Scott Webb (Host): Today, we're going to meet two experts in the pregnancy and labor and delivery field, and in addition to telling us about themselves and what they do, they're going to discuss how the certified nurse midwives and OB-GYNs work together for the best patient outcomes at Community Memorial Hospital.

I'm joined today by Dr. David Crownover. He's an OB-GYN and the Medical Director of Maternal Child Health. And I'm joined by Sally McNally. She's a certified nurse midwife, and they're both with Community Memorial Hospital.

Welcome to Wise and Well, presented by Community Memorial Healthcare. I'm Scott Webb. So, I want to thank you both for joining me today. We're going to learn more about you and what you do and Community Memorial Hospital in Ventura and midwives, or is it midwifes? I never know. I'm going to go with midwives. Dr. Crownover, I'm going to start with you, have you introduce yourselves, discuss your background, experience, and your role as a medical director?

Dr. David Crownover: My name is Dr. David Crownover. I'm an obstetrician-gynecologist. I've been practicing for about 20 years, but been in Ventura for 12, and all of those 12 years have been at Community Memorial Hospital. I currently serve as the Vice Chair of our department and then the Medical Director for Maternal Child Health. So glad to be here.

Host: Yeah. It's nice to have you here. And Sally, I want to have you do the same. Introduce yourself. Tell us about your background and experience and your role at Community Memorial Hospital.

Sally McNally: I'm Sally McNally and I grew up in Ireland where I studied nursing and midwifery and I worked in various places including Saudi Arabia and Alaska and finally came to Ventura where I've been working with Community Memorial for over 25 years. I studied nurse midwifery again here in America. And I worked also at the New Parent Resource Center. I teach childbirth education, hypnobirthing, prenatal yoga, and postpartum yoga. I also hold a doctorate in nursing, and I'm a women's health nurse practitioner.

Host: So, you're not too busy then is what you're saying, right, Sally? You know, lots of experience and it's great to have you both here. And Sally, I'll stay with you, you know, as experts in pregnancy and the labor and delivery field, what do you think are the most important things to consider when a mother or family is deciding where to deliver their baby?

Sally McNally: Safety must be the first thing to consider, I would say. A mother often tells me that they have a desire to have a natural birth, and they think that if they deliver at the hospital, that they won't be able to have any type of a natural experience. And nothing could be further than the truth.

 At CMH, we have the best NICU. We have two ORs right there on Labor and Delivery. And we can, you know, just make sure that women have a really safe experience, but they can also have a beautiful natural experience as well.

Dr. David Crownover: I agree completely with those things. I think I would add to that, and along the same lines of just having experienced staff, all of the staff, so we have great nurses that are there. But, as Sally said, the number one thing to consider, I think, is just safety and is the facility you're planning to deliver at sort of prepared for emergencies? Labor, I always say it's a unique part of the hospital because for the most part, we try to leave them alone, but you're prepared for problems if they come up. So to answer your question, you know, what's the most important thing to consider? I would consider, are you in a place where, as Sally said, you know, that there's that backup there for safe delivery?

Host: Yeah, for sure. Having had a couple of kids of my own, you know, that nothing uneventful happened other than of course, you know, how wonderful it was to have these kids and have them be happy and healthy and all of that. But it was a concern of mine, of course, and I'm sure it's a concern for many parents, is what if they do need to go to the NICU, which is by definition, usually sort of unplanned. So, good to know that you all are, you know, safe and prepared and ready. And doctor, what are the most significant contributing factors when we think about safety and that positive delivery experience?

Dr. David Crownover: From a safety standpoint, I do go back to the experienced staff, because the nurses are often the eyes and ears. And an experienced staff that's there and prepared for sort of those things and have the experience to sort of recognize when something's not going well, I think that's a big piece.

Sally McNally: I agree that education is a really important factor. The nurses are educated so well. They have so many different certificates and some of them are so interested in our topic of childbirth, that they get extra certifications like Spinning Babies. And all of these nurses, they're interested in lactation consulting. And some of them even are nurse midwifery students. So, we've always got somebody interested in making it better for the patients. But all of that adds to the layers of safety as well. There's always somebody watching out for the patients, is safety.

Host: Yeah, those layers for sure. And Sally, Community Memorial Hospital has long been recognized as Ventura County's premier birthing center. So, what makes your hospital such a great place to have a baby?

