Tell me about midwives vs. GPs vs. OBs

[Dangerosa]

@Unauthorized Cinnamon

Dangerosa, the metric I see most is perinatal deaths, either maternal or infant. Midwives also have lower c-section rates (for similar risk pregnancies), and of course an unnecessary c-section by definition is a poorer outcome, involving pain and restriction of movement at the very least, and possibly disrupting breastfeeding, as well as increased health risks for mother and baby.

But when necessary, the c-section is life saving and a delay can be tragic.

Course, I’m a little sensative to the subject since one of my bestest friends’ wife insisted on a midwife with a high risk pregnancy, insisted on a vaginal birth (because midwives and vaginal births have "better outcomes)- and the midwife delayed when the baby went into fetal distress because its so often “false.” They now have a severely disabled daughter who was without oxygen for an extended time at birth.

Another friend of a friend had a midwife that wouldn’t induce when the pregnancy went over forty two weeks and ended up with a stillborn boy. Nice malpractice settlement though.

[Lissla_Lissar]

I just want to let everyone know that if I turn out to be high-risk, or there’s anything to suggest the baby is in danger, I will immediately transfer to an OB, and not insist on vaginal birth. That’s one reason I’m going to be at the hospital.

I have my pre-natal exam with my GP this week (she doesn’t deliver, or I’d probably go with her- she’ll be family doctor to three generations of my family) and I’m going to ask for information on all the midwives in the area.

I’ve heard that countries in Europe with a higher home birth/midwife for care rate have better stats for mother and baby’s health. I can’t remember which book I read it in, though.

[Boyo_Jim]

I am a man who works in a birth education center. However, I am not a birth educator, nor am I an form of health care provider. I just hear lots of stories.

I suggest that if there are any pregnancy risk factors or unusual health issues that could become related to your pregnancy, go with an OBGYN. Because if complications arise that become a serious threat to the pregnancy, you will probably end up being referred to an OBGYN anyway. I have seen cases where midwives basically cancel a woman’s care in mid-pregnancy. They’re not really doing that, but they see a woman who’s pregnancy is not going to go smoothly and maybe needs more medical support during labor, and they pass them on along the medical chain to the specialists with the MDs. To the women affected, though, it seems like a kind of abandonment and they are very distressed by it.

[Unauthorized_Cinnamon]

@Dangerosa

But when necessary, the c-section is life saving and a delay can be tragic.

Course, I’m a little sensative to the subject since one of my bestest friends’ wife insisted on a midwife with a high risk pregnancy, insisted on a vaginal birth (because midwives and vaginal births have "better outcomes)- and the midwife delayed when the baby went into fetal distress because its so often “false.” They now have a severely disabled daughter who was without oxygen for an extended time at birth.

Another friend of a friend had a midwife that wouldn’t induce when the pregnancy went over forty two weeks and ended up with a stillborn boy. Nice malpractice settlement though.

Absolutely. It must be so wrenching to see parents go through that, and you can’t help but question whether the “Rah rah, midwife!” crowd is mistaken. I forget where I heard it, but someone asked an authority figure about what their risk was for something, and the person answered, “100% or 0%.” We can try to investigate what approaches work best over populations, and play the odds in our favor, but for the individual, there is no guarantee.

On the one hand, just because your label is “midwife” doesn’t mean you can’t make bad decisions. On the other hand, these babies may have had similar outcomes with an OB - there’s no way to know.

I would never recommend that a mother avoid doctors and hospitals if her condition was pathological and required medical intervention. That is where I am so glad that we have high-tech methods, and, as you say, life-saving c-sections. As for induction for postdates, there are specific tests to be run to make sure the placenta is not degrading and the baby is not in distress, and not to run them does seem remiss.

Still, it is so hard to tell. For instance, some babies may have preexisting conditions that complicate delivery - there’s a theory that many cases of CP cause complicated labor, rather than vice versa. Sadly, there are some situations where no caregiver can prevent harm, regardless of their training and equipment.

[Malthus]

@Unauthorized Cinnamon

Oh, one of my favorite topics! Short answer: MIDWIFE!

Long answer: from my reading, it seems that OBs are generally taught how to handle pathological pregnancies and deliveries (and thank Og we have them for that, I’m not saying they’re evil), and they are taught that technology is by definition good. Unfortunately, they also have to worry about being sued a lot, in a culture that perceives intervention as responsible and watching and waiting as negligent. Thus, OBs tend to want to hook women up to the machine that goes “Ping!”, do routine IVs, starvation, confinement to bed, worry about “a big baby” (when in reality estimates are pretty damn unreliable), induce labor for no good reason, and resort to c-sections at the drop of a hat. If you have an uncomplicated pregnancy, this approach is likely to cause problems, rather than solve them.

