MATERNITY CARE: UNDERSTANDING YOUR OPTIONS

 

The journey to childbirth is an exciting time. It can also be a time that is rife with confusion. While building your birth plan, it can be difficult to understand which medical professionals will handle the various aspects of your pre-maternity, prenatal and postpartum care. While the information below covers only basics, it may help you make connections between your desired birth path and the medical professionals who can guide you through a healthy, safe delivery–and beyond!
Obstetrician/Gynecologist (OB/GYN) 
An obstetrician is a medical doctor who has been trained in pregnancy, labor and the period directly following childbirth, as well as surgical care. A gynecologist is a physician who received training in the health of the female reproductive system, including the diagnosis and treatment of disorders and diseases. Because there is such an overlap in the care that each field provides, most doctors pursuing this field choose to become obstetrician/gynecologist. The OB/GYN’s role is providing medical and surgical care for all women, often with a focus on family planning, delivery and prenatal care.
The American Board of Obstetrics and Gynecology set the education and training requirements for an OB/GYN. These include graduation from an approved medical school and completion of a four-year OB/GYN residency with specific requirements that they gain experience in primary and preventative care roles. They must be recertified every 10 years.
Most babies in the United States are delivered by an OB/GYN, and only an OB/GYN can perform a Cesarean Section. Typically, they handle the prenatal care of patients who have complicated or high-risk pregnancies, though they may refer patients to specialists. Women who have difficulty conceiving will also often consult with an OB/GYN, who can help better understand what issues are preventing pregnancy, as well as provide medical intervention to work towards a successful pregnancy.
Midwife (CNM) 
“Midwife” is a term used world wide to describe health care professionals who specialize in maternity care including care before, during and after the birth. Generally, midwives handle low risk births–or even difficult situations like breech births–but may care for higher risk situations in collaboration with a physician. According to the International Confederation of Midwives and the World Health Organization, “a midwife is a person who, having been regularly admitted to a midwifery educational program that is duly recognized in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications to be registered and/or legally licensed to practice midwifery.”
This definition has not always been the case. Historically, midwives were women who specialized in assisting women through childbirth. As professional education programs emerged, both men and women became educated and better prepared as midwives to ensure the safety of babies and mothers. National certifications and state-by-state licensure were put in place to provide the public with a method to be sure that midwives are qualified.
Certified Nurse Midwives (CNM) are registered nurses who have advanced training in women’s health care, are certified by the American Midwifery Certification Board and are licensed in the state in which they practice. To be certified as a CNM, they must have completed a graduate level midwifery education program that is accredited by the Accreditation Commission for Midwifery Education (ACME). They must pass a national certification exam administered by the American Midwifery Certification Council (AMCB) and hold both an active registered nurse license and either a midwifery state license or an advanced practice registered nurse (APRN) state license depending on their state rules. In Kentucky, CNMs are licensed as APRNs. Their training includes extensive hours in a clinical site, supervised by a master’s prepared nurse-midwife. CNMs care for women and their families during pregnancy, birth and the postpartum period. They practice in hospitals, homes and birth center settings. They also provide well-woman care, which includes annual exams, primary care, birth control, pre-pregnancy care and menopausal care. Midwives do not perform surgery, such as Cesarean Sections. They generally do not care for high-risk pregnancies or complex gynecological problems, except in collaboration with an OB/GYN.
Currently, the state of Kentucky does not license other types of midwives, including Certified Midwives (CM), Certified Professional Midwives (CPM) or Direct-Entry Midwives (DEM). Before accepting care from any midwife in Kentucky, it is important to check for proof of valid CNM credentials. This can be done through the Kentucky Board of Nursing website.
Many insurance carriers (including Medicaid) cover midwifery services. Be sure to check with individual plan materials before seeking care from a midwife, and understand which services will be covered.
The role of a midwife is often misunderstood. In addition to delivering babies, midwives aim to empower women to make their own decisions regarding health care across their lifespan, including prenatal care and delivery. They often help create the birth plan, including choices about pain relief (such as epidurals), the birth timeline and the birthing environment. They do not try to pressure women into so-called “natural births”, breastfeeding or vaginal birth. While a midwife cannot perform a C-section, they are happy to provide support and care until the procedure and during the postpartum period. Many women opt to receive all their routine gynecological care from a CNM, from well before conception through their menopausal years.
Maternal-Fetal Medicine (MFM) and Perinatologists
Maternal-fetal medicine doctors specialize in high-risk pregnancies, fetal therapy and maternal or fetal testing. They may be consultants or primary care providers during a pregnancy, depending on the situation, especially if there is a higher risk of complications, a chronic medical condition or if the pregnancy involves multiples.
Maternal-fetal medicine specialists are OB/GYNs who undergo an additional 2-3 years of specialized training in the assessment and management of high-risk pregnancies and fetuses at risk. They have training in obstetric ultrasound and invasive prenatal diagnosis. The American Board of Obstetrician Gynecologists requires that MFMs do a minimum of 12 months clinical rotation and 18-month research.
Obstetricians who specialize in maternal-fetal medicine are known as perinatologists. In addition to a residency in OB/GYN, a perinatologist has 2-3 years in maternal-fetal medicine training. They are board certified through the Board of Obstetrics and Gynecology.
While including a MFM or perinatologist in your birth plan may not be necessary, it’s good to ask your prenatal primary care provider about the MFM or perinatologist they typically refer their patients to. If it seems likely that you will need one of these specialists during your care, seek their references and credentials. Also be sure to work with one who is covered by your insurance.
Family Medicine Physicians
Family medicine physicians or family practice physicians are medical doctors who specialize in total health care of the individual and the family. Some of these doctors have certifications and training in gynecological care. This makes them excellent resources for women undergoing a routine pregnancy. These physicians can generally accommodate routine checkups and advice before conception, including the initial confirmation of pregnancy. They will be able to refer you to other doctors or specialists for necessary care, including delivery. Since they are trained in family medicine, these doctors will often be the family’s pediatric care provider.
Doula
A doula is a birth companion. This nonmedical aid helps a woman before, during and often after childbirth by providing physical assistance and emotional support.
Studies have proven that continuous support during labor is closely associated with improved early health for both the mother and child. This includes a lower risk of induction and interventions, with less need for pain relief. This effect is compounded when the support comes from someone who is not family or medical staff. That’s where a doula comes in!
The term doula can be used by anyone. There is no formal or universally recognized certification process or training requirements, and no academic or medical credentials are required. However, many professional birth or labor doulas have completed some training to prepare them for the role, and some (non-regulated) organizations exist that do offer training and certification. It is essential to check into a professional doula’s training, experience and references before becoming a client. It is also important to understand exactly what role a doula might play in the birthing and pre-birth process; be up front about your expectations, and ask a lot of questions.
Doulas are not a sufficient substitute for an obstetrician or midwife: instead, they should be thought of as a helpful supplement to the care that a licensed, certified medical professional provides. A doula’s advice should always be emotional support while an obstetrician or midwife should provide medical and wellness information and guidance.
Birthing Partner
A birthing partner is someone with no training who offers support and comfort throughout pregnancy, labor and delivery. They can be anyone, but are often a good friend, spouse or close family member, while a doula is often someone outside of your family or friends group. Birthing partners often accompany the mother to Lamaze, birthing and childcare classes, as well as important checkups. This person’s role is purely for emotional support and should never offer medical advice. Often, this person is an important part of the birth plan and should be mentioned when consulting with medical professionals near the due date.

