Questions to Ask Your Doctor or Midwife During Pregnancy

November 20, 2010 at 7:41 am (Doula, Education, Hospital Procedures, Informed Consent)

Your care provider and her or his philosophy about pregnancy and birth can shape the emotional tenor and physical experience of your labor and birth.  Ideally, you might want to interview three or four care providers before settling on one.  Here’s a short list of questions that you can ask providers- the answers will reveal something about both their practice and their personality, which can help you in making your decision.

If you already have a care provider, these questions can give you a sense of how your doctor or midwife likes to practice.  If her or his answers differ from your preferences, then you can begin a discussion to explore your options.  If there are any procedures that you would or wouldn’t like that are not in your care provider’s routine scope of care, you can request that whatever you’ve agreed on be noted in your chart, for future reference.  The information you glean from these questions is also helpful in constructing a birth plan.

Questions:

Do you have any recommendations for childbirth classes?

Are you likely to deliver my baby?  Can I meet your backup(s)?

What percentage of your patients deliver vaginally?  By Cesarean?

About how many patients out of 10 are induced?  How many go into labor naturally?

Have you worked with any doulas?  Are there any you could recommend for me?

What do you think of birth plans?

How long could I go with my amniotic sac broken before you’d want me in the hospital?

Do you do episiotomies?  If so, what would make you want to do one?

How often do you perform amniotomies (breaking the bag of water)?  Why do you do them?

How often do you perform cervical checks during labor?  What do you do if a client doesn’t want to be checked?

Are you comfortable with me eating and drinking during labor?

Are you comfortable with me walking and moving during labor?

How do you feel about natural, nondrugged labor?  Would you support me if I chose not to have an epidural?

Are you comfortable with me pushing in positions other than lying on my back or semi-sitting?

Will you deliver a baby in the water?

How do you manage the delivery of the placenta?

This is just a short list of questions.  You can find a more extensive list of questions here.  Remember that it’s not just what your care provider says when they answer your questions, but also how they answer, that’s important.  For instance, when asking about specific procedures, if your doctor says “Oh, all women in my practice…….”, then s/he might not have a lot of flexibility regarding your individual needs.  If your doctor is surprised that you would ask about unmedicated labor (“Why would you want to feel the pain?”), it might be a good time to question his/her belief in your body’s ability to give birth without intervention.  The best care providers are the ones who use their skill and knowledge appropriately, and balance the medical care they provide with the autonomous decision making of their clients.  You have the opportunity to find a care provider that fits well with your outlook and wishes.  Don’t hesitate to “shop around” until you find someone you feel really comfortable with!

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Informed Refusal

August 13, 2009 at 6:58 pm (Hospital Procedures, Informed Consent) (, )

Many mothers who choose to work with a doula are looking for someone to support and advocate for their choices regarding medical treatment and interventions during hospital births.  As a doula, I relish working with mothers as they do research and learn about all things childbirth, from the natural physiology of labor to the functions and effects of an epidural, and many other topics of interest.  They ask me, during this learning time, what I will do if we’re in the hospital and their doctor or nurse tries to make them do something they don’t want to do.  In the discussion that follows that sort of question, I introduce them to a concept that I wish all pregnant women knew about: informed refusal.

Most of us have heard of informed consent.  It’s the idea that a doctor or midwife will inform us thoroughly of all the risks and benefits of a procedure before we agree to it.  This is done so that a patient will understand why a particular procedure is being suggested, and also so they will not be surprised by any side effects or possible negative outcomes of the procedure.  But the understanding underlying informed consent is that the patient will consent- their agreement is implied, the information is designed to elicit that agreement.  But what if the patient has been informed of all the risks and benefits of a procedure, and she decides that she does not want to accept it?  Is she allowed to do that?

