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#22
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I was just wondering, is it standard procedure in a normal delivery...
alath wrote: Midwives have fewer patients (and since they usually only handle childbirth they DON'T also have patients with gyn-related concerns), and are able to plan their schedule so that they won't have more than a few women due any single week. According to the last survey by the ACNM, approximately 90% of visits to nurse-midwives were for primary preventive care including gynecologic care. The 90% figure is somewhat inflated due to midwives who work in clinic-only jobs, but still for most midwives, basic gynecologic care, annual exams, birth control, etc., is a large part of the practice. Actually I was thinking primarily of DEM's and homebirth midwives in general having fewer clients and so being able to spend more time with them. CNMs and hospital based midwives, in general, I would assume work pretty much like OB's do, for the reasons you mention; they have other patients, both in the office and in the hospital, and so CAN'T spend 18 hours sitting there holding a laboring woman's hand. They will have a little less do do because they don't have surgeries and ER emergencies to deal with, but neither are they likely to be in the room the whole time. Naomi In a hospital or birth center setting, having 2 or 3 patients in labor at the same time is really not a problem. Think about it - if your birth attendant is in your labor room for 20 or 30 minutes out of every hour, and is there for the actual delivery, and that is in addition to having a one-on-one primary nurse, that really should be plenty of care and attention for most laboring patients. The problem OB-GYNs have is scheduling GYN surgery. You can't just tell your surgery patients to go home because someone is in labor. The model most private midwife practices are using is to have a very small number of midwives - usually 2 to 4. No patient really has a "primary" midwife, but instead, sees each of the midwives throughout pregnancy. That way, you still have someone you know fairly well attending your birth. At the same time, the midwives are not on call 24-7. 24-7 primary models only work with very small, very low-volume practices. With any kind of volume, it creates an unliveable situation for the midwife and is potentially dangerous. If the midwive has three patients deliver in a week (which is not really very high volume at all), and labor-sits each patient all throughout their labor, you are talking about a midwife who didn't get any sleep that week. The dangers of health care providers going two and three days in a row without sleep are well documented - this is unsafe for patients. Even home birth midwives have to have some kind of back up on-call arrangement in case they have more than one patient in labor at the same time. It is easy to flip back and forth between rooms in the hospital or birth center, but not so easy to go back and forth across town for two patients laboring at home. |
#23
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I was just wondering, is it standard procedure in a normal delivery...
They will have a little less do do because they don't have surgeries and ER emergencies to deal with, but neither are they likely to be in the room the whole time. Not the whole time, no, but we do tend to be there a lot more than OB's are. |
#24
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I was just wondering, is it standard procedure in a normal delivery...
Ericka Kammerer wrote: Bryna wrote: wrote: Bryna wrote: I agree that it's not uncommon (I used an OB for my first birth -- never again!) but it can't simply be because of office hour concerns. Many midwives run practices that are identical to OBs, but are nonetheless able to "wait it out" with the woman in labor, often by having group practices where one midwife is "on call" for office visits, while the others attend laboring women. OBs, in my experience, just have a different standard of care. If you want someone to be with you during labor, use a midwife. As noted in my post, many (most?) OB's have group practices too, to allow some docs to be in the office while others are at the hospital for labors and deliveries. I'd guess that a bigger difference (allowing the typical midwife to spend more time with the laboring woman) is simply the size and scope of the practice. Midwives have fewer patients (and since they usually only handle childbirth they DON'T also have patients with gyn-related concerns), and are able to plan their schedule so that they won't have more than a few women due any single week. I'm sure that when OB's are hanging out in the hospital anyway, they aren't just sitting in the doctor's lounge watching Oprah while waiting for Mrs. Jones to crown. They are tending to the other 5 women who are in labor at the same time, being called down to the ER to check on OB/GYN-related cases, doing emergency c-sections, and much more. I guess I see that as a standard of care issue -- they schedule more patients (therefore making more money) because they intend to spend only a minimal amount of time with a laboring woman, which is SOP as taught in medical school. For women with a separate support system, or who don't need or want that type of "hand-holding," it can be a fine set up. If, however, one wants more personalized attention during labor, I would still recommend a midwife. Actually, I think it's more than that. I think continuity of care is a very real issue. A lot of the art of medicine is instincts. When you limit continuity of care, you limit the ability of the caregiver's instincts to function at peak effectiveness. Most of the time, this isn't a big issue, but when it's important, it's *really* important. I truly believe that ideal care is for one skilled caregiver to participate in all prenatals, much of labor, delivery, and postnatal care. That gives you the very best opportunity for your caregiver to be able to bring every possible resource to bear on detecting problems, especially those subtle ones that are easily missed. Better yet, it allows the caregiver to know you better and know what is normal *for you* rather than relying on textbook descriptions of what should be. So, if one believes that to be the gold standard, there is value in getting as close to that situation as possible, or at least realizing that as one moves away from that situation, one gives something up. I've had three homebirths. Two were with a very small direct entry midwifery practice where the two midwives were at virtually all the prenatals and virtually the entire labor and delivery (well, except the second labor was so fast that the second midwife didn't make it until after the fact ;-) ). The third was with a CNM practice where there were five midwives, you rotated through the midwives for prenatals and were attended by the midwife on call for your labor (along with a birth assistant of your choosing). I definitely perceived a significant difference between the two models. I adored all the midwives at both practices, and I think they are all wonderful caregivers, but there were many more ways for details to fall through the cracks in the group practice and I didn't have the level of communication with the midwives in the group practice that I did with the smaller practice. I would recommend both practices, but if I had my 'druthers, I'd go with the smaller practice. Now, it's *really* hard to get continuity of care. Many women don't even have access to a situation where they could have a reasonable chance of counting on a single caregiver for prenatal/birth/postnatal care. Many wouldn't be willing to consider a homebirth practitioner, which is where one is most likely to find that level of continuity of care if, in fact, it is available at all. Sometimes one has to trade off other desirable qualities against continuity of care. Nothing is perfect, so I don't criticize any individual's choice. We all have to make the best decision we can for our individual situations. That said, I think people in general greatly underestimate the value of continuity of care. What I think is absolutely amazing is that this is one aspect of quality care that is often *cheaper* than the alternative (though not necessarily in terms of out of pocket costs, if insurance doesn't cover midwifery care). Best wishes, Ericka Ericka, For my first pregnancy I had a homebirth and was attended by a small midwifery practice just like your first two. However, most of the prenatal care was carried out by a large hospital as I only discovered the midwives in my seventh month. Whether because I had the good fortune to meet very lovely midwives or because prenatal care with them from the seventh month onwards sufficed, I felt very much cared for and trusted the midwives. Now for my second pregnancy, I would like to follow the same model - first seven months with the hospital, and the rest with the midwives. The midwives were okay with it since we already know each other. For me, this works better because I know my insurance will cover the hospital portion, and the rest only at 75% after a pretty high deductible. My question is - am I losing out in some way by not conducting the entire pregnancy through the midwives? For my second pregnan |
#25
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I was just wondering, is it standard procedure in a normal delivery...
Lady Penelope Creighton-Ward wrote:
For my first pregnancy I had a homebirth and was attended by a small midwifery practice just like your first two. However, most of the prenatal care was carried out by a large hospital as I only discovered the midwives in my seventh month. Whether because I had the good fortune to meet very lovely midwives or because prenatal care with them from the seventh month onwards sufficed, I felt very much cared for and trusted the midwives. Now for my second pregnancy, I would like to follow the same model - first seven months with the hospital, and the rest with the midwives. The midwives were okay with it since we already know each other. For me, this works better because I know my insurance will cover the hospital portion, and the rest only at 75% after a pretty high deductible. My question is - am I losing out in some way by not conducting the entire pregnancy through the midwives? I think so, but the question is whether it's worth it to you in your situation. I think what you miss is the opportunity for the midwives to see first hand how your pregnancy develops. I think that gives greater opportunity for them to develop an understanding of how *you* work and for their intuition to kick in. How necessary is that? Well, most of the time it probably doesn't make any difference at all because everything is straightforward. As far as the insurance goes, does it really matter much in the end? Do you save much money? For instance, with my homebirths, most of the cost was in the birth itself. When they itemized the package price, I wouldn't have saved much by doing the prenatal care elsewhere. I actually had a slightly different situation with pregnancy #3--my insurance would pay at the out of network rate for the prenatal care but wouldn't cover for the birth (although when I submitted the claim for the birth for giggles, they actually paid it). And, if you are going to pay out the deductible anyway for just the cost of the birth, then you won't pay any *more* deductible for throwing in the prenatal care as well. So, you might want to work the math and see how things come out. If I recall correctly, when they unpacked the package fee of about $3500, the prenatals were only about $75/visit with my midwives. If you have prenatals at 10, 14, 16, 20, 24, 28, 32, 34, 36, 37, 38, 39, 40 weeks, then you'd still end up doing almost half the prenatals with the midwives anyway. That would be only about $450 in charges from the midwives, and if you're already meeting the deductible with the birth, then you're talking about a difference in out of pocket costs of only just over $100 (if your costs worked out similar to what mine were). Personally, I wouldn't trade missing out on that continuity of care for $100, but maybe it works out to more money in your situation. Best wishes, Ericka |
#26
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I was just wondering, is it standard procedure in a normal delivery...
