Tag: OBs vs Midwives

An interview with an OB…

by Ashley filed under Pregnancy

A while ago, I posted here and on instagram about my own personal experiences with midwives and compared it to my current experience with my OB. While many commented and shared similar sentiments, there were still others who defended their own positive experiences with their OBs (and hey, more power to them). If there ever was an asterisk attached to anything and everything I share, it would read this: *based only on personal experience. I’m hardly trying to be the voice for anyone other than myself. It’s hard enough at times to find my own voice, I certainly don’t feel the need to put words in the mouths of others.

One reader, however, caught my attention. What she said was not judgmental or harsh, but rather she expressed sadness with the way OBs are bashed. She said, “There are many practices out there, like my own, where its a collaboration between midwives and OBs – we both benefit from each other and most importantly the patient benefits… The focus on birth and birthing stories, birthing photography, videos, etc has sadly turned such a private intimate moment for a family into a business and a chance to out do each other… Birthing is one of the most sacred moments in a woman’s life, but it’s only one moment of many to come for the couplet”.

I use my blog to share my own experiences, sure, and whoever follows along can follow along on their own free will. But when given the opportunity to expand and share a different side of the coin, you better believe I’m grateful. I realize that my own experiences are a mere drop of water in the ocean and anytime the opportunity should present itself to share a different point of view, I’m all about it.

So, I contacted Ema and asked her if she’d be willing to share more about her OB practice and thoughts, in general, about the current state of birth. I feel so fortunate to have her and hope you all can appreciate the conversation; because that’s what it’s all about — not who’s right or wrong, but the dialogue.

For the past 8 years, Ema has chosen to work in OBGYN-Midwife collaborative group at North County Health Services, where they have 5 OBGYN’s and 10-12 Certified Nurse Midwives (CNM). With no further adieu, here’s Ema…

 

It could easily be argued that the way you have designed your practice is quite progressive, as the tandem approach to patient care between OBs and midwives is not something we see often. Why have you chosen this model and what would you say the advantages are?

 

I am certainly blessed to have found North County Health Services. But in reality, I think it actually found me.  My entire training starting in residency has been along side midwives.  I did my residency in the military, an institution that is very progressive in its use of ancillary health professionals, specially midwives.  The biggest advantage I see is that it is a win-win for the patient.  As one of my OBGYN colleagues jokingly says, “they do all the crunchy-granola stuff and we do the high risk stuff”.  But it is all part of the same practice.  Patients get the sense that there is a team based approach to their care, multiple eyes reviewing their antepartum care, if complications arise, the OBGYN is a phone call away and if all goes well, the patient receives a hospital based midwife attended delivery.
The advantage is that it is the best of both practice patterns.  The key to our practice is that it is truly collaborative- we all meet for 4 hours weekly to discuss cases, learn each others’ practice patterns, and share info/management plans on the higher risk patients.  This helps bridge the gap in communication and overtime reinforces the trust needed to have this unique collaborative model.

 

In recent years, there has been several documentaries put out about birth. Take the Business of Being Born, for example. Have you seen it and what are your thoughts on it?

 

Indeed!  There are in fact several documentaries.  I have watched Business of Being Born.  Although this movie was revolutionary in highlighting the natural and gentler side of child birth (providing contrast to the mass media depiction of a screaming birth), what it did do is provide a very biased depiction of this business.
The OBGYNs that were in the movie seemed to be unfamiliar with natural birth options and hence the debate started off with an unfair advantage.  I read in an article while researching this answer, “Noam Chomsky once pointed out that if you only allow two view points, and then allow vigorous debate between the two view points, you can achieve the appearance of democracy and free speech without ever actually having it.”  What I do appreciate about the movie is that it is a good starting point for further discussion.  For example, although the profession of “midwife” or “midwifery” is used in this film, it should be noted that there are several types of midwives. Lay midwives, certified midwives, and certified nurse midwives- which are the only ones who can work in a hospital setting.  They have far more extensive training and education than lay midwives.  The audience is left to think that there is only one kind of midwife practice without any indication that there are vast differences between these subsets.

 

I think these documentaries are somewhat responsible for a certain degree of fear some women have toward birthing in a hospital. Would you agree? Do you think this fear is justified?

