I need a high-risk OB. I want a midwife. How can I do this in Ontario?
September 8, 2016 12:46 PM   Subscribe

Due to my history of pulmonary embolism, I have been told I need a high-risk obstetrician to handle my prenatal care and delivery. However, I want the more hand-holdy and actually present approach of a midwife. But you have to choose one or the other. Is there a team-based practice or some sort that I can use? Or get a midwife first and then get them to bring in the OB, or...?

I am 4 weeks pregnant (conceived about two weeks ago). I have a history of PE and am on blood thinners for the duration of the pregnancy. I am on board with the fact that this is a specialty situation and I need a doctor. I am not anti-doctor or anti-science.

But I want someone who can actually get to know me and I can get to know to answer all my questions, to be there with me through early labour, to take a less hurried approach to the labour (i.e. not shoot me up with pitocin if the labour goes on more than 8 hours or I don't dilate 1 cm per 2 hours or whatever their guidelines are, but to wait and focus on taking the pressure off, as long as the baby is not in distress). And of course I want someone who will actually be there for the delivery (the OB might or might not be the one to deliver the baby -- whoever is on call that night would do it) and stay for the whole labour instead of just coming in at the end to catch the baby. And of course someone who is going to take the time through the whole pregnancy to answer my million questions.

Various midwife practice FAQs make it clear that you cannot have both a midwife and an OB. I get that midwives don't want to feel like they're some sort addendum and subordinate to the doctor. But you hear so much about "team-based healthcare." Surely there exists an arrangement where a midwife and OB work as a team. Does it? How do I get this? I have an appointment with my family doctor tomorrow so if such a practice exists, I can have her refer me there.

I want to give birth at Mt. Sinai hospital in Toronto.

Oh, and I know about doulas but I A) I want actual science, not just social support, and B) I want it pregnancy-long, not just for the birth and C) I do want someone who is going to have some authority to say "let's try massage instead of an episiotomy" rather than someone who can just hold me hand and go along with what the doctor says.
posted by anonymous to Health & Fitness (16 answers total) 1 user marked this as a favorite
Some midwife groups in Boston do work in conjunction with OB groups, so it's not that it's not always possible to have a midwife AND an OB, it's just the circumstances under which it is practiced.

In your case, I think it unlikely you would find a midwife willing to provide the bulk of your care. Midwives excel in uncomplicated, fairly normal, and routine pregnancies and births in all its variations. But when a risk is known that is out of their scope of practice (as opposed to an emergency that occurs in labor) in both a mother and the growing baby, they do tend to refer out for the safety of both to doctors who excel in those circumstances.

I assume that you have a primary care physician and/or a pulmonologist given your history. Why not start with them and see what their recommendations are and/or if they know of practices that are more in line with your needs?
posted by zizzle at 1:12 PM on September 8, 2016 [3 favorites]

Hi, high-risk pregnancy in Toronto veteran here. You definitely want Mt. Sinai's high-risk clinic.

I may have had special treatment but when I was giving birth after my first baby died due to a botched labour, my OB had me rotate through meeting all the OBs on call so that I would be comfortable with them during my delivery, and my OB nurse was amazing. This is something you can ask about and see if your OB is willing to do it.

The L&D nursing team is a different team than the OB nursing team, but they were great and supportive in both of the deliveries I had there, and I was in with threatened pre-term labour several times so met a whack of them. There was a poster of about 9 different pushing positions on the wall, along with a yoga ball, so no "lie back honey" tone AT ALL. In my two deliveries the OB was present for all of the pushing, but not for the pre-pushing phases. (But it was definitely longer than just catching. Except where it was a precipitous delivery.)

I can only speak to my experience but there was never any tone whatsoever of "just go along with what the doctor says" in my deliveries at Mt. Sinai; I was never rushed except when it was a true emergency, and the OB team made decisions along with my partner and I. If you haven't delivered before and are reading horror stories, I am happy to provide my two amazingly good ones from there for you (vs. the horrendous one at a Toronto in cough east end hospital).

