Something Was Wrong
S23 E3: Standards of Midwifery Care with Dr. Amy Giles, DNP, CNM
Thu, 27 Feb 2025
*Content warning: pregnancy, birth, infant & pregnancy loss, medical negligence, medical trauma. *Free + Confidential Resources + Safety Tips: somethingwaswrong.com/resources Amy Giles’ Birth Center & Bio:Allen Midwifery & Family Wellness: https://allenmidwifery.com/ Amy’s Bio: https://nursing.baylor.edu/person/l-amy-giles-dnp-cnm-cne-facnm *Sources:After a C-section, women who want a vaginal birth may struggle to find carehttps://www.pbs.org/newshour/health/c-section-vbac-vaginal-maternal-health American College of Nurse Midwiveshttps://midwife.org/ American College of Obstetricians and Gynecologists (ACOG)https://www.acog.org/ Cardiac conditions in pregnancy and the role of midwives: A discussion paperhttps://pmc.ncbi.nlm.nih.gov/articlesC-Section Rates By Hospitalhttps://www.leapfroggroup.org/sites/default/files/Files/C-Section-Graphic-final.pdf March of Dimeshttps://www.marchofdimes.org/peristats/about-us Midwifery Education Accreditation Council (MEAC)https://www.meacschools.org/ National Midwifery Institutehttps://www.nationalmidwiferyinstitute.com/midwifery North American Registry of Midwives (NARM)https://narm.org/ Postpartum Hemorrhagehttps://www.chop.edu/conditions-diseases/postpartum-hemorrhage Postpartum Hemorrhagehttps://my.clevelandclinic.org/health/diseases/22228-postpartum-hemorrhage Practice profile of members of the American College of Nurse-Midwives. https://pubmed.ncbi.nlm.nih.gov/9277066/ Salary and Workload of Midwives Across Birth Center Practice Types and State Regulatory Structureshttps://pubmed.ncbi.nlm.nih.gov/35191600/ State investigating Dallas birth center and midwives, following multiple complaints from patientshttps://www.wfaa.com/article/news/local/investigates/state-investigating-dallas-birth-center-midwives-following-multiple-complaints-from-patients/287-ea77eb18-c637-44d4-aaa2-fe8fd7a2fcef Texas Administrative Codehttps://texreg.sos.state.tx.us/publicTexas Department of Licensing and Regulation (TDLR)https://www.tdlr.texas.gov/ Thyroid Disease & Pregnancyhttps://www.niddk.nih.gov/health-information/endocrine-diseases/pregnancy-thyroid-disease Zucker School of Medicine, Amos Grunebaum, MDhttps://faculty.medicine.hofstra.edu/13732-amos-grunebaum/publications *SWW S22 Theme Song & Artwork: Thank you so much to Emily Wolfe for covering Glad Rag’s original song, U Think U for us this season!Hear more from Emily Wolfe:On SpotifyOn Apple Musichttps://www.emilywolfemusic.com/instagram.com/emilywolfemusicGlad Rags: https://www.gladragsmusic.com/ The S23 cover art is by the Amazing Sara StewartFollow Something Was Wrong:Website: somethingwaswrong.com IG: instagram.com/somethingwaswrongpodcastTikTok: tiktok.com/@somethingwaswrongpodcast Follow Tiffany Reese:Website: tiffanyreese.me IG: instagram.com/lookiebooSee Privacy Policy at https://art19.com/privacy and California Privacy Notice at https://art19.com/privacy#do-not-sell-my-info.
Chapter 1: What is the introduction to this podcast episode?
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Opinions shared by the guests of the show are their own and do not necessarily represent the views of myself, Broken Cycle Media, and Wondery. The podcast and any linked materials should not be misconstrued as a substitution for legal or medical advice. This season is dedicated with love to Malik.
Until you
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Chapter 2: Who is Dr. Amy Giles and what is her background?
I'm Amy Giles. I'm a certified nurse midwife. I've owned a birthing center north of Dallas for several years. I've worked there since 2006. Our birth center is Allen Midwifery and Family Wellness, and we're in Allen, Texas, which is north of Dallas. I really enjoy taking care of women at the birthing center. I also teach nurse midwife students at Baylor University.