Sally McNally: It's a baby-friendly hospital. We've been accredited as a baby-friendly hospital, which means that we kind of view the world from the babies' eyes. You know, as soon as the baby is born, we do skin-to-skin, delayed cord clamping. We have lactation consultants on every corner ready to help moms and everyone who comes in contact with the baby has gone through education in breastfeeding. Of course, that's one of the most difficult times for a young mom and a young baby, is that early learning, so we're all over that. And of course, all the midwives, we're very baby-friendly. Our NICU is level III, which is the best. I always think that our NICU nurses have wings under those scrub suits.

And then, the level of care of our new ORs are just amazing. The scrub techs, the stocking, the way everything is just up to date. And I always feel so lucky that we can as midwives get in there and deliver in such a safe place. It really is a wonderful, beautiful unit as well as everything else.

Dr. David Crownover: Yeah, it really is a great place. The other thing to highlight is the New Parent Resource Center. I think the hospital is a great place to deliver your baby, but just as a system in terms of being in the system and delivering there, you know, we have this so-called New Parent Resource Center, which is unique. And it gives a resource of, you know, the prenatal education, breastfeeding support, even after people go home. I have lots of patients that go home, need some more support, come back to the New Parent Resource Center for that support. So, I think that's just sort of unique to our system, just to make people aware of.

Sally McNally: Yeah. I'd like to second that, and that's where I also teach my childbirth classes through the New Parent Resource Center, and I have a lot of patients that go back there for free breastfeeding support up to a year with board-certified lactation consultants. It's really amazing. We also have Mommy and Me classes. And lately, we have a postpartum yoga class and an emotional support group. So, girls, if you're listening to this, women in our community, we have you covered every which way.

Host: Yeah, really amazing. It's funny, when we had our first child, you know, I didn't know anything, right? And I really needed the resources, every bit of the resources that our hospital had. By the time we had the second one, I felt like a real pro, you know? I'm sure I still made some mistakes along the way, but I felt much more equipped to have the second one. But a lot of that was those resources that were available with our first one, with our son. Doctor, what programs or initiatives does Community Memorial Hospital have in place to support mothers and families in having their desired birthing experience?

Dr. David Crownover: Well, one of the big ones, just kind of what started this for us wanting to get the word out and do the podcast, et cetera, is really starting a new midwifery program at the hospital. And again, this is unique for anyone who doesn't sort of know the lay of the land. There are several midwives that are around and some that even deliver in a hospital, but we've really created a very unique model that we're really proud of. And this is essentially midwives being in the hospital and an obstetrician being in the hospital with them. And this sort of collaborative model, we've literally been working on this for probably 10 years. And it's finally coming to fruition. You know, there's so many pieces to all of this, of things that we won't get into, of, you know, insurance coverage, and just the logistics and schedules, and how are people going to be reimbursed. There's just so many layers and issues with it. It's taken a long period of time.

So, we've had midwives, like I said, delivering in the hospital. But the model's kind of been they traditionally see low risk patients, then those patients come to the hospital, they deliver them. And it's sort of separated from the obstetrician. And so, what we've created is really us working together, and I keep coming back to that being a unique model because throughout the country, sometimes there's even a bit of a divide, maybe it's been perceived as competition, you know, something like that. But if I may, to kind of walk through logistically, kind of what that means, you show up, you're in labor, there is a midwife that's there taking care of you, planning to deliver you, et cetera, even in the setting of potentially having some high-risk issues. And that's really where that collaboration comes in. And it might be, and I'm just giving you an example, it might be that somebody comes in, they have developed something called preeclampsia with very high blood pressure. We're both working together.

And so, I might be there and managing the high blood pressure, talking to them about the possibilities of things that go along with that, "You're at risk for seizure, and these are the medicines we're going to use," and those sorts of things. Sally's still there, right there and supporting them through the labor and delivering them. Because most of the time, a lot of these high-risk issues, the delivery itself is the same. It's just that some of these issues need to be addressed during the labor process. And so, we're sort of working together. So, that's just something we're really, really proud of. And I think it's a unique model. And, you know, that's sort of my perspective of how it's working. I'd get Sally's take on this as well.