I don't believe you can have a midwife deliver care unless it is a low-risk delivery; it's outside of their scope of practice and Ontario doesn't generally let you double up anyway. But I would encourage you to call and see if you can speak with the Mt. Sinai coordinator when you are putting the referral in to be matched with the right OB. They are a busy busy clinic so some of the early processes will feel impersonal but the actual care and delivery teams are great. It's more the ultrasound booking, etc. that gets to feel like a cattle call.
posted by warriorqueen at 1:29 PM on September 8, 2016 [9 favorites]

The way I would go about this is to request midwifery from whichever midwifery group it is you are interested in, and get in for an appointment, and explain your commitment to midwifery care. Presumably from your post, someone has already prescribed blood thinners, and arranged to monitor them. Your pregnancy care may actually be fairly straightforward, UNLESS you develop signs/symptoms related to either a clot or a bleed, in which case your care would go straight to Maternal Fetal Medicine (who are awesome at Mt Sinai), so don't discount using a midwife for at least some of your care. You would need to discuss the plan around the actual birth with both MFM and your midwife, who can better gauge your risks, but being on blood thinners does not equal a complicated delivery or an inevitable bleed (although it can impact risks for an elective epidural or a spinal for a C-section, so make sure you discuss the plan for pain management and whether you can come off your blood thinners for the delivery, so an epidural is safe). Other folks have commented that Ontario doesn't let you double up on a primary care providers, which is true, but you might be able to swing a midwife as primary with consultation with high risk OB.

I have a busy 5 year old watching some ridiculous thing on netflix as I type this, as proof that pregnancy on blood thinners is totally a doable thing. Feel free to memail me if you have questions.
posted by Northbysomewhatcrazy at 1:34 PM on September 8, 2016 [1 favorite]

I'd phone up the Ryerson midwifery program and ask them to recommend a group that works with high-risk women and Mt Sinai, they might be able to do that.
posted by jeather at 1:39 PM on September 8, 2016

I wanted a midwife; my husband really wanted an OB and since he was much more fearful about the whole pregnancy and birth scenario than I was, we went with an OB. I found a practice that I really liked – it was actually a team of midwives and OBs, but you still had to declare around 2nd trimester whether you were having a midwife or OB assisted birth. I always felt like I got the time and attention that I needed at appointments, and although the OB who attended our birth actually turned out to be one who I’d never met at regular appointments, she was awesome. I also loved our nurses. I ended up being induced, but without Pitocin (there are other options) even though that meant that the process took days. And even though my labor went long once it did get started, there was never talk of any further intervention.

Which is not to say that you should give up yet on your desire to have a midwife; I don’t know how practices work where you are. I just wanted to say that an OB attended birth can also be wonderful. If you don’t find a midwife, interview a few OB practices to find one where you feel at home. I think it’s possible to get most of what you want if you find a good office, and maybe all of what you want if you combine that with a doula.
posted by Kriesa at 2:04 PM on September 8, 2016

I had a (perfectly fine!) hospital birth and hired a doula. Doulas don't provide medical care (that's for your OB!) but ours did everything you describe. She met us a number of times beforehand to talk about the birth and get to know us and answer questions. She hung out with us during early labour and went back and forth to the hospital with us. She stayed during the whole labor and some time after, she asked the nurses the questions we couldn't think of, made suggestions when I couldn't think straight (yes/no Do you want to get in there shower?) she stayed and hung out with me and the baby while hubby got a sandwich, she cheered when bubs latched on right away. She was a great positive, supportive energy and did help with continuity of care (which was nice since I was in early labour a long time and didn't know the nurses etc).

I rang the doula college and hired a student and they asked me a few questions and matched us with someone - doulas come in all ages and all stripes... You might even ask your OB if there's anyone she recommends.

Happy for you to get in touch if you're in Sydney and have any questions or want to know who my doula was!
posted by jrobin276 at 3:31 PM on September 8, 2016 [7 favorites]

Do you know anyone else in your area who has delivered a baby recently? Could you talk to them about who they might recommend based on the experience they had? Seems like kind of a dumb answer but my OB was amazing and respected my every wish in the delivery room, even when it meant my laboring longer with fewer interventions than she would have had me try. I had a say in everything. I also had peace of mind that if it became an emergency situation, she was a surgeon with decades of experience and both baby and I would have been safe.

