Choose Wisely: Studies Show Increased Risk of Cesarean Linked to Choice of Doctor

By Jacqueline Levine

The cesarean rate in the United States has leveled off, as reported last year by the Center for Disease Control and Prevention (CDC). The information came from the National Center for Health Statistics, and it says, in sum: “After 12 years of consecutive increases [1998 to 2009], the preliminary cesarean delivery rate among singleton births was unchanged from 2009 to 2011”;  the report cites the current rate as 31.3%.  That the rate has stopped rising is good news. And that the rate is too high is not in dispute. The World Health Organization and other organizations that promote and support optimal maternity care have been making that case for a long time.

Most recently, the American Congress of Obstetricians and Gynecologists (ACOG) has come out with a report entitled “Safe Prevention of the Primary Cesarean Delivery,” with guidelines meant to prevent a first-time c-section. The study calls for revisiting the list of the common indications for cesarean. The various rationales for cesarean have held sway in maternity care for years.  These new guidelines can be seen as an admission that the rate of surgical birth is indeed far too high, and that current practices do not promote the ideal health of women and babies.

Added to this news are two studies that reveal additional factors that can affect a woman’s chance of having a cesarean. News from the American College of Obstetricians and Gynecologists’ (ACOG) 57th Annual Clinical Meeting, as reported in Medscape Today (Medscape Medical News, May 12, 2009), discussed an article entitled “Liability Fears May Be Linked to Rise in Cesarean Rates.”  The following is a direct quote (bold emphasis is mine):

“It has been suggested that medical-legal pressures are a factor in the high number of cesarean deliveries. A number of studies have borne this out.  Localio and colleagues (JAMA. 1993; 269:366-673) found a positive association between medical malpractice claims risk and the rate of cesarean delivery.   Murthy and colleagues (Obstetrics & Gynecology 2007; 110:1264-1269) found an association between professional liability premiums and rate of cesarean delivery — for every $10,000 increase in insurance premium there was a 15% increase in the rate of cesarean(s) delivery.  Dr. Barnhart said “First of all, I applaud the abstract, in that it quantifies a perceived problem,” ”We all anticipated that defensive medicine might be a reaction to litigation, and this paper demonstrates that that is indeed the case,”  ”So don’t just blame the doctor for doing a C-section, recognize that there’s probably a reason that [he or she is] doing it. And that fear of litigation is the reason,” Dr. Barnhart concluded.”

The study implies that what’s being done in the way of care might indeed be for the welfare of obstetricians who practice defensive medicine, and may not be for the best welfare of the woman in his care. The results of this study are not addressed in the recently released ACOG guidelines to eliminate the overuse of c-section, but it’s helpful to acknowledge the possible affect of malpractice insurance on women’s birth options.

We assume that the most fundamental tenet of care is that what a doctor does is for our benefit, and not for her or his well-being, convenience or safety. A doctor who picks up a scalpel and performs surgery for defensive reasons is behaving in a way that is the antithesis of ethical behavior, a betrayal of our trust in the doctor-patient relationship.

The other study addresses how an obstetrician’s personality affects your risk of having a cesarean. The article, “Women’s Risk of Having C-section May Depend on Her Obstetrician’s Personality,” discusses a study published in the Journal of Obstetrics and Gynecology in 2008. (Allcock, C., Griffiths, A., & Penketh, R., The effects of the attending obstetrician’s anxiety trait and the corresponding obstetric intervention rates. Journal of Obstetrics and Gynecology, 28(4), 390-393. [Abstract]). “Trait anxiety” is an integral and unchanging part of the human personality and is very different from “‘state anxiety’” which happens in response to a particular situation.

The results of the study are very concise (emphasis mine):

“Obstetricians were asked to complete a validated survey that measures ‘trait anxiety’ which is stable and enduring… The obstetricians with the least anxiety had the lowest emergency cesarean rates.  The obstetricians with the most anxiety had the highest rates.”

Statistical analysis revealed that the doctor’s trait anxiety levels were highly correlated with cesarean rates. 

