Tuesday, January 29, 2013

Informed Consent

According to the American Medical Association, informed consent
is a process of communication between a patient and physician that results in the patient's authorization or agreement to undergo a specific medical intervention.
In the communications process, you, as the physician providing or performing the treatment and/or procedure (not a delegated representative), should disclose and discuss with your patient:
  • The patient's diagnosis, if known;
  • The nature and purpose of a proposed treatment or procedure;
  • The risks and benefits of a proposed treatment or procedure;
  • Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance);
  • The risks and benefits of the alternative treatment or procedure; and
  • The risks and benefits of not receiving or undergoing a treatment or procedure.
In turn, your patient should have an opportunity to ask questions to elicit a better understanding of the treatment or procedure, so that he or she can make an informed decision to proceed or to refuse a particular course of medical intervention.
A key factor in the case of labor and birth would be timing.  Be sure to ask if the situation is urgent or if the procedure can wait.  Consider what is being used to indicate timing.  For example, does an electronic fetal monitor indicate baby's heart rate is dipping?  Note your position.  Are you lying on your back?  This position cuts off oxygen to the baby which results in a stressed fetal response,  Try lying on your left side and see if this fixes the problem. 
Continuous monitoring became a standard obstetrical procedure before studies could show if the benefits outweighed the risks, and without clear-cut guidelines on how doctors should interpret the findings. (Brody, 2009)
Evidence shows intermittent auscultation is the best way to monitor baby during labor.  Were you told this or of the risks of cEFM, including increased vacuum extraction, increased incidence of cesarean section without a reduced risk in perinatal mortality?  I have seen all too often women whose doctors told them they'd have the freedom to move during labor only to find once in the situation they were restricted far more than they would have liked and had been led to believe by the monitors.  In the examples above and below, restriction to the bed could be the cause of the 'problem.'

Perhaps your labor seems to not be progressing.  Before you sign the consent for a cesarean , consider dilation is not the sole purpose for contractions.  Labor is a delicate dance, according to an article in Midwifery Today,
What a contraction is doing is always ahead of what a cervix is telling.
There is purpose for pauses in labor, yet some medical professionals tend to jump the gun and assume labor has stalled, opt for a c-section and jot down "failure to progress" on your medical record. Easy, safe, fast fix.  Though it's not always safe.  Let me remind you, to be informed you must be aware of the risks and benefits of accepting the intervention as well as declining it.  Informed consent should not be fear based, yet the laboring woman is told you're not progressing, something is wrong.  This creates fear & anxiety, which are not conducive to labor and birth, and also puts the pressure on the laboring mother to "hurry up and dilate" -a bodily process she cannot directly control. 
Labour in a clinical environment may undermine women's feelings of competence, perceptions of labour, confidence in adapting to parenthood and initiation of successful breastfeeding. (Hofmeyr, Nikodem et al. 1991) 
This referenced study exhibits some of the risks of laboring at a hospital.  A hospital 'requires' at least one cervical exam and the risks explored here include unnecessary surgery, postpartum depression and more.  Were you informed of this?  Were you informed of the risks and benefits of cervical examines?  Did you know you have the option to say no.  Remember, it's your body, your birth experience.  Keep calm and birth on!

A person must be "in a reasonable state of mind" in order to give informed consent.  A woman in a non-medicated labor is in a primal state- this is not of reasonable mind.  When in this state, being coerced with fear does not equal informed choice.  It is essential to educate yourself on labor and birth, create a birth plan, get to know your care provider and hire a doula- this person can advocate for you and help you remember your options and assist you in making informed choices when emergencies arise.  Labor and birth are unique to each woman and each birth yet too frequently women are treated on the same basic template.  When something arises that an intervention is suggested, a woman in labor is not necessarily of a "reasonable state of mind" and her partner may become intimidated, stressed and concerned for her well being and that of the baby.  A doula comes equipped with a clear mind in the time of need and knowledge of the physiology of labor and birth, of various medical interventions and of hospital protocols.  Using a doula facilitates informed consent.  She is not there to make choices for you but to inform you of your choices.