I think the thing that makes me craziest is what I call the “OB intervention cascade,” which I see in birth stories all the damn time. OB does an u/s, and says the baby is “big,” so suggests induction. Mother and baby aren’t ready to give birth, so the induction is tough. More and more pitocin is used, which causes monstrous contractions - way more painful and more dangerous to the baby. So of course an epidural is required, as well as continuous EFM, which means mom is stuck in a bed, which slows labor, and the EFM is likely to give false positives on the baby being in distress. So of course then the doctor says they have to do an emergency c-section. The baby and mother go through all the risks of that, and maybe the baby is even premature after all. Compounding that, c-section is hell on baby’s lungs, so baby is in the NICU, mom is recovering from surgery, breastfeeding is disrupted or destroyed, and mom and baby’s health is further compromised. And usually everyone is so thankful to the doctor for “saving” the baby! :mad:

Midwives tend to look at birth as a healthy process, and go for low intervention, which is less risky for mother and baby. They also tend to have more rapport with the family, and stay with the mother to help her through labor.

But there are OBs that take the “midwife” view and midwives (especially those that practice in hospitals or in OB practices) who take the “OB” view. You have to talk to the individuals involved.

Super long answer is this: read The Thinking Woman’s Guide to a Better Birth, by Henci Goer, and/or Ina May’s Guide to Childbirth by Ina May Gaskin. They both cover a lot of the science on routine obstetric intervention, and address things like chosing a caregiver. Also, take a Bradley class- they are fabulous!

I really loved Ina May’s discussion of Sphincter Law. Basically, humans need calm, safety, and privacy to relax sphincter muscles. Imagine trying to pee on a toilet in the middle of a hospital room, with no lock on the door, lights blazing, and strangers walking in and out all the time, checking on your progress, intimating you can’t do it, and sticking you with needles and stuff!

My personal story is that I did all this research, and as a result had an unmedicated birth in a freestanding birth center with midwives. It was an excellent experience, and I was surprised - it was nowhere, *nowhere *near as hard or as painful as I suspected. I was “allowed” to eat and drink as I wanted, and no one pushed drugs or interventions on me. I felt safe and relaxed. I highly recommend it!

Congratulations and good luck.

Your “cascade” story sounds exactly like what happened with my wife’s labour. The experience was horrible, topped off with an emergency c-section. My wife was very unhappy with the whole thing, and later had an angry confrontation with the doc - who responded by sending social workers in (which seemed to add insult to injury - the implication appearing to be that she was nuts). She later had an infection and was basically wiped out for weeks.

The hospital setting was horrible, just horrible.

On the other hand, the baby was (and is) okay, perfectly healthy. Allegedly, the cord was wound around his neck - without C-section, maybe he would have died. Or is this just what they tell us? I’m no doctor, I have no idea. If given a choice, we would both I think prefer a horrible birth experience and a healthy baby to a great birth experience combined with real medical risk to the baby. Assuming of course that’s the real choice.

There were no particular risk factors noted during pregnancy (which went easily), so this experience came as a bad surprise.

One thing I do note - we got a doula after the birth, and we regretted very much not having one during. Doulas (at least the ones we dealt with) are great, if you can afford them.

[Solfy]

@Unauthorized Cinnamon

Absolutely. It must be so wrenching to see parents go through that, and you can’t help but question whether the “Rah rah, midwife!” crowd is mistaken. I forget where I heard it, but someone asked an authority figure about what their risk was for something, and the person answered, “100% or 0%.” We can try to investigate what approaches work best over populations, and play the odds in our favor, but for the individual, there is no guarantee.

On the one hand, just because your label is “midwife” doesn’t mean you can’t make bad decisions. On the other hand, these babies may have had similar outcomes with an OB - there’s no way to know.

That’s another consideration, at least in the US - not all “midwives” are trained equally. In my state, there are CNM (certified nurse midwives) that are licensed and regulated. Education levels, internships, exams, etc. are required. There also exist “direct entry” midwives. There are no legal requirements or regulations for direct entry midwives in Pennsylvania. Theoretically I could hang a shingle out tomorrow and call myself a midwife. Some states prohibit direct entry midwives. I’m not saying all non-CNMs are uneducated - I know there are training programs throughout the country and I’m sure there are very many competent DE midwives. It’s just important to consider that not everyone who catches babies is educated and experienced equally.

