Obstetricians – 11 Questions To Ask Before Choosing An Obstetrician

Choosing an obstetrician can be pretty daunting for some women, and going by our BellyBelly Forum poll, it seems that the highest percent of women are choosing obstetricians based on recommendations from their friends. However, an obstetrician that may have been ideal for a friend’s birth may not be ideal for yours, because not everyone will have the same experiences or preferences for childbirth. Or perhaps as a result of investigating further, you might decide an obstetrician is not the right option for you. That’s why it’s important to do your own research as well as taking into account the experience and feedback from others.

It’s worth interviewing several obstetricians and not just one, because obstetricians are all so very different in personality and beliefs about the birth process. If you go with the first one you meet, you wont know what else is out there and how much your experience can vary depending on who you choose to see. For example, some obstetricians will happily support a vaginal breech birth and do so frequently. Others will go straight to caesarean because they have no experience (or intend to have any) with breech birth.

Don’t feel embarrassed asking an obstetrician lots of questions. If the obstetrician becomes impatient or dismissive, then you have your answer already. If the obstetrician doesn’t have the time or inclination to listen to you now, do you think it will be any different during your pregnancy, labour and birth? At some stage you will probably need to ask them some very intimate and personal questions too, which wont be so easy if you don’t have that connection with them.

Obstetricians – Experts in Complications

It’s important to realise that obstetricians are experts in obstetric complications, whereas midwives are experts in normal birth. To explain this, I often make the comparison of a person seeing a respiratory specialist for a cold rather than their local GP. The vast majority of the time, the cold is absolutely harmless and doesn’t develop into anything dangerous, in a normal, healthy person. When the GP does their usual investigations and in the odd case does pick up something, THEN they will deem it necessary for the person to seek the services of a specialist and refer them. This is how I think we should approach maternity care, saving huge amounts of money for taxpayers and consumers and also because of the nurturing, continuity women are looking for. By choosing their own obstetrician, it makes for a bit of a rude shock when the obstetrician doesn’t do any hand holding in labour – he/she is not there for you (the hospital midwives do the monitoring) and obstetricians only pop in to catch the baby (if they make it in time!), or if there are any complications.

But for now, it’s commonplace to skip that step of seeing a midwife and go straight for the specialist, despite the process of birth being a normal and healthy event. Evolution has done us well – birth does work and works well the vast majority of the time! But it’s unneccesary interference in that normal process which can result in the complications that so many women fear. In the birth world it’s known as the cascade of interventions.

It’s probably due to private health care, amongst other things, that women are flocking to these experts in complications without realising the full implications, with the possibility that they will have a very medicalised view of pregnancy birth as a result of their training. Not all obstetricians are like this, of course, I am making a generalisation here. Obstetricians are also great when things go wrong, their skills are designed for that. But the best person to care for a low risk pregnant woman, is a midwife.

You can actually hire your own private midwife no matter where you give birth, to help keep your birth as normal and respectful of your choices as possible, or alternately, a doula. But if you want to give birth in a private hospital, you need a private obstetrician – you can have as well as a private midwife or doula, but you still need a private obstetrician if you go private. Click HERE to read our article on birth place options.

When speaking to the obstetrician, try to ask open-ended questions, to help elicit how the Obstetrician feels – encourage discussion rather than ‘yes’ or ‘no’ answers.

Fertility Specialists as Obstetricians

Many women using IVF or other fertility treatments feel automatically obliged to continue on with their Fertility Specialist for pregnancy and birth (where they are also Obstetricians), however it’s still important to see how they feel about your birth philosophies and preferences – don’t feel obliged to continue with them! It’s fantastic if they have helped you to get pregnant, but just like any other Obstetrician, their beliefs and opinions about birth can be as different as any other. Sometimes they can even be more medically focused, especially when medicine helped you get pregnant.

One woman I supported chose to continue with her Fertility Specialist during her first pregnancy, when her baby was found to be breech without any signs of moving, over weeks and weeks of scans. The woman’s Obstetrician was not skilled in breech birth (as many no longer are) and wanted to perform a caesarean, but the woman wanted a vaginal birth. I gave her some names of some Obstetricians who supported breech birth and as a result, the woman made the decision to change Obstetricians, in order to be supported in the birth she wanted.

It turned out to be a great decision – she went on to have an empowering, drug-free, breech vaginal birth. You can only imagine what that experience of taking a big leap of faith and finding someone she could trust, would do for her confidence as a mother and even for her next pregnancy.

