After reviewing the first two steps for achieving a natural birth (found here and here), some parents opt to explore other options, interview other care providers and even switch to a new provider and/or birth place (sometimes as late as 40 or 42 weeks into their pregnancy).  Don't feel bad about switching!  This is your birth and you have the right to be supported and comfortable with the provider of your choice.  Just as no two accountants, teachers or computer programmers are the same, no two doctors or midwives are the same either.  Here are some tips for finding a new provider (and it doesn't hurt to interview several before deciding to stick with your original provider or choose the best of the bunch):

- Ask your childbirth educator, doula, acupuncturist, massage therapist or anyone else who regularly interact with pregnant clients for recommendations. 

- Ask you friends who have recently given birth about their experiences and what they liked and didn't like about the location and care provider they chose.
 
- Search message boards (local community groups or the local groups on national boards like Mothering.com or Baby Center). 

- Read reviews of providers on City Search, Insider Pages or other sites. 

Step Two: Your Care Provider - a team approach to birth

There is a range of attitudes and beliefs about birth. Your care provider's perspective of the birth process can have a HUGE impact on your birth. Is your care provider supportive and encouraging of the natural process or does he/she prefer the medical approach of a "managed" birth? How do you tell???

Ask questions. Some examples are listed below with an explanation of what your care providers answers may mean. Please note, that the medical degree  your care provider holds and their specialty (i.e. Obstetrician, Family Practice, or Midwife) should not be used to assume their perspective on birth.  Some midwives practice "managed" care, while some physicians practice "midwifery-like" care and are very trusting of the natural process. It is up to you to find out what your care provider believes and how they typically practice. Your don't want to be in a position to have to fight for your preferences or try to change your care providers mind during your birth. You want someone you trust, who is on the same page and will openly support your choices during your birth.  Note: these questions are best used to have an open dialogue, not to grill your care provider.  You may wish to choose one or two that are the most meaningful to you and ask for a longer appointment time to discuss your goals and desires for birth. 

Here are some questions to ask your care provider:

· What is your after hours procedure? (Will you be able to talk to your personal doctor/midwife or just the person on call?)

· What percentage of your patients births do you attend? (How individual is the care they offer? Do they make an attempt to attend most of their patients births themselves.)

· How many partners are in your practice? (If there are 10 doctors who rotate call then your not likely to know the person attending your birth. This also means that you are more likely to encounter someone who does not have the same philosophy about birth). 

· What percentage of patients have a cesarean section in your practice? (This doens't tell you the whole story, but it can help you better understand your risk of having a cesarean.  Read more about C-section rates on childbirthconnection.org)

· What percentage of patients have episiotomies? What is your suture rate? How do you help women avoid tearing?  (Again, this can help you better understand your risks.   You can learn how likely they are to provideperineal support, to assist you in finding the best position to avoid an episiotomy and to avoid interventions that increase the chance of having an episiotomy [such as epidurals, forceps or vacuum extraction]).

· What is the most common choice for pain relief amongst your patients? (A provider who encourages pain relief or even chastises a woman for not having pain relief is not supportive of natural birth. There are many alternatives to anesthesia or narcotics to help a woman cope with labor.) 

· What percentage of patients have natural, spontaneous childbirth? (The higher the number, the more supportive your provider likely is. Unfortunately, for many care providers this number is quite low.)

· What is your protocol for postdates (i.e. “overdue”)? What percentage of women are induced in your practice? (Do they routinely induce at 40, 41, 42 or 43 weeks? If the policy is to induce all patients at 40 or 41 weeks, then you greatly increase your chances of having a cesarean due to fetal distress or a failed induction.)

· What is your protocol for preventing and managing a posterior position? (Again, knowledge of optimal fetal positioning techniques can help you avoid this presentation. Avoiding interventions [such as induction, augmentation with pitocin, artificially rupturing the membranes, etc] can reduce complications with a mal-positioned baby.)

· How quickly do you clamp and cut the cord?  How do you feel about delayed clamping?  How much time is allowed for the natural delivery of the placenta? What do you do it this limit has expired? (Assuming a natural birth has occurred, what approach is used during 3rd stage? Is the natural process respected or is there a standard protocol? Is the mother encouraged to nurse and release her own naturally occurring hormones to help expel the placenta?) 

