What to expect when you're expecting (13 page)

Birthing rooms at some hospitals are available only for women who are at low risk for childbirth complications; if you don’t fit that profile, you may have no choice but to go to a traditional labor and delivery room, where more technology is readily at hand. And a C-section (cesarean delivery) is always performed in an all-business operating room (no homey look there). Fortunately, though, with the increasing availability of birthing rooms for most women, odds are great that you’ll be able to experience unrushed, family-friendly, noninter-
ventionist labor and delivery within a traditional hospital setting.

Birthing centers.
Birthing centers, usually freestanding facilities (although they may be attached to—or even located in—a hospital), offer a homey, low-tech, and personalized place for childbirth. You’ll be able to get all your prenatal care at a freestanding center—from practitioner visits to childbirth education and breastfeeding classes (in-hospital centers are usually only for childbirth itself). In general, most birthing centers offer the most comfortable childbirth amenities—from nicely decorated private rooms with soft lighting to showers and whirlpool tubs. A kitchen may also be available for family members to use. Birthing centers are usually staffed by midwives, but many have on-call obstetricians; others are located just minutes from a hospital in case any emergencies arise. And though birthing centers generally do not use interventions such as fetal monitoring, they do have medical equipment on hand, including IVs, oxygen for the mother and the infant, and infant resuscitators so emergency care can be initiated (if required) while you’re waiting for a transfer to the nearby hospital. Still, only women with low-risk pregnancies are good candidates for delivery in birthing centers. Something else to consider: Unmedicated childbirth is the focus in a birthing center, and though mild narcotic medications are available, epidurals aren’t. If you end up wanting an epidural, you’ll have to be taken to the hospital.

Leboyer (or gentle) births
. When the French obstetrician Frederick Leboyer first offered up his theory of childbirth without violence, the medical community was skeptical. Today, many of the procedures he proposed, aimed at making a newborn’s arrival in the world more tranquil, are routine. Babies are often delivered in birthing rooms without the bright lights once deemed necessary, on the theory that gentle lighting can make the transition from the dark uterus to the bright outside world more gradual and less jolting. Upending and slapping the newborn is no longer routine anywhere; less aggressive procedures are preferred for establishing breathing when it doesn’t start on its own. In some hospitals, the umbilical cord isn’t cut immediately. instead, this last physical bond between mother and baby remains intact while they get to know each other for the first time (and until it stops pulsing). And though the warm bath Leboyer recommended for soothing the new arrival and smoothing the transition from a watery home to a dry one isn’t common, being put immediately into mommy’s arms is.

In spite of the growing acceptance of many Leboyer theories, a full-on Leboyer birth—with soft music, soft lights, and a warm bath for baby—isn’t widely available. If you’re interested in one, though, ask about it when you’re interviewing practitioners.

Home birth.
For some women, the idea of being hospitalized when they aren’t sick just isn’t the ticket. If that sounds like you—or if you just believe that life should begin at home—you might want to consider a home birth. The upside is obvious: Your newborn arrives amid family and friends in a warm and loving atmosphere, and you’re able to labor and deliver in the comfort and privacy of your own home, without hospital protocols and personnel getting in the way. The downside is that if something unexpectedly goes wrong, the facilities for an emergency cesarean or resuscitation of the newborn will not be close at hand.

According to the American College of Nurse-Midwives, if you are considering a home birth, you should meet these guidelines:

Be in a low-risk category—no hypertension, diabetes, or other chronic medical problems, and no history of a previous difficult labor and/or delivery.

Be attended by a physician or a CNM. If you’re using a CNM, a consulting physician should be available, preferably one who has seen you during pregnancy and who has worked with the nurse-midwife before.

Have transportation available and live within 30 miles of a hospital, if the roads are good and traffic’s not an issue, or 10 miles if these standards aren’t met.

Water birth.
The concept of delivering underwater to simulate the environment of the womb is not widely used in the medical community, but it is more accepted among midwives. In a water birth, the baby is eased from the warm, wet womb into another warm, wet environment, offering familiar comfort after the stresses of delivery. The baby is pulled out of the water and placed in the mother’s arms immediately after birth. And since breathing doesn’t begin until the baby is exposed to the air, there is virtually no risk of drowning. Water births can be done at home, in birthing centers, and in some hospitals. Many spouses join the mother in the tub or portable pool, often holding her from behind to provide support.

Most women with low-risk pregnancies can choose a water birth, as long as they can find a willing practitioner and hospital (birthing centers may be more likely to offer the option). If you’re in a high-risk category, however, it’s probably not a wise option, and it’s unlikely you’ll find even a midwife who will allow you to try a water birth.

