Sure, have at the ladybits, but hands off the baby.

July 23, 2013 9:21 AM

Can I fire my obstetrician for delivery, but keep her as a gynecologist thereafter? Do I want to?

I am... pretty damn pregnant, and after some agonizing I'm considering pulling a last-minute switch away from the OB I've seen all this pregnancy, to take up with a midwives' practice in the area.

I'm still not 100% sure that my reasons for doing so are justified-- OB is a perfectly respectable doctor, but
(a) she (while nice) is a fast talker and not conspicuously great at listening/dialogue
(b) I've learned that she's apparently very hands-on and pro-active management of the births she attends, which to me sounds distressing and exhausting;
(c)she's turned out to support/perform some practices (amniotomy, fairly routine episiotomies) that are NOT supported by evidence, so I feel like I can't even necessarily trust her to get the Science!-y bits right; and
(d) she'll be out of town for at least 25% of the total "term" time of this pregnancy, so there's some chance I'd end up with her (not well-reviewed) designated substitute doctor instead of her, anyway.

Not all midwives are great, of course, but I do feel as though I'd have a better chance of winding up without a C-section or episiotomy (my two goals, secondary to healthy baby) at that sort of practice. With that said, the complication is that I WOULD very much like to keep seeing my current OB for gynecological care after this pregnancy, mostly because she's the only practitioner in the area who offers/is trained in a particular form of birth control that I'd be using. I have no idea whether this is a perfectly reasonable thing to expect, or whether the switching for delivery is somehow a deeply offensive maneuver that would preclude any kind of patient relationship with this doctor in the future.

Thus, my questions:
-- Obviously, it is going to be a colossal PITA to switch practices at this very late point, with all the shuffling of records and rebilling of insurance and whatnot. Does it sound like the right thing to do for someone with my concerns? Or (given that this woman seems perfectly nice and well-meaning) is there any magical chance that if I just have a nice reasoned sit-down with her and all my printed research articles (from good journals!), explaining why, in terms of the evidence, I don't want this and that, I can get her to consider altering her approach for me? That is, just how serious is it for a doctor to switch up their customary practices a little, assuming it's at a patient's well-reasoned request?

-- If #1 is a pipe dream and I do have to switch for the birth, does it sound reasonable to expect OB to keep seeing me as a gyno patient thereafter?

-- If so, how should I explain the switch to current OB in order to best minimize hurt feelings and preserve the relationship?

posted by Bardolph to Health & Fitness (25 answers total)

(a) she (while nice) is a fast talker and not conspicuously great at listening/dialogue
(b) I've learned that she's apparently very hands-on and pro-active management of the births she attends, which to me sounds distressing and exhausting;
(c)she's turned out to support/perform some practices (amniotomy, fairly routine episiotomies) that are NOT supported by evidence, so I feel like I can't even necessarily trust her to get the Science!-y bits right

If you generally like the woman but are worried about her being bossy: doula doula doula! Have the OB deliver the baby but get a doula to be there with you. A birth doula's job is to advocate for your desires and keep the doctor from pushing you into things you don't want to do.
posted by showbiz_liz at 9:32 AM on July 23, 2013 [14 favorites]

a deeply offensive maneuver

She is a professional. Explain your concerns, let her respond to them. If she doesn't set your mind at ease, explain that you'll be switching to a midwife and why. There's no reason not to go back to her for your gyn needs afterwards.

Another option is to go with both. When my cousin had her baby, she had a midwife attend in the delivery room with the OB standing by.
posted by phunniemee at 9:33 AM on July 23, 2013 [1 favorite]

I am totally in the same situation. I decided to go with a midwife for my prenatal, birth, and postnatal care and am keeping my (totally competent, totally not personable enough regarding baby) OB/GYN as my OB/GYN for my annual girl parts visits.

It is a professional situation. Pregnancy is oh-so-personal of a situation and very special. If it ever comes up (which I doubt it will) I'll let her know that I just decided to go with a midwife for personal reasons.
posted by jillithd at 9:35 AM on July 23, 2013 [2 favorites]

Have you considered typing up a birth plan (ie, no episiotomy, etc) and discussing it with her to see if she will agree to abide by it? Also, I'd discuss your concerns about her being out of town and you ending up with a dr you don't know and aren't comfortable with.