These studies document just two of the many factors that affect a birthing mother’s chances of having a cesarean — factors that have nothing  to do with a mother’s or baby’s actual health status. The more we know about what influences doctors in the decisions they make about our care, the better our ability to recognize and request best-evidence care for ourselves and our babies. And so the question becomes, how can a birthing woman understand and avoid the influence of lesser-known factors on her chances of avoiding cesarean?

As our own best advocates, we must seek out the ethical caregivers who do not rely on routine interventions and who use surgery only to save the lives or health of babies and mothers. Before deciding  on a caregiver , it’s of critical importance to become familiar with best-evidence, optimal maternity care, so that you’re able to
question her/him about all the health care practices that will affect labor and birth. Knowing the facts about normal, healthy birth and conservative reasons for c-section based on our genuine health status help you make informed choices about your care.

Recommendations for OBs, hospitals and midwifery care from women across the United States can be found at the non-profit, all volunteer website www.thebirthsurvey.com. Question your prospective OB or midwife about his/her c-section rate, induction rate, episiotomy rate, and other routine and common practices that may not confer best-evidence care. If you perceive a defensive posture about his stats, or an air of reluctance to tell you what you want to know, consider it a red flag warning and seek a new caregiver for optimal care.

 

Looking for more information and resources surrounding cesarean and VBAC? Check out this list of online resources and test-your-knowledge quiz from Science & Sensibility.

 

About the Author

Jacqueline Levine, BA, LCCE, FACCE, CD(DONA), CLC has been a DONA doula and  lactation counselor  for 10 years, a Lamaze educator for twelve years, and a WIC educator.  She teaches Lamaze childbirth education at Planned Parenthood of Nassau County, where she volunteers birth doula services to the clients of Planned Parenthood, an underserved population.  She won the Lamaze Community Outreach Award for these services to the community, and she has taught and supported pregnant teens in local high schools.

She’s been a contributor to Science and Sensibility, the Lamaze research blog, since 2009, and writes for BreastfeedingUSA, the online peer-to-peer breastfeeding site as well.  Some of her articles for breastfeeding teens have been on the US Breastfeeding Committee site, and she is a guest lecturer in the Sociology Department of CW Post College of LIU, teaching a class in the History of Childbirth in the United States, as well as breastfeeding classes for DONA doula certification that stresses best-evidence care for mothers and newborns.

She is mother of three and grandmother of five, and came to the world of birth after she retired from a career as artist and designer in the Garment Center in NYC.

Positive Pregnancy Test! Now What?

The flood of emotions that comes with a positive pregnancy test is quickly followed by pressing questions.  How do I manage the symptoms I’m feeling?  Should I change my diet and exercise, or the medications I take?  When should I tell my family, friends and co-workers?

But sometimes it’s easy to overlook other issues that can impact your pregnancy and “The Big Day.” Lamaze’s latest webinar will address one of the most important questions any newly pregnant woman can consider.

“What can I do now to increase the chances I’ll have a safe and healthy birth for my baby and me?”

The following webinar discussion (embedded below) will provide resources and perspectives on what newly pregnant women can be thinking about and doing in early pregnancy, and how they can take charge in pushing for the best possible care. The “Positive Pregnancy Test? The Top 5 Things You Should Do Next” webinar will help you to:

  • Consider options for care you might be overlooking
  • Avoid “due date” mistakes
  • Get savvy on real-world childbirth challenges
  • Equip your childbirth partner to be rock-solid support
  • Think about healthy choices in a new light

The presenter of this webinar is Jessica Deeb, MS, WHNP, CLC, LCCE.  Two years ago, she shared her first childbirth experience with fellow moms in Lamaze’s Push for Your Baby video.  Since then, she has applied her professional training in labor and delivery and her passion for better birth to become a Lamaze Certified Childbirth Educator.  She is expecting Baby #2 in December!

Red Light, Green Light – A Quiz on Getting the Best Care

Are you getting the best prenatal care from your provider (midwife, OB, or family doctor)? Take this “red light, green light” quiz to find out. Red light indicates care that is not evidence based or respectful of your choices. Yellow light indicates care that should make you question your provider further to see if she is the best fit. Green light indicates great care!

