What is a Midwife and Why Might a Woman Want to See One? with Jessica Costa, CNM

Podcast Transcript

Nada Youssef:   Hi, thank you for joining us. I'm your host, Nada Youssef, and today we're talking with our featured experts about natural birth. Even though it may cause some discomfort without epidural, many women are more satisfied with the full experience when going natural. In the United States, approximately 39% of women have vaginal birth and they do so without any epidural, and some of you might be wondering why. So to answer some of these questions and more, today we have with us Cleveland Clinic certified nurse midwife, Jessica Costa. Thank you so much for being here.

Jessica Costa:    You're welcome.

Nada Youssef:   And if you want to take-

Jessica Costa:    Thank you for having me.

Nada Youssef:   Sure. And you want to take a moment to just introduce yourself to our viewers and listeners?

Jessica Costa:    I sure can. My name is Jessica Costa. I am a certified nurse midwife with the Cleveland Clinic at the Wooster Women's Health Center.

Nada Youssef:   Great. And how long have you been doing this?

Jessica Costa:    I've been a registered nurse for 10 years, and I've been a certified nurse midwife for five years, and I've been with the clinic for the last year.

Nada Youssef:   Great, excellent.

Jessica Costa:    It's been great.

Nada Youssef:   Very, very happy to have you here.

Jessica Costa:    Thank you.

Nada Youssef:   And before we begin, please remember, this is for informational purposes only and is not intended to replace your own physician's advice. So I just want to start with midwifery. What is a midwife?

Jessica Costa:    So a certified nurse midwife, the word midwife means with woman. A nurse midwife is first a registered nurse, so has a bachelor's degree in nursing, and then goes on to receive a master's degree in nursing, and specializes in midwifery. In Ohio, we are recognized as one of the four advanced practice registered nurses.

Nada Youssef:   Wow. So you have to have a master's-

Jessica Costa:    Yes.

Nada Youssef:   ... to be a midwife?

Jessica Costa:    To be a nurse midwife, yup.

Nada Youssef:   I had no ... Oh, a nurse midwife. Okay.

Jessica Costa:    Yup.

Nada Youssef:   Great. And nurse practitioners are all trained as midwives, then? Is that how it starts?

Jessica Costa:    So it actually does not. There are four types of advanced practice registered nurses in the state of Ohio. There are a clinical nurse specialists, nurse practitioners, certified registered nurse anesthetists, and certified nurse midwives. So we are in that master's prepared nursing field, but separate from a nurse practitioner. We specialize in the midwifery portion.

Nada Youssef:   Oh, excellent. So why should someone consider getting a midwife? What's special about midwives?

Jessica Costa:    I like to tell my patients we're cooler.

Nada Youssef:   Well, obviously.

Jessica Costa:    Obviously. No, I'm just kidding. So, no, it's just a different ... It's in our training. So midwifery really likes to look at the person as a whole. So it's holistic care. We specialize in low-risk normal. We specialize in low-risk pregnancies, labor, and birth, and that's where the midwifery portion comes into play. But we also are able to perform well women exams, gynecological problems. We're able to help women with that, sexually transmitted infection testing and treatments, as well as some common health problems like a urinary tract infection or a yeast infection. We can help women with that.

Nada Youssef:   So after childbirth, they're not done with you.

Jessica Costa:    They aren't.

Nada Youssef:   You are still seeing the patients.

Jessica Costa:    Absolutely. So preconception care to help them become the most healthiest woman that they can be prior to becoming pregnant. We can see them during the pregnancy. We can help support them during the labor. We can actually attend the birth of the baby for them. And then in the postpartum period with breastfeeding support, birth control, and then from teens beyond menopause.

Nada Youssef:   Wow. So you can prescribe medication and everything?

Jessica Costa:    Yes. We have prescription authority in the state of Ohio.

Nada Youssef:   Excellent. Well, let's talk about natural birth versus epidural. What to expect, both benefits and risks maybe for both.

Jessica Costa:    Both, yeah. When we look at natural birth, that word means something different to different women. In certain areas, it may be completely different from another area of practice, which I have been able to experience. So for some, natural birth means completely un-medicated, nothing at all during the labor and birth. For others it may mean that they are just not getting an epidural, so they may have some of the other interventions or other pain management options, but the epidural is just not part of their birth plan. And then for others, a natural birth just means that it's a vaginal birth and not necessary a cesarean section. So kind of to clarify that because it really means something different to different women.

