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Finding the Right Prenatal Care

I'd gone to the same gynecologist for years, so when I became pregnant with my first child, I stuck with him. I wished I had done some comparison shopping instead when I noticed that at every checkup he seemed annoyed by even simple questions. When I went into labor  -- surprise  -- he was on an unannounced vacation and my baby was delivered by the obstetrician on call at the hospital. There were no problems at all (my daughter is almost 3 and thriving), but the experience would have been a lot more positive if I'd had a doctor with whom I could communicate.


"Finding an obstetrician or midwife whom you trust and who shares your philosophy on pregnancy and childbirth makes a big difference in how smoothly everything goes," says Deanne Williams, executive director of the American College of Nurse-Midwives, in Washington, DC. If you're lucky, your current care provider will fit the bill. But if not, you'll want to choose another (and don't be afraid to change practices if you're not happy, even if you're midway through your pregnancy or have previously delivered with that practitioner). The tricky part is knowing what you really want.


Particularly if this is your first pregnancy, you may not be sure about what's most important to you until you start asking questions. To help you zero in on your priorities about pregnancy and labor (and see if your practitioner can accommodate them), we've outlined seven questions to ask your obstetrician or midwife during the first couple of checkups, or during an interview-only appointment if you're still in the planning stages.


1. Where do you deliver?

Ask for written information about the hospital or birthing center your doctor or midwife is affiliated with, and visit it now to determine if it has the features that are most important to you, says James Marquardt, M.D., an obstetrician-gynecologist at Brigham and Women's Hospital, in Boston. You may be looking for a facility that's close to your house or for one with an impressive neonatal intensive-care unit. Perhaps you're more concerned that it has doulas (labor coaches) on staff or allows you to keep your baby in your room after delivery. Mary Weatherhead, of Cleveland Heights, OH, was pleased that she had her baby at a hospital that was breastfeeding-friendly. "I knew that some of my friends hadn't gotten much support from the staff at the hospital where they'd delivered. The obstetrician I chose worked at a facility that had lactation consultants on staff," she says.




2. What tests do you advise? What if they show that something might be wrong with the baby?

Ask your provider to explain each option, including what it tests for, how accurate it is, at which stage of the pregnancy it's performed, and what the risks are. Ideally, he'll give you all the details you need to make an informed decision, and not pressure you into having  -- or not having  -- a particular test. If you're over 35, for instance, he'll probably bring up amniocentesis, which involves extracting fetal cells from the amniotic fluid and examining them for signs of genetic abnormalities, such as Down syndrome or spina bifida. If you've decided not to have the test, however, it makes a big psychological difference to have a practitioner who'll support your choice.


In the unlikely event that a test shows something might be wrong, you'll want a doctor or midwife who'll support your decision about whether to continue the pregnancy. When Ellen Vaugh's (not her real name) amniocentesis indicated that her baby had Down syndrome, she knew she wanted to keep it. "But when I told my obstetrician, he practically recoiled in horror. I could tell he thought I was making a huge mistake, which made an already traumatic situation all the more unsettling. I stayed with him through my pregnancy, but I wish I hadn't because I didn't feel as comfortable with him after that," she says. To avoid unnecessary tension, ask up front about your options, then listen carefully to the response. If you're brushed off with a line like, "Let's not worry about that now," the doctor may not be a good fit for you.


3. At what point do you recommend a C-Section?

In some situations  -- your baby is in distress or in a breech position, for instance  -- surgery is unavoidable. But doctors vary as to how long they typically allow a woman to push in the delivery room before they perform a cesarean: Some will let you try for up to four or five hours, while others have a limit of an hour or two, so ask your provider to explain his policy. You can also inquire about his cesarean rate (the national average is roughly 32 percent), but remember that doctors who handle a large number of high-risk pregnancies will, understandably, have higher numbers than those who don't.


