Choosing a Birth Attendant

Most people see pregnancy as a time to prepare for the baby.  I see early pregnancy as a time to figure out what you want before you even go to your first appointment.  A lot of women don’t even think about the actual birth until a few months or weeks before the baby is born!  It can be difficult to make a change that late in the game.  You should choose the provider who has the same philosophy as you instead of hoping to change them by the end of the pregnancy.

Tips for choosing a birth attendant

  • Think about your core birthing philosophy.  Do you feel that birth is a natural physiological process?  If so, a midwife is your best bet.  Do you have physical issues that dictate that there could be a potential problem?  Do you see birth as dangerous with lots of opportunities for things to go wrong?  Then an OB might be your preferred provider.
  • Visit The Birth Survey, a consumer reporting site dedicated to birth.  Go to rate your OB, midwife, and place of birth.  As of now the site is just up and running and they should have formulated the results by Fall of 08
  • Get recomendations from people who share your birthing point of view, visit online forums (like and ask questions.
  • Interview your potential care provider.  Remember, they are working for you, not the other way around.  Related posts:  Interviewing your OB, Interviewing your Midwife, and Interviewing your Place of Birth
  • Create a birth plan well before your second or third trimester.  Going to your provider interview with a birth plan or at least an idea of what you want can help you ask the right questions.  Just make sure to not be negative or badger the doctor!
  • How much one-on-one, hands-on support do you want during pregnancy? Midwives generally treat the whole woman:  mentally, physically, socially, psychologically, spiritually.  Prenatal appointments generally last about an hour and they are usually there for the majority of labor and birth.  OBs on the other hand are primarily surgical specialists who have a prenatal appointment time of about five minutes and generally just come in at the end to catch the baby.
  • How much involvement do you want in your pregnancy and birth? Many times in midwifery practices the mom gets to do her own urine dip and weigh herself at her appointments.  The midwife tries to explain things to her and tries to get her to interact during her visits.  An OB visit is more in-and-out with the nurses doing everything behind the scenes.
  • Where do you want to give birth? Some women just go to an OB because they think they’re supposed to and then realize late in pregnancy that they want a home birth!  Where you give birth automatically dictates who will be there.  For example in Colorado at this time, OBs work in the hospital, only Certified Nurse Midwives (CNM) can work at a birth center, and Certified Professional Midwives (CPM) and CNMs can do home births.  Most CNMs (90-95%) work with doctors in the hospital.
  • Do you want to have a waterbirth? Some hospitals allow it, some do not.  If you have to give birth in a hospital and want to fight a policy that does not allow waterbirth, having a provider who supports it can go a long way.  Yes, it is possible to change hospital policy!  In Gentle Birth Choices Barbara Harper talks about how to do this.
  • Choose someone you’re comfortable with. If you’re not comfortable with your provider there is no way you can let your body open up and relax enough to have a baby.
  • If a provider or place (like home or birthing center) is out of your insurance network, talk to your insurance provider.  Also, often times a home birth or birthing center is cheaper even though you have to pay in full.  For example, in Colorado a typical, no-intervention birth in a hospital usually costs around $12,000-13,000.  In an insurance plan where you pay 10% of hospital and doctor’s costs you’re looking at a few thousand dollars.  A home birth or birth center birth usually costs around that if you’re paying in full.
  • Do you feel more comfortable with a male or female doctor?  Remember that just because a doctor is female doesn’t mean she believes in the same birthing philosophy as you do.

Interviewing Your OB

Know your Obstetrician

It is so important to know what you’re getting into before you’re in labor!  Interview any OBs, midwives, hospitals, and birth centers you are considering and make the best decision for you.  Also, a great new website, The Birth Survey, provides consumer reporting for doctors, midwives, and hospitals (at this point you can take the survey, but the results are said to be formulated by Fall 2008).

Here are some questions to ask your Obstetrician to make sure you find one who is on the same page with your birthing beliefs.  These are taken from Gentle Birth Choices, written by Barbara Harper, 2005, p. 244 (a great book, also in my library).

