© Copyright 1998-2002 by Grayson Morris.
(Sorta gives you a different perspective, doesn't it? Not that I'm saying this is the most compelling criterion for choosing your prenatal care provider.)
Today you can choose from several different kinds of ably trained pregnancy experts to handle your prenatal care, delivery, and postpartum care: an OB-GYN, a family practice (or general) doctor, a CNM, or a lay midwife. Each places pregnancy in a different context. Who's who, and whom will you choose? Let me summarize my personal opinions about each one:
The OB-GYN (or Obstetrician-Gynecologist) is a doctor who has specialized in care for women (the GYN part) and care for pregnant women (the OB part). An OB-GYN does not see men; he doesn't see children; he doesn't see sick people, unless they happen to be women and the sickness is reproductive in nature. Some people find it reassuring to have a doctor who has spent all her time focussed on women's reproductive systems. The theory is that such a person knows more and better. This is, however, not necessarily true.
The context into which most OB-GYNs place pregnancy is that of a Medical Situation. Pregnancy and childbirth are medical events to be monitored, managed, and treated. If your pregnancy or delivery develops severe problems of an emergency nature, this can be a very fine context. If your pregnancy and delivery, on the other hand, are like those of most women, you don't need special medical monitoring or management to get through. Such treatment can, in fact, interfere with the progress of a normal delivery.
A family practice doctor is one who sees everyone, for everything, referring patients to specialists as necessary. A family practice doctor has delivered scads of babies while training to become a doctor, and multi-scads since becoming one. One plus with a family doctor is that she can deliver your baby, then handle his well-baby checkups; you won't need a separate pediatrician.
Our family doctor is a family practice doctor, and should I ever forsake my midwives, she would absolutely be the one to deliver my babies. (Here's a tip: if you can call your doctor by her first name, chances are she thinks you're a person and not a Condition.) She is a stellar example of what I like about family practice doctors: they have a broader view of every aspect of medicine, because they practice every aspect daily. In one day, a family practice doctor will see babies, children, and adults; people with viral infections, people with broken bones, and pregnant people. I think a family practice doctor has more information available to him as a result of being broad instead of specialized, like an OB-GYN.
The birth of our second baby illustrates the difference between OB-GYNs and family practice doctors perfectly (at least to me). When my water broke at 32 weeks, I was admitted to the hospital (no birthing center birth this time, sigh). My midwives wrangled me into the care of the Family Medicine group, rather than the OB-GYN group. They were very adamant about that!
During the 3 fairly uneventful days that ensued (I didn't spontaneously begin labor, nor did I leak any more amniotic fluid), I was visited by several doctors I was never to see again; some were OBs, some were FPs. Every time, the OB said, "Well, things look good now, but we'll keep you here and monitor you until you reach 35 weeks, if you do, which you probably won't because almost everyone goes into labor within 72 hours of her water breaking, but if you do reach 35 weeks, then we'll induce." Uh....3 weeks in the hospital? Never mind the cost...the food was going to do me in, if I didn't die of boredom first.
Then the FP on duty would come in, and say, " Well, things look good now, and if you don't leak anymore fluid, we'll let you go home after the weekend on bed rest, and we'll come out to the house to check up on you, and if you make it to 37 weeks, which is a distinct possibility, then you can go to the birthing center to have your baby when the time comes!"
As it turned out, the midwives, the FPs, my husband and I decided to induce at 33 weeks after a humongous blood clot plopped out of my uterus. I labored, under Pitocin, unsuccessfully for about 18 hours, at which point we stopped the Pitocin, and the FP on duty inserted a Foley bulb. A Foley bulb is apparently famous (in medical circles, at least) for its use in the bladder (I no longer remember what it's used for there, but they did tell me at the time). The FP felt it would work nicely in my uterus, where it would exert pressure on the cervix, just as the baby's head would in a normal labor, causing my cervix to open up while I got some sleep. If all went well, the bulb would fall out after a few hours, and then we would know that I was 3 or 4 centimeters dilated and On My Way. And that's what happened.
Even after my temperature rose late in the afternoon, after the Foley bulb had worked its magic and I was back on the Pitocin drip, the FPs kept reassuring me that I was days away from a C-section as long as the baby was doing well. I am convinced that, had I been under the care of the OB group, there would have been no Foley bulb nonsense, nor would we have stopped Pitocin so I could sleep, ready to try again later in the day. We would have stopped Pitocin so I could have a C-section, because I was obviously Failing To Progress.
I am not saying that all OBs are knife-happy, nor that all FPs are gentle natural birth groupies. I'm just saying that the trend is that an FP generally has a more holistic, natural view of pregnancy as a normal event in a woman's life, while an OB generally has a more clinical, isolated view of pregnancy as a medical condition (albeit a happy one). Any given OB may be very holistically inclined, as any given FP might be very medically inclined; the individual makes more difference than the title. (Of course, the individual has also chosen which title he wants to wear.)
