#165 | The Holistic OBGYN, Dr. Nathan Riley, on Autonomous, Empowered Birth

I'm Cynthia Overgard, owner of HypnoBirthing of Connecticut, childbirth advocate and postpartum support specialist. And I'm Trisha Ludwig, certified nurse midwife and international board certified lactation consultant. And this is the Down To Birth Podcast. Childbirth is something we're made to do. But how do we have our safest and most satisfying experience in today's medical culture? Let's dispel the myths and get down to birth.

We have an unvalidated continuous fetal heart rate monitoring technology that's been around for 50 years. And we still haven't validated that it actually does anything to improve outcomes. I, what I always say is, is the burden of proof lies in the one who wants to deviate from nature had to actually carry the studies around in order to support my notion that we don't need to intervene, which is, which is backwards from what it should be, we should be using data to support natural physiologic birth. And if there is some reason to deviate, we need to be very, very sure of that. But that's not what's happening. We're using, we're using medical publications in order to support our internal bias, which is publication and confirmation bias, that it's worse. It's like you're damned if you do, you're damned if you don't, unless you just step away and say, Okay, you guys do your thing over there. I'm going to help support the midwifery care model over here.

My name is Nathan Riley. I'm a fairly young physician. And I trained I started in the University of Pittsburgh got all my you know, I was a Spanish major, saw the world and all that stuff and then decided to go to med school. So I went to med school at Temple University. And then I found myself in California, my wife, I was about to say my wife at the time, my my still wife wanted to go to a place with beaches and palm trees, sunshine, because we're from Pittsburgh, and it's a pretty dreary state. So at least that half of the state is and so we found ourselves in LA, I did my residency training, it's four hard years. And that was at Kaiser Permanente in Hollywood in Los Angeles. And it's a great training program, very, very high risk population, because a lot of people that kind of end up at Kaiser, because they're referred from all over the place, they end up there. But of course, we have Cedars Sinai, we got UCLA, it's a massive city with a lot of stuff going on. So it was a very high volume training program. And then I actually did a fellowship at UC San Diego and hospice and palliative care, and then took this, the practice of holding space for death and applied it to my work and birth. And I found my magic niche, which is to to help women understand that they've got full responsibility and autonomy over how their body is treated, and their baby is treated throughout pregnancy into the postpartum period.

Did you learn any of that in med school? Did you see any examples of that in your training? Or to how did you sort of come to see that that is the most important thing for a birthing woman?

Well, when you see so many violations of a person's autonomy and male, it really makes you wonder, like, do I have say over anything that happens to me when I go into a hospital? You know, one story that I like to tell is there was a woman who was like her seventh pregnancy, she showed up and triage, which is the sort of subunit of a labor and delivery suite. And she was there to be evaluated, because she didn't feel as much of a movement. And while she was there, we were so busy. And she just like was kind of tired of being there. She was like, I'm gonna go to Burger King, I'm gonna leave, she took all the monitors off and left. And the nurse looked at me like I was like she would this woman was insane. And I remember standing there by the doorway into saying by, like, send a nerve of her. Right, yeah, right, like the nerve for her to take the monitors off and leave against medical advice. And it was like if that if we see that as a violation of whatever hospital policy you've been married to, then what else could happen downstream, right when you're actually having a baby and, and then, of course, I was trained by CMS, at Kaiser in my intern year, and that kind of set me on this path of like, Oh, we don't actually have to do much of anything. Yet, then you get your second year, your third year, your fourth year and early on, I realized, whoa, there's way too much intervention, the way that people are talking to one another. I wouldn't want to be talked to like that. I certainly wouldn't want my wife at the time we didn't have kids. I wouldn't want her to be spoken to like that I wouldn't want as the partner to be treated that way. And so then there's this this some degree of cognitive dissonance where you have to kind of wash those feelings away in order to survive this training, only to then say thanks, but no thanks. And find yourself in a very, very different world, which is very niche. There aren't too many doctors that are, you know, out there advocating for homebirth or for gosh, for just exercising your basic rights as a human. And it's, it's because a lot of us, you know, 99% of us weren't trained to really see the whole person And like I said, as a hospice and palliative care doctor, there's no, you're not lacking metal at medical intervention when a person dies. And I started thinking, Well, you're not lacking medical intervention when a baby is born. You know, pregnancy is not a disease. This is not a medical procedure. So I don't even want to call them patients. They're not patients. They're not sick. They're here for me to care for them. But I'm treating them like they're sick. And that just seems backwards to me. So you know, over the over four years of residency, my year of fellowship, I was working at Scripps Encinitas seeing some very low risk patients and just standing in the back of the room and giving them a salute when the baby comes out and saying congratulations, maybe I there's a couple people, I brought like a six pack of beer afterwards, because the dad and I got to know each other so well, during the, you know, the labor course or whatever. And so you were drinking beer with the dad after the baby came out?

