Monday, October 18, 2010

The OB at 38 weeks

I am not out to make anyone a bad guy here.  OK, maybe a little.  I have worked as a Natural Childbirth Educator for long enough to make some generalities and feel pretty comfortable with saying them.  I am fully aware that there are exceptions to what I am about to say, but they are so few and far between.  I hope what I am about to say will be listened to and not just heard.

There are two types of maternity care:  the Medical Model and the Midwifery Model.  Briefly, the Medical Model perceives pregnancy, labor, and birth as a disaster waiting to happen;  something a woman needs to be rescued from.  Medicine improves upon the "natural" process.  Labor is all about the cervix and birth canal, always looking for something to go wrong.

The Midwifery Model of Care, on the other hand, trusts a woman's body to grow her baby, start labor at the appropriate time, and labor without time constraints.  A midwife takes into consideration, not just the cervix and birth canal, but the entire woman and her environment.  Birth is as much mental as it is physical.  Medical doctors almost always ignore this fact, usually because the hormones are not working properly when a woman has an epidural.  They just don't see natural normal birth often enough to know what to do -- or more appropriately, what not to do! 

So when couples come to take my Bradley class, I worry about those that have an OB.  And rightfully so.  Most of them will see the light and switch to a midwife, but sometimes the couple is fed so many lines by their OB and hospital nurses, they don't switch, believing their doctor is different. 

From the L&D nurses:

"We have birth balls, showers, tubs, squat bars, dim lights -- everything you want for your natural birth."  (In labor, these things are nowhere to be found.  Only one room has a tub that works, no one can find the squat bar, lights are bright so the doctor can see -- it's all about him, right?  The atmosphere is not what was promised.)

Some of my favorite lines from OBs are:

"As long as everything is going fine, you can do whatever you want."

"As long as your water isn't broken, you can walk around as much as you want."

"We can do intermittent monitoring as long as baby is handling labor okay."

"We don't need to talk about induction unless you are more than a week past your due date."  (No one thinks they will be 'overdue' when they are pregnant.  No one.  They believe this won't apply to them.)

Don't these sound great?  I've got a great OB, right?  Did you hear the clause in each statement?  Remember, an OB is trained to look for things to go wrong.  Statements like these pacify the pregnant woman at monthly/weekly appointments because it seems like she is hearing what she wants to hear.  The problem is, an OB can make up all kinds of reasons to keep you on a monitor in labor, or restrict food and water, or induce labor for a million different reasons.  Seeing this as often as I do, a local doula called this the "Bait and Switch."

Something happens at 38 weeks with an OB, where all-of-a-sudden pregnancy becomes very dangerous.  The placenta starts to deteriorate, amniotic fluid levels rapidly drop, blood pressure is through the roof, and vaginal exams must be done to ensure that your body knows what to do.  Oh yeah, and your baby is getting much too big to fit through your pelvis.  We either need to look at inducing right away or just scheduling a c-section to save you from having to go through the trials of labor.  You'll probably just end up with surgery anyway.

I wish I was making this stuff up.  I'm not.  I see it all the time.  If you stay with an OB who makes "reassuring" statements with a clause and you ignore these red flags, and then you have a c-section, you will always wonder if you really "needed" surgery.  If you change care, even at 39 weeks, to a midwife who trusts birth and encourages you along the way, and then end up with surgery, then you probably did need it. 

I recently had a mom who changed care from an OB at 39.3 weeks to a group of CNMs.  Her baby was over 10 pounds and she pushed for nearly 4 hours.  She had back labor most of her labor and did have an epidural.  Had she stayed with the OB, I am 100% certain she would have had surgery.  Her previous hospital has a 60% c-section rate and they would never have allowed her to push that long.  Sure, she did not have an unmedicated birth, but the switch saved her from surgery.  A good move.

Be on the lookout for these statements from your OB.  The end of pregnancy is so exciting.  You are about to meet your baby for the first time!  A good care provider will reassure you that your baby and body know just when the time is right for labor to begin.  Your care provider should fill you with reassurance, not fear.  And that, really, is the difference between a good care provider and a bad one.


Hannah Reasoner said...

Well done.

I also wish you were making all of that up.

Anonymous said...

So glad I switched! I would have had a C-section for sure!

Cassie said...

Totally true. One little addition- just because you are with a CNM doesn't mean you are totally "safe." You still have to think for yourself and be in control of your own birth.

I've had both of my sons with a CMN. With the first I switched from an OB to a CNM at 28 weeks, and ended up with a c-section- a NEEDED c/s (massive placental abruption at 38 weeks). Had I stayed with the original OB, I would have had a c-section as well. But I wouldn't have had: a caring medical professional holding my hand, reassuring me, keeping me constantly updated, taking pictures of the delivery, and supporting my husband like my CNM was though it all. I also doubt THAT OB would have come to me the next day and assured me she had taken special care in her stitching and that I was an excellent candidate for VBAC with my next pregnancy.

I had my second son via VBAC at 42 weeks exactly, again with a CNM group. But it wasn't because they made it particularly easy on me. It was because I did my research and stuck to my convictions. I didn't let anyone scare me. I had a plan B if things went south with my care providers.

What I have found is that NO ONE likes an "overdue" mama. Even with perfect bio-physical profiles most CMNs believe "that baby has got to come out, the sooner the better." The last two weeks of pregnancy should NOT be spent worried about fighting at every doctor visit... but fighting is better than giving in.

Being a VBAC, I understand I was seen as higher risk and I accept that. I stated early on that I was going for a VBAC until the time at which it could be demonstrated to me that my baby was in danger of suffering some harm from this decision. And in 42 weeks, never was my baby in danger. But I sure felt like everyone else was desperately looking for it.