Lady Penelope Creighton-Ward wrote: Ericka, For my first pregnancy I had a homebirth and was attended by a small midwifery practice just like your first two. However, most of the prenatal care was carried out by a large hospital as I only discovered the midwives in my seventh month. Whether because I had the good fortune to meet very lovely midwives or because prenatal care with them from the seventh month onwards sufficed, I felt very much cared for and trusted the midwives. Now for my second pregnancy, I would like to follow the same model - first seven months with the hospital, and the rest with the midwives. The midwives were okay with it since we already know each other. For me, this works better because I know my insurance will cover the hospital portion, and the rest only at 75% after a pretty high deductible. My question is - am I losing out in some way by not conducting the entire pregnancy through the midwives? FWIW - I saw an OB for the first 20 weeks, however I had already seen my midwife in my first pg which miscarried, so I knew her. (just one, she had assistants but she wasn't part of a practice) I had assorted testing and early u/s done since I m/c'd the first time. It was reassuring to have that since I didn't know I m/c'd til 6 weeks after the fetus had stopped developing and I'd have been a wreck until we had a heartbeat. Also, given my age it was nice to see things developing normally. However, now we've had a successful pg I'm less worried about that. In any case, I didn't officially see my midwife until ~ wk 24, tho I talked to her each month. That was ok, but in some ways less than ideal since she hadn't seen the whole progression of the pg. I kept her updated, but that's not the same. Unfortunately it took til about week 36 to get my medical records to her. Next pg I will see my midwife only from the start. |
#27
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I was just wondering, is it standard procedure in a normal delivery...
I'm sure that when OB's are
hanging out in the hospital anyway, they aren't just sitting in the doctor's lounge watching Oprah while waiting for Mrs. Jones to crown. They are tending to the other 5 women who are in labor at the same time, being called down to the ER to check on OB/GYN-related cases, doing emergency c-sections, and much more. Naomi Actually, sometimes they do just hang out in the lounge and wait. Even if they are in your room, they don't DO anything but sit in a corner and watch. I've had 7 babies, all in the hospital. #1,2,3 and 7 were OB attended, #4,5&6 were CNM's. My midwives labor sat, once I was active they were there with me from that point until the baby was born and settled in nursing. My OB's appeared briefly here and there to see what was going on and left until it was time to catch. With #7 he saw me in the office in the morning, sent me up to the floor for induction, showed up again around lunchtime to check progress, showed up around 4 to break my water, reappeared a couple times between 5 and 6:30 because it looked like she might be coming and his parting words to the nurse the last time he examined me were "Let her push, I'll be in exam 2 doing charts". The final moments of the birth went like this: Me- "She's COMING!!!" baby now visible on perineum and me pushing like mad Nurse "DR. M!!!!!" Dr M literally comes running and skidding into the room and quickly gowns and gloves while I push and the nurses take the bottom off the bed. He sits down and I push for about 2 minutes and my baby is born. Placenta comes on it's own within 10 minutes. He catches that, examines me for any tears, congratulates me and leaves. He was a very nice guy, respectful of my wishes (how many OB's out there would induce a grandp multip VBAC with pre-eclampsia ?) but he was a surgeon/doctor not a midwife. I'd say all in all that OB spent less than 30 minutes with me during my whole labor and birth. Now I did have 2 doulas and my husband and at least 1 nurse with me most of the time. I was pre-eclamptic and a VBAC, someone needed to be attentive to me and the baby. He had nothing else to do. He was not the OB on-call for his practice. He was there just to catch my baby, another doc was covering the other births. I don't expect OB's to labor-sit although there are few here and there that do when they can. You definitely need to use a midwife or hire a doula (or 2) if you want hands on labor support. |
#28
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I was just wondering, is it standard procedure in a normal delivery...
