Doctor vs. midwife

The differences in care provided by a doctor vs. a midwife (especially a homebirth midwife) were on full display at Q's follow-up ultrasound today.

When C scheduled the appointment on Monday, she warned me that she might not be able to come, as it was at prime school pick-up time (3:45 pm) and she lives all the way on the other side of the city. I was a little worried, because my husband couldn't come, either, and while I had a feeling everything would be fine, I really didn't want to face bad news on my own. Well, C called me last night to say that she had made arrangements for her kids so that she could be at my ultrasound! I was so relieved that I almost cried.

The ultrasound was with the same perinatologist who did Q's NT scan. C beat me to the office. When I arrived, I checked in, and the receptionist said that they had no record of my appointment. Say whaaaaa...? Luckily, they were able to just add me to the schedule.

Perhaps due to the appointment confusion, we had to wait about 30 minutes to be seen, so C and I passed the time chatting in the waiting room.

Finally, we went back to the ultrasound room. (No Barbie cars in this one.) The nurse asked me if I knew the baby's sex yet and I said no. She asked if I wanted to find out and I said no. She said, "OK, well, the doctor will look anyway and it will be in the ultrasound report." Sigh.

The perinatologist breezed in. He appeared to have no clue who C was and why we were there -- again, perhaps due to the appointment confusion, or perhaps because he just didn't care. So, he basically repeated the entire anatomy scan from Monday. He did explain what he was looking at, but was very businesslike about it.

When he got to the right kidney, he noted that it was dilated. Duh. He asked the nurse about my Down's syndrome risk from the NT scan. I guess this problem can be a soft marker for Down's, but since I had the NT scan done and my risk was very low, we know it's highly unlikely that the baby has it. He explained that the extra fluid doesn't look serious, and will likely resolve itself in utero as the baby grows. We'll continue to monitor it via ultrasound, and if it doesn't resolve itself, we'll just need to follow up with our pediatrician to get the baby examined after the birth. It could eventually require surgery, but it might also resolve on its own post-birth.

Then he asked (again) if I wanted to know the sex, and I said no (again). He said, "OK, we'll, I'm going to scan that area now, so look away." He did this at the NT scan, too. I'm not sure why he's so obsessed with my baby's genitals.

He concluded by reminding me to schedule another ultrasound in three weeks and to follow up with "my doctor" to do the AFP test (a second trimester blood screening for Down's and other chromosomal abnormalities, which I have no plans to do). Clearly, no clue who C was. Oh, and he asked once again if I wanted to know the sex... seriously? NO! C quietly said, "Surprises are the best." Love her.

And then he and his nurse left. The entire visit lasted perhaps 15 minutes. Maybe it would've been 14 minutes if I hadn't been asked about finding out the sex three separate times.

C told me that she could give me some more information, so I checked out and got the next ultrasound scheduled, and then we stepped out in the hallway.

C started off by saying, "That's the best possible outcome!" We spent about 15 minutes discussing it all. In short, even if the issue doesn't resolve in utero, I can still do homebirth. The only thing that would necessitate a transfer of care would be if my amniotic fluid gets low, which can happen when the kidneys aren't processing properly. But my fluid levels have looked great at both ultrasounds, and so C thinks it won't be an issue, especially since the left kidney is fine. We both laughed at the perinatologist's genital obsession... C knows we don't want to know the sex (I don't have to tell her multiple times per appointment) and so she has taken care to look away at the appropriate times as well. Because if we don't want to know, she doesn't want or need to know, either.

Once all my questions had been answered, I thanked her for taking the time to come, she said she was happy to and gave me a hug, and we went off to pick up our respective kids.

And that, in a nutshell, is why I'm thrilled that I'll be able to stick with midwifery care.

Anatomy scan

The anatomy scan, or "big" ultrasound, is usually performed between 18-22 weeks. It's an in-depth look at every aspect of the uterus and the baby's anatomy, attempting to identify any abnormalities or other concerns. This is also traditionally when parents find out the baby's sex, if desired -- although these days, a lot of people do elective gender ultrasounds around 16 weeks, or even get a gender guess at the NT scan.

With Littles -- January 16, 2007 (20 weeks)

Although my OBs had ultrasound equipment and were able to use it, they sent me to a different office to get the anatomy scan done with an ultrasound tech. I don't know if that was for scheduling purposes (since the anatomy scan typically takes a lot longer than the average OB appointment) or because the ultrasound equipment in that office was better or what.

Anyway, I didn't mind, because the ultrasound tech was fantastic. He really took a lot of time to explain what he was looking at, which was helpful because I don't know about you, but even after three pregnancies, ultrasound pictures usually remind me of those "hidden picture" books where you have to really squint and turn your head just the right way and then bam! oh OK, I see it now :)

We did choose to find out the sex at this time. I'll probably do another post on that whole decision.

