Hints on How to Choose a Caregiver
The first thing you need to do when deciding on a caregiver, is to decide where you want to give birth.
Once you have decided between home, birthing center, or hospital,
you can narrow it down to a practitioner who can attend deliveries at that location. Most home births are attended by non-Nurse-Midwives
(though there are some CNM's who attend home births). Birthing centers can be any kind of midwife, check with the birth center(s) in
your area. Hospital midwives are CNM's (See "The different types of midwives" page for more explanation).
Next it is important to find a practitioner who's attitude about birth and pregnancy is similar to yours,
so that you are able to receive the care you desire and have the birth that you want. Start by
picturing your delivery. What do you see? Consider the following:
Who is in the room with you? (Baby's father, your parents, doula, your other children...)
What are they doing? (massage, verbal encouragement, hand holding, praying, assisting in the delivery...)
What delivery position are you in? (in water, in a chair, squatting, laying on your side, lithotomy...)
Are you able to eat or drink? (ice chips, juice, gatorade...)
What objects are in the room? (candles, tub, religious symbols...)
What is the lighting like? (bright, normal, dim...)
What are the sounds that you hear? (music, voices, silence...)
What are the smells in the room? (special scents from candles, incense, or aromatherapy...)
How do you feel about medication during labor? Epidurals? Cesarean Sections? When would these
be acceptable or necessary?
For out-of-hospital births: what emergency equipment do you want available? When is hospital
transport acceptable or necessary?
For hospital births: how do you feel about IV's, external fetal monitoring, internal fetal monitoring,
amniotomy (also called artificial rupture of membranes, or AROM), episiotomy, Pitocin,
vacuum or forceps assisted delivery.
(Consider writing a birth plan about the above topics.)
Take the time to write down your thoughts and feelings about the above topics, and have your partner
do the same. Then, pick several care givers to interview. Before the interview, write down questions
based on the thoughts you've had of the above topics (Examples). Call the office and ask how much time they block with
the practitioner for initial OB visits (your first visit), and OB revisits (all visits that follow). The more time you have with
your practitioner, the better you'll be able to get to know each other and the more time you'll have for questions or concerns.
Bring your partner to the interview if possible, and come prepared. Take good notes and immediately afterward write down how you
felt about the person, how comfortable you were, etc. Be sure to ask about other practitioners
who cover for deliveries, and try to meet his/her partner as well (there's nothing worse than being totally comfortable
with someone, and then a stranger walks in to your birthing room to catch your baby). If your choice was for a
hospital birth, be sure and visit all of the available hospitals for the caregivers you've interviewed. Ask a friend
who's had her baby there...you want to be comfortable with your caregiver AND the setting, and you may have to choose
your caregiver based on your options for where s/he delivers.
After interviewing all of the possibles, discuss it with your partner and make a decision. Then schedule your
initial visit. If things change during your pregnancy and you find you are not comfortable with
that caregiver, you can always change caregivers. Remember, this is YOUR pregnancy and YOUR birth.
Birth at home
Home birth is low-tech and natural. You labor and deliver among familiar surroundings, in a place of comfort. You
are attended throughout active labor, delivery, and several hours afterwards by your caregiver and usually one or two
assistants. The baby is monitored in labor using a fetoscope or doppler, and the mother's
health is monitored as well. You are free to move around, use the shower or tub, and even deliver in water if you wish (ask your care provider
about water birth experience). The amount and type of emergency equipment and medication available depends on the provider, therefore it
is important to interview possible caregivers carefully to ensure you are comfortable with what is available. If any complications
arise you or your baby can be quickly transferred to the nearest hospital. Studies show that midwife-attended
out-of-hospital births are as safe if not safer than hospital births for low-risk pregnancies.
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Birthing Centers
Birthing centers can be freestanding or physically connected to a hospital. They offer birth very similar to home birth
except that you must go to them. As with most home births, emergency equipment such as oxygen and medication is available.
Many birth centers can offer IV pain medication in labor, however epidurals are not available. Births in birth centers are low-tech and
interventions avoided but some available when necessary. You are attended throughout active labor, delivery, and several hours
afterwards by your caregiver, and usually a nurse or assistant. Your baby is monitored in labor using a fetoscope or
doppler, and the mother's health is monitored as well. You are free to move around, use the shower or tub, and even deliver
in water if you wish (ask your caregiver about water birth experience). You usually go home within about six hours of delivery.
Studies show that midwife-attended out-of-hospital births are as safe if not safer than hospital births for low-risk pregnancies.