Nada Youssef:   Yeah.

Jessica Costa:    For the purposes of today, I'm going to focus on natural birth meaning not having an epidural, just kind of separating those there-

Nada Youssef:   Sure.

Jessica Costa:    ... if that's okay. When we look at natural birth for women, midwifery care specializes in low-risk normal, and when we're able to support women through this process, we really are focusing on helping them have the most optimal care during the pregnancy and supporting their body for a physiological process. Midwives view birth as normal, a normal process that our body is designed to do, and not a medical condition. And that's where our specialty comes in, is the art of midwifery, knowing how to help support these women through the different stages of labor.

Jessica Costa:    So with midwifery care in the natural birth, we want women to come in to labor in active labor, which is around six centimeters, for most women. They're able to labor at home to be comfortable in that environment for themselves. Come in when they're about six centimeters.

Nada Youssef:   How do they know they're at six centimeters?

Jessica Costa:    How do they know? I know, so-

Nada Youssef:   I would have no idea.

Jessica Costa:    Exactly. So that's something we're able to help train, help work with them during the pregnancy to know when active labor is. For women that are first time moms, I like to give them the recommendation of 5-1-1. So when contractions are about every five minutes from the beginning of the contraction to the beginning of the next contraction, the contraction itself is about a full minute long, for about an hour, or when they're becoming really uncomfortable, the contractions are becoming harder to cope with. That's about a time to give your midwife a call and let her know that things are changing. And for a mom that's already had a child previously, I recommend giving me a call about eight to 10 minutes apart, the contractions themselves, because their labors typically tend to go a little bit faster.

Nada Youssef:   Wow. So then they usually would call your office to let you know that they think they're-

Jessica Costa:    Yes, so we have, like during the office hours they're able to call our office and let us know. Sometimes I'm able to bring them in and see how things are going, if they're truly in labor or if they can still continue to labor outside of the hospital, but if it's after-hours they're able to call our answering service or the answering service that gets the phone calls for us, and then they can give us a call-

Nada Youssef:   In triage, and then to you.

Jessica Costa:    ... and I can talk to them. In triage, yeah. I personally like to talk to my patients because I'm able to sometimes hear their contraction, them breathing through it, and be like, okay, it's time. It's time to go in.

Nada Youssef:   Yeah, absolutely, and as a mom, it gives you such comfort when you're talking to your provider on the phone, not just like someone that's going to tell them about your contractions. Okay. So some of the natural birth options, for those who don't know, can you give us some of the techniques that you work with?

Jessica Costa:    Yeah, so with natural birth, the thing that I really like to start with is upright movement. So frequent movement, upright positioning, the woman being able to get in the position that's most comfortable for her. Laying in bed, for a lot of women during labor, is not the best thing for them. It's really uncomfortable. They're not able to cope well during the contraction, so that frequent movement allows the baby to really navigate into the pelvis for optimal fetal positioning for the labor and delivery.

Jessica Costa:    So positioning, movement is good. Midwives are able to use what's called intermittent fetal monitoring, so they don't have to be hooked up to the monitor continuously with those belts that go around your belly, and evidence shows those are just as effective at monitoring the baby and are safe, so we're able to, with a handheld Doppler, just kind of listened to baby at certain points before, during, and after the contraction at certain intervals for them. So that's another great option for women to keep them mobile and not hooked up to anything.

Jessica Costa:    The birthing ball is a great pain management technique. That movement, kind of some deep hip circles on the ball, helps baby navigate that pelvis again, as well as can provide comfort for the woman during the Labor.

Jessica Costa:    Massage therapy. So just sometimes women just need like this gentle rub, just gentle massage. This is a time during the labor that I'm able to get that support person, their partner, their husband, a friend, a doula involved in just showing them just that gentle technique, how to really help that woman cope is a great option.

Jessica Costa:    Water immersion. So getting in the shower is great for women for support during labor for pain relief, and then submerging in a warm tub during the labor really can help release those endorphins, cause them to be buoyant. So all of the pressure is really relaxed. They're able to really relax. I find that women, when they get in the tub, I get this big, "Oh, my gosh." The sigh.

Nada Youssef:   All the pressure is lifted.

Jessica Costa:    Yes. It's great. So I mean, that's exactly what I always see happen. So that's another great pain management option for them.

