Pregnancy, Childbirth, and the Newborn: The Complete Guide, 4th Ed.

CHAPTER 2 So Many Choices

After you discover that you’re pregnant, you begin to make choices that will affect your entire childbearing experience. You choose how you’ll gather information on pregnancy and birth. You select the kind of maternity care you’ll want. You decide how you’ll communicate your choices to your caregivers. Because these choices most affect you, your baby, and your family, it’s important that you play a key role in the decision-making process. Your active participation now will give you satisfaction and fulfillment for years to come, because you’ll feel that your wishes were honored with kindness and respect.

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In this chapter, you’ll learn about:

• Making informed decisions about your health care

• Choosing the place where you’ll give birth

• Finding a caregiver and labor support

• Choosing a childbirth preparation class

• Choosing a caregiver for your baby

• Finding postpartum help and child care

Informed Decision-making

In the United States and Canada, it’s your legal right to play a central role when making decisions that affect you and your baby. To help you make an informed decision (or informed choice) about a health care option or medical treatment (a procedure, test, intervention, or medication), you can consult with your caregiver and other knowledgeable medical professionals, as well as with supportive friends and family.

If you agree to an option or treatment after becoming informed about it, you’ve given your informed consent. By law, your caregivers can’t give you medical treatment in either of the following cases:

• You’re insufficiently informed about the treatment (and therefore can’t give your informed consent).

• After becoming sufficiently informed about the treatment, you refuse it (informed refusal).

A more collaborative approach to making an informed decision is shared decision-making, in which you and your caregiver discuss the medical risks and benefits of treatment and any possible alternatives. You also discuss any questions or concerns you may have, as well as your priorities and preferences. Shared decision-making enhances trust and understanding between you and your caregiver.1

YOUR CAREGIVER’S ROLE IN DECISION-MAKING

Your caregiver’s approach to maternity care depends on training, experience, and general perception of pregnancy and birth. If your caregiver believes that the childbearing process is normal unless proven otherwise, he or she won’t recommend medical interventions unless problems develop. If your caregiver believes the process is abnormal, he or she may recommend medical procedures and drugs to ensure a good outcome.

Sometimes, treatment is routine, which means it’s offered to all pregnant women or newborns. Other times, it’s designed for individuals and their current situations. Before recommending any treatment, your caregiver considers many factors, including your health; care standards set by professional organizations or government agencies; his or her personal experience and preferences for interventions, hospital routines, and policies; the usual care practices among his or her peers; cost; and staffing issues.

In addition, your caregiver considers whether treatment will achieve the desired results or create problems, then weighs the treatment’s benefits against its risks. This benefit-risk analysis sometimes shows that a relatively risk-free option is the best treatment to achieve desired results. Other times, the analysis reveals that the best treatment is the one with the greatest risk of side effects. Some caregivers always choose the treatment that best achieves results, despite any risks that come with it. Others choose a less risky option first, even if its chances of success are low, then consider trying a more risky option if the first option is unsuccessful.

Online Resources to Help You Make Informed Decisions

• Learn more about your maternity care choices at http://www.childbirthconnection.org.

• Learn more about mother-friendly hospitals at http://www.motherfriendly.org.

• Find a birth center at http://www.birthcenters.org/find-a-birth-center/.

• Find an obstetrician at http://www.acog.org/member-lookup/.

• Learn more about family physicians at http://familydoctor.org.

• Learn more about midwifery at http://cfmidwifery.org.

• Find a nurse-midwife at http://www.acnm.org/find.cfm.

• Find a licensed midwife or certified professional midwife at http://www.mana.org/memberlist.html and http://cfmidwifery.org/find/.

• Learn more about the midwifery and medical models of care at http://www.childbirthconnection.org.

• Find a childbirth educator at http://www.icea.orghttp://www.lamaze.orghttp://www.bradleybirth.com, or http://www.birthingfromwithin.com.

• Find a birth or postpartum doula at http://www.dona.org or http://www.doulamatch.net.

You may also visit the web sites of specific hospitals, birth centers, caregivers, doulas, and childbirth educators in your area.

What to Do If You and Your Caregiver Disagree about Treatment

Almost all treatment carries some risks or disadvantages, but you and your caregiver may disagree on just how risky or disadvantageous a treatment is. For example, your caregiver may believe a medical procedure is safe and low-risk, but you may have a medical history that has made you uncomfortable with any procedure. Or you may have religious or cultural beliefs that guide you to seek alternatives to procedures.

If disagreement about treatment arises, you and your caregiver can usually settle it with respectful discussion and good communication—the foundation of shared decision-making.

But what if a disagreement can’t be settled? Although rare, relationships between caregivers and pregnant women may fall apart because of a troubling mismatch in attitudes or opinions. When this happens, one person may feel bullied to change his or her wishes to match those of the other person. Or one person may believe that following the other person’s wishes will cause harm.

When settling a disagreement is unlikely, in the United States and Canada a pregnant woman has the legal right (in most circumstances) to change to a different caregiver, and a caregiver has the right to discontinue care if there are other care options available to the pregnant woman. Given the limited time frame of pregnancy and labor, it’s best to avoid this situation by carefully choosing your caregiver and birthplace (see page 11–21). See page 20 for further information on changing caregivers.

MAKING AN INFORMED DECISION

This chapter covers many of the important decisions you’ll make during pregnancy, birth, and after the birth. You should make some decisions early in pregnancy (such as finding your caregiver); you can delay making other decisions until mid- to late-pregnancy (such as choosing your baby’s caregiver). The following sections discuss topics that require you to make decisions, and they’re presented roughly in the order that you should address them.

Key Questions for Making an Informed Decision

When you’re offered a test or treatment, first ask how urgent the situation is and whether you have time to ask questions, discuss options, and consider the information you’ve learned. Then, ask these key questions.

Benefits: What’s the problem we’re trying to identify, prevent, or fix? How’s the test or procedure done? How likely is it to work?

Risks: What are the possible risks or side effects for my baby or me, and how are they handled? Are there other tradeoffs or disadvantages, such as additional procedures or precautions that will be necessary to maintain safety? What’s the cost (if paying out of pocket)?

Alternatives: What other options are available? Are there other procedures that may work? Can I delay the treatment or choose not to do it? What are the risks and benefits of the alternatives and how effective are they? (Keep in mind that low-risk options are sometimes less effective, so ask for guidance when analyzing benefits against risks.)

Next steps: If the procedure identifies or solves the problem, what can we expect to happen afterward? If the procedure doesn’t identify or solve the problem, what will we need to do next?

There’s no universal agreement among either medical professionals or the general public on the safest, most satisfying ways to manage pregnancy and give birth, especially for a healthy woman having a normal pregnancy. Many types of maternity care are available, but not everyone has access to them. Use this chapter to help you investigate your choices and decide what kind of care best suits your needs, beliefs, and priorities.

