Chapter 1 Are You Pregnant?

Are You Pregnant?

Maybe your period’s only a day overdue. Or maybe it’s going on 3 weeks late. Or maybe your period isn’t even slated to arrive yet, but you’ve got a gut feeling (literally, in your gut) that something’s cooking—like a brand new baby bun in your oven! Maybe you’ve been giving baby making everything you’ve got for 6 months or longer. Or maybe that hot night 2 weeks ago was your very first contraceptive-free love connection. Or maybe you haven’t been actively trying at all, and still managed to succeed. At least, you think you did. No matter what the circumstances that have brought you to this book, you’re bound to be wondering: Am I pregnant? Well, read on to find out.
What You May Be Wondering About
Early Pregnancy Signs
“My period isn’t even due yet, but I already feel pregnant. Is that possible?”
The only way to be positively positive that you’re pregnant—at least this early on—is to produce a positive pregnancy test. But that doesn’t mean your body is staying mum on whether you’re about to become a mom. In fact, it may be offering up plenty of conception clues. Though many women never feel any early pregnancy symptoms at all (or don’t feel them until weeks into pregnancy), others get lots of hints that there’s a baby in the making. Experiencing any of these symptoms or noticing any of these signs may be just the excuse you need to run to the store for a home pregnancy test:

Tender breasts and nipples. You know that tender, achy feeling you get in your breasts before your period arrives? That’s nothing compared with the breast tenderness you might be feeling postconception. Tender, full, swollen, tingly, sensitive, and even painful-to-the-touch breasts are some of the first signs many (but not all) women notice after sperm meets egg. Such tenderness can begin as soon as a few days after conception (though it often doesn’t kick in until weeks later), and as your pregnancy progresses, it could get even more pronounced. Make that a lot more pronounced. How can you tell PMS breasts from pregnant ones? Often, you can’t right away—adding to the guesswork.

Darkening areolas. Not only might your breasts be tender, but your areolas (the circles around your nipples) may be getting darker—something that doesn’t typically happen before a period. They may even begin to increase in diameter. You can thank the pregnancy hormones already surging through your body for these and other skin color changes (much more about those in the coming months).

Bumpy areolas. You may have never noticed the tiny bumps on your areolas, but once they start growing in size and number (as they typically do early in pregnancy), they’ll be hard to miss. These bumps (called Montgomery’s tubercles) are actually glands that produce oils to lubricate your nipples and areolas—lubrication that’ll certainly be welcome protection when baby starts suckling. Another sign your body is planning ahead—way ahead, in fact.

Spotting. Up to 30 percent of brand new mamas-to-be experience spotting when the embryo implants in the uterus. Such so-called implantation bleeding will likely arrive earlier than your expected monthly flow (usually around 6 to 12 days after conception) and will probably appear light to medium pink in color (rarely red, like a period).

Fatigue. Extreme fatigue. Make that exhaustion. Complete lack of energy. Super sluggishness. Whatever you call it, it’s a drag—literally. And as your body starts cranking up that baby-making machine, it’ll only get more draining. See here for reasons why.

Urinary frequency. Has the toilet become your seat of choice lately? Appearing on the pregnancy scene fairly early (usually about 2 to 3 weeks after conception) may be the need to pee with surprising frequency. Curious why? See here for all the reasons.

Nausea. Here’s another reason why you might want to consider setting up shop in the bathroom, at least until the first trimester is finished. The nausea and vomiting of pregnancy—aka morning sickness, though it’s often a 24/ 7 kind of thing—can strike a newly pregnant woman fairly soon after conception, though it’s more likely to begin around week 6. For a host of reasons why, see here.
Smell sensitivity. Since a heightened sense of smell is one of the first changes some newly pregnant women report, pregnancy might be in the air if your sniffer’s suddenly more sensitive—and easily offended.
Bloating. Feeling like a walking flotation device? That bloated feeling can creep up (and out) on you very early in a pregnancy—though it may be difficult to differentiate between a preperiod bloat and a pregnancy bloat. It’s definitely too soon to attribute any swelling to your baby’s growth, but you can chalk it up to those hormones again.

Rising temperature. If you’ve been using a special basal body thermometer to track your first morning temperature, you might notice that it rises around 1 degree when you conceive and continues to stay elevated throughout your pregnancy. Though not a foolproof sign (there are other reasons why you may notice a rise in temperature), it could give you advance notice of big—though still very little—news.

Missed period. It might be stating the obvious, but if you’ve missed a period (especially if your periods generally run like clockwork), you may already be suspecting pregnancy—even before a pregnancy test confirms it.

Diagnosing Pregnancy
“How can I find out for sure whether I’m pregnant or not?”

