Choosing a caregiver

Place of Birth

Introduction

In birth, you will experience the most profound event in your life: the birth of your child. Birth can affect us physically, psychologically, emotionally, spiritually, and sexually. Thus it is important that we maintain as much responsibility and control over our births as possible. Penny Simkin, renowned childbirth educator has found that, "the birth of a woman's first child has an enormous lifelong impact on her… every woman who has given birth has a story to tell. The memory of the experience is vivid…" (Birth, December 1991) Many a woman, in her failing years, when asked to recall events in her past will have vividly etched in her mind her births when all other memories are faint and shadowed.

Your Expectations

A satisfying birth experience is directly related to the control you feel over the birth experience itself. Part of achieving a sense of control comes from careful preparation. Some questions to keep in mind even before your first prenatal appointment will help you in the preparation of your birth:

	Do I want a natural unmedicated birth?
	Do I want to deliver my baby in a birthing room?
	Who do I want with me at the birth? (i.e. husband, children, friend, midwife, doula or birth assistant) Will we ever be separated?
	When will I go to the birth place?
	How will my baby be monitored in labor?
	What prepping procedures will I go through?
	How would I feel about being induced or having my membranes ruptured? Do I know the pro's and con's of these procedures?
	Is freedom of movement during labour and being able to adapt different positions for delivery important to you? (i.e. Kneeling, being on your hands and knees, squatting) How will I push?
	Is the waterbirth an option you would be interested in?
	Will there be time limits on the length of my labor or pushing?
	How would you feel about having an episiotomy?
	Under what conditions would I accept interventions such as a cesarean or forceps use?
	Would I like the baby handed directly to me immediately following birth?
	Will I want pictures to be taken or a video tape recording of the event?
	Would I like to nurse the baby as soon as he or she is ready?
	Who would I like to cut the cord and when?
	Will the baby ever be taken from the parents?
	Do I want to breastfeed my baby? If so, for how long?
	When will you go home if you are in a hospital/birth center?
	What role do I want to play in decision making?

These questions may be overwhelming to you, however, the more you can think about these things and openly discuss them with your caregiver, the more likely you are to have a positive birth. You need to take some kind of class and/or read childbirth books to know what the consequences of each of these is (Check the book list on page ). Your own idea's and needs will evolve as you read more and get to know your caregiver better, be sure to continue discussing your wishes with your caregiver throughout your pregnancy.

Once you've established your own thoughts about the kind of birth you want, it is time to put your thoughts on paper and write a birth plan. List your choices in order of priority - most important first. This is how most medical people think. Are your choices realistic? Are most of your choices openly supported by your birth team? If not, will you compromise or make other arrangements?

Choosing a caregiver

One of your first goals is to find a caregiver with whom you feel comfortable and who shares your philosophy of birth. Your caregiver should respect your wishes and will agree not to override your decisions even if she or he would personally choose something else. Your choices in caregivers are:

General Practitioner with admitting privileges:

This is a doctor who has had a moderate amount of training dealing with uncomplicated hospital births.

Obstetrician (OB/GYN):

This is a specialist in high risk pregnancies, high risk births and gynecological surgery. Should you select an OB as your primary caregiver, the likelihood of experiencing interventions is increased as they are trained in surgery and tend to view birth from a pathological viewpoint. Although, you would see the same obstetrician during your pregnancy, depending on the time you go into labour, the obstetrician you have been seeing may not be "on call" and you would get one of the other obstetricians or residents available. The use of obstetricians for a normal low risk woman is unnecessary because of the increased chance of intervention as well as limiting the obstetrician's availability for high risk women genuinely in need of their service.

Midwife:

This is a specialist in normal pregnancy and birth. Midwives view birth as a safe and normal passage in a woman's life. They instill pride and confidence in women and consequently you are less likely to experience interventions during your pregnancy and birth. A midwife provides "continuity of caregiver" which means she supplies all your care form early pregnancy, through the birth and into the postpartum. Usually your primary midwife works with a back-up midwife who comes later in labour to join your midwife for the birth. Currently midwives attend births in the home or in a birthing center.