Cailin shares a similar story:

“We started seeing a fertility specialist for PCOS (polycystic ovarian syndrome) to help conceive our second child – we had been trying for nearly 12 months with no success. I had lots of tests done and it was conclusive that the PCOS was causing the problems. I was put onto Metformin and Clomid, and after 2 miscarriages we fell pregnant with my son. I was very happy to be pregnant and because I had a caesarean with my first, I was determined to have a VBAC (vaginal birth after caesarean) with this baby. I raised the question with my fertility specialist to which his reply was, “No way. Your last baby was 9 pounds, there is no way you are going to push this baby out. It’s going to be huge.” Riiiiight I thought.

I was quite adamant and asked him if he was sure he wouldn’t consider it. He said he would give me an ultrasound at 36 weeks and tell me then. So I went home feeling torn because I knew I wanted to have my VBAC, and I guess a part of me felt loyal to this fertility specialist because he had helped me to conceive. But I realised that I did deserve the chance try again. I got in contact with some people who knew some VBAC friendly Obs and found the Ob of my dreams, who very much believed in letting nature take its course. He was true to his word – I managed to birth my son the way I had dreamed of.

My advice to others would be is when your fertility specialist asks you, “Will you be needing me as an Ob?,” be straight with them and say, “I’m still looking at my options.” That way you leave it open and you won’t worry about it if you do decide to go with another Ob or even a midwife.”

Eleven MUST ASK Questions

Here are the 11 questions which will help you uncover if the Obstetrician you are considering is best suited to you and your baby. Other standard questions are listed at the end of this article, however these specific 11 questions are designed to help you choose someone who is going to have your best interests at heart, rather than be the first one you can find who is available around your estimated due date.

At first you may think all you need is an Obstetrician who is available and has a good bedside manner, but later when you form more solid opinions and make decisions about your birth, if you haven’t factored this in with your choice of obstetrician, you may find yourself in a quandry about staying with who you chose and comprimising what you want, or having to change last minute, which can be very difficult.

Click here to download a FREE interview sheet to use when interviewing an Obstetrician for the first time. If you are unable to open the document make sure you have Adobe Acrobat Viewer which you can download for free. Alternatively, you can download the document in Word format HERE.

1. What are your philosophies and beliefs about birth?

This is the most important question you could ask an Obstetrician, as it will give you an idea as to how they see birth and how they may try and control the process.

Do they see birth as:

• A medical process which needs to be monitored and managed continuously?
• A process which is fraught with potential minefields and requires preventative procedures? Or;
• A natural process where nature should take it’s course before interfering?

2. How much choice do you feel I should have in the decision-making process?

Women (and their partners) tend to have much better experiences of birth when they are involved in the decision-making process and are given options. Those who feel that they have no control over or are not informed or involved with decision-making tend to have a less positive experience of birth. So it’s very important to choose someone who you feel will involve and inform you throughout your pregnancy and birth, without wanting to race you out the door in five minutes.

3. What are your thoughts on pain relief during labour?

Another great indicator on how they view the birth process.

• Do they just assume that you will have pain relief or will they support and encourage natural pain relief methods?
• Will they openly tell you the side effects for you AND your baby?
• Will they encourage you to accept pain relief in labour, or recommend against it if you are close to birthing your baby?

What they say about pain relief and if they think you will quickly succumb to it says much about what they think of the birthing process and how supportive they will be.

(As a side note, the reason I use the word birthing/birthed as opposed to delivered, is because I think babies are born and pizzas are delivered hehehe! I also think mum does all the hard work birthing her baby and deserves the credit, not the Obstetrician!)

4. Is there anything on my birth plan that you aren’t comfortable with or that you foresee will be a problem at my chosen hospital?

If you haven’t yet put together your birth preferences (birth plan) it’s a good idea to take a rough one with you when you interview an Obstetrician. It can always be altered later, closer to the date, but it’s important that the person who is to be your primary carer can see what you have in mind for the birth – and important for you to find out what he/she thinks about that before it’s too late. There’s nothing worse than being in a situation where you need to make a quick decision and feel like you don’t have enough time to discuss it.

Ask the Obstetrician to tick or initial each point in your plan and/or sign the end of your birth plan in agreement, so when you present it to the hospital or when you face deviations to your plan, you have something signed to show the hospital or the Obstetrician.

