Ep 106: Prenatal Care Models

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This is a very requested episode on the various models of care during pregnancy and birth. Today I am going to break down all the various options for prenatal care and care during birth in the hospital. There is tremendous variation and you really have to ask your own provider about how it works in their practice. This is important to know, especially for when it comes time for your birth, so you know as much as you can about who is there with you during your birth and you can prepare accordingly. And I’ll be honest some doctors are better than others at communicating how their practice works, especially if it’s a group practice.

It’s so important to know how your particular provider works so you can be prepared. This is part of what I teach in my free online class on how to make a birth plan. Part of making a birth plan needs to be understanding who could be there for your birth and how they practice. You do not want to just show up for your birth with your birth plan without having some idea of how the person on the other side is going to react to it and whether or not they will support your wishes.

Be sure to check out my newly updated birth preparation course. The whole series has been re-recorded and includes brand new content. I heard your feedback and have added even more information to the course.

In this Episode, You’ll Learn About:

  • How working with a solo practitioner can provide continuity of care
  • How an academic medical center is structured
  • Who might be providing your care at a medical center
  • How a group practice works - it can be complicated but it is the most common care model
  • What a certified nurse midwife is and how they differ from certified professional midwives
  • How CNMs work with or without doctors
  • What a hospitalist is (that’s what I do!) and how scheduling determines who will be at your birth

Links Mentioned in the Episode

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Ep 106: Prenatal Care Models

p>Nicole: This is a very requested episode on the various models of care during pregnancy and birth.

Nicole: Welcome to the All About Pregnancy & Birth podcast. I'm Dr. Nicole Calloway Rankins, a board certified OB GYN, who's been in practice for nearly 15 years. I've had the privilege of helping over 1000 babies into this world, and I'm here to help you be calm, confident, and empowered to have a beautiful pregnancy and birth. Quick note, this podcast is for educational purposes only and is not a substitute for medical advice. Check out the full disclaimer at drnicolerankins.com/disclaimer. Now let's get to it. Well, hello there.

Nicole: Welcome to another episode of the podcast. This is episode number 106. I am so glad that you are with me today. On today's episode, I am going to break down all the various options for prenatal care and care during your birth in the hospital. This is something that people often find quite confusing. And you'll see why when I explain everything, there's also a tremendous amount of variation. You and your girlfriend could be going to different practices, but both delivering at the same hospital and it can be completely different. What's going to happen for each of you. So it's really an individual thing. So it's important. And I'm going to say this now, and I'll say it again that you ask questions of your specific provider, but in today's episode, I'm going to give you a general overview. So you can have an idea of what questions to ask.

Nicole: So I'm going to talk about what it's like when you are receiving care with a solo practitioner, a group practice, getting care at an academic medical center where there may be residents or medical students. I'll talk about what it's like to get care with a certified nurse midwife, and then I'll end with hospitalist, both OB hospitalist, like what I am and certified nurse midwife hospitalist. Before we get into the episode let me do a listener shout out. This is to Erica S R D. And the title of the review says must have for first time moms and the review says, I've found Dr. Nicole Rankin's podcast from another related podcast. And I am so glad I did because it quickly became my go-to being pregnant during a pandemic was tough and being a first time mom, I had a lot of fears and uncertainties, Dr.

Nicole: Rankins helps to calm typical pregnancy and childbirth fears by reviewing the evidence in a way that is both informative and sincere. There was no need for me to start down the dangerous spiral that is Google because I trusted she presented the information I needed. Childbirth has always been my biggest fear, but in the end, my experience was peaceful and empowering. I know that this podcast helped me get there. Thank you. Oh my goodness. Thank you. Thank you so much for that lovely kind and touching review. I so, so appreciate it. And I'm so glad that you had a peaceful and empowering experience during your birth. And I'm grateful that I was able to play a part in that, through this podcast. So thank you. Thank you. Thank you again, another thing that helps you have a peaceful and empowering experience during your birth is good childbirth education.