If her responses aren't what you're looking for, check with your insurance to make sure the midwife practice is covered, and if so, definitely call the them and see if they can take you as a patient. They tend to be very open to the kinds of things you're concerned about.

I don't see any problem with going back to your OB after delivery, especially if you've talked to her beforehand and she knows that she's not going to be able to abide by your birth plan or even be present for part of your prenatal care.
posted by DrGirlfriend at 9:35 AM on July 23, 2013

Any good OB will listen to your requests and tell you which she'll support and which she will not and why. I'd certainly start there. My kids were born quite a while ago and my very traditional OB was completely willing to work with me (and btw, successfully explained why some of the things I wanted were not in my best interests, and he was right). It's not unusual for moms to have significant input into the birthing process; surely most doctors expect it. I wouldn't give carte blanche to any provider (including a midwife). Find someone you can work with. If it's your current OB, all the better.
posted by Wordwoman at 9:37 AM on July 23, 2013 [1 favorite]

Goodness. It's her job to help you. You shouldn't be afraid to offend the doctor, and midwives are better at deliveries. It may be the most important thing in your life (not knowing what else you do), you should make it the way you want it.
More practical advice: stay on your legs and upright unless there is some real medical reason for anything else, that will keep you free of medicine. You can sit upright in a bath, but never lie on your back, it's torture. A good midwife can deliver the baby while you are standing. Walk around - shout at your husband or anything, just don't lay down.
And good luck!
posted by mumimor at 9:45 AM on July 23, 2013 [1 favorite]

I think switching to a different model of care makes sense as a reason. If you are concerned about being talked out of it then I'd suggest you frame it as informing her rather than discussing it with her. If you would prefer a different kind if birth to the one she routinely provides then switching will probably be less hassle and stress for both sides.

You could also lay out to her the part of the dilemma you have about having to choose between midwife-led care and your preferred method of birth control and ask her whether switching back after birth would be a problem. I suspect her reaction would tell you everything you need to know.
posted by plonkee at 10:03 AM on July 23, 2013 [2 favorites]

Yeah, I agree with showbiz_liz - get a doula. When mrs graymouser had our baby girl, having a good supportive doula by our side the whole way was the best thing we did. Your doula will support your birth plan and advise you, in calm and understandable language, about any changes you might need to make in the middle of it. Having a doula is also a tremendous stress reliever for you and your partner because someone who's been through all this before is there with you and taking care of you, instead of your partner who like me may have no idea what to do at all.

If you don't have a birth plan, bring one on your next visit. A form like this will help a great deal in making sure you are thorough. Ask your OB to review the birth plan with you as well - this is a good way to get yourselves on the same page.
posted by graymouser at 10:03 AM on July 23, 2013 [1 favorite]

Just had a kid. Absolutely switch to a midwife. Keeping the OB for afterwards for OB/GYN care is a totally normal thing. If she asks why (which I seriously doubt), just say you found a midwife you'd like to use and leave it at that.

By the way, the doula is there to support you and your spouse/partner (if you have one present); they will absolutely not speak to the doctor for you! When I was interviewing doulas they made that extremely clear. They have NO SAY with the doc. They will help YOU, as in, give you non-medicinal suggestions for dealing with contractions (for example they could guide your breathing, massage you if you want them to, or give suggestions on how to physically support your back/legs to your husband).
posted by rio at 10:07 AM on July 23, 2013 [4 favorites]

And by the way as for the birth plan idea, it's a great idea **if your doctor is open to birth plans**. That might seem like an obvious statement, but not all doctors are. In fact I've observed nurses (because usually it's nurses caring for you for the most part, many times the doc is only there to "catch" the baby!) and doctors rolling their eyes at the idea of a birth plan. Their reasoning is that having what you want all laid out in a neat list is great and all, but in the middle of things, they will do what they think is necessary for the baby's health (of course); a birth plan could easily be brushed aside and forgotten.

Of course if your hospital is the kind that encourages birth plans -- and I have heard of such places! -- then go for it! Just check first, gauge reaction to the idea.
posted by rio at 10:11 AM on July 23, 2013

Our doula was the best. She gave my wife confidence in the birthing room and knew how to deal with our OB in terms she understood. We had a very very mainline OB at a high intervention rate hospital and wife never even had an IV.
posted by JPD at 10:25 AM on July 23, 2013 [1 favorite]

Expressing your thoughts to your OB may get you 'fired', excluded from the practice and given 30 notice to find a new office. How about asking how she feels about birth plans and doulas? Even that's no guarantee as the nurses may blow them off as well.

