A Tale of Three Births -- Why choosing your care provider and place of delivery is so important.
I want to take some time here to talk about the importance of care provider in birth experiences. I know it’s something I stress time and time again, but it’s because I truly feel it is the most important decision you can make regarding your birth plan.
I’m going to talk about three different births I’ve witnessed over the past year to highlight this. I’m choosing them to talk about in particular because:
- They all occurred in the hospital;
- Though they were in 3 different hospitals, they were all within the same hospital network and within 15 miles of each other.
- One of the three care providers actually has privileges at one of the other hospitals mentioned;
- The only risk factor among them did not necessarily complicate labor in any way as long as the pregnancy is healthy, which in this case, it was exceptionally so. All three women were healthy prior to pregnancy and had very normal healthy and straight forward pregnancies. This was their first baby in each situation.
I want to stress that there is no judgement on my part toward the parents in this situation. I tend to meet clients pretty late on in their pregnancies and understand the hesitation to listen to a near stranger tell you that you might want to switch care for XYZ reasons so late in the game. I recognize my own professional and personal bias and am full aware of how parents might filter that reality through how they interpret our conversations.
However, one of the births I write about below had tested my boundaries as a doula and is one of many I’ve witnessed where I felt that the decisions made by hospital staff were not only disempowering, but actually wildly unsafe. I feel like I have to continue to preach the importance of interviewing multiple care providers, including midwives in and out of hospitals, for the safety of my clients and the longevity of my career as a birth attendant.
The general rundown for these births is:
Birth A: Hospital birth. Saw the same female obstetrician in a private practice with two providers through the entire pregnancy. Primary doctor present at birth.
Birth B: Hospital birth. Saw the same female midwife in private out of hospital practice with two other midwives, each having hospital privileges. Primary midwife present at birth.
Birth C: Hospital birth. Switched providers and hospitals in second trimester to give birth closer to their home. Did not see primary doctor at any point in birth. Had not previously met any of the doctors present prior to labor.
Birth A was a long one. All told, about three full days of prodromal labor; which is the early labor that can switch on and off and is common in first time mothers. Unfortunately, her prodromal labor was quite long and unusually intense at times, leading to some justifiable exhaustion.
When this mama came in on the first day after a long night of mild, but exhausting and painful early labor, she saw only nurses in triage. They checked her and found she was not yet much dilated. Instead of pressuring her to stay, which would have been rather common with a mother who was at 41 weeks and 4 days, they gave her a shot of morphine and sent her home to rest. She labored exhaustingly at home for another day and a half before deciding to come back into the hospital. She did not receive pressure from her OB to come in at any point. Instead, they made a plan together to come in and see what was going on and if it was time for this mama to get some medical assistance in this process.
When she first returned to the hospital, her primary doctor, who she had been consulting with over the phone, was not on shift, so she saw a colleague who is not in her primary’s practice. This care provider wanted to start pitocin and break her bags of waters, but this mama did not yet feel comfortable with either just yet. She decided she first wanted to get an epidural so she could sleep after nearly three days of labor, which seems like a very wise decision.
After half a day, her primary doctor came on shift. She was incredibly supportive—sat down on the bed to chat with mama, went over a potential plan, talked about potential complications but stayed positive, tried to ease this mama’s concerns regarding a long birth. Pitocin was eventually started as a means to avoid going right for a cesarean birth.
Mama eventually crossed through the dilation stall and was fully dilated late on day four. Her epidural had been spotty for most of labor and she was feeling mixed pain and the normal pressure sensation so her doctor suggested pushing. At her doctor’s suggestion, she was maneuvered into several positions to help open her pelvis and move baby through, which is uncommon in a birth with an epidural.
Her OB stayed through the vast majority of four hours of pushing attempts in her normal scrubs minus the white coat or sterile gown and mask many doctors prefer, trying to help get baby down low enough that a cesarean would not be necessary. In the end, baby was in a tricky enough position that it became necessary to have a cesarean birth. Her primary performed the surgery and was calm and supportive throughout. This is why cesareans are life saving and important. Each nurse, anesthesiologist, and doctor she saw once that decision was made reminded her of this and promised her they’d try and be mindful of how to make it likely she could have a vaginal birth with her next baby.