Whenever you’re asked to make a choice about your or your baby’s health care, ask the key questions above to learn more about your options. Always remember that your caregiver can provide information about treatment and recommend options, but only you can decide what’s best for you and your baby.

Health Care Coverage

Having a baby can be expensive, and different kinds of maternity care have different costs. In the United States, a licensed midwife may charge as little as $2,500 for prenatal care and attendance at an uncomplicated home birth. Using a midwife for prenatal care and a birth center for the birth may cost $4,000 to $4,500. Using an obstetrician for prenatal care and having an uncomplicated vaginal birth in a hospital can cost more than $7,500. A complicated cesarean birth can increase that cost to more than $20,000.2

If you have private health insurance, find out which caregivers and birthplaces it fully or partially covers. Also find out the coverage for a hospital stay after a vaginal birth and after a cesarean birth. Learn whether the coverage includes complications (and to what extent) and whether it includes a follow-up visit for you and your baby within the first few days after the birth.

If you don’t understand the extent of your coverage, contact an insurance company representative for clarification so you know what services you may have to pay for (partially or fully). Visit our web site, http://www.PCNGuide.com, to download a work sheet to track this information. That way, if you decide to have an uncovered or partially covered service, you’ll know how much you’ll pay out of pocket.

Some insurance plans cover—but don’t directly pay for—such services as midwifery care, childbirth preparation classes, birth or postpartum doulas (see pages 23 and 26), home birth, and breastfeeding assistance. Instead, you pay for these services and your insurance company reimburses you. If you have such an insurance plan and use these services, ask the service providers how to submit your request for reimbursement.

You may also use a flexible spending account (FSA) to pay for uncovered or partially covered services. Health care FSAs are employer-established benefit plans that let employees set aside a portion of their salaries to pay for specified medical expenses. An added benefit of FSAs is that employees avoid paying income and Social Security taxes on contributions to the account.

Roughly 25 percent of people in the United States can’t afford health insurance or don’t work for employers who offer health insurance as a benefit. If you’re in this situation, check with your local public health department about Medicaid coverage for maternity care to help cover your costs. If you qualify for assistance, be prepared to choose among only a limited number of caregivers and birthplaces. Because Medicaid doesn’t reimburse caregivers and hospitals as fully as private insurance companies do, many caregivers accept only a limited number of Medicaid clients; others refuse to accept any.

If you live in Canada, tax revenues pay for all citizens’ health care, including maternity care (except for out-of-hospital birth or midwifery care in some provinces—check your province’s regulations).

Consumer Reviews of Caregivers and Health Care Facilities

In 2008, the Coalition for Improving Maternity Services launched an online consumer survey that allows new mothers in the United States to share information about their experiences with their caregivers and health care facilities. The aim is to help improve transparency in maternity care practices. To see the continuously updated results of this feedback and view public health data about intervention rates at local hospitals, visit http://www.thebirthsurvey.com.

Choosing a Birthplace

Ideally, the best place to give birth is somewhere you feel safe and comfortable. It should be somewhere you can get the help and expertise you want—not only for the birth, but also during pregnancy and after the birth. That birthplace may be a hospital, a birth center, or your home.

If you can, choose your birthplace before selecting your caregiver. That way, you can select a caregiver who attends births at the place you’ve chosen.

BIRTHING IN A HOSPITAL

Most women in North America give birth in hospitals, and these institutions vary widely in the services they offer, their staff’s attitudes toward patients, and their philosophies of care. Knowing the philosophy, policies, and services of each hospital you’re considering helps you choose wisely. Depending on your health care coverage and where you live, you might or might not have a choice of hospitals. If you do, try to learn about several hospitals, take their tours, then choose the one that best suits your needs. If you don’t have a choice of hospitals, you can at least learn what to expect when you give birth at the only available hospital.

Some hospitals provide only primary maternity care for women having normal, low-risk pregnancies. Other hospitals also have tertiary care, which offers intensive care, complete obstetrical and anesthetic services, a blood bank, 24-hour laboratory services, and a neonatal intensive care unit (NICU). If you have a difficult pregnancy or expect complications in labor or birth, you may need a hospital that provides tertiary care.

In Their Own Words

Perhaps because my first birth was at a teaching and research hospital, I felt my care was “by the book.” My partner liked that the providers performed every test and asked every question for the health and safety of my baby and me.

I gave birth to my second baby at a different hospital, and from start to finish, my caregivers were experienced women, most of them mothers. I felt empowered by the calm, efficient way they took care of business. The time after the birth was more peaceful than it was for my first birth, with many fewer interruptions by staff.

—Anita

When choosing a hospital, consider asking about its staffing policies for laboring women having low-risk pregnancies and for those having high-risk pregnancies. Hospital administrators know the value of having one nurse continuously attend to just one patient, but most don’t guarantee pregnant women one-to-one nursing care throughout labor. Because of nursing-staff shortages, many hospitals must rely on nurses who work in several departments (“floating” nurses) and who might not have experience in maternity nursing. Some hospitals hire temporary “traveling” nurses, who may be unfamiliar with the hospital’s policies. Others use licensed practical nurses or nursing assistants, either of whom might have limited training and might not be legally allowed to perform some tasks.

Hospitals don’t allow pregnant women to choose who administers anesthesia. If you want or need epidural anesthesia when laboring at the hospital, the anesthesia staff member who’s on call administers it. This person may be a nurse anesthetist, an anesthesiologist, or a resident (physician-in-training). When considering a hospital, you can find out the credentials and experience of its anesthesia staff. You can also meet with a staff member to discuss anesthesia services, especially if you have fears or a physical condition that may make anesthesia problematic.

Many hospitals provide birthing rooms, where women labor, give birth, and stay with their families until they’re discharged. Other hospitals have separate postpartum rooms, where mothers and babies stay after the birth until they go home. Rooms usually have a TV, a chair-bed for the father or partner, and bathtubs to use during labor and afterward. Some hospitals’ maternity rooms are designed to look like hotel rooms, with emergency equipment hidden in cupboards or a closet.

Some hospitals try to honor pregnant women’s wishes by offering flexible, individualized, and culturally sensitive care. To determine how “mother-friendly” a hospital is, visit http://www.motherfriendly.orgto view questions you can ask. These questions are based on the Coalition for Improving Maternity Services’ “Ten Steps of Mother-Friendly Care.”

Many hospitals have received the World Health Organization’s Baby-Friendly award, designating that the institution adheres to practices that best support and promote breastfeeding. Visit http://www.babyfriendlyusa.org for the locations of “baby-friendly” hospitals.

