Your 40-week Journey : Who will Handle My Care? A guide to prenatal care (part 3)

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Prenatal care optionsWho provides your care

The options for prenatal care vary across the US. It's best to investigate several different options before deciding upon the type of care that suits your needs. Often, however, the choice is made for you according to the HMO or type of insurance you carry. Usually, there is an option to choose care with a physician (family practitioner or obstetrician) or midwife. Certified nurse-midwives (CNM) and certified midwives (CM) are graduates of a formal program in midwifery who take a national board exam. Direct-entry midwives (lay midwives) serve an apprenticeship and may or may not have formalized education.

Q: What is collaborative care?
A: Sometimes, women develop complications in pregnancy where specialist care is needed to assure the health of the baby or mother but the midwife or family practice physician may still see the mother following the plan of care outlined by the obstetrician or perinatologist. Alternating visits may be made with the midwife. Occasionally, a midwife may request that an obstetrician be present at the time of birth. Collaborative care may also include other specialists for varied conditions. Midwifery care is primarily intended for healthy women. However, the certified nurse-midwife and certified midwife can continue to be instrumental in many cases.
Q: How does midwifery care work?
A: Midwives are dedicated to supporting women and families, serving as advocates for them, and providing safe, expert care. Certified nurse-midwives (CNMS) and certified midwives (CMS), if licensed by the state, can legally provide care to women during their reproductive years. The certified nurse-midwife (CNM) and certified midwife (CM) practice within a health-care system provides for consultation, collaborative management, or referral as indicated by the health status of the client.
Q: When might I be referred to an obstetrician or specialist?
A: Some conditions or events in pregnancy are considered too high risk for management by midwives or family practice doctors. Referral to a specialist would be the best plan for the mother and baby in these cases. The scope of a midwife's practice does not allow for the care of such clients and she would complete the visit and refer the patient to an obstetrician for the remainder of the pregnancy. If later in the pregnancy, an ultrasound reveals that a baby has a congenital defect that requires intervention or a cesarean birth, the midwife would also refer such a client to a perinatologist and the remainder of the visits and the birth would take place at a perinatal high risk center.
Q: Does my care change if I'm having a home birth?
A: Currently, care for home birth is limited in many areas of the US. Licensed CNMS and CMS may and do practice within the home with an appropriately selected client population. If home birth looks like an option for you, it is best to discuss this with your doctor or midwife. You may not receive a ready referral, but at least you can discuss the pros and cons from their perspective. Typically, a midwife, local doula organization, or childbirth educator is the best source for finding a home birth practice in your community. Once you tell your doctor or midwife that you are planning to deliver your baby at home, they may decline to see you for prenatal care. Some home birth providers offer prenatal visits while others prefer you to attend regular visits with your own doctor at his or her office. Be sure to check your insurance plan to confirm benefits.
Q: How will I choose my prenatal care?
A: Begin your search for a care provider as soon as your pregnancy test is positive. Look for one who suits your philosophy on care. Ask questions about his or her experience, credentials, philosophy, birthing practices, and support of breast-feeding. Check your insurance to see if midwifery care is covered. By law, such care must be covered so insist on your rights if there is reticence. Midwives who practice in a hospital or birthing center have all pharmaceutical interventions at their disposal but they prefer to support the natural processes whenever possible. When necessary, midwives may discuss the use of external and internal monitoring, oxytocin augmentation, or induction of labor, intrathecal and epidural anesthesia, and narcotic analgesia. Midwives manage emergencies such as fetal distress, shoulder dystocia (difficult shoulders), hemorrhage, and other obstetric emergencies until their consultant arrives. In some settings, midwives use vacuum extraction to deliver babies who are in need of rapid delivery. They do not perform cesarean births but may assist at such procedures.
Hospital scan:

Part of your prenatal care may take place at the hospital if your doctor's practice doesn't have ultrasound equipment.

At the Doctor's office:

If you have shared care, some of your prenatal appointments will be with your doctor at her office.


An obstetrician will be involved in the care of women with complications or a multiple pregnancy.

Midwife home visit

If your care is midwife-based, a midwife may visit you at home for some of your prenatal appointments.

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