The simple answer is: yes.  Any patient has the right to refuse any and every procedure, intervention, test or anything else that hospital staff or doctors would like to perform.  In fact, if any procedure is performed without a patient’s consent, it is considered criminal battery.  Imagine the uproar if a doctor gave someone anasthesia and did open heart surgery after the patient had strongly and vehemently refused such an operation.  It would be unacceptable, and would probably elicit a national hue and cry.  The exact same rights apply to a pregnant, laboring, or birthing woman.  She has the right to refuse any and every procedure, no matter how much a doctor or midwife thinks she should have it done.  This is the right of informed refusal.

The only difference between informed consent and informed refusal (aside from the lack of consent) is that, once a patient refuses a treatment or procedure, a doctor or midwife is under the legal obligation to explain the risks of refusing that procedure.  The tone and wording of that explanation is up to the individual practitioner, and can range from a calm explanation of the statsitics to an impassioned and perhaps angry description of the danger and possible death inherent in refusing.  But the mother should keep in mind that, no matter how it is expressed, the doctor or midwife’s opinion is just that, an opinion: it is neither an order that must be followed nor a sure prediction of any sort of outcome.

In saying all this, I am in no way encouraging women to discount their caregiver’s opinion or advice.  Doctors and midwives are, in general, looking out for the best interests of mother and baby, and are giving the very best advice they can given the situation and their experience.  More often than not,  women follow their doctors’ advice, because they too want only the best for their children.  But, if a situation arises where a mother truly believes that what is being offered to her would be harmful or injurious to herself or her baby, or just wouldn’t be helpful, she has the full and undeniable right to refuse that procedure.  No doctor can “make her” do anything, and she cannot be denied care based on her refusal (in rare cases she might be transfered to the care of another provider, but she cannot be left doctorless).

Recently, I was with a young mother who exercised her right of informed refusal during an intense moment in her labor.  She was pushing out her baby, and as he was coming through her birth canal, his heart rate was dipping.  As the decelerations became more prolonged, her doctor, who had been staring in concern at the fetal monitor, walked to her side and explained to her that, while her baby wasn’t in danger yet, he needed to come out soon so that his heart rate wouldn’t slide lower, risking his life.  He told her that he could perform an episiotomy to speed the birth.  The mother shook her head vehemently, said “No!”, and then proceeded to birth her baby in the next few contractions.  I was impressed both by her ability to speak up for herself in such a stressful moment, and by her taking the situation in hand and protecting her baby in her own way, by finding the strength and purpose to birth him quickly and safely.  Her refusal did not cause her or her baby injury or harm, and she was able to resolve the situation on her own, with power and strength.  I hope that all mothers will recognize this power and strength in themselves, and that their doctors and midwives will recognize it as well.  In this way, informed consent and informed refusal will not just be informed by the doctor’s experience and wisdom, but also by the mother’s inherent knowing and birthing abilities.

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VBAC’s in the media

April 6, 2009 at 10:54 pm (Hospital Procedures, Informed Consent)

While perusing the magazine rack at my local coffee house, I found an article entitled “The Trouble With Repeat Cesareans” in the March 2nd edition of Time magazine.  I’d recommend reading it in full, but I’ll share a few details.  I find it heartening that a national publication is covering the difficulty many American women are having in completing a successful VBAC. 

“Much ado has been made recently of women who choose to have cesareans, but little attention has been paid to the vast number of moms who are forced to have them.” (emphasis added)  This an important point for both first-time mothers and those who are pregnant after a Cesarean.  Many physicians consider it their duty to restrict a mother with a previous C-section to a surgical delivery in subsequent births.  During research on the rights of informed consent and refusal, I stumbled on a discussion between physicians about “those women” who try to deny C-sections when their practitioners refused to attempt a VBAC.   A lone doctor (immediately one of my heroes) argued that, ultimately, it is a woman’s choice what is done to her body.  He acknowledged the ethical dilemma faced by a doctor who truly thinks a C-section is the safest option, but concluded that if a mother refused one, it was his duty to attend her vaginal birth and usher her through it as safely as possible.  This was not the opinion of most of the other doctors in the discussion, however.  They lamented the VBAC movement and discussed tactics for convincing a woman to have surgery, regardless of her wishes.  To them, informed consent meant doing something because your doctor had informed you it was the right choice, and informed refusal was something to be dismissed with ever-more-dire predictions of disaster if their recommendations were ignored.  I don’t know how many OB’s similarly discount the right of birthing women to determine their own decisions regarding medical care.  I do know that, if a woman wants a VBAC, in many areas around the country she’s fighting an uphill battle, and she should come to the birthing suite armed with information and a doula (our nurturing and comfort techniques have been shown in studies to decrease the incidence of Cesarean sections).