Aside from that most remarkable of diagnostic tools, a woman’s intuition (some women “feel”they’re pregnant within days—even moments—of conception), modern medical science is still your best bet when it comes to diagnosing a pregnancy accurately. Luckily, there are many ways to find out for sure if you’ve got a baby on board:

The home pregnancy test. It’s as easy as 1-2-pee, and you can do it all in the privacy and comfort of your own bathroom. Home pregnancy tests (HPTs) are not only quick and accurate, but you can even start using most brands before you’ve missed your period (though accuracy will get better as you get closer to P-day).

     All HPTs measure urinary levels of human chorionic gonadotropin (hCG), a (developing) placenta-produced hormone of pregnancy. HCG finds its way into your bloodstream and urine almost immediately after an embryo begins implanting in the uterus, between 6 and 12 days after fertilization. As soon as hCG can be detected in your urine, you can (theoretically) get a positive reading. But there is a limit to how soon these HPTs can work—they’re sensitive, but not always that sensitive. One week after conception there’s hCG in your urine, but it’s not enough for the HPT to pick up—which means that if you test 7 days before your expected period, you’re likely to get a false negative even if you’re pregnant.

     Just can’t wait to pee on that stick? Some tests promise 60 to 75 percent accuracy 4 to 5 days before your expected period. Not a betting woman? Wait until the day your period is expected, and you’ll have up to a 99 percent chance (depending on the brand’s claim) of scoring the correct result. Whenever you decide to take the testing plunge, the good news is that false positives are much less common than false negatives—which means that if your test is positive, you can be, too. (The exception: if you’ve recently had fertility treatments; see box.)

     Some HPTs can tell you not only that you’re pregnant but also approximately how far along you are in your pregnancy, displaying along with the word “pregnant”the estimated weeks since ovulation—either 1 to 2 weeks, 2 to 3 weeks, or 3 or more weeks since your tiny egg was fertilized by your partner’s sperm. Operative word “approximately”—so don’t use this reading to calculate your official estimated due date. Also on the market: an HPT that’s app-compatible.

     No matter what type of HPT you use (from budget brand basic to super high-tech) you’ll get a very accurate diagnosis very early in pregnancy—and that early heads-up can give you an early head start on taking the best possible care of yourself. Still, medical follow-up to the test is essential. So if the result is positive, it’s time to call your practitioner and book that first prenatal appointment.

Testing Smart
The home pregnancy test is probably the simplest test you’ll ever take. You won’t have to study for it, but you should read the package instructions carefully before you take the test (yes, even if you’ve taken HPT tests before, since different brands come with different instructions). A few other things to keep in mind:
■ You don’t need to use first-of-the-morning urine. Any-time-of-the-day pee will do.
■ Most tests prefer you use midstream urine. And since your practitioner will prefer that you use this in your monthly urine samples, too, you might as well master the technique now if you haven’t before: Start peeing for a second or two, stop, hold the flow, and then put the stick you’re supposed to pee onto or the cup you’re supposed to pee into in position to catch the rest of the stream (or as much as needed).
■ Any positive read, no matter how faint, is a positive. Congratulations—you’re pregnant! If the result isn’t positive, and your period still hasn’t arrived, consider waiting a few days and testing again. It may have just been too soon to call.

Testing for the Irregular
So your cycles don’t exactly run on schedule? That’ll make scheduling your HPT testing date a lot trickier. After all, how can you test on the day that your period is expected if you’re never sure when that day will come? Your best testing strategy if your periods are irregular is to wait the number of days equal to the longest cycle you’ve had in the last 6 months (hopefully you’ve been keeping track on an app)—and then test. If the result is negative and you still haven’t gotten your period, repeat the test after a week (or after a few days if you just can’t wait).

The blood test. The more sophisticated blood pregnancy test can detect pregnancy with virtually 100 percent accuracy as early as 1 week after conception, using just a few drops of blood. It can also help approximately date the pregnancy by measuring the exact amount of hCG in the blood, since hCG values change as pregnancy progresses (see here for more on hCG levels). Many practitioners order both a urine test and a blood test to be doubly certain of the diagnosis.

The medical exam. Though a medical exam can be performed to confirm the diagnosis of a pregnancy, today’s accurate HPTs and blood tests make the exam—which looks for physical signs of pregnancy such as enlargement of the uterus, color changes in the vagina and cervix, and a change in the texture of the cervix—almost beside the point. Still, getting that first exam and beginning regular prenatal care isn’t (see here).