Sally McNally: I love the way you've put that and it's so nice for the midwife to know that we have that backup. With any problem at all, the obstetrician's just right down the corridor, right in the building, at the end of the phone, that we can just say, "We need you to come to the room right now to look at this or to, you know, help me with whatever might need an extra layer of help." And then, sometimes, of course, a patient might need to go to the operating room for a cesarean section. Our model has extended us so that we have first assist privileges that the midwife doesn't just say bye at the operating room door. We go in and we're first assist right there at the table. And the patient, you know, really feels that continuity of care. It's really nice for the patient. She can feel like there's still an element of normal about her birth, even though she has maybe a high risk factor, like the high blood pressure or, you know, uncontrolled diabetes or something like that. She can still have that element of a normal delivery.

Host: I don't want to skip over this, Sally. I want to have you sort of explain to folks, we've just assumed that everybody would know, but what is a certified nurse midwife? How does your practice differ from that of an OB-GYN?

Sally McNally: We're primary healthcare providers. We work with women throughout all ages of their lives. We're advanced practice RNs. We've graduated from a masters level education program, and we're board certified through, you know, an American certification board. We focus on gyne, family planning services, preconception, pregnancy, childbirth, postpartum, newborn care. We do all things like well-women exams and we have prescription abilities. So, we do everything that a doctor would do in a normal situation for women. So, we complement what the doctor does by normalizing it. So, I think that that is what really appeals to women. They don't like to think of themselves going into a situation like having a baby as it being an abnormal or a scary situation, so we take away a lot of the fear around the childbirth and bring it back to natural and normal. Words like that, that women really, really want, because most women that we trust instinctively that we can birth our babies normally. And then, a lot of women say, "I'd love to be with a midwife, but I'm afraid to come to the hospital because there'll be too much medical intervention. And I won't be able to have the birth that I want." And that's not the truth. What you can have now at CMH is that beautiful, normal or natural birth. But with an extra layer of safety, which is the best of both worlds, isn't it?

Host: It sure is for sure. And of course, not every midwife is going to have an amazing Irish accent. I'm just lost in your accent here. I'm trying to stay focused. But you know, maybe you'll get lucky. Maybe folks will get lucky enough and they can work with you. I'm just wondering, Sally, like who's a good candidate? It feels like a choice, like a personal choice or a choice for couples. But generally speaking, who's a good candidate for a midwife delivery?

Sally McNally: Low risk women, women who are healthy, basically we do the low risk, but we can do the high risk as long as we can co-manage with our obstetricians.

Dr. David Crownover: I was going to say that in many facilities, the answer to that is only a low-risk patient. And we've actually pretty well defined patient population. For example, the things that need co-management, we kind of have them outlined. But back to what I said before, the delivery itself is often still a normal process, there just may be some other high-risk issues. So, that's an interesting question to say who's a candidate, because I think it's been expanded here at CMH who's a candidate because of the collaboration.

Host: Yeah, that's interesting. When we had our second child, my wife was 36 and we were unprepared for the OB-GYN saying that she was of advanced maternal age. And I was, "Oh my goodness. We had no idea." So, you know, when you're talking about risks and that kind of thing, and I think, you know, doctor, maybe you can give listeners a sense of if they have their baby delivered by a midwife versus, let's say, having the child delivered by an OB-GYN, is there much difference as long as we're not talking about higher risk and complications and things?

Dr. David Crownover: I'll actually let Sally speak to this as well, but there are some differences and I'll give you my perspective and she can, because there are some differences. And you know, the saying, "It's not better or worse. It's different." There are differences and our training is different. And so, you know, people do kind of ask that question sometimes, "Well, I'm a little confused. There's a midwife there, there's an obstetrician there. And what's the difference?" And the reality is the obstetricians are trained physicians, surgeons, et cetera. Half of my practice is obstetrics, but half of it is gynecologic surgery. So, patients that might have bladder problems or prolapse or bleeding issues or something like that, non-pregnant. But the point of that is if that patient runs into a problem and ends up requiring a cesarean section, I'm there and that may be what I do. Now, as far as a normal vaginal delivery, we are trained a little differently. And then again, I let Sally speak to that. She can more eloquently describe the difference.