of hospital? No, no, but we would get on to pick about like, oh, you know, finding some common ground and they're like, ah, you know, I can't wait to get a beer after this. And I'm like, What's your favorite? Like, what type of beer do you drink? And I would bring champagne or I'd bring beer or whatever, you know, like, and oftentimes they would crack it open and be toasting in the room and the nurses, I can't. Can they do that? Like, yeah, they can do that. You were emphasizing that it was really on their terms. Yeah, that that woman was like your Rosa Parks moment.

Yeah, I guess so. I guess. So. She was the first one who just didn't obey. Yeah, he didn't follow the protocol.

Right, right. And then we have to be we have to ask ourselves, why are we so confronted when a person doesn't follow a protocol? Like who says that this is like, what contract did they sign that says they have to follow everything I say, the contract that has the heading of ego at the top of it, and I think nothing else. I mean, I've had that thought so many times. And I think it only can come down to ego. Why should anyone be personally bothered, if someone doesn't like, do what they say or follow their advice, it's just there you go. And nothing else, it doesn't really have to do what's in the best interest. In particular, someone especially something like bad leaving when she was in line to be seen. She has the right to leave, why should that bother anybody? Right? It's also the system, the institution, the protocols, and then trying to keep everything in control. So you know, if somebody takes off the monitors and leaves and goes get to get lunch, like, who's all of a sudden, oh, my gosh, who's liable? The nurses or the doctor? What do we, how do we get her back in, we got to start the paperwork over. It's all it's all of that there's this layer on layer of that onion, I totally agree. I want to also emphasize that, you know, for any woman out there who's listening, and they're really, genuinely sort of concerned about what's going to happen to me if I end up in the hospital. And we want to blame the doctors, like you said, we want to blame the nursing staff, we want to blame the the hospital system, we want to blame the government, whatever. Remember that when doctors go into medicine, they've been incentivized and rewarded every step of their way of their 20 years of training, right, starting with college, to get the best answer on the test based on what the examiner expects them to say. So when you have been rewarded, over and over again, over the years for staying in the lines, it attracts a certain type of person who actually likes protocols, they like somebody above them to tell them how to do things, but then they're on the other side of it. So now they would expect now that they're the ones calling the shots, they would expect everyone else to fall in line and do as they say, that's what you're saying. It's attacking someone of that mindset. And then they get there, they get the ultimate reward, which is to be on the other side of it.

Yeah, yeah. I mean, how many times have you heard a doctor say, you came to me for help? Why wouldn't you want me to do this X, Y, or Z thing? Because I don't want that. And they're like, but that's what we do. You know,

I've been doing this a long time. Yeah. Or do you not think I know what I'm doing? I mean, sometimes they wear that on their sleeve, right? They're insecure, they have that? That ego? That's very interesting.