Pregnancy Testing and Fertility Treatments

Every hopeful mama-to-be is on pins and needles (and the edge of her toilet seat) waiting for the moment when she’ll finally be able to pee on a stick to confirm that she’s pregnant. But if you’ve been undergoing certain fertility treatments, the wait for a positive pregnancy test can be even more nerve-racking, especially if you’ve been told to skip the HPT and hold off until a blood test can be done (which, depending on your fertility clinic, may be a week to 2 weeks after conception or embryo transfer). But there’s a very good reason why most fertility specialists prescribe this approach: HPTs can provide unreliable results for fertility patients. That’s because hCG, the hormone tested for in an HPT, is often used in fertility treatments to trigger ovulation and may remain in your system (and show up in your urine) even if you’re not pregnant. Usually, if the first blood test given by your fertility specialist is positive, it will be repeated in 2 to 3 days. Why the repeat blood test? Your doctor will not only be looking to see that there’s hCG in your system, but also making sure the level of hCG increases by at least two-thirds (indicating that all is going well so far). If it has increased, another blood test will be ordered 2 to 3 days later, when the hCG level should have increased by two-thirds or more again. These blood tests will also measure hormones (like estrogen and progesterone) to make sure they are at the level they should be to sustain a pregnancy. If all 3 blood tests point to a pregnancy, then an ultrasound is scheduled around 5 to 8 weeks of pregnancy to look for the heartbeat and a gestational sac (see box).

A Faint Line
“I used a cheaper HPT instead of the more expensive digital kind, but when I took it, it showed a faint line. Am I pregnant?”
The only way a home pregnancy test can give you a positive result is if you have a detectable level of hCG in your urine. And the only way you’ll have a detectable level of hCG in your urine (unless you’ve been receiving fertility treatments) is if you’re pregnant. Which means that if your test is showing a line, no matter how faint it is—you can be positive that you’re pregnant. Just why you’re getting a faint line instead of that loud-and-clear line you were hoping for may have to do with the sensitivity of the test you’ve used. To figure out how sensitive your pregnancy test is, look for the milli-international units per liter (mIU/ L) measurement on the packaging. The lower the number, the better (20 mIU/ L will tell you you’re pregnant sooner than a test with a 50 mIU/ L sensitivity). Not surprisingly, the more expensive tests usually have greater sensitivity. Keep in mind, too, that the farther along in your pregnancy you are, the higher your levels of hCG. If you’re testing very early on in your pregnancy (before your expected period), there might not be enough hCG in your system yet to generate a no-doubt-about-it line. Give it a couple of days, test again, and you’ll likely see a line that’ll erase your doubts once and for all.

No Longer Positive
“My first HPT was positive, but a few days later I took another one and it was negative. And then I got my period. What’s going on?”

Unfortunately, it sounds like you may have experienced what’s known as a chemical pregnancy—when an egg is fertilized, but for some reason never completes implantation. Instead of turning into a viable pregnancy, it ends in a period. Though experts estimate that up to 70 percent of all conceptions are chemical, the vast majority of women who experience one don’t even realize they’ve conceived (certainly in the days before HPTs, women didn’t have a clue they were pregnant until much later). Often, a very early positive pregnancy test and then a late period (a few days to a week late) are the only signs of a chemical pregnancy, so if there’s a downside to early testing, you’ve definitely experienced it. Medically, a chemical pregnancy is more like a cycle in which a pregnancy never really occurred than a true miscarriage. Emotionally, for women like you who tested early and got a positive result, it can be a very different story. Though it’s not technically a pregnancy loss, the loss of the promise of a pregnancy can also be understandably upsetting for both you and your partner. Reading the information on coping with a pregnancy loss in Chapter 20 can help you with those emotions. And keep in mind that the fact that conception did occur once for you means that it’ll more than likely occur again soon, and with the happier result of a healthy pregnancy.

Turning a Negative Into a Positive
If it turns out you’re not pregnant this time, but you’d like to become pregnant soon, start making the most of the preconception period by taking the steps outlined in What to Expect Before You’re Expecting. Good preconception prep before you start trying to conceive will help ensure the best possible pregnancy outcome when sperm and egg do meet up. Plus, you’ll find tons of tips on how to boost your chances of conceiving—and conceiving faster.

A Negative Result
“My period’s late and I feel like I’m pregnant, but I’ve done 3 HPTs and they were all negative. What should I do?”

If you’re experiencing the symptoms of early pregnancy and feel, test or no test—or even 3 tests—that you’re pregnant, act as though you are (by taking prenatal vitamins, eating well, cutting back on caffeine, not drinking or smoking, and so on) until you find out definitely otherwise. Even the best HPTs can slip up, producing a false negative result, especially when they’re taken very early. You may well know your own body better than a pee-on-a-stick test does. To find out if your hunch is more accurate than the tests, wait a week and then try again—your pregnancy might just be too early to call. Or ask your practitioner for a blood test, which is more sensitive in detecting hCG than a urine test is. It is possible, of course, to experience all the signs and symptoms of early pregnancy and not be pregnant. After all, none of them alone—or even in combination—is absolute proof positive of pregnancy. If the tests continue to be negative but you still haven’t gotten your period, be sure to check with your practitioner to rule out other physiological causes of your symptoms (say, a hormonal imbalance). If those are ruled out as well, it’s possible that your symptoms may have emotional roots. Sometimes, the mind can have a surprisingly powerful influence on the body, even generating pregnancy symptoms when there’s no pregnancy, just a strong yearning for one (or fear of one).