Don’t forget to read the BellyBelly article about birth plans, which includes a free downloadable birth plan template which you can edit and print out HERE

5. What are your thoughts on electronic monitoring and when do you think it should be used?

Intermittent doppler monitoring is standard care during labour, however some Obstetricians and/or hospitals prefer to use more restrictive and invasive procedures of monitoring which can affect the way you plan to labour and give birth. Continuous CTG monitoring which involves you being stuck in one position, usually on the bed, and can be detrimental to the progress of labour. The Cochrane Library, a regularly updated collection of evidence-based medicine databases, concludes where continuous CTG was used, there was:

”...no significant differences in cerebral palsy, infant mortality or other standard measures of neonatal well-being. However, continuous cardiotocography (CTG) was associated with an increase in caesarean sections and instrumental vaginal births. The real challenge is how best to convey this uncertainty to women to enable them to make an informed choice without compromising the normality of labour.”

and

“Data for subgroups of low-risk, high-risk, pre-term pregnancies and high quality trials were consistent with overall results. Access to fetal blood sampling did not appear to influence the difference in neonatal seizures nor any other pre-specified outcome.”

You can read the full report HERE

Being armed with this sort of information can really help you prior to meeting an Obstetrician, as you will know a bit more about the facts, feel more confident and can respond or make a decision accordingly. Researching all the choices you make for your birth plan is the key, it shows understanding and dedication to what you have planned. You are less likely to stick to a plan if you haven’t reseached the reasons why you want those choices.

6. What is your induction rate and at what point do you feel induction of labour should be considered?

Obstetricians will have varying protocols on induction, from inducing only days after your estimated due date, some 7-10 days post-dates, some two weeks and some will allow more if baby and mother are well.

The problem with unnecessary inductions is that they start off a cascade of interventions, so while it might sound harmless to start labour earlier with a little bit of hormone, you might change your mind when you end up with an epidural (and a catheter and an i/v as standard with that), forceps, vacuum or a caesarean section – you can read more about the risk of inductions here. Knowing an induction policy before you choose an Obstetrician can help you avoid interventions that you perhaps aren’t hoping for. At the end of the day, you have the ability and power to refuse an induction, but it’s much more pleasant if your Obstetrician is in agreement with your choices.

7. What is your caesarean section rate and in what situations will you recommend a caesarean section?

This is a question worth insisting on if you can’t get an answer – they may not be forthcoming with offering a figure but finding out the answer to this can be very helpful, as well as save you from a 6-week recovery from a caesarean. The World Health Organisation states that around 15% of caesareans are probably needed, as a case of medical necessity. However many hospitals are now sporting caesarean section rates of 30-50% and scarily enough, some even higher. So it’s worth knowing if your Obstetrician is performing caesareans at a rate of 15% or 50%, and perhaps what percent are elective and what are emergency. To clarify, an elective caesarean is a caesarean where labour has not yet started, so if a woman has requested a caesarean, or if baby is breech and a caesarean is performed before labour starts. An emergency caesarean sounds worse than it is, because it’s given that name if labour has already started. So a mother may be tired after a long labour and ask for a caesarean, or if the baby’s heartrate is consistently low, then that would be an emergency caesarean. It doesn’t automatically mean a life threatening situation.

If the Obstetrician isn’t telling you their caesarean rate or can’t give you an estimate, then I would start to think that it was probably a rate they didn’t want you to know.

8. How do you feel about mothers being separated from their babies after a caesarean? What about immediate skin to skin contact if all are well?

Many decisions about what happens in theatre is up to the Anaesthetist and/or the Obstetrician, for example if you can have one extra support person present, a video recorder, if you can have skin to skin contact after the birth etc. So if possible, it’s good to meet the Anaesthetist prior to the caesarean or find your own if you are having an elective caesarean.

In order to perform a caesarean as quickly as possible, things are often done to save time which may not be how you would envisage a caesarean to be. Once your baby has been born, the normal process is to give you a quick look of the baby (after someone else has checked over the baby and wrapped it up) and then baby is given to dad to do all the weighing and other procedures while you are stitched up and sent to recovery, alone. However, if you find the right Obstetrician and if it’s not a life threatening situation, you can have a more special, bonding experience.

