Why You Need to Ask These Questions in Your First Prenatal Appointment
Childbirth is one of the most intimate experiences a woman who becomes a mother will have- yes physically, but also emotionally, spiritually, culturally, psychologically, and more. For both the mother and baby, these foundational elements aren’t separate and do affect one another. A baby’s physical well-being can be affected by her mother’s emotional sense of safety, for instance.
It’s time we educate newly pregnant women that the midwife or obstetrician that ‘delivers’ their baby is actually helping THEM to deliver their baby. And more importantly, deeply influencing them along the much bigger journey of becoming a mother/parent. What this health care provider will do, could do, should do, is quite a bit more than just make sure everyone survives. And here’s why.
Here in the United States, there is a widespread perception that childbirth is dangerous, that OB’s deliver babies, and that they are the best protection from this dangerous event. As a consequence, many assume that whatever their OB does is automatically the best care to be had. However, it can be problematic to ‘just go along’, without asking questions and without actively choosing the sort of care you want.
Birth is a normal biological event. It is the ONLY normal biological event that in the US we routinely move into the medical setting ‘just in case.’ What is often understood by new parents only AFTER they have their first child, is that treating all normal childbirth as automatically very risky (instead of just thoughtful watching, for instance), brings on substantially greater risks through an often unnecessary cascade of interventions. (A cascade is when one seemingly simple intervention, such as inducting labor without waiting for it to begin on it’s own, tends to lead to additional interventions that may not have otherwise been needed.)
This is painfully evident by the fact that the United States spends more per birth than any other nation in the world, yet is currently 64th for maternal mortality and 53rd for infant mortality! More mothers live through birth and their first year postpartum in 63 other countries than in the US! Much of this has been attributed to the US using obstetricians (surgical specialists) as primary maternity care, where the other counties routinely use midwives (normal birth specialists) for most mothers, saving OB’s for when they are medically indicated.
So how your health care team perceives birth, and approaches you and your pregnancy, shape the tone and quality of your prenatal care and experience.
They will bring sensitive excellence, or high-handed invasiveness, to one of the most intimate experiences you can have. They have the opportunity to guide your education about birth, affect your health and your physical experiences for an entire next year, and to set the tone for your empowerment through birth (or not). ALL of our relationships are affected by this health care experience - including with our baby and our mates!
This care provider could be a midwife (CPM, CNM) or an obstetrician (OB-Gyn), and they could work in a range of settings (hospital, birth center, home). As I tell my homebirth clients, as a midwife I see my job as not to just make sure their plane doesn’t crash out of the sky, but to do everything in my power to help them have a smooth landing. To me, this means that I aspire for them to have as seamless transition as possible into the much bigger work of parenting, through all the different ways a birth might unfold.
When we choose professionals to assist us in the care of our pregnancies and babies, we are hiring different strengths and limitations also. Caring for a mother throughout her pregnancy offers a critical opportunity to do much more than just assess her vital signs and the baby for problems. While no one can fully control how a birth goes, when your midwife or OB thoughtfully supports your empowered decision-making, the chance of you experiencing your birth journey in a positive way increases dramatically. Understanding this as you initiate prenatal care can help guide the questions you ask, the care you expect, and the choices you make. There is no one right answer! My goal is for you to be aware that gathering this information empowers you to have make choices that works for you and your baby, and hopefully lead to healthier and more satisfying outcomes.
Here are some initial questions to ask, that will help you understand how an individual midwife or OB’s view of their profession and you shape your (and your baby’s) well-being. It may not be as you expect!
DUE DATES
When a mother and baby are both healthy, how do you care for a mom that goes overdue? What is the longest you’ve have a mother go past their due date?
What happens if I decline induction at 40, 41, 42 weeks?
And, If interviewing a hospital midwife, is her team comfortable and able to manage their patients beyond 42 weeks? If you are interviewing a homebirth midwife, also ask them if they prefer or are required to transfer care after a certain point?
Human pregnancy is considered 40 weeks long, even though this is counting the two weeks prior to ovulation (from the “first day of your last period.”) Normal gestation is actually 2-3 weeks on either side of the due dates, but in the recent generation of physicians this peaceful perspective is nearly completely lost. It’s beyond the scope of this blog to argue it here, but in general you’re exploring their attitude on this hot topic, and how you feel about it/does it make sense to you? Inducing a mother through medication when her body and baby were not ripe and ready to do so (or she would already be in labor), for no medical reason only dates, can have serious negative consequences. In this question, you’re want to get a sense of how bossy or collaborative they are, and what their indications are that they value true ‘informed consent’ and will be responsively providing you with both the benefits and risks of any recommendation.
Frankly, this is one of the two areas that seem to most surprise couples who expect to have a natural birth. When they go overdue a bit from their Estimated Date of Delivery (EDD, which is quite common and normal), they commonly begin to experience increasing pressure to show up for an medical induction of labor. I’m not saying you should or should not decline a recommended induction, but you should be “able to” without threats and micro/macro-aggressions.
WATERS OR MEMBRANES RELEASING WITHOUT LABOR - (PROM/PREMATURE RUPTURE OF MEMBRANES)
What are your protocols when a mom’s waters break, but labor does not start in 12 hours? Or 24, 48 or 72 hours?
