The birth of Stephanie Grant’s first child did not go at all according to plan. First of all, baby Fiona was in a breech position and had to be delivered by Caesarean section.
But even after the infant emerged red and squalling, there was a flurry of activity as nurses hooked Grant up to various tubes and bottles. The problem: Grant had placenta accreta—a rare condition in which the placenta adheres too firmly to the uterine wall, causing hemorrhaging that can lead to death. “I lost three units of blood in about 10 minutes,” she says.
Even in the midst of the crisis, Grant, of Casselman, Ont., recalls her obstetrician, David McCoubrey, explaining to her what was going on. Although performing a hysterectomy is a common treatment for placenta accreta, McCoubrey listened when Grant told him that she wanted more children. He manually detached the placenta and then monitored her carefully well into the night to make sure the bleeding had stopped. The result: Grant, the mother of a healthy 18-month-old, is now pregnant again with her second child.
Grant’s experience graphically highlights the importance of being able to communicate effectively with your caregiver. Throughout pregnancy and birth, women face a host of choices about everything from whether to opt for genetic testing to the type of pain relief they prefer during labour. Sometimes, as in Grant’s case, those decisions have to be made quickly and under duress. Yet they can have very real implications for the health and well-being of both mom and baby.
A key concept in medical care is informed consent when doing tests and procedures. “It’s not legal—in fact, it’s considered assault—to perform a procedure on someone without consent,” explains Winnipeg obstetrician-gynaecologist Margaret Burnett. “Informed consent implies that the physician has asked the patient, ‘Is it all right if I do this?’ And the patient has said, ‘Yes.’”
But asking the question is just the beginning, points out Burnett. To make good decisions, women must have solid information about the benefits and risks of a test or procedure, as well as the benefits and risks of not doing it and the available alternatives. “Good communication is critical,” says Calgary midwife Meryl Moulton.
According to Michelle Morenz, mother of 18-month-old Josh from London, Ont., it helps to know what you’re looking for in a caregiver. Morenz wanted her baby’s birth to be as natural as possible—no drugs if she could manage. She figured a midwife was her best bet. “I’m healthy and I had no other complicating health problems,” she says. She also consulted family and friends for recommendations. “Two of my husband’s sisters had midwives and they both had an awesome experience,” she says.
Read more: Choosing a midwife or a doctor>
By contrast, Toronto mom Alison Yuill was pretty sure she would want something to ease the pain during birth. “My sister had had two girls already and I was there with her,” she says. “Having seen that, I knew I wanted an epidural. I’m not very good with pain.” In her case, a caregiver who regarded drugs as a last resort might have made her feel guilty about her choice. Instead, Yuill was upfront from the beginning about her need to be kept as comfortable as possible, and her doctor was supportive of her wishes.
To that end, says Moulton, at your first meeting with a potential caregiver, you might want to feel them out a little about their approach toward pregnancy and birth and get a sense of whether it meshes with yours. But peppering the doctor or midwife with questions about epidurals and episiotomies may be counterproductive. “I’m not sure you can judge your health care provider just by asking a few random questions,” points out Burnett. “It’s more about a gut feeling. Do you feel comfortable with her? Is this someone who takes you seriously and listens to what you have to say? Does she seem interested in you and committed to the care you and your baby will receive? Women are very intuitive and I think they need to go with their instincts.”
Keep in mind, too, that there are advantages and disadvantages to different practitioners. Family doctors, for example, may have known you for a long time and have a sense of your health issues (if any) and your personal preferences. Ob/gyns are well equipped to handle high-risk pregnancies and emergencies of any kind, but have been shown to have higher intervention rates. Midwives tend to spend more time with their patients and have lower rates of surgical intervention. On the other hand, they must transfer care to a doctor in the case of an emergency and, in some provinces, you will have to pay for them out of your own pocket.
Opinions vary about the usefulness of a written birth plan, but it’s probably a good idea to at least think about your goals and preferences in advance, says Dr. William Ehman, a family doctor from Nanaimo, BC. Are you aiming for a drug-free delivery? Is it important for you to breastfeed right away? What are some of the complications that can occur and what would you do about them? Although you will generally have plenty of time to weigh the decisions you must make, in the midst of an emergency, time is of the essence. “I try to discuss in advance the things that can happen during birth,” says Ehman.
That said, advises Burnett, try to be flexible. “Birth is a wonderful, spontaneous experience, as opposed to a planned and orchestrated event,” she says. Burnett objects to the term birth plan. “You certainly don’t have to make a decision about whether you’re going to have an epidural at 12 weeks,” she says. “It’s going to depend on how quickly the labour is progressing, how big the baby is, whether there are any signs of fetal distress, and how you’re handling the pain.”
In fact, says Ehman, by locking yourself into a particular vision of how your birth will go, “you could be setting yourself up for a feeling of failure.” When a 10-week pregnant woman tells him that she doesn’t want an epidural, Ehman responds, “That’s absolutely fine.” And if she does an abrupt turnaround during labour, he will ask if she’s certain she wants to change her mind. If she is, he supports her decision.