There are some Obstetricians who allow some or all of the following in a caesarean where mother and baby are not in danger:

• No screen to obstruct the view or the screen lowered for the birth
• The cord left to stop pulsating before being clamped and cut so baby can have it’s valuable cord blood
• Lotus birth (no cutting of the cord at all)
• Immediate skin to skin contact after the birth

So once you have figured out how the Obstetrician feels about mother/baby separation, you can clarify with specific points that are meaningful to you. Be prepared to get knockbacks from some Obstetricians on all of these things, but on the off chance you need a caesarean, it’s nice to know you have chosen an Obstetrician who will allow you to have a special one, so it’s worth doing your homework. With consumer demand comes the service, so hopefully more women will ask for these things.

9. What is your episiotomy rate and in what situations would you perform one?

These days it is not common to find an Obstetrician who will do routine episiotomies, however they are still being performed during the birth. It’s a good idea to get an idea of how many episiotomies are being performed by the Obstetrician and how they feel about it’s use.

10. How do you feel about vaginal breech birth? If you support it, what conditions do you have?

This is something you might not have thought about, but for some women, their babies will be breech during pregnancy and some of those will stay that way! Most Obstetricians will perform a caesarean before your due date (usually 38 weeks) if your baby is breech, but there are some attending vaginal breech birth regularly – you just have to do your homework to find them.

Some breech babies do decide to turn head down days before the birth or even just before labour. My mum said that when she was pregnant with me, I was born nine days post-dates, and was breech until 8 days post-dates. Luckily I was given a chance to turn on my own, but unfortunately if it was today, I would have been a caesarean baby, born over three weeks early. That is scary – I wouldn’t have had that chance to turn and be born when I was ready, potentially having breathing difficulties or other problems.

It’s also good to know that on the Royal College of Obstetricians and Gynaecologists website, there is a statement about vaginal breech birth which is supportive of vaginal breech birth in certain breech positions. It’s not perfect, but it’s a great start, and I think a sign that more Obstetricians need to ‘skill-up’ in breech birth.

It is also important to find out what conditions the Obstetrician will attach to a vaginal breech birth, some will do an episiotomy, monitoring, epidural etc – not that they have the final word in it, you can negotiate. Some breech positions are more favourable for a vaginal birth and the position may be the factor in getting that vaginal birth or not. The best Obstetrician for a vaginal breech birth is one who is most experienced in breech birth – it becomes more risky when it is managed by someone who isn’t skilled in breech birth – breech birth ironically requires a more ‘hands off’ approach to the birth. I think any obstetrician who is doing breech birth must have a better philosophy of birth, so even if your baby chooses not to assume a breech position, you are probably on a winner with your obstetrician anyway.

11. How do you manage the third stage?

The third stage is the birth of the placenta. It may seem like something irrelevant, but there are some very important things here that affect your baby, remembering that the placenta has been the baby’s life support system for nine months and contains building blocks of your baby’s body.

Firstly, in order to streamline and hurry things along after your baby is born, just about all hospitals and obstetricians will clamp and cut the cord right away, then give you an injection to expel the placenta (and also prevent haemorrhage which is an increased risk if you have a high intervention birth or induction). You can ask to be given this only if you do show signs of excessive blood loss or if you have had an induction, but for normal, healthy birth, haemorrage rates are low.

In a normal pregnancy and labour, there is no reason to hasten delivery of the placenta either. When you are given this injection, which is similar to what they use to induce labour with a drip (syntocinon) and make the uterus contract, it means that the cord needs to be cut straight away. Why is that undesirable? Because there are several studies now which show that where the cord is left unclamped until it has stopped pulsating (i.e. all the blood has gone from the placenta to the baby), there are less cases of babies with anaemia, blood transfusions and other blood conditions. The baby will get months of iron stores from this valuable blood supply and of course, all it’s precious cord blood and stem cells. If you cut the cord early or donate the cord blood, your baby doesn’t get to keep those super valuable cells – and it’s alot of blood volume for a baby. Read our article on cord blood HERE to read what the studies say about cord blood and why they recommend it should be made a standard procedure to leave the cord alone.

A physiological third stage is something you can ask for if you want the third stage to be completely natural.

Click here to download a FREE interview sheet to use when interviewing an Obstetrician for the first time. If you are unable to open the document make sure you have Adobe Acrobat Viewer which you can download for free.

Standard Questions

Other standard questions you might like to ask a potential Obstetrician are:

Which hospitals do you attend? This is so you can choose a hospital – Obstetricians only work in certain hospitals, so you need to either choose an Obstetrician and have your baby at one of the hospitals they work in, or choose a hospital first and then one of the Obstetricians who work in that hospital.

Who is your back-up and will I get to meet him/her? Of course you would want someone sharing the same philosophies and to meet them if there is the chance your Obstetrician may not be there, which is a fairly common occurrence.