There was a sad case in PA in 2004 where a couple’s baby died during birth. The couple’s first midwife (I’m not sure which type) had discontinued care and referred them to an OB when it was found that the baby was a footling breech. Instead they found another DE midwife who was willing to do a homebirth. There were complications during the birth due to the positioning, and the baby wasn’t breathing. According to the news article I read, the midwife was also not familiar with standard infant resuscitation. She was put on trial, held for the murder of the baby. The parents opposed the charges.
Everyone wants a guarantee of a good outcome. No health care provider, no matter what their training, can provide that. It’s something that has to be considered when chosing less than mainstream healthcare. If, heaven forbid, something does happen, are you prepared to deal with people telling you it’s your fault for chosing a midwife? The safety statistics (see “better outcomes” above) are out there, but not everybody wants to hear that.

[Unauthorized_Cinnamon]

@Malthus

On the other hand, the baby was (and is) okay, perfectly healthy. Allegedly, the cord was wound around his neck - without C-section, maybe he would have died. Or is this just what they tell us?

I’m so sorry your experience was so bad. And that the doctor rubbed salt in the wound as well!

Anyway, my understanding is that babies are often born with the cord looped around their necks, with no ill effects. It’s not like they’re using their windpipes to get oxygen during labor. Again, just going from my memory here, the truly dangerous issue is if the cord drops down between the baby’s head and the cervix, where it gets compressed, cutting off the blood flow.

[Velma]

That’s interesting info about the tipped uterus stories. I just found out I have a tipped uterus at an ultrasound last week (I am almost 11 weeks along, due Christmas Eve.) I was suprised to hear that, as this is my second pregnancy and no one ever told me that before. I had horrible back labor at my first birth but we all just assumed the baby was facing the wrong way. I guess now I have no hope of avoiding the back labor next time around? Is that a proven cause of back labor? When I look up tipped uterus info I get cites that say the uterus straightens out during pregnancy anyway so it doesn’t matter. I was so grateful for the epidural to get rid of the back pain last time that I don’t think I could go unmedicated if that is my future.

to the OP - I think most important is what you and your partner are comfortable with. It is nice that you have so many choices. My insurance won’t cover midwives, they want me with an OB at a hospital. I go to a practice that has many participating OB’s which I know is what most people don’t like, but I am very pleased with them overall. I tried to meet them all and almost succeeded, but ended up having the one OB I hadn’t met yet do my first delivery. Oh well, she was very good and I had no issues with her. Really most of my interaction was with the nurses anyway. The hospital I went to has a very good birth center, made to look like hotel rooms with jacuzzi tubs and they seemed very open to my wishes. When I took the tour ahead of time, (definitely do this) lots of people asked about how accomodating the hospital was about various methods of birth, and they explained everything to us. We could bring birth balls, cds, etc. with us. No one forced medication on me but it was offered and quickly given when I wanted it.

The one thing that can be a little frustrating is relaying information each time from one appointment to the next. I can see how seeing the same person every time would build more of a relationship. But overall I don’t have big issues with seeing different OB’s, I think the overall tone of the practice and the birthing center or hospital is more what you should investigate.

[Malthus]

@Unauthorized Cinnamon

I’m so sorry your experience was so bad. And that the doctor rubbed salt in the wound as well!

Anyway, my understanding is that babies are often born with the cord looped around their necks, with no ill effects. It’s not like they’re using their windpipes to get oxygen during labor. Again, just going from my memory here, the truly dangerous issue is if the cord drops down between the baby’s head and the cervix, where it gets compressed, cutting off the blood flow.

I was thinking more of bloodflow to the head, and also pinching of the cord itself. But of course, I have no real clue.

What I observed was that during each contraction, the baby’s heartrate monitor showed that its heartrate slowed. Labour was long - 15 hours - and this effect got no better; they told us that we should get a c-section, which we did.

[Solfy]

@Malthus

I was thinking more of bloodflow to the head, and also pinching of the cord itself. But of course, I have no real clue.

What I observed was that during each contraction, the baby’s heartrate monitor showed that its heartrate slowed. Labour was long - 15 hours - and this effect got no better; they told us that we should get a c-section, which we did.

My understanding is that a tight nuchal cord can be a problem, but not a major one that necessitates a c-section every time. Emergency birth instructions I’ve read instruct the person catching the baby to check for a cord around the neck as soon as the head is delivered and attempt to gently unloop it if possible.

