Labor And Delivery: What Are Your Options?

Giving birth is both exciting and scary to most pregnant women, whether they are first-time mothers or already "veterans" who've done it before. You are eagerly anticipating the birth of your little one, but you probably worry about the possibility of complications, the pain, and the atmosphere at your birth. A competent healthcare team with which you feel comfortable can help a lot.

Where would you ideally like to give birth? What type of healthcare professional would you like at your labor and delivery? Do you have any pain management preferences? Is there anything else you are specifically hoping to get out of your birth? Many expectant mothers and their partners have lots of options. Those experiencing healthy, low-risk pregnancies are especially lucky in this regard.

What options are available to pregnant women? 

Hospital Birth: Many Options In One

Most pregnant women and their partners will end up giving birth in a hospital. In the United States, 99.8 percent of all births take place in a hospital in a labor and delivery unit. Eighty six percent of these births happen in the presence of a physician, and approximately 85 percent of physician-led hospital births are considered to be low-risk.

Hospitals are the only choice for families experiencing a high-risk pregnancy. These families may still be able to choose between several hospitals, and they'll want to opt for the hospital with the best neonatal intensive care unit or the hospital that is most experienced in dealing with the particular situation they are facing, while simultaneously considering how close the hospital is to their place of residence.

Low-risk pregnant women — and that is, as you see, the vast majority — have more choice. You may be able to choose between a birth presided over by a gynecologist/obstetrician (OBGYN) or a birth attended by a Certified Nurse Midwife.

Midwives are a particularly good choice for women who like the idea of having a natural, unmedicated birth and who would like more personal care and attention during their labor. Midwives tend to care for smaller numbers of laboring women, and are thus able to spend much more time with their clients. They also generally have lower rates of medical interventions, and birthing mothers in their care are less likely to have a cesarean section, as they are guided by a more nature-based philosophy surrounding labor and birth. Midwives are often more comfortable with unmedicated vaginal births, even if they do not progress in a textbook fashion.

If you are pretty sure you would like an epidural during your labor, an OBGYN may seem like a more obvious choice. In many hospitals, you'll still be able to get an epidural if you choose midwifery care.

Women giving birth under the care of an OBGYN will generally have access to emergency care more quickly. Their labors tend to be monitored more closely through the use of electronic fetal monitoring, regular cervical checks, and similar interventions. They may therefore also face more restrictions, like not being able to move around during labor or not being able to eat and drink freely. However, many women feel safest with a highly skilled medical professional who can care for them ever when things go wrong.

It's good to have in mind that the term “emergency c-section” refers to all unscheduled cesarean sections. Only a small number of emergency cesarean sections need to be carried out immediately after the emergency has become apparent. The American College of Obstetricians and Gynecologists (ACOG) believes that obstetrical units should be capable of beginning a c-section within 30 minutes of the decision that one is needed — which seems like a long time to wait. 

You may have to wait for an OR to become free, even if you're already physically very close to one. Patients transferring from midwifery care within the hospital, and even those transferring from birth center or homebirth settings, should not have to wait longer. If you're interested in the c-section decision to actual c-section times at your hospital, be sure to ask. 

If, of course, you are hoping to have a c-section rather than hoping to avoid one, you can discuss this option with an OBGYN. Elective c-sections can be scheduled in advance, so that you will never have to wait for an OR. Not every hospital will happily schedule c-sections for women who do not have a medical need to have one, but some will perform this service for women who have solid reasons.

Birth Center: A Home Away From Home

A birth center is a comfortable, home-like setting usually staffed by midwives. Birth centers are exclusively aimed at women experiencing low-risk pregnancies, who would like to experience a natural birth with few medical interventions. Birth centers can be an excellent choice, and their pleasant atmosphere appeals to many women.

