what is a partogram?

Thanks to moms tinfoil hat http://momstinfoilhat.wordpress.com/I found this great piece of research http://download.journals.elsevierhealth.com/pdfs/journals/0002-9378/PIIS0002937808007758.pdf

The authors take a look at a large number of common interventions during labor and delivery and determine if they are supported by evidence or not.

One of the things they looked was using a partogram. Now this is a term I had never heard before. Naturally I had to google it. I don't know if this is the best page to define the term http://staff.um.edu.mt/csav1/lectures/partogram.pdf but it sure has a lot of charts. As best as i understand a partogram is basically a chart with an "action line" and anything that falls into the range of the "action line" requires some kind of action. Something like the Friedman's Curve.

Barbara over at NavalGazingMidwife http://navelgazingmidwife.squarespace.com/ kindly posted this link to an article that gives a good explaination of that http://emedicine.medscape.com/article/273053-overview

Something I'm going to have to learn more about for sure.

If you're interested they concled that the evidence is insufficient to recommend routine use of the partogram.

International Doula Month

Happy International Doula Month

With all the excitement over international day of the midwife I'm a bit late celebrating the doulas. But now that I'm on it:

Just in case you aren't familiar with the word "DOULA", from the homepage of DONA International

The word "doula" comes from the ancient Greek meaning "a woman who serves" and is now used to refer to a trained and experienced professional who provides continuous physical, emotional and informational support to the mother before, during and just after birth; or who provides emotional and practical support during the postpartum period.

Did you know the benefits of having a doula present at birth is proven by research?

DONA (doulas of north america) goes over the research here http://www.dona.org/resources/research.php and sage birth gives a neat little summary of some of the specific figures here http://sagebirth.com/Doulabenefits.htm

and here are more links:
from the american pregnancy association http://www.americanpregnancy.org/labornbirth/havingadoula.html
from midwife ronnie falcos archives http://www.gentlebirth.org/archives/doulnots.html
from one of my doula friends on facebook
http://dou-la-la.blogspot.com/

I'm really excited to be reminded of Doula Month. I'm still hoping to do some training in that area as soon as the grant money comes through.

trying to start good habits

Once again I am cleaning my in-box of old e-mails. This has been a huge problem for me so I'm posting even though this isn't especially birthy.

I changed my settings on face book so i don't get a new e-mail everytime anybody sneezes ( :lol)

I unsubscribed to a few newsletters i'm not really interested in anymore.

Hopefully these small steps will help keep it from getting to the point its at now ever again.

Also while going through whats left. i'm doing by the page. I just click "select all" then QUICKLY skim the titles/senders. Very little is making the cut to even be read. Much of what I bother to read can be deleted. And that which I really want to keep I'm labeling into folders so I can find it later.

BABY STEPS BABY STEPS.....

(although i admit i just did a huge step tonight. i have halved my inbox. down from 4000+)

thoughts on international day of the midwife 2010

This past Wednesday we celebrated International Day of The Midwife 2010. http://internationaldayofthemidwife.wikispaces.com/International+Day+of+the+Midwife+2010

I took the day off work so as to attend as many online discussions/presentations as possible. As an aspiring midwife it was a tremendous opportunity to hear perspectives from midwives who've been at it far longer than I.

I caught a discussion regarding midwives perceptions of working in a birth center. While it wasn't terribly relevant to me now it did reinforce my notion that the hospital birth culture is not currently woman center-ed.

I'm not sure how I feel about having that notion reinforced though. I do feel that midwives are needed as much or more for hospital birth as for home birth. I feel strongly that every woman deserves midwifery model care http://cfmidwifery.org/mmoc/define.aspx

The Midwives Model of Care is
based on the fact that pregnancy and birth are normal life processes.


The Midwives Model of Care includes:

Monitoring the physical, psychological, and social well-being of the
mother throughout the childbearing cycle

Providing the mother with individualized education, counseling, and
prenatal care, continuous hands-on assistance during labor and delivery, and
postpartum support

Minimizing technological interventions

Identifying and referring women who require obstetrical attention

The application of this woman-centered model of care has been proven to
reduce the incidence of birth injury, trauma, and cesarean section.