However, when I was *finally* in labor the midwifery model kicked back into high gear and the support I received was once again amazing.

I truly appreciate your boldness to speak the truth, and I am so glad people like you are on the front lines, interacting with pregnant mamas and giving them the confidence they need to make the decisions that will give them the absolute best birth possible.

Behler said...

Thank you for sharing this information! I had a homebirth and plan to do so with my next pregnancy. The thought of going to the hospital was so foreign to me. While I faced much scrutiny from family, I know I made the right decision and will continue to stand by my convictions. Proud of all of you!

Anonymous said...

I'm afraid I can't agree with this article becaused I had a very caring and wonderful CNM for my first birth and after 38+ hours of labor and the baby's heartbeat dropping below 40 bpm I had an emergency C-section because I was dying and they believed the baby to be as well. I now have a wonderful OB who took the time to do sonograms and X-rays before the conception of my second daughter and found out that I my bones grew wrong and I cannot go past 8cm dialation (which is where I was stuck for many many hours). She is caring and helpful and was all for a VBAC with my midwife there and I was allowed to do anything I wanted as long as she could be present if there was a need for C-section again. After finding out about my bone abnormality I went with a C-section at 40 weeks, I ended up going into labor at 37 weeks and had a C-section after 8 hours of labor where I was again stuck at 8 cm. I am now having my third daughter with the same OB and even now she asked if how I would like to do this. I have chosen a scheduled C-section because I know I won't dialate sufficiently to let my daughter out. My OB also ensures that from the moment of her birth I have my daughter in my arms as long as I want (my first birth had a dreadful OB and I didn't see my daughter for 26 hours after her birth). So even though I do know that most OB's out there are like you said I think there should be given credit that some are different. Mine is a high risk specialist with several children of her own and to me she truly is a Godsend.

Valerie said...

As a doula I totally agree with you. I always prefer to work with midwives than nurses and OBs, but I will say that doulas can make sure you get the lower lighting and the squatting bar and the birth ball (heck, we bring one!), so I hope you encourage your clients to at least hire a doula, if not a midwife.

Another great post and soooo true.

Anonymous said...

I switched to a CNM for my 3rd child, but due to unexpected cardiac issues at 28 weeks with the baby, I ended up being transferred to 2 different hospitals and perinatologists. She ended up being delivered by emergency c-section at 32.5 weeks, but the CNM were great both at 28 weeks and after delivery. They came to the hospital when I was transferred and supported me as much as possible, given the circumstances. Rebecca has issues from her heart condition and lack of oxygen, but I was never afraid to call when I noticed she wasn't moving and, in fact, they were reassuring and said that the "mom is always right" when thinking that something is wrong during pregnancy.

I wish I'd used a CNM with my earlier pregnancies. Thanks for providing such useful information.

Caroline Marin said...

I am one of the women who is blessed to be the exception to this article. My OB is as much like a midwife as an OB can be. All of the beaautiful things that everyone has described from their CNMs were true with my OB. She supported me finding natural ways to handle everything pregnancy threw at me, encouraged the natural remedies I'd started before and always pushed me to listen to my body. I chose her before I started trying to concieve because I wanted to use Fertility Awareness and many OBs won't rely on your charts. She did, and even made sure I knew about resources to learn more about charting postpartum. When it became a possibility I would need a c-section, she worked with me to find every possible venue to avoid it. She also spent a lot of time preparing me for a VBAC before the birth even happened, just in case. When I did have a c-section, which was needed, she held my hands, talked to me, ensured my husband was involved and immediately handed off my son. I couldn't ask for more. But I know most people are not as blessed as I am.

as for the mama who didn't see the baby for more than a day...that may be one of the most heartbreaking things I've ever heard.

Sarah said...

Just after reading your post, I mosied over to a hospital midwife's blog and came across a post that dovetails nicely with what you've just said.

'Tis a good read.

(p.s. did you do the survey?)

Ritsumei said...

I've come to think of the whole thing as a continuum: Invasive "medical" birth on one side, the other end would probably have midwifery, then a ways past that solo unattended birth on the other.

I am very fortunate to have an OB that practices much like a hospital-based midwife might. And also did work in fertility at Stanford, which gave him the expertise to help me overcome my fertility problems and GET pregnant, and then twice help me to have an unmedicated childbirth (complete with hot tubs, balls, dim lights, and pushing & delivering on hands & knees) ... and deal with a subdermal hematoma with no problem.

I know there are a lot of women out there who don't find a doctor as wonderful as mine. But I'm sure glad I've got him.

Anonymous said...

I can only guess that I am the mom with the 10lb baby. Since I fit the bill and delivered 9/28. Let me add that I am only 5' 4" (3.75" really), and 135lbs pre-pregnancy. In fact, I still shop for pants and some clothing in the Jrs deprtment. So by no means am I a linebacker. I can say that I heard every one of those statements from my OB before transfering to the CNMs, and had I pulled my head out of my butt earlier I would have switched much earlier. I was convinced though that my OB was going to treat me right after 10 years of being with her practice. WRONG! While I had a less than easy labor and birth, I almost enjoyed it, almost. I guess comfortable with my surroundings and care is what it was. I never felt as though I was fighting for something with my CNM delivery, but always felt that way just visiting my OB. My CNM was very supportive in my decisions and my faith in my body to do what it was designed to do. I felt as though after 10 years and 39 weeks with my OB that I never really had it from her.

T said...

I mean't to sign my above comment, and not do it anonymously. Something happened though and it went anonymous.