Your Guide to Answering Early First Trimester Decisions

Male or Female Doctor?

There is no gender-specific advantage in knowledge or skill when it comes to obstetrics. In providing medical care for women, a consensus has been emerging that women do it best. The truth is that it's a great irony that the gender focused specialty of OBGYN is gender neutral when it comes to the best doctors. Being of the male persuasion (I was persuaded at my conception), I've had to suffer from the competitive edge female physicians hold over me in the marketplace. It's a great conspiracy against us male doctors in that smart female physicians don't downplay it, and male physicians themselves tap into it when interviewing a prospective associate who has been screened for the Aright marketable gender. The media propagate this thinking: I went to my gynecologist and she told me that.

For all things gynecological, politically correct commercials assume that your gynecologist is a woman. But on the ads for gastritis, diarrhea, and constipation, "My doctor, he said to take ____"

I've known women who have actually gone out of town to see a woman doctor who was not as good as the male doctors in her hometown. (Of course, tell a man to see a woman urologist and the bells of chauvinism ring even louder.) This type of thinking can get ridiculously distorted even further. Once I had a patient whose husband made her switch to another male doctor because he had five children. Since I had only four, the husband assumed he was probably more of a family man and therefore less likely to look upon his wife in that way. Men! What can one do?

So male or female? Who is the best obstetrician to go to? You're probably already going to him. Or to her, of course. The best obstetrician for you is the doctor who has proven to be the best gynecologist for you. The point is that if you trust your doctor -- male or female -- when you need a gynecologist, you should be able to trust your doctor when you need an obstetrician. They're the same people.

Admittedly, if you're choosing a doctor for the first time, this difficult decision is all the harder when it means selecting an obstetrician, because this special kind of doctor must treat two patients simultaneously, you and the child you're carrying. But the sum of the expectant mother and the expected is more than the mere addition of the parts, because there is a third entity, the pregnancy itself, which is that symbiotic relationship between mother and child. This third entity has it's own type of respiratory system, circulatory system, and nutritional exchange. For that brief time which is the duration of gestation, there is a different anatomy altogether, which is the combined mother-child. But this is only the tip of the iceberg.

To relate properly to an expectant mother (and father), an obstetrician must be able to relate to all kinds of entities; the mother and father individually, the married couple, the developing child, the pregnancy relationship between the mother and child, and the pregnancy relationship among the mother, father, marriage, and child. It can get fairly crowded in this psychodynamic exchange. But the most important relationship is that of the mother and child, for there are diseases of just the mother, diseases of just the fetus, and very strange medical complications that are the result of mother and fetus together.

A lot of this is book knowledge for sure, but there has to be insight as well, because as the mother-to-be, thinking is altered as well. Ovarian, pituitary, thyroid, and adrenal hormones jive together with your fervent hopes and dreams to create another thinking and emotional species altogether—the mother-and-child—the pregnancy—a dynamic metabolism honed over the span of evolution to produce a miracle nine months later. Emotional and behavioral aspects of your personality underscore a maternal instinct that comes from deep inside the primitive human brain.

So how does that affect the selection of your doctor who will mastermind your prenatal care?

Whether male or female, this doctor had better be perfect.

At least in your eyes.

Everyone realizes that perfection is an unattainable ideal. But different couples have different priorities as to what constitutes an "acceptable" level of perfection. You may want the hand-holding type of doctor who will do all the worrying for you, taking both of you through the prenatal course in a mystic cloud of vague pronouncements of well-being. You may want the opposite, a Carl Sagan who will explain the millions and millions of details, pointing out all of the risks and benefits of every option pregnancy has to entertain. You may even want a pal, somewhere in between the first two types, but with enough empathy to struggle with you over a particular decision.

All of these types have successful practices because they attract adequate numbers of patients who seek them out because of their specific approaches. But all obstetricians hope to blend the three types perfectly so that the care is knowledgeable, caring, trustworthy, and endearing.

It is sometimes unfortunate that choosing an obstetrician may be not so much a search for one doctor but an escape from another. Being both an obstetrician and a father, I've had ample opportunity to consider the intricacies of what's important in an obstetrician-patient relationship. A lot of my training in this insight comes from the mistakes of other obstetricians. If you leave one doctor, you no doubt will be switching to another. You new doctor will be smart to listen to the reasons you switched to her and she will incorporate safeguards into her own practice based on what she can learn from you:

"I called my doctor for three days and he never returned my call."

"There are several doctors in the practice, and they all tell me different things."

"I asked my doctor about this and she just blew me off."

As a pregnant woman, you want the best for your unborn child, and you'll usually know after a first visit whether a certain obstetrician's for you. Besides our board exams, we OB doctors must also pass the maternal instinct.