Sally McNally: Well, I have witnessed lots of Dr. Crownover's beautiful normal deliveries. And of course, he's highly skilled in all things obstetrics. But midwives, we like to think of ourselves as highly skilled in natural, normal deliveries. And the obstetrician will come towards pregnancy and birth and view it maybe as a little risky, whereas we come across it and view it as a normal body function. We are more holistic. We have practiced more with the high touch low tech, whereas perhaps the obstetrician might come with more technology and procedures and interventions. They're more inclined to feel like they manage the labor, whereas we see the woman as being superior and she is leading us in how she wants to birth. Perhaps the obstetrician, because he knows his role will be to intervene and do the emergency procedure like a cesarean, he will view childbirth as dangerous, whereas we view it as powerful and instinctual and safe, for the most part. And of course, when we are in the hospital with a highly skilled obstetrician, we feel safe that we can continue to practice midwifery the way we've been taught.

Host: Yeah, I'm sure it's a comfort to have Dr. Crownover and others there, because their skill set and training.

Sally McNally: It's so great. It's just the best. Yeah.

Host: That's great. Doctor, I wanted to ask you, you know, with respect to OB-GYNs and certified nurse midwives, let's talk about the collaboration that goes on, not just when babies are being delivered, but maybe in the prenatal care, the hospital birth environments, you know, those sorts of things.

Dr. David Crownover: Yeah. I mean, this is the beauty of the model. This is one of those that from my own perspective, I'm at a point of saying, "Why did it take us so long?" Because--

Host: Why did take years?

Dr. David Crownover: You start looking at this of what Sally's describing, I'll take the hospital first and then address the outpatient second, you take the example of what Sally's describing. I mean, she's been trained in certain breathing techniques and maybe different positions and things like that. I haven't been trained in those. I'm not aware of some of those things, and she's able, you know, her and the other midwives. We have seven midwives, by the way, just to throw that out because when we started this, I thought, "Oh, you know, hopefully we can get one or two."

Host: One or two. Right.

Dr. David Crownover: And all of a sudden we have seven at the hospital. But they'll be managing these labors and they're supporting these patients and, again, of things that I'm just not trained in. But if that situation arises, I mean, this was two weeks or so ago, I was working, working with a midwife, everything's going well. We always say in obstetrics, things are fun until they're not. And so, things were going well, and then, you know, it was not going well, and I get the call of, "Hey, she's been doing great. She's pushing well. Everything's going well. But we've got this issue. The baby's heart rate is down, and I think we need some assistance." And we're able to use the so-called forceps to assist the delivery exactly as Sally described, that's what I've been trained to do. I haven't necessarily been trained in the breathing techniques and the different positions and Spinning Babies and those things. But when that problem arises, then I have been trained in this. And so, that's what I mean when I say, "What was taking us so long?" Because they can provide this nice, normal, natural birth. And if things go awry, then we're there. So, that's the collaboration. It's been awesome.

As far as addressing the outpatient, again, we actually have had midwives working in the outpatient offices for several years, long before we were working hand in hand in the hospital. So, they've been providing prenatal care in our childbirth classes, et cetera, in the outpatient setting as well prenatal care as well.

Host: Yeah. Sally, I wanted to ask you, you know, if a mom, mother would prefer to deliver with the support of a midwife, which after this podcast, certainly really, for the first time in my life, I think I really understand the benefits. You've really given me a lot of clarity on this, exactly what midwives do. So, it's great, and I'm sure listeners agree. What's the benefit then of choosing to do so in the hospital environment rather than the non-hospital birth center or a home birth?

Sally McNally: While they can do what they wanted at home, they can do that in the hospital. Other than a water birth, we're not quite there yet doing water births in the hospital, but everything else they can think of, we can do in the hospital. They can, you know, be in any position. We deliver women on their hands and knees, on their side, even standing if they don't have an epidural. As long as it's safe, we're going to do it. We encourage them to, you know, make the room feel like a special place, like a sacred space to bring in their little lights and their focal points and you know their aromatherapy and to just make it like home like, to make it like a home birth in a safe place. It's what I would want for my own daughter. You know, it's a really wonderful opportunity, I think.

Dr. David Crownover: You know, to piggyback on that though, something, Sally, that you said earlier in the podcast, I wanted to mention because you said sometimes women feel scared to deliver at the hospital. And with an obstetrician by the way both of these things, because of that fear of interventions, they're going to get things they don't need, et cetera. They're not going to be able to have the birth experience that they want. And, you know, that fear is out there for a reason, because I think that did exist in some locations that maybe still exist in some locations today, but certainly in the past of you come into the hospital and, okay, now it's a medical problem and it needs medical intervention.

