Doctor Who?

In many Twin Cities clinics, continuity of prenatal care is a thing of the past.

Some women who want a continuous advisor throughout pregnancy and childbirth hire a doula, or supportive layperson. Minneapolis doula Lisa Perez says she acts as a "resource and friend" for the pregnant woman, meeting regularly with her prenatally, attending the entire labor and birth and visiting her postpartum. During the labor, when the woman may not know the medical personnel in the room, "I provide encouragement, support, compassion, and a belief in the work of the body, that the body can do this," Lisa says. "I can provide relief, whether physical or comic, and a positive, continual presence." Allina Health System has begun integrating doulas into its delivery rooms, including at Abbott Northwestern Hospital.

Certified nurse midwives

Like the physician clinics, none of the nurse midwife groups in the Twin Cities promise that a woman will have a particular caregiver for her delivery. CNMs also vary in how they provide prenatal care.

At some clinics, such as Park Nicollet Meadowbrook, HealthEast OB-GYN, and Fairview-Riverside Women's Clinic in Minneapolis, pregnant women are asked to rotate through the midwife group during prenatal care. "With our group of seven nurse midwives, that gets to be a bit of a challenge. But most of the time patients do meet most of us," says Karin Hangsleben, CNM, Fairview's director of nurse midwifery. At the HCMC clinics, prenatal patients rotate through only two or three nurse midwives. Patients at the HealthPartners clinics can expect to see the same nurse midwife for each visit. (The Allina clinics do not employ nurse midwives.)

Most midwife clinics that normally encourage prenatal visit rotation will honor a patient's request to see certain providers. Often it is up to the patient to make this happen. When Kirsten Allen went to Community Nurse Midwives at Riverside in Minneapolis for her second pregnancy, she met each of the CNMs once and then scheduled the rest of her prenatal appointments with the ones she liked. "I knew who I wanted the relationship with," she says. "The ones I didn't like, I just avoided."

Carrie Frantzich, a CNM with HealthEast, advises women to find a midwife they are comfortable with at the beginning of pregnancy, see her a few times, and then in the middle of pregnancy rotate through and meet a few more of the clinic's midwives. At the end of pregnancy, when visits become weekly, Frantzich thinks it's a good idea to try and see the midwife who was seen in the beginning. "If you go past your due date, it's really helpful to be talking about that to the midwife who originally determined your date of conception," she says. "Also, if a woman is at risk of preterm labor and we are deciding between bed rest or medications or hospitalization, having the same midwife check her cervix at each visit helps in finding subtleties of change. This can help to avoid an intervention, like hospitalization."

Bonding in labor

Because of the call-group system for deliveries, a woman may not know the midwife who attends her birth. However, unlike most physicians, nurse midwives usually spend several hours with a laboring woman prior to the delivery. "Midwife means 'with woman,'" says Claire Nelson, codirector of nurse-midwife services at HCMC. "It's part of our nature to be with someone when they are in labor and watch the process unfold."

Hangsleben says that "when the patient comes in to the hospital, the midwife spends the time needed to get a sense of who she is and what she wants from the birth experience. Maybe it's not as personalized as if you saw her for nine months, but it's pretty good."

In Frantzich's experience, "[midwives and patients] bond very quickly in labor. You are at the woman's side laboring with her for hours, and it's very intense and emotional and real. You just cut to the chase and bond." Claire Nelson of HCMC agrees that "the real intimate support midwives give in labor means that the woman isn't losing a lot if she hasn't met the midwife before." Lisa Perez says she has also seen laboring women bond with physicians they hadn't met before.

Many midwives will ask their patients to write out a birth plan that states their preferences for labor and delivery, including use or avoidance of medications and other interventions. "All of this will be down on paper so if the woman has a midwife she hasn't met for labor, she won't feel like the midwife doesn't know her desires," Claire Nelson says. Birth plans are rarely encouraged with physician-attended deliveries.

Women who really want to have a particular midwife for their delivery can try to "time" their labor to coincide with that midwife's call schedule. Nancy Nelson says a woman near her due date can try various natural methods to stimulate uterine contractions and begin labor, including drinking raspberry leaf tea, having intercourse, and stimulating the nipples. Carrie Frantzich says if she and a prenatal patient connect well in the clinic, she will tell the patient when she will be on hospital call. "It's amazing how many women will actually go into labor then! There's a real strong mind-body connection," she says. Kirsten Allen got the call schedule for the month she was due and says she "willed" herself to have her baby when her favorite midwife was on duty.

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