Birth B followed a very typical first time birth pattern from start to finish. Likely her bags of water broke the first morning without contractions starting. She leaked through the day and contractions started in a regular pattern around midnight. They lasted through the night without significant change and petered out during the day a bit. That is also very typical of first time births.
She kept in regular contact with her midwife throughout, but did not receive any pressure to come into the hospital. Things picked up mid-afternoon. Mama stayed home, ate, got some rest, spent a long time in the shower, went for a walk, rested more, and was visited by family. She made a plan with her midwife to come in at least for a check in late that evening.
Things had progressed a great deal in about three hours at home and it was clear when she did get to the hospital that she had moved into late active labor and no interventions were likely needed. She got no pressure from her midwife or hospital staff to have an unnecessary IV lock (which is very rare in general and particularly rare for this hospital) or any other interventions. She labored in the shower for several hours where they checked baby with a handheld doppler in accordance with evidence-based indicators and mama never had a single thing tethered to her body. Her midwife spent a good deal of time in the room with mama, partner, the nurse, and myself.
When mama began to feel the urge to push, her midwife suggested she start pushing while still in the shower. There was no vaginal exam done at that time — her midwife trusted that what she was feeling was a valid sign of progression. Eventually, mama and midwife decided to move to the bed where mama was free to push in her desired position. Mama was able to fall asleep in between pushes and we all sat quietly around the bed, all the lights off save for one so the midwife could do the necessary safety checks and let mama determine when to push. The midwife waited until the last minute to put on a sterile gown and gloves and never put up stirrups or broke down the bed, instead sitting on the bed with mama.
When baby was nearly out, the midwife helped mama catch her own baby with midwife and papa’s help.
Birth C fell somewhere in the middle of these two in terms of complications, but was treated quite differently, despite this mama having an equally healthy pregnancy. In all, it was about three days long, typical for an induction of a first time mama.
Toward the end of pregnancy, because of a combination of supposed "advanced maternal age" (she was 37), care provider preference, and non-evidenced based hospital policy standard at this particular birth place, mama received many added tests and pressure. She was still “allowed” to carry her baby to 41 weeks and 2 days before they concluded that her fluid levels were low and induction was necessary. She had received pressure to induce through the last several weeks of her pregnancy, but since all tests came back very positively for both she and baby, she was able to hold off until this final screening.
She received one dose of misoprostol in the afternoon of day one, just after her check up that morning. Her body kicked in and mild contractions started through the evening. After twelve hours of early labor with normal progression patterns, her nurse came in to tell her that they were starting pitocin. At no point was this presented as an option and this mama received a lot of push back from the nurse. This nurse at first resisted going to call the doctor to relay the message that this mama did not want to start pitocin with no medical indication it was necessary, but complied after a long back and forth exchange.
In the hours that followed, several nurses came in to ask if this mama was ready for her epidural and pitocin. This mama’s plan was to forgo both for as long as possible. Only one nurse, who was unfortunately only a relief nurse and so there for just a short half an hour, made suggestions on comfort measures and actually touched this mama beyond moving a few cords.
Pitocin was suggested again, but mama decided to get in the shower again, which was very helpful. She was left alone to do that for a time, but then nurses started coming in to tell her she needed to come out and have baby monitored.
Mama asked for an epidural not long after and was given pitocin along with it. She was seen by a doctor for the first time since triage a few hours after her epidural. Up until then, everything had been done over the phone with an on call doctor affiliated with her hospital, but not this mama’s primary practice. She had never met any of the doctors making medical suggestions at the time of birth prior to going into labor.
The first thing this doctor said was that the progress was too slow and baby’s head is likely too big because they had let her go to 41 weeks gestation. She said it was likely a cesarean birth was necessary. After some negotiation with mama, her nurse (a new and much more caring nurse had come on shift), papa, and myself, a plan was made to wait four hours while shifting mama’s position to see if baby could move down more before having a cesarean.
