Informing OB of birth plans

[MacKinnon]

I'm very happily, and cautiously, expecting our 3rd in September, after my 2 DC and 3 early losses. I transfered care from a CNM to an OB after my third loss. I am intending to do first trimester care with their OB practice, and transfer, most likely to either birth at home or a free standing birth center that is about an hour away. What I know for sure, is that unless their is some crazy complication I'm NOT delivering with an OB in a hospital setting. So, I have several friends (one that is a midwife herself) advising me that I really should tell the OB that I am planning to birth out of the hospital and get, essentially, his clearance. I am NOT high risk, I did not have consecutive losses, or second or third trimester losses, I have had two full term uncomplicated vaginal births, with no tears, no drugs, no complications whatsoever, with a CNM in a very natural birth friendly hospital setting.

I have my first appointments, since getting a positive test, this Thursday at nearly 7 weeks (obstetric history with a nurse) and next Monday (viability scan). I have no interest in telling him, although I suspect I will when I go in around the end of my first trimester, when I intended to stop going there. My friends think it would be best if he knew of my intention from the get-go, so that he was better able to asses if there is any additional risk of my birthing out of the hospital. He does provide back-up care to a CNM group that delivers at their hospital, and is, by all accounts, very laid back and prone to less intervention than that particular CNM group.

So... thoughts? Would you tell them in advance that you were leaving their practice to birth at home as long as things went OK? Just say thanks and good bye at your 12 week appointment? Just stop coming? I'm not sure how to handle this! Thanks!

[etsdtm99]

well, i don't know how your OB would react, but i know how my former OB would react - i am near certain she would throw me out of the practice.. so that is always a fear of mine.. so personally, unless you are sure of his feeling on out of hospital birth, i would not tell until you are 'done' seeing him, and then you can still get his opinion on things, but you don't need him anymore at that point if he says something that you don't like or if he is not comfortable with the position you are putting him in...

[wombatclay]

I changed care providers once with my first pregnancy, and three times with my third pregnancy. I don't think you need to tell a provider that you wont be back "in advance"... and when the time comes to move to a different provider a lot will depend on who (or what) you're moving to. If you're moving into the care of a midwife or other provider then they can request your records and you simply stop going to the first provider, no explaination necessary.

If the concern is that other tests would be necessary to give you peace of mind about birthing in a certain setting, or that these tests might be required to birth in that setting, then whatever provider you have for the birth could order these tests. That shouldn't be a problem.

However, you may want to contact the care provider you'd like to have (or the birth center staff) to learn what they want to see in terms of tests, and to find out if they accept patients who want to change care... I know a few cases where women have tried to switch care providers only to find that the provider they want has a "non-compete" style arrangement going with the provider they want to leave. So I'd want to make sure in advance that the birth center or midwife would be OK with your plan.

Good luck and happy birthing!

[Belle]

A lot of OB's have a knee-jerk reactions when they hear the words "home" and "birth" in the same sentence. Maybe it would be better to just say you want to see him during the first trimester and then transfer to a midwife if all is going well. He doesn't need to know its going to be an out-of-hospital birth. If he backs CNMs he should be used to this setup.

[AustinMom]

[QUOTE=ilovemyavery;14948921 My friends think it would be best if he knew of my intention from the get-go, so that he was better able to asses if there is any additional risk of my birthing out of the hospital. He does provide back-up care to a CNM group that delivers at their hospital, and is, by all accounts, very laid back and prone to less intervention than that particular CNM group.

[/QUOTE]

I think almost every OB can think of a reason why not to HB even in a completely normal healthy pregnancy. I think a skilled HB MW is your best bet is assessing additional risks of birthing out of the hospital.

My OB is very pro-midwife, she has the only practice in central TX that works with MW in hospitals to "deliver". She is though, very antiHB. That would be my worry. I'd leave when you feel you are ready, or past the first trimester. I think notifying him in advance would only make him look harder at your health and pregnancy to find reasons you are "high risk".

If he does believe in HB, he will understand you leaving without telling him, and will welcome you back in his practice if you ever have the need.

[CharlieToaster]

My OB is also my friend. He delivered babies for 30 years. He is very open minded and will allow you just about everything you want because he figures may as well try and if it doesn't work you can always move to plan B. He will always try to go with what you want though. I had a great delivery and every choice along the way was mine to make. The reason it was so great was because I'd already had a natural midwife delivery. I knew what to expect and I had some medical issues I chose to trust him with. (he took me on when I moved to town at 36 weeks) He trusted me enough to know me and what I wanted and to know when to yield. I didn't fight him and he didn't fight me. And, belive me, we talked a lot.