And that's another passion of mine is to build up the next generation of nurse midwives. I'm not from Texas, I'm from Louisiana. I moved here to go to Baylor for undergraduate school. I got married to a Texan and so I decided to stay. But when I got pregnant with our first baby, I really didn't have a provider. Since I wasn't from here, I used to go home to have my annual exams.
I asked a friend of mine where she had delivered her babies, and she said at a large facility downtown, and it's a teaching hospital. She said that she had a nurse midwife, and I had never heard of a nurse midwife before she told me that. Even though I was a nurse at the time, it just wasn't something that was popular 27 years ago. So I convinced my husband to go and meet this nurse midwife.
And when we walked in, it was such a completely different experience than being at any other physician office. We went in, we sat down, she asked about us as people and about our relationship, what we wanted to get out of the pregnancy, how we wanted to have a baby. And then she did all of this education to help us know what to expect and how your body works.
I was a nurse, and yet I didn't know a lot of the things that she was talking about. So it was really eye opening to us. And as we left, I told my husband, I want to be just like her. I want people to feel loved and taken care of just like she made me feel today.
I was actually in grad school to become a family nurse practitioner, and I called my advisor and said, hold on, I need to change my major. This is what I want to do for the rest of my life. So I changed my major. I became a nurse midwife and then worked in a large teaching facility for a couple of years.
Then one of my midwife friends had her baby at the same birthing center that I eventually owned, and I had never seen an out of hospital birth. And when I experienced that birth with her, it was very similar to the first time I had met my midwife. It was like the writing was on the wall. This is where you're supposed to be. I changed jobs and I've been at the birth center ever since then.
It's my favorite thing to do, to be with women and to educate them and talk to them and hug them. It's the best job.
What's unique about practicing midwifery in Texas?
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Chapter 3: What makes midwifery practice unique in Texas?
But while I was on that committee, what I really found was people not necessarily advocating saying something's wrong with me and being ignored. that happens in the hospital, mainly because it's just, there's so many more people. I understand because I deliver in the hospital, but things fall through the cracks because there's not someone with that client all the time.
So I think one of the solutions for that is a birth center birth. In the Dallas Fort Worth area, some certified nurse midwife birthing centers also have hospital privileges.
So what makes your facility unique is that you have hospital privileges, whereas some birthing centers do not.
That's correct. It's a significant difference because if someone becomes high risk, then we continue to follow them and to deliver them in the hospital. So the continuity of care is really lovely because when you don't have that luxury, then you're not able to continue to care for your client. In other words, you become either more of a support person or equivalent to like maybe a family member.
Whereas our midwives, we're able to continue to deliver in the hospital. We can take our clients to the hospital who might need a higher level of care. I think it's really important to be able to have a safe option for people who want to go that route, where they want the midwifery care during pregnancy, but then for safety, they can deliver in the hospitals. I think it's a nice compromise.
How important is proximity to a hospital for a birth center and what do you feel is reasonable in terms of distance?
Every state is a little bit different in how birth centers are licensed. And in Texas, the licensing board says that you have to be within 30 minutes of a hospital. I think that's kind of far. That's just what the state says. So I feel like if you're somewhere between five and 10 minutes, that that's pretty safe. We're about six minutes away from our hospital and it works really well.
I don't ever feel like, oh, we've got to get there, hurry up, because it's pretty fast. There are lots of rural areas in Texas. And so there may not be an option for you to have such a close hospital. And they may just not have any hospitals in that rural area. So maybe a birth center is all you have. And in that case, more power to them, that's gotta be a hard situation.
But if you're in an area where you have a lot of options on hospitals, I would recommend somewhere between five and 10 minutes to the hospital. I just feel like people need to know that there are options for them. There are also safe options. When you do want to get out of the hospital and you want to be in a birth center setting, you just need to do your research.
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Chapter 4: Why is proximity to a hospital important for birth centers?
And I tell clients all the time, if you're not comfortable in the birth center, you won't have a great birth because you'll be too stressed. So they should deliver in the hospital and vice versa. You should always know you have an option, but you should go with your gut and decide what's best for you and your family.
What are some of the common reasons that your clients share with you that they're choosing midwifery?