If you are interviewing a midwife, also ask them if they prefer or are required to transfer care after a certain amount of time has passed?
This is the second area which can really bring some anxiety and bewilderment to a family committed to a low-tech or low/no-med birth if this happens and they’ve never discussed it.
There will be a wide range of answers here, you might want to interview a few different practitioners in your area. The concern is that the baby is generally considered to be in a protected environment inside its intact bag of waters. When the bag (of waters) breaks, there is now an avenue for infection to potentially reach the baby from the outside world. There is no need to be wildly alarmed about this, but the hospital often is.
What you are looking for is a sense of calm, thoughtfulness, and ideally, flexibility and an understanding that this situation can be at least somewhat influenced. For instance, do they offer you the information that studies have found that the more often a vaginal exam is performed in pregnancy, the greater the risk of PROM? Or that infection can be minimized through a practical protocol, which should include no routine vaginal exams (well ever), but especially not until active labor is established?
For context, my longest client went five weeks before labor began after her water broke, actively leaking all the time. We were not casual about it at all (she followed my suggested detailed protocol and checked baby’s well-being with the real kick-tests daily), but also not alarmed. She birthed smoothly and safely in one hour when the time came. This is a place you want to gather more info - look to experienced doulas and midwives, childbirth education classes, and trusted books to help point you in the direction of quality info. (Here’s my blog on empowering and practical books suggested by doulas and midwives!)
At the bare minimum, you’re looking for at least 24-48 hours before routine medical nudging towards induction. Again, does their answer work for you when you ask, “I don’t know if I would, but what if I declined that suggested intervention?” Under all circumstances, a quality practitioner will be respectful, interested in your concerns, have time (or offer to make time) for your questions, and illustrate their willingness to inform, educate, and work together.
STATS
Could you tell me/us about the statistics for you, and your team/practice/hospital?
Since you may not end up having the person you are talking to actually at your birth (I know, shocking, ask questions), it’s important to know what philosophies their colleagues might possibly bring to your birth.
You’re looking for info on:
Surgical delivery -
The WHO has said that there is no excuse for a cesarean rate over 15% under any circumstance; US rate is currently averaging around 30-34%. If you birth in a medical setting, the institution’s rate STRONGLY affects your experience & outcome.
This number is known, it has to be monitored, and there should be no problem with them sharing it. I’ve seen the hard copy of the current week’s stats at the nurses' station, so they know. And if they really don’t, why not?? If you do not want to be 1 of every 3 moms that is (routinely, unfortunately) walking out of a US hospital with major abdominal surgery along with their baby, ask lots of questions, make choices that help you feel more confident, and always have an experienced advocate with you (and your husband/partner) at birth, such as a doula or an experienced mother.
Epidurals - What percentage of your mothers deliver with or without an epidural? The national rate is very high, 60-80%? (My guess.) If you are intending to birth managing any pain by non-pharmaceutical means, is this practitioner/facility familiar and confident in helping you with this goal?
Birth position - What position do most of your moms birth in? Homebirth midwives are nearly always going to answer something like “In whatever position they want” or “Kneeling on the floor.” If the doc looks startled and answer “Semi-supine, but they aren’t in stirrups” (or worse, ARE routinely, not-by-choice, in stirrups), they are still expecting and directing mothers into positions that serve THEM more than the MOTHERS. We care about this question because when the time comes, YOU will care. Mothers naturally position themselves in the most comfortable position for them, which is usually the path of least resistance for their baby & pelvis shape, and may facilitate a smoother, faster, and more comfortable birth for mom and baby!
Cords - When do you typically cut the cord? The issue is that your baby needs ALL of their own blood, and the medical habit is still to cut it way too soon. Again - SOOO MUCH education needed here! WATCH THIS (4 minutes) to understand. If they answer, “When it stops pulsating”, then your follow-up is, “About how long does that tend to be?” No need to argue, just gathering info; LOTS of misinformation continues in the hospitals on this one. A tolerable answer is anything over 10 minutes. One-two minutes means they are not fully informed as to medical research and evidence-based birthing, regardless of how high their student loan debt is. But it’s common. You could ask, “Of course we can always direct it to be longer?” At homebirths it’s generally when the parents ask, and almost always an hour after birth or more. It would be nice if they threw in, “Of course you or whoever you want are invited to do the cord cutting.”
These are NOT all the questions that you need to ask, but it gives you a solid start on building a relationship, gaining confidence and seeing what you might expect. It’s not at all inappropriate to expect time for your questions, and thoughtful dialogue. It’s fairly common, though, to not get it. You might help by informing the scheduling staff that you will be needing time for questions, especially with obstetricians. I encourage you to check out the books mentioned above, and to keep asking questions or checking out your options until you find a fit that works for you! There’s a lot of extra navigating that goes into having a less disrupted birth in a medical setting. If that’s your spot for whatever reason, work on having good support, good info, good health and an extraordinary maternal AND pediatric provider in which you can work on developing a mutually trusting relationship. DO NOT be afraid to keep looking or change providers, along with trusting your intuition most of all.
Have a sweet and nurturing childbearing year!