Nicole: And I have completely updated my childbirth education class, The Birth Preparation Course, that's my online childbirth class that gets you calm, confident, and empowered to have a beautiful birth. I rerecorded the entire course and addressed two of the biggest pieces of feedback that I was getting about the course. I actually look at every single piece of feedback that I get. One was that people wanted more visual elements to help explain things in the course. And the second was that people wanted to see more of me in the course. So both of those things are now the case. There are tons more visuals on things like explaining cervical dilation and pushing positions, optimal positions for your baby to be born, perinatal tears. There's a whole new lesson with visuals and information on medication free pain management techniques and different options to try. There's a downloadable guide that goes with that.

Nicole: And then of course I am in the course, lots, lots more as well with different outfits, different hairstyles and all in total there's an almost two additional hours of content. And compared to the previous version of the course, bringing it to just under 10 hours of content. So you can go through it on your own time at your own pace. You can binge watch it on a weekend. If you need to. I know a lot of folks will like cast the video to their TV. There's also an amazing bonus of a private Facebook group, where there are other pregnant folks that you can connect with. The community manager is a doula, I'm in the group as well. The course is also super duper affordable. So check out everything at drnicolerankins.com/enroll. I would love to see you inside the course. All right, let's get into the episode today with practice models.

Nicole: The first thing I'm going to say, and I said this before, I'm going to say it again. There is such tremendous variation in how different practices operate, and you really have to ask your own provider about how it works in their practice. This is, this is important to know, especially for when it comes time for your birth. So, you know, as much as you can about who is there with you during your birth, and you can prepare accordingly, and I'll be honest, some practices are better than other practices at really explaining and communicating how their practice works. Especially if it's a group practice, I have seen not infrequently that people were expecting that their doctor was going to be there for the birth. And then they're surprised when their doctor is not there for the birth. So you really have to ask so that, you know, for sure.

Nicole: All right. So let me start out by telling you what a solo practitioner is. That is what it sounds like. This is a doctor who practices by themselves. They don't have any partners. This is pretty rare. Okay. Not many doctors are in solo practice anymore. It's just not that common. Now with this type of model, you see the same doctor during your pregnancy and also the same doctor for your birth. So it does have that advantage, but again, it's not very common. The only time you may not see your own doctor is if your doctor is on vacation. And in that instance, they usually have agreements with other doctors in the community who cover for them in the event that they're out. But in general, you're going to see the same person during your pregnancy also for the birth. The next model I want to talk about is an academic center, where there may be residents or medical students and academic centers typically are places where there are medical schools or teaching hospitals.

Nicole: Sometimes community hospitals are affiliated with the nearby academic medical center. So it could be like the main center of the university, or it could be a hospital in the community that's affiliated with the university that also has residents and medical students. And let me back up for a minute and explain what medical students and residents are. So medical students are students who are in medical school. They are in school getting their MD or their D O degree. Okay. MD is medical doctor. DEO is doctor of osteopathy. They are practically the same in terms of how they practice. So that's medical students. Once you graduate from medical school, you can't practice independently. In most states, you have to do a residency training in whatever specialty that you want to go into. OB GYN happens to be a four year residency training program. So residents, they've graduated from medical school, so they are physicians, and now they are physicians in training, learning their specific specialty.

Nicole: So you may encounter OB GYN residents, or you may also encounter family practice residents or family medicine residents, because they also do deliveries. Now attending physicians, they are going to be at academic medical centers as well, or in general, attending physicians are physicians who can practice independently. So they have completed residency training. They have met all the licensure and state requirements in order to practice independently, any place. There are medical students and resident physicians. There are always attending physicians. That is the way that programs are set up. So medical students and residents can not practice by themselves. There has to be an attending physician in the hospital at the same time. Okay. Now, as far as the prenatal care structure, it can go a couple of different ways. And I'm talking in generalizations. Obviously I can't cover like every single permutation of how everything happens.

Nicole: So again, you have to ask your own place for sure. But typically there tends to be a resident clinic where residency patients, and then there is a faculty level or attending clinic where the attending see patients. Now, there, it varies at place in terms of who's seen in resident clinics, who's seen in attending clinics. I can say in general that most often, if you have private health insurance, commercial health insurance, you're probably going to be seen in a faculty or attending clinic. Now, when it comes to your birth, most likely it is going to be whatever doctor is on call. There's always a call system in place. And most likely it's going to be the doctor who is on call. Remember I said that when there are medical students and residents, there has to be an attending doctor in the hospital. So it's going to be that person who is assigned to be in the hospital.

