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Maternity care today offers women three types of clinical care providers. The following is a brief description of each type of care:
Obstetrician - An Obstetrician is a specialized practitioner in the management of illness and disease in pregnancy. If a woman has complication such as diabetes, repeated pregnancy loss or other illnesses that would put her, or her baby, at risk, an obstetrician may be the appropriate caregiver for her. However, the Obstetricians’ usefulness and even effectiveness in managing normal pregnancy has been questioned in recent years. Studies have shown that women cared for by Obstetricians are more likely to experience cesarean birth, forceps delivery or other types of interventions. It is believed that a large majority of women will experience uncomplicated pregnancies and births. Therefore, these women do not benefit from the specialized care of an Obstetrician.
General Practitioner and Family Practitioner - Although the number is falling, some family doctors still attend births and care for women in pregnancy. If you family doctor attends births, you may want to interview them to find out their policies and beliefs around the management of birth. If you family doctor does not attend births, you may be able to get a referral to another family physician that does. You can also inquire yourself. Family doctors tend to spend more time with their patients and also spend more time with women and their families during labour. Each family doctor will have guidelines regarding when they would refer you to an Obstetrician and the limitations of the practice.
Midwife - When statistically analyzing the different types of caregivers, the one that seems to produce the best result in the way of infant and maternal mortality and morbidity is the Midwife. Midwifery has been legislated in Ontario since 1992. Midwives provide primary care to women in low-risk pregnancies. Prenatal appointments are often 30 minutes to one hour and time spent accompanying the family in labour is extensive. Like family doctors, midwives also have guidelines regarding referral and consultation with an Obstetrician. Midwives can attend births in the home or hospital setting and emphasis is placed on the family’s involvement in their care and the promotion of healthy pregnancy and birth choices. The only shortcoming of midwifery care is the low number of midwives we have practicing in Ontario. It is suggested that if you are interested in Midwifery care, you should call to book an appointment very early in your pregnancy. If you are late in your pregnancy, you are welcome to inquire, but it may be difficult to find a midwifery practice with openings at this time.
The following is a list of questions that will enable you to understand a potential caregivers’ philosophies regarding childbirth. Some of these questions do not have a right or wrong answer. These questions deal with policy, as well as personal belief. Every expectant woman and her family is different. Therefore, it seems reasonable that some women are more comfortable with certain caregivers. This list should not be the only questions you ask your caregiver. The following questions are a starting point. Feel free to add to them and ask questions that are important to you. When you are asking questions, do not feel bad about asking for clarification. If you feel the answer you are getting is not precise enough, ask the caregiver to be more specific. An example of this would be when asking a caregiver about their episiotomy rate. If the caregiver responds “I only do them when necessary”, you should probably ask how often they feel it is necessary.
Before you start your questions, thank the caregiver for taking the time to sit with you and answer your questions. Let them know that you appreciate their busy schedule. If the caregiver at any time dismisses your questions as unimportant, this should be a sign. If the caregiver suggests that the question is not relevant until later in pregnancy, explain to him/her that in order for you to choose a caregiver, you need to know the answers to these questions. If the caregiver refuses to answer your questions, thank him/her for their time and leave.
1. Do you attend your patient’s births or are you on rotation? If you are on a rotation, how many other doctors/midwives do you rotate with? Is it possible for me to see these other doctors/midwives as well?
PURPOSE: It is very important to be working with someone that will attend your birth. If the caregiver you have chosen will not be there, anything you have negotiated with him/her may or may not be what you get in labour. An example is if you caregiver does not do episiotomies, but the doctor that attends your birth has an episiotomy rate of 70%. Saying no to unwanted interventions is harder than it sounds.
If your caregiver is part of a small rotation (2-3 doctors/midwives), it may be possible for you to meet them all.
2. Do you have limits on the number of support persons I can have with me?
PURPOSE: If a caregiver limits the amount and type of support you can have, this may have a big impact on your birth experience. Generally, caregiver that impose these limits are not likely to support family-centred maternity care.