Find the Best Care Provider and Hospital through Referrals

When you’re on the hunt for the best midwife or OB and hospital or birth center to have your baby, it can be hard to narrow down the field. Yes, you can schedule interviews. Yes, you can talk to friends and family. Yes, you can even Google search for other moms’ opinions online. But if you want a direct, dependable, and knowledgeable referral, your best bet is to talk to your local birth network or group of doulas and childbirth educators.

It can be tough to find the rates of interventions and cesareans for care providers and hospitals, as they often are not published nor are they readily available. Even doulas who have been practicing for less than a year have the inside scoop on providers in your area, as well as the typical policies and standards found at local hospitals and birth centers. Doulas work in the presence of midwives, doctors, and nurses on a monthly or even weekly basis. They can tell you which care providers regularly practice evidence-based care, which ones have high rates of cesarean, and which ones truly support VBAC. Independently certified childbirth educators not affiliated with a specific hospital (many of whom are also doulas) also have this insight. Talking to doulas and childbirth educators in your area will give you a starting point to finding the best care provider and birth location for you and your baby. With referrals in hand, you can then proceed with scheduling interviews and tours to find the provider who best aligns with your preferences for birth.

Choosing Your Care Provider: Why the Closest Doesn’t Always Mean Best

When it comes time to choose your doctor or midwife for the prenatal care and birth of your baby, it is wise to consider: are the nearest care providers necessarily the best ones? It may be convenient to choose a practice that is just a few miles away and who delivers at the hospital closest to you, but if you choose a care provider based on mileage alone, you may not receive the kind of evidence-based care that can give you the best experience and outcome.

Driving 45 minutes or an hour (some women drive even further!) to your place of birth is possible, even in labor! And for the right kind of care, it’s worth the effort. For most women — and especially first-time moms — labor gives you plenty of warning and ramp-up time before baby is born. It is very rare for babies to born in the car on the side of the highway, despite what the media would have you believe.

So how do you find the best care provider now that your radius is wider? The simplest first step is to ask for recommendations. Ask your friend or sister who had a great birth experience and contact doulas and childbirth educators in your local birth network for referrals — these women see first-hand, on a regular basis, how care providers in your area practice.

To better evaluate a prospective care provider, learn about the kinds of questions you should ask when choosing your doctor or midwife, and some of the “red flags” to be aware of once you are in their care.

 

Did you choose a care provider that wasn’t the closest to you? How did it affect your birth experience?

What to Know if Your Labor Stalls

Labor is unpredictable. We have no way of knowing in advance when labor will begin, how long it will last, or how it will feel. Sure, there are some universal markers and generalizations about the process of labor, but every experience is different, and the variables are numerous. First-time mom vs. mom with a subsequent baby, baby’s position during labor, home or birth center birth vs. hospital birth, pain med-free birth vs. heavy intervention birth, complications vs. low-risk mom… the list could go on. All of these factors influence the course of labor and birth.

Perhaps one of the most variable parts of a woman’s labor is length. Healthy babies and mamas can come through a labor that lasts 3 hours, 12 hours, or 48 hours (or longer). Despite this fact, many health care providers in the United States place time limits on a woman’s labor in the hospital. It is not uncommon for a doctor to recommend the use of Pitocin to speed up labor if a woman’s cervix has not changed dilation in two hours. As a standard practice, obstetricians are encouraged to govern labor by Friedman’s Curve, an analysis developed in 1955 by Dr. Emanuel Friedman that dictates how a woman’s body should progress in a normal labor. The problem with this? According to Rebecca Dekker, PhD, RN, APRN, of Evidence Based Birth, who recently investigated this practice:

“Modern researchers have come to the definitive conclusion that we can no longer apply Friedman’s curve to women of today’s world. Too many things have changed since 1955. Women are no longer sedated during labor, but epidurals are commonplace; Pitocin is used much more frequently for both labor induction and augmentation, women are older and tend to weigh more, and forceps are hardly ever used. All of these things can either slow down or speed up the rate of labor.”

A “abnormal” labor, according to Friedman’s Curve, is one in which a woman is dilating less than a centimeter an hour. Care providers who adhere to these guidelines will often prescribe Pitocin to speed up labor, or if the stall continues (with no dilation for 2 or more hours), may call “failure to progress” and recommend a cesarean. According to Dekker’s article, research published this year from a sample of 38,484 women showed that “10%, or 1 in 10, of all first-time mothers in the U.S. had a cesarean for failure to progress during the years 2002-2008 (Boyle, Reddy et al. 2013).”