 

Once again by the biased portray of the business of midwifery vs. obstetrics, yes, movies like BOBB, feed the fear in the masses.  As I mentioned before there are a plethora of documentaries on birth that I would recommend:

1. Birth Story: Ina May Gaskin and The Farm Midwives
2. Midwife
3. From Conception to Birth
4. BBC documentary Childbirth All or Nothing

In addition, there is a great website that we encourage moms to look at:  www.evidencebasedbirth.com
I had horrible side effects following induction via Pitocin. I’ve read that Pitocin, while FDA approved for the induction of labor is not actually FDA approved for the augmentation of labor. Can you discuss the validity of this? 

 

Regarding pitocin- Pitocin is the brand name of the synthetic form of a naturally produced hormone called oxytocin.  It is derived from the pituitary gland of mammals.  According to the FDA or look on the FDA or other resources such as Physician Desk Reference, or websites such as drugs.com or rxlist.com,  Pitocin is indicated for the initiation (induction) or improvement (augmentation) of uterine contractions.
Therefore, I am not sure about the validity of the statement that it is not FDA approved for labor augmentation.
That being said, Pitocin is a drug and like any other drug it does have negative side effects.  Some of the reported reactions include:  anaphylaxis, nausea, premature ventricular contractions, hypertensive episodes, and with high doses uterine hypertonic its, spasm, or rupture of the uterus.  Therefore, beyond a certain limit, pitocin needs to be administered with an intrauterine pressure catheter.

 

There is a presumption that some OBs prefer performing a c-section to a natural birth for selfish reasons: more money, easy to schedule, etc. Have you noticed a trend of this sort among your colleagues? Can you speak to how the decision for some to go this route may taint the perception of the field of obstetrics as a whole? 

 

I think this is similar to the “bad apple” question.  I would like to think that I work in field with other altruistic physicians whom also have taken an oath to do no harm.  Therefore, even though there might be some who shift the pendulum, I firmly believe that these practices of financial gains and convenience are outliers and certainly not the norm.  And therefore, I am incredibly saddened that the few have tainted the perception of the many.  But I do hope that with conversations like this and continuous open discussion we can help shift this biased view.

 

I have two young children and a very busy schedule. We’re new to the area that we live and this will be my first birth in this new area. What tips would you recommend to someone like myself for finding a good fit in an OB without having to waste time I don’t have interviewing several? And what kinds of questions or things should one ask or look for when searching for an OB? As I touched on in my initial post, the OB I see was recommended to me by the local birth center, which was a huge deciding factor for me. It is also important that he is a sole practitioner as I mentioned that many of the OB practices in my area are part of a larger medical group and that continuity of care within these medical groups is typically lacking. 

 

I think what you did is exactly perfect.  Reach out to your local birthing center and ask for references or the names of their back up doctors.  Generally, but not always, these physicians have experience with midwifery care and can appreciate the different approaches.  You do need to interview, there is nothing, no Yelp, for physicians that would beat the actual gut feeling when you meet a physician.  I would encourage women to ask A LOT of questions regarding the relationship between the midwives and the supporting physicians.  One key factor is the financial drive in the relationship.  For example- if a group of midwives is working with a group of physicians and the midwife refers a patient to the physician for a consult, it would be financially advantageous for the physician to “label” this patient as high risk and therefore take the patient for him/herself.  This would then create a distrusting relationship between the two groups and ultimately put the patients at risk.   The midwives would fear loosing their patients and would be less inclined to refer or consult.  Therefore, a true collaborative model where there is no financial incentive between the parties is the model that works best.

 

Because you’re passionate about what you do, does it bother you that a few bad apples have more-or-less tainted the overall impressions of OBs? I’m sure reading experiences like mine weighs heavy on your heart and I wonder if you can’t see how other OBs have essentially worked against the fight you are fighting? And if I’m wrong on this entirely, feel free to call me out. I understand this statement may boarder on being presumptuous. 

 

Of course, in all professions however, there are always outliers.  The key here is to not be swayed by the “bad apples” and media and continue to do what at the end of the day is good medicine.  There is an art to medicine and that is one of the reasons I truly love my job.  Unfortunately, “bad apples” lead to stricter guidelines that ultimately end up in the loss of this art.  It is a continuous battle.

 

You clearly see the benefit of utilizing midwives as they are, in your own words, “the first responders” in your practice. Why don’t you think more midwives are used within the hospital / obstetrics settings? 

 

To answer this question you need to recognize that the term midwife is an umbrella term referring to several different types of midwives.  There is a CNM- certified nurse midwife, a certified midwife, and a lay midwife.  There are training differences for each of these types of midwives and the only ones that can work in a hospital setting are CNM’s.  There are strict state/medical/nurse midwife/hospital board guidelines that dictate the scope of hospital-based practice.  I am not sure why a person would choose the different routes, but I am sure that the cost and duration of training are huge factors.