Yeah, they came in with pain. And for them, it's painful to not have somebody actually telling them how to do it, whether it's a cog, the CDC, some study that was just published in the green journal, whatever else like thank goodness, somebody is here to tell me what to do. And then when you actually parse out the data, which is what doctors should do, but we don't necessarily have the time or the will or even the skills to actually digest a study. They see the study is like, Oh, great, I've got another guideline I can follow. Whereas for me, I'm very right brain thinker. I'm very deductive like, Well, wait a second, is this one study enough for us to be violating a woman's autonomy? Or telling them that you can't leave triage by ripping the monitors off? Of course not. Because this is still a person that we're caring for. So it would be similar to like a person who's dying at the end of life and they do not want the ventilator. But if we don't put the ventilator on them, we're gonna die like, yeah, they've accepted that, like, can we just align ourselves with them in stands shoulder to shoulder as opposed to head to head as if you're the captain of the ship? Because you're not you're not the captain of the ship period.

That point about the right brain left brain is so important because that is what med school does. And even midwifery school as a sort of as a certified nurse midwife nursing school. It's the same thing. It's all left brain. It's like, I mean, in nursing school, they really do try to bring in the other side. But I understand that feeling of like wanting to follow protocols Show me, show me what acnm says. And that's when I'll do it. Tell me what ACOG says. And that's what I'll do, because that's the safest. And you know, that's the truest and that's the best. But then going in to becoming a homebirth. midwife, I had to I had to let go of all that I had to be able to, like, say, Sure, that's what it says. But in this situation in this moment with this woman, does that apply? Right? Yeah, and make my own decision. Nature rewards courage, and it takes a lot of courage to do what you did, Trisha, it takes a lot of courage to do what you do, Cynthia, it takes a lot of courage to have a baby. And nature rewards that. So there are that's why there aren't a lot of us that are talking like this, because we are the minority, because we have to have a lot of courage to do this. And to say thank you, ACOG I appreciate the guidelines. But ultimately, I'm the person in charge of, of Empower empowering a woman in order to exercise her autonomy using the information I gave, and then it's my job to support you and not use coercive language, it's my job to give you the information and then support you and say, Man, that's not what I would have done. But that's on me. This is your experience and the whole idea of you know, experience doesn't matter it's not measurable Yeah, that's exactly the point. That's why we only look at the the measurable things the metrics, the vital signs, infection rates, mortality, like is that all at birth is is avoiding death? Or is it more than that? And I would of course argue as you guys would that there's more to this than just blood loss and and the premise of our whole podcast and our first episode is a healthy mom and baby isn't all that matters. Everyone on earth agrees it's the most important thing that matters, but it seems the medical community draws the line there okay, well you got your healthy baby be on with you now like don't get on with your life so upset about what we did a great job. It's the it is the it's the lowest denominator of what we must have. Right? And can we please aspire to more like and Maslow, Maslow's hierarchy of needs? Like this is the broadest thing at the bottom we need Can we please aspire towards something more than this? Yeah, must

Dr. Stu I'm sure you are familiar with Dr. Stu Fischbein. Even your you guys are good friends. I really tell him you're on with the dental birth lady. What he always says is in obstetrics, it's, it's a baby in a bassinet, that's the only thing they're looking at is the baby live and well in the bassinet. The mother is almost outside of a postpartum hemorrhage. They're just like, not even paying attention to her. Right, right.

I wanted to make a comment about your reference to research and ACOG, the American College of Obstetricians and Gynaecologists for any listeners who want to know what that stands for. And that's basically like the governing body who provides these, these these standards and guidelines that obstetricians are supposed to follow. But what I think we forget, there's really, really two things. One, their guidelines are always changing. And you know, you know, darn well like 1020 years from now the guidelines of today are going to be completely different. For example, like you can still see they're holding on desperately to Amjad me. But even in their very language, they're saying, Well, studies really don't support this or show any benefits, and it comes with risks, but they won't just come out and say, let's stop giving Amjad dummies and 99% of instances. In the 70s. They used to say, once a C section, always a C section. Well, that's changed finally, and it only changes with us. It only changes with the women giving birth, it only changes with people saying, No, I'm not doing that. I saw a headline a couple of months ago. I get so concerned when I see headlines, I'll tell you in the field past couple years hasn't taught us enough about looking under the headlines at research. Honestly, I think then it's a hopeless cause because there have been so many opportunities to look under the headlines and look at real data in the past couple of years. But there was a headline on I don't know, it was like a mainstream parenting page that said, good news. epidurals really don't slow labor. And I was like, what, how on earth? Is that possible that everyone knows they slow labor? So and then they had a doctor like, well, this is really good news because many women are reluctant to get an epidural because they don't want it to slow labor. So I found the tiny fine print that pointed to the research and I looked it up. And I'll tell ya, like these things are published in medical journals. And when you read the research, they excluded women who didn't use an epidural. They excluded women who had a natural birth, they only looked at women who had an epidural right up until they were pushing and they compared them to women who had an epidural during pushing. Yeah, and that The headline was epidurals don't slow labor, you're only looking at a population of women who had hours of epidurals. It's so manipulative and how few people, even doctors, right? I mean, you can confirm this, I kind of look beneath the headline.