Copyright (c) 1996-2008, Midwifery Task Force, Inc., All Rights
Reserved

I can't see how I can take the many years of schooling required to become a CNM (certified nurse-midwife) just to be able to attend hospital births, though. Taking the direct entry route to midwifery and then providing out of hospital birth AND in hospital doula services, childbirth education or other non-medical forms of support for women who prefer to birth in a hospital would allow me to work towards changing hospital birth culture. But it would be quicker and a lot less expensive. I also think i could work "with woman" as a labour and delivery nurse.

So who knows what i'll end up doing?

After that i watched a presentation entitled "Cesarean Delivery on Maternal Request" http://www.slideshare.net/VirtualIDM/cesarean-delivery-on-maternal-request while I listened to The Feminist Breeder's http://thefeministbreeder.com/ podcast interview w/ Amy Romano, Mary Murray and Amie Newman and simultaneously joined the twitterfest @ #idm2010. The feminist breeder's show was dedicated to midwives online presence and tied in nicely to the next presentation "Online Presence for Midwives".


Next up was a session from Gloria Lemay on "Nutrition for Two". Iloved simply Gloria presented the task of eating healthfully. In fact I'm trying to incorporate some of her suggestions into my own eating even though i'm not pregnant.

The presentation on "Fetal Monitoring for Low-Risk Women" went a little over my head at some points but was fascinating nonetheless. I think the important thing I took away was how inportant it is for midwives to learn "high touch/low tech" means of monitoring the mama-baby dyad. These skills are being lost and its up to midwives not to let that happen. If skills like ascultation, palpation, and simple observation are lost what will happen to women when the power goes out? or women who have unplanned out of hospital births?

The drop in sessions for student midwives was a bust but i did enjoy the story telling that took place in its stead.

One session that I missed that I really wanted to participate in was the one about midwifery in South Carolina. That's so close to my location!


Even though these session were mostly targeted towards midwives I came out feeling highly motivationed to get back out in the birth related relms of the internet. (Look, ma! I'm Blogging again!) I'm not a midwife yet but that doesn't mean I don't have a voice to contribute. I have a desire to share what I know and to learn MORE MORE MORE.... and then pass that on.

Additionally I feel motivated to take a few baby steps towards midwifery . I've earned one credential that relates to my midwfery aspirations. Last year I earned my CLC (certified lactation counselor) which I see being really beneficial in postpartum doula work and in childbirth education. Next on my list is to earn my CPR certification and my NRP certification. Beyond that I plan to take advantage of some local networking opportunities. I'm involved in a local Healthy Start group http://www.heartofgeorgiahealthystart.org/ http://www.healthystartassoc.org/ so I want to become more active in that group and make inroads into other groups as well.

Why I Want to be a Midwife (or why does midwifery attract so many wannabes?)

This is a post in reply to a comment on a post from Barbara over at Navelgazing Midwife

I've muddled around with this post for a long time and I think I'm finally happy with it.


Like a lot of us in the birthy blogosphere I am an aspiring midwife.


I have a few reasons for wanting to be a midwife. In the main I see a need in my community for midwifery, perhaps homebirth midwifery in particular. There is no midwife in my immediate community. There is one freestanding birthcenter in my state. It's about 2 and a half hours away and is staffed by Certified Nurse-Midwives. Thats the only out of hospital birth option besides unassisted that is legally available. Certified Professional Midwives (CPMs) are the only birth assistants mandated by their certifying body to receive training in out of hospital birth but CPMs are not legally authorized to attend any birth in my state. I can choose to birth in a hospital assisted by a Certified Nurse-Midwife (CNM) if I'm willing and able to travel an hour or more. There is a CNM in my area who has recently graduated from The Frontier School of Nurse-Midwifery but as far as I know she has not yet set up practice. There is (or at least was, 5 years ago) a CNM in practice about an hour away. About 2 hours away either north or east there are clusters of both CNMs and CPMs.

I find the body of knowlege encompassed in midwifery to be fascinating. As a woman and as a feminist I enjoy the demystification of my own bodily processes. Just as a birthing woman, gaining resources and information about the normal and the abnormal, techniques and treatment involved in managing either is incredibly empowering. I have learned a lot just researching my own births and reading as much as I can about birth and midwifery. One of the most important things i have learned is just how much more there is to learn. Going into a formal training program to earn the title of Midwife would give me some structure to my studies and hands-on experience with clinical skills.

