Can I refuse advised treatment? Informed CHOICE

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.

For example:
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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