Interviewing a birth provider, and making the tough calls.

Recently I have had to help a client get a new provider four weeks shy of her due date, and also had a friend who is trying to conceive talk to me about options for birth providers. This got me thinking. I have this HUGE three page list of questions I give to people to give them a general idea of what ask and why, but it's too cumbersome, and too detail oriented... I thought, there has to be a way to make this simpler....

So I came up with this.

1. How can help me to achieve the kind of birth I am looking for (un-medicated, intervention-free, etc)

This question is open ended enough that you can hopefully gauge their REAL opinion on what you're hoping to do, as well as their level of comfort talking off the cuff about the topic. Stammers, and side topics are a good indication the doc you're looking at doesn't know much about it, or doesn't do it much.

2. How do you feel about doulas?

Now, obviously, I think everyone would benefit from a doula. But that's not the point of this question. Some doctors don't like doulas, and I have found that those doctors are the ones with high rates of intervention and cesarean rates. Not to mention that closed-mindedness is not helpful when it comes to healthcare providers! Some people may have had a bad experience with a doula, just like doulas sometimes have bad experiences with doctors-- the goal here is not to judge by those terms, but to gauge open-mindedness, and intervention rates.

Many doctors who straddle 'the line' of medical/natural have told clients of mine things like, 'well if that's the kind of birth you want, you would definitely be better off with a doula'. Meaning, if you're calm and under control and I don't have to worry about you, you can do whatever you want. But if you're NOT, then I just might throw the book at you. And this is not necessarily a bad thing, but can be a point of concern and warrant more questions on your part.

3. What is your cesarean section rate?

The US average (mind you we're 37th in the world when it comes to maternal and infant mortality, which is ABYSMAL) for cesarean sections is 31.8%. The World Health Organization states that there is no reason the number should be above 10-15%. Don't rest until you get the real number! They have it, or they can get it.

This can also be a good spot to segue and ask if they accept VBAC births. Even if you're not a VBAC, the answer to this question says a lot about the open-mindedness of the clinic, as well how much power the legal department has over the medical decision making.

4. What is your epidural/narcotic usage rates?

Some places give a combined stat, and some keep them separate. Either way, if it's over 60 or 70%, it's not LIKELY that the provider has seen the ebb and flow of many un-medicated deliveries, and may overreact to a situation that is normal, but 'could' be abnormal. Only someone who sees a large number of natural births will be able to adequately monitor support and gauge a mother who is un-medicated. This is where the science and the practice of medicine seem to really split. They learned about normal birth in college (theoretically), but may have not attended enough of them to be comfortable with them. Practice makes perfect-- find a practice who regularly supports natural birth, and you'll be in much better hands!

Also keep in mind that you need to have some symbiosis with ALL the providers in the group, because if you end up with the one OB who does not support the birth you are looking for, that can be a problem. Though, having been in this situation once, we did got mom through an all natural, un-medicated delivery without so much of an IV (which he was not happy about), but afterward he told us that was his first natural birth, and he was very impressed and learned a lot. So who knows... maybe we converted him. :)

Next, you need to ask about their office/hospital policies on the following things:

1. monitoring.

What kind and how often? All the studies show that too much monitoring can be really detrimental to the process of natural birth, so we like intermittent, external monitoring, or even doptone. And 'intermittent' can mean different things to different people, so be sure to ask what that entails for them. Another great question is if they have telemetry units. These report the results on radio waves, and therefore, have no cords. They can also be used underwater and in the shower. Not many places have them, but those that do are worth searching out.

Clearly, if the situation warrants a closer look, you can change your 'wish list' on monitoring, but if your office has a standard 'break the bag and insert the internal fetal monitor' policy, you may want to run screaming.

2. IV/hep lock usage

Is an IV standard? Is it possible to used a saline/heparin lock instead? Many doctors express concern over the skipping of he IV, and I can understand why. Many of the medications needed for emergency situations kept on the floor are meant to be administered directly through an IV-- so if you injected it, it could be all kinds of horrible for you, and probably wouldn't work either. So, there is a safety risk for women without IVs in unexpected situations, HOWEVER, there is no reason that a heparin lock IV start/access point isn't good enough. they can hang the saline, and literally have you connected and medicated with only a few extra moments. For most women, those extra moments are not critical, and the freedom of movement gained from not being tied to a pole, and going pee all the time is invaluable.

3. pushing positions

If they tell you supine with your legs up is best, run screaming. This has been proven time and time again to be THE WORST delivery position possible-- though, doc can see much better this way.

While many women do prefer to climb into bed to deliver, there are many options for positions even while in the bed that can help the mother use gravity, and help her use her body for leverage. Not having a choice here dictates that the doctor has not delivered in other positions often enough, and I wouldn't want to be their first case out of their comfort zone!

4. what kind of 'clock' can I expect to be put on?

Do I have 24 hours from when my water breaks until baby NEEDS to be born? 48?? In other countries women go days, and sometimes even weeks with broken waters before active labor sets in. It is not necessarily harmful at all, however, the legal-political climate in this country allows little room for situations like this. If your labor isn't 'fast enough' to beat the clock, you will be looking at pitocin at the least, and a cesarean at the most. So, the answer to this question is quite important.

5. food and drink in labor

The ACOG has recently come out in favor of food and drink in labor. A mother's blood sugar needs to be able to keep up with the marathon events happening, and allowing no food or juice is very detrimental to that process. There is really no reason to keep a mother from doing what comes natural, especially if she is hungry!

6. What are your 'standing orders'?

Standing orders are what doctors have on file at the hospital to do to get every patient ready for laboring. It often includes blood work, some monitoring, an IV, and in many cases, AROM, an internal exam, and pitocin. These orders are going to tell you a lot about how they practice, and how much patience they have for longer labors.

And lastly, ask WHY a lot, and use your gut! If you get a funny feeling, stick with it, and interview some other people. And remember-- charisma and charm are for getting the baby in there, they don't help get the baby out! Some doctors are very personable in the office, and turn out to be abrasive, short, or different in the hospital, so knowing their policies will tell you a lot about what you can expect when 'the going gets rough'.

I hope this list is helpful-- and remember to choose wisely!


Dou-la-la said...
November 1, 2009 at 12:48 PM

What a great list! I totally plan to share this. I especially like #2, it really IS very revealing.

One minor thing - I was under the impression that the new ACOG position on food and drink in labor was specifically limited to now allowing intake of clear liquids only. I think I recall it saying something about forbidding even soup if it had "solid particles" in it. While this is a step in the right direction from withholding even liquids from poor thirsty moms, I don't think they're quite endorsing actual food. (Not that *I* agree with this, of course!) I could be wrong, but check it out.

Lauren said...
January 7, 2010 at 6:42 PM

Thanks for this list...I plan on sharing it all around!

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