[Sileree]

Not really sure where to post this, but I do want some advice from midwives (and anyone else is welcome too).

Hi guys, I am a doula and I have a client, E, who is planning on getting pregnant for the second time soon. She had a c-section for her first, and was and is very upset over it. She plans to go to an OB for prenatal care because of her miscarriage history but give birth at home. She wants to know if she should tell the OB up front or not? She knows it may be dishonest but she's worried they will harrass her and drop her from their care if she admits this. Not sure what to do. Would an OB necessarily be better at prenatal care than a midwife, even with a history of miscarriages?

Any advice or opinions will be welcome.

 

[memiles]

IMO, the prenatal care from a MW far exceeds that from an OB. You get hour long appointments, a provider who actually knows not only your name, but the names of your children, and someone who really cares how you are feeling, both physically and emotionally. It would be important to find a mw comfortable with the history of miscarriage, and possibly even see an MD *if it's medically indicated. However, starting out with the OB is only setting the woman up to consider the pregnancy high risk, which I think is more stress than it's worth.

 

[Reha]

Quote:

Originally Posted by Sileree She knows it may be dishonest but she's worried they will harrass her and drop her from their care if she admits this. Not sure what to do. Would an OB necessarily be better at prenatal care than a midwife, even with a history of miscarriages?

I would be concerned about seeing any birth attendant, even for just prenatal care, that she feels may harrass her or drop her from their care due to their disagreement with a birthing decision she is making.

I must say that imo, a homebirth midwife would provide far superior prenatal care for a woman with a history of miscarrige. A midwife will (usually) provide much more information about nutrition and health to the mom. If you think about it, what can an OB do that is superior to a midwife in terms of miscarraige? Sure, they can offer her an U/S (Which she can still request even if she is with a homebirth midwife for prenatal care) and stick her on bedrest (which hasn't been shown to be all that effective anyways)....If I were a mom with a history of miscarriage, I would feel perfectly safe and secure in a decision to see a midwife for my prenatal care. I think that with a midwife's knowledge of nutrition, herbs, and health, she will have a much more likely time to carry her baby to term.

 

[MamaRabbit]

The first thing that popped into my head was that even if she did use an OB, then at the end of her pregnancy from about 38wk on, she's going to get a lot of pressure to "have the baby now, or else!"

That said, I did use an OB for prenatal care and then did a homebirth. He just assumed the baby came too fast to get to the hospital. And he still doesn't know. I think he was more upset about losing money from a delivery

 

[boscopup]

I'm seeing an OB and a homebirth midwife at the same time. I do feel that I get better prenatal care from the midwife, although not knowing your client's miscarriage history (and what the reasons for the miscarriages may be), it's hard to say whether an OB would be helpful or not. There are women with clotting disorders, progesterone issues, etc. that sometimes require medication just to stay pregnant. So if that were the case for this woman, seeing an OB wouldn't be a bad idea. OBs *can* do more than just an u/s to see if baby is alive, once there have been multiple miscarriages and a cause is known (usually through blood tests done on the mother before getting pregnant again).

Anyway, as for whether to tell the OB or not... I told my OB. For one thing, I don't believe in lying. For another, I feel that if my OB can't accept my birthing decisions, I don't want him/her to be my care provider. My midwife agreed with me about telling him, as she said that SHE likes to know when someone is also seeing an OB - it goes both ways, ya know? And as it turns out, while talking to my OB, I found that at least 2 or 3 women had "accidentally had their babies at home", when they were really planning it all along and didn't tell him (he had heard through the grapevine before hand that at least one of the women was planning this). His feelings were hurt by that - that they weren't honest with him about their plans. But then again, my OB is not your average OB - he's actually very open minded and tries to best accomodate a woman's wishes, as long as he thinks it's medically safe to do so (and if he's not sure of safety, he does some research).

If I make it to 36 weeks (my previous birth was preterm), my midwife can deliver me, and I can stop going to the OB and have my wonderful out-of-hospital birth. If I go early, I have a good, open minded, NCB-friendly OB that I won't have to argue with to get the birth experience I want. I've done the randomly assigned OB thing in the hospital, and don't recommend it! But I also recommend seeing the midwife through the whole pregnancy, and just using the OB in tandem for as long as needed.

 

[Reha]

Quote:

Originally Posted by boscopup There are women with clotting disorders, progesterone issues, etc. that sometimes require medication just to stay pregnant. So if that were the case for this woman, seeing an OB wouldn't be a bad idea. OBs *can* do more than just an u/s to see if baby is alive, once there have been multiple miscarriages and a cause is known (usually through blood tests done on the mother before getting pregnant again).

Yes, this is true, but a midwife can order blood tests to check hormone levels and refere out for the suggested treatment accordingly (progest. supositories, etc). A midwife will also be able to offer much more than just drugs with a threatened miscarraige (vitamins, herbs, overall nutrition). Depending upon the cause of her miscarriage history, it would even be a good idea to have a consult with a midwife to discuss all of these things before conception occurs.

But, yes, more than anything, it is important to find a care provider who you can be honest with and who you know will respect your decisions.

 

[Maggi315]

I think she is setting herself up for problems. I don't care about the being dishonest part, but I just see more women end up with hospital births when they go this route. They dont full trust the homebirth model and/or their midwife. And going to the ob every appointment sets her up for more interventions, differing opinions, etc. which can be confusing and upsetting.

My clients are free to see another professional or get a second opinion, but around here if they find out you are seeing a homebirth midwife, they will "fire" you as a client. Nice, huh?