Making the First Appointment
“The home pregnancy test I took was positive. When should I schedule the first visit with my doctor?”

Good prenatal care is one of the most important ingredients in making a healthy baby. So don’t delay. As soon as you have a positive HPT result, call your practitioner to schedule an appointment. Just how soon you’ll be able to come in for that appointment may depend on office traffic and policy. Some practitioners will be able to fit you in right away, while some very busy offices may not be able to accommodate you for several weeks or even longer. At certain offices, it’s routine to wait until a woman is 6 to 8 weeks pregnant for that first official prenatal visit, though some offer a “pre-ob”visit to confirm a pregnancy as soon as you suspect you’re expecting (or have the positive HPT results to prove it).

     But even if your official prenatal care has to be postponed until midway through the first trimester, that doesn’t mean you should put off taking care of yourself and your baby. Regardless of when you get in to see your practitioner, start acting pregnant as soon as you see that positive readout on the HPT. You’re probably familiar with many of the basics, but don’t hesitate to call your practitioner’s office if you have specific questions about how best to get with the pregnancy program. You may even be able to pick up a pregnancy packet ahead of time (many offices provide one, with advice on everything from diet do’s and don’ts to prenatal vitamin recommendations to a list of medications you can safely take) to help fill in some of the blanks. Of course, you’ll also find plenty of pregnancy advice in this book.
     In a low-risk pregnancy, having the first prenatal visit early on isn’t considered medically necessary, though the wait can be hard to handle. If the waiting’s stressing you out, or if you feel you may be a high-risk case (because of a chronic condition or a history of miscarriages, for instance), check with the office to see if you can come in earlier. (For more on what to expect at your first prenatal visit, see here.)

Your Due Date
“I just got a positive result on my pregnancy test. How do I calculate my due date?”

Once the big news starts to sink in, it’s time to reach for the calendar and mark down the big day: your due date. But wait—when are you due? Should you count 9 months from today? Or from when you might have conceived? Or is it 40 weeks? And 40 weeks from when? You just found out you’re pregnant, and already you’re confused. When is this baby coming, anyway?

     Take a deep breath and get ready for pregnancy math 101. As a matter of convenience (because you need some idea of when your baby will arrive) and convention (because it’s important to have benchmarks to measure your baby’s growth and development against), a pregnancy is calculated as 40 weeks long—even though only about 30 percent of pregnancies actually last precisely 40 weeks. In fact, a full-term pregnancy is considered to be anywhere from 39 weeks to 41 weeks long (a baby born at 39 weeks isn’t “early”any more than one born at 41 weeks is “late”).

     But here’s where things get even more confusing. The 40 weeks of pregnancy are not counted from the day (or passionate night) your baby was conceived—they’re counted from the first day of your last menstrual period (or LMP). Why start the clock on pregnancy before sperm even meets egg (and before your ovary even releases the egg)? The LMP is simply a reliable day to date from. After all, even if you’re pretty positive about ovulation day (because you’re a master of cervical mucus or an ovulation predictor pro), and definitely sure about the day or days you had sex, you probably can’t pinpoint the moment egg and sperm got together (aka conception). That’s because sperm can hang out and wait for an egg to fertilize up to 3 to 5 days after they’ve arrived through the vagina, and an egg can be fertilized up to 24 hours after it’s been released—leaving a wider window than you might think.

     So instead of using an uncertain conception date as a start date for pregnancy, you’ll use a sure thing: your LMP, which (in a typical cycle) would have occurred about 2 weeks before your baby was conceived. Which means you’ll have clocked in 2 of those 40 weeks of pregnancy by the time sperm and egg actually meet, and 4 weeks by the time you miss your period. And when you finally reach that 40-week mark, your baby bun will have been baking for just 38 weeks.
    
     Still confused by the system? That’s not surprising—it’s a confusing system. Happily, you don’t have to understand the system to work it. To arrive at a due date (called an EDD, or estimated due date, because it’s always an estimate), you can just do this simple calculation: Subtract 3 months from the first day of your last menstrual period (LMP), then add 7 days. For example, say your last period began on April 12. Count backward 3 months, which gets you to January 12, and then add 7 days. Your due date would be January 19. Don’t feel like doing any math at all? No need to. Just plug your LMP date into the What To Expect app and—baby bingo!—your EDD will be calculated for you, you’ll find out the week of pregnancy you’re in, and your week-by-week countdown will begin.