I think of midwifery as both a teaching and a caring profession.I want to share the empowerment I have found. I love helping other women find the things they need to know for their own births. As a midwife I would have the opportunity and obligation to pass on the things I learn.

I also believe I would be a good midwife. Who doesn't want to find something they love to do, and can do well? Some of the things i think I already have that might be the beginnnings of a good midwife? I listen.At my current job I have recieved compliments from my customers for my empathetic nature. I'm not tied to "being right", so I think I'd be good with mama's who choose to birth differently than I would. Communication is a two way street and I think I'm good at telling too. I can already envision myself conveying information to new parents on controversial topics like vaccination, or circumcision, or VBAC. I think I have the emotional/ mental stability and stamina to handle midwifery.

And moving beyond my personal reasons and qualifications I think midwifery serves the greater good. Its an honorable and simple profession that doesn't seek fame and fortune. Midwives are not accountable to many beyond each mother-baby dyad. No corporate adgenda to bow to (though I do realize midwifery politics can draw one into dogmatic allegiences if you let it ;>) They say "peace on earth begins with birth." and I think theres some truth to that. I think midwifery model care for the majority would be more economically and perhaps environmentally sustainable.

cool contest alert

woman to woman childbirth is sponsoring an awesome giveaway http://www.facebook.com/l.php?u=http%253A%252F%252Ftinyurl.com%252Fykmb8e8&h=469fb47e25f3950c5e6db49aedc1104d&ref=nf of the book breastfeeding with comfort and joy http://go2.wordpress.com/?id=725X1342&site=womantowomancbe.wordpress.com&url=http%3A%2F%2Fwww.thebreastfeedingbook.com%2F

good luck w/ your entries (this is my entry)

preview of future post

so i'm currently researching the gay parenting journey. a comment i overheard the other day promted me to look into it. it was meant as a joke when one half of a lesbian couple said "you know its hard for gay folks to have a baby" but it got me to thinking.....

i can see that it would be a more difficult journey than it would for a hetero couple. so far i've found out that more than half of the homosexual population wants kids. and they have multiple routes to that goal. adoption, artificial insemination, surrogacy, etc.

but if they want a child who is biologically tied to at least one half of the couple, well how many of those procedures would be covered by insurance? how costly are they?

i learned that most children sucessful artificial insemination produces male offspring. some people really do have a preference for one sex or another so thats something to consider.

i'll be posting something on the topic soon, maybe this month if i get a chance to do enough research.

additionally the recent live streeamed birth http://www.facebook.com/l.php?u=http%253A%252F%252Fwww.theunnecesarean.com%252Fblog%252F2009%252F11%252F6%252Flynsee-is-in-labor-broadcasting-birth-live-right-now.html&h=f67aa58d7a5a5128bff33de74c36c390&ref=mf has me thinking about the nature of birth advocacy. the discussion has fallen from one end of the spectrum with complete disrespect for hospital birth to a sort of resigned "well at least it wasn't a cesarean" to total acceptance of that mamas experience epidural, hospital and all.

so i'm re-evaluating my role as a self appointed "advocate for normal birth". i mean what does that mean? canada defined "normal birth" almost a year ago http://www.sogc.org/guidelines/documents/gui221PS0812.pdf and i know other countries have done so as well. but what is "normal birth" in america and how best to advocate for it?

more to come on that topic as well as i mull it over.

Domestic Violence Awareness Month

So October is Domestic Violence Awareness Month

I'm doing my part by going to the town hall meeting and making sure my congressperson knows I support removing the inclusion of domestic violence from pre-existing condition clauses in insurance contracts (pregnancy can also be considered a pre-existing condition btw)

the section of the healthcare reform bill thats relevant is

SEC. 2706. PROHIBITING DISCRIMINATION AGAINST INDIVIDUAL PARTICIPANTS AND BENEFICIARIES BASED ON HEALTH STATUS.
'(a) IN GENERAL.--A group health plan and a health insurance issuer offering group or individual health insurance coverage may not establish rules for eligibility (including continued eligibility) of any individual to enroll under the terms of the plan or coverage based on any of the following health status-related factors in relation to the individual or a dependent of the individual:
(1) Health status.
(2) Medical condition (including both physical and mental illnesses).
(3) Claims experience.
(4) Receipt of health care.
(5) Medical history.
(6) Genetic information.
(7) Evidence of insurability (including conditions arising out of acts of domestic violence).
(8) Disability.
(9) Any other health status-related factor determined appropriate by the Secretary.


