Monday, June 17, 2013

Childbirth Choices Series Part II: Meeting Your Care Provider

This is the second in my Childbirth Choices Series, geared toward newly pregnant or planning-to-be pregnant couples with the goal of educating women and their partners about the many options they have when it comes to their prenatal and maternity care, including choosing a care provider, choosing where and how to give birth, and information about labor, delivery, and the immediate postpartum time. This is not meant to replace or substitute for a childbirth education class. Rather, it is intended to get women thinking about their options and making informed choices when it comes to their care throughout pregnancy and labor and delivery.

More articles in this series:
Part I: I've Just Found out I'm Pregnant; Now What?
Part III: Do I Need a Doula?
Part IV: What Will Happen at My Prenatal Appointments?
Part V: It's Almost Time to Have a Baby!
Part VI: Labor and Delivery

So, let's talk about that first meeting with a potential care provider. What are you looking for in a care provider? How do you know if this person is the one you'll want to see throughout your pregnancy? How do you know this is the person you want to help you deliver your baby?

Your first meeting can be a simple "meet and greet" appointment even before you're pregnant, just to get a feel for the practice, his or her personality, how the office is run, and other general impressions, as well as a chance to ask specific questions relative to your situation. Your first meeting might be early in your pregnancy, when you're still looking for someone to help you through the rest of this process. Or, you might have a care provider you've been seeing for your GYN care, and this is your first prenatal appointment. Keep in mind that often the first prenatal appointment isn't until you're 8 or 9 weeks along, so there will be some time for you to think about your concerns and questions you might want to ask. Your pregnancy will  be pretty well established by the time you have your first regular prenatal appointment.

Depending on whether this is a meet-and-greet or a prenatal appointment, the atmosphere of the meeting may be different. I'll start with the universals, things you'll probably want to ask or judge your impressions of no matter what. I'll then move on to a typical "first appointment" scenario.

What kind of provider are you looking for?

We discussed in the previous article the three basic options for a maternity care provider (CP). These were a certified nurse-midwife (CNM), a licensed midwife (LM/CPM), or the most common choice, an obstetrician (OB). Now I want to look at the type of person or personality you might be looking for. 

We all have different expectations when it comes to someone who will be providing us with medical care. Some may prefer a certain clinical distance: you don't want your CP to be your friend, you want your CP to be professional, reserved, authoritative, and objective. Others prefer a warmer or friendlier relationship: you want someone you connect with on a personal level, someone you'd like to go out for coffee with. Still others might like a mix of the two: someone you feel meshes with your personality, sense of humor, and style, but who still maintains a comfortable distance. Remember that this person will become fairly intimately involved with your most private and sensitive of areas, so you want to make sure that you are personally comfortable with him or her, however that comfort is manifested for you. You should think about what kind of personality you're looking for as you prepare for your first meeting so that you can assess whether this person meets that need. Since you'll be seeing this person fairly regularly for the next several months, you don't want to dread your appointments because you don't "like" him or her!

Male or female?

While most midwives are women (probably over 99%), there are about the same number of male obstetricians as female. Female doctors are increasingly joining the field of obstetrics, and many patients prefer a female obstetrician, for various reasons.

I have been equally happy (and in some cases equally dissatisfied) with male and female CP's over my four pregnancies. Several of the most celebrated obstetricians in the natural birth community in my local area are male. I don't think you can make any kind of sweeping generalizations about male or female practitioners being "better." It's really about your personal preference.

Why a woman?
Some women are simply more comfortable being unclothed in front of another woman. This is quite understandable. You may also feel that a woman will have more empathy for your situation, especially one who has given birth herself. You may feel a certain sisterhood with her, or feel that her personal experience is to her benefit as a practitioner. You may feel more comfortable discussing intimate problems with a woman, because you feel she may have "been there" herself, or that she will understand why it's difficult for you to talk about. There's a peer relationship you can have with a woman that you can't necessarily have with a man.

Why a man?
Some women feel that a male practitioner will have a more objective view of the process. Having not experienced childbirth or other "woman problems" directly may mean that he will view your situation with a clinical eye not clouded by feelings. You may feel he is better able to distance himself from the emotions of the situation in order to give you the best objective advice. Indeed, does a cardiologist have to have had heart surgery to perform it? Does a pediatrician need to have children to take good care of yours?

