Consider this: child birth is the one and only time in your life when you will be admitted to the hospital – completely healthy. Birth is normal, and labor is not an illness, so you are not sick or diseased. You’re just having a baby. Yet, from the time you walk through the door at triage, you may be subjected to an avalanche of procedures, tests, monitoring, and interventions. In the age of information, it’s no surprise to anyone that many interventions in childbirth are overused, many times to the detriment of mothers and babies.
Before I continue, please don’t misunderstand me – I’m not saying that interventions are bad. They are designed to be used when necessary, and they certainly can save lives. Medical interventions are tools – nothing more.
However, evidence shows that the use of interventions during childbirth increases the risks of complications. In fact, as soon as a woman is given an intervention or drug of any kind in labor, she is automatically considered high risk.
If you are not sick, but risks are real, and your body is doing something completely normal doesn’t it make sense to have fully informed consent prior to accepting a procedure that will interfere with a normal, healthy process?
Most would give a resounding yes to that question.
So what is informed consent?
Wikipedia (not that I am stating Wikipedia is in any way a reputable resource…) defines informed consent as such: Informed consent is a process for getting permission before conducting a healthcare intervention on a person. A health care provider may ask a patient to consent to receive therapy before providing it.
The “process for getting permission” portion of the definition should always – always – include a discussion about the benefits, risks, and alternatives available. You can’t have informed consent without all of the information – the good and the bad, the alternatives, and a discussion about what would happen if you do proceed by doing nothing.
This is what informed consent would look like for Pitocin: “I’d like to start some Pitocin on you. I believe it is important because your water has been broken for 18 hours. At this point, your risk of contracting an infection starts to climb and I would like to do my best to make sure you have a vaginal delivery without any infections. If you were to develop a uterine infection before the birth is imminent, we will need to perform a cesarean because an infection can be very dangerous for you and especially for the baby.”
“Pitocin is a drug that mimics your body’s own oxytocin, though not perfectly. It will likely make your contractions stronger (and/or closer together) to encourage the birth to come a bit sooner. Because it isn’t exactly like oxytocin, your body’s own coping hormones won’t be as high, and you may experience more pain with your contractions.”
“The risks associated with pitocin are: we don’t know how your body will respond to it, and it could hyperstimulate the uterus. If this were to happen we would just shut it off. Because pitocin makes contractions stronger, it can cause the baby to go into distress. Babies who have been subjected to pitocin often times have lower APGAR scores, a higher risk of heart abnormalities, central nervous system damage due to lack of oxygen, and a higher risk of developing jaundice. In rare cases, death can occur, as with any drug.”
“For alternatives, you can try nipple stimulation, walking, and other natural augmentation methods that are available. What would you like to do?”
NOT informed consent: “I’d think we need to start you on some Pitocin. Your water has been broken for 18 hours and your risk of infection is higher now. I’ll have the nurse get it started so you can have your baby in arms!” And if you say nothing, silence implies consent.
Informed consent is NOT “I inform you, and you consent.” Furthermore, any discussion about informed consent also needs to include a discussion about informed refusal. Informed refusal simply states: “What are the risks associated with my choosing not to accept this procedure?” There is a flip side to every coin and consent also includes the right to refuse.
To simplify informed consent, refer to the BRAINED acronym:
Benefits – What are the benefits to having this procedure done?
Risks – What are the known risks?
Alternatives – What else can we do to manage this situation?
Intuition – What does your intuition say?
Nothing – What happens if we choose to do nothing?
Evidence – What does the evidence say?
Decision – Remember that your decision is your own and nobody but your lives with the consequences – good or bad. Own it.
So how does a mother get as much information as possible so that she can be fully informed going into her birth? How can she be sure she is truly informed?
Can the doctor do it? Statistically, OB appointments between doctor and pregnant patient are only an average of 5-7 minutes long. If a woman sees her doctor a dozen times prior to her birth, that is only about an hour of time they have spent together. Can an OB possibly explain everything a birthing woman needs to know in an hour over the course of many months? I think the answer is obvious.