I asked him this same question. His reply was very interesting. What it boiled down to is it's a matter of trust. You want him to take responsibility for your pregnancy, your unborn child and, essentially, your life. If you are going to treat your OB like a second class citizen why should your OB treat you like royalty? If you were to stop showing up for appointments he would make you come every day until he knew he could trust you. I thought that was a little weird. But, he had a good point. He has to pay insurance in order to deliver. If something goes wrong, he's responsible. He actually does care about your life and the life of your child.

Be honest. Take the life of your unborn into consideration. Take your life into consideration. Yes, you can simply not show up for the delivery and no one would really be the wiser but you may want to keep an OB on your side if you think you may need one.

[AlexisT]

There are two issues here:

1) Your obligations to the OB. I would say that your obligation is to terminate care once you feel you are past the danger point. No fuss, no drama, just a change of provider. If you are planning to see your OB for shadow care throughout your pregnancy, this is a sticky situation. On the one hand, you have an obligation to tell the OB that you aren't planning on using him for the delivery. You're using his time, and he's not going to get the delivery (and the pay) at the end. He could be seeing other patients instead. I don't believe this is a respectful way to treat a professional. However, many OBs do not like being used in this way (whether for ideological or liability reasons) and informing them can get you fired as a patient.

2) Whether or not you should "ask permission" from the OB. I don't think you should. It's not likely that you'll get it. I agree with the suggestion to consult the midwife you plan to use. She would have a better idea (and it's her policies and protocols that will dictate whether or not you are a candidate for home birth, anyway).

[noobmom]

Originally Posted by AlexisT

There are two issues here:

1) Your obligations to the OB. I would say that your obligation is to terminate care once you feel you are past the danger point. No fuss, no drama, just a change of provider. If you are planning to see your OB for shadow care throughout your pregnancy, this is a sticky situation. On the one hand, you have an obligation to tell the OB that you aren't planning on using him for the delivery. You're using his time, and he's not going to get the delivery (and the pay) at the end. He could be seeing other patients instead. I don't believe this is a respectful way to treat a professional. However, many OBs do not like being used in this way (whether for ideological or liability reasons) and informing them can get you fired as a patient.

2) Whether or not you should "ask permission" from the OB. I don't think you should. It's not likely that you'll get it. I agree with the suggestion to consult the midwife you plan to use. She would have a better idea (and it's her policies and protocols that will dictate whether or not you are a candidate for home birth, anyway).

I really like this post and also the previous one where the PP was friend's with the OB. It's about respect, both ways.

Now, it sounds like from your OP that you're only planning to see the OB during the first trimester. In my experience, basically nothing happens in the first trimester except maybe a confirmation/dating ultrasound and possibly some blood tests. You end up having 2-3 appts at most? So, on one hand I don't see that it's a big deal to drop a doctor at that point. I dropped my OB after one visit because I just didn't like him--I just called the office and canceled my appts, told them I wouldn't be coming back.

On the other hand I'm not exactly sure why you're seeing an OB at all. I guess what I'm saying is that I don't know what you're trying to get out of utilizing an OB for just first trimester visits when not much really happens during that time.

[wombatclay]

I may be off base here, but it suonds like the OP just wants (or needs) to see an OB for the first trimester because of her medical history. It doesn't sound like she wants (or is planning to seek) long term shadow care... it's not a question of not calling the OB during labor after seeing them all pregnancy. (which I agree gets into a very grey area in terms of trust and honesty).

At 12 weeks there really shouldn't be any difficulty in leaving one care provider and moving to another... and unless it's a small town and there are non-compete type agreements in place she shouldn't have to explain her decision to the OB's office staff. It might be polite to inform them directly with something like "I've decided I'd prefer to birth at X with the midwife team from Y", but it's not required. She wouldn't be wasting anyone's time.

[MegBoz]

Originally Posted by ilovemyavery

So, I have several friends (one that is a midwife herself) advising me that I really should tell the OB that I am planning to birth out of the hospital and get, essentially, his clearance.

Uh, OBs don't "give clearance for HB" cuz they don't believe HB is safe for anyone!
ACOG specifically states that they oppose HB. So, that just doesn't make sense.

Expecting an OB to 'clear' or 'approve' you for HB is like expecting a firefighter to "approve" playing with matches. They think it's dangerous - they won't ever approve anyone doing it. (Ok, with RARE exceptions! But, as already written, the official ACOG policy is that HB is never safe for anyone!)

Originally Posted by ilovemyavery

My friends think it would be best if he knew of my intention from the get-go, so that he was better able to asses if there is any additional risk of my birthing out of the hospital.

