Here are some questions to think about with your partner and to ask your physician or midwife. They relate to a variety of decisions about birth. Generally, when a woman and her partner have no preference, the physician or midwife will do what she or he is accustomed to doing. Therefore, it is good to know what the usual practices of your provider are and what restrictions are put upon her or him by the institution where your birth will be. If you don’t know what your own preference would be in answer to any of the following questions, continue reading this book. See the book list in the Appendix. Talk to other mothers and fathers. Look at videos, watch television, search the internet, think about what feels best for you. Nobody can really tell you that except yourself.

• How many members are there in the practice? What are their specialties?
• Will you have a primary provider, or will you see all members of the group during your pregnancy? Will this provider be of your own choosing and can you choose between a physician and midwife?

The labor

• Will your primary provider be your birth attendant or will you be cared for in labor by whomever in your group practice is on call that day?
• Can you choose between a physician and midwife to attend your birth?
• Will your physician or midwife meet you in the admitting area of the hospital or birthing center or will you be examined initially by a resident who will then contact your provider?
• Will you have a routine pubic shave (not shown to be effective in reducing infection rates)?
• Will you have a routine enema (not shown to be effective in stimulating or shortening labor and may have side effects)?
• Will you be allowed to walk around in labor (shown to help reduce the length of labor)?
• Who and how many people will be able to accompany you in labor?
• Will children (if you wish) be able to be present in labor?
• What is the provider’s rate of epidural anesthesia? The institution’s? What other pain relief measures does the provider generally utilize or recommend? If you have an epidural, will it be a low-dose, “walking” epidural?
• Can you bring your own pillows, clothes, food?
• Will you be able to eat/drink in labor?
• Will you routinely have intravenous (IV) tube feedings?
• Will you have routine continuous electronic fetal monitoring, intermittent electronic fetal monitoring, or intermittent monitoring of the fetal heart tones by fetoscope? Will the type of monitoring be determined by your risk status?
• What is the limit to how long each stage of labor will be able to go on, as long as progress is being made?
• What is the limit to how long you will be able to push as long as progress is being made?
• Will you be able to push in a variety of positions, such as knee­chest, side-lying, squatting, on the toilet?

The birth

• Will you be able to birth in the same-room as your labor?
• Will you be able to birth in a variety of positions, including squatting or side-lying, as you prefer at the time?
• Who and how many people will be able to be with you at the birth?
• Will children (if you wish) be able to be present for the birth?
• Will your partner or other support person be able to cut the umbilical cord? Will he or she be able to put hands on the baby at the delivery?
• Is there a policy regarding audio or video taping of labor and/or birth should you want this option?
• What is the physician’s or midwife’s rate of episiotomy (should be very low as routine episiotomies have not been shown to be beneficial) ?
• What is the provider’s rate of cesarean birth? (This may be difficult to evaluate as it will depend on the type of practice the provider has, for example, if the provider is known as a “high­risk” physician, or is certified in the subspecialty of maternal and fetal medicine, other physicians may send women with serious problems to this physician, increasing her or his cesarean birth rate. in any case, it should be as low as possible. The Healthy People 2000 goals of the U.S. Public Health Department advised a cesarean birth rate of 15 percent by the year 2000. While this takes into consideration not only what IS desirable, but what is possible, It can be used as a reasonable cut-off for a cesarean birth rate, even by a specialist in problem pregnancies.)
• Will your partner/support person(s) be able to accompany you if you have a forceps, vacuum, or cesarean birth?
• Will you be able to have epidural anesthesia for a cesarean birth, except in the situation of severe fetal distress requiring the fastest type of anesthesia available (most likely general anesthesia)?