What if I don't have a preference?
Some women don't have a gender preference for their CP. Sometimes, you're just looking for the best fit, the person who is best at the job at hand and who meshes best with your expectations. You may feel going in that you couldn't possibly be examined by a man but then find that the woman you choose is not as empathetic as you hoped. Or, you may think that you prefer the objectivity a man will likely provide, only to find that his approach is too clinical and you prefer a warmer touch. There's no way to generalize. Midwives and doctors are human, too, and their practice is colored by their training, their background, their personal experiences, and their personal biases. That's why it's prudent to have an open mind when interviewing or meeting with your practitioner.

Group Practice or Individual?

We talked about the different advantages of a group practice versus an individual practice in the previous article as well. 

If you're going with a group practice, it's a good idea to try to make appointments with each of the available providers throughout your pregnancy so that you'll get a chance to meet everybody. In a group practice, you would hope that there's a unifying philosophy among the members of the practice. However, each doctor or midwife in the practice may have a different style and will certainly have a different personality, and you may find you simply "like" some of them better than others. It's up to you to decide whether you can be comfortable with whoever ends up attending your delivery. I was with a group practice in my first pregnancy, and I definitely found I preferred two of the doctors over the other two. Toward the end, we scheduled all of the appointments with our "favorite" doctor, but he didn't end up being on call for the delivery. But, we were comfortable enough with the level of knowledge and competence, as well as the personalities, of each of the four doctors that we were willing to "take what we got" when it came time to have the baby. 

With an individual practicing on his or her own, a major concern will be whether this is the person who will attend your birth. Some individual practitioners cannot guarantee that they will be available or on call when you go into labor, while others make it a point to be there. This is something you'll definitely want to find out early on! If your doctor or midwife can't be there for the delivery, then whoever is on call at the hospital or birth center will be there for your birth.

What do I want to know?

Okay, so what questions should you be asking, and what information should you be sure to acquire? Well, there are a few things you'll definitely need to know. 
  • Where will I deliver my baby? What hospital or birthing center does this CP deliver at? (For a home birth, this is obviously not a relevant question.) 
  • Who will deliver my baby? This goes back to the on-call situation: are you the one who will be there when I call to say I'm in labor, or is there no guarantee? If you are not available, who can I expect to see? Do you have arrangements with another practice to work with you for backup, or am I stuck with whoever is on call? How much of an effort do you make to be there personally?
  • What is your cesarean section rate? This question applies to OB's, since midwives can't perform c-sections. Midwives in birth centers and the home-birth setting will instead have a "transfer rate" - that is, how often the patients in their care need to transfer to the hospital for emergency care. This is something you will want to find out if possible. Knowing if your OB has a relatively high c-section rate (the national average is about 32%, which most experts agree is too high) or a relatively low one may help you decide if you feel you are in capable hands. An OB with a lower rate is probably more "hands off" in the birth process, more inclined to let things happen naturally. An OB with a higher rate may be more likely to err on the side of caution if there are any concerns during the labor process. Remember that OB's who handle more high-risk cases will likely have higher c-section rates by virtue of their type of practice and not necessarily because of their philosophies.
  • What kinds of recommendations do you make for managing the pain of labor? This is going to be a big question. What you're trying to find out is, how likely is this person to immediately turn to medical interventions such as epidurals and IV narcotics before or instead of trying non-medicinal methods of labor relief, such as breathing, changing positions, shower or bath, and relaxation techniques. Is this a CP who is more likely to let labor progress on its own, or is he or she going to recommend interventions early on? How do you as the patient feel about that? Are you more interested in "letting nature take its course," or do you feel strongly that you want an epidural the second you walk into the hospital? Are you more comfortable with laboring in more hands-off environment, or are you nervous about laboring without monitoring and assistance? These are very, very important questions for you to consider as you progress through your pregnancy, and we will definitely be addressing the issues of interventions, medications, and monitoring in a future article in this series. How your CP answers this question will help you understand how he or she views the birth process and how you as the mother will be treated.
  • What is your (or the hospital's) policy on continuous fetal monitoring? Continuous fetal monitoring (CFM) means that you would wear a fetal heart monitor strapped to your belly at all times. This is a tool that we will discuss in more detail in a future article. You may want to know if you will be required to wear this monitor at all times, as it may limit your mobility and ability to change positions or use alternative pain relief options such as a shower/bath, and CFM has some unexpected risks, such as increasing your chance of emergency c-section. You may want to follow up on this question by asking if intermittent monitoring is an option. In this scenario, you'd wear the monitor for 20 minutes every hour and otherwise be disconnected and free to move about, if you want.
  • What is your policy on eating and drinking during labor? What is your (or the hospital's) policy on the use of an IV? Labor can be long and uses a lot of your energy. Many CPs and/or hospitals will not permit a laboring woman to eat or drink during labor in case she requires an emergency c-section and emergency anesthesia. You will want to know if you'll be allowed to bring food and drink with you to fuel your labor. Often, if your provider or birth location has a policy against eating and drinking during labor, they will require you to be on an IV for fluids at all times to prevent dehydration in you and the baby. They may also prefer to have an IV ready in case any medications such as antibiotics or Pitocin are deemed necessary.
  • How do you feel about my having a doula? Even if you don't plan to hire a doula (and we'll talk about doulas in a later article, too, never fear!), you may want to know whether your CP is open to your having a labor coach or additional support in the room with you. A "doula" may also simply be a friend or family member who is there to encourage and support you as you labor. Most CPs, birth centers, and hospitals are amenable to the presence of a labor support person other than the baby's father or a close family member, but some are not. Knowing your CP's attitude on this subject may be informative for you.
These questions should help you gauge your potential provider's approach to labor and birth so that you can determine if these ideals are in line with your own. We will be getting into considerably more detail about many of these topics in future articles, to help you gauge your own birth preferences, as well!

Your First Prenatal Appointment

This is a description of what typically goes on during a first prenatal appointment, especially in a more traditional setting, just to give you an idea of what to expect.

You'll first be asked to fill out some paperwork about your general health history and gynecological history specifically, especially previous pregnancies and births, if applicable. Your provider may have these forms mailed to you in advance of your appointment so you can arrive with them already completed, or you may be asked to fill them out when you arrive. You'll probably need addresses and phone numbers to use for emergency contacts, how to contact you and your partner at work, your insurance information, and so on. You may also want to have on hand information about previous GYN care providers and be prepared to have your records transferred if you are moving to a new provider. It's important that your provider has a picture of your medical history so that they can care for you appropriately. Conditions such as diabetes, hypertension, thyroid issues, psychological disorders, and various GYN problems will likely be relevant to your treatment during pregnancy and delivery and possibly postpartum as well.

You'll probably be asked to provide a urine sample (by peeing in a cup), which will be quickly tested for protein and glucose content. The presence of protein in your urine could signal kidney problems, which would need to be evaluated. Glucose in the urine may indicate diabetes or the potential for diabetes, which would need to be managed.

You'll then be taken to the exam room. Your provider will most likely want to perform a full gynecological exam. For this, you'll be asked to take off all of your clothes, and you'll probably be given either a hospital gown or a paper vest and towel to put around yourself. (From personal experience, I recommend keeping your socks on if you're wearing socks - sometimes the room is cold, or the stirrups are uncomfortable on bare feet.) The care provider will examine your breasts and genitals and do a quick internal vaginal examination with gloved fingers and possibly a speculum to check your cervix and feel for your uterus and ovaries. If you have had a gynecological exam before, this should all be familiar to you.

Many care providers will then perform a transvaginal ultrasound to "see" the pregnancy. An ultrasound machine measures the way high frequency sound waves bounce off various structures in your body and creates a live picture on a computer screen of the tissues, organs, and bones the sound waves encounter. The provider can manipulate this picture to focus on the organs of interest, in this case your ovaries and uterus, and to view the growing fetus. You may be familiar with a traditional ultrasound machine, which uses a wand and some gel on your abdomen. For this type of ultrasound machine to get a clear picture, you generally need to have a full bladder. A transvaginal ultrasound, by contrast, uses a wand that is covered by a lubricated condom and inserted into your vagina. It does not require a full bladder to get a clear picture of your uterus, cervix, ovaries, and the baby. The provider will use the ultrasound machine to take measurements of the fetus and look at the heartbeat as well as to check the placement of the pregnancy to make sure everything looks healthy. Based on the measurements on the ultrasound, your CP can get a pretty good idea of how many weeks and days the baby has been growing, and from there determine whether your estimated due date, based on your last menstrual period, is accurate or if an adjustment needs to be made. If the estimate from your ultrasound and your last menstrual period are within a few days of each other, your due date will probably not be changed. If there is a larger difference, they may want to change the date based on the baby's actual growth.