 

[lolar2]

I have a clotting disorder, and am seeing a perinatologist concurrently with my homebirth CNM. This was the midwife's idea, because she said she does not know enough about clotting disorders to treat me for it. Both of them are aware of what I am doing.

When I had my first pregnancy, during which I miscarried at 27 weeks, I saw an OB practice for my regular prenatal care. They said the same as the midwife: that when I got pregnant again, if I used them again, they would have a perinatologist deal with the clotting disorder while they did the regular prenatal care. No difference there. Typically, a perinatologist treats pathologies of pregnancy and leaves the actual delivery and regular care to an OB. So to a perinatologist, leaving the delivery and regular care to a homebirth midwife doesn't change his or her life one bit. Plus they are better-equipped than regular OBs to treat some miscarriage risks, anyhow. Your client might ask the midwife if she has a relationship with a perinatologist she can use.

The only things that would change this recommendation would be if you are in a state where midwives have an iffy legal status, or the available perinatologists have some sort of malpractice insurance issue with homebirth, or something like that. Otherwise, it is working well for me, and my midwife said she has used that arrangement in the past.

 

[mwherbs]

something I have seen in recent years that happened a long time ago is clients who get dual care. there are some good reasons especially for a VBAC to have established care- one would be if there was cause to transfer care for a problem mom would already be an established client and she can hopefully find an OB who would support a VBAC- so she would not be harassed and may still end up with a VBAC

now the thing about telling about intent to home birth - probably not a good idea at this point docs feel that if they know you are doing a home birth that this some how translates to back-up and support and they are quick to disassociate themselves so you may get fired as a patient and then if you needed help even if this was the on-call doc the doc may refuse to show up for you-
things to be careful about dual care- what is the client's commitment level? are they second guessing everything both providers are saying? sometimes this represents a form of internal struggle about belief systems. and could end up being a mess-- but a good midwife can usually sift through this with a couple.

 

[boscopup]

Quote:

Originally Posted by Lennon Yes, this is true, but a midwife can order blood tests to check hormone levels and refere out for the suggested treatment accordingly (progest. supositories, etc).

This probably depends on the area. My midwife has no "backup OB". She does have access to a lab (insurance usually won't pay for it), but she has no prescriptive authority, and no OB in my area (in my state or the state she practices in) will see you for "just one visit". It's pretty much - get all the prenatal care with the OB or none at all. Believe me, I called around trying to get basic labwork done at an OB so insurance would cover it last time!

I ended up paying out of pocket for the labwork, because I'm not willing to lie in that situation - telling an OB I'll see them and then canceling all appts.

The OB I have now... He'd probably have been more willing to see someone on an as-needed basis, but insurance billing gets screwy, so it's really difficult for the OB to do that in my area. My OB might find a way anyway, because he's just a really nice guy and will bend over backward for his clients (he just did his first waterbirth last night, at a hospital that's never had a waterbirth, and he did everything his client wanted, even though most of it was out of the norm for that hospital).

The PP mentioned a perinatologist... That's a great idea for the OP's client. Then you don't have to worry about the issue of "where to birth" as much, and she probably wouldn't need to see the peri much past the first trimester.

 

[lolar2]

Quote:

Originally Posted by boscopup The PP mentioned a perinatologist... That's a great idea for the OP's client. Then you don't have to worry about the issue of "where to birth" as much, and she probably wouldn't need to see the peri much past the first trimester.

Actually that depends on the specific types of miscarriage in her history. In my case, I will not have an actual peri appointment (he just called in a Lovenox prescription at the beginning of my pregnancy) until I am at least 16 weeks along, and then the appointments will be more frequent in the third trimester.

 

[mwherbs]

even when the HMO's won't cover us as providers they usually will take the labs and run them and bill the insurance. you either draw the labs and send to the proper one the HMO covers or you send them in and have the lab do the draw.
another trick we us to use was to have women go to someone else who has some legal right to request labs like a chiropractor- in many places a chiropractor can order all kinds of labs- and ultrasounds as well as x-rays. or how about clinics that don't do deliveries but do prenatal care we have several one is a Catholic charity, others are for migrant health care... or there is always the county health department and planned parenthood (although planned parent hood has become fairly expensive in recent years look for a title 9 funded one if low income)

 

[boscopup]

I don't even have an HMO. It's BC/BS PPO. In my state, most of the BC/BS plans do not cover anything midwife, since midwives are illegal here (even though my midwife practices in a state where it IS legal). Very few people are actually able to get anything covered at all in my area. And chiropractors? Hahaha... I am seeing a wonderful chiropractor, and supposedly, my insurance covers 80%... BUT... They only cover up to $400, AND you have to first meet a $300 major medical deductible (which counts towards the $400). They ended up paying a whopping $87 of my entire pregnancy chiropractic treatment.

No, I wouldn't get anything from insurance by going through a chiropractor for anything pregnancy-related.

Most of the BC/BS plans in my state won't even cover midwives as out-of-network providers.

:

 

[darsmama]

I remember going to the OB when I was pregnant with my first and on my birth sheet I wrote "water birth". The Dr looked at me and said "That's not going to happen"
I replied "well, I'm having a home birth, I just want to see you for the pregnancy" (this was before I knew MW's knew pren. care too)
He looked at me like I had just announced "I AM SATAN!" in his office. I was utterly confused and that was when he informed me that seeing an OB generally meant he was to deliver the baby, they didn't do care with MW's like that.
I was like oh. Ok. Well, a regular birth is fine then. Whatever you are offering

Got my tests, and ofcourse had that homebirth

but I learned that honesty is not the best policy with OB's sometimes, especially if they aren't friendly to that sorta thing.