3. What is your personal cesarean rate (not the hospitals)?
PURPOSE: Even if the hospital you have chosen has a low cesarean rate, it is still important to find our your caregiver personal rate. Often caregivers are not sure, but they can usually give you an approximate percent. In Ontario, the cesarean rate is too high at 17% - 27%.
4. What is your episiotomy rate?
PURPOSE: Episiotomy is a surgical incision at the opening of the vagina. There is no good scientific research that supports the routine use of episiotomy. Some doctors believe that episiotomies heal faster, have less pain and are easier to control than a spontaneous tear. All of these have been proven false by a great deal of research.
5. What do you do to prevent a tear of the perineum?
PURPOSE: It’s great if a caregiver rarely performs episiotomies, but if he or she does nothing to protect the perineum, you are likely to have more injury to the perineum than needed. Things such as applying warm compresses, massage with oil, encouraging birth in positions other than semi-sitting or lying flat will help prevent tears.
6. How often do you deliver babies with the mother in positions other than lying or semi-sitting? For instance will you allow me to give birth on a birth stool?
PURPOSE: Caregivers who want women in positions that are convenient for them generally make other decisions based on their convenience.
7. How often do your patients give birth without the use of pain medication and epidurals? Do you support women giving birth in this manner?
PURPOSE: If a caregiver supports birth without medication, he/she usually understands that all interventions and medications have risks and steps should be taken to avoid the necessity of these interventions.
8. Under what circumstances would you consider labour to be too slow and what type of intervention would you suggest to speed it up?
PURPOSE: Diagnosing failure to progress in early labour (before 4 cm) is more likely to lead to a cesarean section. Women should be encouraged to stay at home until labour is well established. This will help reduce the number of women receiving unnecessary cesareans. Early labour can take 12 hours to two days and can be very on-again, off-again. If a caregiver assigns an arbitrary time limit to labour, it is likely that you will have interventions to speed your progress.
9. How long do you feel pregnancy should be allowed to continue if monitoring of the mother and baby shows no problems?
PURPOSE: Caregivers who have arbitrary time limits for the length of pregnancy tend to apply time limits to labour and have many other restrictions. Caregivers who answer this question with 42 weeks or greater are likely to be more individual in their approach to care.
10. What suggestions would you have for me if my baby was breech at 35 weeks gestation?
PURPOSE: What you are trying to establish by asking this question is does the caregiver believe that vaginal breech birth is safer than automatic cesarean. The research suggests that women with breech babies should receive external version to attempt to turn the baby after 37 weeks. If this fails and the baby is judged to be of reasonable size, and the mothers’ pelvis is of reasonable size, and the baby is presenting with its bottom first, feet above the waist and head tucked down, a vaginal birth is likely to produce equal outcomes for the baby and better outcome for the mother than an automatic cesarean.
11. What is your opinion on fetal monitoring?
PURPOSE: Continual fetal monitoring has been proven through over 10 studies involving over 20,000 labours to increase the cesarean rate by 3-4 times and provide no improved outcomes for babies. It is now recommended that baby be monitored every hour in active labour and after every contraction during transition and 2nd stage. Internal monitoring should only be used to confirm a suspected problem or under high risk circumstances. Continual monitoring is recommended with the use of Pitocin or for women in high-risk pregnancies.
12. For how long do you feel a woman should be allowed to push?
PURPOSE: Doctors who have arbitrary time limits for the pushing stage are much more likely to use forceps and vacuum extractions. If mother and baby appear to be doing fine and there is progress during this stage, women should not be limited in length of pushing stage. A doctor who is less flexible will suggest a 2 hour limit on pushing.
Use these questions to interview as a minimum of three caregivers. It may be helpful if you see one of each type. The above questions tend to show if a caregiver believes in women playing an active role in the decision-making process surrounding their care, and their respect for the choices a woman may make. Informed-consent is the key to good decision-making. You should feel that your caregiver is a partner in this relationship and a source of good research-based information.
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