What questions to ask OB to tell if will get evidence-based care?

[SeekingJoy]

Here are the questions I have come up with to ask an OB to see if one could reasonably expect evidence-based care. A good friend is pg and trying to learn about natural childbirth. I can't get her on-board with homebirth. She is already seeing an OB, but is less than thrilled. I no longer have the medical research/citations to support what I remember.

Can you help me out with other questions to ask an OB and the medical research for the "right" answers?

OB QUESTIONS:

How actively does she manages labor?
What percentage of her patients are induced? Why and under what conditions?
Is there a point during pregnancy after which she routinely induces? Would she let a woman go to 41wks? 42? 43?
Does she expect patients to progress 1 cm per hr on average?
What percentage of her patients are c-sectioned for failure to progress?
How does she handle it is a patient's water breaks (once full term/37wks) before labor starts?
Does she break women's membranes "to get things going"?
What percentage of women receive an episiotomy? Why and when?
Under what conditions does she recommend the use of Pitocin during labor?
What positions can women push and deliver in? When does she encourage women to change positions during pushing?
After delivery, how does she manage placental delivery?

[Kappa]

My suggestion is for your friend to go in with her actual birth plan so that can be discussed. Honestly, to find a decent doctor I had to go based on recommendations of others. If you can find a local doula who supports natural childbirth, she will know what doctors also support and enable women to have the birth that they want. Also, any doctor that practices as a back up OB for midwives in a birth center is also likely to give pretty decent care.

I hear a lot about OBs just say what women want to hear (natural birth, no epi, walking in labor, etc.) and string them along until the last minute. If he has no comment on your birth plan, that is a red flag.

[MegBoz]

Originally Posted by Kappa

I hear a lot about OBs just say what women want to hear (natural birth, no epi, walking in labor, etc.) and string them along until the last minute.

:

It is for that reason that I suggest she not let on what sort of birth she wants. Act all mainstream....

The OB can't "tell her what she wants to hear" if he doesn't know what she wants to hear.

I recommend asking very open ended questions. Instead of "Would she let a woman go to 41wks?" ask,
"What are some reasons you feel induction is necessary? Is there a certain date by which induction is required?"
(If she phrases it, "Would you LET a woman..." then your friend reveals that she isn't mainstream... i.e. she MAY think for herself & not automatically go along with whatever the OB says. I think it's important she not reveal the fact that she is thinking for herself. That will help the OB leave her guard down & show her true colors.

If I do say so myself, I posted some great open-ended Qs here:
http://www.mothering.com/discussions...d.php?t=979964

[meganmarie]

Well, the birth plan discussion is a good idea absolutely - it focuses the conversation on what the provider will or will not be flexible on when it comes to the woman's preferences for her own birth.

However I do think there is still a risk that the OB can respond to the birth plan by saying "sure, we are open to all of those things as long as things are going well" - which leaves you open to that scenario where suddenly at 38 weeks an U/S shows your [insert scare here: baby is big/baby is small/fluid is low/BP is high] and now your birth plan is off the table.

This is why I do advise a set of questions about actual stats and practices in addition to a birth plan discussion which is, by nature, somewhat theoretical.

I like most of the questions you list very much. I think the ones with very factual answers (What is your c-section rate? What % of patients are induced? What % of patients are augmented with pitocin during labor? How many weeks are you comfortable with letting patients continue?) are particularly helpful. A refusal to answer or a claim of "don't know" is not good.

You might also raise questions about the OB's practices vs. the hospital's - if the most flexible OB works at a teaching hospital with a 40% c/s rate where residents are likely to show up and deliver your baby when the OB is late, you are still in big trouble.

For evidence-based practices the 2 best sources I know of are Henci Goer's book and this site: (you have to register but you will be glad you did)

http://www.childbirthconnection.org/...k=10218&area=2

Is your friend open to a CNM practicing in-hospital with backup OBs? If she has that option available in her area perhaps she might at least meeting with one. She'll find the difference so striking even at the 1st appointment I bet she'll never go back.

[meganmarie]

I think it's important she not reveal the fact that she is thinking for herself. That will help the OB leave her guard down & show her true colors.

As usual, MegBoz has a great thought here.

We have, apparently, not only the same 1st name but also the same battle-scarred, conspiracy-theory mentality when it comes to traditional OBs.

[SeekingJoy]

Great points! I will pass all of this on to her.

Does anyone remember the study showing no negative effects until after 42 wks? Or was it a recommendation by the AMA? My memory is so faulty.

[1littlebit]

yes. my OB and midwife went along with everything i said until 2 weeks before my due date and then told me a scheduled c section was necessary and if i wouldn't agree to that i had to find another practice.

'wonder' out loud if there are any benefits to natural child birth and if its even possible. see what they say

[lifeguard]

I also agree with the open-ended question thing. I would add to that to stretch quetions out to separate appts she's not bombarding the ob with too many questions at once & putting them on guard.

[SeekingJoy]

Thanks for the responses.

My friend is frustrated with her OB's recent care anyway, so I think she and her DH are planning a full-on discussion next visit anyway. Otherwise, spacing these questions out would be ideal.

Arming her with the medical research to support the things I have been telling her would be great -- but I don't have the citations and bookmarks anymore. Anyone else remember who did some of these studies?

ETA: I would love to be able to show her clinical research instead of it just being something I told her.

