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Sunday
Feb172013

Becoming a Monitrice

I’ve been asked more and more how one becomes a Monitrice, so I thought it good to write a post instead of continuing to answer in private. For those who don’t know, a monitrice is a doula with additional midwifery skills. I am a monitrice and doula, but as a monitrice, I go to mom’s home while she’s in early labor and monitor her and baby until the woman is ready to go to the hospital or I think birth is becoming more imminent. Or if I detect a problem with either mom or baby.

Here, a doula wanting to be a monitrice asks me questions:

Does a monitrice have to be a midwife?

Being a monitrice is more than a doula with a doppler. There are several skills needed and also the need for midwifery/obstetric training in order to be a skilled monitrice.

When the monitrice goes to the laboring mom’s home, she’ll not only monitor vitals and listen to fetal heart tones, she will also be on the lookout for signs of labor not progressing normally or even more dramatic, watching if something is wrong with either the mother or baby. And if there is, she needs to know what to do… change mom’s position or call 911… or something inbetween.

This knowledge comes with time and experience with laboring women. I believe that would include midwives, midwifery assistants or experienced apprentices who do hands-on co-care and L&D nurses. It’s not that the skills can’t be taught, but it takes a lot of on-the-job learning to be able to catch the nuances that can occur while mom labors at home.

Or can a monitrice truly be a separate professional goal?

I believe it can be a separate goal, but still apprenticing with a home birth midwife for a year or two would be necessary. I just don’t think a doula can jump in and be responsible for the lives of two people without having the experience doing it. Even experienced doulas, I think, would need at least some home birth experience.

If that’s all it takes, finding a midwife to apprentice with would be all that’s needed, right?

What’s hard about that is midwives might be wary of hiring an apprentice that isn’t eventually going to be a midwife. Apprenticeship is pretty much a linear generational experience; one teaches another teaches another teaches another. To teach the skills and nuances of midwifery to someone who’s leaving, possibly even becoming competition (monitrice jobs are not nearly as common as doula jobs), isn’t so appealing. I’d love to hear from midwives about whether they would be willing to teach a woman midwifery skills so she could branch off to be a monitrice. Would she ask that the monitrice apprentice pay her to learn?

What training and/or amount of experience would make this a safe option?

I believe it would take at least a year or even two of home birth midwifery training before a woman was ready to be a monitrice. She really would need to be familiar with the pace of home birth (it’s much slower than hospital birth) and understand how women labor out of the bed, which most doulas don’t often see, at least for extended amounts of time with untethered women.

With the apprenticeship comes learning the nuances of deciphering fetal heart tones. It can take years to learn what to do with them completely, but here I believe experienced doulas might have the edge over completely green women, that is if they have paid attention to the fetal heart monitor in the hospital. If the doula hears the heart tones going down, does she know to turn the mom on her side before the nurse even comes into the room to do just that? Has she listened to the machine and watched how the nurses responded over the years?

How experienced is experienced for a doula? I think that can best be served in numbers versus months or years. I’d say at least 100-150 births would give a decent idea of the rhythms of fetal heart tones. I still believe the monitrice-to-be needs home birth experience because hearing a deep deceleration in the home setting is treated much differently than a decel in the hospital.

What is the legality of working as a monitrice-doula without a midwifery license?

This is certainly going to depend on where you live and the midwifery laws. My own personal belief is I think monitrices need to be Licensed &/or Certified Professional Midwives, Certified Nurse Midwives or Registered Nurses, but I also acknowledge that many licensed women have no desire to do anything but midwifery or nursing work. It takes a specific type of person who is okay with abdicating responsibility mid-stream… as a matter of course, not only if there’s an emergency. In fact, some of the midwives in my area that do do monitrice work will only be with the women while they labor at home, abandoning the woman to labor alone or with another person as doula in the hospital. Can you tell how foul I think that is? Where’s the continuity of care?

Listening to fetal heart tones isn’t the part that’s practicing midwifery… it’s interpreting them that is. When I was a doula and occasionally had a mom laboring at home for an extended period of time, I would sometimes listen to fetal heart tones to see how the baby was faring. I didn’t interpret the heart tones; I would tell the mom that between 120-160 was normal and then tell her what the heart tones were when I took them. She interpreted them, not me. But this shows you how ignorant I was at the time. Fetal heart tones are not read on a one time reading every couple of hours, but more frequently and before, during and after a few contractions. (Even as a midwife, I was remiss in doing this too much.) So much can happen during labor to the baby, just listening for the heart tones, inbetween contractions, once an hour just isn’t enough. Once labor kicks into higher gear, every 15 minutes really is necessary and listening before, through and after the contraction simply should be done. And of course, there is the interpreting part. We are back to that experience thing.

I want to help my clients keep safe and wonder if there aren’t skills I could learn that would help them. Perhaps palpating the uterus or checking cervical dilation could help them more than if I didn’t do the skills?

Palpating the uterus takes longer to learn than interpreting fetal heart tones. Your hands, literally, have to “see” what is beneath the flesh, muscle, fascia, etc. And only in touching dozens of bellies hundreds of times can your hands begin to see what is where. Of all midwifery skills, I think palpating is one of the most difficult to learn well.

Learning to do vaginal exams isn’t as challenging, but still takes time to learn. Once you’re able to find the cervix and use your two fingers inside it, there is still the subjective aspect of the skill. Only with time do you learn what is six is six for the others also checking dilation.

Or, perhaps the answer is that, because I don't have these skills, I shouldn't be assisting women in their homes? That by virtue of being there, I am taking responsibility for something that I don't have the skills to be responsible for? And that I should only be meeting women at the hospital?

This is what I do. As a monitrice, I go to their homes. As a doula. I meet them in the hospital. I cannot, in good conscious, be at their home with mom in labor and not monitor her and the baby. I know too much. I know many doulas don’t have any problem going to the home in labor and staying with them for an extended period of time, especially with VBACs, but I just don’t feel it’s safe without monitoring. Do I think doulas should never go to a mom’s home? I think that’s up to each individual doula, but I tend to find the more a doula knows, they less likely she is to hang out at home for a long time because she knows monitoring is so important. The laboring woman’s blood pressure could climb precipitously. The baby could be stressed or the mom could develop a fever, which affects the baby, too. There are infinite hidden variables that monitoring can uncover. As I said, I know too much.

I would love to take a monitrice apprentice, but the women who have approached me rethought the idea when they realized the legalities of taking care of a woman in labor. Would it be practicing midwifery without a license? Probably. I try to think of how it could be a gray area, but it wouldn’t be, at least here in California. A monitrice without a license would be at risk for prosecution if anything untoward occurred.  In other states, the issue might be different.

There is only one online place to study the monitrice occupation. That’s through Birth Arts International and it’s a $1250, year-long program. I’d love to see the program to better be able to comment on it, but the outline for it looks comprehensive. Even so, I still believe an apprenticeship has to happen.

I wish there were more monitrices out there. I’d love to see the profession grow. Maybe I should start a monitrice organization to gather together the monitrices out there. Not sure if I have the energy for that, but would love it if someone did, me or someone else.

To the woman asking these questions, I think you have your answer now, yes? Do let me decide what you choose to do and I will add an addendum to the post.

Does the prospect of being a monitrice intrigue you? Do you want to try this profession? What do you think of the legalities? What about doulas who go to mom’s homes, good or bad idea? I’d love to hear your opinions.

 

Photo by Nova Bella Conte

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