So, if 1cm an hour dilation is considered too stringent and outdated, how long can you safely labor before intervention is called for? In 2012, the American Congress of Obstetricians and Gynecologists, the Society for Maternal Fetal Medicine, and the National Institute for Maternal and Child Health came together and issued new guidelines for stalled (or, “arrested”) labor. Among the guidelines, as posted in Evidence Based Birth’s article:

“Progress in the first stage should not be based solely on cervical dilation but must also take into consideration change in cervical effacement and fetal station. Similarly, progress in the second stage involves not only descent, but also rotation of the fetal head as it traverses the maternal pelvis.”

“Adequate time for normal latent and active phases of the first stage, and for the second stage, should be allowed as long as the maternal and fetal conditions permit.”

“1st stage arrest can be diagnosed ONLY if a woman has reached 6 cm and the water has broken, AND if there has been no cervical change for 4 or more hours of adequate contractions or 6 or more hours of inadequate contractions. If the mom is still less than 6 cm, then she needs additional time and interventions before an arrest of labor can be diagnosed, because she is still in early labor.”

Stall during pushing can be “diagnosed if there has been no improvement in descent OR rotation of the baby after at least 4 hours in first-time moms with an epidural, at least 3 hours in first-time moms without an epidural, at least 3 hours in experienced moms with an epidural, at least 2 hours in experienced moms without an epidural.”

Stall of an induced labor can be diagnosed if there is “failure to have regular (every 3 minutes) contractions and failure of the cervix to change after at least 24 hours of oxytocin (and if the water has been broken, if possible).”

How can you avoid unnecessary interventions due to a stalled labor? First, be sure to talk with your care provider well in advance of your birth. Find out her policies on allowing a normal labor to progress. If you are in labor and your care provider recommends Pitocin or cesarean due to stalled labor or “failure to progress,” there are three questions to ask your care provider that will help you assess your situation:

  • Is my baby OK?
  • Am I ok?
  • What’s the risk in doing nothing or waiting? 
You can also ask your care provider about using natural techniques to get labor moving again, including:
  • Walking, moving, changing positions
  • Laboring in the shower
  • Change in environment (time alone, dimmed lights, music, etc)
  • Nipple stimulation
The most important thing to know about a stalled labor is that it is usually not an emergency. As long as you and baby are healthy, you may have options outside of medical intervention.

Have you experienced a stalled labor? How did you handle it? How did your care provider react? 

 

photo credit: Jug Jones via photopin cc

Care Provider Red Flags: Signs You May Not Be Getting the Best Care

Throughout your prenatal care, you may hear comments or experience reactions from your care provider that could signal a red flag that she is not providing care that is evidence based or that supports your preferences for birth. If you encounter any of the following red flags, open a dialogue with your care provider to find out more. It may be a misunderstanding. Or it may be an indication to change care providers.

Dismissive, inattentive. If your care provider quickly dismisses concerns you bring up during appointments or acts as if your questions are burdensome, consider how this care provider may attend to your concerns during birth.

Quick appointments. If your appointments last only 5-10 minutes and your care provider doesn’t regularly ask, “What questions do you have?” it may be a sign that your care is not as personalized as you might want it.

Birth plans. If your care provider raises an eyebrow/smirks/reacts negatively about submitting a birth plan, it could be an indication that he is not willing to take your ideas, preferences, and questions into consideration. You have a right to be involved in your care and reviewing your birth plan is part of that process. 

Doulas. If your care provider does not allow doulas to be present at birth, or if she says something like, “You can have a doula, but she needs to know her place in the delivery room,” it could signal that your care provider isn’t practicing evidence-based care.

Predictions. If at any time during your pregnancy, your care provider suggests induction or a cesarean based on the estimated size of your baby, you may want to consider a second opinion from a care provider in another practice. Induction or cesarean for a suspected “big baby” is not evidence-based care. Babies’ weight can vary wildly from predictions made based on ultrasounds.