and here is some background info

http://www.huffingtonpost.com/2009/09/14/when-getting-beaten-by-yo_n_286029.html

http://www.miamiherald.com/news/politics/AP/story/1266054.html

http://www.southernstudies.org/2009/09/domestic-violence-a-pre-existing-condition-for-insurers-in-some-states.html

friday follow-up

regarding the perils of hombirth

so the today show did a recent scare segment re homebirth (originally titled 'the perils of midwifery' but later changed to 'the perils of homebirth' and naturally the birthing blogosphere has been abuzz

http://blackhillsportal.com/npps/story.cfm?id=3430
http://www.rhrealitycheck.org/blog/2009/09/11/nbc-today-shows-homebirth-scare-segment
http://mybestbirth.ning.com/forum/topics/the-perils-of-journalism-ricki

of course the topic of home birth has been a contentious one for quite some time as these earlier links attest.

http://www.babble.com/CS/blogs/strollerderby/archive/2009/04/18/home-birth-a-right-or-a-must.aspx
http://www.timesonline.co.uk/tol/comment/columnists/melanie_reid/article6101189.ece


some of the debate focuses on the rights to even have a homebirth, some on the safety of homebirth



the australian healthcare system has been duking it out over homebirth for a while . heres some of the latest from over there http://www.thepunch.com.au/articles/homebirth-wars-confusing-a-right-with-whats-right/



despite the evidence regarding the safety of homebirth http://www.bmj.com/cgi/content/full/330/7505/1416 the american college of obstetrics and gynocology has been on a campaign to remove the choice of homebirth... they put out a press release in february 2008 in which they re-iterated their stance http://www.acog.org/from_home/publications/press_releases/nr02-06-08-2.cfm and now they are using the media to skew public perception as to the dangers of homebirth and the competancies of midwives.

heres the thing though....

i think most women do take their own health factors into consideration when preparing for a home birth. most wome will change their plans when the situation requires it. there may be some disagreement as to what requires a change of plans: breech baby? twins? higher order multiples? postdates? what about vbac? but in other situations theres just not as much grey area and most women and midwives recognize that and respond appropriately.

according to this study http://www.jmwh.com/article/S1526-9523(08)00338-3/abstract a perception of GREATER safety was one of the major factors involved in planning a home birth.

The percentage of women choosing to birth at home has remained fairly steady for the past 2 decades http://www.uptodate.com/patients/content/topic.do?topicKey=~l0l0wKntyU7Dhn1

"From 1989 to 2003 the rate of home births in the United States declined from 0.69 to 0.57 percent of births, or by an average of 0.01 percent annually. The 2006 figures represent a very slight increase in both absolute numbers and rate, reaching 0.59 percent of all births [5]. This rate is comparable to that in other industrialized countries with two exceptions: England has experienced a slight rise in its home birth rate from 1.0 percent in 1989 to 2.7 percent in 2006 [6], while the Netherlands has maintained rates of home birth of approximately 30 percent [7]."

acog recently released a statement http://www.acog.org/from_home/publications/press_releases/nr09-11-09.cfm that basically says obs are practicing in a manner that is highly concious of the risks of litigation.

here are the results from the listening to mothers II survey http://www.childbirthconnection.org/pdf.asp?PDFDownload=LTMII_report this shows women are suffering as a result. rather than focus on the less than %1 of births that occur at home why not focus on improving the care women recieve during the %99 of births that occur at hospitals or birthcenters?

homebirth is already 100% LEGAL in every state in the us. the legality of attendance by a midwife is fast becoming just as legal.

