I worked as a labor and delivery nurse for many years before I became a midwife. I can remember numerous times when my fellow nurses and I would question a provider’s clinical judgment, particularly when the decision was made during labor to proceed to a cesarean section.

It was easy to criticize from where I stood as the nurse. I considered myself the patient’s advocate, and wanted to avoid major abdominal surgery unless it was absolutely necessary for her or the baby’s health.

It was also easy for me question the provider’s clinical decisions because the reality was, the onus was never on me to make the big decision — “Should we continue with labor or call a c-section?”

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If something went wrong during the birth, it would ultimately be the provider who made the decision to have to defend his or her choice, possibly in court.

I think one of the hardest transitions to make from labor nurse to midwife has been the responsibility of the role change, and the tough clinical decisions I have had to make. I have worked with many student midwives who struggle with calling their first cesarean section, even when it is clear that vaginal birth is no longer an option.

It isn’t easy to be on the other side now, having my clinical decisions questioned by nurses “Monday-morning-quarterback-style.” I will always listen to input from nurses, even if it is criticism or questioning, as long as it is done in a respectful and constructive way. We all need to work together as a team and look at the entire clinical picture, and then do what is best for both the laboring mother and the baby.

Being a midwife, my wish would be for every woman to have a vaginal birth. But that isn’t the reality of my chosen profession. I still feel like I’m an advocate for my patients. I try to give them every chance for a vaginal birth, which sometimes requires a lot of patience and out-of-the-box thinking.

But I also want the best outcome for mom and baby, and sometimes the best outcome is achieved with a cesarean delivery. I don’t ever want to let my desire to avoid a cesarean cloud my clinical judgment. I never want to look back and say, “I should have called that c-section sooner.”

These are the hard decisions that I didn’t fully understand back when I didn’t have to make them and could sit on the sidelines and criticize those who did. I didn’t understand that these decisions could keep you awake at night, replaying every step of the labor in your head. 

I didn’t understand how difficult it could be to stand up to nurses that you truly like and respect, but who question your decisions, sometimes inappropriately, or in front of patients or family members. I didn’t know that this transition would be one of the most difficult parts of being a midwife.

Robyn Carlisle, MSN, CNM, WHNP, works as a full-scope midwife at University Doctors and Kennedy University Hospital in Sewell, N.J.