Nada Youssef:   So these are things you could do at home before you even show up, right? To the hospital.

Jessica Costa:    You can do those at home, but in those hospital, those are-

Nada Youssef:   You do it at the hospital as well.

Jessica Costa:    ... techniques, yup, to help them, and we're able ... Midwives during natural birth are able to help guide them. So sometimes they might be in the bed, maybe on their hands and knees, laboring and I'll say, "You know what? Why don't we get in this next position?" because I really want them frequently, every 20 to 30 minutes, to move, and sometimes they'll say, "I don't want to, I'm comfortable," and I'll say let's just try. It's general coaching, and they'll be like, "Oh, this is so much better," or, "No, I need to go back." So it's great to really ... It's the art of midwifery, of knowing like what technique, what movement, what motion, what pain management option might help them better support.

Jessica Costa:    So those are some natural things we can try, and then other options we have are pain medication. So we can give them narcotics through an IV, intravenous catheter, if they would want-

Nada Youssef:   This is still natural birth, just some pain relief.

Jessica Costa:    Yup, some pain relief.

Nada Youssef:   Okay.

Jessica Costa:    So if those other techniques aren't working for them and they would like to go to another option, we can get them IV pain medication. So I tell women it doesn't take the pain away, it just kind of takes that edge off. So they're able to kind of relax in between the contractions more effectively, and that peak of the contraction is probably where they're waking up a little more, feeling that, and then they're able to kind of relax back to sleep.

Nada Youssef:   And they're still mobile, they're still able to get up, they're still able to move positions?

Jessica Costa:    Usually, they can move positions in the bed, but normally we have them kind of still stay in the bed kind of resting and relaxing, and for most women, maybe one to two hours of relief they get with that. So that part of it, they're able to rest in the bed for a duration of time.

Nada Youssef:   So as a midwife, you have a patient, a mother that you're attending to. Are you with her the whole time she's in labor?

Jessica Costa:    For women, yeah, and so that depends on their preference as well. I tell my patients that, as soon as I enter the room and they're in labor, I say I get real bossy. I tell them ... No, no, no. I say, "You know what? This is your labor, this is your birth. So what are ... You have choices." I can be at your bedside from active labor, about six centimeters, with them helping labor support them, giving them those recommendations, the massage, really coaching them through, or I can be out just kind of monitoring the baby, sitting out and waiting for them to have me come in at their request, or if they just want a presence in the room. Sometimes I've honestly just kind of sat there and we'll just coach them like, "You're doing a really great job. Nice job. Keep breathing. Deep breath. It's almost over. You're almost there. You did it. Good job." You know, just kind of coaching them through. Not actively doing any management, but just a presence for them.

Nada Youssef:   Yes.

Jessica Costa:    So I really like my patients to make that call, what they are wanting, and oftentimes it's getting closer to the end too that they're like, "Okay, you're not allowed to leave the room. Stay."

Nada Youssef:   Yeah. You're not going anywhere.

Jessica Costa:    Yeah, you're not going anywhere.

Nada Youssef:   That would be me.

Jessica Costa:    Exactly. Right there.

Nada Youssef:   I'm like terrified, yeah, yeah.

Jessica Costa:    And that's their choice too. So that's a great part of midwifery care, is we are able to support women during the labor portion of it and not just the delivery itself.

Nada Youssef:   Sure. Okay, and then there are people like me that went full epidural, didn't do anything natural. Let's talk about some of the risks to epidural or benefits. I know the benefits, but let's talk about it.

Jessica Costa:    Yeah. So there are some women that come in and they don't have any desire for a natural birth, and I say it's really a mindset going into natural birth, but with an epidural itself, some women, that is their choice, and we're able to fully support them with that option. The benefit is that ... An epidural is, for those that are not aware or don't know, it is a catheter that goes into the epidural space and then medication is instilled into the spine that kind of numb from the waist down. They don't have as much mobility with their legs, and that pain is really relieved during that time. Sometimes they can still feel pressure, maybe a little bit of pain, but definitely not to the extent that they would have previously, and those are inserted by an anesthesiologist or a CRNA, another advanced practice nurse, a certified registered nurse anesthetist, is able to do that. So, much benefit.

Jessica Costa:    The risk with an epidural could be potentially that infection at the insertion site, bleeding if it is inserted incorrectly. Back pain with that. Also, sometimes a mother's blood pressure can drop a little bit and cause some variation in the baby's heart rate, which we are able to help correct with medications if needed to the mother-

Nada Youssef:   Sure.