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Hospital Births
The kind of hospitals births available varies widely from one hospital to another. Much depends on your
caregiver, nurses, and the policies of the hospital. Most hospitals now offer labor and delivery in the same room, while
some even allow you to stay in that room for your entire stay. Others move you to another area several hours after
delivery. Most hospitals now allow your baby to stay with you, however many still take the baby to a nursery not long
after birth, and not all let the babies stay with you during the night. There may be restrictions on how many people
are with you during the birth, and how long they can stay afterward. Hospitals offer the most options for pain medicine,
offering several kinds of IV medication and epidurals. Hospitals are also able to perform Cesarean Sections.
There are 3 different types of Obstetric hospitals, Level 1, Level 2, and Level 3.
In both level 1 and level 2 facilities, surgical personal are not necessarily immediately at hand, and a Cesarean, even in an emergency, can take
up to 30 minutes. In a Level 3 facility, surgical personal are on hand at all times. Cesareans can be performed within 10 minutes if needed.
Therefore, if complications or a high-risk delivery are expected, you should be aware of the differences among
hospitals and know what is available at the one you have chosen. On the other hand, having a low-tech, natural birth when there are
no complications (as with most births), is not always an easy in a hospital. Those who desire such a birth should be very careful about
the caregiver and hospital they choose. You are not always free to move around or shower in labor, as continuous fetal monitoring (either externally,
or internally) is often used. Most women are restricted to taking in ice chips only, often necessitating an IV because of dehydration.
Medication and Epidurals are often encouraged and in many hospitals, the norm. These things can vary from one hospital to the next, or one caregiver
to another, but you may not always have many options (ask potential hospitals about epidural and Cesarean rates). Some hospitals do offer jaccuzzi's for
labor, and a few even allow water births (ask potential hospitals about jaccuzzi's or tubs, how many rooms have them, and when and how often they
are used). A woman usually stays in a hospital 12-48 hours after vaginal delivery, and 48-72 hours after a Cesarean.
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Examples of interview questions
How many births have you attended? Where?
How do you feel about labor coaches?
Will you be with me throughout labor or just at the delivery?
Who covers for you when you are not on call? Do you have a regular call schedule, or does someone only cover in the case of illness or vacation?
What position(s) can I deliver in?
What is your philosophy about birth?
How long will you allow me to push before intervening?
For what reason(s) would you recommend inducing my labor?
How do you feel about birth plans?
For out-of-hospital births:
What would cause me to risk out during pregnancy?
How often do you transport? For what reasons?
How is your relationship with your back-up doctor? ...with the hospital?
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Glossary
Amniotomy is artificially breaking the sac that surrounds the baby. "Early amnitomy, though more convenient for the
doctor, does not usually benifit baby or mother" (Boston Women's Health Collective, pg. 380).
A birth plan is a "game plan" written by you and your partner before you go into labor. It communicates your wishes
about your birth (ie. who you want in attendance, what position you'd like to deliver in, whether or not you'll want pain medicine, etc.).
It is a way to personalize your labor and delivery and convey what kind of birth you want. A birth plan should be written for hospital
and out-of-hospital births. Birth plans are not always received well, and care should be taken in how it's written and how it's
presented to hospital staff. Ask your doula or caregiver to help you write your birth plan, and be sure to be well informed
about your requests and their consequences. Know what you want but be flexible- nature doesn't always hand us what we want or expect.
A Cesarean Section is the surgical delivery of a baby. An incision is made through the mother's abdomen and uterus
in order to remove the baby. A cesarean section is most often done under epidural or spinal
anesthesia allowing the mother to be awake during surgery. The procedure is done in a sterile operating room, where one family member
may be allowed. The hospital stay is usually 48-72 hours, while full recovery for the mother may take a few weeks.
A doppler is an ultrasound device used to listen to the fetal heartbeat during pregnancy and labor.
A doula is someone who is trained in professional labor support. S/he assists the mother during labor, helps
the father to participate, and can be the family's advocate or intermediary with medical personnel. Check with your hospital or caregiver, but in
most places, you must seek out and hire a doula on your own. See doula internet links for more info.
External fetal monitoring (EFM) is monitoring the fetal heart rate and contraction pattern with a machine which displays
the data on a screen and paper tracing. Belts are placed around the mothers abdomen to hold the external devices in place. Continuous EFM
requires the mother to be relatively immobile.
Epidurals are anesthesia placed by a specialist to assist with labor pain. Medication is
injected in the spinal column, which numbs the woman from the point of injection down. This usually takes away the
contraction pain, but will not take away the pressure of the baby coming down or the baby being born. The medication
can sometimes limit a woman's ability to move her legs, and may impede the process of labor. An epidural increases
the risk of cesarean and causes fetal distress in about 10% of babies (Goer, Chap 13).