In addition to the Lamaze 6 Care Practices that support Normal Birth http://www.lamaze.org/ChildbirthProfessionals/ResourcesforProfessionals/CarePracticePapers/tabid/90/Default.aspx

the coalition for improving maternity services has already created the mother friendly initiative in order to give hospitals and providers some concrete goals to focus on in improving their maternity care http://www.motherfriendly.org/mfci.php these steps are a good focus point for anybody involved in birth reform.

this is a good year for legal birth reform: we have a new president, congress is involved in overall healthcare reform. and the numbers are on our side 80% of women experience childbirth. within that majority of women i would guess theres enough support to protect by law the normal, healthy birth care practices that the evidence supports and women want

Lamaze Healthy Birth Practices

The six Lamaze Healthy Birth Practices below are supported by
research studies that examine the benefits and risks of maternity care
practices. Therefore, they represent "evidence-based care," which is the gold
standard for maternity care worldwide. Evidence-based care means "using the best
research about the effects of specific procedures, drugs, tests, and treatments,
to help guide decision-making." Please note: The English versions
were revised in 2009.

Let Labor Begin on Its Own

Walk, Move Around, and Change Positions Throughout Labor

Bring a Loved One, Friend, or Doula for Continuous Support

Avoid Interventions That Are Not Medically Necessary

Avoid Giving Birth on the Back and Follow the Body’s Urges to Push

Keep Mother and Baby Together – It’s Best for Mother, Baby, and
Breastfeeding

Ten Steps of the Mother-Friendly Childbirth InitiativeFor
Mother-Friendly Hospitals, Birth Centers,* and Home Birth Services
To receive
CIMS designation as “mother-friendly,” a hospital, birth center, or home birth
service must carry out the above philosophical principles by fulfilling the Ten
Steps of Mother-Friendly Care.


A mother-friendly hospital, birth center, or home birth service:


Offers all birthing mothers:

Unrestricted access to the birth companions of her choice, including
fathers, partners, children, family members, and friends;

Unrestricted access to continuous emotional and physical support from a
skilled woman—for example, a doula,* or labor-support professional;

Access to professional midwifery care.


Provides accurate descriptive and statistical information to the public
about its practices and procedures for birth care, including measures of
interventions and outcomes.


Provides culturally competent care—that is, care that is sensitive and
responsive to the specific beliefs, values, and customs of the mother’s
ethnicity and religion.


Provides the birthing woman with the freedom to walk, move about, and
assume the positions of her choice during labor and birth (unless restriction is
specifically required to correct a complication), and discourages the use of the
lithotomy (flat on back with legs elevated) position.


Has clearly defined policies and procedures for:

collaborating and consulting throughout the perinatal period with other
maternity services, including

communicating with the original caregiver when transfer from one birth site
to another is necessary;

linking the mother and baby to appropriate community resources, including
prenatal and post-discharge follow-up and breastfeeding support.


Does not routinely employ practices and procedures that are unsupported by
scientific evidence, including but not limited to the following:
shaving;
enemas;
IVs (intravenous drip);
withholding nourishment or water;
early rupture of membranes*;
electronic fetal monitoring; other
interventions are limited as follows:


Has an induction* rate of 10% or less;†


Has an episiotomy* rate of 20% or less, with a goal of 5% or less;


Has a total cesarean rate of 10% or less in community hospitals, and 15% or
less in tertiary care (high-risk) hospitals;


Has a VBAC (vaginal birth after cesarean) rate of 60% or more with a goal
of 75% or more.


Educates staff in non-drug methods of pain relief, and does not promote the
use of analgesic or anesthetic drugs not specifically required to correct a
complication.


Encourages all mothers and families, including those with sick or premature
newborns or infants with congenital problems, to touch, hold, breastfeed, and
care for their babies to the extent compatible with their conditions.


Discourages non-religious circumcision of the newborn.