Within that four hours, mama had dilated significantly and was almost complete and baby had moved down into the perfect position. It seemed like a cesarean would not be necessary if baby’s heart continued to have it’s normal patterns. After another four hours, she was checked again by a nurse and told that she was complete and should begin pushing.
Pushing went exceptionally well right from the get go, which is not common for first time mothers, especially with an epidural. The room was not prepared for baby’s arrival at the pace in which it was about to arrive. A new doctor swooped in, without ever having met mama or touched her, began to tell her that things are going to go wrong because she was giving birth at 41 weeks and she was at advanced maternal age and it was likely they were going to take baby away after birth, that this doctor would make the decision whether or not to let the cord continue pulsing before being cut, etc.
This doctor asked mama to stop pushing through contractions despite mama feeling the urge through the epidural so that she could put on her sterile suit and get her table set up and the bed broken down. This doctor berated the two nurses through all of this, loudly, and she and the other nurses talked about another laboring woman loudly in front of this mama for several minutes. Mama was concerned about tearing in this time and her requests for massage or perineal support were unanswered. In fact, no one answered any of mama’s questions throughout pushing, but they would stop occasionally from bickering to tell her she was doing something incorrectly despite the fact that baby was nearly fully born by the time the doctor even entered the room.
Through the next several pushes, this doctor aggressively maneuvered baby out, yelled at the nurses through the whole thing, talked about how it was lucky she was there because this woman was so high risk, told this mama that the baby was likely too big because she let her grow too long inside of her, yelled at the nurses for not previously noticing meconium even though there were no prior stains or indications of fetal distress and it was likely the meconium had been passed while mama was holding back from pushing, and laughed at the papa when he asked for delayed cord clamping and immediate skin to skin saying that it was her call what happened there and that because of postdates and nurse neglect, they need to get a cord blood sample and take baby away — this all when baby was just moments from being delivered.
Mama had a few short moments with baby before they were taken to the warming tray. the cord was cut immediately and this doctor started immediate internal removal of the placenta. She continued to berate the nurse for not being helpful enough during the delivery of the placenta while placing her entire hand up to her wrist inside of mama, despite blood loss not yet being near hemorrhage levels.
Doctor stayed for about twenty minutes to stitch, joked about getting all the glory, and left promptly before baby was even given back to mama. Baby spent most of the first hour with nurses at the warming tray, despite high APGAR scores at time of birth. Baby was just over 6 pounds without a caput succedaneum worth mentioning — no indication of being “too big” or necessitating a cesarean.
The reason why it is important to take a close look at each of these births, and births like them, is not to focus on the outcomes — cesarean or not; epidural or not — but to instead examine how each pregnancy and labor, and really each woman, was treated. Why does that matter? It matters for two fundamental reasons:
- It is a matter of safety.
- It will effect the postpartum period and the confidence and support this mama gets in being a parent of a newborn.
There is plenty of writing on the first point, so I’m going to talk a little more about the second point. What do I mean when I say it’s a matter of safety? I mean that often times, what I see as disempowerment of women in labor is also a neglect of evidence-base care which increases the risks to both mother and baby when it is likely physiologically appropriate birth would have been far safer.
And yes, I say “physiologically appropriate” instead of “natural.” Like in the case of Birth A, her physiologically appropriate birth required medical assistance, and that’s important. Under supportive care that met guidelines for best practices, she was not pressured into interventions that were not necessary. Further more, she was informed of her options throughout and ultimately made all the medical decisions in consortium with the whole birth team. That is the safest model of birth support, and not just some crunchy ideal.
The reason I wanted to write about Birth B is not just to share a beautiful and positive birth story with midwife support, but to highlight a birth that was treated as normal and safe in accordance with good practice medicine and not an outdated set of hospital standards, which have been shown for decades now to not reduce risk for mothers or babies. An empowered birth is often the safest birth.
Birth C was riddled with standard protocols that have been shown to be based more on doctor opinion than on evidence of safety. As a support person who has seen a lot of births in many different settings, I felt like the latter part of her birth was actually very unsafe. I was worried throughout that the doctor’s narrow style of support, her distraction with the nurses, her increased use of unnecessary interventions, aggressive practices, and harsh treatment of my client were increasing the odds of life-threatening complications by the minute. Luckily, everyone was safe in the end, but it seemed like this doctor needed to create her own set of “glory” circumstances to validate her ideas on how birth typically unfolds. My client said she did not like this doctor and mourned having her there for those crucial moments. This birth is why I no longer work in this hospital.
