The birth of a child is considered one of life's most precious moments. Mothers cherish the time spent bonding with their newborn after the delivery. Yet, before the delivery, the bond developed between a mother and her nurse midwife can become just as memorable.

"As a nurse midwife, it's so rewarding when you can connect with a patient on a personal level--and then you are there on the happiest day in their personal life," said Maj. Nicole McKenna, who is the only active duty nurse midwife on Ire-land Army Community Hospital's staff. "Nurse managers are respon-sible for the greatest gift--bringing some-one's child into the world--and I love being a part of the gift of life."

McKenna's civilian colleague Shelly James agrees, adding how developing a bond is the overall purpose of being a nurse midwife.

"We have the opportunity to make it the best memory for the Family throughout the pregnancy, but primarily in the delivery room--and that's our goal," said James, a retired lieutenant colonel who has delivered more than 2,000 babies in her 23 years delivering children, 13 of which were as a nurse midwife.

"For a nurse midwife, it's all about the word of mouth and reputation," said James. "It takes a special kind of person to do this job so you have to naturally have the ability to connect with patients."

Midwife, which literally translates to 'with woman for life,' is an appealing option for patients who want a more individualized, personal approach to childbirth compared to traditional birthing plans using obstetricians.

IRACH's nurse midwives adhere to a philosophy of care that focuses on accommodating the patient's mental, physical and emotional needs by incorporating a "whole woman" approach throughout the pregnancy.

But that doesn't mean nurse midwives only work with alternative medicine, James said.

"The perception is that all nurse midwives are all granola-loving naturalists, and that's not the case,

" James said. "Patients will meet with us and ask 'can I still have an epidural?' and we're like 'of course!'"

James and McKenna reflect with amusement on witnessing outlandish, alternative methods preferred by some patients. They have witnessed such events as women taking home the placenta after delivery to plant it in their yard or to encapsulate the organ into pills as a natural remedy for postpartum depression. As advocates for the mother, they never explicitly encourage nor dissuade such preferences.

"If a woman wants an all-natural, hippie-type pregnancy, where she wants to eat her placenta afterwards, we'll just say 'if that's what you want!'," said James. "But it's not like we promote that stuff."

While Army nurse midwives encourage the use of alternative remedies if viable for the patient, their primarily role on the OB/GYN team is to treat patients who have "normal," healthy pregnancies.

Nurse midwives are integral to health care by allowing doctors to spend more time with women who have been diagnosed with high-risk pregnancies. Patients often expect to always see a doctor, even if there are no complications, said McKenna. Most patients don't understand that pregnancy is a normal process of life that has been handled by midwives for centuries, she said.

McKenna's experience in 2012 while working with nurse midwives in the Philippines expanded her understanding of homeopathic treatments in remote places where doctors aren't available to treat women.

Assigned as the only nurse midwife to a 50-personnel medical team, McKenna worked with more than a dozen local midwives to teach them about basic care of women and baby after the delivery, such as treating postpartum hemorrhaging without medicine and good hygiene techniques.

But McKenna also learned a great deal about cultural differences in therapeutic medicine, explaining how Filipino women will tie a man's necktie around their upper abdomen while in their third trimester to constrict the area enough to prevent baby from moving higher in the womb.

Although McKenna regrets not being able to attend a home birth in the Philippines, she doesn't consider herself an advocate for home deliveries just because she is a midwife.

"Not everybody should have a home birth, even if they want a more natural delivery," she said. "Some women need to deliver in a hospital setting, especially if they are high risk."

These are the times when the patient's desire for a natural delivery often conflicts with the nurse midwives' recommendations, said McKenna, explaining how patients will refuse certain types of medical tests if it wasn't originally included in the patient's natural delivery plan.

"One patient failed a diabetes screening so we recommended specific treatment, but a number of patients will refuse," McKenna said. "Even though we are nurse midwives, we still have a medical scope of practice that we have to follow to ensure safety for the mom and new baby."

McKenna said she feels her role as a nurse midwife is to engage women on becoming more informed in their own health. By understanding the physical and emotional changes during pregnancy, women become active participants in their wellbeing.

"Medicine in general is starting to change by encouraging patients to take a more holistic approach to health--even if it's simple changes like adding diet and exercise," said McKenna. "The same change in holistic health is true for giving birth, so the need for nurse managers is slowly becoming greater."

With only 43 active duty nurse midwives, the Army's need for civilian nurse midwives is also increasing. James ended her military career as the IRACH's chief of OB/GYN services to immediately transition into a civilian midwife position.