Strives to achieve the WHO-UNICEF “Ten Steps of the Baby-Friendly Hospital
Initiative” to promote successful breastfeeding:

Have a written breastfeeding policy that is routinely communicated to
all
health care staff;

Train all health care staff in skills necessary to
implement this policy;

Inform all pregnant women about the benefits and
management of
breastfeeding;

Help mothers initiate breastfeeding
within a half-hour of birth;

Show mothers how to breastfeed and how to
maintain lactation even if they
should be separated from their infants;

Give newborn infants no food or drink other than breast milk unless
medically indicated;

Practice rooming in: allow mothers and infants
to remain together 24 hours
a day;

Encourage breastfeeding on
demand;

Give no artificial teat or pacifiers (also called dummies or
soothers) to
breastfeeding infants;

Foster the establishment of
breastfeeding support groups and refer mothers
to them on discharge from
hospitals or clinics

† This criterion is presently under review.

choices in childbirth

so this is like a thursday post on friday.....

this topic has been on my mind lately. and this video from msnbc http://www.msnbc.msn.com/id/21134540/vp/32795933#32795933 brought it to the forefront for a blog post. i actually haven't watched the video b/c i don't have speakers on my computer right now but i did post a reply on the discussion (the question was basically what are your thought on the risks of homebirth) heres my reply

"Its always a risk/benefit analysis. There are risks and benefits to either scenerio and its a matter of choosing which risks are acceptable and which benefits are most important to you.

there are benfits to homebirth that show up in the research: fewer interventions, more skin-to-lskin, more rapid initiation of breastfeeding, greater satisfaction with the birth experience, one-to-one care for mom, etc

there are also risks. an emergent situation can arise that requires urgent action. sometimes a transfer to hospital care can be accomplished in time and sometimes time is of such essence that a transfer can't be accomplished in time. sometimes a woman will find labor to be more painful or more exhausting than anticipated and she wil want to tranfer for a non-emergent complication.

there are several kinds of midwives and the kind of training they have will vary but most midwives have training in ergency situations. most midwives can perform at least basic rescucitation on mom and or baby. many midwives carry oxygen, pitocin, suture equipment and other equipment to deal with emergencies. that would definately be a question to ask a midwife: "what kind of training do you have to manage an emergency?" "what are your transfer protocols?" etc

there are times when the benefits of a hospital birth will outweigh the benefits of a homebirth. if a woman goes into pre-term labor at say 32 weeks, or has pre-eclamsia, or an unmanaged health condition then a hospital birth may be the wisest choice. but there are very real rsks to hospital birth. some of these risks are the same risks anyone faces walking into a hospital : hospital aquired infection, medication errors, miscommunications between care providers during shift changes. some risks are specific to labor and delivery. the epidural delivers very good pain relief but it can also cause fever and a decrease in blood pressure. pitocin can jump start contractions but those contractions can be very intense and can even hyperstimulate the uterus leading to an emergency section. even some basic hospital procedures such as denying food and drink carry risks. you wouldn't run a marathon w/o adequate nourishment why expect to have a baby w/o eating and drinking?

the way transfers are managed is one area where improvement is sorely needed. a study was done recently that showed that there is so much fear on both sides that it is affecting the care women recieve when a transfer is needed. i think some kind of no-fault transfer policy needs to be implemented at a national level so obs can use their training when it is needed w/o fear of a lawsuit, so midwives can transfer women who need hospital services w/o fear of lawsuit....so everyone can share information freely and no one lets fear get in the way of care.

and as to the actual question, i've had 2 hospital births and one birth in a freestanding birth center. if i have another it will be a planned homebirth."


And this topic homebirth versus hospital gets to the heart of the matter. Your choices in childbirth boil down really to 2 things: your choice of healthcare provider and your choice of birthing place.

Many many women plan to just use whoever they've been using for well woman gyno care. You probably know and like your hcp. But this post from jen at vbac facts demonstrates how liking your hcp is not enough. http://vbacfacts.com/2009/08/26/an-ob-you-like-or-who-makes-you-comfortable-isnt-enough/

you pretty much have 3 choices in birth care: An OB, a family practice dr, or a midwife. any one of the 3 can be a good choice if they have a birth philosophy that works for you but in general obs will be the most interventive of the 3 and midwives the least interventive.

midwives work within the midwifery model of care. http://cfmidwifery.org/mmoc/define.aspx

The Midwives Model of Care

The Midwives Model of Care is based on the fact that pregnancy and birth are normal life processes.

The Midwives Model of Care includes:

• Monitoring the physical, psychological, and social well-being of the mother throughout the childbearing cycle
• Providing the mother with individualized education, counseling, and prenatal care, continuous hands-on assistance during labor and delivery, and postpartum support
• Minimizing technological interventions
• Identifying and referring women who require obstetrical attention

The application of this woman-centered model of care has been proven to reduce the incidence of birth injury, trauma, and cesarean section.