     Keep in mind that if you have irregular cycles, you may have difficulty calculating your due date with the LMP method. And even if your cycles are regular, your practitioner might give you a different date than you arrived at by using the LMP method or an app. That’s because the most accurate way of estimating a due date is through an early ultrasound, usually done at about 6 to 9 weeks, which reliably measures the size of the embryo or fetus (measurements done by ultrasound after the first trimester aren’t as accurate).

     Though most practitioners will rely on the ultrasound-plus-LMP method to officially date your pregnancy, there are also other physical signs that may be used to back it up, including the size of your uterus and the height of the fundus (the top of the uterus, which will be measured at each prenatal visit after the first trimester and will reach your navel at about week 20).

     All signs point to the same date? Remember, even the most reliable EDD is still just an estimate. Only your baby knows for sure when his or her birth date will be . . . and baby’s not telling.

All About:
Choosing and Working with Your Practitioner
Everybody knows it takes two to conceive a baby. But it takes a minimum of three—mom, dad, and at least one health care professional—to make that transition from fertilized egg to delivered infant a safe and successful one. Assuming you and your partner have already taken care of conception, the next challenge you both face is selecting that third member of your pregnancy team and making sure it’s a selection you can live with—and labor with.

Obstetrician? Family
Practitioner?Midwife?
Where to begin your search for the perfect practitioner to help guide you through your pregnancy and beyond? First, you’ll have to give some thought to what kind of medical credentials would best meet your needs.

The obstetrician. Are you looking for a practitioner who is trained to handle every conceivable medical aspect of pregnancy, labor, delivery, and the postpartum period—from the most obvious question to the most obscure complication? Then you’ll want to consider an obstetrician, or ob. An ob can not only provide complete obstetrical care, but can also take care of all your non-pregnancy female health needs (Pap smears, contraception, breast exams, and so on). Some also offer general medical care, acting as your primary care physician as well.

     If yours is a high-risk pregnancy, you will very likely need and want to seek out an ob. You may even want to find a specialist’s specialist, an ob who specializes in high-risk pregnancies and is certified in maternal-fetal medicine. These physicians spend an extra 3 years training to care for women with high-risk pregnancies beyond the typical 4 years of ob-gyn residency training. If you’ve become pregnant with the help of an infertility specialist, you’ll probably start your prenatal care with him or her, then “graduate”to a general ob or midwife (typically toward the end of the first trimester, though possibly sooner)—or, if your pregnancy turns out to be high-risk, a maternal-fetal medicine specialist.
    
     More than 90 percent of women select an ob for their care. If you’ve been seeing an ob-gyn you like, respect, and feel comfortable with for your gynecological care, there may be no reason to switch now that you’re pregnant. If your regular gyn care provider doesn’t do ob, or if you’re not convinced this is the doctor you’d like to have caring for you during pregnancy or while delivering your baby, it’s time to start shopping around.

The family physician. Family physicians (FP) provide one-stop medical service. Unlike an ob, who has had post–medical school training in women’s reproductive and general health as well as surgery, the FP has had training in primary care, maternal care, and pediatric care after receiving an MD. If you decide on an FP, he or she can serve as your internist, ob-gyn, and, when the time comes, pediatrician. Ideally, an FP will become familiar with the dynamics of your family and will be interested in all aspects of your health, not just your obstetric ones. If your pregnancy takes a turn for the complicated, an FP may send you to an ob for consultation or for more specialized care, but will remain involved in your care for comforting continuity.

Paging Dr. Google?

Visit those pregnancy websites and apps, by all means, but search (and research) with care. Realize that you can’t believe everything you read, especially online—and, emphatically—on social media. Before you consider following any of Dr. Google’s prescriptions and guidelines, always get a second opinion from your real practitioner—usually your best source of pregnancy information, particularly as it applies to your individual pregnancy.

The certified nurse-midwife. If you’re looking for a practitioner who will put more caring into your ob care, take extra time with you at prenatal visits, be as attentive to your emotional wellbeing as your physical condition, offer more detailed nutritional advice and comprehensive breastfeeding support, be open to more complementary and alternative therapies and more birth options, and be a strong advocate of unmedicated childbirth, then a certified nurse-midwife (CNM) may be right for you (though, of course, many doctors fit that profile, too). A CNM is a medical professional—an RN (registered nurse) or a BSN (bachelor of nursing science) who has completed graduate-level programs in midwifery and is certified by the American College of Nurse-Midwives. A CNM is thoroughly trained to care for women with low-risk pregnancies and to deliver uncomplicated births. In some cases, a CNM may provide continuing routine gyn care and, sometimes, newborn care. Most midwives work in hospital settings, and others deliver at birthing centers and/ or do home births. Ninety-five percent of births with CNMs are in hospitals or birthing centers. Though CNMs have the right in most states to offer pain relief, as well as to prescribe labor-inducing medications, a birth attended by a CNM is less likely to include such interventions. On average, midwives have much lower cesarean delivery rates (performed by their affiliated obs) than physicians, as well as higher rates of vaginal birth after cesarean (VBAC) success—in part because they’re less likely to turn to unnecessary medical interventions, and in part because they care only for women with low-risk pregnancies, who are less likely to end up needing a surgical delivery. Studies show that for low-risk pregnancies, deliveries by CNMs are as safe as those by physicians. Something else to keep in mind, if you’ll be paying some or all of your costs out-of-pocket: The cost of prenatal care with a CNM is usually less than that with an ob.