 

Can you discuss how beneficial it has been to have midwives as part of your practice and how what they might bring to the birthing experience differs from what an OB might bring? And perhaps how having the two together – midwives + OBs – proves most beneficial to patient care?

 

It is actually a little hard to answer this question because I don’t think of the practice as an OBGYN practice that has midwives but rather a collaborative practice.  Therefore, the benefit of having CNM’s in the practice is that our patients truly get the best type of care. CNM’s appointments are longer, although not by much, some patients get one CNM for the entire antepartum care while most others see a fair share of our CNMs.  I think this is helpful as there is a familiarity with the CNM attending your triage calls, L&D triage visits, and delivery.  In the clinic setting, patients benefit visits like a “spiritual cesarean” and other wisdom from Birthing From Within as some of our CNMs are also Birthing From Within educators. In the hospital setting, peanut balls, robozo techniques, and other Spinning Babies expertise to help rotate babies.
At the discharge, CNMs spend a great deal of time going over common questions, follow up precautions, and of course breastfeeding is highly encouraged and there are hospital based lactation consultants.  In case of clinical concerns, the OBGYNs are a phone call away and each high-risk patient is discussed in a weekly case conference for management collaboration.  In the hospital setting, if an emergency or complication arises, which needs immediate attention, the OBGYN’s are again a phone call away.  Truly, the collaborative models are an incredible resource that puts the patient and her pregnancy and birth experience at the forefront of the practice.

 

How do you balance the defense of the obstetrics profession with your empathy for those individuals who, like myself, have less than ideal things to say about their own experience with their practitioner?

 

I welcome opportunities like this to educate and communicate.  The professions have become so segregated but ultimately the end goal is a happy healthy couplet.  We can’t loose sight of this in the name calling game.

 

One of my friend’s husbands is an OB and he says he is very bothered by the birthing-at-home trend. He said, “Birth either goes totally fine or there are major complications requiring a hospital setting. There’s rarely an in-between.” What are your thoughts on this?

 

I would agree.  That is why sticking to strict guidelines for eligibility of a home birth is so important.
These guidelines were created to ensure a level of safety in a risky situation.  Our bodies and our births are unpredictable.

 

Do you find that the location of an OB practice matters? It seems that in very busy metropolitan areas, the staff is so overbooked and stressed, so even if the doctors have good intentions, they simply don’t have the time for personalized care.

 

I don’t think I can fairly answer this.  I will say that the example you pose would argue completely against the UCSD model- a hospital based birthing center inside a metropolitan academic institution.  I don’t think the location of an OB practice is so much the issue but the administration and staffing support of the hospital.

 

I have a friend who recently birth her fifth baby and for the first time was told she needed to put her legs in stirrups. Can you touch on how different hospitals have different practices and how somethings might be allowed at one hospital but aren’t at others?

 

I encountered this myself the other day at a birth.  Typically the people helping a woman push for 1-3 hours is a loving family member and the labor and delivery nurse.  This nurse wears multiple hats during this second stage of labor.  Having her be responsible for leg holding takes her focus off fetal monitoring, vitals monitoring, and overall lay of the LDR.  Therefore, if no other family member is available to help with leg holding, especially in an anesthetized birth, where the leg is really heavy, then stirrups are used.  The growing trend of rise in BMI’s also feeds this answer.  It is something that is worth addressing but women with higher BMI’s have a higher risk for pregnancy complications and in the second stage require a greater level of nursing support.
As far as differences in hospital delivery practices it comes down to the administration as well as the attitude/culture of the OBGYN Division in that particular hospital.  We are all governed by ACOG, American College of Obstetrics and Gynecology. However, there are variances within and different degrees of confidence/training/expertise amongst the staff in each L&D setting.  For example, an assisted vaginal delivery can be either via a vacuum or by forceps.  If the department has OBGYN’s who were trained in either technique more than the other, then you will see a shift in assisted vaginal delivery techniques.  The culture of our training sites has so much to do with how OBGYN’s practice as well.  For example, in my residency we used cytotec, misoprostol as an induction agent.  However, in my current practice, everyone was using cervidil and so I had to adjust my level of comfort with in.

 

How much of a role does the hospital have on the dictation of care a physician renders?