"don_tspamme" wrote in message ups.com... ...for the doctor who is delivering your baby to only show up when you are at the pushing stage? It's how it's done here in my area of the US. I switched to a midwife before my 8th month along because I discovered my area *had* one, and my last few remaining checkups were 45 minutes to an hour instead of the 5 minutes the OB spent with me. That was nice, to be able to talk about all my concerns and issues. When I went into labor with the midwife (who was backed up by a partnered OB group, a different group from my original OB BTW) she spent lots of time on the phone with me helping me decide when to come in and she met me at the hospital (the on-call OB and midwife sleep at the hospital when they are on duty), and my labor was way over 12 hours long....she spent a lot of time with me when we were just waiting for dilation (I had to be induced), the nurses were checking on me a lot, and I was basically just trying to catch some sleep. When it was time to push the midwife was right there with the nurse and spent a ton of time with me..I had a problem (baby was stuck) but the midwife spent a lot of time with me trying different positions of pushing. Finally we did end up having to let her call the OB in and the baby was delivered by forceps very quickly. The OB spent all of about 15 minutes with me. I decided that since I now don't feel I "need" as much time spent during the office visits since I have experienced pregnancy, and since the OB ended up delivering anyway I am just going to use the OB who ended up delivering my baby's group next time. To be honest, the NURSES at the hospital are the ones you see the most while you are just in labor, and then the OB comes in for pushing. The nurses really do a lot of work (under the supervision of the OB of course). Nurses are underrated--they deserve more credit. I wouldn't have been as worried about having a midwife to "hold my hand" if I had realized that just because the OB only comes in for pushing, that doesn't mean NO ONE is there! Nurses constantly come in and check on you, and help you push as well. As it turns out the midwife group I used lost their contract with the hospital and are out of business- the midwives still practice but had to split up and go to other areas that still use their services. It's a shame but I can't help but wonder if they had a high rate of having to have OB intervention? There is some reason the hospital didn't allow them to remain. They were good--they deserve more credit too. But I think the hospital must have had some reason for letting them go. Insurance wasn't the reason because they were able to bill through the partner OBs office so they took most insurances. I think the hospital was just cutting costs when the same work was being done by the delivery room nurses and OBs anyway, I guess... But yeah, OBs just showing up for the pushing is normal, and it doesn't have to be worrisome. A good OB will still give you good care and some will go a little extra...I just thought I would respond to this post because the OB-not-coming-until-pushing was one of the things that really worried me during my first pregnancy. It seemed like abandonment, LOL. But things will be fine assuming the hospital staff is good. |
#29
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I was just wondering, is it standard procedure in a normal delivery...
"Elfanie" wrote Not only that,...but OBs don't see you after the birth until 6 weeks postpartum. I come back 1 day after the birth, 3 days aftrer the birth, 1 week, 3 weeks, and then 6 weeks after the birth. and still manage to do all my prenatals and birth care. True that the doctors won't be able to take a gazillian clients at once like they do.... This is my biggest problem with OBs, they take a gazillion clients all at once. SOME OB offices actually have the on-call OB take appointments on the same day that they are on call for labors and I ran into that and was forced to see the nurse instead of any doctor when I showed up for my appointments, because the doctor was "doing a delivery". Also, I showed up some when the OB was just running out of the office to go to a delivery and the staff said they should be back in about 30 minutes! That's robo service. It's wrong...at least some OB offices rotate the doctors to where the one on call does not have to also take regular appointments all day! This should be a standard IMO. (BTW my OB office was located right at the hospital in a medical office section so they literally could run out and if the lady was able to push the baby out in 15 minutes, they really could be back in 30! Whew. I liked that the midwives at least had the one on call NOT taking appointments too. It's a shame that now I don't even have the *chouce* to use them again. Well if I want to use a hospital an hour away from home instead of 10 minutes I could see one of them again...but from experience I know at 8 months pregnant with swelled up feet I don't want to drive into huge city traffic for an hour each way for weekly appointments etc... It is also true that the OBs schedule your checkup for 6 weeks after birth- they check you before you leave the hospital last thing then unless you had a C section they'll see you in 6 weeks. The midwives actually did this too though--except I complained of pain so they had me come in at 4 weeks, and they told me my stitches had all dissolved already, and that very night, I decided to feel up where it was hurting and pulled out- you guessed it- a suture. Still, the midwives were great, they really were...they deserve credit...at the time their contract was cancelled with the hospital they had a pretty busy patient load as more women found them and liked their treatment. Their office visits were lengthy, relaxed, and sort of informal...they had a great nurse. It was very convenient too. I did say I decided to just see the OB group next time though, before I even found out they were closing, but it was NOT to their discredit. I have some OB problems that are going to require surgery so I figured I may as well get in with an OB group anyway, and I had discovered that the one the midwives partnered with that ended up actually delivering my daughter is extremely excellent. So I figurd I may as well get established as their patient to make the treatment I am going to need (that nurse midwives can't do) easier... |
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