Effect of epidural analgesia for labor on the cesarean delivery rate (article from the Journal of Obstetrics and Gynecology).
Episiotomy is a incision made in the perineum to enlarge the vaginal
opening for childbirth. Episiotomies cause more tears than they prevent, should NOT be done as often as they are, and
are only necessary in a few rare occations. (Goer, Chap. 14)
A Fetal Scalp Electrode is placed through the mother's vagina on the baby's head, and measures the fetal
heart rate by detecting electrical signals. It offers more information than an external fetal heart rate monitor, but is only
used when that additional information is desired.
A Fetoscope is a special stethoscope used to listen to the baby's heartbeat during pregnancy and labor.
Forceps are an instrument used to pull out the baby when immediate delivery is needed in the case of fetal
distress, or when a mother is unable to push out her baby (as can happen with epidural anesthesia). Forceps resemble hinged salad tongs, and are placed, one at a time, on
the side of the baby's head. Because of risks inferred with the use of forceps, they should only be used in the event of emergency. (Boston Women's
Health Collective, pg. 383).
Internal fetal monitoring (IFM) is similar to external fetal monitoring, except that the
baby's heart rate and uterine contractions are measure by devises inserted through the mother's vagina. The fetal heart rate
is monitored with a Fetal Scalp Electrode (FSE), and contractions with an Intra-Uterine Pressure
Catheters (IUPC). Internal monitoring provides additional information not available from external monitoring, and is only used when
that information is desired. An internal fetal heart rate monitor may be used with an external contraction monitor, or vise versa, depending
on need. IFM requires the mother to be relatively immobile.
Intra-Uterine Pressure Catheter (IUPC) is a soft tube placed through a woman's vagina and sits between the baby and
the wall of the uterus. It measures the pressure change in the uterus that occurs during a contraction, and can give information on the
strength of contractions. An IUPC can also be used to place fluid into the uterus if needed.
IV means "Intravenous", and usually refers to a small catheter that is placed in a vein for the
administration of fluids or medicine. An IV can be hooked to fluids which is hanging on a pole, or it can be capped
(often called "heplocked") to be used only when necessary.
A Level 1 facility usually only cares for healthy babies, and may have to transfer the baby to another hospital for
complications or if born before 37 weeks. If delivery is possible before 37 weeks, the mother may be transferred before delivery.
A Level 2 hospital can handle many complications that may arise, but cannot provide neonatal intensive care.
If such care is needed, or if the baby is born before 34 weeks, a baby may need transfer to another hospital. If delivery is possible before 34
weeks, the mother may be transferred before delivery.
A Level 3 facility has neonatal intensive care units available, and can handle most complications and pre-term births
which are treatable.
Lithotomy position is laying on your back with you feet up, with your legs in stirupps or feet in foot pads. "The lithotomy
position...is the worst, most ineffective and most dangerous position for labor. It is used in most hospitals for the convenience of the
doctor" (Boston Women's Health Collective, pg. 373).
Pitocin is a medicine used to bring on contractions. It is a synthetic form of the hormone oxytocin,
the hormone that causes uterine contractions. Pitocin is used to induce or begin labor when needed, or to augment or speed up
labor when needed. Pitocin is administered through an IV, and it's rate is regulated through a pump, increased
or decreased by a nurse depending on the contraction pattern. Continuous fetal monitoring, either externally
or internally is required throughout labor when Pitocin is used, because of the increased risk of fetal
distress and uterine rupture. (Boston Women's Health Collective, pg. 381).
Spinal anesthesia is similar to epidural except that is placed in a slightly
different area of the spinal column. Spinal anesthesia is usually used for surgery and not for labor.
A vacuum is a suction cup placed on the baby's head to allow the physician to pull and assist with the delivery.
Because there is a small risk involved, a vacuum should be used only when there is fetal distress and delivery is needed quickly, or when the
mother is unable to push out the baby (as can happen with epidural anesthesia).
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References
Obstetric Myths Versus Research Realities Henci Goer, Bergin and Garvey, 1995
Our Bodies, Ourselves for the New Century Boston Women's Health Book Collective, Simon and Schuster, 1998
Choosing a Nurse-Midwife: Your guide to Safe, Sensitive
Care During Pregnancy and the Birth of Your Child Catherine M. Poole & Elizabeth Parr, Wiley, 1994
Pillitteri, Adele, Maternal & Child Health Nursing, J.B. Lippincott Company, Philadelphia, 1995.
For more books on this topic, go to book list
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