Wednesday, September 22, 2010

Surviving Pregnancy: Choosing a care provider

18 Weeks of Pregnancy - 164 Pounds
Measuring 23 Weeks
This is the one task that brought more stress to me during my pregnancy than any other single topic. At one point, the birth educator in a hospital class questioned the fact that I had a family practitioner for a high risk pregnancy and urged me to transfer care immediately. After calling around and learning I was too far in my pregnancy for any of them to willingly take my case, I consulted with one of specialists my doctor was working who completely laughed off the concern and said my doctor was certainly more than capable!

Choosing a Clinic
Early on, I chose a clinic and doctor because they had family practice physicians that would attend your birth and deliver your child. This was at Allina Clinics. I simply went to the Allina clinic website and read doctor profiles and philosophy and picked the one I liked.
The advantage of this was that unlike a standard OB/GYN practice, you could be assured that you would see the same individual for your prenatal visits as you would in the delivery room, ensuring as few surprises as possible. In other words, if you know your physician only performs episiotomy in urgent situations where the only other choice is C-section, then you won’t have to wonder about that when you are dilated to 10 and someone you’ve never seen before walks into your room covered in light green sterile clothes and only her eyeglasses peaking out as she says ‘hi, I’m doctor Smith and I’ll be delivering your baby today!”

Choosing a hospital
Another consideration is which hospitals your physician works with. In this respect, you might start your physician hunt by hospital shopping. You can start by going online and looking up the birthing centers or maternity wards of hospitals in your area. Often, their websites include basic information on rooms and policies. Most often however, if you want any specific information you will have to call. When you call, ask if they have a free tour or information session that you can attend. This is often the best way to lean more, and will give you an idea of how hospitals are different.
The hardest part is deciding what is important to you. Any good literature on multiples will recommend that you choose a hospital with a level II Neonatal Intensive Care Unit, as many multiples end up spending some time in a NICU. One consideration, especially for those who have high risk pregnancies (besides the fact you are having multiples) or are having  triplets or more is how easily accessible the hospital is from your home in case there is an extended stay there. The choices in this respect may be limited. Also, consider that if you are leaning toward a hospital without a level II NICU, that if your babies must be transferred there, you will still be recovering at the hospital you birthed at – making visiting your new babies complicated.
Aside from those factors, other items may be important to you, such as
*What are is the practice regarding fetal monitoring during labor? (see my birth stories to understand why this may be significant)
*In what situations are IVs are mandatory for laboring moms?
*Do I labor, deliver and recover in the same room?
*Where will you be delivering? (it is common for mothers of multiples to deliver on the operating table in an Operating room.)
*Is there a bathroom with a bathtub in the labor room?
*During recovery, may the baby(ies) remain with me, or are they required to be monitored in the nursery for certain periods of time?
*In what circumstances will the babies need to stay in the NICU? (based  on birthweight? Feeding needs? *Body temperature maintenance? Breathing assistance? etc.)
*Are laboring mothers able to eat, drink and eliminate on their own? (You may need to ask your physician this question also)
Be sure to preface these questions with the fact you are expecting multiples as the answer is often different.

Multiples: an automatic 'high risk pregnancy'
Most hospital and physician protocols go into ‘hyper-over-protective’ mode because you are having twins. And yes, they have some good reason to, as multiples are often born earlier, or smaller, and have complications such as Twin to Twin transfusion that singletons are not at risk for. However, there is a tendancy for protocol to be over-restrictive or overly-intervening even when there is no true benefit to the action in YOUR particular case.
I personally believe this is due both to lack of adequate research regarding risk in multiple pregnancy as well as a subconscious tendency to practice ‘defensive’ medicine. There is often not enough research to know for sure what things really are more risky for expectant M.O.M.s because there are just not enough multiple moms out there and not enough studies being done on them to provide reliable risk information. The tendency to practice medicine defensively stems from an emotional reaction (rather than a logical one) which inappropriately favors a known risk over an uncertain risk. This happens because we all have an innate desire to avoid liability and potentially poor outcomes, but as a result we may minimize or ignore the known and unknown side effects and risks of the intervention or restriction being proposed. (More on this in a future post).
This means it is critical for you to know and understand what conditions and risks are pertinent to YOUR pregnancy, and not just multiple pregnancy in statistics. Statistics often don't account for factors like previous poor pregnancy outcomes, socioeconomic status, access to health care and education. All of these are factors in general in pregnancy outcomes, and all should be considered when making decisions about YOUR pregnancy - not JUST a raw statistic. It is also very important to understand every procedure, test and intervention your provider recommends, why it is being done, what it's risks and side effects are, whether you and your physician has reason to think those same statistics would apply to you, and what the risks are of NOT doing it.