Jessica Costa:    ... as well.

Nada Youssef:   So with the risks of epidural ... You know, I think about my own experience, the contraction, you're not feeling the contraction. This is when you have the support system telling you to push. Is this an advantage for natural birth versus epidural, to feel the contraction for pushing?

Jessica Costa:    Absolutely. So with natural birth, women typically will get that urge to push. They're able to work along with their body. For some, it can shorten that pushing duration. The epidural can make pushing for some be a little bit of a longer process, and like you said, we're able to coach them along. It might take them just a minute. I will say sometimes now you're getting your groove. You know, now you're understanding what that feeling is where to push, and we're able to really coach them along with that during that pushing phase for sure. So it can take a little bit longer, but natural birth, they definitely can feel those pushing efforts.

Nada Youssef:   Now with recovery, it seems to be completely different with epidural versus natural. Can we talk a little bit about recovery?

Jessica Costa:    Yeah. So after a natural birth, the woman is free ... Once they've been recovered, the mom is stable, the baby's stable, they're able to breastfeed their baby if that's their choice, and mom is really able to get up and move around freely after. There's not like a duration she needs to really stay in the bed, as long as she is medically stable. With the epidural, the medication has to wear off. Their legs, they have to make sure that they're able to stand safely. So it is, recovery is a little bit longer with the epidural.

Nada Youssef:   It's longer with the epidural.

Jessica Costa:    Mm-hmm (affirmative).

Nada Youssef:   Okay. Great. So if I don't go for an epidural and I do want to do a natural birth, you mentioned that we could still have some pain management options. Can you tell me what are those options?

Jessica Costa:    Another pain management option that we are able to offer women at some facilities is nitrous oxide. So this is an inhaled gas of nitrogen and oxygen that a woman is able to self-administer via a mask. So no one else is able to do this for her, no support person, nursing staff. The woman has to be able to do it herself, and she is able just to put the mask over her nose and mouth, inhale through and exhale through this mask. And what this does, it's kind of a halfway point between that epidural and that IV pain medication. It releases the body's natural endorphins, the dopamine, and is able to really help them just kind of relax and not care as much during that process.

Jessica Costa:    There are some women that we don't recommend nitrous oxide for, but we're able to review all of those with them during the pregnancy or before they are in labor if it is not recommended, but it is a great option. There are some women that don't do well with it. However, the majority of the patients that I've had have really done well with the nitrous oxide, and I really offer this option a lot to them because I think it does a great job at helping support them and be able to continue through that process of natural birth and having a vaginal delivery.

Jessica Costa:    Another way I do like to use nitrous oxide though is, if there is any vaginal laceration or any repair is needed, nitrous oxide is a great option for them.

Nada Youssef:   So after birth-

Jessica Costa:    Yes.

Nada Youssef:   ... when like there's ... Okay, yes.

Jessica Costa:    So after the birth, if they require repair, they are able to inhale this nitrous oxide and able to get some pain relief if they have gone without an epidural. So obviously the pain is going to be a little intensified during that repair, so that's a great way to help them have some pain relief.

Nada Youssef:   Is there a limit on that or you just use it every time you feel pain?

Jessica Costa:    Yeah. So as soon as they, the contractions starts, and women figure this out real quick, what the system-

Nada Youssef:   How long it actually lasts.

Jessica Costa:    Yeah, what the system is. So it's coming. They'll grab their mask, inhale, exhale. And as soon as they take it off, it exhales out of the body, so there's no lingering effects. So that's the great part of it.

Nada Youssef:   Is this the same thing as a dentist office?

Jessica Costa:    Basically.

Nada Youssef:   Like the laughing gas.

Jessica Costa:    Yeah.

Nada Youssef:   Oh, laughing gas.

Jessica Costa:    That's what some people call it.

Nada Youssef:   But I don't think they're actually laughing.

Jessica Costa:    It's not funny, though.

Nada Youssef:   Okay. So what if ... Do you ever have a mom that comes in and she wants to do a natural birth, and she's going through it, and all of a sudden she just can't handle the pain and she changes her mind? And if she does that, is there something in place where you can give her an epidural last minute?

