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Shifting Care

When a woman comes to me, there is unlimited hope for a care-free and delightful pregnancy. When signs crop up that there might be underlying or encroaching issues, we both re-evaluate the relationship.

I don't typically think of myself as a jittery midwife - I've seen and done a lot and don't jump to conclusions or to a place of fear as quickly as I've seen other midwives do. But, on a couple of occasions (one somewhat recently), when I have risked out a client, I find they have moved on to another midwife and attempted a homebirth with them.

A piece of advice several midwives have shared is allowing one out-of-the-scope-of-practice item per woman, but when two serious issues arise, it is time to release the woman from homebirth care. I don't think I follow that exactly and actually believe I give most women more leeway than others would. (Sister midwives whose counsel I appreciate have told me I am farrrrrr too liberal in who I take and retain as clients.)

I was wondering if I was too hasty in risking women out. Should I wait longer? Should I just wait until labor to do it? Do I tell the mom what I am thinking along the way? Do I have her sign consents stating their understanding of what is on my mind?

My wonderful apprentice asked me if I was sure of what I was doing when I risked women out and I assured her I was 100% sure at the time. She encouraged me to just find a way to let it go, then... but I am still troubled by this.

I've said before I wish I knew the outcome before labor and birth so I could proceed without worry or concern. I'd be MUCH more relaxed about most situations if I could see ahead that all would be fine.

This is an interesting inner discussion for me. Shouldn't I just be as calm and un-concerned with every pregnancy? Shouldn't I think the best for all women unless proven otherwise?

Well, it is the proven otherwise part that is annoying/concerning me. How much out of the realm of norm do I "allow" a woman to go in my practice? Are these women really withIN the realm of norm and I am simply seeing them in a more medicalized light? Will more years of being a primary care provider offer me a more relaxed attitude? Is it all that much different observing and counseling women than being the midwife on record? (Of course the answer is yes and moves me into the wondering of - am I doing this for liability's sake? Am I afraid and that is why I am risking women out? Is this fear affecting my relationship with my clients [if in fact I am feeling fear]?)

I chuckle because I have risked less than a handful of women out, but have certainly been closer several times. Women who have their issues resolve seem to have a closer time with me for the rest of the pregnancy. No matter how hard I work to keep the relationship alive with a risked out client, I see they are hurt and invariably feel abandoned. I am still trying to figure out the way to minimize any feelings of abandonment; it is one aspect I am still working on.

When I am considering risking women out, there is talk all along the way. It would never be a blind-sided letter in the mail (unless the client has abandoned care and is being released). When I get to the place of releasing her, I talk about it at length, re-iterating my place as a midwife versus as a friend and that I am doing it because of my concern for her health or the health of her child. I let the woman know I have to write a letter, it has to be sent registered return receipt and to please know the letter is a formality and has to go in the chart, but it does not Not NOT mean that I am cutting off communication or access to my services as a doula, midwife-advisor, monitrice, breastfeeding counselor, etc. How else can I say it that doesn't push women to think I am slamming the door on them? I try so hard to be tactful and loving.

It hurts when I fail.

I'll just keep trying.

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