To learn about a hospital’s routines and policies, ask the questions on page 13 when touring the hospital and when seeing your caregiver. If you dislike a particular routine, your caregiver may be able to write orders that override it. (See also Chapter 8 for additional questions that may arise as you create your birth plan.)

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Questions to Ask When Choosing a Hospital

Here are questions to ask your caregiver at a prenatal visit, a hospital representative, or the guide during the hospital tour. The answers will give you a good idea of what to expect when birthing at that hospital. Visit our web site, http://www.PCNGuide.com, to download a work sheet to record the answers. If the person can’t answer your questions, find someone who can.

• What’s the ratio of patients to nurses during early labor? Active labor? Birth? After the birth? Are these registered nurses or paraprofessionals (aides, practical nurses, or technical assistants)? Do you use floating or traveling nurses who aren’t familiar with the hospital’s policies?

• Do you encourage birth plans? (See Chapter 8.)

• What equipment do you use to monitor the baby’s heart rate? Can I move around while being monitored? (See pages 252–253.)

• Do most laboring women have intravenous (IV) fluids? Do you allow women to eat and drink during labor?

• Is anesthesia available at all times? (See Chapter 10.)

• What non-drug methods of pain relief do you encourage?

• How many bathtubs do you have? How often do women use them to relieve labor pain? Do women give birth in the tubs? (See page 211 for more information on water births.)

• Who can be with me during labor? Do you welcome doulas?

• If I have a cesarean, how many people do you allow to attend?

• How long is the usual hospital stay after a vaginal birth? Cesarean birth?

• What usually happens to a baby immediately after birth? Will my baby go to the nursery or stay with me? May I hold my baby for the initial assessments? Who will examine my baby after birth? When?

• Do you have breastfeeding specialists on staff? May I call them after I go home?

• Do you offer any postpartum and newborn follow-up after I go home?

The Hospital Tour

For many expectant parents, seeing where they’ll give birth helps boost confidence and reduce uneasiness. For this reason, most hospitals offer tours of their maternity departments. To learn details about a tour, visit the hospital’s web site or call the prenatal education department or labor-and-delivery unit. Tours typically involve a visit to the triage area (see page 249), a birthing room, a postpartum room (if separate from the birthing room), the nursery, and the family waiting area. Tours usually don’t include the operating room where cesarean deliveries are performed. The tour guide discusses some usual routines and policies, gives practical advice (for example, which entrance to use in the middle of the night), and answers questions you may have.

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BIRTHING OUTSIDE A HOSPITAL

In some areas of the United States and Canada, women with low-risk pregnancies have the option of giving birth with highly qualified midwives in a freestanding birth center (unaffiliated with a hospital) or at home. A woman who chooses this option prefers to give birth in a relaxed, low-tech, and cozy environment. She desires the continuous personal care of her caregiver during pregnancy, birth, and the postpartum period. During labor, she wants the freedom to move and act as she wishes, surrounding herself only with people of her choosing and permitting only essential interventions.

For women with low-risk pregnancies, good prenatal care, skilled caregivers, and hospital backup, planned out-of-hospital births are as safe for mothers and babies as planned hospital births—sometimes even safer.3 Because planned out-of-hospital births are usually uncomplicated and normal, they require fewer routine interventions and less medical equipment. As a result, the cost of a birth-center birth or home birth is less than the cost of a hospital birth. Medicaid and many health insurance plans often cover the cost of out-of-hospital births. If a woman is transferred from a birth center or home to a hospital, however, insurance plans might not cover some costs resulting from the transfer.

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You’re a good candidate for out-of-hospital birth if you’re physically and mentally healthy when you become pregnant and remain so throughout pregnancy. You also should have a well-trained, highly qualified midwife assess your and your baby’s condition throughout pregnancy, screening for problems that make out-of-hospital birth unsafe.

Even after carefully screening women who intend to have an out-of-hospital birth, 15 to 25 percent of first-time mothers and 5 to 10 percent of second-time mothers are transferred to the hospital during labor or after the birth for problems judged to require medical intervention.4 Almost all transfers during labor (96 percent) are for non-emergencies such as prolonged labor, meconium in the amniotic fluid, prolonged ruptured membranes, or desire for pain medication.5 In these situations, procedures or medications aren’t immediately necessary for the welfare of the baby or mother.

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For 3 to 4 percent of home births, urgent transfers to the hospital are necessary during labor.6 In these cases, the women were screened and had uncomplicated, normal pregnancies, but a condition arises during labor that requires immediate medical action, such as cord prolapse, hemorrhage, or concerns about the baby’s heart rate and oxygen supply. After a home birth, just over 1 percent of mothers and just under 1 percent of babies require a transfer to the hospital for reasons such as bleeding in the mother, retained placenta, and respiratory problems in the baby.7

Qualified midwives are trained for emergencies such as these. Their immediate response is similar to the first response of medical personnel in hospitals. To handle emergencies, midwives carry oxygen tanks, IV fluids, and suctioning devices, as well as medications to stop contractions temporarily, to stop bleeding, and to lower blood pressure. When further medical care is needed, they arrange for quick transfer to the hospital.

Although emergency transfers to the hospital are rare, they can be frightening and stressful. If you’re considering an out-of-hospital birth, take this possibility into account and consider how far away your home or birth center is from the hospital. (See Chapters 13 and 16 for further discussion on problems that can arise during labor and after the birth and how they’re treated in hospital and out-of-hospital settings.) Visit our web site, http://www.PCNGuide.com, to download a list of questions to ask your midwife and yourself about out-of-hospital birth.

Choosing Your Caregiver

When you begin your search for a maternity caregiver, first ask yourself the following questions:

1. What options do I have?

Learn what kinds of caregivers are available in your area, which ones your insurance covers, and which ones attend births at your chosen birthplace. Then, consult a trusted medical professional, local childbirth preparation group, or knowledgeable friend to further narrow your list.

2. How does group care work? Who’s in the group?

Most often when you choose a caregiver, you select a group of caregivers, not just one person. Your prenatal appointments may rotate among the group members, or you may see one or two caregivers throughout your pregnancy. The caregiver who attends your labor is the one on call at the time—and may be a stranger to you.

3. What type of caregiver do I want? Does the sex of the caregiver matter to me? What approach to maternity care do I prefer?

The following sections provide further information to help you answer these questions.

TYPES OF MATERNITY CAREGIVERS

Different types of providers care for women during pregnancy, birth, and after the birth. Some have extensive medical training, while others acquire much of their knowledge through hands-on training.

When choosing a caregiver, it’s important to consider the state of your health. A healthy pregnant woman can safely choose among any of the following types of caregivers. If your pregnancy is complicated or if your caregiver anticipates problems in labor, your safest option is most likely an obstetrician or perinatologist, either as the sole caregiver or as a consultant with a family physician or midwife.