 

A LOT.  A silly example would be how much of a role does the HOA of a condo complex have when you rent out the community area and pool.  Ultimately, the HOA is also liable in any adverse events.
Therefore, the hospital administration, nursing administration and along with the division of OBGYN staff, together dictate the guidelines.  Protocols are written by, reviewed, and agreed upon by all involved.

 

I’ve often gotten the sense that the majority of OBs are most comfortable when delivering a baby in bed. Is this due to the way OB’s are taught / trained? Why is there trepidation with allowing a woman to labor and birth a baby in water? Water is a wonderful pain reliever for those who chose to go the natural route but it is rarely allowed in the hospital setting (outside of showers, which don’t really offer the same great relief as a birthing tub). Can you discuss this? And how does your practice navigate around the hospital limitations?

 

You are correct.  I am not aware of any OBGYN residency that offers training in water births.  The typical delivery position we are trained in is supine/semi fowlers.  However, those residents who have the fortune of having CNMs in their training institutions may have experience and comfort with other delivering positions. It is unfortunate that the OBGYN is finger pointed as the bottleneck for water births when there are so many layers to consider.  These have to do with infection control, staffing, resources/equipment, and the rate of turnover (house keeping).  There needs to be buy in from all these departments including Administration (finances, maintenance, engineering), Infection Control, RN, and Housekeeping in order to keep a water based practice practical and safe.
As one of my CNM mentors asked me in discussing this answer, “do you like cleaning your own tub at home?”
Now imagine this with industrial strength chemicals, several times a week.

 

The number of c-sections performed has gone up dramatically (only now starting to go down a bit). Do you think this is because of fear of liability issues? Or insurance payouts? Or convenience for all parties? Or all of the above?
 
There are many factors to this beyond what you have listed here.  First, you need to consider the change in the body habitus of women.  We are seeing a lot more obesity and women with BMI > 35 having children.  In addition to underlying obesity, the associated medical conditions such as diabetes, PCOS, and liver disease certainly affects the health of the pregnancy.  Babies of diabetic mothers are bigger and certainly at higher risk for birth trauma and therefore warrant evaluation and discussion for a primary cesarean section. The second overlooked factor is general living condition of pregnant women.  Our society has become one of “deep couch sitting” and screen time.  This reclined posture found in cars, theaters, at home, etc. perpetuates an occiput posterior (OP) position for the fetus.  In the OP position, the largest portion of the fetal vertex needs to engage the pelvic bones hence making labor more painful and longer.  The insurance payout, convenience statement might be true for some “bad apples” but it is certainly not for the majority of OBGYNs.  Fear of liability is better understood as a fear of bad outcome for either the mom or the baby.  OBGYNs have the lives of 2 people on their hands and it is the high desire for a good outcome along with the litigation scares that may sway decisions.  The invention of fetal heart rate monitoring has contributed to the overall higher number of cesareans.  Now we have a tracing that indicates what the fetus is experiencing and OBGYN’s are going to act to rectify the intrauterine environment, which may mean a cesarean section.

I read recently that “because birth matters. How you give birth matters.”  This was a very well done article on thebestofbaby.com.  For the most part I agree.  It does matter if your arms are tied down to the operating table, if your legs are in stirrups, if you are on your back, or upright in a tub, or squatting on a ball.  The entire birth experience matters as it becomes your babies story and how you both exist as a couplet now.  In order to have your birth experience, I encourage women to speak up, ASK questions, TALK to your physician.  There is no way that you will get your birth experience if you haven’t communicated and understood the practices of your physician.  Brining in a doula is essentially giving your power to someone else, someone who is paid to be your advocate.  But you can be your own advocate from the beginning.

 

Image of pregnant woman by By Rosenoff | Birth art found on Pinterest

The Asterisk Attached…

by Ashley filed under Pregnancy

San Clemente Family Photographer-1490I’ve come to realize that in sharing my birthing fears I may have given you, the reader, the sense that I am not comfortable with the plan I have been – more-or-less – going with. And sure, while I may appreciate the care I have received in the past from the lovely midwives I was seen by, I would ultimately agree that in the hands of an OB is probably the best fit given previous circumstances (it’s taken me time to get here, but I am here — in a place of agreeance and acceptance). So the answer, to those who have asked, why I stick with this plan and why I presumably put up with something I’m not entirely comfortable with is because I think it’s best for our current situation. And by “our”, I am including Willy’s wishes and fears as well, because they count too.