 So for instance, a doctor may recommend that you do not do any regular exercise because it is a risk that in their mind is not worth taking, but there is not data to show how risky it is - or even that it is correlated with complications at all. My question would be, what is at risk? They probably think the extra stress on your body could cause early labor. But are the chances of that really significant? Especially if you have had previous non-complicated pregnancies in which you DID exercize? Are there studies that show complications arising due to M.O.M.s exercising? Or is it just an 'extra' precaution? Is there is an intuitive reason that exercise will cause complications? If not, what are the potential side effects and risks of just remaining sedentary during multiple pregnancy?  You can see there is nothing clear cut, it all requires reliance on your doctor's knowledge and communicating your own risk tolerance and preference to her, and finally, using your intuition when logic is not available.

Natural Birth hopefuls: Critical Question for your physicians!
In the end, I worked with the same doctor both times – but the important part, which is critical here, is that she worked in coordination with a group of perinatologists who were on call during my birth, and actually attended them. In fact, because of a slight complication with thrombocytopenia, I was transferred totally into the care of the perinatology clinic for my second birth. Because of my experience, I highly recommend that all M.O.M.s (mothers of multiples) seek a highly trained perinatologist either for primary care, or that will coordinate with  your physician to attend the birth. The reason for this is that many physicians (even OB/GYNs) and midwives are not trained or experienced in breech birthing, especially the younger ones who were not practicing decades ago when it was more common.

Most OBs and physicians will advise you that as long as baby A (the first baby to be born) is head-down, you will be able to attempt vaginal birth. If vaginal birth is important to you to avoid C-section, you should pay careful attention to this subject. Some physicians will have a low personal risk tolerance, and may advise you that unless both babies are both vertex (head down) you should really consider having C-section. This is code speak for “I certainly wouldn’t try vaginal birth, but I guess I would put up with it if you did”. Do you really want to work with a doctor with that attitude? If you are like me, this won’t be the only issue you struggle about with him or her. And in reality, the advice is extremely short-sighted, as even if baby B is in a vertex  position, she is likely to present differently after baby A is born and will either need to be turned or birthed breech. (in both my pregnancies, after A was birthed, B had changed positions from where she was even during pushing of A) It is important to know if your doctor (and the other doctors in the practice) are able and willing to do a breech extraction on Baby B if the conditions are right (they may not do it if baby B is significantly larger) or to do an internal inversion of baby B after the birth of A. If they are not able or willing to perform either of those procedures, you will very likely be one of those mothers who had the ill fortune of delivering one child vaginally and the other via C-section.
In my personal experience, and from listening and knowing the experiences of those in the mothers-of-multiples group I am in, it seems that perinatologists are much more well-trained and experienced in these procedures than your average OB or midwife. Not to say that an OB practice would not be appropriate for you, but be sure to ask the important questions, and that you are comfortable with the answers.

Questions to ask when choosing your physician:
*Are you (and those in your practice) able and willing to do a breech extraction on Baby B if the conditions are right (they may not do it if baby B is significantly larger) or to do an internal inversion of baby B after the birth of A?
*In what situations would I be required to have a C section?
*For what reasons do you recommend bed rest?
*If all is healthy, is there a reason I would need to be induced?
*Can I have a doula present at my birth?

These are not all-inclusive by any means, but they are the most likely to bring up topics that can vary widely between providers and their experiences.
In reality, and in today’s medical care economy, it is extremely rare that you would actually be able to meet with doctors from various clinics, though sometimes they will make such appointments or have office hours. More often than not, they expect you to just schedule a regular exam or checkup and become a patient first, and ask questions later. For that reason, I would choose to start by taking hospital tours very early in pregnancy to choose a hospital first. Then I would find clinics and physicians that can practice at that hospital and call their offices to find out what resources are available to answer your questions. Don’t rule out a doctor or clinic because they are too busy to take your questions – it is probably a good sign. Join a local Mothers of Twins club or Mothers club and ask what hospitals/clinics/physicians other M.O.M.s had for their pregnancies. Pick a clinic or physician and ask lots of questions your first few visits. If you are not happy with the answers, make your next appointment with someone else. Choosing the right care provider is definitely an art and not a science!


  1. I have to disagree with the fact that midwifes aren't trained in breach extraction. Breach extraction is the exact reason why many woman go to midwifes - they want to avoid a c-section that most OBs and peris would advise.

    That being said, I wouldn't seek the help of a midwife again. I nearly lost the babies...long story...but my "minimally invasive" perinatologist didn't give me the option of a vaginal birth when it came down to delivering at a day short of 33 weeks (too much of a risk of brain bleeding so early on). He never even mentioned the posibility of a c-section, knowing full well that I would probably deliver early AND that I wanted a natural birth. He was awesome in every other way and saved my preganancy but every day I grapple with the loss of having a vaginal birth.

    Anyway, congrats on having twins twice!

  2. You are right! although I don't have much experience with Midwifes, I too would assume they have more experience with breech births than OBs. I guess what I was focused on is that they probably don't see as many twins births and have experience with internal version and breech extraction in twins births. How relevant that is compared to singletons I guess is up for discussion. You are right I should be more clear though!
    I'm glad your story ended happily. Though I know how disappointing it is to not know what was in play until it is happening. I am a type that definitively wants to experience everything!


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