Midwives spend considerably more time with their clients (30 minutes – 1 hour) at each appointment. However, these appointments are dedicated health monitoring prenatal visits and birth planning, not childbirth education.
As for birth doulas, we do 2-3 prenatal visits that are an hour or so long. Certainly we can’t give you all of our training’s worth of information in 3 hours!
Doulas and childbirth educators go through many hours of training and instruction on birth prior to certification. There is a lot to know about the birthing process and available options for women today. A dedicated independent childbirth education course will provide you with the most information you need to be fully informed. Independent educators can teach about scopes of practice, alternative protocols that are oftentimes used for various procedures, models of care, and many more crucial topics. Childbirth educators could easily make their childbirth classes a semester’s worth of daily instruction, and still feel like they didn’t give you all the information you could use.
Hospital based childbirth education classes are really good at explaining what is available in their facility and what to expect during certain procedures. They cannot explain or offer alternatives to the facility’s available interventions and procedures because hospitals do not offer those things. Furthermore, the majority of childbirth education classes at hospitals are not taught by certified childbirth educators – they are taught by OB nurses. OB nurses are WONDERFUL at what they do. They do not, however, have training in alternative protocols, models of care, alternatives to hospital protocols, or natural methods, so they cannot teach you those. This does not make hospitals bad at all – they just can’t teach about what they do not offer or do. They are a medical facility – they practice medicine – and we are grateful that they do.
To make sure you have as much balanced information as possible, an independent childbirth education class is going to be your best bet. As a birth doula, I have access to local resources for independent childbirth education that I’m glad to pass along to you.
Informed consent means choosing to be informed. Do everything you can to be fully informed prior to the onset of labor, so that you will understand risks, benefits, and alternatives before you even arrive at your birthing facility. That helps to make your labor easier, and your provider will appreciate knowing that you know exactly what you are choosing. Ultimately, the decisions you make are yours and nobody else. Make sure they are the right ones for you.
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Use your BRAIN(ED): Navigating Choices in Childbirth using THIS easy to remember Acronym
In childbirth today, women have more choices than ever in history. There are high tech options, surgical interventions, low tech management options, pharmacological interventions, pain medications, augmentation capabilities, natural remedies, and other paths that can be used to help manage complexities of labor.
With all the options, good childbirth education is key to understanding the options available to you. Still, even with a solid foundation of knowledge, every family is going to have their own path to walk as they bring their baby into the world. How a family prioritizes their options are going to be unique to them.
When navigating labor, a mother will make many choices. Having a simple but efficient way to weigh risks and benefits as you navigate labor is of tremendous benefit. So, just remember, when you are faced with a decision in labor, use your B.R.A.I.N.(E.D.)
How does this look in the application? Say you are in labor and your provider suggests augmentation with Pitocin. Go through this list so you can be fully educated and comfortable with your decision.
Benefits – What are the benefits of this particular intervention at this time? How will it change my provider’s approach to my care? What outcome are we hoping to achieve with beginning Pitocin? What will we have as a result of this intervention that we currently are not experiencing?
Risks – What are the risks associated with this option? Explain the risks that Pitocin carries and their effects on both mom and baby.
Alternatives – What can we do instead of Pitocin? Are there natural remedies we can try? What about nipple stimulation? Can mom walk around on the labor and delivery floor a while?
Intuition & Indication – Mom, what does your intuition tell you about this course of action? Never ever underestimate your gut feeling. Your intuition is strong and wise and it’s prudent to heed its warnings and follow its peace, especially in labor. Also ask and consider, what is the indication motivating the provider's recommendation?
Nothing – What happens if we do nothing? If I choose not to go forward with augmentation with Pitocin, what is going to happen? As long as mom and baby are doing fine, sometimes doing nothing is the safest option. This requires patience, but it’s many times worth it.
Evidence – What does the evidence say about this option? For instance, pharmacological augmentation with Pitocin is supported by evidence after a woman’s water has been broken for 18 hours. It is not supported for a woman who is not progressing at the same rate as the Friedman’s curve. What reason is your provider giving for wanting to go down this particular path?
