Now that you have some sense of what’s involved in those prenatal appointments, you need to pick one. As above, if you have a family practice M.D. or someone who does your women’s health that you have a good relationship with and that catches babies, you probably want to start there. Do not assume you need an Ob/Gyn specialist. Those people are surgeons. Surgeons are good at cutting and sewing, which we hope there will be none of in your pregnancy and birth. If, later on, you need cutting and sewing, you can get one of those involved later. What you need is someone who is good at helping you learn how to live your life while pregnant, and give birth to your baby (or babies) in a way that is safe, healthy and empowering. Midwives are very good at all of these things. Their training varies from region to region. Certified Nurse Midwives (CNMs) have a relatively standard nursing background plus midwifery training. Lay midwives learned on the job and may or may not have other certification or training. Certified midwives have some kind of training or licensing that does not go through the standard nursing background. Depending in part on which kinds of midwives are recognized in your state, your insurance may or may not cover midwives; you’ll have to check with them. Midwives are often breathtakingly less expensive than Ob/Gyn M.D.s and even family practice M.D.s (sometimes cheaper than your copays and deductible). They have a fantastic safety record that has been documented extensively. For all but the highest risk babies, midwives have as good or better outcomes than the more typical M.D./hospital approach to having babies, largely because they intervene in the process of birth less, they support the process more effectively and their total level of medical interventions (C-section, forceps or vacuum extractor assisted delivery, episiotomies, analgesia etc.) is so much less, which greatly decreases your risk exposure where you can most readily control it. Not all states have licensed midwives; you’ll have to check yours.
In addition to who you choose (an M.D., and, if so, which specialty, or a midwife and if so, which kind of training and/or certification), you will also choose where you will have your baby. These decisions are closely intertwined. In general, if you want to have a home birth, you will not be using an Ob/Gyn specialist, and you probably won’t have an M.D. at all. If you choose a free-standing birth center, you will work with one of the midwives or doctors which is affiliated with the free-standing birth center. In a similar manner, if you choose a hospital, you will work with one of the midwives or doctors which is affiliated with that hospital (for my purposes, birth centers in the hospital are considered part of the hospital). Your choices now influence who will catch your baby and where that event will take place but cannot determine it. In addition to the various sitcom possibilities (the backseat of a taxi, for example), events during pregnancy or the birth may dictate a different place of birth than you initially intended. Some midwives will help you manage that transition. Others will not (or possibly cannot). In a large Ob/Gyn practice with many doctors and/or midwives, you may have no way of predicting who will catch your baby, and how much of the labor they will be present for.
Try to learn what you can expect from who you choose. While through tools like a birth plan, you may be able to modify the usual procedures, in general you will be more likely to get the outcome you desire if you pick a provider who generally does things the way you want them to be done, rather than picking a provider for some other reason and attempting to convince them to change their procedures to fit you.
There are two main strategies for dealing with pain. The first strategy is to avoid it. Now that you are through laughing about how you’ve missed that chance already by choosing to get pregnant, give some serious thought to alternate ways to avoid pain. When resistance training (or engaging in any physical activity that requires good form to do safely and effectively like, say, throwing a ball or negotiating a mogul), preparation by maintaining a healthy body, careful attention to form, and responding to your body's feedback are all ways to avoid pain. Likewise, being physically fit, being in an environment in which you can choose positions moment to moment, with people to assist you in maintaining those positions and responding to your body’s clues about what positions will be less painful are all ways to avoid and reduce pain in labor, and to make it an efficient process.
The second strategy is to suppress the pain, interrupt the feedback mechanism, turn it off. For some people, for some pain, meditation, hypnosis or distraction work well to interrupt or reduce the experience of pain. Trained breathing patterns (as are taught in many childbirth classes) and other rituals rally these techniques. Application of heat, cold, immersion in water, use of electricity (supplied via TENS units) , the injection of sterile water solution into the back, massage and other forms of healing touch (including acupuncture and acupressure) are all mechanisms to suppress pain, interrupt pain or turn it off. Drugs are another way. They can turn it off locally, regionally, or at your brain. They can be delivered by mouth, as a suppository, via injection into tissue, or injection into the spine, either into the epidura (an epidural) or the dura (a spinal). Suppressing and interrupting pain, a feedback mechanism, may also disrupt the process it is giving you information about. Epidurals used early in labor and soaking in a bath early in labor are both associated with labor slowing or stopping. Drugs rarely have just one effect, and those effects are dose dependent, with the effective dose varying unpredictably by individual.
