[liliaceae]

I've been working on my birth plan and I'm planning on taking in a list of questions for my OB to my prenatal appt tomorrow. I want to get a feel for how intervention-minded she is and see how much of a fight I'll have on my hands. (I won't tell her that though

) I figure after I get her answers I'll have a better idea of what to write in my birth plan and I'll be able to further research any suggestions she makes. Unfortunately the practice I go to has 8 (!) med. providers (5 OBs and 3 CNMs) so I'll have to go over my birth plan many more times, if I even get a chance to see them all.

Anyway, here are my questions. What do you all think?

--What time limits do you put on laboring before suggesting medical intervention? Time limits after membranes rupture? Time limits while pushing?

--How often do you feel it is necessary to check the cervix during labor? How do you feel about minimizing vaginal exams?

--Is there any reason you would artificially rupture membranes?

--Are you comfortable with different birthing positions-squatting, standing, hands and knees, etc.? Are you comfortable with laboring and birthing in the tub? Under what circumstances would you want me to leave the tub?

--Under what circumstances would you want to do an episiotomy?

--Do you routinely suction vigorous babies? With meconium?

--When do you clamp and cut the cord? Are you comfortable with waiting until it stops pulsating?

--Do you allow the placenta to birth naturally? Do you use traction or pitocin?

--Would you be comfortable with me checking out early, if all is well?

 

[paintedbison]

Looks good to me!

 

[hollydlr]

I hate to say this, but honestly, if I were the doc I would see those questions as a clear sign that this patient is mistrustful of the medical model...in other words, he/she will be able to tell by the questions themselves as well as how you ask them, what kind of responses you want to hear to make a good impression. I would hate to suggest it, but there might be some docs out there who would tell you what you want to hear now even though that may not be what they really think. Maybe a better way to get a good idea would be to sort of act dumb and ask a very open ended question like "what are the routine things that will happen when I get to my due date?" Or even say something like "I think I want to just have a c-section, its much more convenient." and see what they say! You'll get a better idea of their true thoughts on the matter. Once you figure out what kind of a doctor you are dealing with, you will already have a good idea of their ideas on your above questions, and can talk about your desires openly, or get a new practice if you need... Just my 2 cents...good luck with your appointment!

 

[lifeguard]

I would keep questions as open-ended as possible so you get her answer & not the answer she thinks you want to hear (ie. How do you deal with...?)

With my ob appts I tried to keep it to no more than 4 questions about the birth plan at once so he wouldn't feel defensive - it was important to me to build a trusting relationsip. that said after the first appt I had a good feel for his approach from just those couple of questions.

 

[Turquesa]

I agree with Hollydlr. I would ask the same questions but do so with as neutral of wording possible. I would also change the phrasing on a couple.

Prefacing a question with "do you feel comfortable" could put a doc on the defensive. Also, references to "time limits" is a surefire indicator that you're one of those crazy, over-educated natural birthing fanatics who post on MDC.

Try: "In your opinion, how long is too long to labor? What steps would you take if you thought my labor was taking too long?"

And yes, as PP suggested, feel free to play dumb: "Really? A friend of mine gave birth while squatting. Would that be something worth trying?" Or (ETA) "What if my baby starts getting big? Should I get an induction?" Playing dumb can reveal a lot about the OB and his/her attitude toward women and childbirth.

 

[liliaceae]

Man playing dumb sounds like a lot of work.

I'll work on re-wording the questions though. Thanks for the advice!

I know this OB practice is at least moderately open-minded, I think all of them have attended waterbirths before for example. Why do you think they would just say whatever I want to hear? Are OBs that hard up for patients?

 

[pantufla]

Quote:

Originally Posted by liliaceae Why do you think they would just say whatever I want to hear? Are OBs that hard up for patients?

OBs are people too. Lots of people like to say "the right thing" to someone with whom they have a professional relationship. But more to the point, they know that when you're in labor you're going to be too tired to mount a defense, and it will be easier to override your wishes at that time than to argue with you ahead of time.