Nicole: That's going to be the doctor who is there when you give birth. Now residents and medical students may or may not be involved in your care. In some places, medical students are only involved in a few patients care in some places, uh, residents may be involved in everyone's care. In some places residents may only be involved in the resident patients and the attendings take care of the attending or a faculty patients. It really just depends. So you need to ask ahead of time, if you want more clarity on this, which I suggest you do, if you're going to be delivering in a place that has the medical students and residents. And I'll say that there's nothing wrong with having medical students and residents involved in your care. There's always a supervising doctor there, and they're often super excited, especially students to be involved in a birth. WBut you can go to my website, drnicolerankins.com/resources

Nicole: And there's the guide you can download where you can ask questions to know exactly how medical students and residents may be involved in your care. Okay. The next thing I'm going to talk about is a group practice. And this is by far the most common type of practice that is out there these days. And it's becoming increasingly more common. So a group practice is when two or more physicians usually tends to be four at least four in a group work together and practice together. They practice in the same office. They cover for each other, take call together. All of those types of things. Sometimes groups can be very large. Okay? Sometimes it may be a group of like 13 or sometimes it may be a multi-specialty practice where it's a bunch of OB GYN, just a bunch of internal medicine doctors.

Nicole: And they're all under one big umbrella. Also, it's possible that a group may have multiple locations. This is becoming increasingly common that hospitals are purchasing practices. Um, so they're like big groups that are forming and they're different places, all of these kinds of things, um, just growing more and more and more. So group practice is the most common thing and that you are likely encountering. Okay. So it's also the most confusing one as a result. So for prenatal care in a group practice, you may see the same doctor for all of your visits, unless there's a schedule conflict, the doctor's on vacation or something like that. Okay. So it may be set up that you see the same doctor for all of your prenatal care visits. It also may be the case, depending on the practice, the practice may be structured that they intentionally have, you see different doctors in the practice so that you can get to meet all of the potential doctors who could be there for your birth.

Nicole: Okay. So they may intentionally say that you need to schedule appointments with all of the doctors, so you can meet everybody before your birth. Now, obviously, if they have that model where they want you to schedule with the different doctors in the practice, then, you know, right off the bat, that it's going to be whatever doctor who happens to be on call, that's going to be there for your birth. So that's pretty easy and straightforward. Where it gets to be a little bit less, not straightforward is if you see the same doctor for all of your visits, is that doctor going to be there for your birth? And the truth is it depends. Okay. So I'm going to break it down by what happens during what could happen during the day, and then what can happen at night and on the weekends. So during the day, it could be the case that if your doctor's in the office, your doctor will come for your delivery.

Nicole: If you're giving birth during the day during office hours. Okay. So certainly possible that even in a big group practice during the day, if your doctor is there, he or she will come and do the birth, however, it could be the case that your doctor does not come from the office. It could be the case that you're, it's whatever assigned doctor is assigned to the hospital for that day. There's some practices where they assign a specific doctor to be at the hospital during that day. Or if your doctor is not in the office, they're at another location, it may be one of their partners, or will be one of partners who does the delivery during the day. Okay. So during the day could be possible that your doctor comes may not be possible that your doctor comes. It really just depends. Now I can almost say pretty confidently that in most group practices at night and on the weekends and at night, I'm saying like, you know, after six o'clock and then on the weekends, it is almost always going to be the doctor who is on call for the practice.

Nicole: That's one of the reasons why practices or group practices are formed in order to have a call schedule in order to have more work-life integration in order to have more of a predictable schedule. So at night, and on the weekends, it's almost always going to be the doctor who was on call and may also be a hospitalist doctor like me. And I'll talk about that in just a second. Now, some doctors will say, Hey, you know what, if I am off, um, if it's like before, you know, midnight I'll come in for the birth, or if it's, you know, after five o'clock in the morning, I can come in or if it's on the weekend and I'm in town, then I can come in. Some doctors will offer that and you can ask, it puts your doctor in a little bit of an uncomfortable situation sometimes to answer the question, but you can certainly ask if they're available to come in at any times when they are off, if you really, really want them to be there for your birth, that really just depends.