Isn't that a job for your HB MW? You mentioned your considering HB or an FSBC, so I assume by "HB" you mean with a MW (not a UC). Shouldn't you trust your MW to be competent enough to handle this task?? I'm really surprised at your friends!

I would absolutely, positively, NOT tell him in advance that I was going to birth OOH!

You can also still get his opinion on whether or not you are "high risk" by just asking, "Hey, doc, I had uncomplicated, totally natural births before - you think my odds are good now of accomplishing that again?" There ya go! That will get you his assessment!

[MegBoz]

Originally Posted by CharlieToaster

He has to pay insurance in order to deliver. If something goes wrong, he's responsible. He actually does care about your life and the life of your child.

These sentiments are used very often to bully women into unnecessary interventions! "I care about your baby & am looking out for his best interests. Trust me."
Whereas, the fact of the matter is that American OBs are doing MORE damage with way too many unnecessary interventions. And interventions that science has PROVEN makes the birth process tougher on the baby!

Most American women may say, "My OB is responsible for my baby. He's 'to blame' (aka "responsible") if something goes wrong." BUT I DON"T! I don't think my HCP is solely responsible for my child. By choosing to HB, I'm already taking my birth into my own hands, to a large degree & doing something very non-mainstream. I think to HB is to take on some of the responsibility for the birth yourself. & I don't see a problem with that.

I just have this knee-jerk reaction of anger at the patriarchal attitude that "Papa OB knows best and you have to trust me."

No, Papa OB should be a trusted ADVISER, like an attorney or something. But decision making & therefore responsibility of the outcome, should be SHARED between mama & HCP. Yeah, if there's an 'emergency' (baby's HR drops precipitously or something), the OB has to act quickly & take charge, but in healthy women, with healthy births, WITHOUT iatrogenic [doctor caused] problems, such scenarios are rare.

Originally Posted by AlexisT

On the one hand, you have an obligation to tell the OB that you aren't planning on using him for the delivery. You're using his time, and he's not going to get the delivery (and the pay) at the end. He could be seeing other patients instead.

Well, I've very rarely heard of OB practices turning away patients. So I really don't think the OB is missing out on revenue from other pts by seeing her! Besides, as we all know, most OBs spend, maybe 5 minutes per appointment with each PG mama (and many of us spent maybe 45 minutes waiting for them!) So I disagree with this.

[kltroy]

I think this is pretty common... I know several women w/ recurrent losses who have been in a high-risk care or OB who specialized in recurrent loss, or a reproductive endocrinologist or whatever, for the first 3-5 months of pregnancy. Then once they know that it's going to "stick" they transfer to wherever they actually want to give birth (for my one friend it was a birth center). I would just have a conversation w/ the OB on your last appointment, thank him/her for the care, say you're transferring care now that you're not in danger of losing the pregnancy, and ask what followup, if any, they recommend.

[AlexisT]

wombatclay: I thought she also meant seeing an OB for first trimester only, but it wasn't 100% clear.

MegBoz: I do in fact know OB/GYNs who are fully booked, and it's an increasing problem as practitioners drop obstetrics. Yes, they are losing the delivery fee, and in any case, it's rude. You wouldn't do it to your midwife; don't do it to an OB. S/he is a professional. You're asking them to reserve time for you. I have health issues and see several doctors. I would never treat them that way. The failures of the American health care and maternity system do not excuse us from basic courtesy.

[MegBoz]

Originally Posted by AlexisT

The failures of the American health care and maternity system do not excuse us from basic courtesy.

I disagree. As one poster already said, she knows her OB would fire her from care if she told him she plans (if all is well) to birth at home or a FSBC. What else is she to do but not say anything???

If OBs were treating women with basic courtesy (respecting their autonomy, practicing evidence-based care [which would include supporting HB for low-risk mamas], for example), then we should in turn treat the OBs with basic courtesy. But that is not the case in America today.

If I had good input from others (say, other MDC mamas in my tribal area) that this OB was at least tolerant of OOH birth, then I'd tell the truth. But without that input, I'd have to assume he went along with ACOG policies & was therefore hostile to OOH birth.

If my choices are to keep my mouth shut, or take a big risk that I'll be dropped from care, then I don't think it's so wrong of me to keep my mouth shut.

[Turquesa]

Originally Posted by MegBoz

I disagree. As one poster already said, she knows her OB would fire her from care if she told him she plans (if all is well) to birth at home or a FSBC. What else is she to do but not say anything???