For any caregiver, find out his or her educational background, credentials, training, and experience, especially if you’re considering a caregiver whose practice is unregulated. Also learn about the caregiver’s backup and referral arrangements, in case you need to transfer to a specialist during pregnancy or labor.

Physicians

Obstetricians/gynecologists (OB-GYNs) have graduated from medical school or a school of osteopathic medicine. They’ve had three or more years of additional training in obstetrics (a surgical subspecialty focused on pregnancy, birth, and the postpartum period) and gynecology (medical and surgical treatment of diseases of women). Much of their education focuses on detection and treatment of problems. To qualify for board certification (which demonstrates an OB-GYN’s exceptional expertise), they must pass an exam administered by the American College of Obstetricians and Gynecologists. In the United States, obstetricians provide most maternity care (85 percent), and pregnant women in Canada commonly use their services (although many choose to use those of family physicians).

Perinatologists are OB-GYNs who have received further training and certification in managing very high-risk pregnancies and births. They often consult with other physicians and midwives or accept referrals from them. These specialists practice only in major medical centers in urban areas.

Family physicians have graduated from medical school or a school of osteopathic medicine and have completed two or more years of additional training in family medicine, including maternity and pediatric care. Their education focuses on the health care needs of the entire family, which many expectant parents find appealing. They refer to specialists if their patients develop complications. To qualify for board certification, they must pass an exam administered by the American Academy of Family Physicians.

Midwives

Midwives are the typical maternity caregivers in most countries and are becoming increasingly popular in the United States and parts of Canada.

Certified nurse-midwives (CNMs) have graduated from nursing school, passed an exam to become registered nurses, and completed one or more years of additional training in midwifery. Their education and practice are based on the Midwifery Model of Care (see page 18), which focuses on the needs of healthy women during the childbearing year. When compared to obstetricians, CNMs tend to spend more time in prenatal visits with their clients, individualizing their care; however, they refer clients to obstetricians if serious medical problems arise. To become certified, CNMs must pass an exam administered by the American College of Nurse-Midwives. They deliver babies in homes, hospitals, and birth centers.

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Do Women Make Better Caregivers?

Some pregnant women believe they’ll feel more comfortable with a female caregiver than with a male caregiver, because she can better understand and empathize about what happens to a woman during pregnancy and birth.

It’s true that many female caregivers are sensitive, caring, understanding, and competent—but so are many male caregivers. Some caregivers, regardless of their sex, can be impersonal, rushed, and uninterested in you as an individual. Try not to choose a caregiver based on gender. Instead, focus on a caregiver’s personal qualities, philosophy of care, and professional qualifications.

If you prefer a female caregiver for cultural, religious, or personal reasons, remember that many caregivers work in groups, and anyone from that group may attend your birth. Most physicians’ groups include both men and women. Most midwives’ groups are all women.

Licensed midwives (LMs) have completed up to three years of formal training according to their state’s requirements. The focus of their education and style of care is based on the midwifery model, and is similar to that of CNMs, although a nursing background isn’t required. They refer to obstetricians when medical problems arise. To become licensed, LMs must complete the educational requirements, attend a minimum number of births, and pass an exam administered by their state licensing board. Twenty-one states recognize LMs and offer these exams. Most LMs provide care only for women planning births in homes or birth centers.

Certified professional midwives (CPMs) have received training from a variety of sources, including apprenticeship, school, and self-study, and have been the primary attendant at twenty or more births. They practice outside hospitals and their care is similar to that of LMs. CPMs must pass an exam administered by the North American Registry of Midwives. Many LMs are also CPMs.

Other Caregivers

Advanced practice nurse practitioners provide prenatal and postpartum care, although they don’t attend women during labor. They often work with a group of physicians or midwives.

Naturopathic doctors (NDs) have completed three or four years of postgraduate training in natural medicine; some take an additional year of midwifery training to be able to provide prenatal care and attend births.

Lay or empirical midwives also provide care for pregnant women. Their qualifications and standards of care vary—some are well-trained and highly skilled; others aren’t. Some are legally registered in their state or province, while others practice in states in which no laws regulate their practice. Some object to certification or licensure and have chosen to practice outside the law.

Models of Care

Midwifery Model of Care

This model of care is designed to maintain and enhance a woman’s physiological and psychological resources for giving birth. It’s based on these premises:

• Birth is a normal physiological process and an emotionally transformative experience.

• A woman’s state of mind influences the labor process, so individualized care is necessary.

• Because a woman’s participation contributes to a healthy pregnancy, labor, and birth, childbirth preparation is necessary.

• Low intervention and cesarean rates are desirable.

• Caregivers monitor the mother’s and baby’s well-being and provide education and support. If problems arise, they start with tools that cause the least intervention to regain a healthy physiological process.

Medical Model of Care

This model of care is designed to replace or alter the body’s own resources with medical and technological interventions. It’s based on these premises:

• The natural childbirth process is unpredictable, unreliable, and potentially unsafe. Routine care protocols for all women give the caregiver a sense of control over the birth process.

• Medical interventions improve labor and birth.

• Cesareans are no less safe for the mother or baby than natural labor and vaginal birth; in fact, they may be safer.

• Caregivers use routine interventions before problems arise. If problems arise, they intervene quickly with the tool most likely to have the quickest effect.

A CAREGIVER’S APPROACH TO MATERNITY CARE

Education, training, peers’ attitudes, and personal experiences influence a caregiver’s approach to pregnancy and birth. A caregiver’s philosophy of care typically follows either the midwifery model or the medical model (see above). Despite the names of these models, some physicians’ practices resemble the midwifery model, and some midwives’ practices lean more toward the medical model. Caregivers who follow the midwifery model treat pregnancy and birth as a normal family-centered event; they use medical interventions only when problems arise.

Caregivers who adhere to the medical model rely heavily on technology, interventions, or surgery, even when caring for a woman having a normal, healthy pregnancy. They frequently induce labor; prescribe medications and IV fluids; use continuous electronic fetal monitoring, vacuum extraction, or forceps; or perform an episiotomy or cesarean delivery. Some expectant couples may feel reassured with a caregiver who’s prepared to intervene should a problem arise. But research shows that the routine use of technology and intervention isn’t always safer for mothers and babies. In fact, this approach to maternity care sometimes causes side effects that lead to more medical problems. (See Chapter 13 for more information.)

Some caregivers (often those following the midwifery model) practice holistic care, focusing not only on the medical parts of pregnancy but also on a woman’s emotional, spiritual, and physical well-being. If a caregiver doesn’t provide holistic care, a woman can discuss non-medical problems with friends or relatives, other pregnant women, a childbirth educator, a doula, a birth counselor, or a psychotherapist.

