by Craig L. Bissinger, MD, FACOG
I am constantly amazed at how little attention pregnant women pay to their choice of physician and hospital. To me, this decision sets the tone for the entire pregnancy and birth experience. Not all physicians or hospitals are alike! There are major differences in the way doctors and hospitals approach pregnancy and delivery. I'd like to spend the next few minutes making you a savvy consumer.
Picking Your Hospital
Perhaps you will be surprised when I tell you that the hospital is the most important choice you will make with regards your pregnancy. Hopefully, the following example will give you some insight. A cardiologist is at a concert when suddenly, someone has severe chest pain. The doctor is asked to help out but doesn't have any medical equipment with him or her. The doctor can do little besides comfort the person until the proper equipment arrives. This is analogous to the predicament the obstetrician is confronted within certain hospital settings.
Since the physical appearance of each hospital may be similar you need a more sophisticated approach to assess them. You cannot rely on a hospital's overall reputation either. Some hospitals may have a great reputation due to their heart bypass program. Others have excellent transplant programs. While these institutions are to be commended for the fine service they provide, as a pregnant woman, you need a hospital with a good reputation in Obstetrics. The first key ingredient to look for is the ability of the hospital to care for newborns. This is a critical issue for an expectant mother. Despite our best efforts, some babies are delivered prematurely while others have significant birth problems. These babies must be cared for at hospitals with more expertise and resources in treating these problems.
Understanding Hospital Classification
Hospitals are given a classification based on their ability to care for newborns. Each hospital has one of four designations:
• Basic (a.k.a. Level 1) - can deliver mothers who have completed 37 weeks and have babies over 2500 grams (approx. 5 ½ pounds)
• Intermediate (a.k.a. Level 2) - can deliver mothers at or beyond 32 weeks who have babies over 1500 grams (approx. 3 ½ pounds)
• Intensive (a.k.a. Level 2+) - can deliver mothers at or beyond 28 weeks who have babies over 1000 grams (approx. 2 pounds)
• Regional Perinatal Center (a.k.a. Level 3) - can deliver any mother and any baby regardless of the circumstances. These are typically academic institutions or large hospitals that are the referral center for an entire region. In my home state of New Jersey, there are seven hospitals that meet this stringent classification.
The following example will quickly allow you to realize the importance of the hospital classification for newborn care. A woman comes to a Level 1 hospital in advanced labor. She delivers her baby eight weeks before it's due. There is no pediatrician at the hospital, even though the baby needs urgent care. A call is made to the closest referral hospital. They agree to send a team to pick up the baby, but will not get there for several hours! During the interim, a local pediatrician is called to come in and help stabilize the baby. We all would agree that this situation is less than optimal. Ideally, this woman should have been sent to the closest hospital able to handle her baby's special needs. This institution would have a special care nursery and neonatologists, who are specially trained pediatricians who treat premature and critically ill babies.
The Importance of Anesthesia
A second critical issue that needs to be examined when choosing your hospital is the anesthesia. Most women assume that epidural anesthesia is available upon demand. However, this is not the case throughout the country. Some smaller hospitals do not offer this type of pain relief whereas others will offer it on a limited basis. In some instances, hospitals will only offer epidurals during the day while the anesthesiologist is available. At other institutions, women will only be offered an epidural once they are in advanced labor (you could be in labor for many hours before becoming eligible). In either case, your pain control needs may not be handled to your satisfaction.
The ideal hospital has a full-time dedicated anesthesiologist or nurse anesthetist assigned to the labor and delivery area. In this way, laboring mothers can have pain relief based upon their need, not convenience. I can't tell you how many patients have come to my practice after having had their first baby at a hospital that offered anesthesia only to women at an advanced stage of labor!
Another major benefit to having in-hospital obstetric anesthesia is the ability to do an emergency c-section in a timely fashion. According to the standards of the American College of OB/GYN, an emergency c-section should be performed within 30 minutes. Often, delays longer than this are due to the lack of an available anesthesiologist. Even if the "30 minute standard" is met, can you imagine waiting an extra five minutes for an anesthesiologist to arrive if your baby is in stress? Believe me, it adds stress to your obstetrician, too! For those of you trying to have a vaginal birth after a prior cesarean section, this is a major issue to consider when choosing your hospital.
Many hospitals offer amenities to lure you to use their facilities. They may have created wonderful birthing suites, candlelight dinners for the new parents or other enticing features. Sure, these are nice touches and, if all issues are even, they might be the tiebreaker. However, don't be fooled by the bells and whistles. These amenities do not address the ultimate goal -- having a healthy baby.
Once you have picked the hospital, your choice of physician will be more defined.
Picking Your Doctor
Many of you have an established relationship with a gynecologist. Although they may be the logical choice to help guide you through pregnancy, this isn't always the best option. A good gynecologist may not translate into a good obstetrician. Your potential obstetrician should withstand some scrutiny before being allowed to handle your pregnancy.
The doctor's personality is important. You have to feel that he/she will listen to you. Pregnancy is not the time to become passive. This is a special time in your life! It is both exciting and scary. No matter how unimportant the question, it should be answered with kindness and accuracy.
Let's not forget the office staff, either. From receptionist to nurse, these people make a huge impact on your pregnancy. A pleasant, helpful staff member can set your mind at ease. Scheduling appointments, helping direct you for testing and giving you advice on insurance issues are just a few of the roles these hard working people perform. I've always told my staff that they are the ones that make our office feel like a second home. I've seen offices where the staff has a bad attitude or the office is in chaos. It can make for a very unpleasant experience.