Morenz’s midwife used a similar technique during labour. “She would say, ‘Well Michelle, you’re already seven centimetres dilated.’ Then she would tell me how much longer she thought it would be,” explains Morenz. “She always underestimated, but she made me hopeful and optimistic. Then she would offer some other way to keep me comfortable — like walking around or taking a bath.” True to her wishes, Morenz got through the birth with nothing more than a little gas.
Caregivers, says Ehman, have a responsibility to ask pointed questions and to give patients the time and answers they need. But communication is a two-way street, and patients can’t abdicate responsibility for keeping the lines of communication with their caregiver open.
If you’re worried for any reason—perhaps you don’t feel your baby is moving enough or you have an unusual symptom — by all means let the doctor or midwife know, he urges. “We have a lot of ways we can assess a mother and baby throughout pregnancy and birth, but nothing is as effective as a mother’s intuition. I always say to women: You need to trust your feelings. If you think that there’s a problem either with you or the baby, have that dealt with right away.”
As well, stresses Moulton, if you have to make an important decision and you’re just not sure, by all means “ask for more time.” And be assertive as opposed to aggressive when expressing your views, she advises. “It’s all in the approach.” If, for example, your caregiver is calling for another ultrasound and you’ve already had four, be diplomatic. You might say: “I’ve done some research and I just believe that multiple ultrasounds are not really in the baby’s best interest. Is there any way we could do it every second or third visit?”
Similarly, Ehman contends, if your care isn’t going in the direction that you want, you need to say something. Try the line: “I’m uncomfortable with (fill in the blank). Do you have a suggestion as to how we could resolve this?” Burnett concurs. “It’s much better to state your disagreement and open the lines of communication,” she says. “What would be counterproductive is to decide to do it on your own just because you don’t agree with something your caregiver says. Our goal is a common one. It’s the health and well-being of you and your baby.”
Stephanie Grant admits she’s a researcher by nature. “I think part of the reason I have a good relationship with my doctor is because I do my research and go in with a list of questions in my hand.” If Grant has questions she figures are easily answered by asking a friend or consulting a book, she does so. “I try to be as informed as I can be, and he is very appreciative of that,” she says.
Indeed, says Burnett, a patient who takes the time to educate herself about pregnancy and birth is a joy to work with. But make sure, she cautions, that your information source is reliable. Data on the Internet or in the popular press may be well researched and documented, she points out, or it may be aimed at selling you on a particular procedure. “And just because your Aunt Sadie said it doesn’t mean it’s true.” She maintains her own Internet site (margaretburnett.yourmd.com) with links to some of the more credible sources of information about pregnancy and birth.
Have a list of questions two pages long? Recognize that your doctor may not get to every point on the list in one visit. “It doesn’t all have to be done in 15 minutes,” says Burnett. If there are one or two items that are more pressing, she advises, list them first. “Maybe you’ve had a terrible headache for the last 24 hours and you don’t know what to take. That’s a priority. Your health care provider shouldn’t say, OK, we’ll talk about that in two weeks.” Similarly, if you have many concerns to talk over, tell the receptionist when you book your appointment or, at the very least, let the doctor know right away, so there’s time to discuss them adequately.
A compassionate caregiver can offer the kind of comfort and reassurance you can’t get anywhere else. Just ask Grant. She suffered two miscarriages after Fiona’s birth and was understandably nervous about her current pregnancy. The result? Her 11-week appointment with McCoubrey lasted 45 minutes. “He was looking for the baby’s heartbeat,” she says. “He said even though it was early, he knew how scared I was about miscarrying again and he wanted to make sure that I could hear the heart before I left.”
So you and your caregiver don’t see eye to eye. It happens. The problem in Canada today is that there may well be no alternative. “In terms of maternity care, there’s no question that we’re seeing a shortage,” says Dr. John Maxted, associate executive director in health and public policies for the College of Family Physicians of Canada. The reasons? Fewer family doctors are delivering babies, and a significant percent of doctors who specialize in obstetrics and gynaecology choose to focus solely on gynaecology as their careers progress, or specialize in areas like infertility. Finally, since there are only some 700 midwives in the whole country, they’re not able to pick up the slack.
What can you do if the only caregiver in town is someone you don’t feel comfortable with? First of all, says Maxted, give him the benefit of the doubt. “If someone feels that I’m not very communicative, they need to tell me, so that I can explain things better.” If that doesn’t work:
• Make sure you have an advocate. Your partner, a family member or friend and, in particular, a hired doula can provide support throughout labour and delivery and give voice to your wishes, points out Calgary midwife Meryl Moulton. “There’s lots of research to support the fact that one-on-one care, when you’re in labour, is extremely beneficial,” she says. “There are some excellent labour and delivery nurses, but you don’t get to choose.” Neither can you control how busy they are when you’re in labour.
• Not sure you trust your caregiver’s advice? Back it up with research. Good sources of information include prenatal classes and provincial health hotlines. Motherisk offers info about the safety of drugs, chemicals and diseases during pregnancy and breastfeeding. (416) 813-6780; motherisk.org.
• Write down your birthing goals. When your preferences are clearly stated on paper, it may be more difficult for a caregiver to ignore them. “But keep in mind that this is an art, not a science,” says Moulton. “Things don’t always go according to plan.”
Originally published in April 2007.