Jessica Costa:    Absolutely. So I tell women like none of this is in stone. These are your options, and that's why I highly encourage all of my moms to take childbirth education. This is able to help them understand the whole birth process from start to finish, what their options are, and then if we ever need to deviate from that plan, we're going to help ... we're going to work together in that shared decision making to figure out what the best option is. I like to tell women when I go in at the beginning of their labor, "Okay, you're the boss. I'm bossy, but you're the boss."

Nada Youssef:   You're the boss.

Jessica Costa:    Yeah, you're the boss. You're the boss. So what it is, what are your pain ... what is your birth plan? What is your birth plan for this? And when I'm able to find out what their birth plan, I can fully support them. I say, oftentimes, I'm not going to offer that epidural in terms of saying, "Are you ready for an epidural now?" I'm going to wait for her to tell me that.

Nada Youssef:   To ask for it. Sure. Sure.

Jessica Costa:    To ask for it. And that really is a great part of the process, is understanding and able to really watch them, how they're coping. Sometimes a mom may not ask for it, but I can see she's not coping as well. She's not advancing in dilation is much. And medically, sometimes we recommend an epidural. If there are reasons pre-pregnancy, if there's something during the pregnancy that arises that we would recommend an epidural, or during the labor, there might be a reason we medically recommend an epidural. But if a mom decides that she's not wanting to go without any medication, we start with that IV pain medication if she would like, that water immersion if possible, and then if not, we can definitely get the epidural whenever she is ready. I tell women there's really not a time that's too late unless the heads actually coming out.

Nada Youssef:   That's what I was going to ask you. So my next question was, this is because my friend was going to get an epidural and went to Fairview Hospital. I think she was like eight centimeters and they were like, "Sorry, you're going to start pushing." Isn't there like a certain centimeter, once you reach it, we should not be giving epidural or ...

Jessica Costa:    So I don't like to tell women that there's a certain centimeter. Unless someone is actively feeling the pressure to push, that would be a time that it would be more unsafe because you have to sit up at the bedside to be able to have the epidural placed. So I don't technically like to put that centimeter. There are 10 centimeters is complete dilation, prior to them actually pushing.

Nada Youssef:   Ten centimeters is ... Yeah, okay.

Jessica Costa:    Yeah. But typically I don't like to give a number because everybody's really different. I have had patients get an epidural at 10 centimeters because they didn't feel the pressure to push, nothing was really happening right there, and so they've had to get it at that point. That's not common, however. Typically I would say women get it anywhere between six and eight centimeters.

Nada Youssef:   So what happens if the baby ends up being breech?

Jessica Costa:    So if the baby is breech, normally we like to find this out during the pregnancy. It's something that, if we are able to find this out, we're able to help ... midwives can help, or a physician, can help women have certain techniques or things to do to help the baby turn while they are still pregnant. Different techniques I recommend for women is to see a chiropractor. A huge part of the management to help kind of relax that pelvis, get it in the optimal position, so then baby is able to rotate. There are stretching and exercise techniques, breech techniques that we can have women do to help, and then some old midwives' tails, some things that we can help women do as well to help baby turn.

Jessica Costa:    And for babies, for a mom that this is just naturally how her body is with this pregnancy and the baby is not turning, then we're able to refer the patient to the physician to complete a cesarean section because that is the safest way to deliver with a breech presentation.

Nada Youssef:   Great. All right. So sometimes you plan, your whole nine months you're planning a natural birth, and things don't go as par and you end up having some kind of medical emergency. Can we talk about, as a mom coming to the hospital, if my blood pressure is out of whack and then all of a sudden everything has to change, can we talk about what happens next?

Jessica Costa:    Absolutely. And that is one of those times where midwives are able to get involved with the collaborating physician, and that's where that standard care arrangement for us is a great part because now we become a part of a collaborative team. So when something medical arises, midwives are specialized in low-risk pregnancies, in normal pregnancies. So when something becomes more high-risk, there are certain conditions that we're able to still be involved with the care of the patient. High blood pressure for some is a part of that. So we are able to consult or collaborate with our collaborative physician and come up with the best care for that patient.

Jessica Costa:    So I really try and encourage moms that, even when things don't go as planned, the best thing is that we want to make sure all of the physical, emotional, spiritual needs are met for that mom and that everyone is safe for the mom, the baby, and along all of those different spectrums of care. The collaborative physician then is able to help make recommendations for us if needed, if something becomes high-risk. We have the nursing staff to help support the mother. Different hospitals will have a neonatal team or a neonatal physician on staff to help if anything was needed for the baby, and then our physicians are able to help as well.