  1. What is your general philosophy concerning pregnancy and birth?
    When you interview obstetricians, it is important to assess right away how liberal or traditional they are in their own practice.  Are they open to new ideas or do they practice by the book?
  2. How long have you been practicing?
    Some women may want a doctor who has attended a few thousand births, others may want to work with someone who is just starting out in practice and has fresh energy and openness about all birth situations.
  3. Are you board-certified?  If not, why?
    Each specialty of medicine has its own examining board that certifies doctors by written and oral examination.  Being board-certified states that this doctor holds to a very high set of standards within the obstetric profession; however, this is no assurance of a particular physician’s ability.  Some physicians voluntarily choose not to be certified; others have been denied certification.
  4. Do you have any children and how were they born?
    Having a female obstetrician will not automatically guarantee a lower intervention rate.  Sometimes you will find a compassionate male doctor who actually gave birth at home or in a birth center or who has caught his own children.  They are more likely to understand your requests for freedom of choice.
  5. Do you use midwives in your practice?
    Not all obstetricians will advertise the existence of midwives on their staffs.  If they do work with a midwife, you can request her services.
  6. What are your guidelines for “normal” and “high-risk” pregnancies?
    Screening requirements vary from doctor to doctor.  Some view all women over thirty-five as high risk; others do not see age as a significant factor.  Standard obstetrics today views a woman who has had three children as high risk as well as the woman who is having her first baby.  The set of guidelines that each doctor uses provides him or her with a picture of possible complications.  By concentrating on the person and not the picture, better maternity care can be provided.
  7. What is your regular fee?  What does this fee include?
    Normal prenatal care usually includes all tests performed within the doctor’s office (blood tests for hemoglobin, urinalysis, and blood glucose levels) and delivery at the hospital.  What fees do not cover are extra lab tests or the initial diagnostic work-up.  These fees are paid directly to the laboratory.
  8. What routine tests do you require?
  9. Under what circumstances would you require ultrasound during pregnancy, alpha-fetoprotein (AFP), chorionic villi sampling (CVS), amniocentesis, glucose tolerance test (GTT)?
  10. How often do you do cesarean sections and for what reasons?
    Definitely assess this doctor’s cesarean-section rate and ask for the reasons for them.
    (I would also add, they cannot do anything to you in the hospital without your consent, but having a doctor with a high cesarean rate makes it more likely that he/she will pressure you)
  11. If my baby is breech, can I give birth vaginally?
    By 1990 most medical schools were no longer teaching the procedures for vaginal breech birth.  A breech baby, no matter what position, was classified as an automatic reason for a cesarean.  There have been a number of studies that show that breech births are safer for mother and baby and there are some doctors who will agree to at least a trial of labor and possibly a vaginal birth.
    (Dr. Michael Hall at Swedish Hospital does vaginal breeches when appropriate and he is the only doctor I know of in the Denver area)
  12. Do you encourage women who have had one cesarean section to give birth vaginally?
    Definitely know the position of both your care provider and hospital about vaginal birth after cesarean.  If you have already had a cesarean, this will be the most important determining factor in considering who will be your provider.
  13. Do you have specific recommendations concerning weight gain, diet, and excercise?
    Doctors are less likely today to insist on a restricted weight gain and more likely to recommend a healthy diet and exercise plan.  Keeping active throughout your pregnancy will enhance your ability to labor and give birth and decrease your chances of gestational diabetes.
  14. Do you require or suggest that I take a childbirth class?
    All first-time couples benefit greatly from taking an informative and practical birth preparation class, and doctors are recognizing the value of preparation.  If you encounter a doctor who doesn’t think childbirth classes are important, keep looking.
  15. How often will I see you?
    Visits are usually scheduled once a month until the seventh month, every two weeks until thirty-six weeks, and once a week after that.  Extra appointments can be scheduled at any time between regular visits.  Depending on how busy the practice is, you might only be seeing your doctor for as little as five minutes at each appointment.  If you want longer prenatal visits, look for a new provider, especially a midwife.
  16. Do you return calls personally or ask your nurses to call?”
    If the nurses on staff in the doctor’s office can handle normal questions, it can be pleasant to develop a relationship with them.  But it is good to know how calls and questions are handled before they arise.