If you're strongly committed to a vaginal birth, ask your provider about what he does to avoid surgery. Possibilities include everything from administering oxytocin, a medication that speeds up labor, to allowing you to squat while pushing. If you've had a cesarean section and would like to try a vaginal birth after cesarean (VBAC), ask the doctor if you're a good candidate (women who've had a vertical incision aren't, for example), and his policy about VBACs. Many doctors strongly encourage a VBAC, preferring to stay away from surgery unless necessary; others are fine with letting a patient elect to have a repeat cesarean.



4. Who'll deliver my baby if you're away on vacation or delivering someone else's infant?

No one's available 24 hours a day, 365 days a year. In many group practices, you'll routinely get whichever doctor's on call when you go into labor. If that's the case, most practices arrange for you to meet with each physician at least once during your pregnancy (if not, ask if you can do so). Take advantage of that opportunity to discuss their delivery-room philosophy. If you dislike one of them, find out if you can request an alternate if she happens to be on call.


Other practitioners try to attend all deliveries unless they're out of town, so inquire about the doctor's contingency plan in the event she's on vacation when you're due. If she has a trip scheduled then, ask to meet her backup.


5. What's your stance on drugs during labor?

You can't know in advance how you're going to feel during childbirth, but you probably have some idea of whether you may want pain relief. "If you really prefer to stay away from medication, for instance, ask what the practitioner does to encourage drug-free labor," says Cynthia Cover, director of midwife services at the Cleveland Clinic. Look for someone who recommends techniques like massage or showers, or even less mainstream options, such as acupuncture.


If you're leaning toward  -- or are unsure about  -- drugs, ask an open-ended question: "What's your feeling about medication?" Someone who answers, "We'll figure that out closer to delivery," or "It's up to you," probably won't do much to help you decide. Another red flag: a judgmental comment like, "I don't know why anyone would want to feel labor pain if they don't have to," or "I gave birth twice without drugs, and it's the best way to go." Ideally, your provider will give you as much detail as possible  -- what types of relief are available, when each is administered, and the pros and cons  -- to help you make up your own mind.



6. How much weight should I gain?

The American College of Obstetricians and Gynecologists recommends gaining 25 to 35 pounds (35 to 45 for twins) if your weight is considered normal at the beginning of the pregnancy. Some providers strongly encourage expectant women to stay within those guidelines; others think it's fine to gain 40  -- or even 50  -- pounds. If you don't want to be nagged about adding extra baggage (or conversely, prefer someone who will keep you in line if you start gaining too much), ask what range your doctor suggests. "If he says something like, 'Absolutely no more than 35 pounds,' you have your answer," says Williams.


You should also bring up any specific concerns  -- if you are overweight or a vegetarian, for instance, or if you have a history of eating disorders. "A woman with particular needs should look for a provider who's willing to work with her," says Williams. That can mean anything from making concrete suggestions about portions or substitutions in your diet to referring you to a nutritionist. If your doctor responds to your questions with vague or incomplete answers, such as, "Just try not to eat too much junk," you probably won't get the extra guidance you may really want.


7. How much control can I have over childbirth?

Keep in mind that for the majority of the time you're in labor, you'll be in the hands of nurses and at the mercy of hospital rules. But since you probably have some idea of how you want your delivery to proceed, try to find a practitioner who's in sync with your philosophy and willing to override hospital policy when possible  -- letting you walk during labor if you want, rather than hooking you up to a fetal monitor, or forgoing an IV if you don't need fluids or pain medication. Jennifer Drawbridge, of Guilford, CT, chose a nurse-midwife who supported her decision not to have an IV. "When the hospital staff tried to force one on me," she says, "my midwife was able to dissuade them."


Another issue to consider: the provider's stance on episiotomies (when a cut is made to provide a larger opening for the baby's head). ACOG does not recommend the procedure be performed routinely—only in certain cases, such as when the baby is in distress (and needs a quick delivery) or when it may help prevent severe tearing in the mother. Still, some doctors still perform them regularly, since they feel that they cause less damage and are easier to repair than a tear; others try to steer clear of them whenever possible, thinking that they cause more bleeding and postnatal pain than tearing will.


When asking about any decisions concerning your pregnancy and delivery, keep an open mind. And remember that the final call about some issues is best made in the delivery room with the baby's  -- and your  -- well-being in mind.