If OBs were treating women with basic courtesy (respecting their autonomy, practicing evidence-based care [which would include supporting HB for low-risk mamas], for example), then we should in turn treat the OBs with basic courtesy. But that is not the case in America today.

If I had good input from others (say, other MDC mamas in my tribal area) that this OB was at least tolerant of OOH birth, then I'd tell the truth. But without that input, I'd have to assume he went along with ACOG policies & was therefore hostile to OOH birth.

If my choices are to keep my mouth shut, or take a big risk that I'll be dropped from care, then I don't think it's so wrong of me to keep my mouth shut.

Yes, this. All of this.

I will add that we need to start behaving less like helpless "patients" and more like health care consumers. Even if it's through your insurance or tax dollars, you are ultimately paying these people and should have a say in what you're paying for.

If you're getting your haircut with a stylist and you're less than satisfied--or even if you know all along that you'll only see her temporarily--you don't "owe" her a phone call explaining that you're switching over. You don't need her "clearance" or approval to go to somebody else. She may be losing the money she could get from you later, but that's how the free market works, and there's nothing "discourteous" about it.

[CharlieToaster]

Do you perhaps have an option to use a midwife or CNM who is associated with and OB? I delivered in a freestanding birthcenter with CNM and they had a back up. That way you could all work together.

Oh, I do know many that have been turned away from and OB when they want to switch during their pregnancies. The practice where I started my last pregnancy in OK was in a town surrounded by a lot of indian reservations. It was a very large hospital practice that serviced the local arm base and many, many surrounding towns. I traveled an hour to get there. The indian hospital had decided to stop delivering babies but to continue prenatal care. They wanted to transfer into that practice in the third trimester. All the docotors in the practice debated the issue and decided that the prenatal care provided by that hospital was substandard. They didn't want to take on problems they believed could have been avoided.

My SIL is a nurse, she could also not change practices. Actually, when I had to change practices at 36 weeks my doctor was very concerned that I'd find someone. He took transfers but knew so many who didn't. Luckily that is basically unheard of here but not in a lot of places. When I asked him what my options were he said if you just go into labor and go to the hospital whomever is on call will deliver your baby and that's not always the best option. As it was, my OB did deliver my baby it we became friends afterwards because it was an awesome experience.

I'm all for homebirth. I really am. I'm all for a woman knowing their own body and being able to deliver. I am against dishonesty and treating a doctor like crap. Home birth doesn't always work out and you just may need him or her.

I also don't like the PAPA OB comment. I know it may be an isolated incidence but my OB delivered for 30 years and his father before him did as well. His dad was a huge supporter of women's rights in this area from the beginning.

When I did choose to use a doctor for my second delivery I was disowned by women I thought were my friends because I chose not to do a home birth in a town where I had no friends, no family and the midwife was 2 1/2 hours away and couldn't guarantee a homebirth from that distance. Any problems would have been med-evac from the local hospital. I was told I was uneducated because I didn't choose homebirth. In the end, I had a wonderful, natural birth experience with prenatal and delivery care from male doctors who supported me and all my choices with respect.

[MegBoz]

Originally Posted by CharlieToaster

I'm all for homebirth. I really am. I'm all for a woman knowing their own body and being able to deliver. I am against dishonesty and treating a doctor like crap. Home birth doesn't always work out and you just may need him or her.

Well what do you define as "treating a doc like crap?"

The simple fact of the matter is that the average American OB is hostile to HB. So if you do indeed support a woman's right to HB, then you have to accept that it simply MUST involve hiding HB plans from OBs. Period. It's the sad but true fact about American maternity care.

Also, please correct me if I'm wrong, but it seems to me that you are arguing the OB has a right to attend the birth in exchange for providing prenatal care? Almost as if you "cheat" him out of revenue that is due to him if you don't finish through care with him. Am I right?

Well, what if the mama miscarries? What if she moves out of town? What if she has a fast labor & an accidental, at-home UC?

If an OB feels that providing prenatal care is not economical unless he gets to attend the birth, then maybe he needs to raise prices (negotiate with insurance) etc. for those services. But to say, "I don't want to provide prenatal care to any woman unless I'm guaranteed to attend her birth [for the revenue.]" is unreasonable & unfair.

I like Turquesa's hair stylist analogy. Just because I make appointments with an OB for prenatal care doesn't mean he should expect that I will keep coming back! Same thing with the hair stylist. It's a free market - we don't like the services then we should take our business elsewhere!

Originally Posted by CharlieToaster

I also don't like the PAPA OB comment. I know it may be an isolated incidence but my OB delivered for 30 years and his father before him did as well. His dad was a huge supporter of women's rights in this area from the beginning.