When choosing a caregiver, find one who’s qualified to provide the care that meets your health needs and whose approach to care appeals to you. You may learn about a caregiver’s (or group’s) approach to pregnancy and birth on his or her web site. Some midwife or physician groups have open “meet and greet” sessions in which you can talk with the caregivers in person. Others are glad to schedule a private consultation.

INTERVIEWING A POTENTIAL CAREGIVER

The initial interview can help you decide whether a potential caregiver inspires your confidence and trust. During an interview, you can learn whether a caregiver is open and comfortable with you, responds thoughtfully to your questions, and is happy to provide additional explanation upon request. If a caregiver seems impatient and defensive during the interview, it’s likely you’ll see that behavior in his or her care.

If you have a choice of caregivers, feel free to interview more than one, but schedule the appointments early. Appointments for many caregivers have long waiting periods, and it’s easier to cancel appointments than to make them quickly. When scheduling an appointment, make it clear that it’s only to learn more about the caregiver and his or her practice.

Because an interview typically lasts only ten to thirty minutes—and because most caregivers charge for office visits—you may want to first visit a caregiver’s web site to learn about his or her qualifications and experience, fees, backup care when off duty, and birthplaces. (You may also learn this background information by calling the caregiver’s office.) That way, during the interview you can focus on three or four essential questions to help you decide whether the caregiver is a good fit for you.

Questions to Ask a Potential Caregiver

• Will I see you or another caregiver at each prenatal appointment? Does a nurse sometimes handle prenatal visits?

• Do the caregivers in your group share a similar philosophy of care? What are the chances you’ll attend my birth? Do you think it’s a good idea to induce labor so I’ll give birth when you’re on call? Will your colleagues respect the birth plan I’ve made with you? Will the hospital staff?

• Do you recommend childbirth preparation classes? Doulas? Birth plans?

• What do you think of trying for natural childbirth and how do you support this approach? Do you use non-drug ways to relieve labor pain and avoid routine interventions if possible? How many of your clients attempt natural childbirth? How many succeed?

• How often do you use interventions such as labor induction, IV fluids, artificial rupture of membranes, continuous electronic fetal monitoring, episiotomy, forceps, and vacuum extraction?

• How often do you find it necessary to perform an unplanned cesarean birth with a first-time mother having a low-risk pregnancy? How many of your clients—low- and high-risk—have a cesarean? What can I do to help reduce the likelihood of needing a cesarean?

• If I develop complications during pregnancy or labor, will you manage my care or will you refer me to another caregiver? Who is that person?

• When and how often will I see you for checkups after the birth?

If you’re taking medications or have a medical or mental health problem, disclose that information to the caregiver during the interview. It may affect the care he or she can provide you.

To prepare for the interview, read the questions on page 19 and become as knowledgeable about them as possible so you can better judge the caregiver’s answers. Visit our web site, http://www.PCNGuide.com, to download a work sheet to record the caregiver’s responses at the interview.

If you’re concerned about whether the caregiver will respect your legal right to informed consent and refusal (see page 8), visit http://www.solaceformothers.org/tools/Informed_with_notes.pdf for a list of questions that you may want to ask.

In Their Own Words

My family physician referred me to my first caregiver, an obstetrician. After two unpleasant appointments with her (she “did not have time” to answer my questions), I realized I didn’t want her delivering my child. I contacted a birth center. The difference in care was amazing. I had a full hour with my midwife at every appointment. I brought scores of questions to each checkup, and they were all fully answered.

—Heather

CHANGING CAREGIVERS IF YOU’RE DISSATISFIED WITH YOUR CARE

To have a satisfying birth experience, it’s essential that you feel comfortable with your caregiver. You need to feel you can trust your caregiver’s recommendations and believe that he or she listens to you and cares about your well-being.

But what if you don’t feel comfortable with your caregiver? Here are three ways to handle the situation:

1. Express your discomfort and explain what will make you feel more at ease, but do so calmly and without using accusatory language.

For example, you may say something such as: “Dr. Jones, this is hard for me to say, but I get the impression that my questions are an inconvenience to you. When I need to know more about something, I feel that you brush me off and I shouldn’t ask you anything.”

By using the pronoun I often, you communicate that you are the one experiencing a problem with the relationship. You’re not directly criticizing your caregiver’s behavior by saying something such as: “Dr. Jones, you’re always in a rush and you don’t let me ask any questions. You don’t even care about your patients.” Such language will likely make your caregiver defensive and less willing to improve your relationship.

Expressing yourself with direct but respectful language may evoke an effort to work together as equals and may improve communication, perhaps convincing one of you to agree to the other’s way of thinking on some matter or to agree to a compromise. Your birth plan should contain these joint decisions. (See Chapter 8.)

Especially if you anticipate this conversation to be challenging, practice what you want to say ahead of time with your partner or a friend.

2. If the above approach doesn’t work, consider changing caregivers. Although it’s always uncomfortable to change caregivers, doing so may be better than staying with someone who makes you feel uneasy.

Don’t drop your caregiver until you’ve found someone who better suits you and who has agreed to become your caregiver. If your original caregiver is in a group practice, try to select a new caregiver who’s not in that group. (By choosing another caregiver in the same group, you risk having your original caregiver attend you in labor.)

3. If you can’t change caregivers (or don’t want to) and you can’t discuss your feelings with your caregiver, consider talking with the office nurse, a childbirth educator, doula (see page 23), or others to help you cope with the relationship. Try to work with your caregiver as best you can by asserting your position reasonably and calmly. For example, you may say something such as: “I realize you don’t agree with some of my choices, but I’ve learned that they’re not unreasonable, and many caregivers allow them. Please work with me.” If your caregiver continues to push for options that go against your wishes, remember that you have the right to refuse unacceptable care practices. It’s unlikely you’ll need to take this step, but in case you do, having the support of family, friends, and other advocates will be essential.

Different Views on Childbirth Classes

After the birth, new parents were asked to comment on how well childbirth classes prepared them for birth. Although there were many different views, the responses shared the following sentiments:

Childbirth classes prepared us for what to expect and do at each stage of labor and delivery. They took a lot of the “shock value” out of the process.

The classes gave us a better understanding of the big picture of birth. Although the class was well taught and formatted, we discovered that some things can be learned only from experience.

The class gave me confidence and a sense of security. I didn’t feel scared or unsure. It gave me the chance to clarify my preferences before I went into labor.

Choosing Childbirth Preparation Classes

Many hospitals, colleges and universities, nonprofit community organizations, groups of caregivers, and independent childbirth educators offer childbirth preparation classes. The programs vary in size, philosophy, cost, topics covered, and number of classes in the series. The background and training of the instructors vary (they may be registered nurses, physical therapists, teachers, psychologists, social workers, college graduates, or others), as does the quality of the classes.