According to Dr. Neel Shah of the Harvard School of Public Health, recent surveys suggest that women spend little time interviewing potential care providers in pregnancy. They are more likely to go with a hospital and provider who is closer to their home rather than one with better birth outcomes. In a recent interview with Science and Sensibility, Dr. Shah states:
Generally speaking, when patients who encounter the healthcare system get harmed it is because we either did too little or too much. In the context of our study, some of the harm of doing too little is reflected in the mortality rates. However, the harm of doing too much is not evident in the study because by only looking at mortality, we are just seeing the tip of a very deep and wide iceberg.
Working with a care provider who is prone to seeing birth as a medical catastrophe requiring more intervention than fewer in all cases, it is more likely that both mortality and morbidity rates are increased. Too often, the only metrics looked at in terms of birth outcomes are cesarean rates and mortality. Little attention is paid to maternal morbidity and overall sense of treatment.
This general view of the safety of labor is something that is generally keeping women away from seeking midwifery supported and out of hospital births. These unsafe practices of denying women the opportunity to see how physiological birth can unfold creates a myriad of actually unsafe practices in fear of a small possibility of risk.
Since I am a student midwife with experience supporting births in birth centers and at home, my clients sometimes ask me what would have happened if something like what they experienced happened at home. It’s hard for me to honestly address this issue, since the answer is that their midwives at home never would have introduced a certain procedure or set of procedures which made their births unsafe for a time before the doctor eventually came in to fix the damage at the last minute with another set of interventions.
I also explain to them that in situations like Birth A, the midwife would have likely counseled this mama that hospital transfer is the safest option and she would have had the same outcome of a cesarean birth. But the outcome doesn’t matter — her hospital-based OB was practicing in line with best practice medicine that hopefully if she had planned a home birth, her midwife would have practiced as well.
But let’s look deeper at this situation, too. The care providers present at Birth A never made this mama feel like the outcome of her birth — surgery — was in any way a fault of hers. They did all they could to ease any suffering she was feeling and ultimately made decisions along with her that felt the safest. It was done with the lights low, her doctor next to her in bed, her husband included in the conversation, the nurse with her hand on my shoulder, and only after all options were presented. If mama in Birth C had the same set of circumstances arise at some point in her labor, it seems unlikely she would have been treated as such an important actor in the decision making process, seeing as though she did not have any actual complications when her last doctor swooped in and she was told that she had done many things wrong up until that point and so she had to have her baby taken away. THIS IS WHY CHOICE OF CARE PROVIDER MATTERS.
If you are a pregnant person, I want you to really examine the quality of your care. It’s more than a smiling face. Ask the difficult questions — What is your cesarean rate? What are the various circumstances that would lead you to suggest a cesarean birth? What is your induction rate? What is your experience in working with doulas? How often do you see unmedicated births (not just epidural or not, but intervention-free births)? What do you see your role being in an uncomplicated, unmedicated birth? How often do you catch babies in positions other than lithotomy? What are your suggestions for helping me cope through the pain of contractions through unmedicated sources? Do you have experience working with parents using hypnobirthing? How often to you take baby away from mothers after birth? How likely is it that you will be the one present for my birth?
If you care provider uses a lot of “we don’t allow”s, it is unlikely they are going to be supportive of your decision to have a low intervention birth. If you have made an informed decision to refuse certain standard protocols, but you are met with hesitation from your doctor, you should switch. If your doctor can’t even say how often she witnesses low intervention or intervention free births, you should switch.
Getting a doula does not mean that you will have an empowered birth or that you are likely to have a care provider that supports your options, but one of the biggest benefits to working with a great doula is how she is able to point out some of the gaps in care, mention providers and places of birth that are not generally supportive of the type of birth you are looking for, and can help you formulate language in your prenatals and birth plans so that it can be more likely you know your options and can vocalize them.
Best wishes for a safe and satisfying birth. -em