VBAC. If your care provider is unwilling to allow you to have vaginal birth after cesarean, you may want to seek a different practice, as VBAC is now considered a reasonable option for most women. If your care provider says that you can “try” for a VBAC, but has a low success rate, you may be with a care provider who appears to be supportive, but may not be as patient with the process during your birth.

Your gut feeling is also a good indicator of whether or not your care provider is the best for you. Pay attention to how you feel after appointments. If you’re unhappy during prenatal appointments, it won’t get better during your birth. Your choice of care provider can have a big impact on your birth experience and outcome — changing care providers is usually an easy process and can take place at almost any point of your pregnancy.

 

Great Expectations: Heather @ 28 Weeks

What am I so afraid of, lately? Why so nervous and defensive? Look at my sleepless, 2am face. I have three months to get everything in place and ready for a new life, for Baby and Husband and me. It’s finally that time where thinking and planning aren’t enough. I actually have to make sure this is going to happen. I have to be a mom, too. Oh, dear, that’s a lot to think about. Can I unload a little?

I mentioned that I’ve been considering a change in care providers. Today’s visit was going to be the last chance, and now I’m pretty certain.

At the previous visit, we finally got down to the first of many common procedures to come. Glucose screening time had arrived. I thought it was a good opportunity to begin the discussion on how she views and manages different complications. This one in particular for me, was a concern. Being insulin resistant before, I do have a higher risk of developing gestational diabetes. But it’s also a concern for me because of the mode of care that accompanies that GDM label… Dire predictions. Extra tests. Induction—shiver. It goes on from there.

Despite the fact that I knew any sense of tact had been drowned in the hormonal tide, I made the bravest start I could. “I’m not sure how I feel about this test, and gestational diabetes as a condition. I’ve read some things that…” The truth is, I’d read everything from ‘This is not a disease; you just need some extra time to birth gently’ to WebMDoom-and-Gloom’s list of 20+ potentially fatal complications. That’s a wide range of opinion. The midwife’s response was definitely more in line with the latter. “I have NEVER delivered a baby over nine pounds, and I don’t intend to…perineal trauma…brachial plexus injury…STILLBIRTH.”

On the bright side, it was heartening that I already knew the terms and what she was talking about. I finally just negotiated for a food
source of 50 grams of sugar instead of the drink, and made my next appointment. She was probably right. But I continued to wonder. HOW BIG A PROBLEM COULD THIS BE? No, seriously. I wanted to do the right and healthy thing, but couldn’t I do that with a little home testing, care in eating and exercise, somewhat more frequent monitoring in the last weeks, no procedures that might contribute to malpositioning or possibly slow my labor, and by staying off my back during delivery? I could accept a ‘no’ answer, I just needed to really talk it through.

The next scheduled day started out okay. I couldn’t recall all of the specific directions for the test, and the office wasn’t due to open
until about the time we arrived. How long was I supposed to fast, again? I looked it up and apparently EVERYONE does it differently,
from one to twelve hours, with or without a breakfast which might be specifically prescribed. I couldn’t recall any mention of eggs and
cheese, so just maintained the fast I’d begun through the night before choking down a Snickers and some fudge brownie ice cream. We commenced our early morning hour’s drive, with the sugar making me sicker every minute. Of course, halfway there, the car overheated. Grr! We arrived 10 minutes late, and they didn’t take us back for another 10-15. Too late. I was SO mad—well, as mad as I ever am. I got quiet and pouty and hid behind my hair while Preston tried to poke and make me look him in the eye. Not the best way to begin.

I thought it worth another attempt to clear things up with the midwife and explain how I simply wanted to understand her approach to this and other conditions, how she assessed risks and dealt with them. What I wanted to say is: I know my behavior seems odd and inconsistent, and logically speaking, I’m being a little bit silly. Not to mention that I had NO time to understand the PCOS thing before having to add the pregnancy changes, too. I don’t entirely know what it means for me, how serious it is. But doesn’t that indicate another side to the care that I need? I’m confused. I just need to talk. I especially need to know that you understand why I’m concerned, and that you actually care enough to let us work together to find a solution. Maybe you hear “I choose to remain lazy and ignorant regarding this diabetes thing,” but what I’m really saying is, “I don’t understand how big a risk this is for me. Is it a big jump from pre-pregnancy insulin resistance to full-blown GDM? Is the real problem just a big baby? HOW MANY stillbirths happen, and how serious were the cases that caused it? Do you think I’m that bad? I hear the glucose test is not that accurate. Why do you use this option? Can it really be that beneficial when it makes me feel so sick and doesn’t reflect my natural habits? What about…A1C, is it? Or home testing, as others have done? What are they and how do they compare?”

We never made it that far into the conversation. This time the immediate and stern response was, “Well, yes, we induce—again, dead or
injured baby—but WHY are you worried about this? You think because you had a little PCOS one time that you’re guaranteed to have full-blown diabetes? Given the baby’s measurements, your small weight gain, etc., I don’t think it’s going to be a problem. Calm yourself.” Somewhere in there was a lecture about evidence-based care vs. whatever anecdotal reasoning I’d heard from whoever was certainly not qualified. These things come from the top. They’re in the big journals. End of story.

(One note in my defense: a 2011 study—in one of those big journals, no less!—determined a mere 1/3 of ACOG recommendations to be based on consistent scientific evidence as opposed to limited evidence or consensus of opinion. I think that leaves some room for questions.)

On one hand, she is in the right. She has settled on what method of patient management she feels is her responsibility to follow through
with as a care provider, with the backing of general medical opinion and practice. I don’t question that at all. On the other hand, there
was a level of care I found completely lacking. Never did I feel like there was any considerable effort to understand what I was asking for, to address my concerns other than outright dismissing them.

Doulas often talk about the importance of providing support, physical, emotional, and INFORMATIONAL. Childbirth educators obviously understand the necessity of a thorough understanding of common occurrences and procedures in preparing mothers and birth partners for the journey, emotionally and otherwise. Why is this somehow occasionally missing in the people ultimately responsible for supervising this process? Lack of available time and other resources? Limited interest among the typical patient set? Simple differences in personality? Probably some level of each.

So I’m leaving with some bruised but not deeply resentful feelings. I knew in the beginning that employing a midwife was no guarantee of the treatment I was hoping to receive, particularly one so closely connected with a hospital. Every provider has a different personal and professional attitude. My lasting fear is the question of whether or not I’ll find someone who’s matches mine. There are other midwives available in that town, but I’m finding it hard to muster the fortitude to weed through them. The despairing side of me says that if I’m going to have to endure this type of stress and treatment, I’m at least not driving an hour each way for it. I mentioned earlier that we have a nice hospital, with staff members dear and familiar to various family members. There is a local family physician I have visited before who provides obstetrical care. My grandparents are fond of him; my doula also speaks well of her experiences with him. His wife apparently teaches yoga and does essential oils, so I figure he’ll be fairly open-minded. I hear he’s good at giving options. It seems like the next best thing to try. We have an appointment next week.

My final gripes are these: all of the differing ‘experts’ have left me in a very difficult position discerning between them, and I fear I have no safe place to go for answers and care. If you want me to feel safe, please talk to me openly. Please listen to me. Please give me some control and don’t belittle my confusion in this fragile state. This is WHY if I could afford it, I’d be at a birth center or at home. Because I know how much more likely I am to find someone who cares about ME just as much as my health, who knows when to act, when to
refer, when to let be, but keeps at the center of her practice a love for the spirit and whole being of a mother, child, and family. I hear
them talking. I read the things they write. And THAT’S what I want to accept as the truth. Why? In that place, it’s about hope, and
confidence, not fear, not efficiency, not covering your back. You can Tuteur-bash me all you want, but I’m going where the positivity is. The downside comes when I have to manage all these voices in my head, compare them with what’s in front of me and available to me, and figure out which is the best way to go.