Colleges and universities, community groups, and independent educators usually sponsor consumer-oriented classes, which prepare parents to take responsibility in decision-making and self-care. Hospitals or caregivers usually sponsor provider-oriented classes, which inform parents about the type of care provided by a hospital or caregiver group, but avoid discussion of reasonable alternatives or controversial topics in maternity care.

Visit the web sites of organizations and institutions offering childbirth classes in your area. If possible, compare your options to determine which class best suits your needs.

CHILDBIRTH PREPARATION ON DVD OR ONLINE

Childbirth preparation classes on DVD or online cost less than traditional childbirth classes, and you can watch them whenever you have time and whenever you need to review topics.

But in key ways, these classes can’t compare to in-person classes. They can’t address local practices and incorporate up-to-date research data. They can’t provide opportunities for asking the instructor questions or getting feedback and advice on comfort measures if they’re not working for you. Lastly, they can’t provide an opportunity for developing new friendships with other expectant parents.

Questions to Ask When Choosing Childbirth Preparation Classes

• Who sponsors the classes?

• What’s the instructor’s background and training?

• What’s the instructor’s experience with birth and childbirth education? Does the instructor participate in continuing education in the field? Is she certified by a reputable organization?

• Does the instructor cover normal childbirth as well as complications? Does she cover all choices and include their pros and cons? Does she teach self-help comfort measures and natural childbirth techniques? Does she describe disadvantages and risks as well as advantages of various procedures and medications?

• Does the series cover postpartum adjustment, newborn care, development, and feeding?

• How are the classes scheduled? As a series of four to eight weekly meetings? A one- or two-day course? (Classes that last only one or two days may be convenient, but they can be exhausting and overwhelming. Classes that meet regularly over a longer period let you better absorb the information, practice the techniques, and think of questions to ask at the next class.)

• What is the cost of the series? (A few health insurance plans and government assistance programs cover the cost of childbirth classes.)

• What is the ratio of students to instructor?

• Is the instructor available to students by phone, e-mail, or in person for questions outside of class and after the series?

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All about Birth Doulas

In 2007, the Cochrane Library (a prestigious collection of databases that contain high-quality, independent evidence to inform people when making decisions about health care) issued a report about the “dehumanization” of women’s birth experiences, caused by a lack of continuous support for laboring women. Concerned by this development, maternity experts and professionals have called for a “rehumanization” of childbirth by reestablishing continuous support of laboring women. The review found that support was most effective when provided by women who weren’t hospital staff.8

Many studies show that continuous support benefits laboring women, especially when the support begins in early labor and is given by someone whose only role is to provide it. Benefits include the following:

• Shorter labors, with less need for medication to speed up labor

• More spontaneous vaginal births (that is, births that don’t require forceps, vacuum extraction, or cesarean delivery.)

• Fewer requests for pain medications

• Less dissatisfaction with birth experiences

The desire to provide laboring women with continuous support has led to the emergence of the birth doula, a person (almost always a woman) who’s trained and experienced in supporting women and their partners during labor and birth. Unlike a caregiver or a nurse, a birth doula doesn’t concentrate on the clinical parts of labor or give medical advice, and she doesn’t work in shifts (and leave a laboring woman when the shift is done). Instead, she stays with a laboring woman continuously throughout labor and birth, giving encouragement, reassurance, advice, and help. Her presence can help ease the stress, unpredictability, and pain of labor.

Consider hiring a birth doula if you want someone you trust to be with you throughout your labor and birth. She can give you and your partner confidence and a sense of well-being. If necessary, she can guide your partner through the comfort measures to help make you more comfortable. See page 190 for more information about doulas.

FINDING A BIRTH DOULA

To find birth doulas in your area, ask your friends, childbirth educator, or caregiver for recommendations. You can also search online. Try to consult with several doulas by phone or e-mail to help you decide which ones you want to interview in person.

During the interview, ask the questions on page 24. Pay attention not only to what the doula says, but also how she says it. Her behavior and body language will help you decide whether she’s a good fit for you.

Most doulas charge a fee for their services, although some doulas-in-training charge a small fee (if any) and some experienced doulas may waive or reduce their fees for clients with tight finances. A few hospitals provide doula services at low cost or no cost to the patient, and some charitable agencies or public health departments cover doulas’ fees for women who can’t afford the services. Given doulas’ contributions to improved outcomes in maternity care, their services make financial sense; however, health insurance plans rarely cover doula services.

Questions to Ask a Potential Birth Doula

DONA International is the world’s oldest, largest, and most respected doula association. The following questions are based on those found on its web site (http://www.dona.org/mothers/how_to_hire_a_doula.php).

• What training, education, and experience do you have?

• What’s your philosophy of childbirth and supporting women and their partners through labor?

• When do you try to join a woman in labor—in early labor, later in labor, or whenever she feels she needs you? Do you go to her home or the birthplace?

• Will you meet with me before the birth to discuss my birth plans and the role that you’ll play in supporting me through labor? Will you visit me after my baby is born?

• May I contact you with questions or concerns before or after the birth?

• Do you work with one or more backup doulas for times when you’re unavailable? May I meet them?

• What’s your fee? What services does it include? What are your refund policies? (If her fee is more than you can pay, ask if she provides a sliding scale or can refer you to someone who does.)

• Will you provide references?

Your Baby’s Health Care

After your baby is born, adjusting to new parenthood will be easier if you make some decisions about his health care well before the birth. (See Chapter 8 for more information on developing a postpartum plan.)

While you’re pregnant, you can research early health care choices you’ll make for your baby after the birth, including circumcision (see page 372) and vaccinations (See page 386). Learning about these options before the birth prepares you to make an informed decision when the time comes.

You can also learn about the types of health care available for your newborn. Considering these options before the birth gives you time to arrange for the best available health care for your baby.

CHOOSING A CAREGIVER FOR YOUR BABY

By choosing your baby’s caregiver before the birth, you’ll have someone to call whenever you’re concerned about your newborn’s health, from the moment she’s born. You can also find out the schedule of well-baby checkups ahead of time.

Several types of caregivers provide care for children. Pediatricians specialize in children’s health care. They’ve graduated from medical school and completed a pediatric residency. Their offices and waiting rooms are geared for children.

Family physicians provide care for the entire family. They’ve spent several months in pediatrics during medical school and as part of their residency training. They diagnose and treat most illnesses, but refer seriously ill children to pediatricians. If a family physician provides your care before, during, and after pregnancy, it may be a comfortable decision to have him or her care for your baby.