Copyright (c) 1996-2008, Midwifery Task Force, Inc., All Rights Reserved

An OB on the other hand is a sugeon trained in the technocratic model of care. this is a long read but explains the technocratic model in great detail http://www.davis-floyd.com/USERIMAGES/File/TECHNOCRATIC%20MODEL%20OF%20BIRTH.pdf

basically in the technocratic model the birthing mother is seen as a machine destined to malfunction at some point.

Afamily practice dr who still attends births is hard to find but if found is oftn somewhere in between midwife and ob in mindset.

regardless of the letters behing your hcp's name you have got to be sure your birth philosophy meshes with theirs. Because if she usually cuts an episiotomy she'll probably cut one on you too. If he only "allows" a 12 hour labor before he starts a pit drip to "move it along" thats probably the care you'll get too.

And then you also have to be sure that the place you choose to give birth is willing and able to be supportive of your birth philosophy also. What are their usual procedures? If everybody who goes to hospital A has to do some time on the fetal monitor you probably will too unless your dr or midwife has okay'd you not doing it in advance. if they don't "allow" most of their mothers to labor in the tub they probably won't "let" you either.

a good place to start is with this list from the coalition for improving maternity services

Having a Baby?
Ten Questions to Ask
©2000 Coalition for Improving Maternity Services (CIMS).