Yeah, there's a whole bunch of problems within, within the medical publication industry. The first is there's a book by John Gerardine called I think he's actually a JD, like a lawyer. And he, he wrote a book called The illusion of evidence based medicine. And part of the problem is that there's a lot of publication bias. You know, there's also a lot of pharmaceutical dollars that are in these magazines, these journals, if you flip through, you're gonna see 10, Pfizer ads, you're gonna see 10, Bayer ads, whatever else. And all of these new meds are on big giant, single page, you know, ads. And so one problem is that these, the journals are not going to publish something, even if it is extremely interesting, like, I don't know, homebirth homebirth is better than hospital birth, whatever, like, let's just take that headline, they're not necessarily going to be enticed to publish that, because ACOG hasn't really fully put their, their their chips in, you know, supporting homebirth, even for the, you know, quote, low risk, I don't even like the risk stratification. But you get my point, it may appear, right, but it's not going to be it's going to be one article that slipped somewhere in the back versus that the big headline articles that are about how useful hormonal contraception is, or how, how great it is that we can induce people at 39 weeks and not have to worry about anything, just get that baby out. I mean, these are all the phrases that I was I was raised with. And the studies just seemed to support the bias that I was inculcated with through my training. So people are truly curious about what's better, or what's worse, they're just trying to publish for the sake of saying, look at what we were doing is right all along. And so the other aspect of that is, I what I always say is, is the burden of proof lies in the one who wants to deviate from nature. However, when I was in residency, and I started realizing less intervention actually leads to better outcomes, patients love me, they want to, they want me to be their doctor next time, and I'm the resident, so I can't really have that continuity, necessarily. Plus, you know, with 80 people in the practice, you never know who's on call whenever you come in for your next birth. So, you know, so they're, like mom and baby are, are thriving, not just merely surviving. And I had to carry around an accordion file that was about this thick of all of the data from mostly international journals that actually supported hands and knees, burst sideline bursts, not opening the waters, you know, artificially, not starting Pitocin right away completely, discarding the entire first stage of labor and trying to put it on some curve. You know, that's all data that's out there. And I had to actually carry the studies around in order to support my notion that we don't need to intervene, which is, which is backwards from what it should be, we should be using data to support natural physiologic birth. And if there is some reason to deviate, we need to be very, very short of that. But that's not what's happening. We're using medical publications in order to support our internal bias, which is publication and confirmation bias that it's worse.

And unfortunately, natural birth doesn't require a lot of pharmaceuticals. Pharmaceuticals have large one page ads all throughout the green journal that, you know, support the need for induction and Pitocin and Cytotec for this or that or whatever it is there, you know, those articles are gonna get published more?

Yes, it's a revenue problem.

Right, right. I mean, not to mention, a lot of these pharmaceuticals are almost by definition, they're totally synthetic. Otherwise, they wouldn't really be. You wouldn't have to advertise them. I think that you have to consider that. Let's say that something were let's say that a woman you know, her Mina has clients, a good friend of mine, she does a lot of, you know, human rights in childbirth.