The Birth Plan: Do You Need One?
Whether she knows it or not, every mother has a birth plan. For some, the plan is as loose as “go to the hospital when it’s time”. For others, it’s much more detailed. Detailed birth plans are increasingly common among expectant mothers. Should you have a birth plan?
What it is
A birth plan is an outline of the medical care you intend to prefer to recieve during the delivery. This lets your medical team know your preferences regarding decisions like pain management, which medical staff will be on hand and how soon after deliver you’d like to hold your baby. It can be as detailed or loose as you prefer. Some couples even have informal birth plans that include details such as what music is played when the baby is born.
Birth plans signal to the medical staff on hand for the birth what choices you have made. They will often double-check to make sure you’re still going with your plan. It will also signal whether you’ll need special personnel available after delivery, such as a lactation coach.
how to start your birth plan
At your next checkup, ask your doctor or midwife how you can get started on your birth plan. Many hospitals and delivery centers have brochures to guide you through the decisions you will be considering, but your chosen medical professional will likely have a few questions of their own. Take time to think each decision through, and ask questions about any options you don’t understand.
Why it matters
Birth plans empower you to understand and decide the care that you and your baby will recieve. Outlining these choices now allows you time to research and understand your options instead of forcing you to make decisions on the fly while you’re in labor!
While it may be an unpleasant thought, you should give thought to what choices you wish to make regarding emergency scenarios. Be sure and ask your doctor what scenarios you haven’t thought through.

Posted on 2015-07-12 by Amanda Harper
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