The article described the climate that has contributed to the decrease in VBAC availability in the US.  “In a 2006 ACOG survey of 10,659 ob-gyns nationwide, 26% said they had given up on VBAC’s because insurance was unaffordable or unavailable; 33% said they had dropped VBAC’s out of fear of litigation.”  Doctors are afraid of being sued if there is a bad birth outcome, and they have been encouraged to believe that VBAC’s are likely to lead to a bad outcome.  But is this really true?  And what are the risks of repeat Cesareans, as compared to the risks of VBAC?

“The risk of uterine rupture during VBAC is real….but rupture occurs in just 0.7% of cases.”  Add to that the fact that uterine ruptures, although they have serious potential complications for mother and baby, are not necessarily fatal to either.   And uterine ruptures can also occur in an unscarred uterus, especially when the mother is given Cytotec to induce her labor (see this article by Marsden Wagner, a reknowned researcher into American birth practices). 

“With each repeat cesarean, a mother’s risk of heavy bleeding, infection and infertility, among other complications, goes up.  Perhaps most alarming, repeat C-sections increase a woman’s chances of developing life-threatening placental abnormalities that can cause hemorrhaging during childbirth.”  This point cannot be emphasized enough.  During their “informed consent” process, are mothers being given this information?  If so, why is there the pervasive cultural belief that C-sections are somehow easier on the mother’s body than natural birth?  Mothers need to know that Cesareans pose significant risks to their reproductive and abdominal health- I personally would not approach this risk lightly, and would only choose a Cesarean if the risks to my baby’s or my own health truly outweighed the risks of the procedure.

Not mentioned in the Time article, but worthy of mention here, are the risks to the baby resulting from a Cesarean.  Babies who are born via c-section are more likely to develop difficulty breathing than babies born vaginally.  There is the risk that, if dates were miscalculated, a baby could be delivered prematurely.  And babies can be injured during the cesarean.  See this link for references and more info on Cesareans.

I am so glad that the VBAC dilemma, and the risks of Cesarean sections, are being covered in the national media.  Once doctors and mothers look at the real risks of Cesareans, we will have motivation to return to the VBAC-friendly practices of the 80’s and early 90’s, to the benefit of mothers and babies everywhere.

For more information on VBAC’s, and Cesareans in general, you can visit:

http://www.ican-online.org

http://childbirthconnection.org/

Any book by Marsden Wagner, Henci Goer, or Nancy Wainer Cohen

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Adrenaline in Birth News

March 23, 2009 at 4:01 am (Hospital Procedures)

This story came from my local NC newspaper:

http://www.citizen-times.com/apps/pbcs.dll/article?AID=2009903210323

This kind of training is obviously important for doctors who may run into emergency scenarios when caring for birthing women.  But doesn’t it also set in the idea that birth can always go wrong, that birth is always a potential emergency?  What about training scenarios where the mom and the baby are healthy….and the mom chooses to deny fetal monitoring…..or she won’t take RhoGam because of religious reasons….how about training for sensitivity when the need arises to examine a mom?  Do doctors train for these interesting communication situations, where they must employ all their skill and knowledge as a doctor and yet take into account the wishes and beliefs of their clients? Do they train for collaborative care?  It’s interesting to me that the special training scenario involves a situation where a doctor must take complete charge and use heroic measures to save a woman and a baby’s life.  This highly emotionally charged situation will be remembered much more quickly and clearly than the routine, mundane case of a woman for whom everything goes naturally and well.