A CNM (Certified Nurse Midwife) is a nurse who has specialized in pregnancy and childbirth. She can handle all aspects of a low-risk pregnancy and birth, and can refer you to other specialists as needed (radiologist for an ultrasound, dietician if you develop gestational diabetes).
A CNM generally places pregnancy into a nurturing, holistic context (though this can vary; if your CNM works within a hospital, she may be much more medically inclined). She expects the pregnant mother to educate herself, and to be an active force in shaping the course of her pregnancy and delivery. (Ideally, a good doctor expects this, too.) Unlike the average doctor's visit, a routine prenatal visit to your CNM is generally a relaxed, unhurried event, with plenty of time for questions.
Many CNMs, like many people who experience pregnancy as a positive, normal event in a woman's life, make use of natural remedies for discomfort during pregnancy and labor. Vitamins, herbs, homeopathic remedies, and physical touch are common tools for relieving stress, headaches, and other complaints, or for stimulating the onset of labor. You are unikely to hear an epidural or an episiotomy recommended by a CNM. During labor, she will encourage eating and drinking; walking, squatting and a soak in the tub; occasional, rather than constant, fetal monitoring; slow pushing - or no pushing at all - as the head emerges, to give the vaginal opening time to stretch rather than tear. She will usually strongly encourage breastfeeding, and provide excellent support for you while you master this skill.
My provider of choice is the CNM. The CNMs at our local birthing center have provided my prenatal care in my last two pregnancies, and it has been a real pleasure. I feel like a peer, not a patient; I'm a mother, being treated by other mothers who happen to have a deeper, more thorough knowledge about the technicalities of having babies. I'm a woman, being counseled by other women during an event we've all been through, and which they've been through with many women. (Not that a man couldn't make an excellent CNM; it's about a state of mind and a way of being.)
When my second pregnancy ended prematurely, the midwives checked on me every day I was in the hospital. The morning I passed the blood clot, Maureen, the CNM who had just stopped by to see how I was doing that day, dropped everything and stayed by my side for 20-plus hours as I was wheeled to Labor and Delivery, hooked up to Pitocin (and a monitor and an annoying finger pulse thingy, and a horribly annoying blood pressure cuff which went off automatically every 2 minutes and then pinged until someone came to look at the result). She massaged my feet; told me stories about her own kids; and left me the Thin Mints which were to be my first food after the birth (I had developed gestational diabetes, which disappears with the delivery of the placenta, so I was very pumped about getting some chocolate again). She was replaced by Lynn, who was by my side during the last hours of labor and the birth of Benjamin. Lynn got me through the first pushes (you know, where they say "Don't push, the doctor isn't here yet", like how could they not know this was coming?), and the last ones, and took our first pictures of Ben, nursing just after birth and snuggled in our arms. The presence of staff from the birthing center, with whom I had grown very close, was a reassuring, affirming, heartening experience during a pretty scary time. And, as pregnancy experts and people with delivery privileges at the hospital, they knew the ropes and knew what to ask, what to insist upon, and what to refuse - which took a huge burden off Marco and myself.
This illustrates part of what I love about CNMs: they don't pop in posthaste to see how you are doing, you who are one more Medical Event among a group of Medical Events of a kind they have seen a zillion times before. CNMs are there for you, from beginning til end. Though they are very busy, and somehow survive on tiny amounts of sleep, they are not Busy People who can only spare a few moments for you, whose time is so precious (spent on other Important Things) that you must wait for them when you reach 10 centimeters and some primal, torrential force takes over which you cannot possibly hold back ("don't push", my backside). I wasn't the only woman the CNMs had in labor that weekend; there were 3 others (lucky women who were actually at the birthing center for their births), so it wasn't that they had nothing to do and thought they'd attend this unusual birth. I was under their care for my pregnancy; maybe they couldn't deliver my baby, but they could do everything else. And they did, including a home visit two days after we left the hospital.
A lay midwife is much like a CNM, without the certification or the licensing. Simply put, she's a woman (or he's a man) with lots of experience delivering babies, but she hasn't been to school for it, and the state doesn't recognize her. A lay midwife is what you'd need in most states in America if you wanted to have a home birth - because no doctor or CNM will endanger her standing by breaking the law to attend a home birth.
Aside from the legal issues, a competent lay midwife possesses all the advantages of a CNM, as I see it. (And more advantages than a medically-inclined CNM, who can approach OB-GYN-ness without the medical degree.) If you are gung ho for a home birth, and can satisfactorily answer for yourself what you'll do if an emergency lands you and your midwife in the hospital, where her presence at your home will have to be explained (for which she can end up in jail, by the way), then I don't think you will be ill-served by a lay midwife. But good luck finding one; they don't advertise, and you'll have to gain someone's trust before you get any names.
My friend E has had all three of her babies at home with a lay midwife, and has loved the experience. She said it was very uncool in the beginning, when she went to a meeting for people interested in home birth and no one would give out any names and they all seemed very paranoid, but once she found her midwife it was fantastic. I can't stand the stress of possibly endangering someone else if something goes wrong during delivery, but if I had a solution I was comfortable with for that, I'd have had home births in a flash. If you are so inclined, find out everything you can about the laws in your state (or consider moving to California or a handful of other states where home birth is a viable option...or to the Netherlands, where home birth is as common and everyday as hospital birth).