As a nurse, I have a better understanding of doctors than most. I get “it”. And though I share much about my OB that I’m not stoked about, I also believe he is the best – for this pregnancy – in terms of delivering this baby safely. He’s not warm and fuzzy, nor does he take the time to review anything from my chart prior to him stepping foot in the room and running through the series of informal questions he without-a-doubt asks every pregnant woman that comes through his door. That said, I also know that it doesn’t matter. Whether he knows my birthing history or not is not going to have an impact, ultimately, when the proverbial push comes to shove and he’s catching my baby. It makes no difference if he knows my pervious babies were large because he’s going to deliver this one the safest way possible regardless.

The thing with birth is that nothing can be predicted; so I get that the birthing experiences I’ve had in the past, no matter how traumatic for Willy and I, have no bearing on this birth. He doesn’t ask about them or remember a damn thing I’ve said about them because he’s privy to the aforementioned truth, too (the truth being that it doesn’t matter, in terms of relating to the significance of this upcoming birth).

That all said, sure, he could have better bedside manner. He could take the 5 seconds it takes to look up what my due date is so he doesn’t have to ask me. He could validate my worries and concerns instead of harshly telling me to “not worry and be positive” as if I’m doing something wrong by expressing and attempting to work through my fears. And if he did all of the above, he’d add a couple extra minutes onto what’s been an average long 6 minute appointment and with those added two minutes, he could simultaneously nurture my trust in him exponentially.

It sucks to leave an appointment and not feel like you were treated as an individual; to feel like your worries are not valid and that your past experiences have little impact on your current situation. But I do feel confident that this baby is in good hands and if it weren’t for the latter, I would find someone I felt more comfortable with. In the end, I know it’s not about a doctor’s conversation skills but in their skill as an OB… and I believe in him in that respect. Thus, why I stay.

Does bedside manner matter to you if you know that the end goal for both parties is the same? Would you change practitioners and perhaps risk having a different outcome all for leaving your appointment actually liking the person you’re seeing?

OBs vs. Midwives

by Ashley filed under Pregnancy

AshleyWilly-160mattandtishWhen I begrudgingly agreed to have an OB deliver our third baby instead of a midwife, I called the local birth center and asked for a few names they felt comfortable recommending. We interviewed an OB they suggested and given the fact I had already been defeated on the decision to birth with a midwife, I agreed with Willy that the OB recommended to us was fine. He didn’t blow me away, nor did he send me running out his door with the nervous energy to continue the interviewing process with additional OBs. And, as I’ve mentioned in posts prior, I’ve been going through the motions and jumping through the hoops ever since.

Each time I leave his office, I leave with the same frustration; it’s like a copycat performance of the visit before, starting with the appointment itself and concluding with me calling Willy on the way home referring to our OB by adjectives that aren’t so nice.

It sucks to be in the care of someone you don’t really feel comfortable with. I’m sure most would say, “why not just find a new doc that you like” and the answer is because I’m tired. And perhaps a little cynical. Probably more of the latter than the former. The fact he was recommended by a birth center truthfully means more than his horrible bedside manner. The other challenge inherent to the place we live is that many of the OBs are part of a medical group; meaning you may see a different doc each time and whoever is on-call when you go into labor is who you get. I suppose there is some comfort in the fact that my guy is a sole practitioner and that come the day of my labor I won’t have to guess who will be there.

In any event, I interviewed a few doulas in hopes of finding the comfort that all along has been lacking and all three of the fabulous individuals I interviewed supported my choice of OBs. They said things like, “Oh I’ve been at a birth where he let the laboring women labor on her hands and knees” and though it was said with zero amount of sarcasm, I couldn’t help but think (with all the sarcasm I could muster), “wow, this is what it’s like when you move away from birthing with a midwife? You celebrate things like a laboring women birthing on her hands and knees?”… I’m still having trouble grappling with the idea of some doctor dictating how a women can or cannot labor and the fact that some insist on a women staying in bed to push just makes me scratch my head.

We have our first appointment with our doula coming up and thus far, I think it’s the best decision I’ve made and perhaps the closest I’ll get to building the birthing experience I not so badly want, but feel that I need.

