of that is mid levels in primary care and CRNAs in anesthesia. It always starts out with "our scope of practice is different" and ends up with "we provide so much better comprehensive care who needs those pesky doctors anyway we can follow an algorithm as well as anyone".

 

[THP]

Yep, I've heard this argument. All I can say here is that I can only speak for myself. I want to deliver babies, I'm not interested in doing surgery. I would welcome physician oversight and input, especially in doing surgery. As an CNM, I want the birth process to be all about what the mother wants- whether thats a natural birth, lots of medical interventions- its up to her. As a CNM, your scope of practice is obviously different- the training of a nurse is so different from a physician. In many ways a CNM's knowledge is inferior to that of the OB physician- but that doesn't mean those CNMS don't offer a valuable service to their patients.

It seems to me like your mind is already made up.

 

[brightness]

At this point I do feel like I've reached a decision on this issue. I am still concerned about the future of midlevels, doctors, and their relationship.

It seems to me like your mind is already made up.