Based on my research on it for myself, there is a reason why women have for generations regarded OBs skeptically. However, OBs today are more and more in tune with treating a woman and her baby holistically and respecting her wishes. Just my two cents, as I am in no way a doctor or nurse.
posted by Pearl928 at 3:35 PM on September 8, 2016

Sorry, on preview I see you're in Ontario! Yes my doula did A, B, and C. It was pregnancy long, she was trained in childbirth - though not a medical practitioner, she's an environmental scientist so there was no woo, and she negotiated several things like C with the nurses and got good explanations when I couldn't anymore - but still cared and could still listen. I'm in Australia where it sounds like a similar set up; I couldn't have a midwife and an OB either. I started out in the hospital midwife centre and ended up getting transferred to the labour ward anyway. Doula was able to just tag along, which was awesome.
posted by jrobin276 at 3:37 PM on September 8, 2016 [1 favorite]

I'm in the US, so can't comment on Onterio/Canada specifics, but me mail me if you want to discuss pregnancy/labor on blood thinners, or just want a friendly ear to complain to about injecting yourself! Pain management during labor will probably be more complicated- if you're interested in meds, discuss whether remifentinal is an option at your hospital or not. Would type more but I have a fussy 3-month-old on me.
posted by Jaclyn at 3:42 PM on September 8, 2016

Seconding find a doula! I know some, but not in Ontario, and they provide what you want.
posted by mareli at 4:05 PM on September 8, 2016 [1 favorite]

1. Yes, a doula. And 2., high-risk OBs have a much more hands-on relationship with their patients than do regular OBs, and take these deliveries very, very personally.
posted by Capri at 5:40 PM on September 8, 2016

Yeah, you can have a more hands-on, involved OB, interview them! I go to a practice (in Illinois) that has both midwives and OBs in the same practice and you can pick which you prefer. (If you're midwifing it and things suddenly go wrong, it's a seamless handoff to the OBs, which is great -- you can choose a more midwife style of care but the minute there's a problem it all moves seamlessly to the surgeon.) Since the OBs in the practice obviously respect the midwife style of practice (or wouldn't be in that practice), they're pretty friendly to a more hands-on, hand-holding style of care. I went with a midwife my first pregnancy but ended up with an OB because of late-term complications, and he was great, took the handoff smoothly from my midwife and was very hands-on. I just used him for my subsequent two pregnancies and he's lovely. Sometimes I see him for routine GYN stuff and sometimes my midwife.

But interview! You can find out so much about doctors' style of practice with a 15-minute interview appointment!
posted by Eyebrows McGee at 6:13 PM on September 8, 2016

Mod note: From the OP:
Thank you everyone for the advice. I am slightly more inclined now to consider a doula and I'm also encouraged by the people who had good OB experiences, especially at Mt. Sinai. I want to clarify that I've been told not just to use an OB, but to use a *high-risk OB* specifically. That would mean one of the OBs in the Special Pregnancy program at Mt. Sinai, which means there aren't that many to choose from, and I think during actual labour they all work together/interchangeably so it almost doesn't matter who you pick. It's whoever is in L&D the day you go into labour. Anyway, I'm not sure asking about c-section or intervention rates is a useful question when dealing with doctors who do high-risk pregnancies exclusively. Obviously they'll be higher than average, but I have no possible way of judging if they're TOO higher than average.

And yes, I am already being treated by a hematologist and endocrinologist (the PE is just the biggest most-relevant bit of my complicated medical history). Those are both already at the Mt. Sinai special pregnancy program. They've been treating me since I started trying to conceive.

For those of you who have given birth at Mt. Sinai in particular A) Did you use the new birthing centre? Do I understand correctly that you get a big room to be in with your family during active labour with all the marvels one could possible want? B) I see that they want only two support people at a time. I would want two support people (i.e. two family members). I assume a midwife wouldn't count as part of the two, but a doula would, right? How enforced is this? I tend to find that hospitals only enforce the two visitor rule if people are being noisy or making a nuisance of themselves, but as long as you behave and stay out of the medical staff's way, they often let you have more (I woke up from one surgery with 14 family members by my bed at Mt. Sinai and nobody said boo about it). But maybe it's different in L&D?

