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Giving Birth: Choosing a caregiver
settings and treatments abound for Palo Altans
Source: Becky Trout -Palo Alto Online Date: 1/10/08

As the New Year's Day sun streamed through her kitchen window, Miranda Ford lay down on the couch in her Old Palo Alto home, baring her bulging belly.

Midwife Faith Gibson, wearing a white doctor's coat and old-fashioned lace-up
boots, her hair pinned up in tight braids, pressed a small monitor into Ford's flesh.

Out spilled gurgling whooshes, the sounds of the womb's liquid world, and then -- ba-boom, ba-boom, ba-boom -- the baby's heart, beating steadily.

Gibson was giving Ford a regular check-up -- regular except the baby, a girl, was late. Due on Dec. 27, Baby Ford still hadn't made her appearance, and Momma Ford was ready.

She had purchased an inflatable birthing tub and her own mother had flown in from Wisconsin to help out.

Unlike nearly all childbearing couples in Palo Alto, Ford and her husband, Michael, decided to have their baby at home.

Ford, 37, an English teacher, knew her choice placed her in a tiny minority.

It had provoked countless questions, even from close friends.

"A friend asked, 'What are you trying to prove?'" Ford said. "It's not 'Oh, I'm so strong, I can do it without drugs.'"

True, she doesn't like hospitals or drugs, but it's more than that, she said.

She feels healthy and wants to avoid the "drama" of a medical birth.

Ford had her son, Elijah, nearly 3, at home. He came a day early, and the labor was nearly seamless.

She knows there's no guarantee her daughter will come out as easily. But Ford said she feels comfortable with Lucile Packard Children's Hospital a few minutes away.

And she feels safe with Gibson, a 64-year-old midwife with decades of experience.

Palo Alto and Stanford residents have more than 700 babies each year.

About 95 percent of them choose to give birth in a hospital.

But despite the apparent conformity, childbirth in the Palo Alto area is characterized by the wide variety of choices, said Pam Rollin, executive director of Blossom Birth, a California Avenue nonprofit that aims to provide a community and information for expecting and new parents.

And the most important choice is the caregiver, Rollin said. According to studies, women have the most satisfactory births when they trust and feel respected by their caregivers, regardless of their amount of pain or the birth's location, she said.

There are three main types of caregivers, aside from family members and partners -- doulas, midwives and doctors.

Doulas are experienced birth attendants who provide non-medical support during birth. Midwives, like Gibson, can assist a woman through a normal birth, turning only to physicians if there is a complication.

And doctors care for healthy women, providing information and skilled intervention, and are critical for women with high-risk pregnancies.

Palo Altan Suzanne Andrews likens her role as a doula to a substitute for a grandmother or a close woman friend or relative who has witnessed many births.

Doulas cost between $500 and $1,500, a flat fee, for a pre-birth meeting and providing emotional support and answering questions throughout the birth, Andrews said. They can be present for births at home or in the hospital. And they offer advice.

Andrews said she recommends that women interview several practitioners and consider all their options.

"There's such a huge spectrum of preferences regarding birth. ... People are all over the map," Andrews said. Some physicians recommend epidurals, a regional anesthesia often used to block the pain of childbirth, while others hold off unless the woman really needs it.

"Don't dismiss your gut feelings because often times they're good," Andrews said.

Jan Rydfors, a well-regarded obstetrician/gynecologist, said he considers himself "pro-doula."

Doulas serve as a "middleman" between doctors, nurses and the woman and her partner, Rydfors said. Often, they can help the woman labor longer at home, he said.

Midwives, like Gibson, perform pre- and postnatal checkups and deliver a baby for about $3,500. They have special training, some midwives are also nurses, and can assist women with normal births.

Gibson delivers babies at home but other midwives are associated with hospitals.

She is both a midwife and an advocate, but she believes strongly that her client, the pregnant woman, is free to make her own choices. She has accompanied women to the hospital, where they have made choices she wouldn't necessarily recommend.

Once in the hospital, "it is very, very difficult to have a natural birth," Gibson said. Hooked up to monitors, and often banned from sitting in tubs or showers, women find it nearly impossible to cope with the pain, she said.

Doctors are risk-averse and often overcompensate by providing too much care, Gibson said. In addition, epidurals are routinely recommended by anesthesiologists, paid generously to be on-hand at all times.

She, too, urges pregnant women and couples to do their homework.

She contends childbirth has become usurped by doctors, and "people need to know how (it has) because otherwise it just doesn't make any sense," Gibson said.

She takes only about 20 patients a year to leave plenty of time for writing and other projects.

But those she does take receive a hefty warning. Gibson firmly believes in what she calls a "physiological" childbirth, a birth determined by the needs of the mother's and baby's bodies.

"I tell them that if they really want a physiologically managed childbirth they have to be willing to tolerate the reality of labor pain and the anxiety of not knowing it will work out the way they want it to," Gibson said. "You experience childbirth on a moment-to-moment basis."

But for most women, birth at home is just too scary, risky or complicated. Although hospitals in Redwood City and Mountain View offer midwives, many women go straight to their doctor.

Doctors in the area have a variety of opinions, and approaches, to childbirth, said Rydfors, who delivers babies at Sequoia and Stanford hospitals.

But the profession had undergone significant changes in the last few decades, agree Rydfors and Stanford's Deirdre Lyell, an assistant professor of obstetrics and gynecology at Stanford Medical School.

Hospital births are no longer directed by doctors who pay little attention to a woman's needs, Lyell said, noting that physicians now take time to explain procedures and choices.

And many patients come in having done research online, both doctors said.