I think that fear is not unfounded from the past. So, you know, hopefully, discussions like this will kind of get the word out that times have changed and that's really not the way that it is. And we really do try to do everything we can. And when I say we, I'm talking about everyone, from the nurses to the nurse management to all of the staff, they really do try to be supportive of, as I described before, my spiel to patients when they come in, I say, 'We're here and we're here if there's a problem. But otherwise, we're going to try to leave you alone." And that really is how we try to approach it. And I think that's what draws a lot of people to deliver in a birthing center or at home, which, you know, I completely understand that. But hopefully, the word can get out that they can have that birth experience in the hospital. And if there's a problem, they're there and we're ready. But if there's not a problem, we're not going to be intervening unnecessarily.

Sally McNally: Yeah. If I could follow up on that, having the midwives in the hospital can really compliment that, that we're inclined to listen, we touch the patient a lot, we have a lot of patience, because we know that this is a really, really important thing that this woman is doing. Whether it's her first baby or her 10th baby, it's a wonderful thing to have in her memory bank. If she can have the birth that she desires that's not traumatic, then she's going to look back on it as a wonderful time in her life instead of this awful, terrible, fearful story that she passes on through other women and to the other women in her family, that then childbirth is perceived as this awful, scary time instead of the wonderful, powerful time that it can be for women.

Of course, we know that, you know, somewhere between 24 and 33% of women may end up having a cesarean section. We can even make that a joyful experience as much as possible so that women can look back at this time of their life with a smile on their face.

Dr. David Crownover: Sure, 100%. We have a department meeting every quarter. And at our last department meeting, a fantastic woman gave a talk about her traumatic birth experience. And it really opened my eyes, it really did, of hearing the patient's perspective. Let's just say that I was the one that was performing that cesarean, I don't know that she would have shared all of that with me, but she shared all this with our department about how traumatic her experience was, and things that could have easily been done differently. This wasn't at our hospital, by the way, just to clarify. Because we actually work really hard at that. I mean, just for an example, I think sometimes people find it surprising. There are people will ask for it and then they're surprised when I say, "Oh, that's, normal. We do that all the time," of having a patient in the operating room, having a cesarean section, and the baby still comes to the mom right after delivery and does so-called skin-to-skin, so direct skin-to-skin contact. And so, people will, sometimes request that. You know, "Is it possible? Maybe, is there any way?" And I say, "Oh, that's normal at CMH. That's what we do." And they're often surprised for that to be the case, but I couldn't agree with Sally more of giving people that positive experience. It's something that they literally carry with them the rest of their life.

Host: Yeah. This has definitely brought a smile to my face today and reminded me of having our kids and we did actually have the second one, was a C-section. And yeah, so been there, done that sort of thing. Sally, let's give folks, expectant mothers and families, you know, if they're trying to find an OB-GYN or a midwife who works in partnership with Community Memorial Hospital in Ventura, how do they do that? What are some of the resources we can share?

Sally McNally: And they should start by going to mycmhbaby.org. They will find the different clinics that would be close to their home. And hopefully, soon they'll be able to find the clinics where there'll be a midwife ready to see them as well as an obstetrician. So, they'll be covered by both throughout the whole pregnancy.

Host: And doctor, just going to finish up with you here, again, just sort of educating folks, getting the word out as we're doing here today. Where could folks go to learn more about the incredible Maternal Child Health Program at Community Memorial?

Dr. David Crownover: Yeah. The big site is myCMH. So, mycmh.org. That's our entire system. And then, mycmhbaby.org is sort of the subsection. And that really is the best resource. Everyone has access nowadays to the internet and that's really the best way to sort of see. You can see pictures, there's videos, there's kind of virtual tours, things like that. You can do everything at that site. So, that's a great resource to have.

Host: Yeah, so mycmh.org, mycmhbaby.org. Well, it's been a pleasure to have you both here today. Really educational for me, just to learn more about what certified nurse midwives do and really understand that women and families can have the sort of, as we're saying here, Sally, these natural births at the hospital. In my mind, because apparently I was wrong, but in my mind, I was thinking it's one or the other, you can't have both, but you can. And the midwives working with the OB-GYNs is, you know, real teamwork. After this long journey, doctor, you know, 10 years get here, seven midwives. It's just all really amazing. And I appreciate your time.

Sally McNally: Thank you very much, Scott.

Host: And for more information, go to mycmhbaby.org. And if you found this podcast helpful, please share it on your social channels and check out the entire podcast library for additional topics of interest.