This stands for Do-It-Yourself, and as with home improvement, this is a Terrible Idea for most people. Unless you or your partner are pregnancy experts (i.e., you fall into one of the categories above), what insanity is possessing you to give birth alone? Sure, it's a lovely intimate experience if everything goes right, but what if something goes wrong? You will have very little idea what to do to fix it, and your baby - or even the mother - might be permanently damaged or even die from your lack of knowledge.
Friends of mine have gone this route with two of their babies, and while they say it was what they desired, I think their circumstances were a forcing factor (lots of messy ex-spouses and going into hiding to avoid turning over an older child to an abusive parent). Once, the placenta did not deliver on its own, and they were clueless as to what to do. Fortunately, they had a book which described blowing into a Coke bottle with a reluctant placenta, and this worked, but gosh! What if they hadn't had the book? Or the placenta had only partially detached? Women become seriously ill, and can die, from a placenta which remains inside the uterus (it dies after the baby is born, and decaying flesh is not a good thing to have inside one's body). Sure, in an emergency they could always rush to the hospital, but just imagine the explaining they would have to do, and the investigation that would result.
I am a firm believer that this is a very scary alternative, given the fact that some complications of pregnancy do not have visible symptoms (such as gestational diabetes), and some complications of labor demand immediate medical response (such as cord prolapse). However, if you and your partner are committed to going the DIY route, and are prepared to become experts on the subject, that is, of course, your prerogative. You will have far more legwork to do before you become (and while you are) pregnant than most couples. For example, you'll need some way to test for gestational diabetes - which could be buying a home glucose monitor and checking your blood glucose levels after every meal for one day a week throughout the pregnancy. You'll have to read up on every possible delivery complication, way ahead of time, to ensure that you are prepared should a time-critical emergency occur during labor. Certainly most pregnancies and births are uncomplicated affairs, but if yours is not, you'll want to be able to handle it properly.
Should you DIY and end up in the hospital due to a complication, you'll want to have thought out, long and well, how you are going to explain your choice to the Powers That Be. It won't matter in the moment of the emergency; but later, when the dust has settled, there may well be questions about why you don't have a doctor, were delivering at home, and so forth. Think this through long and hard; there may be legal consequences to your choice, especially if something goes wrong. It is unlikely that many people will agree with your choice, which is of no consequence unless those people happen to be able to put you behind bars if they think you have been criminally irresponsible.
How can you sort out who's the best care provider for you? Talk with friends about their birth experiences. Watch The Learning Channel's Baby Story series, which shows many hospital, birthing center, and at-home births. Interview several care providers of each persuasion and see what you like! (Just remember, you have to know what you want before you can know if a provider is a good match for you.)
Categories aside, what you are looking for is a person whose beliefs and practices regarding pregnancy and childbirth closely match yours. You might lean toward the idea of a birthing center staffed by midwives, but be open to a really great OB whose personality and methods are just what you're looking for. If you are certain you want an OB and the emergency backup a hospital birth can provide, be on the lookout for one whose personal style makes you feel good - they're not all alike! Make no mistake: the path your birth will take depends a great deal on the care provider you have chosen. (If you watch the Baby Story series mentioned above, you'll soon get an idea just how varied births can be, all based on the doctor's personality and preferences. I've seen fantastic OBs, and midwives I'd like to strangle. The individual is stronger than the title!)
Last but not least, don't be afraid to switch care providers during your pregnancy if you find yours isn't living up to your expectations. We did this with our first baby - at 36 weeks! - and were very glad we had. There was nothing wrong with our first doctor, though we had made some compromises in our desires to accomodate his preferences (we wanted no IV, he wanted us to have one, and so forth). The kicker came when, right after having seen him, we walked to the front desk to schedule our next appointment, and were told he'd be gone the entire month of August (the baby was due August 29). What?!? We'd just spoken with him, and he hadn't mentioned it. We made an appointment with a different doctor, who didn't work out - too many "IV / no IV" differences - and went on to a third, who was fantastic. (By the way, we finally met with this third doctor at week 39...good thing #1 was two weeks late.)
(TV SERIES) A Baby Story. Created by The Learning Channel, and shown around most of the country on cable / satellite channels. (We see it on Discovery People.) It's a great series to watch for the tremendous variety in each birthing situation. Each 30-minute show follows a pregnant couple from about a month before the birth through the first few weeks after the birth, with full coverage of the birth itself. You'll see twin pregnancies, home births, birthing center births, hospital births, C-sections, women getting epidurals, women not getting epidurals, at least one father catching his own baby (in a hospital birth, by the way). Some births are fraught with complications and the outcome seems uncertain, but I have yet to see an episode where the end result was not happy.
© Copyright 1998-2002 by Grayson Morris.