Decision – What is your decision? Own it. The consequences of this decision lie with you and you alone. If you choose to have Pitocin and it leads down a common path of causing further intervention and complication, ultimately you are the one that is going to be living with that decision. Your provider is not, your doula is not, your partner sometimes is not. Responsibility for the decision you make needs to be yours alone and you can move forward with it confidently after weighing all the factors at hand.
Using this acronym is something your birth doula can help you with at each step of the way as you labor. It can be applied to each decision in your pregnancy, labor, birth and postpartum time. For instance, you can use it to decide if you want to move forward with artificial rupture of the membranes (AROM), induction, cesarean, or even epidural anesthesia.
Labor is never “textbook.” It is a very individual experience for each family. Every situation is different the way labor progresses, the priorities that a family places on certain values and the way those two things come together as a baby is being born. There are no wrong choices in birth – just make sure your choices are fully informed ones.
A birth doula can help you formulate questions and think outside the medical box for options.
Doulas Benefit Providers TOO!
By now, many people know and understand the way birth doulas support mothers in labor and how this support creates healthier births. While the research backs it up, it’s kind of just plain old common sense. Women need support on the biggest day of their life, performing the greatest physical and emotional feat they will ever accomplish – of course!
But what about doctors and midwives? For their patients that employ the service of birth doulas, what benefit is a doula to the care provider? It’s a sad reality that many people – physicians included – think of doulas and care providers as being opposing forces, always trying to “win” on the side of what they feel is best for the patient/client. A professional birth doula will do no such thing.
In fact, a well trained, professional, career doula will make every effort to be of service and support to the client while being a valuable member of the birth team. Professional doulas recognize and respect that they are working within a limited, yet extremely valuable scope of practice. Fully embracing that role, they can be of benefit to care providers in many ways.
A primary priority for birth doulas is making sure that their clients have all the information to make a fully informed decision. The care provider can rest assured that their patient is discussing at length the risks, benefits, and alternatives to their options. Patients are not alone in their rooms consorting with Google, but with someone who is knowledgeable. Furthermore, the birth doula is not emotionally or financially attached to the birth so the information they give is unbiased toward any particular path. Providers are busy in hospitals caring for several patients at a time and they don’t always have the time to have great, lengthy discussions with their patients. A doula’s job is to stay with the client through the whole birth. She is committed to being there anyway and she can take all the time needed for an informed decision to be made that satisfies the family.
Once a birth doula has spent time discussing options, she can help facilitate open communication between the provider and the laboring mother. Since she has a client relationship with the mother, the doula can make sure that the mother is fully understanding what the doctor is saying. Doulas do not speak on behalf of their clients. Rather, the doula’s priority is to facilitate an open conversation where fully informed consent can be made and this limits a provider’s liability if complications arise.
Research shows that women who hire birth doulas are much more likely to rate their birth with a high level of satisfaction, regardless of how the birth played out (http://evidencebasedbirth.com/the-evidence-for-doulas/). Patients are more satisfied with their natural birth, their induction, and their cesarean. Satisfaction with the overall birth experience naturally translates into higher satisfaction with the provider. This increases the likelihood that this patient will return to this provider and that they will recommend them to others.
Doctors and midwives can also rest assured that the patient is being monitored with trained eyes. For instance, if a woman spontaneously begins pushing, a doula can recognize that and notify the staff. A professional doula knows that her scope of practice does not include any clinical skills, including catching the baby. She can sometimes be the first line of defense in ensuring that everything happens as it should ensure a healthy birth.
Evidence also shows that births with doulas have lower intervention rates. This benefits the physician because it means lower complications associated with interventions. Patient satisfaction further increases and makes the birth with a doula more likely (but of course not guaranteed) to be straightforward and uncomplicated. These tend to be simpler births for physicians.
Doulas work primarily for women in labor. However, their unique expertise in the labor room is beneficial to all of the birth team, including the primary care provider. A doula is an advocate, a source of information, and a benefit to all involved in the birth.