Can The CNM, Doula And MD Work Together?

Audrey Puentes, MD
June 10, 2016
Can The CNM, Doula And MD Work Together?

How many times did I ask that in residency? Zero…That’s how many. I remember being in Labor and Delivery as an Ob/Gyn resident and hearing the words “she has a doula”. I’m not going to lie, we ALL groaned. Why did we all have this feeling of dread when we heard the word “doula”? One simple reason: we did not understand what a doula really was. The image that came to my mind was an older woman in a big flowing skirt who smelled like lavender telling my patient that she shouldn’t listen to doctors and should challenge everything we said because we were out to ruin her birth experience. Well, I will tell you right now—I was so wrong! Now when a patient tells me she is hiring a doula, I am thrille!

So, what is a doula? A doula is a woman who is specially trained to provide continuous physical and emotional support to the mother during her pregnancy, labor, birth, and postpartum period. Although a doula is not formally medically trained and does not give medical advice, she is there to support the mother during her birth, regardless of the type of birth she has. Having a third party present may feel like a hindrance to an obstetrician, however it can be very helpful. Sometimes the patient feels pressured by her family or hospital staff and having someone there to remind her of her options is helpful.

When speaking of doulas, the topic of midwives inevitable comes up. During residency, I worked side-by-side with Certified Nurse Midwives (CNMs), although we had very different roles as obstetrical care providers. As a result, after finishing my residency, my response to the word “midwife” was not nearly as negative as my response to “doula”.

When I left my Ob/Gyn residency, I went to work at a small hospital and have had the privilege of working with a special group of CNMs. These women have taught me the gentler side of birth. I may know the medical aspects of obstetrics, but these ladies know “birth”. I must admit, though, when I was told that I would be working closely with a local birth center, I did picture women birthing by candlelight. Of course, I was wrong yet again. Why did I feel that way? I simply was ignorant to what went on behind the doors of a birthing center.

To clear things up a bit, a CNM is a registered nurse with additional years of training to prepare for work in birth centers, outpatient clinics, and hospitals. Their practice extends beyond pregnancy to general women’s health care. CNMs have a great deal to offer their patients and other obstetrical care providers. As an MD, they have taught me many “midwifery tricks” to try during labor (thank you, peanut ball), and I have personally grown as an obstetrician thanks to these women.

As wonderful as this sounds, many times CNMs, doulas, and MD’s feel as though they are on different teams. Why is that? Aren’t we all just looking out for both mom and baby? Of course! We all want what is best for both parties, however our good intentions are oftentimes misguided. When a midwife, doula and MD are involved in the care of pregnant women, what can be done to help facilitate a compromise?

As MD’s, being willing to communicate with the CNMs in the community, not just the hospital, will go a long way. If that line of communication is open and welcomed, the chance of a bad outcomes decrease. The call from the CNM will hopefully be made sooner and the patient and baby will benefit. Sometimes, the patient simply needs pitocin or a little something for pain. Other times, it is for fetal or maternal concerns. If the CNM feels comfortable calling the MD with questions, then there is a better chance she will be directed to the appropriate hospital and/or nursery where the care of both mom and baby can be optimized.

Even if the CNM has transferred her patient into MD care, her dedication to the patient does not cease. She is simply bringing the patient’s birth team to join the hospital’s birth team. Keeping an open dialogue and discussing the care plan with all parties is still very important. The accepting hospital often doesn’t know the patient and what birthing options or birth plan the patient has chosen, so trying to accommodate her desires as much as possible when things aren’t going as planned is key. The doulas are a part of the birth team as well and are extremely important. Sometimes it is necessary for the patient to discuss the plan presented by the MD with her birth team prior to making a decision. This should not be taken as an insult. It is simply a way for the patient to have some time to think and talk with people she feels comfortable with. This empowers her.

In order for us to all communicate freely, there has to be a level of respect amongst the birth team. Like I said before, I know obstetrics. The CNMs and doulas know “birth”. They can run circles around me when it comes to hip squeezes and sacral releases. I would be naïve to think that I know more about birth than a CNM or doula that has been practicing for decades. They are amazing teachers and love to share their skills! We each have our strengths, and we each were trained very differently. If we all respect each other, then we will have a better chance at achieving our mutual goal of a healthy mom, healthy baby, and great birth experience.

At the end of the day, we are all a team and have the same goal. I am thankful everyday for my training in my Ob/Gyn residency, as well as all what I have learned from my local birth community. I am confident that we can bridge the gap between MD’s, CNM’s, and doulas. We are already making progress towards that goal and continue to do so every time a group of powerful women comes together to support a woman on her journey as she becomes a new mother .

Audrey Puentes, MD

Audrey Puentes, MD

Dr. Puentes has been a member of the Cleburne Obstetrics and Gynecology group in Cleburne, TX since 2013. She completed her residency at the University of Texas Medical Branch at Galveston. There she received the distinguished Golden Apple Award for medical student teaching in 2010 and 2011. Dr. Puentes believes in the family approach. Her patients are family. She involves and educates her patients and their support systems.

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