This chapter focuses on the practice of midwives with regard to operative obstetrics. The mission of American College of Nurse-Midwives (ACNM), the oldest women's health care organization in the United States, is to promote the health and well-being of women and infants within their families and communities through the development and support of the profession of midwifery as practiced by certified nurse-midwives and certified midwives. The standards direct the midwife to consider relevant statutes and regulations that might constrain the midwife from incorporation of a particular procedure. First assisting is one of the most common expanded practice skills of interest to midwives. Midwives are cautioned to ensure that privileging bodies and insurers understand when a midwife is providing vacuum-assisted birth services. The use of hospitalist physicians is a trend that might influence the profession of midwifery and midwifery practice in the future.