Nada Youssef:   That's great.

Jessica Costa:    Some hospitals do not have physicians in the hospital themselves. So as a midwife, I'm able to attend births, attend the births of women, and the physician is not in the hospital with me. However, if a problem arises, they are able to come in and help during those times.

Nada Youssef:   That's great.

Jessica Costa:    For midwives, we don't perform like a vacuum extraction. If there needs an assisted vaginal delivery, the physician is able to help with the vacuum extraction-

Nada Youssef:   You have to tell me what a vacuum extraction is. I have no idea.

Jessica Costa:    So a vacuum extraction is ... Yeah, so basically it's like a little suction cup that goes on the top of the baby's head, so sometimes medically indicated that we are able to help the baby kind of come through the birth canal. It doesn't do the work. Mom still has to help, but the physician is able to help guide baby through the birth canal a little bit with just a little bit of pressure, so that helps. Or forceps, for those who are trained in forceps, basically are a metal device that can go around the baby's head to help assist the mother in pulling the baby out of the vaginal canal.

Nada Youssef:   Oh, okay. Are these the same kind of tools that are used if the baby is not head down or no?

Jessica Costa:    That would be different.

Nada Youssef:   That's different.

Jessica Costa:    That would be a cesarean section.

Nada Youssef:   Oh, okay.

Jessica Costa:    So that's a-

Nada Youssef:   No, that's C-section. Okay.

Jessica Costa:    That's a C-section. Yeah. But the assisted ... the forceps or the vacuum is one-

Nada Youssef:   The vacuum. Okay.

Jessica Costa:    ... way that we are able to help that woman have the vaginal birth as well, and then the physicians join in on that. And then if a woman would need a C-section, the physicians are able to take over the management of the patient and complete the cesarean section if needed. Now some midwives are trained to actually assist with cesarean sections as well, so they're able to still kind of be involved in that care, and then other times our role turns to supportive. So we aren't actively involved in the management any longer, but we're still able to support the women during.

Nada Youssef:   Sometimes that is all you need.

Jessica Costa:    Exactly. And I will say I'm so blessed because the physicians that we work with are so supportive of midwifery care, and it's not like when they come to assist or take over management of the patient that we're kind of just pushed out of the way. Like we're able still to support and still be a part of that team, and that's really such a beautiful part of the collaborative teamwork.

Nada Youssef:   That is. Can you tell me what the difference is between a doula versus a midwife?

Jessica Costa:    So a doula versus a midwife, and what the difference is, and sometimes this does get confused. That was another question, is it gets confused that a doula and a midwife are the same thing, but we're actually really different but similar.

Nada Youssef:   Yeah.

Jessica Costa:    So ... in some of the things that we do. So with doulas, they are nonclinical professionals, so they are not able to offer any medical advice. They cannot prescribe any medications, and they don't deliver the baby. However, they are an amazing support person for the mom and her partner during the labor, sometimes during the pregnancy and postpartum for like childbirth education or follow-up support in the postpartum period for mom. Doulas offer continuous labor support, so they're able to help them cope during labor, coach them, offer those breathing techniques, different positional changes, able to provide relaxation during that process, during pushing. So they're a great support, and research actually really encourages doulas because it helps prevent cesarean sections and promotes vaginal delivery. So that's a great part of the doula being a part of that team.

Jessica Costa:    Midwives, like we had discussed, that's part of our role too, is we offer that continuous labor support, but in areas where it may be a collaborative practice where physicians and midwives work together, and midwife might not always be available, a doula is a great option in those settings as well.

Nada Youssef:   So a doula is a great option for like mental, emotional support.

Jessica Costa:    Absolutely.

Nada Youssef:   Can you do a doula and a midwife?

Jessica Costa:    Absolutely.

Nada Youssef:   Oh, okay.

Jessica Costa:    I've worked ... Exactly. So I've worked great with ... I've worked alongside doulas, and it's kind of nice because we're able to kind of share, share that load. We might both have different offerings, so yeah. So I have worked alongside doulas as well.

Nada Youssef:   So how does someone get a doula?

Jessica Costa:    So a doula is someone that a woman and her partner or support person is able to get on their own outside of the hospital facility. Normally doulas are not on the staff of the hospital or in the practice itself. So they're able to research this option on their own. Some of my patients will interview a couple of different doulas and find which one that is most aligned with their desires or their wishes and that they click with the best, that they will enjoy having at their labor birth. So this is definitely someone that is outside of the medical portion of their care.