In my own experience, my first daughter had a “snug” nuchal cord. It was noted in the CNM’s record of the birth, as well as the somersault maneuver she did to untangle it as soon as the baby was out. Toward the end of pushing, the baby’s heartrate was dropping between contractions (the opposite of what I would expect - still not sure why) and I was given oxygen. A tiny episiotomy was cut to speed her progress due to the heartrate decelerations. (which disappointed the midwife - it was the first she had to cut in 2yrs, but it was only out of necessity)

The school of Google gives this info:
Conclusions: Nuchal cord is not associated with adverse perinatal outcome. Thus, labor induction in such cases is probably unnecessary.
From here

and this:
Conclusions
The sensitivity of the ultrasound diagnosis of a nuchal cord is low prior to induction of labor at term. A nuchal cord does not appear to increase the risk of Cesarean section or of poor neonatal outcome. The low ultrasound detection rate of a nuchal cord limits its use in decision making prior to induction of labor in high-risk pregnancies
From here

This abstract seems to indicate the jury is still out on the risk of a nuchal cord:
Approximately 1 in 4 of all babies are born with cord round the neck. Being such a common obstetric condition, there is a view that nuchal cord ordinarily does no harm. A number of studies have recognised cord round the fetal neck as a significant cause of fetal death in utero and perinatal morbidity. However, many obstetricians have different views about the significance of nuchal cord as a cause of perinatal morbidity and mortality.

from here

[Litoris]

Regarding the cord around the neck issue – with my daughter (midwife birthed) the midwife noticed that with each contraction, her heartrate would go wonky and insisted on an internal monitor (very uncomfortable). My daughter was born hand-first, palm up making my midwife comment “oh it must be a girl – she’s holding her hand out for money before we even get to see her!” (we did not know the sex yet). Somehow, during labour the umbilical cord had gotten wrapped around my daughter’s neck, but she had wedged her hand up under the cord, allowing blood flow to continue. I tell her all the time that she was smarter than most adults before she’d even exited the womb!

[Malthus]

@Solfy

My understanding is that a tight nuchal cord can be a problem, but not a major one that necessitates a c-section every time. Emergency birth instructions I’ve read instruct the person catching the baby to check for a cord around the neck as soon as the head is delivered and attempt to gently unloop it if possible.

In my own experience, my first daughter had a “snug” nuchal cord. It was noted in the CNM’s record of the birth, as well as the somersault maneuver she did to untangle it as soon as the baby was out. Toward the end of pushing, the baby’s heartrate was dropping between contractions (the opposite of what I would expect - still not sure why) and I was given oxygen. A tiny episiotomy was cut to speed her progress due to the heartrate decelerations. (which disappointed the midwife - it was the first she had to cut in 2yrs, but it was only out of necessity)

The school of Google gives this info:
Conclusions: Nuchal cord is not associated with adverse perinatal outcome. Thus, labor induction in such cases is probably unnecessary.
From here

and this:
Conclusions
The sensitivity of the ultrasound diagnosis of a nuchal cord is low prior to induction of labor at term. A nuchal cord does not appear to increase the risk of Cesarean section or of poor neonatal outcome. The low ultrasound detection rate of a nuchal cord limits its use in decision making prior to induction of labor in high-risk pregnancies
From here

This abstract seems to indicate the jury is still out on the risk of a nuchal cord:
Approximately 1 in 4 of all babies are born with cord round the neck. Being such a common obstetric condition, there is a view that nuchal cord ordinarily does no harm. A number of studies have recognised cord round the fetal neck as a significant cause of fetal death in utero and perinatal morbidity. However, many obstetricians have different views about the significance of nuchal cord as a cause of perinatal morbidity and mortality.

from here

Very interesting information - though I think in our case it was the heart-rate data that was the determining factor - the cord thing was only discovered after the kid was born. Can’t say whether the cord thing was the cause of the heart-rate thing or not; it wasn’t what got the docs to recommend a c-section though - that was the lengthy labour combined with the troubling heart-rate decrease during contractions.

[Lissla_Lissar]

Regarding midwife training- I’m pretty sure all the midwives that have privileges at Ontario hosptials are RN midwives. Nurses with midwife training. We will of course make sure of the credentials of the midwife we choose.

I went for my first full exam today with my family doctor, and got certified as absolutely healthy. We looked for the heartbeat, but it’s only eight weeks, which is a little early. Maybe in two weeks.