Evidence shows that using a doula decreases the request for epidurals.  When a woman asks her doctor about pain relief it isn't very often they recommend a doula, most frequently they'll mention narcotics and epidurals.  Ask about the risks and benefits! And don't accept the answer that there aren't any risks- it's simply not true. 

Empower yourself on this Journey of Life with education to understand all of your options for labor and birth.  Be informed when you consent!

Tuesday, January 22, 2013

Big Baby

According to Frisco Women's Health Blog the top three indications you're Doctor is planning a c-section revolve around having a "big" baby.  How awful is it that women are being scared into c-sections and inductions for "big" babies!!  Are they even being told what a "big" baby really is?  Are doctors following ACOG's said standards of presenting accurate information and a balanced evaluations or are they using scare tactics?  Are insurance companies and business costs affecting the way they practice? 

According to the American Academy of Family Physicians
Fetal macrosomia is difficult to predict, and clinical and ultrasonographic estimates of fetal weight are prone to error. Elective cesarean section for suspected macrosomia results in a high number of unnecessary procedures, and early induction of labor to limit fetal growth may result in a substantial increase in the cesarean section rate because of failed inductions.

Fetal macrosomia according to Mayo Clinic is defined as
A baby diagnosed with fetal macrosomia has a birth weight of more than 8 pounds, 13 ounces (4,000 grams), regardless of his or her gestational age. About 9 percent of babies born worldwide weigh more than 8 pounds, 13 ounces. However, the risks associated with fetal macrosomia increase greatly when birth weight is more than 9 pounds 15 ounces (4500 grams).
So how accurate are predictions of fetal macrosomia in utero??  Not very!  Fetal macrosomia cannot accurately be diagnosed until after birth.  Ultrasound estimates can be off by two pounds or more! 

Q. What about post term gestation?
Well what is post term gestation?
A. Post gestation is a pregnancy that is 42 weeks or greater!  Yes, you're risk for fetal macrosomia does increase, with associated risks occurring more frequently in a birth weight greater than 9lbs 15 oz.  If you're at 39 weeks and worrying about your baby getting bigger, remember, fat is squishy and a longer length can help you while bearing down and pushing during birth. 

Q. What about shoulder dystocia?
A.  70% of shoulder dystocia cases are related to macrosomia but there are many factors that go into this unpredictable complication such as a higher incidence in boys than in girls, in obese mothers and when maternal diabetes is a factor.  Furthermore, one half of reported shoulder dystocia cases occur in normal birth weights.

Your doctor should not be scaring you into scheduling your cesarean or your induction for fear of a "big" baby getting stuck!  Consider first the limitations of medical judgment in predicting birth outcomes. Consider what the evidence says.
A healthy mantra would be "My body will make a baby just the right fit for me."  On this Journey of Life, I urge you, trust your body and trust birth.  The vast majority of macrosomic infants do well when delivered vaginally, even those experiencing shoulder dystocia.

Monday, January 14, 2013

Who Will Attend Your Birth

Did you realize this the birth of your baby?? The people there should be those chosen by you!  You hire your doctor/midwife, you hire your doula, you invite whoever else you please and restrict anyone you like.  I've already mentioned the benefits of a doula here and be sure to read up on what the American Pregnancy Association has to say about having a doula. 

If you're wondering whether or not to have your mother or mother-in-law present, have a chat with her.  Let her know what kind of support you will find beneficial at your birth and decide from there.  Do you have a sister who offers too much unsolicited advice?  A best friend who loves updating her facebook every contraction?  You may want to kindly ask them to wait in another room and invite them to visit your new little bundle whenever you're ready.

An OB or a Midwife- which is right for you? 


An obstetrician/gynocologist is a phsycian who provides medical and surgical care for women, with specialize training of the female reproductive system and pregnancy.

This OB/GYN link specifies their training requirements and more.  An OB is a great choice if you are high-risk because they are trained to find complications and manage them. OB's attend hospital births which typically cost $16,000-$21,000 for an uncomplicated vaginal birth.

