Choosing a Caregiver

One of THE most important determinants of what happens during your labour and birth is your caregiver's style of practice. Yet hardly any books, classes, or websites even discuss this topic. I say caregiver to refer to the physician, group of physicians, obstetrician, or midwife you choose to attend your birth. Writing a birth plan is entirely useless if what you want in the plan is at odds with the caregiver's normal style of practice.

Many people hoping for a drug-free birth, or not to cut the cord immediately, for example, don't find out until labour that their caregiver practices in a way which may be at odds with their wishes. At that point, it is too late to negotiate new decisions, or change caregivers. It is best to find out in early pregnancy what styles of practice various caregivers have, and which ones suit you best.

What people generally don't realise, is that different caregivers can have different protocols for the exact same situation. There is much disagreement about what is the safest and best ways to manage various birth situations. different caregivers have different viewpoints, just as different mothers have different viewpoints. Some women want epidurals, or cesareans, or a highly medically managed birth. Some women want to try to avoid epidurals, or cesareans, and have medical intervention only when necessary. Either way, women would be much happier choosing caregivers that matched their own philosophy. Being satisfied with the way you are treated during labour makes for an easier time post-partum.

People are under the impression that medical practice, being very scientific and all, is based on solid research and evidence into what is best practice for each situation. Shockingly this is not true. Studies in the British Medical Journal state that only around 30% of current medical practice is evidence-based. In hospital maternity care, decisions about how to manage normal labour is often based on what doctors before them did, and those before them and so on. So even when solid research emerges that shows those practices may be harmful instead of helpful, changes may take years or decades. It is quite difficult for individual doctors to keep up with the multitudes of research, some of which is contradictory. Some decisions are made based on what is convenient for caregivers, or what will protect caregivers from being sued, rather than what is best for mother and baby. Midwives also may or may not practice based on what is best practice according to the evidence. It is up to you to ask questions and suss out if what they beleive is in line with what you believe.

There are various ways of describing the general schools of thought. Among doctors, there are those who practice Active Management, and Expectant Management.
In addition there is the Midwifery Model of Care. Midwives and physicians only attend low-risk births. Obstetricians are trained to manage high-risk births.

Active management's philosophy is that labour is full of potential dangers, and medical intervention is necessary at every step of the way to prevent disaster.
Expectant management's philosophy is that labour is a normal process that usually works out well, but if problems arise, intervention is useful. The midwifery model of care is similar in that it believes that birth is normally safe and mothers are best left to follow their own instincts, but to intervene if problems arise.

Active management caregivers often have short prenatal appointments, make use of lots of technology such as frequent ultrasounds, and make the decisions for the mums. If this makes you feel comfortable and safe, then this is the caregiver for you. Having options and making informed choices can feel very overwhelming to some mums. They would prefer a caregiver who made all the decisions for them.

Expectant management caregivers usually use more hands on techniques to feel the baby, spend time discussing the mum's emotional well-being and support the mum's informed choices. Midwives often spend between 45 min - 1 hour at each prenatal session. If it is important to you that your unique preferences and needs be respected, find a midwife or a doctor who has a low inductions, low epidurals, and low cesarean rate, and is genuinely listening to your needs.

In choosing a caregiver, ask questions about things that are important to you. If you want to get an epidural asap, ask your potential caregivers how soon they are comfortable giving them. Some caregivers don't mind giving epidurals any time in labour. Some will only give them between 4 cm and 8 cm dilation. If you would prefer not to have an epidural as far as possible, but choose a caregiver who has a high induction rate, expects mothers to stay in bed, and uses continuous fetal monitoring, you can throw your expectations out the window. Inductions, and being confined to the bed drastically increase the pain in labour, making epidurals the only way to cope with the unnatural pain.

Most importantly, choose a caregiver that you trust and feel safe with. There is no one option that is suitable for every person. A good reference book to read is "The Birth That's Right for You" by Amen Ness and Lisa Marie-Goulding.