I left my last OB appointment thinking about the differences in being seen by a midwife versus an OB. I can sum up my appointments with my OB more quickly than I’d like:

-Pee in a cup
-Have same elderly nurse copy my weight down on a post-it and check my blood pressure. Last appointment, she left a snag in my dress from the velcro part of the blood pressure cuff. She’s slightly cold and continues to tell me whether my blood pressure is okay, ignoring the fact it says I’m a registered nurse in my chart.
-Doc comes in and asks the following questions in the same order, every time, without fail and rolls through them in the same intensity as a military drill sergeant: Any bleeding? Any cramping? Any headaches? Any water leaking? Belly getting bigger? He throws the last one in there to try to fool me into the repetitious “no” that precedes the obvious “yes” answer and every time he smirks like he thinks he’s clever and nearly fooled me.
-He performs an ultrasound that literally takes less than a minute, asks me if I have any questions, reminds me to make an appointment in another month, and leaves the room.
-I brought the boys with me to one appointment. Not one person even said hello to them, there was nothing there to keep them entertained, and I got the general feeling that they were expected to be quiet and not touch anything.

I started timing my appointments because I get some (sarcastic) joy in calling Willy and confessing that the entire appointment, including wait time, took 6 minutes and 8 seconds. That’s 30 seconds longer than the appointment before, where he also performed a vaginal exam within the 5 minute and 30 second appointment that included all of the aforementioned in addition to the vaginal exam.

All my appointments with midwives averaged somewhere in the ball park of 30 minutes to an hour and included the following:

-Peeing in a cup and using a urine dipstick to check my own urine. This may seem minuscule and perhaps there are some that prefer not to have that kind of responsibility, but I like that there was a feeling of trust; it built a different kind of relationship where the control was more-or-less shared. I’d also weigh myself, because who needs someone else to follow you to the scale and write the number down when you’re capable of reporting such yourself?
-They’d check my blood pressure, measure my belly using a tape measurer, and use a handheld doppler to listen to the heartbeat. They’d palpate my belly to determine the baby’s position. I remember my midwife with Hooper commenting on how long he was… just by palpation (and, indeed, he was long).
-We’d go over my diet and what foods are good sources of protein. I think I may have received a handout in my “welcome packet” from my OB that had some vague mention of changes in diet during pregnancy, but nothing that has ever been enforced or asked about. In fact, I ate very differently during my previous pregnancies as a result to the constant checking in with the midwives; this pregnancy? Not so much. Of course that’s on me, but it is nice to know the person in charge cares about your overall well-being and is making the connection between healthy mom and healthy baby.
-The remainder of the appointment was more psychosocial related and allowed for time to discuss fears or issues or “what happens if” sorta questions and to fine tune the birth plan, my birth plan. The time spent talking was longer and more in-depth during my first pregnancy and more to the point with the second, highlighting the fact it was all individual and catered to my needs (we needed more time to discuss fears and issues with our first than we did with our second).
-I’d have new reading material to take home after each appointment, along with the reminder to keep doing my kegel exercises… which is a word I haven’t even heard throughout this entire pregnancy, which is unfortunate because it’s kinda a funny word and I like saying it.
-I’d see my midwives once a month until about the 8th month, when the time between visits would lessen to two weeks and by the ninth month, I would see them once a week.
-If I brought Hooper to my appointment, he was always included. He’d get to hold the doppler or play with the stethoscope or hung out in corner where they had toys and books for the siblings they anticipated to be tagging along during appointments.

I asked my OB during my last appointment if research proves that having gone past your due date in the past is any indication that it will happen again (I was 10 days late with both boys), to-which-he-replied, “did you go late with your prior two?”. Going past my due date is one of my biggest fears, given the fact that I fear having another big baby and that more time in the womb equals more time growing in that damn warm and comfy womb of mine, and I felt sad that this (insert negative adjective here) OB has no idea what my fears are or even what my past experiences are comprised of despite conversations we’ve had in the past. To make matters most, he went on to offer inducing me before my due date to “ease my fears of having another overdue, big baby”. And then he was dumbfounded when I told him I’d downright refuse pitocin unless he were insisting that it was something that I’d have to have. Again, forgetting that the induction via pitocin with Hooper led to unrelenting titanic contractions that ultimately landed me on the operating room table. Considering an epidural is not even an option for me this go-around, I felt like saying “you (insert many mean adjectives here)” for even suggesting such (contractions resulting from pitocin are much stronger than your regular, though still unrelenting, contractions). I told him I fear pitocin ten times more than I do being overdue or having a big baby. And I’m hoping I said it with enough stink eye that he remembers such and that we don’t have to have the conversation again, because where is the trust in that?