You should feel free to ask any potential caregiver any questions you may think are relevant to your care, such as:

	What is your training and how many births have you attended?
	How do I contact you between visits if I have any concerns?
	How do I contact you when I am in labour?
	How much time do you normally spend with a labouring woman?
	If a woman is in labour and you are not there, who provides her care?
	Do you have a working relationship with another doctor/midwife if needed? Who and where? What happens in the event that you are unavailable?
	Do you do prenatal checkups? How often? Do you do postpartum checkups?
	Do you offer prenatal classes? Where are they held?
	How will you assist me in preparing for labour?
	What percentage of women receive episiotomies in your practice? How do you prevent the need for episiotomies?
	What percentage of women receive cesarean sections in your practice?
	How long does it take, on average, to prepare for a cesarean section?
	What do you do in emergency situations?
	Do you encourage family-centered maternity care? How do you see this working in practical terms?
	Are medications available?
	How do your services differ from that of other birth attendants?
	Do you offer water births?
	What is your policy on informed decision making by the parents?

Once you have established who you will have as your caregiver, take your Doula to meet him or her. Everyone will be more comfortable at the birth if they have met beforehand. If at any time you become uncomfortable with your caregiver, feel free to change. It is never too late, women have been known to change during their labours! Women often feel that changing would be disloyal, but remember you are a consumer and you cannot afford to compromise your health or the health of your baby. Even if health and safety are not a risk you still have the right to a personal, satisfying birth experience. If you thought the mechanic working on your car was compromising your personal safety or simply not listening to your concerns, you wouldn't hesitate to find a different mechanic!

Place of Birth

Women labour and birth most successfully in the place they feel the most comfortable. Therefore the second step in preparing for the birth of your baby is to choose where to give birth. Your choice of caregiver will affect the options available to you.

Hospital Birth

For a planned hospital birth, you will have to choose a doctor, either a general practitioner or an obstetrician. It is important to find a doctor who understands and supports the kind of birth for which you are striving and is prepared to help you towards that goal. When making your first appointment, tell the receptionist that you wish for consultation rather than an examination. Once you have selected a doctor, it will also be necessary to meet the doctor's partners in the event one of them attends the birth if the doctor you are seeing is not on call.

Your choice of hospital will limit your choice of doctors to those with admitting privileges at that hospital, or vice versa. Hospitals are not all alike. Their styles of care can differ dramatically. Most offer tours to show what facilities they offer and it is worth your while to attend one. But it is even more important to meet the staff and ask them questions. The nurses are the people you will be dealing with and a staff that approaches birth as a normal, natural event rather than a medical crisis makes far more difference than any home-like decor you may be offered. It is a good idea to take a list of questions to ask that cover the issues that are most important to you - the things that you would have a hard time compromising on. Remember, it doesn't matter how cooperative your doctor is, if hospital policies run counter to your desires, hospital policy generally takes precedence. Some questions you might ask are:

	Do women labour and deliver in the same room?
	Is waterbirth an option?
	Are partners and welcome to remain during all procedures?
	Are siblings welcome at the birth or shortly thereafter?
	Are women allowed to eat and drink lightly during labour, should they so desire? May they bring their own food and beverages?
	Are other support people allowed for both the labour and birth? Is there a limit? Are women allowed to move about during labour?
	Are women allowed to choose to give birth in whatever position they find most comfortable? Does this include kneeling, being on hands and knees and squatting?
	Which of the following are done routinely: intravenous drip, electronic fetal monitors, enemas, shave or mini/shave preps, medications, episiotomies? (For more information, see Interventions below)
	After birth, is immediate and unrestricted contact for mother and baby allowed, or is the baby required to go to the nursery for examination and/or observation? Do you allow 24 hour rooming-in: for the baby? For the partner?
	If the baby requires special care can both parents visit the intensive care unit and touch and hold their baby? Can the mother breastfeed the baby in the intensive care unit?
	What sort of postpartum support is provided with early discharge?
	Is there breastfeeding support? Does this hospital have a lactation consultant on staff?
	What percentage of this hospital's patients had a natural unmedicated birth last year?
	What is the cesarean section rate of this hospital?
	Are partners welcome to attend cesarean sections?
	What percentage of this hospital's patients had a forceps delivery last year?
	Is perineal massage and support practiced by the birth attendants (nurses and doctors) here?