If you are not comfortable with the idea of an ultrasound in general, or a transvaginal ultrasound specifically, you should bring up your concerns with your provider. It is your right as the patient to refuse any procedures you feel are unnecessary or carry unreasonable risk to yourself or your baby. Though it is a useful tool, an ultrasound is not necessary to date or assess the pregnancy. You should feel comfortable asking your provider what the purpose of the procedure is and whether and why he or she feels it is important. While you may not be able to hear the baby's heartbeat using external methods (such as a Doppler machine or stethoscope) at eight or nine weeks, by about 12 weeks it is possible to hear the heartbeat using noninvasive methods, and you may be more comfortable simply waiting to use a less intrusive method to hear the heartbeat. On the other hand, you may be excited to get to see your baby so soon (no, you can't see the gender this early!), and seeing the little heart fluttering on the screen is very reassuring.

You will also be given information about certain blood tests your CP recommends. These will include general blood tests such as checking your blood type, measuring your iron stores, thyroid function, and white blood cell count. Your CP will also likely recommend that you be tested for antibodies to certain diseases such as chicken pox, measles, rubella, and other viruses that may be dangerous to a growing fetus. If you have had any of these diseases in the past, or you have been vaccinated against them, there should be nothing for you to worry about. There is a blood test, as well, to look for certain chromosomal abnormalities in the fetus, specifically Down syndrome. Your CP will ask if you would like to receive this testing and give you information about how it works and what they look for.

Your CP will also discuss with you whether you want genetic testing to find out if you are a carrier of any known genetic diseases such as cystic fibrosis, sickle cell anemia, or Tay Sachs (depending on your ethnicity and risk of being a carrier). If you are a carrier of a genetic disease and the father of the baby is as well, there is typically a one in four chance that your baby will have that disease. You may want to know whether your baby is at risk of having one of these terrible genetic disorders. Some people choose to be tested for this before deciding to have a baby, but often you don't know about them until you are pregnant. If anything is found, you can receive genetic counseling to help you decide what to do and how to handle future pregnancies.

Remember, again, that you have the right as the patient to refuse any tests or procedures you are not comfortable with. For example, if you don't think that knowing the results of a genetic test would change your desire to carry your pregnancy to term, then you may want to decline the testing. On the other hand, knowing about a potential disability or disease may be important to you, even if you still plan to carry the pregnancy to term, so that you can be prepared with services and support when the baby is born. You probably want to discuss this decision with your partner to make sure you both feel the same way.

Your next appointment will likely be scheduled for four to six weeks in the future, and you will probably be asked to have your blood tests in the meantime. Some blood tests need to be taken during a specific time frame for accuracy.

Your provider will then likely discuss with you some issues such as exercise and diet and what you can expect in the next few weeks. You should be given an opportunity to ask any questions you may have and air any concerns that have come up.

If, for any reason, during your appointment, you feel uncomfortable, you should let the provider's office know via a phone call or, better, a letter. If it's in writing, you have evidence of what you said. If you do not wish to return to see this provider, start looking for a new one quickly so you can schedule your next appointment, and arrange to have your records sent over to them. You also have the right to request a copy of your records to keep for yourself if you want. The provider's office may charge a copying or processing fee, usually not more than $25, for the time and supplies used by the office staff in copying the records, but they are not allowed to refuse to give them to you.

If this is not your first pregnancy and there was anything of note or unusual about your previous pregnancy(ies) and/or delivery(ies), you may also want to request your hospital records from the birth(s) so that your new provider will know about these circumstances. That information can be valuable in planning your next birth.

Stay tuned for the next article in this series. If you have any questions about this or any of the topics covered in the Childbirth Choices Series, feel free to comment below or on my Facebook page, or send me a private message via the Facebook page.


More articles in this series:
Part I: I've Just Found out I'm Pregnant; Now What?
Part III: Do I Need a Doula?
Part IV: What Will Happen at My Prenatal Appointments?
Part V: It's almost Time to Have a Baby!
Part VI: Labor and Delivery

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