[MegBoz]

Personally, I recommend just buying the book, "The Thinking Woman's Guide to a Better Birth." I think so highly of this book, I actually bought a copy to donate to my library (they didn't have it.)

But here is one study
that states that women undergoing labor induction are at increased risk for obstetric complications compared to spontaneous labor.

Once you're on that site, you can easily search for other things. I've killed waaaaay too many hours there browsing medical research. It's totally fascinating!

[MamaChicken]

I mentioned to my OB that I had been doing some research on my own, and I would appreciate if he shared with me research that he found about different topics. He gave me print-outs of articles about breech extraction, optimal gestation, and several other twin related topics. Since I didn't tell him ahead of time what I wanted/expected, it was very telling. I stayed with him, and was very pleased with the care I recieved.

[SeekingJoy]

This is a great tip.

I found this on Pubmed. Anyone care to help me out? I thought the risk to mom and baby only increased after 42 weeks, not 40.

CONCLUSION: The risk of cesarean delivery and neonatal morbidity in low-risk women increases at 40 weeks and beyond, whereas the odds of serious neonatal pulmonary disease were highest at 37 weeks. Recognition of such variation in term outcomes should lead providers to avoid iatrogenic morbidity and consider interventions to prevent complications of late-term pregnancy.

[MegBoz]

Originally Posted by SeekingJoy

This is a great tip.

I found this on Pubmed. Anyone care to help me out? I thought the risk to mom and baby only increased after 42 weeks, not 40.

Well, I read, "Delivery at 40 or 41 weeks was also associated with higher overall maternal morbidity."

My guess would be that maternal morbidity is higher at 40 weeks due to the higher incidence of induction!! Induction is known to increase the rate of OB interventions, such as CS. So to truly assess the correlation between maternal morbidity & gestational age, the groups should be separated into spontaneous onset of labor vs. induction. That way you compare "apples to apples" so to speak.

[elanorh]

If I were you, I'd get her a copy of the Thinking Woman's Guide. Explain that it does have a home-birth 'bias' but that a friend of yours who's only birthed in the hospital (that'd be me ) has read it, used it, and loves it!

If there's any way for her to get recommendations from women who've actually used the OB, that would be best. My town has two OB's and I chose mine because a friend and my aunt see him for gyno visits, and my cousin saw him (and had an unplanned UC at home, which he was very matter-of-fact about). My aunt had all NCBs so I figured she'd choose someone like that for her OB here .... And that's very much how he's been, having done more research after the fact, I'd say he's one of the OBs who practices a more midwifery-model of care. He's quite hands-off, practical, not pushy - no episiotomies, he's good with our delayed cord clamping, immediately-to-breast, my extended breastfeeding, etc. etc. I wish a midwife were an option where I live, but I pretty much love the guy. :

I think a lot of times OBs can be agreeable 'in theory' to a lot of things mothers plan in their birth plans. But if their inclination is always to go into worst-case-scenario, I-must-manage-this mode, then unless a mom labors quickly with no interventions at all then it's easy for the OB (or even MW) even with the best of intentions, to switch to med mode. So knowing how other mothers have labored with him, would be helpful.

A local AP playgroup or LLL group may have suggestions, in terms of their experiences?

Otherwise, I agree - very much open-ended questions, where s/he doesn't get tipped off by your question itself.

When is "too long" past due dates, or what signs do you use to know that you need to induce?

etc.

I think it's also fine to ask upfront, "What's your experience with uninduced, natural labors (no pain medications at all)?" Because I think that not all OBs consider pit etc. to be a divergence from natural labor -- and I think that the number of OBs who've seen natural labors (no interventions) is lower than we'd like. My friend who just finished her residency last year, had only seen a few of them; and another friend who's a FP, was telling me that he sees 'quite a few' now, but I didn't get the impression he saw as many as a resident .... He definitely has the low-intervention model for his approach, though. As opposed to my OB friend, who's still pretty intervention-heavy. (I expect her to come 'round as she sees more natural births though).

If the dh asks this question (about uninduced, natural labors) then I think that's a great set-up. OB will be answering from the perspective of reassuring the spouse -- and may well say, "Well, lots of mothers want them, but we usually end up doing X or Y," etc. and tip your friend off. I believe my OB would respond more along the lines of "It's hard to know what a mother will want until she's in labor, but natural birth is wonderful and there are ways to achieve it (and then tell about the NCB classes at the hospital here, it's a small town, that's the option)."

[meganmarie]

This is my favorite source for evidence based maternity care:

http://www.childbirthconnection.org

Their "Guide to Evidence-Based Care" is a pdf you can download by registering (Which is worthwhile, if you are interested in normal childbirth). It reviews all research studies and describes what is and isn't good care practice. As you'd expect the research generally supports the kind of hands-off approaches we advocate at MDC, but overall it is absolutely balanced, scientific, and aimed at influencing mainstream care providers.

Ch 26 deals with post-term:
http://www.childbirthconnection.org/...e.asp?ck=10040

I had never read this section before. It does suggest that there is increased risk of perinatal death *after* 41 weeks. It is very clear that routine induction at 40-41 weeks has NO benefits, but states that induction at 41+ weeks will slightly decrease risk of perinatal death - specifically, 1 life saved for every 500 inductions.

You may find other chapters in here relevant for your friend. Just use the search function to find the right chapter - it works pretty well.