Updated: Jul 13
So often we think of medicine as a science, but it can really be an art form. Doctors have professional training, medical textbooks, and access to an abundance of research studies, but at the end of the day they're still individual people. They each have their own style, preferences, and philosophies. There's no one way for providers to practice medicine.
This difference of professional opinions is even more pronounced in birth because of the gray nature of labor and delivery medicine. Of course there are professional guidelines and recommendations (such as ACOG's or ACNM's stances on various aspects of birth), but ultimately each professional is going to lean on their education, experience, and preferences when making recommendations.
You might be thinking: "this is nuts. Every OB or midwife is going to practice excellent medicine - I'm hiring them to take care of me, and trust that they'll do that!"
To be clear: there's a difference between being hospitalized for birth, vs. almost anything else. When you're pregnant, you're not sick or dying (usually). A lot of medicine in L&D is really preventative, and not necessarily life-saving. Because you're not dying, you have a lot more options when it comes to the nuances of your care, compared to someone who ends up in the hospital after a car crash.
Let me give a common example of a scenario that about 1/3 of families will experience in 3rd trimester: a suspected big baby. This means you had a late ultrasound (usually around 36 weeks) and it showed that your baby is predicted to weigh more than 8lbs 13oz (4 kg) at birth.
There are a few different ways providers will approach this scenario:
Provider #1: "You're having a big baby, so we definitely need to schedule a c-section at 39 weeks. there's no way this baby is going to fit through your pelvis"
Provider #2: "You're having a big baby, so we're going to schedule an induction at 39 weeks to prevent baby from getting too big to fit"
Provider #3: "Looks like your baby is measuring big on this ultrasound, but late ultrasounds are known to be inaccurate. Even if your baby is big, I trust that you can birth your baby - there's no need for interventions."
The confusing thing is that in the moment, you won't hear all 3 of these options. You'll just hear the one your provider prefers.
So how do you know that your provider is going to be a good fit for you? Well....it starts long before the big baby conversation. Take time to interview multiple providers and see who is the best fit. Just because you've loved someone for your gynecology appointments, doesn't mean they're the right person to catch your baby!
Check out the list of questions below as a starting point for these interviews. If you don't like their answers, it might mean they're not the right provider for you.
P.S - if you're told you're having a big baby, you NEED to read this article from Evidence Based Birth.
10 questions to ask your provider about their birth philosophy when you interview them:
1. How do you work with doulas?
This first question is going to give you great insight into how your provider feels about you taking control of your birth. If they tell you they don't like working with doulas, that's a sign that they're not going to want you questioning anything they do.
2. What happens if my water breaks before contractions? Do you recommend I head straight to the hospital, or labor at home until contractions have begun and/or are closer together?
When your water breaks first (which happens in about 10% of births), it is valid and evidence-based to induce labor, but it's also valid and evidence-based to wait for contractions to begin on their own. Your provider's answer to this question is going to help you understand if they are more medically-minded or more holistically minded.
3. What positions do you catch babies in?
Many providers were only taught how to catch babies when the birther is on their back, with their feet up in stirrups. We now understand that this position isn't ideal, for a lot of reasons. Your provider's answer to this question will help you understand how flexible they're willing to be when it comes time to push your baby out.
4. Do you encourage laboring in water (shower / tub)? Do you catch babies in water?
There are very few hospital providers who are comfortable with water birth, yet we see it used in around 60% of out-of-hospital birth centers and home births. There are many benefits to water birth, and the biggest reason why hospitals discourage it is for their own liability.
5. What is your rate of episiotomy?
Episiotomy is when a provider uses scissors to cut the perineal skin and widen the opening of the vagina (as opposed to doing nothing which could result in a natural tear). Up until the 1990s, this was standard practice. Today we understand that natural tears heal better. Ideally, your provider shouldn't be cutting episiotomies.
6. What is your rate of c-section?
Don't take "average" or "good" for an answer here - get a number. Your #1 risk for unplanned c-section is the birth location and medical team you hire. In the Twin Cities, our hospitals have c-section rates ranging from 21% - 40% (see them all here). The World Health Organization recommends that c-sections rates be around 10-15% for healthy outcomes. We know that about half of c-sections in the US are unnecessary. Ask your provider what their rate is - are they higher than average (29% in Minnesota)? If so, that's a good sign that they're quicker to jump to surgery than their counterparts are, and it's not necessarily keeping you safer.
7. If my baby is breech, will you require a c-section?
Most providers today were not taught how to catch breech babies vaginally. If your provider is not skilled in breech birth, a c-section is a safer method of delivery. BUT if your provider is trained in breech birth, then vaginal delivery is safer. Many communities do not have any providers trained in breech. We're lucky here in the Twin Cities and Western Wisconsin to have a few who know this skill. Talk to your doula about options, if your baby is breech.
8. Do you recommend routine induction at 39 weeks?
In 2018 the ARRIVE trial was published, showing c-sections decreased from 22% to 19% when people were induced at 39 weeks, rather than waiting for labor to begin on it's own. However, there are lots of issues with the study, and it's not applicable to the general population (look back at question #6 - our general population c-section rates are nowhere near 19-22%). Since 2018, many OBs have implemented 39-week inductions. A 2022 observational study showed that our c-section rates have not decreased since ARRIVE. If your provider standardly recommends 39-week induction, this is a good indication that they believe in medically-managed labors.
9. Do you support delayed cord clamping, and how long do you delay?
After baby is born, there are lots of benefits to waiting to clamp their umbilical cord so they can get all of their blood from the placenta. It can 10 minutes or more for the cord to turn fully white, indicating that there is no more blood in the cord. Providers will delay this clamping anywhere from 30-60 seconds (ACOG), to 1-3 minutes (WHO), to 5 minutes (ACNM). If your provider says they delay cord clamping, but then only do 30 seconds, your baby isn't getting the full benefit.
10. What are your COVID-19 practices? Will you encourage induction if I contract COVID while pregnant?
This question is an ever-moving target, and there's not a gold-standard answer yet. As your provider answers, listen to the underlying meaning - are they going to support your birth plan, even if you've had COVID? Will your partner be allowed to attend the birth if you're COVID+? Will you be expected to wear a mask in labor (reminder: they can't actually require this, but they can pressure it)? Will you be denied using nitrous oxide as pain relief?
Listen carefully to how your provider responds to these questions. If you don't like their answers, it might mean they're not the right provider for you. Take time to interview multiple providers and see who is the best fit. Just because you've loved someone for your gynecology appointments, doesn't mean they're the right person to catch your baby!
BONUS: Ask your provider if the other doctors in their group have similar philosophies, and consider meeting with their colleagues during future prenatal visits. There's a good chance your provider won't be on call when you go into labor. Will the on-call doc be supportive of your birth preferences?
Not sure what some of these terms mean? You're not alone! Birth on the internet is scary - take a course taught by a real human instead: