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<p>So, I'm planning a homebirth and am just seeing the OB for the first 20 weeks for ultrasounds, bloodwork, and Zofran.  I would probably go back later if I had a UTI and needed antibiotics or something like that as well.  I have Kaiser, which means that the insurer is also the provider, thus there is no real choice of doctors ... I could see one person if I wanted during the pregnancy, but they have a large call schedule and it would be really hard to meet every potential person who could be at one's birth.  Anyway, based on some things I read in the booklet they gave me at my first appointment, I am curious about/skeptical of the organization's support for/hostility toward normal birth, and I want to ask some questions when I see the OB on Wednesday.</p>
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<p>What I need help with is getting my tone right!  I will readily admit that I am uber-biased against OBs in general, so in my head there is all sarcasm and snark.  But, I would like to maintain a cordial relationship in the event that something occurs during my pregnancy that risks me out of midwifery care and necessitates going back to them for the birth. </p>
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<p>The things I read in the booklet that bother me are: (1) routine cervical checks after 36 weeks (mega old school, why do they do this?  of course I would decline); (2) continuous fetal monitoring for all (I am thinking the booklet was written to the mainstream audience most of whom will have epidurals, and perhaps does not preclude intermittent monitoring for those who prefer a natural birth?); (3) everyone pushes in the lithotomy position -- seriously, they gave a detailed description of your legs being up and supported, etc.  I was horrified; (4) mention of episiotomy (with the half hearted disclaimer "if you need one" as if ANYONE needs one in anything other than a dire emergency.  Those are the ones I can think of off the top of my head.  I guess in general I want to ask if they support normal birth, then ask about those specific things, and then perhaps ask how they would react to me declining various things (the aforementioned cervical checks, pitocin in the third stage, the IV, continuous monitoring, etc, the list goes on and on).  How do I broach these things without sounding like, well, a problem patient?  (Which I am and would be). </p>
 

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<p>I would just be honest with them.  Tell them that you were reading through their provided literature and had some questions.  Just state your questions calmly and listen.  You don't have to get into a debate with them.</p>
 

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<p>Just treat the OB like a regular person. Talk to him like he ISN'T going to try to push for everything you're against. Give him the benefit of the doubt. He is just doing his job and honestly doesn't know better. You don't really need to talk about any of those bothersome things unless you do end up risking out. But if you have questions, ask them. Don't argue, just listen. And you can come up with a plan to deal with them later if you need to. I got really lucky... My midwife has a good relationship with a pair of OBs that she actually sends ALL her patients to for their 20 week u/s or at least a little meet and greet, because they are the ones who will deliver your baby if you end up at the hospital. They are old guys, one of them is foreign and a little mean... But they are all for home birth for low risk women. The OB who placed my cerclage is awesome. If I couldn't get my midwife to take me on because of my history of preemies, I'd just see him. As it is, I see him only for the medical stuff my mw can't do because she is a cpm and not a cnm.</p>
 

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<p>Hmmm Kaiser California didn't give me such literature at all! They actually have super low c-section rates and many CNMs on staff. I can't speak for actual birth experience since I switched to private insurance mid-pregnancy.</p>
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<p>Anyways, with Kaiser I wouldn't be afraid to be open and voice my opinion and wishes. They can't fire you like private obgyns can.... And don't forget, you can always say no to whatever you don't like. Since you are not planning to give birth there, don't sweat it. But in case of a transfer, have a birth plan on file. That would be great I think, have it in the file just in case. You can always refuse a monitor, the checks... Btw all obgyns in the town in CA where I actually gave birth started cervical checks at 35 weeks. It's pretty standard in the obgyn world.</p>
 

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<p>Maybe you could use the episiotomy as an opening...  Since they say "if you need it", that could be a good non threatening way to get a feel for your OB's position on such thing.  You could ask about what kind of situation would make you "need it", how often he finds that moms "need it".   Whether he answers "I've only done a handful the last couple years" or "It makes it a lot easier on the mom when I cut" should give you a good feel for his overall attitude. </p>
<p>Or you could ask "At what point in labor do the nurses start the continuous monitoring?  From the moment I come in?  When Im in active labor?  When Im stuck in bed because of an epidural if I choose to have one?"   I think it's a way of asking that's non threatening, it doesnt question his way of doing things, but it opens the door to discussion</p>
 

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<p>Thanks for the responses!  I wanted to report back that I went to my appointment this morning and asked some questions and was really encouraged by the responses.  I first asked about the degree of discretion that Kaiser docs have (versus what is "policy"), then I moved on to some specific items.  The doc I spoke with this morning is a young woman and she seemed pretty "with it" as OBs go.  They do allow intermittent monitoring as long as heart tones are reassuring, and she said the last natural birth she attended was just this past Sunday.  She said that there are some differences among different doctors, but that they will be responsive to your wishes and just to let them know upfront that you want a natural birth.  It was a very cordial conversation, she didn't seem threatened by my questions at all.  I get the impression that depending on the doc you draw, you could still be in for argument/have to be firm in your refusal regarding some things, but I'm reassured that they aren't as strict as it seemed from the written material.</p>
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<p>So, I'm still planning to have my homebirth, but I'm reassured that I will still be able to maintain a relationship with this practice in the event that I need obstetrical care later on.</p>
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<p>I wouldn't make assumptions before you visit. In CA, Kaiser has lots of CNM on staff and a super low csection rate. Also have good breastfeeding support in the hospital. Why? CHEAP. =) Or because it is better for mom or baby. Either way, your doc might be open to a lot of your ideas. Don't let a single brochure depress you.</p>
 

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<p>slightly an aside but i would consider an episiotomy a "need" in case of an upward tear. i mean, you'd survive but what a cost. </p>
 

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<div class="quote-container"><span>Quote:</span>
<div class="quote-block">Originally Posted by <strong>tzs</strong> <a href="/community/forum/thread/1282436/help-me-take-the-right-tone-with-my-ob#post_16086464"><img alt="View Post" class="inlineimg" src="/community/img/forum/go_quote.gif" style="border:0px solid;"></a><br><br><p>slightly an aside but i would consider an episiotomy a "need" in case of an upward tear. i mean, you'd survive but what a cost. </p>
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That sounds great in theory. Certainly I too would chose a cut in the perinium vs. a tear up into the urethra & clitoris. However, it's not evidence based. It's just not. It's not really possible to tell what way a tear might be happening and "redirect it." <strong>Episiotomies just don't prevent worse tears <em>in any direction</em>- they LEAD to worse tears.</strong></p>
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<p>Besides, a doc fussing and poking around down there alone can contribute to worse tears - fingers in the vagina, "wrenching it open" (sometimes incorrectly referred to as "perinial massage.") While <span style="text-decoration:underline;"><em>prenatal</em></span> perinial massage can reduce the risk of tears, vagina 'wrenching' during 2nd stage doesn't. Quite on the contrary - it can cause the tissues to swell & therefore increase the risk of worse tears.</p>
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<p>I'm pretty sure the only things a HCP can really do to reduce the risk of tears from a physical support stand point are warm compresses and counter-pressure at the time of crowning. In addition to other helpful things like encouraging mama NOT to push, if possible, at the time of crowning, encouraging her to push in whatever position feels the best for her, and encouraging her to listen to her body (not "purple push", etc.)</p>
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<p>Oh - the one & only other case I know that is legit for epis aside from fetal distress is in the case of a mama with severe scar tissue that simply is truly incapable of stretching. of course, in that case, prenatal perinal massage could fix the problem. My MW herself said she had a fourth degree tear and prenatal perinial massage enabled her to birth in the future with no tears at all.</p>
 
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