There are a lot of articles out there about how epidurals are great, every woman should have them, people who don’t want them are crazy, they’re completely safe and effective, and they don’t slow labor down. Quite a lot of the women you talk to about their birth experience will tell you how wonderful their epidural was and how you should have one too (which you can probably only have in a hospital context). Some women may tell you a very different story. This is why I think it is so important to collect as many stories as you can, to balance what you read and to show you what to investigate so you know what you want and how strongly you want it. Epidurals are not completely safe (the dura can be punctured, leading to lifetime pain and disability). They will definitely limit your ability to move around. Choosing drugs means you don’t get to use your other main strategy for dealing with pain. They are not effective in all women. When they are not effective, they may do nothing, but they may also be "patchy" working on part of you but not equally throughout the region. This can be an awful experience, as your body’s natural pain relievers will probably be turned off once the epidural kicks in – leaving you to feel excruciating pain you cannot relieve through movement (or only with a lot of assistance that may be erratically available). Epidurals can also cause your body temperature to rise, leading to antibiotics for you and your baby, and possibly several days observation in a NICU with regular heel sticks to make sure the wee one is not sickening. The cumulative effect (reducing feedback, limiting motion, slowing or stopping labor) increases the number of other interventions likely to be taken, including, but not limited to, breaking the waters, administering oxytocin or misoprostol to restart labor, an episiotomy to allow the use of forceps or vacuum extractor to extract the baby and, all too often, an emergency C-section because the interpretation of the fetal monitor trace suggests the baby’s heart beat is slowing (bradycardia) or not recovering between contractions. This is "the cascade" and I’ll return to it.
You know better than anyone else what level of pain you can tolerate. You can choose to put off the decision of what kind of pain medication to accept or reject until you are in labor (subject to a possible transfer in labor to go to a place which has the kind of pain medication you want). If you intend to avoid pain medication, the easiest way to do so is to plan to give birth in a place where it is not available. It cannot be offered, and you cannot be talked into, accepting something which isn’t there. To the extent that you can build a tolerance for thinking about your options, reading more about the tradeoffs of medication vs. other methods of avoiding or relieving pain can help settle you in your mind. Fear aggravates pain and more knowledge may take some of the edge off fear.
No one likes to recover from an episiotomy, although some women would prefer to have one than rip, despite all the medical evidence that indicates serious tears virtually never happen without an episiotomy, and rips heal better than cuts. For the rest of us, this whole process is frightening enough, without having a bunch of stitches around our vagina and/or rectum (the perineum, which is sliced open during an episiotomy, and sewn back up after). Episiotomies are completely without merit (other than when necessary for using forceps or vacuum extractor); they are nevertheless performed by many doctors and some midwives quite routinely. Ask your birth attendant what their policy is on episiotomies, and assisted or operative (with vacuum extractor or forceps) deliveries. It would be nice if they could give you percentages, and those percentages were so low you could not imagine them happening to you.
A few women want to have their baby by C-section, and would just as soon not be conscious for the operation, either. For the larger number of women who would prefer to give birth vaginally, it is helpful to know what percentage of births in a given setting are by C-section. In a setting where C-section requires transfer, it would be helpful to know the transfer rate, how transfers are managed and outcomes post-transfer. Ideally, midwives who need to transfer won’t need to do it very often, will recognize when they need to do it, will be able to transfer with you and participate in your care in the new setting, and, in that new setting, you will not automatically get a C-section.
Unfortunately, most birth settings do not make this information readily available. Most health care providers who work in these settings don’t know why you might want this information or, worse, will view you as troublesome if you ask for this information. In general, large teaching hospitals have higher C-section rates than public hospitals. The ritzier the private hospital, again, the higher the C-section rate. The teaching hospitals will generally justify their higher rate (which can be 50%) by saying they get all the tough cases. It is quite likely, however, that they are just making sure that all their medical students get a chance at learning how to do a C-section -- which, in practice, means that you are not only more likely to have a C-section done in a teaching hospital, it is quite likely it will be done by a not-yet-fully-trained doctor. The ritzier private hospitals will generally tell you that they're trying to provide the safest birth possible, and may come right out and say they believe that C-sections are safer than vaginal births (they are wrong). This rationale is suspect, as they make quite a lot more money from a C-section than from a vaginal birth.
While it may seem very early to be thinking about breastfeeding, I urge you to do so. Your choice of health care provider can strongly influence what information you are given about infant feeding and infant care. Formula companies spend a lot of money influencing doctors, nurses, midwives and other health care providers. Their offices are often littered with little goodies left by sales reps. Until HIPAA in the US, many health care providers sold your name, due date and address to formula companies so they could market directly to you (in violation of international guidelines for marketing infant formula). Prenatal vitamins are made by the same companies that make formula, which are pharmaceutical companies. They'd like to have as much of your business -- and your baby's business -- as possible. I'd strongly suggest you find a health care provider that makes a point of showing sales reps for formula the door and does not accept any goodies from those reps. A health care provider with the sense to do so is also a health care provider that might be able to help you get the support and help you need to breastfeed successfully for as long as you and your baby care to do so.
The training and background of health care providers predisposes them to believe in certain kinds of family planning strategies. People trained in medical schools, for example, believe that hormonal birth control and surgical sterilization are the only sure methods of avoiding pregnancy. They believe this because they have been trained to not believe in the ability of their clients to make and implement decisions that are best for them, if they are not also the easiest thing to do from one moment to the next. You may also have blind spots when it comes to family planning. Hopefully, your health care provider can help you avoid strategies that will sabotage breastfeeding or other goals.
Copyright 2005 by Rebecca Allen
Created May 20, 2005 Updated March 8, 2006