Everyone is a little bit different in why they seek us out. But for the most part, people are looking for individual attention, individual plans of care, not being cared for like everyone, but instead having a midwife sit down and really talk about your specific needs and how you wanna have a baby and what's really important to you. That's a big deal.
Another thing is that we do have longer appointments. We have 30 minutes to an hour, depending on how far along you are in labor. We have that extra time. Another reason is that people who have already had children, they're able to bring their kids in and We have toys in just about every room, so they have a place to be able to play. We're very family friendly.
We want everyone to come in and feel like that's a place where they belong. And how can we make that a different experience? because everybody deserves the birth that they want. There's always little things, you know, that come up. There are emergencies or risk factors. But even at that point, we try to make the birth as close as we can to what they want.
As far as like the different kinds of clients that we have, it ranges from very young people who are having their first baby to people who are having their 10th baby. We've had someone who's had 10 babies with us
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Chapter 5: What are common reasons clients choose midwifery?
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What are some of the common concerns you hear from clients regarding care that they've received at other birth centers in the area?
For people who maybe have had a bad experience in the past, a lot of people say they're just looking for a healing birth. So we can really dive into some of the things that they experienced that were really negative for them. We try our best not to ask which birth center was that or to really ask a lot of questions that are specific to that birth center.
We try to just ask questions about what was it that made your experience different or difficult. A lot of times it is that maybe they were more high risk and they didn't quite realize it. And then maybe they ended up transferring to the hospital without that continuity of care. And it was just very disappointing to them. We hear that more often because if you feel like
You're low risk and you're a good candidate for this particular type of care. And then it doesn't come to fruition. And then later on, you hear someone say, oh, well, my midwife would have never let me do that in a birth center or my midwife would have never let me do that at home. I think that's the number one thing that we hear. It is a small community.
And so when there are poor outcomes, everyone kind of knows about it. There are times that the public will try to avoid different midwives or different birthing centers. And that's why I think it's just super important to interview the midwives that would be taking care of you and get a feel for them and to ask questions about how they would handle different situations.
Excellent advice. Is there any other advice that you would share with listeners who are considering a birth center?
I think you need to know what level of care that you want. there are people that they really don't want types of intervention. So those are people that might be more inclined to do a home birth with a licensed midwife or a birth center with a licensed midwife.
And people that are a little more comfortable having what I would call a safety net would look at more of a certified nurse midwife birthing center because of the fact that we can give antibiotics if needed, or we do have some pain medication that we can give at the birth center. And we do have that relationship with the hospital.
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Chapter 6: What advice is there for choosing a birth center?
What would you consider a good transfer rate for a birth center?
It is hard to know. If it is too low, then are we doing things that we shouldn't be doing? And if it's too high, are we overreacting to some things or are we having patients that are a little high risk? So it is a hard number to come up with, but I would say 10% is probably a good number. Sometimes it just depends on the patients that you have.
I agree with the fact that you shouldn't be afraid to transfer. You should transfer when you feel like it really is necessary. And so sometimes if you have a 2% or 3% transfer rate, then that's a little questionable.
But if you had a 20% transfer rate, that's unacceptable as well because you're either having too many high-risk clients that you're signing up or you're overreacting maybe to things that should have probably just been handled at the birth center. The other thing is what is the emergency transfer rate?
Because we break ours up into non-emergent and emergent because you need to know how often are they having to call an ambulance and it's an emergency as opposed to you've become high risk, let's get in the car and drive. The emergency transfer rate should be low because you should be able to transfer most of the time before you get to it being an emergency.
There are always situations that you just can't see coming. They surprise you. But for the most part, we can see if something's going south. If things are not looking good, we would rather get to the hospital in a non-emergent way than to wait for an emergency. It is one of those things that for the public, it's hard to know.
But my suggestion is somewhere around 10 to 12% is probably a good transfer rate.
Could you give us some general examples of what things can occur where these sorts of emergency transfers need to happen?
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Chapter 7: How are high-risk pregnancies managed in birth centers?
Whenever someone is coming to the birth center to decide if this is the right place for them, these are actually the things that I discuss with them. So I appreciate that you asked that question because it is important to know which providers and which birth centers feel are emergency situations. One of them is if we have not diagnosed breach and a breach presentation comes in.
