Continuum of Care Provider Philosophy
Understanding how your care provider views labor and birth and their consequent style of management is vital to creating a trusting relationship. Discovering any differences of opinion between you and your care provider and honestly discussing those differences early in your pregnancy will go a long way in avoiding any "surprises" at the end of your pregnancy or during labor & birth.
The below chart offers a look at two styles of management on either end of the obstetrical care continuum.
At one end of the continuum, a care provider may suggest more invasive interventions (testing, procedures) to stay one step ahead of pregnancy, labor & birth rather than let nature take its course. These care providers may also present their points of view as the best option, or provide little information on alternative treatments and protocols. Often, a care provider at this end of the spectrum asks for your compliance and emphasizes faith in his/her judgment, rather than look for your input. This style of care is most compatible for those women who prefer a less active role in their care.
At the other end of the continuum are care providers who take a wait-and-see approach to pregnancy, labor & birth often using less invasive technology, testing and procedures before moving into more invasive. These care providers often present their points of view along with differing opinions and management protocols. In discussing options with patients, this care provider will emphasize patient responsibility and education as key in making decisions. These care providers will likely look for a partnership with their patients when deciding on interventions and options. Women willing to take responsibility for educating themselves, and desiring active participation in their care are most compatible with this care provider philosophy.
Premature Rupture of Membranes at Term
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One End of the Spectrum.. |
...The Other End of the Spectrum |
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"ROM increases the risk of infection. I'd most likely start a Pitocin drip as soon as we're sure your membranes have ruptured." |
"ROM increases the risk of infection. However, if mother is GBS negative and in good health, we have 24 - 48 hours to see if labor can start on its own. I'd watch carefully for signs of infection and monitor the baby with NST daily until delivery. If mother and baby show no signs of distress or infection, I'd rather wait for labor to start on its own." |
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One End of the Spectrum.. |
...The Other End of the Spectrum |
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"The risk of fetal and intrapartum complications increases once a pregnancy progresses to the 42nd week. At 40.5 weeks, I'll strip your membranes to see if it gets things going. If you reach 41 or 41.5 weeks, I'll want to induce labor. |
"The risk of fetal and intrapartum complications can increase if gestational age, of which we are certain, progresses past 42+ weeks. However, there is little evidence that induction before 42 weeks improves the health of mother or baby." |
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"I don't want to see any patients pregnant past 41.5 weeks." |
"85% of all women will deliver by the end of the 42nd week. If a pregnancy starts to progress into the 43rd week, I'd like to monitor the baby with daily NSTs, amniotic fluid level checks, and fetal kick counts. As long as both mother and baby show no signs of distress or infection, I'd prefer to wait for labor to start on it's own." |
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One End of the Spectrum.. |
...The Other End of the Spectrum |
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"Babies can turn at anytime. There is no benefit to diagnosing an OP position before labor. It'll just stress-out the mother." |
"Babies can turn anytime. However, if your baby's position is OP before or after the head engages in the pelvis, it's more likely you'll labor with the baby in the OP position. Encouraging the baby to assume an OA position before labor is ideal". |
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"There are no proven benefits to maternal exercises or positioning to encourage an OA position before labor." |
"There is no guarantee that maternal exercises will turn an OP baby to an OA baby. However, the controlled studies have shown that mothers who consistently practiced optimal fetal positioning exercises were able to turn their babies 76% of the time. In the control group, who did nothing, no babies turned. |
Eating and Drinking During Labor
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One End of the Spectrum.. |
...The Other End of the Spectrum |
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"I recommend no eating or drinking during labor. You could vomit during a c-section under general anesthesia and aspirate the vomit into your lungs”. |
“I recommend eating and drinking to thirst and hunger during labor. Hypoglycemia can dramatically slow labor.” |
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“Nothing but ice chips during labor.” |
“You can’t run a marathon on ice chips.” |
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“An IV is just as good or better at maintaining hydration than drinking. It’s easier to start an IV early in labor.” |
“IVs can over-hydrate and over-nourish mothers, causing maternal and fetal hyperglycemia. I prefer to wait until necessary to start an IV.” |
Failure to Progress: Active Labor
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One End of the Spectrum.. |
...The Other End of the Spectrum |
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“I like to see dilation at a rate of 1 cm/hour. I define “failure to progress” as no dilation over 4 hours.” |
“As long as both mother and baby are fine, I don’t have any time limits on dilation. " |
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"Taking longer than 6 hours to go from 4 - 10 centimeters is failure to progress." |
"Dilating from 4 - 10 centimeters can take as long as 19 hours and still be completely normal." |
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"If there has been no dilation for more than 6 hours, I'll suggest a c-section." |
"If mother is progressing slowly, I'll suggest a variety of positions, activities, and relaxation techniques to enhance progress. If we've exhausted all attempts and baby is showing signs of distress, then we should start looking towards a cesarean delivery." |
Failure to Progress: Pushing Stage
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One End of the Spectrum.. |
...The Other End of the Spectrum |
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“I like to see the second stage finished by 2 or 3 hours. There are increased risks to the baby if pushing lasts longer.” |
“As long as both mother and baby are fine, I don’t have any arbitrary time limits on second stage. There are no risks to the baby of a longer than average second stage.” |
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“If you have an epidural, you can push as soon as you reach 10 centimeters.” |
“If you have an epidural, I prefer you wait to push until you feel the urge, or the baby’s head is just visible on the perineum”. |
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“If the baby can’t rotate or descend, I’ll assist with a vacuum or forceps.” |
“If the baby can’t rotate or descend, I’ll want you to get into a variety of gravity-enhancing positions to assist rotation and descent.” |
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“I’ll suggest a c-section delivery if there is no progress after 3 hours or if the baby can’t rotate or descend.” |
“I’ll suggest a c-section if all measures to enhance progress fail and there is developing maternal or fetal distress.” |
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One End of the Spectrum.. |
...The Other End of the Spectrum |
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“I’ll only cut an episiotomies if necessary.” |
“I’ll only cut an episiotomy for marked fetal distress or for an instrumental delivery”. |
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“I’ll cut an episiotomy if it looks like you’re going to tear.” |
“I’ll support your perineum with warm compresses and gentle massage. Tears very rarely go as deep as the smallest episiotomy.” |
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“Episiotomies heal better than tears” |
“Episiotomies are easier to repair than tears but take a significantly longer time to heal. “ |
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“I try to get the perineum out of the way for crowning. It makes the birth faster and that’s what most mothers want.” |
“As the baby begins to crown, I’ll ask you to slow down your pushing to allow the perineum a chance to stretch around the baby’s head.” |
Letter of Agreement: Describes the nuts and bolts of my practice, including my fee.
Dads and Doulas: How fathers and doulas work together.
Articles: Clinical studies on the benefits of doula-attended births.
Questions for Your Care Provider: Determine your care provider's philosophy and style of management.
Email me with comments and questions: pjames@oz.net