To illustrate the point, I want to share a story about a personal friend of mine. She picked her obstetrician by networking through doctors at the hospital she'd chosen for the birth of her baby. To her surprise, she was carrying twins. She called her doctor on a frequent basis with many concerns. One time, the person who answered the phone forgot to put my friend on hold and she heard the nurse say, "It's her again!" My friend felt horrible and refused to call the doctor again. When she started contractions at seven and one half months, she called me instead of her obstetrician! I sent her to the hospital for what turned out to be premature labor. Fortunately, the doctor there was able to stop her labor. While in the hospital, she switched her obstetrician and eventually had healthy twin girls who are now thirteen years old and doing great.
I think it's easy to see how important getting along with your obstetrician and his or her staff can be. You aren't supposed to know which symptoms are normal and which foretell problems. This is why communication is the key to a safe, healthy delivery. And there is no reason why pregnancy and delivery can't be an enjoyable experience as well!
Let's move on to some of the key ingredients in selecting a doctor.
Our specialty has a rigorous set of written and oral tests that must be passed in order to obtain board certification. Doctors who have just finished training can't take their final tests until they have practiced for 2 ½ years. These tests are designed to ensure that your doctor has an extensive knowledge of obstetrics and gynecology. If a doctor is not board certified/eligible, you may want to look elsewhere. You may want to ask this question before going for your first visit.
2. Is the doctor in a group?
The days of the solo obstetrician are gone. Obstetrics is a physically demanding specialty and there are times when I work throughout the night. I am tired the next day. I don't believe it is in either the patient or doctor's best interest to have a fatigued physician caring for a laboring woman. Working in a group practice is a good solution. It allows doctors to share the nights on-call as well as maintain continuity of care. Some physicians have shared call arrangements (called cross-coverage). In this situation, a physician you may not have met before could deliver your baby. Although excellent care may be provided in this situation, the familiarity and comfort of knowing and trusting your doctor is missing. In our group, all the doctors know all the patients and they know us, too! Not only does this result in good medical care, it also gives women the comfort of knowing the person who delivers their baby.
3. How do you manage patients in labor?
This is a very important question. We have all heard about doctors who make a mad dash from the office to catch your baby. They are in and out in a jiffy. Although this may be a reality of managed care, it isn't always the best way to monitor labor. It goes without saying that labor has some potential risks. Having your physician watching over you and physically being around helps insure the best possible outcome. I'm not suggesting that the doctor stay at your bedside. However, I think he or she should intermittently monitor your progress and look at the baby's heart rate. In addition, doctors who sprint back and forth from their office to deliver babies are notoriously behind schedule and frequently must cancel appointments. The ideal setting is to have one physician in the group whose sole responsibility is to take care of laboring patients. In this way, your office appointment is honored while other laboring patients are adequately cared for.
4. What is the doctor's c-section rate?
Though this sounds like a good question, it can be misleading. Most obstetricians have a c-section rate between 15-20%. Higher rates may be due to a number of causes that are out of the doctor's control. For example, an obstetrician may take on more high-risk cases where c-section is required. In reality, there are better questions to ask to determine the obstetrician who is right for you.
5. Do I always see a physician at my visits?
Many groups have enlisted the aid of nurse practitioners, physician's assistants, and midwives to help make their practice more efficient. These professionals are good sources of information and are capable of doing routine prenatal visits. In some practices, the midwives may be delivering babies as well. This information is nice to know in advance.
When you want the real scoop, don't be afraid to do some detective work. First, decide on the hospital where you want to deliver your baby. Next, do some networking. If you like your present OB/GYN, ask around to see what others' birth experiences have been like with him or her. If the feedback is good, you can feel pretty comfortable staying where you are. If not, you may want to follow some of the tips listed below.
You can try calling the hospital's doctor referral center and make an initial list of doctors based on their office location and board certification status. Using your list, try talking to friends and neighbors. Often, a few names will come up more than once. Alternatively, if you have a doctor who you trust in another field (pediatrician, internist, etc.), try asking them for suggestions. Ask who delivered their children!
Another way to narrow your list down is to call the labor and delivery unit at the hospital where you want to deliver. Ask to speak with one of the nurses. Tell the nurse you speak with that you are new to the area and ask them to help you pick an obstetrician. The nurse may be reluctant to give a name, especially if there is a hospital policy against giving referrals. You can try mentioning a few names of the groups you are considering. See if the nurse is willing to help you narrow down your choices. If the nurse is a woman, you may ask who she uses for herself. If you strike out, you may want to call another time. In any event, it is worth a try.
Armed with information, you can now call the doctor of your choice and make an appointment. It goes without saying that you should feel comfortable on a personal basis with whomever you select. Don't settle for less than you deserve!
Should I Wait Until I Am Pregnant to Make My Choice?
You probably should not. You can make a pre-pregnancy consultation with a doctor to see what you think. Again, you should be deciding whether this person is someone with whom you feel comfortable. During this visit, you should cover some of the issues listed above. If you have specific issues to discuss based on your situation, this is an excellent time to do so.
About the author: Craig L. Bissinger, MD is a board certified Obstetrician/Gynecologist practicing in Parsippany, NJ. Dr. Bissinger is vice-chairman of the Department of OB/GYN at Morristown Memorial Hospital where is is also actively involved in teaching medical students and residents. Dr. Bissinger is a frequent speaker on a host of women's health topics and a member of the Eli Lilly Speakers Bureau.
Copyright © Craig L. Bissinger. Permission to republish granted to Pregnancy.org, LLC.