I often get asked by expectant moms, how they can avoid pitfalls during labor and know if an intervention is truly necessary.  They want to set themselves up in the best way possible to have the natural birth they really want.  I think there are a few important steps that couples can take well before the birth to ensure the smoothest possible experience.  In Denver, we are blessed with many choices for how, where and with whom to birth.  Let's explore these options a little further.  

Step one: Your choice of birth location really matters and can influence the course of your labor!
The best birth location is the one in which the laboring woman feels most  secure and comfortable and offers her the greatest amount of safety, respect, patience and support.  Sometimes your choice of location comes along with your choice of your care provider or vice versa.  Sometimes it is influenced by insurance or costs (more on that later), location, amenities or necessity.  Sometimes it is a gut reaction to the feelings you have while exploring your options.  It just feels right.   Put some time and thought into your choice because it is one of the most important aspects of having a great birth experience.  

There are three main locations that women choose to give birth in:
Hospital
Birth Center
Home 

Each has advantages and drawbacks, but ultimately the choice is yours. Let's explore each option in the following blog posts:

Hospital
The most common choice for birth location in the United States is a hospital. There are some obvious advantages, but also many drawbacks to consider about your choice to give birth in a hospital.  Even if you ultimately decide to give birth in a hospital, it is important to be aware of the pitfalls and avoid hospitals with higher rates of intervention or greater restrictions placed on the laboring mother. Childbirth Connection provides really valuable resources for parents and has a great discussion on choosing your birth place.  No two hospitals are alike, so shop around... the closest isn't always the best choice. Ask friends and co-workers to tell you about their experiences.  Go on tours and ask questions about the hospital policies.  Don't judge a book by it's cover... a pretty room isn't that important during labor, but a supportive nurse and a deep jacuzzi tub may be all you need.  

Some of the advantages of a hospital birth may include: 

• Immediate access to medical technology, medications, and surgery if needed.
• Can be more safer for some women than a home or birth center birth
• Access to pain medications
• Assistance during the postpartum period (healing, breastfeeding, newborn care, etc)
• Safer for "high-risk" women

Some of the drawbacks to a hospital birth may include: 

• Typically encounter the Medical model or "managed" birth
  
• Subject to unnecessary interventions (routing I.V's, continuous fetal monitoring, time lines for progression or delivery)
• More likely to have an episiotomy.
• Small, but real risk of acquiring an infection while at the hospital.
• More restrictions on movement and positions with the use of medical equipment (EFM, I.V., epidural, etc.)
• Foreign environment that can make the mother more fearful, anxious or uncomfortable, which can slow or stop her labor. 
• More interruptions, less privacy and more variability of care. Parents may not know or have limited familiarity with the care provider on call.
• Food or drink may be limited or banned for the laboring woman.
• Many interruptions during the postpartum period. Mothers are more likely to be separated from the newborn. May be more difficult to establish breastfeeding.

Birth Center 
Birth Centers are great options for low-risk women who would like to be close to a hospital, but would like a more home-like and intervention-free environment.     Most birth centers are located near hospitals (for quick transfers if needed) and offer most of the comforts of homebirths.  Most are staffed by midwives and do not offer pain medication, but instead rely on a variety of other ways of comping labor.   In the Denver Metro area, Mountain Midwifery is the only Birth Center and has a wonderful reputation.   They do fill-up so don't delay in checking them out if you are interested in this option!

Some of the advantages of a birth center may include:  

• Comfortable environment that is more home-like than a hospital
• Usually more privacy and intimacy than a hospital
• Freedom of movement, mother led labor and birth
• Midwifery model of care
• Usually in close proximity to a hospital for transfer, if needed
• Less medical interventions (such as routine I.V.'s, continuous fetal monitoring, strict time lines for delivery, etc.)
• Often covered by insurance.  Usually significantly less total cost than an uncomplicated birth in a hospital.