With Noob -- September 15, 2009 (20 weeks)

The anatomy scan was done at my midwives' office, although not by either of the midwives, because they aren't able to do ultrasounds. Instead, it was done by the same ultrasound tech who did Noob's initial dating ultrasound. I was unimpressed by the tech's bedside manner at that first ultrasound, and the anatomy scan was no better. It was a lot faster than the scan with Littles, because the tech just did the scan, barely explaining what she was looking at.

We elected not to find the sex with Noob. I'm not sure how much that played into our experience. At certain points, the tech asked us to look away to avoid accidentally getting a peek at the genitals, so we weren't able to look at everything like we had with Littles. She may also have been reluctant to do anything beyond what she had to do, to avoid the chances of another accidental peek.

I'm also not sure if the tech could say very much. At some offices, ultrasound techs aren't really able to give the patients the results (good or bad) directly; they simply take pictures and pass them along to the OB for review. So that might have been the case here.

Regardless, it was fine, but definitely a bit of a letdown from our experience with Littles.

With Q -- February 20, 2012 (20 weeks, 6 days)

C sends her patients to a local women's center for the anatomy scan. Must be interesting for them to get C's patients in there, since I'm guessing that many of the scans they do are for women with an unplanned pregnancy who are considering abortion...

We decided to bring Littles along, and it was a really nice setup for her. Unlike the ultrasound rooms where we'd had Littles' and Noob's anatomy scans, this one was clearly designed with the idea that women might bring their kids along. There was a stool for Littles to stand on to get a good look, and lots of toys to play with if/when she got bored of watching the confusing images on the screen. Littles hung in there for a good 10 minutes or so, but she quickly discovered the hot pink Barbie toy car, and that occupied her for the remainder of the scan.

Another difference from the previous anatomy scans was that C was there. (For the other scans, it was just my husband and me with the ultrasound tech.) This turned out to be a good thing, as during the scan, there was a problem identified with Q's right kidney. C was able to look at the ultrasound side-by-side with the tech, rather than relying on pictures after the fact. She was able to discuss the implications with us immediately, in person, rather than waiting till our next appointment or calling us on the phone. And within 10 minutes of the end of the appointment, she had me scheduled for a follow-up ultrasound with a perinatologist to get a better look at the kidney and determine a course of action.

Of course, I would have preferred to have had a totally normal scan, as I did with Littles and Noob -- but if I had to pick one of the three anatomy scans to be abnormal, it would have been Q's for sure, due to C's calm presence.

The follow-up ultrasound is tomorrow, and I'm hoping to get some better answers as to what's going on and how big (or small!) of a problem it is. Right now, we just don't know.

A typical prenatal appointment

If you've never been pregnant, I'll let you in on a little secret: Prenatal appointments are boring. (At least, you hope they are.) At this point, on the third time around the block, my husband doesn't even come to most of the appointments, because honestly, there's no need. I'd probably skip them too if I weren't physically required to be there :)

Anyway. There are 5 things that are typically checked at prenatal appointments:

1. Weight
2. Blood pressure
3. Urine test
4. Baby's heartbeat via doppler or ultrasound
5. Later in pregnancy: fundal height measurement (size of your uterus) and baby's position (vertex vs. breech) via abdominal palpitation

Pretty basic, right? How much variance can there be between providers? Well... a lot.

Let's say I have a prenatal appointment at 2 PM. How would that appointment have gone in each of my three pregnancies?

With Littles
2:05 PM - I arrive at my OB's office. (My dad likes to joke that I was born two weeks late and I've been late ever since. He's right.)

2:15 PM - I'm called back. A nurse directs me to the bathroom to give a urine sample, which I leave at the lab for testing. She then checks my weight and takes my blood pressure.

2:20 PM - I go into the exam room.

2:30 PM - Enjoying a year-old issue of People.

2:45 PM - Since this is 2007, I don't even have a smartphone to use to surf the Internet. Sucks.

2:50 PM - My OB finally arrives. He or she lets me know that my urine test looked good, my blood pressure is excellent, and my weight gain is right on track. I'm asked a few questions, like whether I'm feeling the baby move and whether I'm having any contractions. I'm given the opportunity to ask questions, too. As a first-time mom, I usually try to come up with a couple, at least.

2:55 PM - I hop up on the table and the doctor examines my belly. They don't have ultrasound machines in the exam rooms, like some OBs do, so we listen to Littles' heartbeat on the doppler.

3:00 PM - Appointment done.

With Noob
2:05 PM - I arrive at my midwife's office.

2:10 PM - I'm called back. A nurse directs me to the bathroom to give a urine sample, which I leave at the lab for testing. She then checks my weight and takes my blood pressure.

2:15 PM - I go into the exam room.