We don't know she's been on our podcast already two times. Yeah, she's got a third episode coming out right there. She's amazing. And I've actually reviewed charts for her and helped her you know, if it ever comes up that she needs an expert witness, since I'm a fellow ACOG, she could call me to the stand, etc. And a vast majority of that is oh, they added this code of fetal distress. And in retrospect, that justifies this, this this they did that they did later. So really the way that we're taught to document which is ridiculous. If he asked for a prenatal chart, it's gonna be like 600 pages of nothing and maybe 10 pages that are actually useful. All of that documentation is in order to cover our butts in case whatever hospital is sued, even if it's a totally healthy mom healthy baby unmedicated birth because they feel like I wasn't respected my I was held down and a vaginal exam was forced upon me or whatever else. They could say, oh, but there was fetal distress us, that's why we had to do the vaginal exam. Not that that actually warrants a vaginal exam might I add, but that then in court, it would be like, Why did you force this to happen if the baby wasn't in distress, it wasn't, it wasn't documented. So they document all like a big catch. All they just write for themselves just cover everything possible. And then we even have templates. And Trisha, you probably know this from hospital, it's, it's like dot, vaginal birth or something. And it brings up a whole template with everything that the insurance company is going to look for, and everything that could possibly be solidity litigated against, so you'll see a full physical exam did they actually listen to heart and lungs, no. OBGYNs forgot their stethoscope back in med school. So they didn't do that it part of the exam. But who says they didn't do it? It's in it's in the note, if you if there was fetal distress, and you didn't note it, and then the baby had, you know, some sort of hypoxic injury, which is very rare. But if it were to happen, and you didn't note it, now you're screwed. So you just say whatever you need to say not only to cover your butt, but also to justify whatever actions you took. And the benefit of having those big, beautiful documented notes, which are full of fluff is that you can now bill at a higher reimbursement rate. So it's really, really tricky. And of course, all of that is related to the culture of your hospital and your practice as well. Like if you didn't note that thing, and your colleagues, your boss or whatever takes over at 7am And you didn't document it, then that might also cause problems for you and your practice. So just jump in the current and go with the flow and do your thing and go home and try to get some rest. That's that's really the goal.

And by the way, that fetal distress could have just simply been because the mother was on her back and just needed to change positions and the baby was fine.

Or you you did any of those interventions. It caused the fetal distress, or they may not have been fetal distress, which was kind of one of the points to the right, right. They could just say that. Right?

Right. We have an unvalidated continuous fetal heart rate monitoring technology that's been around for 50 years, and we still haven't validated that it actually does anything to improve outcomes. So we have to bear that in mind. But there are people who will testify against Obstetrician arguing that yeah, there was definitely fetal distress based on this thing that I saw on the chart on on the on the tracing and all that like there was definitely some Distress right there. So it's like you're damned if you do damned, you're damned if you don't, unless you just step away and say, Okay, you guys do your thing over there. I'm going to help support the midwifery care model over here.

Let's come back to your original overarching topic of personal responsibility and birth because I am convinced any of us who've worked closely with women for long enough all come to this same conclusion that your birth outcome is so largely driven by the degree to which you are willing to take responsibility for your birth outcome. It was my takeaway after giving birth before I worked with a single woman, so can you talk about your own perspective on that and how you came to it and how you would talk about that, because I'm convinced we're all saying the same thing. I just would love to hear your experience with that.