 

[Kappa]

For me, it was very important to know whether an ultrasound would be required and how many. Many docs give monthly ultrasounds, exponentially increasing the "risk" of finding something "wrong." If you would like to go with the "play dumb" model, you can anxiously tell the doc that you do not want to know the sex so you don't think you need an ultrasound. There are no reasons to do late term ultrasounds without a medical reason, it just keeps the techs employed, so the doc should be pretty easy about that. If s/he feels he won't be able to tell, for instance, whether the baby is breech, run for the hills.

My midwife did not require an ultrasound, but would order one at about 20 weeks if the patient wanted one. I had to switch to an OB because of insurance, and I allowed her to do an additional ultrasound, but I did argue with her about it, tell her my measurements were fine, and that I did not understand why I needed one. She never gave me a good reason, but I gave in because she was, generally, natural minded and turned out to be that way in the end.

 

[hollydlr]

Quote:

Quote: Originally Posted by liliaceae View Post Why do you think they would just say whatever I want to hear? Are OBs that hard up for patients? OBs are people too. Lots of people like to say "the right thing" to someone with whom they have a professional relationship. But more to the point, they know that when you're in labor you're going to be too tired to mount a defense, and it will be easier to override your wishes at that time than to argue with you ahead of time.

:

This would imply that the doctor is not interested in forming a relationship of trust, but rather, managing your birth according to his/her preference. This kind of attitude is unfortunately all too common, as the doctor feels he/she knows best, and ultimately should be the one to make decisions about your care. This kind of attitude is exactly what you want to uncover and avoid. I think asking questions like "what do you usually do if a mom goes past her due date?" instead of "I won't let you induce me just for post dates, are you comfortable with that?" will help you figure that out. The first question will let you in on his/her labor management mindset, whereas the second question automatically puts him/her in defensive mode...

As for "plying dumb" I guess I just meant avoiding using technical terms like "artificially rupture membranes" and instead say "break my water." Giving the doc the impression that you have read a lot of books like "Thinking Woman's Guide" will make them respond differently than if they just think you are asking about things that happened to your friend or sister that you are wondering about, kwim?

 

[meganmarie]

I did run my birth plan past every one of the 6 docs in my practice for birth #1 so I know what I challenge you have ahead of you but encourage you to do it - when you make appointments, try to rotate through each one. That way I knew whoever showed up in labor was at least marginally aware of and the key elements of my birth plan. And I knew more what to expect from each one.

I like with the "open-ended" phrasing idea... "How do you handle" vs. "Are you comfortable with." If you just present your preferences (which I did) you do have to kind of "interpret" how they respond and question whether you trust it.

There was definitely a mix in my case - one doctor was genuinely supportive ("absolutely we can do those things, here's the only issues we might have with the hospital, here's how we can deal with that, etc."), one was totally awful but at least honest ("you know, you can't get too attached to a birth plan...don't be too sure you won't want the epidural...you wouldn't get your appendix out without drugs would you?") and one was totally "yessing" me without really engaging and so I never felt totally confident about his support.

Nonetheless - by the time I had rotated through all of them I knew which were the two most open-minded, which seemed neutral and which two were more intervention-oriented, and I was prepared to deal with them accordingly. At least I felt less anxious after this. Also, I was careful to schedule the crucial 40-week appointment with the OB I knew was willing to be most hands-off, so as to avoid the chances of pushy induction-talk.

 

[liliaceae]

Well I asked her the questions today. Most of her answers weren't too bad, and I could tell she wasn't telling me just what I wanted to hear. The appt left me feeling kind of disappointed though, I guess just her general demeanor. She was very willing to talk about everything, but I could tell she was kind of uncomfortable with me questioning things.

It sucked because at the beginning of the appt. she asked me to sign a consent form for another HIV test (apparently they do one at the beginning of the pregnancy and at 6 months). I said that I wanted to decline it, and I could tell she was not ready for that answer. She told me if I declined it the baby would have to get tested (which I know is BS because they can't do a blood test on my baby without my consent). But I ended up consenting to it because I don't want to have to fight about it after the baby is born.

Anyway I thought I'd share with you all her answers to my questions. I did reword them a bit, and I didn't ask them exactly as they're written here, I just adapted based on her responses.

Q: How long is it safe to labor after my water has broken?

A: She would start wanting to use pitocin after 12 hours.

Q: How often should the cervix be checked during labor?