When deciding on an obstetrician get an idea for their view of childbirth with these questions:
1. What is your philosophy about childbirth? What do you feel your role is?
2. What is your cesarean rate?  (The WHO recommends no higher than 15%)
3. How do you feel about parent written birth plans?
4. How do you feel about unassisted childbirth? (This isn't to say your planning on one, it's just to get a feel for how much this particular care provider trusts birth.)
5. What is your episiotomy rate?
6. What do you do to reduce the chance of tearing or the need for an episiotomy?
7. How do you feel about doulas?
8. (If they are female) Do you have children? Tell me about your birth experiences.
9. What happens if my water breaks before labor begins? What kind of time-frame am I restricted to?
10.  Do you practice active management of labor? Do you routinely intervene or allow labor to progress normally?
11. What hospital(s) do you practice in?
12. What happens if I go past 40 weeks? 41 weeks? 42 weeks?
13. What is your induction rate? Under what conditions to you advice an induction?
14.  What natural induction techniques do you recommend?
15. What percentage of your "patients" are high-risk / low-risk?
16. What conditions do you consider high-risk?
17. How do you handle fetal monitoring?
18. Will I have freedom of movement during labor?
19. Can I try alternate birth positions?
20. Do you have any plans or interferences around the time my baby is due?
21. What prenatal procedures do you typically do?


A midwife is a person trained to assist women in childbirth. 

There are different types of certification and training for midwives, the most common of which I'll cover. 
There are direct-entry midwives, who do not require prior education as a nurse.  These are CPM's, or a certified professional midwife who has met the standards for certification set by the  North American Registry of Midwives or licensed midwives, LM, who practice in a specific state.  These midwives work in out of hospital settings. A typical home birth varies in cost by location.  After midwife fees, supplies and labs you can probably expect to pay $4000-$5000.

Some questions to ask a potential midwife:

1. What is your philosophy about childbirth?
2. What is your training and experience?
3. Do you routinely perform vaginal exams or only by request?
4. What other methods do you use to assess dilation?
5. What happens if I go past 42 weeks?
6. What do you do if the baby is breech?
7. Regardless of whether you will attend a vaginal breech birth, how do you feel about them?
8. What do you consider high risk?
9. When in labor do you come to my home?
10. How often do you check baby's heart rate and what do you use?
11. What is your episiotomy rate?
12. What do you do to help prevent a tear? 
13. What kind of equipment and medication do you have at a birth?
14. How does a transfer work? What is your transfer rate?
15. What are your fees? What is included/not included?
16. Do you offer placental encapsulation?
17. What happens if my water breaks before labor begins?
18. What is your experience with shoulder dystocia? Cord prolapse? Postpartum hemorrhage?
19. Do you work with doulas? Birth photographers?
20. Do you recommend or work with a doctor in case of emergency?
21. Who will attend my birth if you are sick or unavailable?
22. Do you offer or recommend a particular childbirth education class?
23. Can I have a water birth? Do you supply the tub?
24. Can I eat while in labor?
25. What do you normally do during labor?
26. Can my partner catch the baby?
27. Under what circumstances would you artificially rupture the membranes?
28. What newborn procedures do you typically do?

A CNM, or certified nurse midwife, is an advanced practice nurse who attends your birth in a hospital or home.  They work with a doctor who backs them up should complications arise.  I like to think of CNM's as the in-between- you don't want a doctor but you still want to birth at the hospital. Or possibly you'll choose a CNM because they are covered by your insurance provider.  No matter who you choose, remember you have hired them! You can change care providers at anytime if you determine they are not the right fit for you!

Getting ready for your baby's Journey of Life can involve making a lot of decisions; it's important to have people beside you who will support you in positive ways and empower you in your childbirth experience.  

What questions do you ask potential care providers and doulas?  Share your experiences here!

Tuesday, January 8, 2013

Childbirth in Pop Culture {A Birth Circle Topic}

From stethoscopes to dopplers to continuous fetal monitoring, we've come a long way in childbirth but we're still hearing the same thing.  The media distorts childbirth, painting images of fear and chaos that are being forever imprinted on impressionable young girls.  I implore you, to more closely examine what you believe about birth and where you get your notions from; take a look at what you're daughters are learning about childbirth and where they are learning it.  Birth should not be something we fear, rather something we trust.  Yes, labor is hard work but it doesn't have to be excruciating.  Most low-risk labors would progress normally and without complications if women were left to natural progression, contrary to what some Hollywood films would have us to believe.