"Patients (in the Bay Area) are very well informed and question doctors," Rydfors said. Maintaining communication throughout the labor and birth is key, he said.

Gone are routine episiotomies, incisions that enlarge the vagina, making it easier to remove the baby but often creating complications, Lyell said.

And many doctors now try to treat pregnancy as a normal condition rather than as a sickness, Rydfors said. He said he doesn't always use an IV or even wear a mask.

And caesarean sections -- a procedure, also known as a c-section, that removes the baby by cutting the mother's abdomen -- are growing in popularity, although not necessarily due to doctors' recommendations, Lyell and Rydfors said.

Nationally, about 31 percent of babies born in 2006 arrived via caesarean, up from 21 percent a decade earlier, according to the Centers for Disease Control and Prevention.

Lyell calls the trend "not necessarily a good thing."

She estimates that Stanford delivers about a quarter of its babies with a c-section. She said women who have had a previous caesarean and those who are expecting twins usually opt for caesareans.

Many Midpeninsula women wait until their late 30s or their 40s to give birth, which increases the use of caesareans, Rydfors said.

At Stanford, if a woman without any complications requests a c-section, she is advised about the risks inherent in both types of delivery, Lyell said. She said Stanford hasn't seen a significant increase in the number of women requesting them.

And Lyell doesn't have a problem with epidurals. Numerous studies have shown they are safe during labor and anesthesiologists have also grown more skilled at monitoring and preventing complications, Lyell said.

Costs for a hospital birth vary greatly due to differences in insurance. One study, published by the Henry J. Kaiser Family Foundation in June, showed that costs for an uncomplicated birth range from about $1,500 to $8,000. C-sections, long labor or extra newborn care can push the cost to more than $20,000, the study states.

As a physician Lyell supports using doulas and midwives in hospitals, but cautions against home birth.

"I don't think home birth is a woman's safest option," she said.

"I think it's too bad. I can understand why women would want to have a home birth. It's a very personal experience, and I think that hopefully there'll be a trend in obstetrics that mimics (the home), but in a setting where if something happens, which it rarely does, complications can be addressed."

Rydfors said he thinks home birth is an acceptable choice for many women with normal pregnancies. But because he has seen so many complications, he wouldn't feel comfortable himself with a birth at home.

John Solano and Toni Ouradnik, who live on a quiet East Palo Alto street tucked behind the Four Seasons, planned diligently for their baby's birth -- they researched doulas, practiced breathing and Solano even painted puffy clouds on the ceiling of the baby's room.

But their experience shows that even the best plans can be nearly useless when Mother Nature takes over.

Ouradnik, 35, felt great throughout most of her pregnancy, teaching at Palo Alto's Keys School until just a week before her Oct. 12 due date.

She was aiming for a natural childbirth, although she wasn't opposed to an epidural.

On Oct. 14, a Sunday, her contractions started. At first, they were twice an hour, painful, but bearable.

Monday, the contractions continued, speeding up to four times an hour, but failing to meet the go-to-the-hospital standard of once every five minutes, lasting at least 30 seconds.

By Tuesday, Ouradnik was exhausted, and she and Solano climbed into the car to head to Kaiser Permanente's Santa Clara Medical Center, which they had selected for its new facilities. She was given an opioid painkiller and sent home to sleep.

After three hours of rest, Ouradnik was again awakened by the contractions.

Wednesday morning, the couple returned to the hospital.

"Isn't there something you can do?" Ouradnik asked. "I can't do this anymore."

"I was just broken down, I hadn't slept. I didn't want to eat much."

Having been warned against excessive medical interventions, Ouradnik said she was surprised, and extremely disappointed, when they were sent home again, again with a painkiller.

This time the drug brought little relief.

She calls Wednesday night "my darkest hour."

"I was a shell of a person," Ouradnik said. They had run out of hot water, as Ouradnik moved from shower to the pillow-packed living room.

"I didn't know how I was going to deliver the baby. I was already exhausted."

Early Thursday, they returned to the hospital.

"I went from 'I'll have a natural birth' to I had every drug they had," Ouradnik said.

For some reason, her first epidural didn't take, so another anesthesiologist was brought in to give a second one. Doctors gave her pitocin, to induce the birth, manually broke her amniotic sac and gave her other drugs, always asking if she wanted them, Ouradnik said.

When the epidural kicked in, Ouradnik was blown away.

"It just felt amazing to not be in pain," she said.

She went from panicked and writhing, attended by Solano, her mother and a friend, as well as the team of nurses, to peaceful. And she made everyone be quiet so she could watch "The Office," one of her favorite shows.

Without the pain, Ouradnik regained her confidence and near sunrise on Friday morning, after about 100 hours of labor, out popped Oscar Calvin Solano, eight pounds and eight ounces of healthy baby boy.

Despite the challenges, Ouradnik and Solano credit Kaiser's nurses with keeping them sane and said they would return if they have a second child.

"In the end it all worked out. We are both healthy; that's the most important thing," Ouradnik said several months later, glowing at her grinning son.

Rollin, of Blossom Birth, said she tries to advise new parents that birth is inherently unpredictable -- they should consider their choices a tentative plan, rather than an absolute decree.

Like many Palo Altans, Rollin was accomplished professionally but knew next-to-nothing about childbirth when she became pregnant.

At Blossom, she said she met women from around the world with traditions, opinions and questions about birth, interactions that helped her decide which type of birth was best for her family.

It's especially important to remain respectful of everyone's choices, even if they are different than yours, Rollin said.

"There's no one way to give birth," she said. "If you are comfortable in a hospital, then that's right for you."

And an area where women know their options, and demand excellence from their physicians, is a great place to give birth, Rydfors said.

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