A: Depends on what's happening, usually every 2 hours or so during active labor.

Q: Under what circumstances would you artificially rupture membranes?

A: After about 8 cm if they haven't ruptured already (she said you wouldn't want to wait until your pushing, I have no idea why though), or if internal monitoring is required.

Q: What do you think about giving birth in different positions-squatting, standing, hands and knees, etc.? Laboring and birthing in the tub? Under what circumstances would you not want me to be in the tub?

A: She's fine with different positions. Birthing in tub is okay as long as everything is pretty much perfect--no meconium, no problems with the fetal heartbeat, she'd want me to get out after an hour of pushing.

Q: Under what circumstances would you want to do an episiotomy?

A: She doesn't really do episiotomies, says it's better to tear. Sounds like she'd only do it for the baby's safety.

Q: Do you normally suction vigorous babies? When meconium is present?

A: She does light suctioning of all babies, but not deep suctioning. (I mentioned the AAP saying suctioning of vigorous babies isn't necessary, and she said they were just talking about deep suctioning with vigorous meconium babies.)

Q: Do you clamp and cut the cord immediately? Is it safe to wait until it stops pulsating?

A: She usually clamps it immediately but doesn't mind waiting. She says it doesn't make a difference and she doesn't think the baby gets any extra blood by waiting, because the baby is up higher than the placenta.

Q: Do you normally do anything to encourage the placenta to birth? Do you use traction or pitocin?

A: She lets it birth naturally unless there's a problem. She said some women try nipple stimulation but that doesn't work.

Q: What percentage of women whose birth's you attend end up getting pitocin to speed up labor?

A: She kind of balked at giving a percentage, I could tell she was uncomfortable with this question. I asked if most of them do and she said, no not most, maybe 50%. So I'm not sure if that was an honest answer or not.

What do you all think of those answers? Most of them weren't exactly what I wanted to hear, but I was happy that she doesn't do episiotomies and doesn't have a problem with different birthing positions. I wasn't happy about the fact that she would rupture membranes for no apparent reason, but I figure I can just say no to that.

 

[*MamaJen*]

Sounds pretty standard for a hospital. Any chance you could get care through a midwife?

 

[liliaceae]

Quote:

Originally Posted by *MamaJen* Sounds pretty standard for a hospital. Any chance you could get care through a midwife?

The only CNMs around here are part of an OB practice. Is it common for CNMs to have their own practice in other places?

My only other option other than home birth (which I've decided against) is a birth center that's over an hour away from me.

 

[paintedbison]

I think the answers aren't bad coming from an ob. The episiotomy answer, waiting 12 hours to start pit after your water breaks, waiting to cut the cord, birthing in different positions... all sounds good to me. However, I think the vibe you get is more important than the answers you get. If you feel like something isn't right, it probably isn't. Any other more natural obs around that you can give a shot? An hour to a birthing center doesn't sound horrible to me...

 

[MegBoz]

Quote:

Originally Posted by liliaceae Why do you think they would just say whatever I want to hear? Are OBs that hard up for patients?

Another issue here I think is that OBs might not deliberately lie to you... but they might tell you how they THINK they ought to practice (more naturally minded & hands-off), but that might not be how they REALLY practice. For example, they might think that you're desire to work with your body naturally is great... but when it comes down to it, old habits die hard & impatience might perservere. Impatience combined with the natural distrust most OBs have of birth that would lead her to worry about the baby & she may start to 'push' your birth.

So that is why I advocate open-ended Qs to help reveal the OBs typical practice style without revealing to the OB your desires for a non-pushed birth.

Quote:

Originally Posted by liliaceae The only CNMs around here are part of an OB practice. Is it common for CNMs to have their own practice in other places?

Regulations for MWs vary by state. I'm not sure if they're legally required to have OB backup in some states or not.

Anyway, my CNMs had OB backup, but if you were a patient of the CNMs, you NEVER saw an OB, nor would you unless the MW herself suggested it! The OBs didn't "oversee" things & check-up on the MW. They only came into the picture if there was a need - and then only if the MW called them in. So at the hospital, there was always a MW, and an OB on call. There were 3 CNMs, so whichever of the 3 was on call would attend your birth. IS that not how it works there?