When are you planning holidays in the next 12 months?

How do you feel about waterbirth? Some Obstetricians (and hospitals) wont permit it, yet some will happily support waterbirth. So if this is something you think you might like to consider, choose an Obstetrician where your options are open – if they don’t mind waterbirth it tells you more about their philosophies about birth – normal, natural, safe.

Vaginal Birth After Caesarean

If you have had a caesarean previously or have a scar on your uterus (e.g. from fibroid removal, hysterotomy, abnormalities repaired or any uterine surgery which leaves a scar) and would like a vaginal birth, here are some extra questions you might like to ask:

• How do you feel about me going past my due date and how long before you will recommend a caesarean?
• When I go into labour, what monitoring will you recommend?
• What do you think about time limits for labouring?
• Will I be required to have an epidural or an I/V bung?
• Will I be able to breastfeed my baby right away?
• Will I be able to have a natural third stage?

Things to Bear In Mind

When asking these questions there are three main things to realise.

1. Your Obstetrician May Have Their Hands Tied

The hospital which your Obstetrician attends will have their own policies and procedures, which all staff need to adhere to regardless of individual preferences. Some will not allow breech birth or waterbirth. So while your preferred Obstetrician may be fully in favour of your choice to have a waterbirth, VBAC or breech birth, the hospital you choose may have policies which are not in line with what you are wanting. So if you can choose an Obstetrician who’s philosophies are closest to your own, you can also ask them to recommend a hospital which is most compatible with the birth you want. If the Obstetrician doesn’t or can’t recommend one to you, then you will have to do her own homework, ringing around and making appointments with the individual nurse unit managers and discussing your birth options and preferences.

2. There Is Policy, But It’s Not Law

While there may be policy, there is no law to say you must do anything during labour – let alone have your temperature taken. Everything requires your permission. So if the hospital is insisting on continuous electronic monitoring and you do not want this, you can just say no and it will be noted on your file. You can say no to an internal on admission – anything at all. I have been to births where some women have been told by hospital staff that, ‘We want to do xxx because we don’t want you to end up with a dead baby.’ They aren’t afraid to use the ‘d’ word which can be very distressing no matter what your plans may be. So please make sure you do your research on the specific things you do and don’t want, so you wont be swayed by such comments and will know that ‘x’ procedure has little difference in preventing a such a thing, of which the rates are very low anyway.

3. It’s All Open To Negotiation

Many Obstetricians and hospitals can be negotiated with. Sometimes it can be wise to meet them halfway, depending on what you are happy with. Their concern is for safety so even just acknowledging that can help. For example, there have been women I have supported with ruptured membranes (broken waters) for over 24 hours and no labour. The hospital was keen for induction, but the woman not. So she had done her research and acknowledged their concerns, before negotiating regular check-ins with the hospital and a session of monitoring.

Same thing sometimes happens with VBAC women who go post-dates by more than a week or two. Negotiations have resulted in the women able to go into labour naturally despite much pressure to be booked in for a caesarean date, the outcome, healthy baby and healthy mother.

While it may not be exactly as you want, sometimes meeting halfway (as opposed to giving in) can relieve the tension and appease.

Educate Yourself!

I can’t stress enough: please make sure you choose sufficiently educational books and materials or hire a Doula/Birth Attendant who can help direct you to such resources. It’s scary seeing the books friends and family often pass onto each other!

Hospital based pre-natal education can not prepare you well enough, and they often tailor the classes to what they want you to hear, or what the majority of their clientèle want to hear, so take control over your experience with good education. Many hospital classes cover medicated pain relief in great detail rather than more information on labour and coping without pain relief. An example of this was a recent birth I attended in a Melbourne Private hospital, the woman told me the classes were mostly about pain relief. I asked the midwife what the classes were like, and she said yes it was true with the pain relief, because most women walked in the door and wanted an epidural.

There is a Recommended Reading List on BellyBelly, which is a fantastic starting point. Also check out The Pink Kit which you can do in your own home and provides fantastic information about your labouring body that you wont find in ANY pre-natal classes.

Kelly Winder is a birth attendant (aka doula), the creator of BellyBelly and mum to two beautiful children. Become a fan of BellyBelly on Facebook here or add Kelly as a friend (frequently adding articles and stories) here. This article includes contributions from BellyBelly’s midwives, Brenda Manning MIPP and Alan Rooney.