"I was literally out-processing from the military while in-processing as a civilian," said James, who attests to missing the leadership role and physical fitness requirements in the Army, which helped her stay motivated.

McKenna and James attribute their success to having previously worked in labor and delivery. They feel that experience shaped their ability to work closely with patients in a bedside manner by reducing the austere feelings of a clinical environment.

They also agree nothing--no matter the clinical experience or inherent qualities of a nurse--can ease the emotional burden for a midwife of witnessing the mother and family cope with death and hardship.

For McKenna, her most difficult delivery turned into a learning experience in which she came out stronger as a result. While assigned to Tripler Army Medical Center in Hawaii, McKenna said she was excited to work with a patient for the second time after having delivered the patient's first child the previous year. The patient was in the second semester of pregnancy when the fetus died unexpectedly. McKenna struggled emotionally knowing she was responsible for inducing labor.

"I was terrified to do the delivery because I didn't think I knew how to console her through the pain," said McKenna. "I cried with her afterwards though. And then I just spent time with her, just sitting there and being quiet."

Months later, McKenna was leaving for Fort Knox when the patient, who was preg-nant again, return-ed to the hospital to say goodbye and give McKenna photocopied pages from her journal that were written after the loss of her child.

"She said the most beautiful things about me, even though it was her trying to cope with the feelings of loss," said McKenna, who was surprised and touched by the gesture. "It was a total experience that taught me so much about myself. I learned that I didn't always have to know what to say. But as a nurse midwife, I have to always know how to be supportive."

James recalls a situation where she too faced her emotional fears while assigned to Fort Campbell. One of her patients was in the third trimester when her husband was killed while deployed.

"She was so distraught that she wouldn't come to any of her medical appointments," she said, remembering how she would call the patient to offer support and encouragement. James then planned the patient's medical arrangements so she could travel at 38-weeks pregnant for the husband's memorial at Fort Bragg. Like McKenna, James also received personal

solace by remaining in contact with the former patient long after the delivery.

"For a while, I didn't do well with coping. I had to learn how to separate myself without hardening myself too much," said James. "Now I do a lot of meditating--and we have each other to vent to when it gets hard. We always lean on each other for support."

The midwife team know the sad moments will always stay with them, but because of them, they have learned their own techniques to cope with the emotionally demanding side of the job. For every sad moment though, they recall numerous joyful ones as well.

James will always remember the proud feeling when a patient's husband asked her to give a letter to his wife at her next medical appointment, which was scheduled after he deployed. At the woman's appointment several weeks later, they both cried when James gave her the letter.

"She hadn't heard from the husband since he left so it was a really big deal," saw said. "Then when the husband got backafter the baby was born, he came to thank me. That was a really special moment."

Both have experienced the joy of helping families stay connected during childbirth by setting up computer cameras for "Skype deliveries," which was a common occurrence last year while 3rd IBCT was deployed to Afghanistan.

"The husband will count with their wives during the delivery," said James with a smile. "It's great unless there is a delay in service. So he'll still be on eight when we're already at 10."

The midwives fondly recalled how fathers would always touch the computer screen as if trying reaching for his newborn baby.

"One time a woman kicked out everybody from the delivery room--even the nurses--so it was just her alone with her husband on Skype," said James with a laugh.

These are the moments where McKenna and James witness the Family bonding, but the mid-wives also feel connected to the family.

"It's like we're a Family member or close friend because of the connection developed from being so involved," says McKenna.

Denise Renz, who is 37-weeks pregnant, is a new patient of McKenna's after her husband was recently assigned to Fort Knox.

"I've only heard good things about working with nurse midwives," said Renz, who is considering a natural birth plan after working with IRACH's midwives. At the end of the appointment, McKenna recommends evening primrose oil to help Renz induce labor. James ensures Renz is familiar with the installation's gate operations as well as the hospital's admissions process if she goes into labor earlier than expected.

"It's so rewarding when we get to see patients at their first exam and follow their care all the way through to their date of delivery," said McKenna, adding that this helps to better connect with their patients and the Families." I think that I'm a nurse first--which is the crucial part--but I'm also a woman so I instinctually relate to patients better as a midwife."

As IRACH's midwife team, they recognize each other's unique skills and differences in managing patient care. McKenna admires James' ability to be more 'hands on' during deliveries while James thinks McKenna is better at working with patients who prefer more natural deliveries.

"But despite our differences as nurse midwives, how we care for our patients is the same," said James. "And we will do whatever our patients want because we do care."