2:20 PM - My midwife comes in. She lets me know that urine/blood pressure/weight gain look good, and asks me questions about how I'm feeling. I'm given the opportunity to ask questions, too. Even early on, I usually ask at least a question or two about labor/delivery. It's important to me to make sure my midwives are on the same page as me regarding topics like induction for postdates, eating/drinking during labor, etc.

2:35 PM - I hop up on the table and my midwife examines my belly. No ultrasound machines here, either -- the midwives aren't able to do ultrasounds anyway -- so doppler it is.

2:40 PM - Appointment done.

(As an aside, I wondered if the promptness and the willingness to spend time/answer questions was simply a difference between the practices I saw with Littles vs. Noob, rather than a difference between OBs and midwives. Well, I had one appointment during my pregnancy with Noob where I was required to see an OB in the same practice as my midwives -- office policy. And it went pretty much identically to the OB appointment I described above, with Littles. The OB was about 45 minutes late and then was literally walking out of the room as I was asking a question. Ironically, I ran into my midwife in the hallway afterwards, and spent more time chit-chatting with her than I had spent during my entire appointment with the OB. So I guess it wasn't a difference between practices...)

With Q
2:05 PM - I arrive at C's office. She's there and waiting for me. She hands me a cup and a dipstick to do my own urine test. Littles comes with me.

2:10 PM - Urine test done. Littles is fascinated by all the colors on the dipstick and asks what they're for. I have no clue, so we both ask C when we get back. C patiently goes through each one with us. I knew from my previous pregnancies that she was looking for protein (possible sign of pre-eclampsia) or sugars (possible sign of gestational diabetes) in my urine, but C shows us that there are also tests for illness, healthy diet, etc. I have no idea whether my previous providers did all those same tests. I never asked and they never told me.

Everything looks good, except I do have some sugars in my urine. C notes that that's unusual for me and asks me what I ate today...

Me: I had yogurt and cereal for breakfast, and a cheese sandwich and an orange for lunch. Oh! And some crackers.

C: Hmmmm. I guess the sugars could be from the orange. Well, we'll keep an eye on it. *pause* No soda or candy?

Me: No. Oh wait! Yes. I had some gummi worms at lunch, too.

Busted :)

2:15 PM - C asks me how I'm feeling and then asks about our recent trip to China. "They have toilets you have to squat over!" Littles exclaims.

2:20 PM - Littles regales C with tales of our adventures on the Great Wall of China.

2:25 PM - Somewhere in there, C sneaks in a blood pressure and pulse check, and we also chat quickly about my nutrition.

2:30 PM - Littles entertains both of us with her theory on umbilical cords: "The baby can get ice cream through the umbilical cord, but not the cone. It's too big. It won't fit." C smiles. "That's a new one!"

2:35 PM - I make a coloring book for Littles to take to each appointment, with pictures of various pregnancy- and baby-related things. For today's book, she specifically requested a picture of a uterus. Okay. I found a picture online, so we spend a few minutes talking about the uterus, ovaries, and cervix. "My uterus is empty!" Littles proudly tells C. Thank goodness. I hope to keep it that way for many years to come.

2:40 PM - C directs me to the scale in her closet. I step on and call out the number to her.

2:45 PM - Littles has moved on to discussing the fact that Noob threw up this morning at the dentist's (hence why he wasn't at the appointment) and that she's seen two of her classmates throw up as well. "It's a potty humor kind of day, huh?" C remarks with a smile.

2:50 PM - I hop up on C's exam table. Littles stands right near my head. She told me last night that this is her favorite part. C squeezes blue ultrasound gel on my belly -- all the kids know about C's "blue goo," and so when her supplier stopped carrying it a few months ago, she found another supplier that did. She quickly finds Q's heartbeat, and follows Q for a minute or so as s/he moves around my belly. Littles listens intently, amazed by the sound.

2:55 PM - A little more chit-chat as we schedule my next appointment.

3:00 PM - Appointment done.

In summary
They all did the standard stuff, but...

• My OBs were much more likely to be significantly late.
• My midwives spent more time with me at each appointment. Especially C, my homebirth midwife. I joked that I probably spent more time with C during my pregnancy with Noob (after switching to homebirth less than 4 weeks before his birth) than I did with my previous hospital-based midwives during the first 36 weeks of that pregnancy, and with my OBs over my entire 42-week pregnancy with Littles. Well, it wasn't really a "joke;" I'm pretty sure it's the truth.
• Thanks to all the time spent together and random chit-chat, I have a much more personal connection with C than with any of my previous providers. She even came to Noob's first birthday party :) I know that some women don't want that personal connection -- they want their doctor/patient relationship to be more professional -- and that is totally fine. But it's something that's very important to me.
• Besides just giving me more time to ask my own questions, C also probes me more for information, going beyond standard baby-related questions ("Are you feeling the baby moving?") to ask about nutrition, sleep, stress levels, etc.