Well, I didn't mean to insult your OB in particular, so I apologize if that's the way it came off. It's the perspective that I objected to. It is just my personal opinion, but for an OB to say, "I am responsible for the outcome of this birth, and I have a woman's best interest in mind," is a bit paternalistic and DOES mean he REMOVES some of the woman's own personal responsibility for her own birth. Again, by simply saying, "I am responsible," that strips her of her own piece of the responsibility.

[CharlieToaster]

Oh, I don't think that at all about the doctor feeling he needs to attend the birth. In a hopital practice it goes to the doctor on call if it's the middle of the night etc.... I was allowed to go 41 weeks 4 days past due before I induced. He game me the choice to try it on my own or have him do it. He was on call the next day so we planned it that way.

Even if you don't deliver in the hospital you still have to pay for antipartum care. I paid a heck of a lot out of pocket for the first OB I had with the last pregnancy. It came down to pretty much $30 per visit and ultra sounds. Thank goodness he trusted me to count kicks so I didn't have to have weekly stress tests with my GDM diagnosis. I'd have been even more broke. The actual delivery is different then the care you receive prior to the birth.

I don't think they have the right to attend a birth. It is basically their job but that's pretty much up in the air depending on doctors. You are right, some probably don't care. Others, even midwives are happy to attend your birth if you have a good relationship with you. My first birth had every midwife in attendance at some point! Even the receptionist came upstairs because we'd developed a relationship. I do think that doctor's care about the birth. If you saw him last week pregnant and he never heard from you again in the 3rd trimester I'm pretty sure someone would call.

I don't think that you have to keep going back to the same doctor. he or she is a business person as well. Quite frankly, they might not like you either. They may not want you to come back!

Essentially, I've seen the issue from both sides and have come to respect both. I lucked out. I got the birth I wanted even in a really bad situation. I had many conversations about the same subjects with my doctor before I delieverd. Simply because I was curious to hear his point of view. He said it really is an apples and oranges conversation and respects that. He thought midwives have gotten a bum rap in a lot of ways. Because he practiced for so long he saw the pros and cons to everything having lost a few moms and a few babies in the process and in respect for human life from a doctor's point of view he'd prefer to have birth attended by a medical doctor or at least have one on call in a midwife delivery.

Many pro-natural birth women have a tendency to belittle doctors. I'm not saying I haven't belittled my share of doctors in my time but only after I've received bad care. To assume you are going to receive bad care from a doctor or in a hospital is ignorant. My hospital experience was 100% better then my birth center experience in every way. You know why? I listened to people talk about how bad doctors and hospital deliveries are. I was already terrified of doctors and couldn't imagine spending 9 months being belittled by one. I went midwife and accepted it for what it was. I was hoping I'd go into labor when my favorite midwife was on call. I did. But My least favorite midwife caught my son. She had much more experience and I felt so much more comfortable in her care. Post partumn care was judgemental and very one sided and I was left hanging. I lucked out. The hospital I went to had everything a woman could possibly need to breast feed etc...

So, I'm speaking from my actual experience.

If you were unable to make a decision at some point in your birth wouldn't you want someone to have your best interest in mind? I know of no doctor who just does something without asking. Everyone is always given options if they are able to respond. I don't think you could get away with that anymore. Too much liability. And that, is a fact of life. I was induced and my best interest was always kept in mind. Pain meds were offerred, I declined, no problem. Pit was offered but only to the point where I'd be helpd and not pushed and only if I wanted it. He was up all night anyway. he gave me chances. The only thing he was adament about was when my water broke I had to check in but even my labor was started at home so I could walk outside etc... We were fine with that. I could have waited to call him but I didn't want to labor in front of my son.

Relationships go two ways if you allow it.

Oh, yeah, and back to the OP, if you think you need an OB in the first trimester what makes you think you won't need one later on?

[MiaMama]

nvm.

[CharlieToaster]

The reason I talk about this birth situation so passionately is because it's completely contrary to any medical experience I'd ever had before except for when I was 20 and wanted the pill and went to planned parenthood. That was a positive experience. The other situations completely sucked. I eventually had to take it all into my own hands and take the natural route. I've even been belittled by a naturopath. When I had kids, I changed. Luckily, I've been blessed to find good doctors that give me choices. Even when my children are involved. I think it's in my son's files at the pediatrician that I'm chill about medicine because they always take me very seriously when I have a question or bring my kids in at all. They always comment that I don't overreact etc....

Other then that I had the same issues. Hell, last family doctor I went to spent the whole time looking me over and deciding if I were crazy or not. She actually said that. LOL