     If you choose a certified nurse-midwife (about 9 percent of expectant moms do), be sure to select one who is both certified and licensed (all 50 states license nurse-midwives). Most CNMs use a physician as a backup in case of complications, and many practice with one or with a group that includes several. For more information about CNMs, look online at midwife.org.

Direct-entry midwives. These midwives are trained without first becoming nurses, though they may hold degrees in other health care areas. Direct-entry midwives are more likely than CNMs to do home births, though some also deliver babies in birthing centers. Those who are certified through the North American Registry of Midwives are called certified professional midwives (CPMs)—other direct-entry midwives are not certified. Licensing for direct-entry midwives is also offered in certain states, while in other states, direct-entry midwives can’t practice legally. It’s important to know that the training CPMs receive falls short of most international standards, and many wouldn’t qualify as midwives in other developed countries. Less than half of 1 percent of births in the U.S. are attended by a direct-entry midwife. For more information, contact the Midwives Alliance of North America at mana.org.

Division of Labor

What happens if your ob is away on the day you deliver? Some obstetricians and hospitals turn to laborists—obs who work exclusively in the hospital (which is why they may also be called hospitalists), only attending labors and delivering babies. These laborists don’t have an office and don’t follow patients through pregnancy, but are there to help your baby come into the world if your ob (perhaps because he’s on vacation or because she’s attending a conference) isn’t available.

     If you’re told that a laborist may be delivering your baby, ask your practitioner if he or she and the hospital laborists have worked closely together in the past. Also ask whether their philosophies and protocols are similar. You might also want to call the hospital to ask if you can meet the staff docs before labor, so that you’re not being attended by a complete stranger during childbirth. Make sure, too, that you arrive at the hospital with your birth plan (if you have one; see here) in hand, so whoever is attending you is familiar with your wishes even if he or she isn’t familiar with you.

     If you’re uncomfortable with the whole arrangement, think about switching practices sooner rather than later. Remember, though, that if you’re with a multiple-doc practice already, there’s a good chance your “regular”ob won’t be on call the day you go into labor anyway. Keep in mind, too, that because hospitalists focus solely on deliveries, they’re extra-prepared to give the best possible care during labor. And extra-rested, also, because they work on shifts instead of around the clock.

Types of Practice

You’ve settled on an obstetrician, a family practitioner, or a midwife. Next you’ve got to decide which kind of medical practice you would be most comfortable with. Here are the most common kinds of practices and their possible advantages and disadvantages:

Solo medical practice. Searching for a doctor who’s one of a kind, literally? Then you might want to look for a solo practice—in which the doctor of your choosing works alone, relying on another doctor to cover when he or she is unavailable. An ob or a family physician might be in solo practice, while a midwife must work in a collaborative practice with a physician in most states. The major advantage of a solo practice is that you’ll see the same doctor at each visit—familiarity that can definitely breed comfort, especially when it comes time for delivery. You’ll also receive consistent advice, instead of being consistently confused by seeing different practitioners sharing different (and sometimes conflicting) points of view. The major disadvantage is that if your one-of-a-kind doctor is out of town, sick, or otherwise unavailable on the day (or night) your baby decides to arrive, a backup practitioner you don’t know (in some cases, a laborist; see box) may deliver your baby. Arranging to meet the covering practitioner ahead of time can help you feel more comfortable about that possibility. A solo practice may also be a problem if, midway through the pregnancy, you find that your one-of-a-kind doctor really isn’t the one you were hoping for after all. If that happens and you decide to switch practitioners, you’ll have to start from scratch, searching for one who fits your patient profile.

Partnership or group practice. In this type of practice, two or more doctors in the same specialty care jointly for patients, often seeing them on a rotating basis (though you usually get to stick with your favorite through most of your pregnancy and start rotating only toward the end of your pregnancy, when you’re having more frequent office visits). Again, you can find both obs and family physicians in this type of practice. The advantage of a group practice is that by seeing a different doctor each time, you’ll get to know them all—which means that when those contractions are coming strong and fast, there’s sure to be a familiar face in the room with you. The disadvantage is that you may not like all of the doctors in the practice equally, and you usually won’t be able to choose the one who attends your baby’s birth. Also, hearing different points of view from the various partners may be an advantage or a disadvantage, depending on whether you find it reassuring or head-spinning.