As for the answers, I agree with paintedbison.

"she said you wouldn't want to wait (to rupture membranes) until your pushing,"

OK, that is a new one for me! That seems a little wacky to me. So far as I know, there's no reason you "wouldn't want" the baby to be born IN his bag!!! ("in the caul" I think it's called.) Particularly if you're GBS+, keeping him in the bag will shield him from the dangerous bacteria in your vagina.
My bag stayed in tact until I gave my first big push (a whole 30 min after I got through 1st stage! I hadn't left my house yet.) It broke as I pushed for the first time, no problem with that at all. As a matter of fact, the "forewaters" that start to spill out actually cushion the cervix & provide a cushion for baby's head. I've never heard that they make it difficult to push or anything.

 

[Belle]

Quote:

(she said you wouldn't want to wait until your pushing, I have no idea why though)

Because then there is the possibility of her getting soaked with amniotic fluid and that's just yucky for her. Its actually easier for you to push with intact membranes.

Quote:

A: She usually clamps it immediately but doesn't mind waiting. She says it doesn't make a difference and she doesn't think the baby gets any extra blood by waiting, because the baby is up higher than the placenta.

I have doubts about this comment right here. Why would the blood not continue to go to the baby from the placenta because the baby is higher. Do people not get blood to their brains because their brain is higher than their hearts? The blood gets pumped up to the baby, until the cord stops pulsing.

Quote:

A: She kind of balked at giving a percentage, I could tell she was uncomfortable with this question. I asked if most of them do and she said, no not most, maybe 50%. So I'm not sure if that was an honest answer or not.

I'd be wary of this one. Her answers on episiotomy, VEs and water breaking didn't seem too bad though.

 

[alegna]

Sounds pretty typical to me. If that's not what you want I'd reconsider homebirth.

-Angela

 

[hollydlr]

Not bad, not great answers to your questions, but it depends on how much you are ok with having to be defensive during labor. I pretty much agree with pp. Have you asked anyone in the birth community in your area what kind of a repuation this practice has? I think that is a really valuable way to evaluate your chances of having a low/no intervention birth with them. Call around to the local doulas, LLL leaders, childbirth educators, etc. and ask what they know of this doctor/practice. You'll learn a lot!

 

[Goatriffic]

She sounds pretty average for an OB but these are the things that stood out to me. I would be uncomfortable with any care provider that did procedures, rupturing membranes at 8cm, for no medical reason. I would also be uncomfortable with a care provider who lied to me about my ability to decline a test for my baby simply to get me to consent. Will you be able to stand up for yourself during labor? What if she "accidentally" breaks your water during one of her many vaginal exams? Will you trust her if she tells you a test/intervention is necessary?

I know that I am unable to stand up for myself well during labor so after 3 births with OBs/Midwives I couldn't trust 100% I chose a homebirth with someone who gave all the right answers and I had complete trust in. The difference was amazing. Do you have any other options? No woman should have to fight her way through labor to have her wishes respected.

 

[meganmarie]

These would be my specific reactions to some of those items:

I would be very specific in writing that I do not want membranes ruptured for no reason, even if they don't break before pushing. And that I want them to ask my permission before doing any such thing. And I'd make sure my DH or doula is reminding them of this during VEs because I have heard of care providers who forget to ask.

Also, I would ask for at LEAST 24 hours after water breaking before starting pit. My CNMs said 12 hours at first (because they were restricted by hospital protocol) but were willing to give me 24 hours when I questioned them. (The key thing here is to avoid infection, and therefore you don't want exams or anything in your vagina during this time.) Another option of course is not to call in right away if water breaks first without cx so the ticking clock doesn't start until later. (I ended up doing this with birth #2 because I didn't actually much like having a 24 hour limit either!!)

I personally don't love the idea of VEs "every 2 hours" because the only thing that will do is give them more reasons to think you aren't progressing "fast enough" and need pitocin, or give you information that discourages you ("It hurts so much and I'm only 4 cm! I give up!" When who knows, you could get to 9 cm in an hour). And of course, every VE increases the odds of infection. So... worth asking if you can limit these to an "as-needed" basis. Of course, you can avoid this issue altogether by not going to the hospital until you are pushing