  17. If there is more than one doctor in the practice, what is your rotation policy?  How often are you on call?   Will I be seen by each doctor in the practice?  Who will actually be at my birth?  Do I have a choice?  Will the other doctors respect the agreements you make with me?
    It is very important to meet either the other partners in your doctor’s practice or whoever covers the practice when he or she is out of town or unavailable.  If your doctor has a buys practice, it is not reasonable to assume that he or she can attend every birth.  Therefore, interview the other doctors and make sure they share your philosophies and goals and that they understand how you want your birth to be.  Don’t wait until you are in labor to be disappointed.
  18. Where do you have hospital privileges?  Can I choose which hospital if you have privileges at more than one?
    Take a tour of each hospital and choose the one you want to birth in.  Your doctor may not want to travel across town or out of his area.  Hospitals often grant privileges to other doctors in special circumstances.
  19. Do you encourage women to walk, squat, or be on their hands and knees during labor?
    Understanding the philosophy behind why you need to remain active during labor encourages women to move.  Lying still on a bed during labor is probably the hardest thing for women to cope with.
  20. Can I birth the baby in the position of my choice?
    Hospital beds often break apart at the foot to “allow” a woman to semi-squat.  What some women have found easier is to simply put the mattress on the floor or be supported by their partners while they squat on the floor.  Assess early on if those alternatives are acceptable to your doctor and the hospital.
  21. Can I use a warm bath for pain relief during my labor, even if my water has broken?
    There is absolutely no reason to restrict the bath even with ruptured membranes.  One woman at Santa Monica Hospital was promised that she would be able to use the brand-new baths that had been installed for labor.  What her doctor did not tell her was his list of restrictions:  A woman could not take a bath if her water had not broken and the head had not engaged into the pelvis (for fear of a cord prolapse), and she could not enter the water after her water had broken (for fear of infection).  She never once used the new baths and ended up with an epidural and her baby experienced the application of low-forceps.
  22. Can I stay in the water to birth my baby?
    Find out right away what position your doctor takes on waterbirth.  It might be your opportunity to educate him or her.
  23. What kind of pain medication do you routinely use?
  24. What kinds of nonpharmacological pain management techniques do you recommend?
  25. If I want an epidural, what are your guidelines?
    Some doctors offer a “walking epidural” which is a different kind of epidural.  Question your doctor carefully about the kids of medication used and the guidelines with which they are administered.
  26. Do you do episiotomies?  Why?  In what percentage of births?
    Does your doctor think that episiotomies are necessary?  Is he or she willing to allow you to try other techniques?  If a doctor cuts more than 10 percent of birthing clients, look for a new doctor.
  27. Do you ever use vacuum extractor?  In what percentage of births?
    Vacuum extractors were developed to take the place of low forceps.  A large suction cup (usually made of hard plastic and sometimes silicone) is placed on the baby’s scalp.  The cup is attached to a tube that is attached to a vacuum.  When a suction on te baby’s head has been achieved, constant suction will quite literally pull the baby out within ten to twenty minutes.  There are some risks with extraction, such as perineal lacerations, hematomas on the baby’s scalp, and pain for both mother and baby.  It requires a fully dilated cervix, a baby with at least some part of the scalp visible in the birth canal, and the cooperation of the mother.  Vacuum extraction is preferred over the use of forceps.
  28. Do you ever use forceps?  In what percentage of births?
  29. What is your policy concerning stripping or rupturing membranes?
    Rupturing membranes is often the first intervention that doctors do to “get labor going.”  Ask your doctor if a labor can progress normally and slowly without rupturing the membranes.  Will you be informed of his or her desire to break your water?  Do you have the right to refuse this intervention?  Assess your doctor’s guidelines for ruptured membranes.  How long will he or she allow you to go without starting labor?  What lab tests are required? Some doctors take white blood counts every twenty-four hours and body temperatures every hour and leave a woman alone.  Others want her hospitalized immediately and induce labor with Pitocin.  Studies have shown that women who walk and remain active have fewer cesareans and generally give birth before those who receive Pitocin.
  30. How long will you allow me to labor before starting interventions?
    Does your doctor go by the book in judging length of labor?  What are his or her considerations:  maternal exhaustion, nutritional needs, movement?