1. Ask, “Who can be with me during labor and birth?”
Mother-friendly birth centers, hospitals, and home birth services will let a birthing mother decide whom she wants to have with her during the birth. This includes fathers, partners, children, other family members, or friends.
They will also let a birthing mother have with her a person who has special training in helping women cope with labor and birth. This person is called a doula or labor support person. She never leaves the birthing mother alone. She encourages her, comforts her, and helps her understand what’s happening to her.
They will have midwives as part of their staff so that a birthing mother can have a midwife with her if she wants to.
2. Ask, “What happens during a normal labor and birth in your setting?”
If they give mother-friendly care, they will tell you how they handle every part of the birthing process. For example, how often do they give the mother a drug to speed up the birth? Or do they let labor and birth usually happen on its own timing?
They will also tell you how often they do certain procedures. For example, they will have a record of the percentage of C-sections (Cesarean births) they do every year. If the number is too high, you’ll want to consider having your baby in another place or with another doctor or midwife.
Here are some numbers we recommend you ask about.
They should not use oxytocin (a drug) to start labor for more than 1 in 10 women (10%).
They should not do an episiotomy (ee-pee-zee-AH-tummy) on more than 1 in 5 women (20%). They should be trying to bring that number down. (An episiotomy is a cut in the opening to the vagina to make it larger for birth. It is not necessary most of the time.)
They should not do C-sections on more than 1 in 10 women (10%) if it’s a community hospital. The rate should be 15% or less in hospitals which care for many high-risk mothers and babies.
A C-section is a major operation in which a doctor cuts through the mother’s stomach into her womb and removes the baby through the opening. Mothers who have had a C-section can often have future babies normally. Look for a birth place in which 6 out of 10 women (60%) or more of the mothers who have had C-sections go on to have their other babies through the birth canal.
3. Ask, “How do you allow for differences in culture and beliefs?”
Mother-friendly birth centers, hospitals, and home birth services are sensitive to the mother’s culture. They know that mothers and families have differing beliefs, values, and customs.
For example, you may have a custom that only women may be with you during labor and birth. Or perhaps your beliefs include a religious ritual to be done after birth. There are many other examples that may be very important to you. If the place and the people are mother-friendly, they will support you in doing what you want to do. Before labor starts tell your doctor or midwife special things you want.
4. Ask, “Can I walk and move around during labor?
What position do you suggest for birth?”
In mother-friendly settings, you can walk around and move about as you choose during labor. You can choose the positions that are most comfortable and work best for you during labor and birth. (There may be a medical reason for you to be in a certain position.) Mother-friendly settings almost never put a woman flat on her back with her legs up in stirrups for the birth.
5. Ask, “How do you make sure everything goes smoothly when my nurse, doctor, midwife, or agency need to work with each other?”
Ask, “Can my doctor or midwife come with me if I have to be moved to another place during labor? Can you help me find people or agencies in my community who can help me before and after the baby is born?”
Mother-friendly places and people will have a specific plan for keeping in touch with the other people who are caring for you. They will talk to others who give you birth care. They will help you find people or agencies in your community to help you. For example, they may put you in touch with someone who can help you with breastfeeding.
6. Ask, “What things do you normally do to a woman
in labor?”
Experts say some methods of care during labor and birth are better and healthier for mothers and babies. Medical research shows us which methods of care are better and healthier. Mother-friendly settings only use methods that have been proven to be best by scientific evidence.
Sometimes birth centers, hospitals, and home birth services use methods that are not proven to be best for the mother or the baby. For example, research has shown it’s usually not helpful to break the bag of waters.
Here is a list of things we recommend you ask about. They do not help and may hurt healthy mothers and babies. They are not proven to be best for the mother or baby and are not mother-friendly.
They should not keep track of the baby’s heart rate all the time with a machine (called an electronic fetal monitor). Instead it is best to have your nurse or midwife listen to the baby's heart from time to time.
They should not break your bag of waters early in labor.
They should not use an IV (a needle put into your vein to give you fluids).
They should not tell you that you can't eat or drink during labor.
They should not shave you.
They should not give you an enema.
A birth center, hospital, or home birth service that does these things for most of the mothers is not mother-friendly. Remember, these should not be used without a special medical reason.
7. Ask, “How do you help mothers stay as comfortable as they can be? Besides drugs, how do you help mothers relieve the pain of labor?”
The people who care for you should know how to help you cope with labor. They should know about ways of dealing with your pain that don’t use drugs. They should suggest such things as changing your position, relaxing in a warm bath, having a massage and using music. These are called comfort measures.
Comfort measures help you handle your labor more easily and help you feel more in control. The people who care for you will not try to persuade you to use a drug for pain unless you need it to take care of a special medical problem. All drugs affect the baby.
8. Ask, “What if my baby is born early or has special problems?”
Mother-friendly places and people will encourage mothers and families to touch, hold, breastfeed, and care for their babies as much as they can. They will encourage this even if your baby is born early or has a medical problem at birth. (However, there may be a special medical reason you shouldn't hold and care for your baby.)
9. Ask, “Do you circumcise baby boys?”
Medical research does not show a need to circumcise baby boys. It is painful and risky. Mother-friendly birth places discourage circumcision unless it is for religious reasons.
10. Ask, “How do you help mothers who want to breastfeed?”
The World Health Organization made this list of ways birth services support breastfeeding.
They tell all pregnant mothers why and how to breastfeed.
They help you start breastfeeding within
1 hour after your baby is born.
They show you how to breastfeed. And they show you how to keep your milk coming in even if you have to be away from your baby for work or other reasons.
Newborns should have only breast milk. (However, there may be a medical reason they cannot have it right away.)
They encourage you and the baby to stay together all day and all night. This is called “rooming-in.”
They encourage you to feed your baby whenever he or she wants to nurse, rather than at certain times.
They should not give pacifiers (“dummies” or “soothers”) to breastfed babies.
They encourage you to join a group of mothers who breastfeed. They tell you how to contact a group near you.
They have a written policy on breastfeeding. All the employees know about and use the ideas in the policy.
They teach employees the skills they need to carry out these steps.

Would you like to give this information (and more)
to your doctor, midwife, or nurse?
This information taken from The Mother-Friendly Childbirth Initiative written for health care providers. You can get a copy of the Initiative for your doctor, midwife, or nurse by mail, e-mail, or on the Internet.
To Get a Copy by Mail
Write to:

Coalition for Improving Maternity Services (CIMS)
1500 Sunday Drive Suite 102
Raleigh, NC 27607
Tel 1: 888-282-CIMS
Tel 2: 919-863-9482
Fax: 919-787-4916
E-mail: info@motherfriendly.org
http://www.motherfriendly.org

Permission granted to freely reproduce in whole or in part along with complete attribution.
To Get Copies on the Internet
http://www.motherfriendly.org

please vivist their site. they have lots of useful info on there.

i feel like this is a long post so i'll stop for now but i think i'll continue on with this topic tuesday....