Combination practice. A group practice that includes one or more obs and one or more midwives is considered a combination practice. The advantages and disadvantages are similar to those of any group practice. There is the added advantage of having the extra time and attention a midwife may offer at some of your visits and the extra medical know-how of a physician’s extensive training and expertise at others. You may have the option of a midwife-attended delivery, plus assurance that if a problem develops, a doctor you know is in the wings.

Maternity center or birthing center practice. In these practices, certified midwives provide the bulk of the care, and obs are on call as needed. Some maternity centers are based in hospitals with special birthing rooms, and others are stand-alone facilities. All maternity centers provide care for low-risk patients only.

     The benefits of this type of practice are obviously great for moms-to-be who prefer a CNM as their primary practitioner. Another possibly sizable advantage may be the bottom line: CNMs and birthing centers usually charge less than obs and hospitals. That can be a key consideration, since while your health insurance is required to cover maternity and delivery care, you may need to foot part of the bill, depending on the type of insurance you have, your deductible, and whether you go in or out of network. A potential disadvantage of this kind of care: If a complication arises during pregnancy, you may have to switch your care to an ob and start developing a relationship all over again. Or, if a complication comes up during labor or delivery, you may need to be delivered by the doctor on call—someone you may never have met before. And finally, if you are delivering at a freestanding maternity center and complications arise, you may have to be transported to the nearest hospital for emergency care.

Independent CNM practice. In the states in which they are permitted to practice independently, CNMs offer women with low-risk pregnancies the advantage of personalized pregnancy care and a low-tech natural delivery (sometimes at home, but more often in birthing centers or hospitals). An independent CNM should have a physician available for consultation as needed and on call in case of emergency—during pregnancy, childbirth, and postpartum. Care by an independent CNM is covered by most health plans, though only some insurers cover midwife-attended home births or births in a facility other than a hospital.

Centering Pregnancy

Looking for an alternative to the traditional model of prenatal care? Maybe Centering Pregnancy is for you. Instead of booking appointments for monthly checkups, you’ll join a group of 8 to 12 other moms-to-be (and their partners) with due dates close to yours, usually for about 10 sessions over your pregnancy and early postpartum (babies attend, too!). You’ll get your monthly assessments by your practitioner, as you would with individual care, but you’ll also spend about 2 hours at each session getting your questions answered, sharing experiences with the other parents-to-be, and discussing topics ranging from pregnancy nutrition to birthing options. Think Centering Pregnancy might be just the care you’re looking for? Go to centeringhealthcare.org to learn more, and to see if there’s a site near you.

Finding a Candidate

When you have a good idea of the kind of practitioner you want and the type of practice you prefer, where can you find some likely candidates? The following are all good sources:

■ Your gyn or family physician (if he or she doesn’t do deliveries) or your internist, assuming you’re happy with his or her style of practice. Doctors tend to recommend others with philosophies similar to their own.

■ Friends, coworkers, or pals from your local group on WhatToExpect.com who’ve recently given birth and whose personalities and childbirth philosophies are similar to yours.

■ Your insurance company, which can give you a list of names of in-network physicians who deliver babies, along with information on their medical training, specialties, special interests, type of practice, and board certification.

■ The American Medical Association (ama-assn.org; click on “Doctor Finder”) can help you search for a doctor in your area.

■ The American Congress of Obstetricians and Gynecologists (ACOG) Physician Directory has the names of obstetricians and maternal-fetal specialists. Go to acog.org and click on “Find an ob-gyn.”

■ The American College of Nurse-Midwives, if you’re looking for a CNM. Go to midwife.org (click on “Find a Midwife”).

■ The local La Leche League, especially if breastfeeding support is a priority for you.

■ A nearby hospital with facilities that are important to you—for example, birthing rooms with whirlpool tubs, rooming-in for both baby and dad, or a NICU (neonatal intensive care unit)—or a local maternity or birthing center you’d like to deliver in. Ask for the names of attending physicians and midwives.

Making Your Selection
Once you’ve secured a prospective practitioner’s name, call to make an appointment for a consult. Go prepared with questions that’ll help you figure out if your philosophies are in sync and your personalities mesh comfortably. (Don’t expect that you’ll agree on everything.) Be observant, too, and try to read between the lines at the interview: Is the doctor or midwife a good listener? A patient explainer? Equally responsive to both you and your partner? Does he or she have a sense of humor, if that’s a must for you? Does he or she seem to take your emotional concerns as seriously as your physical ones? Now’s the time to find out this candidate’s positions on issues that you feel strongly about: unmedicated childbirth versus pain relief as needed or wanted, breastfeeding, induction of labor, use of continuous fetal monitoring or routine IVs, VBAC, water birth, or anything else that’s important to you. Knowledge is power—and knowing how your practitioner practices will help ensure there won’t be unhappy surprises later.