It’s getting considerably more tempting to abandon my own responsibility in this. I could so easily just go with the flow and ‘leave it to the experts’. But what do I do about the other things I’ve learned and seen? What about the choices I’m told I should have or press for? Sigh. I suppose this means I’ll have to summon some humility, as well. I wonder if anyone will connect my name with the rather…passionate note left on the hospital’s facebook page a few months ago in my displeasure with there being no nurse midwives available (or possibly allowed) to deliver there. What will this doctor think of my having gone elsewhere for prenatal care when he was the one to diagnose me and prescribe the medication that probably enabled me to conceive? And after all this, who knows, I may finally get around to taking that stupid glucose test. :P

Is Your OB or Midwife Right for You? An Interview Guideline

Finding the right person to care for you and your baby during pregnancy, labor and birth is one of the most important decisions you will make, and it can help you feel confident to push for the safest, healthiest birth. As you review doctors and midwives in your area, the following questions can help you find someone who will provide the care you are looking for. Asking questions and providing information builds trust, and it’s the best way to make sure everyone is working toward the same goal – the safest, healthiest birth possible for you and your baby.

1. What is my role in helping to achieve a safe and healthy birth? 

This is an important question that will help you determine whether your care provider will be respectful of your choices and invite your input. By being an active and attentive participant in pregnancy, labor and birth, you can help achieve the best outcomes for you and your baby. Your health care provider – doctor or midwife – has important knowledge and skills, but they don’t always know everything about you or what is best for you and your baby. Find out how openly you can share your needs and work in partnership with your care provider to get the care that’s best for you.

2. What standard routine practices should I expect in labor?

This information will help you identify any practices that your care provider may see as needed or routine. While many interventions may seem like they would make childbirth easier, did you know that some of the care that pregnant women routinely receive can have unintended consequences and potentially make birth more difficult and less safe? Many practices in maternity care aren’t always necessary, including:

  • C-sections;
  • Electronic Fetal Monitoring;
  • Epidurals;
  • Episiotomy (surgically cutting the area between the vagina and the anus, called the “perineum,” in order to make the vaginal opening larger)
  • Induced labor;
  • Restricting women from eating and drinking freely;
  • Restricting movement;
  • Directed pushing; and,
  • Separating mom and baby.

Get the most out of your conversation and be specific. Find out more here in Childbirth Challenges.

3. How will you work with me as your patient to identify mine and my baby’s unique needs?

You and your baby’s unique needs should be front and center throughout pregnancy, labor and birth. Like any other kind of health care, maternity care isn’t perfect. A lot of the regular care that pregnant women get includes interventions that don’t always help and can sometimes even cause harm. Ask your care provider about what’s negotiable and what’s not. Weigh the answers you get; they will give you good insight into whether you’ve found a good match. It’s important to work with your health care provider early on, because routine care isn’t always designed for you and your baby’s individuality. Remember that getting the care that matches your and your baby’s needs may mean saying, “I’d like to consider another option.”

4. How do you feel about me bringing someone like a doula for one-on-one support?

Many women count on having a nurse by their side to provide important support. But labor nurses may be caring for several women at the same time, and may not have the time to provide contraction by contraction support. Dads are often expected to fill this role, but many times they are new to the process too and need cues on how to best be supportive in labor. A continuous support partner, such as a doula, can help you navigate your labor, support good decision-making and help make sure you’re able to communicate your wishes to your health care provider. Keep in mind, some health care providers may not agree to the use of a continuous support partner, such as a doula. Be prepared to ask them “why?”

5. What is your rate for C-sections? What are the main reasons you perform them? Is there anything you know about me and my baby that might suggest I would need a C-section?

A health care provider’s C-section rate can tell you a lot. Cesarean surgery can save lives, but just like any other surgery, it carries risks for you and your baby. More and more babies are being delivered by cesarean, even when there’s not a good medical reason to do so. One of the best ways to reduce your chances of a C-section is to give birth in a location , and with a provider, that maintains low cesarean rates . There is no federal requirement for health care providers to report this information, so you need to ask your care provider directly for these details. If your health care provider has a high rate because they say they care for many “high risk” women, be sure to probe about what they consider to be “high risk.”

6. Do you limit the length of labor? Or will you support continuing labor as long as my baby and I are doing OK?

Certain care providers and birthplaces may be under pressure to speed up the birthing process, or put a time limit on your labor and birth. Labor is an intense process, at times overwhelming and draining. But, the good news is that your body is perfectly designed to birth your baby. It’s important for you to find out if your care provider will give your body and your baby time to move the process along, and let nature take its course . Childbirth education classes can help you identify various options to keep labor progressing.