I met with my family doctor today and she said to call the midwife collective that has admitting privileges at Mt. Sinai. So I did that. We'll see what they say, but the various reassurances here do make more more inclined to give up on the midwife idea, if I get a doula (I note that none of the "My OB was so wonderful" stories make any mention of the OB in early labour, or the OB coming to your home to teach you baby things post-natally...so I'd still be giving that up if I didn't get a midwife).
posted by restless_nomad (staff) at 6:53 PM on September 8, 2016

We did OB + doula at Toronto East General and it was fantastic. One of the huge benefits of the doula was her familiarity with that specific hospital. Having been present for several deliveries there, she knew all the ins and outs, and how things were done. She gave us a really accurate idea of what to expect, and answered a lot of questions like yours above. You'd be able to find a doula who has experience with high-risk at Mt Sinai, no problem.
posted by DrJohnEvans at 7:16 PM on September 8, 2016

I don't think that in your particular situation, you are going to get everything you want: individualized attention from one practitioner for your entire prenatal, labor, delivery & post-partum, PLUS the high-level medical expertise that is crucial to getting you and your baby out alive and healthy from this high-risk pregnancy. High-risk OB plus doula is your best bet.

I don't know how it works in Canada, but in the US, the midwife does not stay with you the whole labor or follow up with you at home -- at least, not the actually trained hospital-based midwives that you need. If you went to a poorly qualifed home-birth midwife, you'd get the kind of intense personal care that you describe. BUT it would come at the cost of the medical expertise you need.

The reason for this is that medical experts concentrate on medical care. That model does not permit them to provide in addition the kind of emotional support that you want. For the emotional support, you should look elsewhere.

Luckily, the doula profession is well developed and well respected now in most places. I'm certain you'll be able to find a doula who will give you the emotional support you're looking for during your labor and delivery, and post-partum.
posted by yarly at 6:42 AM on September 9, 2016 [1 favorite]

I've been pondering your follow-up questions a bit. I will lay my bias out on the table. My first child died. My third was in the NICU himself. I had a whack of pregnancy drama with my middle and youngest children's pregnancies, although one of those deliveries was super easy.

I was not treated with dignity in my first labour, especially after things went so wrong. I am totally an advocate for excellent obstetrical care.

But due to my experiences, I do lean a bit towards "what is important is a healthy baby and a healthy mom" and away from stuff like what the room you spend probably 24 hrs of your life in is like.

So from that perspective...A) I wasn't in the spiff rooms i don't think (2010) but they were big and had room to move around and most importantly large enough for a whole crash team to be brought in when needed.

B) For support in early labour, unless you're on a monitor for a particular reason (which I realize could happen) you can totally walk around the hospital. You may not even be at the hospital depending on your OB's orders. So I don't know if I would worry too much about the limits for who can be there because everyone may be able to come and go, including you (I walked all around the main floor.) But it is totally worth asking about a doula + two people, why not find out?

C) Just reiterating that I was _so_ supported by the team at Mt. Sinai - starting with my ob (Dr. Seaward, who is not however a touchy-feely guy) and I am a fan in particular of Dr. Maxwell, Dr. Keunen, & have a personal connection to Dr. Spitzer which makes me think she would be great as well. And many more whose names I was not retaining at moments of stress. I seriously never had an ob or a nurse that I did not feel was working hard for me.

But I also owe my youngest child's health to the LC who took a blood test for him at his 6-day checkup, waited for the results, and then rushed us to the NICU - I mean rushed - and we had amazing care there from the neonatal nurses and doctors. I owe some of my mental health at the time to the warm and caring nurses on the antenatal unit when I was hospitalized at 22 weeks, and at 26, and...I hope you do not need that level of support and the stats are really that you will not!! But if you do, it's a great team all the way through.

D) I think the books and talk online really focuses on early labour and interventions and that's fine because it's a common part of the experience and it's what we have to talk about. And I wish I could not say this but I am me and I do have to say it: that's fine but if you are possibly going to have serious issues, what really, really counts is all the other stuff.

E) For aftercare, a pediatrician for questions and a doula for baby care is a pretty good combo too.
posted by warriorqueen at 4:14 PM on September 9, 2016

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