Nicole: And it's completely individualized. But most often, I would say that if you are in a group practice, you can plan that it's more likely that it's not going to be the doctor you've been seeing on a regular basis, who is there for the birth, unless the birth is scheduled. Like if you have a scheduled Cesarean birth or a scheduled labor induction, then it's more likely to be the doctor who you've been seeing during your prenatal care. But otherwise it's not. Okay. I hope that was clear. The group practice can be a little bit tricky, but also is the one that is the most common. Right? Next thing I want to talk about is certified nurse midwives. So certified nurse midwives are midwives that have a graduate level degree. Okay? So they have a master's degree or higher. Some certified nurse midwives have a doctorate level degree that is in comparison to a certified professional midwife that does not require an academic degree. It's based on a demonstrated competency in a certain level of skills for hospitals, it's always going to be a certified nurse midwife. You won't see certified professional midwives in the hospital. Certified professional midwives are in birth centers or do home births. For a hospital births, it is always a certified nurse midwife.

Nicole: Now, depending on your state, certified nurse midwives may be independent practitioners where they can practice independently, have their own office set up. They can prescribe do all the things independent, or they may have to have a collaborative agreement with the physician. I would say about half of states, certified nurse midwives are independent practitioners and roughly the other half, they have collaborative agreements where they have to have an agreement with the physician. That's how it is. And here in Virginia, and then in just a handful a sprinkle of states, they have to have a supervisory agreement with the physician. Now, when you're seeing a certified nurse midwife, if you're in a state where they are independent practitioners, it could be a nurse midwifery practice with a group or a solo practitioner. If it's, if you're in a state like Virginia, where I am, then certified nurse midwives are within a physician practice, or they are collaborating with the physician.

Nicole: It's very clear that they are working with a physician and who the physician is that they're working with. Now, if you're seeing certified nurse midwives, and they're going to see you, if you have a low risk pregnancy certified nurse midwives are specialists in low risk pregnancy and birth, they will see you for your prenatal care. They will also be there for your birth now, and maybe a rotating system or call system similar to physicians, just like that talked about where you may see the, um, different nurse midwives during your prenatal care. And you get whatever certified nurse midwife is on call. Now, these tend to be smaller groups like it doesn't tend to be like 16 nurse midwives who could be possibly there for your birth in my experience. And again, I can't speak for every single practice, but it typically tends to be maybe like three or four. So not a huge, huge group. So it's easier to meet different people during the pregnancy. But again, it may be that rotating system, similar to physicians where it's the certified nurse midwife, who's on call who will be there for your birth.

Nicole: Now, some practices that have certified nurse midwives have a system set up where even if you see a physician for prenatal care, even if you have a higher risk pregnancy, the certified nurse midwives actually attend all of the vaginal births, okay and the physician will only attend births for their specific patient. Like if they're on call and one of their patients is in labor, then they would deliver their own patient. Otherwise the nurse midwife would deliver the rest of the patients or the physician attends operative vaginal births. So with vacuum or forceps, or they attend to Cesarean births, okay. Or it may be the case that the physician attends births for their patients during the day and the certified nurse midwives do the deliveries in the evenings and weekends with the on call doctor only being available again, if they want to, for their own patients or for operative births or Cesarean births.

Nicole: I know that is very confusing about how this might happen. So again, you have to ask the questions. All right. And then the last thing I want to talk about is what I am and that is a hospitalist. Hospitalists are similar to what the name sounds like. We only work in the hospital. I am an OB hospitalist. Sometimes we're also called laborist, but the more comprehensive term is, is hospitalist. We don't just manage labor. We manage all inpatient obstetric things and lots of gynecology things as well. So that's an OB hospitalist or an OB GYN hospitalist. There are also certified nurse midwife hospitalists. I happen to work side by side with certified nurse midwife hospitalist. I think this is becoming increasingly more common as well. Again, we only work in the hospital. We do shift work, usually 12 hour shifts or 24 hour shifts. So for me, I work seven 24 hour shifts every four weeks.

