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!

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.

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!