A few weeks back you may recall that I was experiencing horrible neck pain. I had pulled a muscle in my upper trap so bad that it pulled so taut over a screw in my spine and presumably caused damage to the tissue overlying the screw. Every time I lifted my arm or moved my arm, that injured tissue would rub over the screw and it felt like, because it was, an open cut being rubbed over a metal screw. I got the okay from the pain doc I’ve seen in the past to take something for the unrelenting pain and reluctantly, I took half of the dose I would in the past on three separate, most desperate days. I sent my OB an email informing him of the situation because I felt like he should be involved in my care and the decision to take a narcotic while pregnant. Not only did I never hear back from him, but he also didn’t ask anything about it during my appointment. A midwife would have been all over that. Again, it just erodes the trust I think all of us pregnant women are looking for. And the feeling that we’re being well cared for.

On the flip side, he did agree that the glucose testing was not needed given the fact I have the tools to check my blood sugar from home and it did feel somewhat good that he trusted me to do so. He also agreed, after my coaxing, that the followup with the perinatologist I was dreading was also unnecessary and so, I canceled that appointment which surely would have me fretting even more over the size of this baby than I already am. So I suppose there are some things he’s worked with me on, on an individual level. But all in all, I miss the care I received while in the hands of midwives… hoping that this first meeting with our doula eases some anxieties.

What has your experience with your OB been like? Can you relate? What are things you like / don’t like about the care you’ve received? And curious to know if anyone else has been seen by both an OB and a midwife and has similar comparisons to mine? And lastly, any suggestions for lowering the birth weight of the baby growing inside me? I kid… but no really, the Marlboro man may be calling.

*Image by Tish Carlson, and don’t let the small bump fool it… it was taken back in November…

The difference between midwives and OBs

by Ashley filed under Home Birth, Pregnancy

I have a lot of conflicted emotions about medical care and for anyone that looks in through a window at my life, I’m sure they would be confused as well.

For starters, I work in the medical field as a registered nurse. I work with doctors, surgeons, case managers, social workers, physical, occupational, and speech therapists, dietitians, radiologists and so on and so forth. I seem to baffle a lot of my co-workers when I divulge the fact my first two children were planned to be born at home, in the care of midwives, given the fact that I should know what “could” happen and all that jazz.

If I’m being honest, I’m happy to be planning a hospital birth this time around. Two failed attempts is enough for me and while I support it wholeheartedly for other women, I’ve come to the conclusion that it’s just not for me. I wish it was.

This is the first pregnancy I’ve been followed by an OB, from the beginning. The OB that delivered Hooper was fantastic, fully knew and supported the midwives I was working with, and did a fantastic job navigating Hooper’s tumultuous birth (though I’m still against induction despite the fact I know it’s necessary at times — I blame much of the decline in Hooper’s birth experience on the pitocin I was given).

During my pregnancy with Van, I had to chose a different back-up OB (the previous OB suffered a sudden death heart attack, which hit many in the OB community like a ton of bricks). I met with the new OB one, maybe two times. Because Van’s birth involved an ambulance transfer to the closest hospital, the OB that actually delivered him had never met us before (and to-be-clear by delivered, what I actually mean is pushed on my belly until his 9.8 pound body literally popped out — it was, um, audible). Point being, I’ve had OBs that have had to intervene along the way, but this is my first pregnancy where I will have been seen by the same OB from beginning to end, and more-or-less, only by him (I can’t help but think as I type that how ironic it would be if he couldn’t make my birth for some unforeseen reason and baby #3 ended up being delivered by yet another, new-to-me, OB. Hashtag: funny not funny).

So in a sense, I’m merely jumping through the hoops this go-around. I’ve had more ultrasounds in the first half of this pregnancy than I had combined in my pregnancies with Hooper and Van. I’m taking my first ever glucose screening test (I opted not to with the midwives because I was checking my blood sugars regularly at work and knew that if anything, my sugars were running on the low side of normal — therefore ruling out gestational diabetes).

The one thing I did turn down was the genetic testing and that’s based on nothing other than the fact that finding out the results of the test would have no bearing my decision to go through with the pregnancy.

I had my first ever ‘comprehensive ultrasound / anatomical screening’, which I was surprised to learn is not performed by regular OBs but by perinatologists instead. The very definition of a perinatiologiat, by the way, is “a physician that works in conjunction with a patient’s obstetrician when pregnancy complications develop and is able to provide care for both the mom and unborn baby”. My eyes were already rolling before I even made the appointment because I understand the absurdity in involving a physician who deals with complications being involved in the care of an individual experiencing an uncomplicated pregnancy. But, alas, the hoops — I’ve agreed to jump through them (almost entirely for Willy’s sake; as he was rather traumatized from the first two births).