Well, sort of through the same lens of how doctors are used to staying in the lines, I think most people in the general population see it the hospital as a place of safety that is going to guarantee them a good outcome, right, which is why many women are totally open to the interventions, doctor, whatever you say, let's just do that thing. The problem that I that I've, that I've been facing is that when people come to me to you know, because they want me to help backup their midwife for a breach or something like that at home, I've got one on Khan on call for right now. The problem with that is that if you're coming to me expecting me to save the day, I am not a hero, healthcare hero. I am here to support you in this journey. And if if if if you can feel empowered, to stand on your own two feet and make decisions for yourself, things are probably going to be okay. But good or bad the outcome, it's important that you when you get pregnant, realize that the responsibility is on you. It's respect, you're responsible for putting the good, right food into your body for moving throughout the pregnancy, for doing all of those things to ensure the best possible outcome. And that's not always possible. Even you know, in the mammal world, there are sometimes bad outcomes, sometimes babies will die. That's a part of life. Now, that doesn't mean that we should just be hands off and say bye, pray for the you know, pray to the heavens, although for some people that might actually be important to them. It's not my job to to save you from the responsibility of what it means to have a baby anymore than it is for me to say hey, you know you're having a hard time with your kid I better take that kid from you because you're having a hard time. That's not how it works. So we've when we medicalize and pathologize pregnancy, we see it as something that can be controlled and that's why in the hospital system there's such this is such a low threshold to intervene because we are the captain of the ship. I must deliver this baby to safety in this woman to safety and healthy mom healthy baby rollout not really knowing what happened to themselves. And if you flip that over and look at home birth, a woman making decisions for herself like that is the birth process, you're going through a transformation of spirit. And part of that is owning up to what's about to happen to you. And having some people in the back background that might be able to and facilitate some things once in a while when absolutely necessary, period. But a lot of people don't you know, who go to the hospital, don't see it that way. If you're hoping for a home birth, and you want to work with me, for example, like this is a contract between me and you. And I will support you in exercising your sovereignty, and your connection to Mother Earth into the cosmos. And that's it. That's my role. And I fortunately have some skills where I can say, you know, what, if your goals change, if your values change midway through, and you become scared, you hit the brakes, and we do have to transfer, that's okay, too. But when you get pregnant, and you're going to have a baby, this is on you. Nobody can save you from that.

So Nathan, how do you handle it when you know that a woman is making a choice that could potentially put herself and her baby at risk? Because I in that role, see myself as the person who has the knowledge that inexperienced that she may not have? I feel responsible in that moment for helping her to make the right choice? Yeah.

Well, this is a I mean, Trisha says, like the Gordian knot, how do you support a person in exercising their autonomy, without inadvertently empowering them to do something that is very likely going to lead to something that's not in line with their goals. So the scenario I can give everybody out there is you're let's say, you're having a hospital birth, you're on the monitor, right? This stupid thing that's strapped to your belly. And it shows that the baby's heart rates dropping these decelerations that's a sign of perhaps some changes in the baby's acid base status, fetal distress, as we call it. And the doctor runs in and says, Oh, my gosh, I miss so and so I'm really worried about your baby, I think we need to move to the operating room. And they say, yeah, why do you think that and they explain, you know, here's the risks or the benefits of keeping going, whatever. And they say, you know, I appreciate that. But let me take 20 minutes to talk to my part. And they're like, oh, let's make it 15 minutes, right? And they come back in 15 minutes. They're like, we gotta get there. And they hand the guy, the bunny, this, you know, his or her partner that bunny suit. They start pulling things out of the wall, and the patient says, no, like, I don't want you to cut into my belly. Absolutely not under any circumstances, will I let you cut into my belly? Right? So she's exercising her autonomy and her right to refuse treatment. If that baby dies, we would say this woman, I can't believe she let her baby die. Like what a horrible person. The doctor feels like, I didn't push hard enough. I didn't. I didn't I should have forced her to do that or whatever else, right, like whatever language, you know, ends up resolving either person's kind of fingerpointing, you know, in that scenario, the woman has every right to refuse a C section, even if her body if baby dies, that's not something I would be comfortable with, personally, if it was me and my wife, but that's also not my position. So that's the extreme example of that. I think that what I think that what we're missing in the conversation is that it's not me against them. It's that if you and I have good enough rapport, and you know that I am standing back and holding space for you to make your own decisions and giving you information as it comes up, and then we have a new conversation, these new labs say something slightly different, or man, your blood pressures are really high, I'm really getting concerned about how high they are, you're too hot to 10 over 100. Here are the risks and you know, stroke, seizures and whatnot. Oh, man, you've developed help syndrome, I'm really concerned about you having a home birth, here's why. They can still say no, but the reality is that if we have actually built a relationship, and I haven't been sitting in the captain's seat the whole time, 100% of the time, they're gonna say, this guy really cares about me. And that recommendation is one that I'm going to listen to, and we're going to have a hospital birth. Now that doesn't happen or trust that, yeah, we have to build trust, we can't just walk in and say, you know, pull up our scrubs, and with our big white coat to show that we're the authority figure and say, here's what we have to do based on the data that doesn't, there's no trust there. They don't know who you are. In fact, you didn't even introduce yourself before you shoved your hand in her vagina last time. So maybe we should start there. Build some relationship, treat this as a person like it's your own wife, for example. And then let's maybe prepare ourselves for the possibility that that recommendation against what her intuition tells her could actually be exercised, and if not, it's still my job to do risks, benefits, alternatives, and using non coercive language and then to support you in that decision. And if I'm really desperately concerned about this, then I might say, I'm not comfortable attending your home birth I think you need to find a different provider. And that's that but it's not my job to say you're stupid for having a wanting to have a home birth. How could you want to do that your baby is going to die us and all that other language, which is coercion.