That would be an emergency for us. We would get into the ambulance and go to the hospital. More unforeseen things might be if the cord collapses, basically meaning that the cord comes out in front of the baby's head and then it compresses the cord and it doesn't allow oxygen to get to the baby. That is a very rare occurrence, but it can happen at any time and for no reason whatsoever.
Postpartum hemorrhage is another. Honestly, that's the number one reason that we transfer to the hospital is unforeseen bleeding. So once the placenta is delivered, the uterus has to contract to stop the bleeding. For whatever reason, sometimes that just doesn't happen.
At our birth center, because we are nurse midwives, we have all the same medications that we would give to women in the hospital to stop that bleeding. However, we don't want to stay at the birth center.
We want to take them to the hospital so that in case they need blood and the fact that they need to be monitored for at least a day at our birth center after six hours, if our moms are not stable, then our policy is that we transfer them. It can be serious in a very short period of time. You can lose a lot of blood in a short period of time.
As soon as we see that there's a hemorrhage and we start giving medications, if it doesn't respond really quickly, then we go ahead and call 911 and we go via the ambulance. If we have a mom whose blood pressure is incredibly high that we're afraid she might have a seizure, I know all those things sound very scary, but they can occur due to high blood pressure.
That's another mom that we might want to get her to the hospital in an ambulance. when the baby's heart rate is decelerating, so showing us that something is not going well with the baby. We would rather get to the hospital, get the mom on the continuous monitor so that it doesn't progress to an emergency situation.
I'm curious if your birth center allows VBAC, meaning a vaginal birth after cesarean, and what your experience is with that within the birth center setting.
It's kind of a controversial topic because there are lots of birthing centers that will do VBACs. However, at our birth center, we just don't feel comfortable with it because of the risk that is involved. Risk to the mom and risk to the baby. And we just don't feel like that's a risk that we want to take. It's not that we want to tell someone how to have their birth.
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Chapter 8: What is considered a good transfer rate for a birth center?
Even though it sounds like it's more about sanitary things with having towels, it's actually more of an important thing because if you don't have those, then you can have a baby that gets really cold. Let's say you have a water birth and you need that warmth around the baby in order to maintain the heat. I feel like there should be a standard that everyone should really have.
If you're going to own a birth center or you're going to deliver babies outside the hospital, you have to have a standard that you have created and to meet that standard every single time that you have a client come in. Staffing is another thing that you should have a minimum number of staff at each birth. You should have a minimum number of suture if you need to do a laceration repair.
You should always have preparation before you have someone come in in labor. I just feel like that's the baseline of care, the bottom foundation, and then you build up on that. So that's disturbing.
I love that you mentioned staffing because this seems to be another major issue in some of these birth centers where I've interviewed clients who have had negative outcomes. What's being alleged is that students were seeing clients without their perceptor due to staffing issues. But that's not correct, right? The student should be overseen at all times. They should not be practicing solo.
You are exactly right. And one of the things that you said that upsets me as well is them not knowing. If you are going to have a student working with you, I think that's great because how else do you learn? The students that I have at Baylor that I teach, they have preceptors all over the country and we precept at our birth center.
But you have to ask and you have to get permission from a client to have a student at their birth. If you're not asking, to me, that's just completely unacceptable. People need to know who are taking care of them and they should know what your credentials are. To have a student taking care of someone without their preceptor there, to me, is below the standard of care.
That is putting your client at a huge risk because that person is still learning. They don't know everything. There has to be another person there that knows what to look for, looks for those signs of an emergency. I wouldn't want a student, only a student, taking care of me. That would make me very nervous. A midwife and a student? Absolutely. I'm more than happy. Come and be a part of my birth.
But it's very disturbing to me if you did not know that it was a student and if that student was caring for you solely. But I do think that happens. I understand being so tired. You don't want to take care of people when you're tired, but you also don't want to defer to a student. Instead, you should call in another midwife and have them come in and be with the student.
I just don't find that to be acceptable at all. Our birth center is Allen Midwifery and Family Wellness. We're a family-owned center. So my midwife that I met when I was in midwifery school, she was kind of my mentor. And so she opened this birth center in 2003. That was the same place that I saw my friend deliver. And I begged her, I'm like, please, please let me be a part of your birth center.
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