Some birth centers have basic facilities, and look much like a hospital. But many are luxuriously decorated and give you the feeling you're enjoying a vacation in a nice hotel rather than giving birth. Birth centers typically have birthing tubs, balls, and stools, and they tend to actively encourage women to try out different positions during labor and birth. Some hospitals also have these facilities and attitudes, but they are harder to find. 

Women who would love to give birth at a birth center should know that not all are equally equipped to deal with emergency situations. The first thing you should know is that, in the United States, there are several types of midwives. At birth centers, you'll usually find either Certified Nurse Midwives (CNMs) or Certfied Professional Midwives (CPMs).

Certified Nurse Midwives are nurses are advanced practice registered nurses who have also specialized in midwifery care. The midwives you will meet at hospitals are always CNMs. These midwives had rigorous training and a broad skill base.

Certified Professional Midwives have met the requirements set by the North American Registry of Midwives (NARM). In order to become certified, a person goes through a self-study program and apprentices with an experienced midwife. She'll preside over a small number of births under supervision, and answer 350 multiple-choice questions.

It's no wonder that many OBGYNs are critical of the CPM credential. Unlike a CNM, a CPM would not be able to practice in another first-world country like Canada or the United Kingdom. Individual CPMs may be excellent and experienced midwives, but their credential means they definitely require more scrutiny. That means you'll benefit from finding out how many births a particular midwife has led, if she's dealt with complications successfully, and if any mothers and babies have died in her care.

If you're going to go with a birth center birth, one prime concern is how long it would take you to transfer to a good hospital if the need were to arise. This is something you can test yourself by driving from the birth center to hospital both in light and heavy traffic. Some birth centers are part of hospitals, and some are even on hospital grounds. Though this gives some women comfort, it's good to note that these birth centers are generally a little more medically minded — the very thing you may be trying to avoid by giving birth at a birth center.

Finally, just in case you're wondering — you are not going to have access to epidural anesthesia at a birth center. If you're looking for an epidural but still want personalized care, a midwifery unit in a hospital may be a better option for you. 

Choosing A Homebirth

While around 0.3 percent of United States moms opt to give birth at a free-standing birth center (meaning, independent from a hospital), 0.6 percent chooses to give birth at home. Homebirth is a controversial choice to many, but well-designed studies consistently show that it is a safe choice for mother-baby pairs that are deemed to be low risk.

It's not difficult to see the benefits of having a homebirth — you may feel safer and more comfortable in your own home, and feel more at ease with the process of labor and birth without the watchful eyes of many people. People who choose homebirth (and I was one of them, twice) see pregnancy and birth as natural events and not medical conditions, unless evidence indicates otherwise.

While complications can and do sometimes occur, it's good to know that there are almost always warning signs that can be acted upon in time to transfer to a hospital. This is where the midwife (or team of midwives) attending a homebirth really matters. One of the midwife's most important roles is to watch out for signs of complications that are outside of her scope.

Homebirth midwives can be CNMs or CPMs, like you'll find at birth centers. They can also be lay midwives who do not have any formal training and have instead learned through self-study and apprenticeships. If you opt to have a homebirth, choosing your midwife is your most important decision.

I personally believe that, based on their lack of formal education, CPMs and lay midwives require a lot of careful scrutiny. Families who are not sure if they are capable of performing this scrutiny will probably be most comfortable with a midwife who has already thoroughly been scrutinized by others — that is, a Certified Nurse Midwife. CNMs do not attend homebirths in all states, however.

I have previously written an article on choosing a homebirth midwife, which I've inserted into the links box below. Please refer to that if you're wondering how to choose a good homebirth midwife. The article includes a list of questions that can help folks who are in the process of interviewing midwives find one they can trust. 

Those moms who are going to give birth at home can test out how long it would take to transfer to the hospital of their choice (look for one with a good neonatal intensive care unit, rather than simply the nearest hospital), in all types of traffic. They may also want to preregister with the hospital to make it easier to receive care. If you have a CNM at your homebirth, she may have privileges at a local hospital, which also makes transferring a simpler and less stressful procedure.