I think the best advantage any homebirth provider has or any doula has or even childbirth educator has is we can be very selective about the couples we work with. And I think we must be. And I think rapport was the key word. And I would never want to be in a position working with pregnant women in a setting, even if it was a aligned with my values in a setting where clients are coming in, and I must work with them. Because you can feel if it's not going to be the right fit, you can't force a relationship, you do want to have a sense of trust and mutual respect. And I think women have to think when they're hiring, they that's what they need to be looking for. And they can't just show up at Oh, well, this doctor was recommended. So I guess I'll just show up there and trust them. That's what we always say like you're the hiring manager hire Well, yeah. But those of us working in the field, we can be selective about the people we work with. And what's the key thing? We're looking for that degree of personal responsibility? Yeah, yeah, I'm here to support you. I'm not here to drive the car.

I think this is a really common problem with the midwifery model of care in the hospital, and why many midwives are called midwives, because they don't have the opportunity to build that trusting relationship they're seeing, you know, so many people in one day, and they are oftentimes at a birth, getting that woman they've never met before, they have no prior relationship with them. And they in they want to come from that place of the midwifery model of care. That's how they were trained. That's their education that's in their heart for most of them. But they don't have that relationship. They don't have that trust so. So they tend to lean more toward the management of the decision making and fall back on hospital protocol and policy.

Yeah, yeah, in a lot of ways people who attend homebirths, they get this on a deeper level, that they're not here to be the captain of the ship. In fact, that's why you might actually choose to serve women in the home environment, because it's on their terms, and you see some intrinsic value to them giving birth in a place where they feel safe and seen, and that you're certainly not the captain of the ship in their home.

Plus, those policies and protocols don't follow you into the home.

I don't have a culture of people who were saying this is how we do things in the home. If anything, it's the culture of the home that tells me here's how we do things in the home. So and what and what a, you know, what a great relief of the burden of responsibility for me. I don't have anybody telling me how I have to do it except for the person who I'm serving. So there's a lot less of I need to follow the way the hospital does or the culture of my practice or whatever else there's a lot more like okay, I've got my skills. I brought it there in the car. They're hanging out here. How can I how can I help? How can I be here for you? I want you to sit in that room over there and I don't want to ever see you until the baby comes out. Okay. You holler if you need anything in the meantime.

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At the last shift, I did a C section at like 4am and it was like a 37 second like a horrible abruption. I mean, like it was one of those true emergencies. I did it. And the doctor there this patient's doctor walked in and was putting the scrubs on and I was like already closing fascia. I was like, you're fine. Like, go. And he was like, Whoa, thanks, you know, whatever. And I just went to the desk and like the way that the nurses were all chitter chattering about the sports or whatever else while I'm like saving this woman's life. I was like I'm done no more. I went into the office into the call room and wrote for like the next three hours of my shift. I just wrote this nasty blog post. And then I read it. I've read it live on my own not live but I recorded it for my old podcast, which is called OB GYN. Why no and it went. We had like 400,000 views or something ridiculous. Which tells you that there's a pain point there that people want permission to feel into.

And they suppress it and suppress it and suppress it and suppress and then somebody brings it up and it's like yes.