The period after birth (postpartum)

• Will you be able to hold the baby immediately? Will the physician or midwife put the baby on your abdomen as soon as s/he is born?
• Will you be able to nurse immediately after birth?
• Will you ever need to be separated from the baby-i.e., will you have 24-hour rooming-in starting immediately?
• Will the baby’s physical examination be at your bedside or, if not, can you go to the newborn nursery for the examination?
• How many hours/days will you and the baby need to stay in the hospital/birthing center?
• Will you be able to stay in the hospital if the baby needs to re­main there longer than you do?
• What kind of emergency care is available should the baby need special care? Is this care on-site or via transfer? If transfer, what is the transfer system?
• Will the nurses give the baby formula if you do not have 24-hour rooming-in or will they wake you up to nurse?
• Does the hospital have a breast-feeding specialist or lactation consultant on staff?
• What, if any, type of classes for newborn and mother care are available postpartum?
• What are visiting policies postpartum-for your partner, other family members, friends, other children? Does having visitors mean the baby will have to go to he nursery?
• If your baby needs special care, is kangaroo care available ?
• What are visiting policies for the mother/father/others in the special care nursery (often called the NICU-Neonatal intensive Care Unit)?
• Can the parents participate in the newborn’s care in this nursery?

Health care practices today are increasingly following the team model. An obstetrician will often work, for example, with a midwife, a physician assistant, and a nurse practitioner. A physician assistant (PA) is specially trained to provide some components of medical care and work directly under the supervision of a physician. A nurse practitioner (NP), also called an advanced practice nurse, provides primary health care. In a maternity care service, the NP might be an adult nurse practitioner (ANP), a woman’s health nurse practitioner (WHNP), an obstetrical and gynecological nurse practitioner , or a family nurse practitioner (FNP). PAs and NPs generally provide in-office care, bur usually do not attend births.In group practices such as these, you mayor may not have a choice of provider. Sometimes prenatal care is rotated among the many different types of practitioners and either a physician or midwife will attend your birth, depending on who is on-call when you go into labor. In other such practices you can choose your birth attendant the midwives and physicians see separate groups of women. This is based on you preference, your health, and whether your pregnancy is complicated by problems. Of course, in any of these cases, an obstetrician is always available for emergency care should the need arise.

Many women feel that collaborative practices offer the best of all possible worlds. In many of these practices, other health care personnel also are available to provide components of care. These may include, for example, a nutritionist, a childbirth educator, a massage therapist.

Doulas

A doula is an old concept and a new profession. A doula is somebody who provides support to the laboring woman and the new mother. Labor doulas are sometimes called labor coaches or monitrices. They are often on-call, like obstetricians, midwives, and other birth attendants, and will be with you for labor and birth. The advantage of a doula is that she (generally she) is especially trained or experienced in attending births and can provide excellent psychological and physical support. She can be great at massage, assisting with breathing techniques, helping with relaxation. She can often act as an advocate for you, intervening when hospital policies and your wishes seem incompatible.

The disadvantage of a doula, for some women, is that she is another professional. She is not a loved one and can interfere with the bonding that can occur during childbirth between a woman and somebody she loves. In well-staffed hospitals, nurses can provide the type of care that doulas provide. As midwifery, by definition, means “with woman,” many midwives provide the same type of support that doulas provide, as well as managing the labor and birth.

In some cultures men are prohibited from being present during child­birth, or are not allowed to touch the woman in labor. In such cultures, a female doula may provide invaluable support. Some partners travel or may be otherwise unavailable for birth and again, in this situation, a doula may be a big help. Well-conducted, controlled studies in a variety of countries and settings consistently have shown that a trained support person in childbirth has definite benefits in labor, including reduced use of pain medication, lowered incidence of vacuum or forceps delivery, and fewer cases of a 5-minute Apgar score below 7.

Support has been shown to shorten labor. Many doulas also provide care for mother at her home after the birth. Unlike a baby nurse, doulas focus on the physical and emotional needs of the mother. Some doulas provide only postpartum care.

