Once you decide you want a midwife to care for your growing family, it’s important to find one who you’re comfortable with and trust. “Just like any healthcare practitioner, you want to be sure you have someone who fits with you philosophically,” says Katrina Kilroy, a registered midwife who practices at The Midwives Collective of Toronto and is president of the Canadian Association of Midwives.
You may have to do a little digging by asking questions and visiting their practice to see if the midwife you’re planning to go with will be a good match. (But, keep in mind, midwife shortages in some areas of Canada could make for limited options.) Here’s a list of some topics you can discuss with them to get a sense of their practice and philosophy.
1. How does your practice work? “The first place to start is to look at the midwifery practice,” Kilroy advises. While in some parts of the country there may only be one practice, in other communities, there may be many to choose from, and they’re all organized in different ways.
Some practices focus more on continuity of care (meaning you’d deal with one midwife the whole time), while others work with a shared care model (so you could see multiple midwives who provide care as a team). Find out what your care would look like with a particular practice: Would you see just one midwife throughout your pregnancy? Or would you be with a team of two or three? What happens if your midwife can’t attend your birth? Who would be there with you?
2. What does prenatal care with a midwife look like? You’re likely anxious to find out the specifics of your prenatal care. Ask the midwife: How many appointments will I have? What does a typical appointment look like? Generally, you’ll see your midwife monthly until you’re 28 weeks pregnant, then biweekly until you’re 36 weeks, and then weekly until you have your baby. An average appointment lasts 30 to 45 minutes.
This is also a good time to ask the clinic what tests and screenings are offered during the prenatal period. Decisions regarding these are based on informed choice, meaning your midwife will talk to you about what the tests offered look for, how they are performed, possible advantages and disadvantages, and any risks involved. Midwives offer the same routine tests as obstetricians and physicians.
3. Will a student midwife be involved in my care? Lauren Kouba, a mom from Oakville, Ont., currently expecting her second child, asked this. “I wanted to know how my midwife and the clinic integrates teaching and training during the birth,” she says. During the birth of her first son, Kouba didn’t feel there was a clear line as to when the student midwife, who was having a great deal of trouble stitching up a vaginal tear and inserting a catheter, should step back and let the primary midwife takeover. She wanted to have a clearer idea of the student midwife’s role the second time around.
Most clinics that are located near midwifery schools have student programs, and student involvement varies from practice to practice, says Kilroy. “If people don’t feel comfortable with student involvement, they need to pick their practice accordingly.”
4. What happens if there’s a complication in my pregnancy? Midwifery colleges, which regulate the profession and exist in provinces where midwifery is regulated, have guidelines for the kinds of situations that would warrant consultations with a physician, and the kinds of things that would require transfer of care. Should a particularly complicated situation arise, such as preterm birth before 34 weeks or placental abruption, the patient’s care might be fully transferred to a specialist. In this instance, your midwife may provide supportive care if it’s within her scope of practice.
Nicola Hives, who had a midwife throughout her pregnancy, learned at her 20-week ultrasound that she had a condition called complete placenta previa, where the placenta lies very low in the uterus and completely covers the cervix. As a result, she had more frequent ultrasounds, some consultations with an OB and had to deliver early via Caesarian birth because spontaneous labour would have put her and her baby at risk. Despite the complication, she was able to keep her midwife as her primary care provider throughout her pregnancy and in the postpartum period, though the OB performed the surgery.
5. What happens if I’m overdue? Practices have different protocols when it comes to going past due, but all offer an informed choice approach to decision making regarding timing of induction. In some areas, midwife practices may face community pressure to follow hospital policies, so induction at a specific time might be encouraged (for example, at 41 weeks and three days). In other practices, there may be greater leeway for midwives' own practice protocols to inform the way in which care is provided in this situation. In general, midwives are expected to support the approach to care that uses the fewest interventions, as supported by evidence, and this will impact when induction is recommended.
As you get close to your due date, your midwife will discuss these policies with you, along with the guidelines set in place by their professional association, as well as your own needs and expectations. They will also make sure you understand risks and benefits associated with each option.
6. Can I have a home or hospital birth, or deliver at a birth centre? Your midwife will provide care for you throughout your birth, no matter where you choose to deliver your baby: at home, the hospital, or a birthing centre (depending on what facilities are available in your area).
When Natalie Fullerton, who is expecting her third baby this March, was pregnant with her first, she told her midwife at her first appointment that she wasn’t sure where she wanted to give birth. “I appreciated how she allowed me not to commit to a birthplace,” she says. “She was open and comfortable with seeing how things went. I knew she’d be supportive of any location.”
“You might want to ask questions about their individual experience and comfort levels in whatever your chosen birth place is,” says Kilroy. “Make sure that you feel confident in the answers that you’re getting.”
Note that some hospitals restrict the number of births booked by midwives, so if that quota is filled at the midwifery practice you’re looking at, you may have to find another that is accepting hospital births. Of course, if you need to transfer to a hospital during labour because of a complication, or for any reason throughout your care, you could do so.
7. What might labour look like? Typically, in early labour, you’ll be in touch with your midwife by phone. Once in active labour, your midwife comes to you and gives you continuous support throughout your active labour, birth and for a few hours after your baby is born. Midwives offer the lowest intervention approach to care that’s supported by the evidence, says Kilroy. For example, the evidence shows there’s no benefit to being hooked up to a monitor for low-risk labouring people. Throughout labour, a midwife will listen to the baby’s heartbeat intermittently, usually with a handheld Doppler.
Generally, midwives help to facilitate some common birth plan goals, among them: avoiding episiotomy; promoting skin to skin with the baby; keeping the umbilical cord attached until it stops pulsing; including any labour support the client might want, such as a doula; and encouraging mobility.
Midwives offer a variety of natural solutions to pain management, such as massage, positional changes and water (a shower or bath may provide comfort) which can be accessed at home, birthing centres, and most hospitals. Some midwives are able to provide nitrous oxide (laughing gas) or use a TENS (transcutaneous electrical nerve stimulation) machine at a home birth or birth centre. Epidurals and narcotics are only accessible at a hospital.
8. What are my chances of needing intervention during labour (such as a caesarian section, forceps, vacuum delivery)? Most practices across the country should be able to access data from their own practice illustrating what proportion of pregnant people end up having a caesarian, or requiring some other method of intervention, such as a forceps delivery, explains Kilroy. If you have a goal to avoid intervention during labour, this type of data may be worth investigating.
But keep in mind that the population attending one clinic may be different from another (for instance, one clinic might have a higher proportion of people who know from the get-go that they want an epidural). Still, these stats can help you understand the likelihood of certain interventions.
9. How are my baby and I cared for postpartum? Whether you deliver your baby at home, at a birth centre or in the hospital, your midwife will come to visit you within 36 hours of the birth. You will be seen multiple times during the six-week postpartum course, including frequent visits in the first week. These first few visits are most likely to be provided in your home. Your midwife will monitor both your health and the baby’s, and provide breastfeeding support. A midwife is available by pager 24 hours, seven days a week. At six weeks postpartum, most people are discharged from the clinic, and care is transferred to your family physician.