Groups, Solo Doctor, or Midwife?

Whether you seek a large group practice or a solo practitioner, there are trade-offs no matter what the flavor. Large groups tend to have a wide variety of personalities to choose from while maintaining a consistent quality of medicine. The many doctors keep each other sharp, and these are the ones most likely to keep up with the medical literature in a timely manner. A large group is also more likely to have subspecialists easily available, because the volume of patients can justify the expense of a consultant on the payroll. But this volume also tends to depersonalize your experience. You may not see the same doctor twice in a row, which can be disturbing while being followed for a problem that may span several visits. Also, this is that exact type of situation that will have two doctors advising two different things. On the other hand, coverage for emergencies is usually better in a large group, the shared "on-call" schedule is so infrequent for a particular doctor that she is well-rested, fresh, cheerful, and keen. The flip side of this is that your baby may not be delivered by your chosen doctor. Perhaps not even a doctor at all.

Midwives have been successfully attending deliveries for thousands of years. Today's certified nurse midwives work in hospitals and are backed up by obstetricians in case of complications. I myself like midwives. A midwife walked me through my very first delivery, and it was a technique I have maintained all of these years. (She later went on to become an obstetrician, mainly out of political frustration.) In my opinion, a normal vaginal hospital or birthing center delivery, attended by a certified nurse midwife, backed up by an obstetrician, is as good as a delivery by an obstetrician. It may even be better, since midwifery entails more of a total psychodynamic approach. Large groups are usually the ones employing routine use of midwives.

The small group or solo practitioner won't be as swank as the large group, but you're liable to spend much more one-on-one quality time with the same doctor throughout your pregnancy. Also, since there's usually a financial penalty when another doctor covers for her and delivers your baby, you're more likely to have her at your delivery. But she'll be running late for many of your appointments, at the mercy of her other patients who may be laboring during the office hours you were scheduled for.

How Qualified Is Your Delivery Person?

The safety of your pregnancy depends on the quality of person to whom you're entrusting your baby, his eighty years or so of life, your own life, and…. You get the point. Is there any certification your midwife has passed, or is she some sort of grandfathered (grandmothered?) provider? What amount of continuing medical education has she taken in the last two years? Does she have the official back-up of an obstetrician ready to take you on as a surprise obstetrical complication? And if so, does that doctor have an arrangement to deal with this sort of thing with other doctors should he be off? Or are you on your own if you need transport to a hospital nearby, taking pot luck with whatever doctor is on the indigent A life-and-limb unassigned patient list for that day? How heroic is she when it comes to pulling off that difficult vaginal delivery she sees as a victory, and does this victory conflict with what's best for your baby? What is her protocol with fetal assessment during labor and how well does she respect signs of fetal distress, like meconium?

If you're not comfortable with any of her answers, that's your maternal instinct flaring its nostrils. If her answers are well thought-out and give reasonable explanations, then the only peril left to deal with is the controversy over home delivery.

What's the Best Hospital for You?

The greatest doctor or midwife in the world will be inadequate if the facilities are, too. The ideal hospital for pregnancy, labor, and delivery is one that has in-house anesthesia, a Level III neonatal nursery (that designation that can handle anything), neonatologists to run the Level III nursery, nursing personnel whose numbers aren't continually adjusted based on the hospital census, private rooms that transform themselves for labor, delivery, and recovery (LDR rooms), pediatric cardiovascular and neurosurgeons, and protocols intuitively sensitive to your needs. There are only a couple of hospitals that meet all of these criteria. One is in Shangri-la, the other is in Oz.

All of this stuff costs money. With the diminishing reimbursements to hospitals by third party providers, cost containment has made this type of hospital very unlikely. Some endowed large city centers come close, but gilded edges tarnish very easily.

We're talking trade-offs here, right? Not your baby, we're not! Well...maybe.

So what are the deal-breakers? If you can't have it all, what should you have? Twenty-four hour in-house anesthesia is an assurance for safety, which can't be replaced. If you have anesthesia available to you any time, even at three in the morning, that means that there's C-section readiness should your baby take a bad turn during your labor. It also means that you can have your epidural immediately if you decide that Lamaze is for the birds, that you hate your husband, the callous brute, and that jumping out of the window might seem reasonable.

There should be at least a Level II nursery, which has a neonatologist who can take action when surprises happen. A good Level II nursery can handle a lot of difficult situations or at least stabilize a baby for transport to a Level III nursery should the need arise.

You have many decisions so you should keep in mind that it's not how you have the baby as much as it's how you raise that baby.

Besides studying up on pregnancy, you might also start training for parenting, because after you have your baby, your obstetrician's job is over. Yours is just beginning.