Nicole: So roughly, you know, an average two 24 hour shifts a week, all right. The midwives that I work with, they do 12 hour shifts and they do, um, evening 12 hour shifts or they do on the weekends they do a 24 hour shift. Okay. So it really just depends and every hospital is different. You cannot schedule appointments with us. You can't schedule to be with us at a specific time, whatever hospitalist is there is there. Now in some hospitalist, the hospitalist only takes care of what's called unassigned patients. So that would be patients who come to the hospital, but their doctor, or that practice doesn't deliver at that hospital. Probably the easiest way to explain that is if you were in a, um, driving, you know, on a trip and you were going through a town and you had a pregnancy issue and you stopped at a hospital on the way of your trip, you would be considered an unassigned patient, meaning that you don't have a doctor that delivers at that hospital.

Nicole: If the hospital has hospitalists, then the hospitalist would take care of you. And I should say that hospitalists are not at every hospital. I would say even not at most hospitals, but they're certainly growing, growing every day, every day, every day. Um, for many reasons, one is that it is safe. It doesn't, um, keep people like in the office all day and then up all night. And it's important to have people in the hospital provider, in the hospital to deal with any types of emergencies. Also, there's no rush for us. Like it doesn't matter to me if a hospital is, if you, as a hospitalist if you deliver at 6:00 PM or 11:00 PM, I'm going to be there regardless. I don't go home after you give birth. So there's no rush. It actually has been shown by studies that having hospitalist programs will decrease this Cesarean birth rate.

Nicole: And that's probably part of the reason why now in some hospitals, the hospitalists take over all the patients, they don't just take care of the unassigned patients. They take care of all the patients or most of the patients in the evening and on the weekends, most practices will continue to see their patients during the day. But again, the evening and weekends, the hospitalist doctor may take over. I think the model I know actually the model of hospitalist care is growing and just continues to grow. As I said, as a matter of fact, I think is eventually going to be considered, um, a specialty within obstetrics of inpatient obstetrics. So you probably will see more and more that hospitalists are becoming increasingly common. You may also see a hospitalist in what's called an OB E D or an OB emergency department. Some hospitals have emergency department areas that are specifically for pregnant people, and those are often staffed by OB hospitalist.

Nicole: Okay. So that is it for the different practice models. Just to recap, there is the solo practitioner. That's obvious that's the person by themselves. There's the academic medical center with residents. Medical students always have an, a, they always have an attending physician who is able to practice independently and is supervising them. There's the group practice model, which is the most common one and has the most common permutations of what could happen during your prenatal care and for your birth there's certified nurse midwives CNMs, and they can be in collaboration with a doctor or practice independently depending on your state. And then there are hospitalists, both OB hospitalist like me and certified nurse midwife hospitalist as well. I want to reiterate again, that it is so important that you know how your particular provider and practice works so that you can be prepared. This is part of what I teach in my free online class, on how to make a birth plan.

Nicole: Part of making a birth plan needs to be understanding who could be there for your birth and how they practice. You don't want to just show up for your birth with your birth plan, without having some idea of how the person on the other side is going to react to your birth wishes and whether or not they will support your birth wishes. Figuring that out when you show up for your birth is entirely too late. So in my free class, I teach you how to figure this out ahead of time. So register for the class at drnicolerankins.com/register. It's on demand offered every day and again, completely free. All right. So there you have it. Be sure to subscribe to the podcast, wherever you're listening to me right now, Spotify, Amazon Podcast, Apple Podcast, Google Play. And I would love it if you leave an honest review, especially in Apple Podcast, because it helps other women to find the show and it helps the show to grow. I so appreciate those reviews in there. I just love hearing what you all have to say about the show. So I totally totally appreciate those reviews, especially in Apple Podcast. Also, don't forget to check out the entirely updated Birth Preparation Course. You can check out all the details at drnicolerankins.com/enroll. Okay. So that is it for this episode, do come on back next week. And until then, I wish you a beautiful pregnancy and birth. Thanks so much for listening to this episode of the, All About Pregnancy & Birth podcast. Head to my website, drnicolerankins.com to get even more great information, including free downloadable resources on how to manage pain and labor and warning signs to look out for after birth. You'll also find information on my free online class, on How To Make A Birth Plan That Works as well as everything you need to know about my signature online childbirth education class, The Birth Preparation Course. Again, that's drnicolerankins.com and I will see you next week.