When I arrived at the perinatologists office, the receptionist pointed out where the bottles of water were; they sat on a fancy mirrored tray above the magazines that included none of the trashy stuff I only pick up in doctor’s office and in line at the grocery store, but instead “Travel & Leisure” and other sophisticated crap my burnt out brain cells didn’t feel like picking up. The sofa was oversized and included a large velvety blanket that I presume was there  in the event anyone felt like cuddling. Point being, it felt very spa-like. Very pampered. And this experience continued as I was shown to my room, which was dimly lit with a desk at the window like you would find in a hotel room; a desk I’m sure no one has ever sat at with a small cup of pencils I’m sure no one has ever written with. At the sink were special soaps and lotions and a basket of hand towels. I sat back in the large chair, with my feet up, and watched the ultrasound on the big screen tv placed in front of me. I was a bit disappointed the chair didn’t have one of those massage mechanisms like they do at the manicurists. I’m being facetious.

It’s funny because sometimes I want to remind the very patients I care for in the hospital that they are in fact in the hospital, because of medical necessity no less, and not in a hotel. But I found myself on the flip side, wanting to remind the staff that they are indeed in a medical office and not some kind of massage pallor. It made me question further if any of this were necessary as I assume things that are necessary contain less fluff and more, I dunno, latex gloves.

In any event, all checked out fine. I closed my eyes while they checked out the baby’s goods and met with the doc at the end who summarized the findings; “My only concern”, he said, “is the baby’s size. You’re measuring a week ahead of where your dates put you”. He went on to suggest I have an additional test done to rule out gestational diabetes (because gestational diabetes accounts for larger babies). We then had a conversation about the birth weight of the boys (Hooper was 8.15 and Van was 9.8) and how neither of those involved any gestational diabetes. He also confirmed that birth weight has a genetic component (both Willy and I were 8+ at birth). And despite all the exchange of information, and this is the part that makes me hate the medical field, he wrote me script for the additional gestational diabetes testing and said he’d like to see me back, at 32 weeks, to “see how the baby is growing”.

Surely at 32 weeks the baby will be growing. It isn’t rocket science. It also doesn’t take rocket science to make the prediction that I will be carrying another large baby. The best indicator of the future is to look to the past, after all. I also know that ultrasounds later in pregnancy are less accurate due to the fact the baby is taking up more room. Sometimes they say weight can be plus or minus a pound, which is pretty substantial when you’re talking about a being that is only a handful of pounds anyway. And what’s it matter? It bothers me that women are not trusted to birth babies anymore; that so many are encouraged to go down the planned c-section path or the planned induction path (and while I have no judgements toward woman that chose this path, I do have judgments on practitioners that lead their patients to this path based on some kind of instilled fear). I have no doubt that this baby will be big. I also have no doubt in my ability to work with my doctor to get it out safely.

I could go on and on. I could even jump over to the other side of the coin and defend certain arguments from that side as well but all in all I think the take home message that I want to remind myself is this: Trust your gut. The care you receive is at times reflective of the larger population and fails to take the individual experience into account. Be your own advocate and ask questions that force your practitioner to see you as an individual.

And so, thus far I haven’t had many, if any, questions for my OB. I spend more time waiting for my food at the drive-thru window than I do in his office for an appointment. But when I did ask about the baby’s weight and his confidence level in delivering a big baby, he more or less shrugged off my concerns, boasted about the 9 pound baby he delivered that morning, and before-I-knew-it I was back in my car, on my way home.

I miss the care of midwives. I miss having my belly measured and touched. My OB appointments are exactly the same: pee in cup, stand on scale, check blood pressure, wait a minute for doc, doc comes in and asks “any bleeding, cramping, discharge, headaches?”, performs an ultrasound and listens to the heartbeat for maybe 7 seconds, asks if I have any questions, and I’m dismissed.

I remember listening to Kevin & Bean on the radio talk about that show ‘I didn’t know I was pregnant’, about women who actually go into labor and deliver a baby having never known they were even pregnant. They talked about how surprising it was that a lot of these women birthed healthy babies despite the fact they didn’t receive prenatal care. I’m not so surprised; prenatal care thus far has not impressed me. I feel like a cow being led through a corral.

Would love to hear from any mamas out there that also birthed big babies. I have a friend who birthed a thirteen pound baby at home and I always channel her in my pregnancies. Would also love to hear from any others about their prenatal care / OB experience.