Meet up with the midwives, take an appointment or two with them, see how it feels, transfer then. I've transferred multiple times during multiple pregnancies under various circumstances. Billing and such gets straightened out, just keep track of appointments and what your insurance company says they'll cover.
posted by tilde at 10:43 AM on July 23, 2013

I wish I had listened to my intuition at the last minute after having a wonderful pregnancy... delivery was a nightmare and 2 years out I'm stilling dealing with the emotional and physical fallout.

RUN RUN RUN RUN RUN.

RUN.

PS! Congratulations & get out there and insure you have the birth experience you want:))

All my best to you and your family!!!
posted by jbenben at 10:46 AM on July 23, 2013 [1 favorite]

... 30 days notice to find a new office ...
posted by tilde at 11:06 AM on July 23, 2013

I switched OB's at 27 weeks (due to my OB yelling at me in the office, in front of his entire front office staff and a waiting room full of people, for trying to pre-book my appointments going 6 weeks forward. He said I was screwing up his schedule. Ugh.) I couldn't go into a labor and delivery situation with someone who would yell at me like that. And I recommend that no one should go into such a personal and emotional situation with someone that they are not 110% comfortable with.

If you feel now that something is just not-quite-right with your current doctor, listen to your instincts and make a change. Look, up until the last minute, you can always change back if you feel like you made a mistake.

With regard to birth plans, having been through it now I understand why doctors and nurses take it with a grain of salt, but doing a birth plan was helpful for us for two reasons. Number one, it forced my husband and I to talk about the details of our expectations of the event (for instance, I just assumed he would want to cut the cord. He wanted no part of that, as he knew he would be nervous and tired). Number two, it allowed my dr. and I to also talk about all of those details, and for her to elaborate on what she would allow and wouldn't allow, and why. For instance, she told me that for legal reasons she would not allow video-taping during the delivery (although she did, I think because our delivery was relatively uneventful), and we had a long discussion about epidurals, pitocin, etc. The point is, everyone's expectations were addressed beforehand, so there was no arguing or difficult conversations when everyone's emotions were running high.
posted by vignettist at 11:15 AM on July 23, 2013

Or (given that this woman seems perfectly nice and well-meaning) is there any magical chance that if I just have a nice reasoned sit-down with her and all my printed research articles (from good journals!), explaining why, in terms of the evidence, I don't want this and that, I can get her to consider altering her approach for me?

Why not first have a sit-down without the research articles? For context, I had the same concerns, but was also really open to pain meds (and got them). At one of my routine appointments, I just told my OB that I really, really wanted to avoid a C section and an episiotomy. I asked her if there was anything I could actively do to avoid these. She then described to me the circumstances under which she would think either of these were necessary. I could then gauge how much she viewed these as go-to procedures, and her answers satisfied me. I stuck with her, and did not have either procedure performed on me.

Congratulations, and good luck!
posted by pizzazz at 11:48 AM on July 23, 2013 [1 favorite]

Best answer: L&D nurse here, with experience in both midwifery-based settings and high-intervention teaching hospital settings. I now work in a place where there's one old-school private practice doc doing deliveries on the same unit as a small army of midwives. It's a very interesting perspective.

I guess the bottom line is this: do you want to risk having a potentially confrontative birth experience during which your husband and your doula are constantly at odds with the provider and staff? Do you want to argue for everything you want? If you stay with your current OB knowing that she prefers to utilize interventions that you would rather avoid, this is a possibility.

I would bet money that your OB would be grateful not to be part of that kind of experience, and your relationship with her will be more likely to be preserved if you choose to transfer care now and return to her postpartum for family planning services.

After many years of helping women have babies, I have very few strong opinions about the process by which women choose to deliver their babies. You want an elective c-section? OK. You want an epidural before you're really in labor? OK. You want to have your baby at home? OK. You want to have a baby in a hospital but want midwives and no IV and no pain meds and no Pitocin? OK. Do I think all of these things are universally good ideas? No, and neither does the evidence[1]. But the baby is overwhelmingly likely to come out vigorous and healthy, and you are overwhelmingly likely to be healthy throughout your labor, no matter what kind of experience you choose to pursue.