Pediatric and family nurse practitioners are registered nurses who have additional training in pediatrics or family health. They provide well-child care and treat common illnesses. They usually work with a group of physicians, and refer serious problems to a physician. Nurse practitioners are knowledgeable about children’s emotional, social, and physical development.

Naturopathic doctors (NDs) and other alternative practitioners provide well-child care and emphasize non-medical complementary treatment of illness. Their education varies but may consist of four years’ training after college. Most care for the entire family, although some don’t provide care for babies or children. They don’t have hospital privileges, and refer seriously ill children to physicians.

HEALTH CARE COVERAGE FOR YOUR BABY

The cost of your baby’s health care depends on your health insurance coverage and on where your baby visits a caregiver. In most cases, your baby will see a caregiver for well-child visits, during which the caregiver checks your baby’s growth, development, and overall health, and gives immunizations. If you have a choice of health insurance plans, compare coverage of well-child visits. Some plans don’t pay for well-child visits but cover nearly all expenses to care for an ill child.

Some caregivers practice out of private offices; others practice in clinics. Private-practice care is more expensive than clinic care, but it may be more personalized and convenient. Many health insurance plans cover most (or part) of the costs of private care and provide a list of approved caregivers.

Children’s health clinics usually cost less than private practices, but they may have longer waiting times. If the clinic is associated with a medical school, its staff may change frequently. Its caregivers are physicians or nurse practitioners who are rotating through their advanced training under the supervision of fully trained professionals. Other community-based children’s clinics offer low-cost care and a consistent staff (which means you see the same caregiver at each visit). Such clinics usually also provide social services and other services to low-income families.

Community health clinics or well-child clinics associated with a public health department offer free or low-cost checkups and vaccinations, but they usually don’t provide care for sick children.

Questions to Ask a Potential Caregiver for Your Baby

• Do you support breastfeeding? Formula feeding? Do you have expertise in breastfeeding? Do you work with lactation consultants or other breastfeeding resources? Do you refer to them?

• What are your thoughts on circumcision?

• What are your thoughts on vaccinations? Do you support delayed schedules? How about the refusal of vaccinations?

• How comfortable are you with the use of home remedies or alternative therapies for minor ailments and common illnesses? Are you concerned about the overuse of antibiotics?

• How available are you (or your office) for phone consultation? Who takes calls when you’re unavailable?

• Do you have hospital privileges? Where? If my child must be hospitalized, how involved will you be in his or her care?

• Will you be available to examine my baby soon after the birth (at the hospital or in my home)?

Visit our web site, http://www.PCNGuide.com, to download a work sheet to record the answers to these questions.

FINDING A CAREGIVER FOR YOUR BABY

After choosing a type of caregiver for your baby and the setting for the visits (private office, clinic, or other), you can focus on choosing a caregiver that suits your needs. A helpful way to start your search is to ask your caregiver, childbirth educator, local hospital, and family and friends to recommend pediatric caregivers. Visit these caregivers’ web sites to learn information about their practices (such as the convenience of their locations and office hours). Or call the caregivers’ offices to learn the information from the receptionist.

If possible before the birth, schedule an interview with one or more caregivers. Check your health insurance plan to determine whether it covers such appointments. If it doesn’t, find out whether the caregiver will charge a fee for the appointment, and if so, the amount.

During the interview, time may be limited, so make sure you ask the questions you most want answered. (See page 25.) Pay attention to how a caregiver answers your questions. Does the caregiver seem competent, caring, and considerate? Does his or her style and philosophy match yours? It’s important that the person who will care for your baby’s health has your confidence and trust.

Finding Help after Your Baby’s Birth

For the first several weeks after the birth, you and your partner may be surprised by how timeconsuming baby care is, leaving you few free moments for meal preparation, basic housework, sleep, and socializing. (See Chapter 15.) During this period, it’s important to arrange for someone (or more than one person) to help you as you adjust to life with a newborn.

WHO CAN HELP YOU?

For many new parents, family members (typically, a mother, mother-in-law, or sister) and friends provide help by cooking meals, running errands, doing laundry, housecleaning, and watching the baby so the parents can sleep or relax by themselves.

If family and friends don’t live near you or have little time to help, or relationships are strained, others can provide much-needed help. Baby nurses or nannies can take care of your baby, allowing you to do other activities. Mother’s helpers cook and clean, but they don’t help with baby care or give advice.

An especially knowledgeable source of help is a postpartum doula, a person (almost always a woman) who’s trained and experienced to help a woman and her family adjust to postpartum life by teaching them about newborns’ needs and abilities, and about infant feeding, sleep, and cues. A postpartum doula focuses on enhancing a new mother’s confidence and competence and fostering her bond with her baby.

Postpartum doulas and other helpers typically charge by the hour, and the potential costs may seem daunting to expectant parents. But many parents find that the help and care are well worth the price, especially years later when recalling those first few days and weeks with their newborns.

Heath insurance plans rarely cover the services of a postpartum doula or other helper. To pay for these services, put money aside during pregnancy. Or if friends and relatives ask how they can help you after the birth, suggest they contribute money for this purpose, or request the money as a shower gift.

Questions to Ask a Potential Postpartum Doula

DONA International is the world’s oldest, largest, and most respected doula association. The following questions are based on those found on its web site (http://www.dona.org/mothers/how_to_hire_a_doula.php).

• What training and education do you have? Tell me about your experience.

• Have you had a criminal background check?

• Have you had a recent TB test (for tuberculosis) and DTaP vaccination (for pertussis and other illnesses)? Is your CPR certification current?

• What’s your philosophy of parenting and of supporting women and their families after the birth?

• May we meet before the birth to discuss our needs and the role you’ll play in supporting us after the birth?

• What additional services do you offer?

• May we call you with questions or concerns before the birth?

• When do your services begin after the birth?

• What’s your experience with breastfeeding support?

• What’s your fee? What’s your refund policy?

FINDING A POSTPARTUM DOULA

If you decide you want a postpartum doula, try to hire one before the birth. You may have trouble finding a doula who suits your needs if you wait until after the birth to start your search.

To find postpartum doulas in your area, ask your friends, childbirth educator, or caregiver for recommendations. You can also search online. Try to consult with several doulas by phone or e-mail to help you decide which ones you want to interview in person.

During the interview, ask the questions above. Pay attention not only to what the doula says, but also how she says it. Her behavior and body language will help you decide whether she’s a good fit for you.

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RETURNING TO WORK

In the United States, the length of maternity and family leave policies is generally short, and parents must return to work earlier than do parents in Canada and other industrialized countries whose leave policies are generous.

Typically before the birth, families decide who will return to work after the baby is born. For some new families, only one parent is able or available to work (such as a single parent). For many other families, both parents return to work for the family’s financial well-being, for career development, or because they love their jobs.