If you decide to choose a hospital birth, personalizing your birthing room with your own things from home can help relax you as you prepare for the birth of your baby. Including such things as a special ornament for the bedside table, your own nightgown to wear, bring a recording of your favorite music and something to play it with can really help. Being relaxed and calm during your labour and delivery are very important, a woman's flight instinct has slowed down and stopped many labours when a labouring woman arrives at the hospital, to an unknown place where the woman is uncertain as to what is expected of her.

Homebirth

Keeping in mind the statement that "women labour and birth most successfully in the place they feel the most comfortable," the home seems a logical option when deciding where to give birth.

"Some women say that since birth is an act of love. Personal and intimate, it should take place in one's own environment, without unnecessary observers, among friends in a loving atmosphere. They want to know that the father of the baby or a close friend can be present throughout, can take an active part, and can give emotional support through the labour… Often a woman would like to ensure that her baby has a "gentle birth" and is welcomed into the world tenderly, without the machinery and bright lights that are almost inevitable in hospitals." Kitzinger, 1989.

If you have chosen to birth in your own home, you will need to find a midwife to be your caregiver. It is important to select someone that you feel you can grow to trust with whom you can develop a good relationship. You should feel free to ask your midwife any of the questions that you would have asked your doctor or hospital staff. In addition to the "questions for caregivers" above, you might want to ask the following:

	When do you come to my home?
	What do you bring to the birth?
	Will you be the one to come to my home? Do you bring anyone with you? Who? How do your services differ from that of other birth attendants?
	How do you handle complications?
	How much do you charge? Is there a flexible payment system?
	Do you offer water births, and what are their benefits?

The biggest difference between hospital and home birth is the way in which childbirth is approached - the philosophy. Midwives, who attend home births, believe in the birth process and instill in their clients a confidence in their body's ability to birth the new baby.

If you choose to give birth at home you are not subject to any particular policies or procedures. You alone, with the help of your partner and selected family and friends, create the birth plans ideal for you. For example, you might plan to wear a special nightgown while labouring (or wear nothing at all), you might plan to go for a walk in you neighbourhood with your partner during early labour, you might want to give birth in front of the fireplace, or in the bed where the baby was conceived, or in a warm pool of water. You may want your partner, your 2 children and your 2 best friends with you - or you may choose to have only your partner present. Maybe you will mark the occasion with a celebration following the birth, complete with champagne and birthday cake!

Father's find that supporting their partner comes more naturally at home - in the hospital they are more apt to feel like an outside, less competent. Parental bonding to the newborn is also enhanced in a relaxed home environment. When the birth is at home, siblings and grandparents are welcome to cuddle the new baby and be as involved in the labour as desired by the parents. Many families have noted that home birth siblings do not experience as much jealousy or the feeling of separation from the mother that they might have experienced if the birth were in the hospital. They feel that this helps the siblings accept and adjust to the new baby more easily.

A certain amount of support in establishing breastfeeding is often needed by new mothers to gain confidence. When the baby is born at home, it is always close to the mother and can suck as soon as it is ready. This is not only good for the baby, but also helps the mother by releasing the hormone oxytocin into the body to help expel the placenta and prevent hemorrhage. The new mother is encouraged to do what feels right to her and the breastfeeding support from her midwife continues well into the postpartum period. At home you have complete access to your baby. This gives you the advantage of being able to act spontaneously with him or her and to develop a sense of confidence in your abilities as a new parent. Your midwife and your support people continue to nurture you in the early days following the birth so as you can fulfill the important job of nurturing your new child and "discover more about this unique being who has come into the world" Kitzinger, 1989.

(The information on Preparing for Birth was provided by ASAC, the Association of Safe Alternatives in Childbirth)

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