7. How often do you perform inductions? What are the main reasons you perform them? Is there anything you know about me and my baby that might suggest I would need an induction?

Due dates aren’t an exact science. Even if you and your care provider feel sure about your date, every baby matures at a different rate. Inducing labor can mean your baby is born before he or she is ready. Labor should only be induced if it is more risky for your baby to remain inside than to be born. Studies have consistently shown your risk of having a C-section nearly doubles with induction with your first labor. It also increases your baby’s chance of being born premature. Your best chance of avoiding an induction is by finding a health care provider who uses them sparingly. Lamaze childbirth education classes can also give you many strategies to help labor start on its own.

8. How will you monitor the baby’s heartbeat during labor?

We all want to know our babies are doing OK. Using the same thinking, most care providers will monitor your baby’s every heartbeat during labor using electronic fetal monitoring, or EFM. However, EFM can mean you are confined to a bed and not able to use gravity and movement to advance the birthing process. Studies show that a baby’s heart rate can be monitored just as safely with a nurse, doctor or midwife regularly checking in to listen at key points in your labor with a Doppler hand-held monitor or something similar. Talk with your health care provider about whether they use intermittent listening so you can move freely, relax between contractions, and avoid the anxiety that comes with being tied to a machine. Ask whether the nurses on staff will use it too.

9. Will I be able to move around during labor, or will I be confined to bed? In what position will I be giving birth?

Contrary to Hollywood’s portrayal of labor, lying on your back in a hospital bed is not the only way to give birth! In fact, walking, moving around and changing positions throughout labor makes the birth of your baby easier. Movement is a natural and active way of responding to the pain of childbirth. When it comes time to push, staying off your back and pushing with your natural urges can be key to making it as easy as possible on you and your baby. Find out if your health care provider will encourage you to stay mobile.

10. Will my baby be kept in the nursery or in my room?

In many hospitals, it’s standard procedure to separate mom and baby for periods of time. However, research has shown that it’s best for mom and her healthy baby to stay together after birth. Skin-to-skin contact helps your healthy baby stay warm, cry less, and be more likely to breastfeed. In fact, interrupting, delaying or limiting the time that mom and baby spend together may have a harmful effect on their relationship and on successful breastfeeding. Talk to your care provider and ask if they support “rooming-in ,” which will maximize your time with your little one, as well as opportunities for breastfeeding.

This and more resources can be found on the Lamaze Push for Your Baby website.

Push for Better!

Be an active partner with your care provider, and get the best care.

Oh the joys of pregnancy… you’ve battled nausea, your back hurts, you’re not sleeping, and you’re running to the bathroom every 20 minutes. Still, you’re absolutely 100 percent devoted to having the absolute best of everything for your baby. You’ve researched the safest car seats, highest-quality strollers, best cribs and smartest baby monitors. You and your baby are all set, right?

There’s one thing that’s important not to leave off your “smart shopper” checklist; your baby’s birth day!

Like any other kind of health care, maternity care isn’t perfect. You can help your baby and you get the best care by being an active partner in your care. Your health care provider – doctor or midwife – has important knowledge and skills, but they don’t always know everything about you or what is best for you and your baby. They need you to speak up about your concerns and needs early so you can get the care you’re looking for throughout pregnancy, labor and birth.

Why does your voice matter? A lot of the regular care that pregnant women receive includes unnecessary interventions that don’t always help and can sometimes even cause harm. Routine care isn’t designed for you and your baby’s unique needs.

So when you’re told that you can’t eat or drink in labor, that you should stay confined to bed to stay attached to the monitor, or that your labor should beartificially started because you’re a few days “overdue” it’s fair to question and discuss these practices with your health care provider.

Remember that getting the care that matches your and your baby’s needs may mean saying, “I’d like to consider another option.” Asking questions and providing information builds trust, and it’s the best way to make sure everyone is working toward the same goal – the safest, healthiest birth possible.

 

The Lamaze “Push for Your Baby” campaign encourages women to advocate for better care for their babies and themselves. With the right information and education, women have the opportunity to be active partners in their care during pregnancy and birth. This campaign is designed to help women be ‘savvy shoppers’ and prepared to seek out the best care for their babies and themselves. Watch the video to find out what moms and dads have learned about pushing for the best care