Nada Youssef:   Great.

Jessica Costa:    Yeah.

Nada Youssef:   So then after the patient delivers the baby, then they see you, it's like a six week appointment, kind of like the same thing as a physician.

Jessica Costa:    Yeah.

Nada Youssef:   They would come see you, correct?

Jessica Costa:    Yup.

Nada Youssef:   Okay.

Jessica Costa:    Yup. They would see us for their postpartum visit, and at that visit we talk about birth control. We talk about how their breastfeeding is going, or bottle feeding if that's what they have chosen. We talk about emotional, how emotionally things have been going. Are they sleeping okay? Any bowel or bladder problems? Postpartum bleeding, has that been normal for them? And then what are their plans for future family planning? We're able to discuss how long they're wanting to have family spacing in between. So a lot of discussion at that visit.

Nada Youssef:   Yeah, there's a lot. So-

Jessica Costa:    And usually I like them to bring the babies.

Nada Youssef:   Yeah, I definitely want to see the baby, for sure.

Jessica Costa:    I feel gypped if you don't.

Nada Youssef:   Yes. So as a midwife, what are the most common questions that you get from mothers?

Jessica Costa:    So honestly, when I have patients come in during the pregnancy, normally the questions that I get are, "Do you do home birth?" So that's something-

Nada Youssef:   Do you?

Jessica Costa:    No, I don't.

Nada Youssef:   Okay.

Jessica Costa:    So actually, most midwives in the United States attend births in the hospital. So that's kind of a misconception of what our role actually is, and so that's something that I tell them, no, actually we deliver ... certified nurse midwives are able to deliver in the hospital setting. So then they're like, "Oh, well I might want a midwife." So then we talk about that part of it. So I get that question a lot.

Jessica Costa:    Another question I get is, "Well, I really don't want a natural birth. I want an epidural. Can I still have an epidural if I see a midwife?"

Nada Youssef:   Yeah. That's a good question, and you can still get a midwife and epidural.

Jessica Costa:    It is. Exactly. Can I have best of both worlds? And absolutely they can.

Nada Youssef:   Oh, okay.

Jessica Costa:    And so for me, having a midwife and still wanting the epidural, I will encourage them, like I really recommend holding off on getting that epidural till labor is well established. You're kind of on that threshold of being able to cope with the pain and able to support them in that decision too.

Nada Youssef:   Sure.

Jessica Costa:    So, yes, if you have ... If you're wanting an epidural, you can still have a midwife and we can support you that way.

Nada Youssef:   That's excellent.

Jessica Costa:    So those are probably the questions I get.

Nada Youssef:   That you get. Okay.

Jessica Costa:    Yeah.

Nada Youssef:   Great. Well, I mean, we're kind of running out of time, but is there anything else that you would tell our viewers or listeners if they are thinking about natural birth versus epidural, where to go, someone maybe like me that would have been scared? Anything that you would tell our audience?

Jessica Costa:    Yeah. So when we look at natural birth versus an epidural, I just really encourage women to get that childbirth education to help them decide what the best option for them is, and that can actually help really promote their decision-making. And for natural birth, it honestly ... Our bodies are designed to do this. It's a natural physiological process, and natural birth is so empowering, and you can totally do this. It's a mindset going in knowing those coping techniques, having good coaches by your side, knowing the process, preparing, that really is the key to natural birth, is preparation. And then if we have to deviate from that plan, we're still by your side helping support you, help make those decisions, shared decision making, and getting to the end goal of helping mom.

Nada Youssef:   That's really assuring to know that, even if I end up going epidural, even if I end up anything, you're still by my side.

Jessica Costa:    Yeah.

Nada Youssef:   It's very comforting. Thank you so much for your time today.

Jessica Costa:    You're welcome. Thank you, thank you. It was a pleasure.

Nada Youssef:   Sure thing. And for more information about midwifery, please visit clevelandclinic.org/midwife, and make sure you check us out on other interviews for practical health advice from Cleveland Clinic experts on our Health Essentials podcasts. And for more health tips and information from Cleveland Clinic, make sure to follow us on Facebook, Twitter, Instagram, and Snapchat @clevelandclinic, one word. Thank you so much for tuning in.