Some families can explore the option of having only one parent return to work, letting the other parent stay at home full-time to care for the baby. If this option interests you, discover whether it’s possible for your family by answering the following questions. Visit our web site, http://www.PCNGuide.com, for a list of additional questions to consider.

• Can you or your partner delay returning to work until your baby is older?

• Can you or your partner work part-time or job-share? Can either of you work from home?

• What are the costs of returning to work? These may include clothing, transportation, child care, convenience foods, and more visits to your baby’s caregiver. (Your baby may become sick more often from exposure to ill children in child care.)

• Will your income exceed the total costs of working outside the home and make working worthwhile?

• Can you simplify your lifestyle and lower your cost of living to offset the loss of income?

• How will the person who works feel about the other’s staying at home?

After you’ve made the best choice for you and your family, make sure you and your partner support each other to accommodate the change. Whether you stay home with your baby or work outside the home, life is more challenging with a baby—it’s helpful to have an ally!

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FINDING CHILD CARE FOR YOUR BABY

If you and your partner decide to return to work (or you’re a single parent who must), your first priority is finding affordable, safe, dependable child care. The best time to arrange for child care is well before the birth, but that might not be possible for some families. If you can’t make arrangements before the birth, try to wait three to four months after the birth before returning to work. This will give you time to recover and focus on your baby. When you start your search, allow at least a month to find child care that best suits your needs.

Start your search by asking coworkers or other working parents about their child-care arrangements. Contact local agencies that can help you find licensed child-care facilities, homes, or other providers such as nannies. If you’re considering using a nanny or babysitter, see whether you can share his or her services (and the costs) with another family.

If you don’t want a stranger caring for your baby, consider asking family members or friends to care for him. Or think about staggering your and your partner’s work schedules or working part-time so you and your partner can provide at least some child care. In some work settings, it may be possible for you to bring your baby to work and care for him during the workday. (Some companies even offer on-site child care for their employees.)

If you decide to have someone care for your child outside your home, first visit http://www.saferchild.org/caregiver.htm and http://www.childcareaware.org for advice on evaluating child-care providers. Then visit potential child-care facilities and homes with your baby. How do the providers behave with babies in their care? With gentleness and kindness or with impatience and detachment? How do they deal with crying babies? What do they do when a baby becomes ill? How do they support breastfeeding mothers? How will they feel about your visiting when you can? Find out the facility’s or home’s hours of operation and holiday and vacation schedules, and ask to see their licenses to ensure they’re current. Pay attention to how the providers respond to you and your baby, and trust your instincts about the home or facility.

If you decide to hire a nanny or other in-home provider, interview candidates in your home. Ask the same questions you’d ask providers at a child-care facility or home (see above). Also ask candidates how they plan to cover their child-care duties should they become ill or go on vacation. Pay attention to how candidates interact with your baby and you, and trust your instincts on what you observe. Request references and contact them.

After you’ve chosen suitable child care, remember that you’re establishing a partnership with the child-care workers. Always treat them with respect. Offer compliments and acknowledge their valuable service by giving appropriate holiday gifts.

If at any point you decide a child-care arrangement is no longer right for your baby, be willing to find another provider so you can be assured your baby is receiving the best care.

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Ten Steps to Improve Your Chances of Having a Safe and Satisfying Birth

Here’s a summary of things to do and choices to make to increase the likelihood of having a safe, satisfying birth and avoiding a cesarean birth and other unwanted interventions.

1. Take care of yourself during pregnancy so you begin labor in the best possible health. Exercise in moderation and eat well. (See Chapters 5 and 6.) If you’re overweight when you become pregnant, aim to gain a small or moderate amount of weight. Seek prenatal care to help you detect and manage any health problems that may arise.

2. Choose a birthplace that has a low rate of cesarean birth and minimal routine interventions. (Ask the questions on page 13.) If your pregnancy is low-risk and you prefer minimal interventions, consider birthing at a birth center or at home. Several studies show that women having low-risk pregnancies undergo fewer interventions in an out-of-hospital setting and their birth outcomes are just as good as those of women birthing in hospitals.9

3. Find a caregiver who has low intervention rates and encourages the use of self-help techniques in labor. (See Chapters 10 and 11.) If your pregnancy is low-risk, consider using a midwife (if available). Midwives typically use fewer medical interventions than physicians do. If intensive medical care becomes necessary during pregnancy, a midwife will refer you to an obstetrician.

4. Educate yourself and prepare a birth plan. (See Chapter 8.) Take childbirth preparation classes that emphasize informed decision-making and self-help methods to relieve pain and aid progress. Visit http://www.childbirthconnection.org to read and download a copy of “The Rights of Childbearing Women,” which outlines a set of basic maternity rights for all childbearing women. Keep these rights in mind as you create and review your birth plan with your caregiver.10

5. Hire a birth doula. The continuous labor support a doula provides often leads to a shorter labor, reduced need for pain medication, increased chance of normal vaginal birth, and increased satisfaction with the birth experience.11

6. Avoid labor induction for non-medical reasons. If your caregiver suggests induction for a debatable medical reason (such as a suspected big baby), ask about other alternatives. (See page 276.)

7. Use medical interventions only when clearly necessary, not because they’re routine. For example, avoid routine IV fluids, continuous electronic monitoring, and augmentation with Pitocin or artificial rupture of membranes. (See Chapter 13.) In some situations, interventions may be the best option for you or your baby. Ask questions to ensure that you make informed decisions. That way, when you remember the birth in the years to come, you’ll know you made the right choices. (See page 10.)

8. Learn to differentiate between early labor and active labor so you can delay hospital admission until active labor. (See page 170.) Use labor-coping skills at home to manage pain and aid progress. (See Chapter 11.) Eat, drink, and rest as needed to keep up your energy.

9. Use a variety of positions and activities during active labor, such as walking, dancing, rocking in a rocking chair or on a birth ball, or taking a shower or bath. (See page 208.)

10. Push in positions that aid descent, unless the birth is happening fast; then use positions that slow descent. (See page 220.) Use spontaneous pushing if you have an urge to push. Delay pushing if you don’t have an urge to push (and you and baby are doing fine).

Key Points to Remember

• As an expectant parent, it’s your responsibility and legal right to become informed about the available options in maternity care and to communicate your preferences to your caregivers.

• To help you make informed decisions, ask key questions and consult with your caregiver and other knowledgeable medical professionals. After considering the information you’ve learned and weighing it against your values and concerns, you can make the best decisions.

• During your pregnancy, you can make many choices that will help make positive experiences of your labor, birth, and postpartum period. You can decide where you want to give birth, who will provide your care, what childbirth preparation classes to take, whether you want a birth doula and postpartum doula, who will provide medical care for your baby, and what child-care arrangement will best suit your needs if you return to work after the birth.