The variable here is whether or not you're happy with your experience. I strongly advise you to choose a provider that is more likely to share your idea of what a good birth experience is.

[1] She does routine episiotomies, still, in this day and age? Really? I furrow my brow.
posted by jesourie at 12:00 PM on July 23, 2013 [6 favorites]

I switched from an OB to a midwife at 30 weeks (a midwife I had prior experience with, even) and since it was in a hospital setting I still had to fight with a nurse over whether I was going to lay down for the 20 minutes of monitoring they required on admission. Nurse said yes, I....screamed.

That said, my midwife had my birth plan and when it came time for the show I delivered upright as I wished and I don't regret for a second switching providers.

Short answer: do it. If she asks you questions at your six week follow up, simply say you prefer less interventions but that you've always appreciated her services and that's why you'd like to continue as a postpartum patient.
posted by annathea at 1:42 PM on July 23, 2013 [1 favorite]

I would fire her in a heartbeat, but then I wouldn't want her as my doctor afterwards (or ever) either. Nothing offends me more than people stepping on my bodily autonomy. Why on earth would you even want to be in the same room with such a person, let alone trust her with your contraception or any other aspect of care, let alone birth?
posted by Violet Hour at 3:01 PM on July 23, 2013

Hi, I was pretty much you 3 years ago! I began feeling more and more like my OBGYN was not the person to deliver my baby. I also wanted to avoid a C-section/episiotomy (and IV and pain meds) at all costs except if the baby was in distress, and my OBGYN was not on board with certain aspects of my birth plan.

I switched from an OB/hospital birth to a midwife/waterbirth center at 35 weeks, so that part is totally fine and possible (though beware, both the old and new providers can do a "global bill" so you might end up paying more). The point I wanted to make here is I AM SO GLAD I SWITCHED. I ended up with a 74-hour labor and 11 hours of pushing. Completely natural, no meds and no tearing. If I had been in a hospital I would have been labeled "failure to progress" and pressured into a C-section. My recovery was much, much faster because I did not have the surgery, which is nice when you have a brand-new baby to look after.

Did I mention how glad I am that I switched? However I did not want to continue a relationship with that particular OBGYN, so all I did was have the waterbirth center notify the OBGYN of my decision to switch. If you want to continue a relationship, you need to talk to her about it. Good luck.
posted by rabbitrabbit at 3:41 PM on July 23, 2013

I can't read your Ob's mind, but Ob/Gyn's get fired all the time for any and no reason (I am not saying that you have no reason) including not getting along great with the patient. Many women feel the need to regain some control in their pregnancy and chose birth providers as they see fit. "I wanted a doctor for the prenatal care and postpartum follow-up but a less medical L&D environment" is a common sentiment that she will be familiar with.
posted by a robot made out of meat at 5:44 PM on July 23, 2013

Are you sure she's the only one who can do your birth control? Have you asked the midwives if they can do that too?
posted by dawkins_7 at 7:44 PM on July 23, 2013

Giving birth is one of the most intensive crazy 12-48 hours of your life. You want to trust and be comfortable around the person who will be delivering your child.

I switched at I think 31 weeks. I've heard of people switching later. I went to a birthing center and loved it. I called up the nearest midwife office, asked if they had an opening for my due date (luckily they did) and schedule an interview where they made sure I was really interested in a birth center birth and I made sure I liked the team of 3 midwives.

Like you, my OB was good, but I wasn't comfortable with her. I knew the moment I met my midwives and saw the birth center I was where I needed to be to have the best delivery I could.
posted by HMSSM at 8:30 PM on July 23, 2013

Insurance was no trouble at all to switch. I see my ANRP as my family "doctor" and she does pap's and birth control (though she can't do an iud, but gave me a recommendation for someone who could).
posted by HMSSM at 8:34 PM on July 23, 2013

Oh, and I've seen women transfer care as late as a week past their due date, to avoid an unnecessary "post dates" induction at another higher-intervention place. It's never too late!

If you do choose to transfer care, it's incredibly helpful to have a copy of your prenatal record to bring with you to your first appointment. It doesn't hurt to keep an additional copy in the bag you plan to bring to the hospital in labor, just in case communication between the clinic and the delivery unit is less than ideal.

Some offices can take a long time to process requests for a copy of the chart, so you might want to start now even if you haven't made your decision yet.
posted by jesourie at 12:44 PM on July 24, 2013