Even if you don’t find the idea of a water birth inviting—or don’t have the option of one open to you—you might welcome the opportunity to labor in a whirlpool tub or regular bath. Most women find that the water not only provides relaxation, pain relief, and freedom from gravity’s pull, but it even facilitates the progression of labor. Some hospitals and most birthing centers offer tubs in the birthing rooms. For more information on water births, go to gentlebirthchoices.org or waterbirth.org.

The certified nurse-midwife.
If you’re looking for a practitioner whose emphasis is on you the person rather than you the patient, who will take extra time to talk to you not only about your physical condition but also your emotional well-being, who will be more likely to offer you nutritional advice and breastfeeding support, and who will be oriented toward the “natural” in childbirth, then a certified nurse-midwife (CNM) may be right for you (though, of course, many physicians fit that profile, too). A CNM is a medical professional, a registered nurse who has completed graduate-level programs in midwifery and is certified by the American College of Nurse-Midwives. A CNM is thoroughly trained to care for
women with low-risk pregnancies and to deliver uncomplicated births. In some cases, a CNM may provide continuing routine gynecological care and, sometimes, newborn care. Most midwives work in hospital settings, others deliver at birthing centers and/or do home births. Though CNMs have the right in most states to offer epidurals and other forms of pain relief, as well as to prescribe labor-inducing medications, a birth attended by a CNM is less likely to include such interventions. On average, midwives have much lower cesarean delivery rates than physicians, as well as higher rates of VBAC (vaginal birth after cesarean) success—but that may be due in part to the fact that they only care for women with low-risk pregnancies, which are less likely to take a turn for the complicated or result in surgical births. Studies show that for low-risk pregnancies, deliveries by CNMs are as safe as those by physicians. Something else to keep in mind: The cost of prenatal care with a CNM is usually less than that of an ob-gyn.

If you choose a certified nurse-midwife (about 8 percent of expectant mothers do), be sure to select one who is both certified and licensed (all 50 states license nurse-midwives). Most CNMs use a physician as a backup in case of complications; many practice with one or with a group that includes several. For more information about CNMs, look online at midwife.org.

Direct-entry midwives.
These midwives are trained without first becoming nurses, though they may hold degrees in other health care areas. Direct-entry midwives are more likely than CNMs to do home births, though some also deliver babies in birthing centers. Those who are evaluated and certified through the North American Registry of Midwives (NARM) are called certified professional midwives (CPMs); other direct-entry midwives are not certified. Licensing for direct-entry midwives is also currently offered in certain states. in some of those states, the services of a CPM are reimbursable through Medicaid and private health plans. In other states, direct-entry midwives cannot practice legally. For more information, call the Midwives Alliance of North America at (888) 923-6262 or check their website at mana.org.

You’ve settled on an obstetrician, a family practitioner, or a nurse-midwife. Next you’ve got to decide which kind of medical practice you would be most comfortable with. Here are the most common kinds of practices and their possible advantages and disadvantages:

Solo medical practice.
In such a practice, a doctor works alone, using another doctor to cover when he or she is away or otherwise unavailable. An obstetrician or a family practitioner might be in solo practice; a nurse-midwife, in almost all states, must work in a collaborative practice with a physician. The major advantage of a solo practice is that you see the same practitioner at each visit. This way, you get to know and, ideally, feel more comfortable with this person before delivery. The major disadvantage is that if your practitioner is not available, a backup you don’t know may deliver your baby (although arranging to meet the covering physician or midwife in advance helps remedy this potential drawback). A solo practice may also be a problem if, midway in the pregnancy, you find you’re not really crazy about the practitioner. If that happens and you decide to switch practitioners, you’ll have to start from scratch again searching for one who suits your needs.

Partnership or group medical practice
. In this type of practice, two or more doctors in the same specialty care jointly for patients, often seeing them on a rotating basis (though you usually get to stick with your favorite through most of your pregnancy and only start rotating toward the end of your pregnancy, when you’re going to the office weekly). Again, you can find both obstetricians and family doctors in this type of practice. The advantage of a group practice is that by seeing a different doctor each time, you’ll get to know them all—which means that when those labor pains are coming strong and fast, there’s sure to be a familiar face in the room with you. The disadvantage is that you may not like all of the doctors in the practice equally, and you usually won’t be able to choose the one who attends your child’s birth. Also, hearing different points of view from the various partners may be an advantage or a disadvantage, depending on whether you find it reassuring or unsettling.