     Almost as important as what the interview reveals about your potential practitioner is what you reveal about yourself. Speak up and let your true patient persona shine through. You’ll be able to judge from the practitioner’s reaction whether he or she will be comfortable with—and responsive to—you, the patient.
    
     You will also want to consider the hospital or birthing center the practitioner is affiliated with, and whether it provides features that are important to you. Though your delivery preferences clearly shouldn’t be your only criteria in picking a practitioner, they should certainly be on the table. Ask about any of the following features and options that are important to you (keeping in mind that no firm birthing decisions can be made until further into your pregnancy and many can’t be finalized until the delivery itself): Does the hospital or birthing center offer a tub to labor in, a squat bar for pushing, a comfortable place for dad to room-in, plenty of space for family and friends to hang out in, a NICU? Is there flexibility about rules or procedures that concern you (say, eating or drinking during labor or routine IVs)? Is there an on-call anesthesiologist so you won’t have to wait for an epidural if you want one? Is VBAC encouraged (see here) if that applies to you? Are “gentle”cesareans offered (see here)? Are siblings allowed at delivery? Does the hospital have a Baby-Friendly designation or has it implemented breastfeeding- and baby-friendly policies (such as making skin-to-skin contact right after birth a priority)? Is there round-the-clock breastfeeding support from lactation consultants (or support if you choose not to breastfeed)? See here for more on birth choices and options.

Before you make a final decision, think about whether your potential practitioner inspires trust. Pregnancy is one of the most important journeys you'll ever make, so you''ll want to secure a copilot you have faith in.

Where Will You Give Birth?

Absolutely set on giving birth in a hospital? Wondering if a delivering in a birthing center is more your speed? Hoping for a home birth? Pregnancy and childbirth are full of personal choices—often including where you’ll be welcoming your brand new baby into the world:

In a hospital. Don’t think cold and clinical. The birthing rooms at nearly all hospitals are cozy and family-friendly, with soft lighting, comfy chairs, soothing pictures on the walls, and beds that almost look like they came out of a furniture showroom instead of a hospital supply catalog. Medical equipment is usually stowed out of sight inside home-like cabinetry. The back of the birthing bed can be raised to support a laboring mom in a comfortable position, and the foot of the bed snaps off to make way for the birthing attendants. After delivery, there’s a change of sheets, a few flipped switches, and presto, you’re back in bed. Many hospitals also offer showers and/ or whirlpool tubs in or adjacent to the birthing rooms, both of which can offer hydrotherapy relief during labor. Tubs for water birth are also available in some hospitals (see box for more on water birth). Most birthing rooms have sleeper sofas for your coach and other guests.

     Most birthing rooms are used just for labor, delivery, and recovery (LDRs), which means you and your baby will most likely be moved from the birthing room to a postpartum room after an hour or so of largely uninterrupted family togetherness.

     If you end up needing a c-section, you’ll be moved from the birthing room to the operating room, and afterward to a recovery room—but you’ll be back in a nice postpartum room as soon as the business of birthing your baby is done.

At a birthing center. Birthing centers, usually freestanding facilities (often just minutes from a hospital, although they may also be attached to—or even located in—a hospital), offer a cozy, low-tech, and personalized place for childbirth, with softly lit private rooms, showers, and whirlpool tubs for labor and water birth. A kitchen may also be available for family members to use. Birthing centers are usually staffed by midwives, but many have on-call obs. And though birthing centers generally do not use interventions such as fetal monitoring, they do have medical equipment on hand so emergency care can be started as needed while waiting for transfer to a nearby hospital. Still, only women with low-risk pregnancies are good candidates for delivery in birthing centers. Something else to consider: Unmedicated childbirth is the focus in a birthing center, and though mild narcotic medications are available, epidurals aren’t. If you end up wanting an epidural, you’ll have to be transferred to the hospital.

At home. Only about 1 percent of the deliveries in the U.S. are home births. The upside of delivering at home is obvious: Your newborn arrives amid family and friends in a warm and loving atmosphere and you’re able to labor and deliver in the familiar comfort and privacy of your own home, without hospital protocols and personnel getting in the way. The downside is that if something unexpectedly goes wrong, the facilities for an emergency cesarean delivery or resuscitation of the newborn will not be close at hand.

     Statistics show that there is a slightly higher risk to the baby in a home birth attended by a midwife compared to a hospital birth attended by a midwife. According to the American College of Nurse-Midwives, if you are considering a home birth, you should be in a low-risk category, be attended by a CNM with a consulting physician available, and have transportation readily available and live within 30 miles of a hospital.