In sci-fi and horror films women are victimized into their pregnancy and throughout the birth.  In comedies panic ensues and women are unqualified.  The biggest fear expressed by expectant mothers is pain; it's no wonder why when that's what Hollywood wants us to see; the drama sells.  Twilight offers a horrific scene of a disfiguring, painful childbirth. Real childbirth seems to be Hollywood's last taboo, as Dr.'s hand over perfectly clean and swaddled babies from under the blue sheet to their mothers. In our pop culture births like this will be hard to come by. 

Historically Speaking

In the 1950's CBS would not allow the word pregnant to be said on the popular sitcom I Love Lucy today a model faces controversy while keeping her pregnancy secret for the first four months.  Whatever happened to having the freedom of choice?  The biggest assault of choices for pregnant women is with whom and where they'll birth.  Women are assaulted as to exactly how they should birth, much of this assault stemming from the media.  In America, when childbirth moved into the hospital, adds came out slandering midwives, depicting them as decrepit and for the poor.  Historically speaking we've gone through our fair share of childbirth fads- with hospital births came the option of "pain free" childbirth.  Moving birth out of the home created the mystery surrounding birth as each generation no longer saw birth as a normal part of life.  Twilight sleep induced an even bigger mystery as mothers had no memory from the experience and fathers weren't permitted.  All we knew now was what we heard- birth hurts, be pain free.  It got to the point where it was thought that wealthy women couldn't birth naturally because they were too pampered.  In the 40's and 50's Lamaze became popular after Marjorie Karmel smuggled in the "pornographic" video of natural childbirth.  This wave of natural childbirth, where mothers longed to be an active part of their birth experience, lasted into the 90's.  In the popular culture of today we most commonly see women asking or should I say screaming, for their epidurals.  Again we're seeing a repeat of "too posh to push" with scheduled c-section/tummy tuck combos flashed about by Hollywood. 

So take the time to re-think your views on birth and trust this beautiful part of your Journey of Life.  Birth can surprise you and not all birth plans go accordingly but that's ok.  Read and watch positive birth stories and videos.  Enjoy browsing through the folios of birth photographers.  Take a childbirth preparation course!  Watching Birth Day, One Born Every Minute or Call the Midwife does not count.  Find a Bradley Method, Lamaze, HypnoBabies or Hypnobirthing instructor near you.  Ask your care provider what they recommend.  Check with your doula; some offer childbirth education.  Another great resource is http://www.icea.org/.  Check out what your local hospital has to offer.  Read empowering books like Birthing From Within, by Pam England and Birth Reborn, by Michele Odent.  Don't believe everything you see on T.V.  Take the time to share with your daughter what birth really can be like; perhaps you can be part of bringing birth back into the home as the intimate experience it is.

Other Birth Circle Topics:

Thursday, January 3, 2013

Technology in Childbirth

Each new year brings new knowledge and new technologies.
From stethascopes to continuous fetal monitoring, we've come a long way in childbirth but are all these advancements helping or hurting us.  With the introduction of continuous fetal monitoring came an increase in the c-section rate but no benefit to the health of baby.  From 2D ultrasounds to 3D ultrasounds; we can see so much more detail today but at what cost?  With these advancements we are losing the art of birth.  Experienced midwives on The Farm will tell you that they can guesstimate a baby's weight by palpation alone with just as much if not more accuracy than the technology.  If you consider pain management a technology, this is another change women face; their expectations changed all together.  What many women don't realize is that we are still learning the effects of epidurals and certain narcotics.

I challenge you- with everything offered to pregnant women today it's hard to filter through it all and know what's best for you and your baby, but this is your body, you birth!  Take charge of it- do your research.  Today, women will spend more time planning for their wedding than the birth of their baby and that shouldn't be.  Some things to consider while planning your birth-  Where you will birth, who you will have there, what procedures you will have done prenatally, how you will best embrace labor, birthing positions, newborn procedures and your postnatal care plan.  All of this to come in future blogs!  This is the start to a very important someone's Journey of Life, this is very important part of your very own journey.  Birth is one of the most transformative times in the lives of at the very least two people!

Contact info

Jennifer Valencia | Labor & Postpartum Doula | 928.300.1337


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