A pregnant woman is a ready target for a wide range of well-meant but unasked-for instruction. Even in today’s very medically oriented society, superstitions about pregnancy abound. Few pregnant women have escaped the warnings of well-wishers who caution them against going swimming, reaching up to high shelves, wearing high heels, indulging in intercourse, eating certain foods, and so on. The list is apparently end­less. Many claim to be able to predict the sex of the fetus by gazing into the eyes of the mother to be or by looking at the shape of the bulge, or through a variety of other mysterious ways. Pregnancy is a very public state and even strangers do not hesitate to communicate their prediction the mother. Of course they are correct about 50 percent of the time.The best way to handle advice that you readily recognize as pure superstition is to listen to it politely and then follow the dictates of your own common sense. Remember that there is no truth to the old tale that port wine stains or strawberry marks, which are actually diffuse collections of blood vessels within the skin, are produced by experiences of the mother during pregnancy. But it has been scientifically proven that the baby does experience events in the world outside the uterus and after birth can remember sights and especially sounds experienced in the late months before birth. A baby may be born knowing the rhythm of his or her mother’s voice through hearing it repeatedly while in utero. Sensitive fetuses can even learn a melody this way. Evidence exists that the higher centers of the fetal brain are working in the last trimester, or last three months, of pregnancy. There is no evidence, however, that visual, auditory, or other sensory stimuli received by the mother during pregnancy can cause any physical changes in the fetus.

Women also love to tell pregnant women their own birth stories. Unfortunately, too many women whose births are normal feel that their stories are too boring to tell or that once the baby came, nobody was interested in their experience anymore. This means that often we don’t hear birth stories until we are pregnant and that most birth stories we do hear are the ones in which something went terribly wrong. A pregnant woman today could easily get the feeling that birth is a very scary and dangerous event, when in fact most births are totally normal. Ask women who do not volunteer their birth stories to tell them to you. Most often they will be reassuring and medically uneventful, but there will be something to learn in them. Do not try to plan your birth, however, on any­one else’s. Each birth is different-even for the same women.

Not all pregnancies can be planned. Both human and technological errors occur with all methods of family planning. Planning, however, has definite benefits, healthy pregnancies are most likely to occur in healthy women. Effective methods of contraception should be used until you know you want to get pregnant.Once you make the decision that you are ready for children, or more children, the best advice is to continue using birth control until you have had a pre pregnancy health care visit.Although many forward-thinking doctors and midwives have informally provided preconception care to women for decades, the concept that at this is a distinct type of care visit has only recently gained wide acceptance. In 1989, an Expert Panel on the Content of Prenatal Care,convened by the Public Health Service of the United States Department of Health and Human Services, advocated that pregnancy care begin in preconception period.

If you are planning to become pregnant within a year, or are actively trying to get pregnant, and have not discussed your plans with your gynecologist, midwife or nurse practitioner, you should call for an appointment. Screening tests that can pick up potential problems for a pregnancy were probably not conducted at your routine annual gynecologic visit, nor were you likely to have been given information regarding self-help measures and practices to aid in preventing birth defects and other problems that can occur in pregnancy. These measures can be most important even before you know you are pregnant.

A few birth control methods, such as Norplant or the IUD, require a health care visit for removal. This would be a good time to have preconception care. If you use Depo-Provera, you can combine a preconception visit with your last shot.

Nutrition

Women who are either overweight or underweight should use this planing time to try to achieve a healthful weight. Women who are underweight at the start of pregnancy tend to have smaller babies, even if they gain as much weight during pregnancy as somebody who starts her pregnancy at a normal weight for height. Optimal weight should be achieved :through a well-balanced diet. . If you have ill eating disorder, such as anorexia, bulimia, or pica (eating nonfood substances), this is the time to seek help from therapists and care providers skilled in these areas and to consider joining a support group.

Little is known about whether the father’s nutrition can affect the developing fetus. It is known, however, that four nutrients are essential in making sperm: vitamins A and E, linoleic acid (a type of fatty acid), and zinc. In general, a well-balanced diet will supply these nutrients.

A Final Word

Remember, becoming pregnant should be pleasurable. With a little advance planning, it also can be a time for you and your partner optimize your health and health care. A simple preconceptionist combined with good nutrition, vitamin supplementation, and common-sense avoidance of exposures will provide an excellent start to a healthful pregnancy.