Some of the drawbacks to a birth center may include: 

• Unlike a homebirth, it does require mom to change locations during labor.
• Limited access to life saving medical technology. Birth centers will have some equipment and supplies do deal with emergencies such as oxygen, medications for hemorrhage and resuscitation equipment. 
• Risk factors may make the birth center less safe or inadvisable (for example: high blood pressure, premature labor, breech, twins, etc.). Most Birth Centers are regulated and have strict guidelines for the type of care they can offer.  
• Birth center policy may only allow for a short postpartum stay. Parents are sent home shortly after birth which may be overwhelming for some.

Home Birth
Giving birth in your own home (or a friend or relatives home) is an increasingly popular option.  There are many factors that weight into the decision to have a home birth, with many who choose to give birth at home doing so because they feel it offers them the safest and most respectful environment for birth. 
 
Some of the advantages of a homebirth may include:

• Safer for the mother - Less chance of an episiotomy, postpartum hemorrhage, and cesarean
  
• No chance of developing a hospital acquired infection
• No unnecessary medical interventions (such as routine I.V's, continuous fetal monitoring, strict time lines for delivery, etc.)
• Comfortable and familiar environment for labor (which may make labor faster and easier)
• Freedom to labor as the mother sees fit and total control of the people present
• No access to pain medication (to avoid the temptation or pressure)
• Limited interruptions
• More peaceful environment after the birth, easier to bond and breastfeed.

Some of the drawbacks to homebirth may include:

• No access to pain medication without a transfer
• Greater parental responsibility for the preparation and safety of the birth
• Cost - Fees generally range from $2000-$4000+ and while some insurance plans cover all or part of the costs of a homebirth, even paying out of pocket this fee is just a fraction of the cost of most weddings, new cars, vacations, etc.  Don't forget to consider your co-pay and deductible costs for a hospital birth which can average $10,00-20,000+.  
• Limited access to life saving medical technology. Midwives have some equipment and medications and are trained in resuscitation, but could not preform an emergency cesarean or and do not have the range of equipment and medications that are available in hospitals.  
• Risk factors may make home birth less safe or inadvisable (for example: high blood pressure, premature labor, distance from a medical center, breech, twins, etc.). Each case should be evaluated individually and risk/benefits should be weighed.

There have been a few studies done which looked at the safety of homebirth in the U.S., Canada, the U.K. and other countries.  A national study of births in the Netherlands published in 2009 concluded:These results should strengthen policies that encourage low-risk women at the onset of labour to choose their own place of birth. They show that planning a home birth is a safe option in a country with a maternity care system, which facilitates this choice through adequate numbers of well-trained midwives who assess the appropriateness of a home birth and through a rapid transportation and an integrated referral system.de Jonge A, van der Goes B, Ravelli A, Amelink-Verburg M, Mol B, Nijhuis J, Bennebroek Gravenhorst J, Buitendijk S. Perinatal mortality and morbidity in a nationwide cohort of 529 688 low-risk planned home and hospital births. BJOG 2009;116:1177–1184.

While there is some debate about the research both confirming and dismissing the safety of home birth in the United States, there are some considerations to be aware of that can affect the availability and safety of this choice:

• There are several types of providers who attend homebirths (see this list for a definitions of acronyms), but the availability of providers varies greatly depending on where you live.  In Colorado, home birth are primarily attended by either Certified Professional Midwives (CPM) (certified by the North American Registry of Midwives (NARM)) or  Certified Nurse Midwives (CNM) (certified by the  American Midwifery Certification Board (AMCB)).  Occasional in others areas of the country, Family Physicians or Obstetricians attend home births.  
• Homebirth is safest for those having a healthy pregnancy.  Risk factors that increase the likelihood of complications should be considered carefully.  In many states, there are rules governing the ability for a care provider to attend a birth with certain risk factors.  Tips for maintaining a healthy pregnancy will come in a later post, but the usual suspects are important:  diet, exercise, reducing stress, and avoiding harmful substances (like smoking, drugs/medications, chemicals, etc).  
• Distance to the nearest medical facility should be considered.  Generally, a good rule of thumb a drive of is 20 minutes or less is usually considered reasonable.  Keep in mind that it is extremely rare for a woman to rapidly develop a life threatening emergency and most transfers for planned home births are not urgent.  

A new year means many changes and I am starting off with a brand new website!  I hope you will enjoy the new features (this blog, birth story section, photos, etc).   Feel free to comment here and don't forget to connect with me on facebook!  

Happy New Year!