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Breaking Waters: Amniotomy or Spontaneous Rupture?

March 19, 2009 at 2:01 am (Hospital Procedures, Informed Consent) (, , , )

One of the myths of childbirth is the idea of a dramatic beginning to labor:  a very pregnant woman is innocently going about her business when all of a sudden: gush-SPLAT!  Her waters break, she is immediately in hard labor, and she is rushed to the hospital.  Sometimes, it is true, labor starts with a tidal wave of breaking waters and intense contractions, but this is the exception, especially for a first-time mother.  The majority (although there are an amazing diversity of variations) of labors are comprised of a gradual buildup of contractions, increasing in intensity and strength.  The most common time for the membranes to break naturally is during the pushing phase, when the waters can act to “slick the slide” (to quote a favorite midwife of mine) and help the baby on down the birth canal.

Since people hold the idea that labors typically start with broken waters, it is understandable that one of the most common and accepted interventions during labor is amniotomy, which is artificial rupture of the membranes (amniotic sac) by a doctor or midwife using an amnihook.  If the membranes haven’t broken on their own, won’t it help  speed things along if a practitioner does it?  This thinking has led to the acceptance of a practice which, when used routinely, may or may not be beneficial, and which does have documented risks to the mother and the fetus.

According to Henci Goer (The Thinking Woman’s Guide to a Better Birth, Perigree, 1999) there are two different types of amniotomy: those done routinely, early in labor, and those done later on for a specific reason.  Let’s look at each type.

The use of amniotomy in early labor is based on the presumption that, when the waters break, it fits the baby’s head tightly into the cervix, allowing contractions to work more effectively to speed dilation and resulting in a shorter labor.  Some studies have shown a shortening of labor by 1-2 hours when this kind of amniotomy was employed (Goer 99).  But before these results influence a mother’s decision about amniotomy, she should ask herself why these labors were shorter, and whether there are any risks resulting from amniotomy that might outweigh the benefit of a possibly shorter labor.

The length of labor described in these studies may be deceptive.  In nine studies of amniotomy vs. “conserving membranes”, Cesarean rates were consistently higher for women whose waters were broken by their practitioner (99).  A Cesarean delivery is usually done before the last minutes of labor, so the length of these labors would have been artificially shortened by the surgery. If amniotomies are more likely to result in a Cesarean section, perhaps it would be prudent to reserve their use until later in labor, when or if an indication arises for which they might be truly beneficial.

Another downside of amniotomy use in early labor is the perception of pain.  Many labor stories (mine included) mention that after the waters break, the pain becomes more intense,  This makes sense, since the amniotic fluid provides a cushion between the mother’s pelvis and the baby’s body.  Once that cushion is removed, the baby exerts more pressure on the mother’s tissues and bones which in some cases can result in more pain. If this happens toward the end of labor, it provides impetus for the mom to push harder and get the baby out.  If it occurs in the beginning of labor, then the process can become more painful at a time when there’s less that the mother can do actively to relieve that pain.  This is not to say that if waters do break naturally or artificially in early labor, it means that the labor will become unmanageably painful.  There are many comfort measures that are quite helpful.  However, if it’s not necessary, why should the mother be subjected to a potentially more painful labor early on unless it’s a natural part of her body’s plan for the birth?

So we see that the supposed benefit of early artificial rupture of membranes might not hold up under scrutiny, and we see that for some mothers there is an elevated experience of pain resulting from amniotomy.  Bur are there any objective, medical risks resulting from amniotomy?  According to Goer, the answer is yes.

As I’ve already mentioned, the amniotic sac provides a cushion around the baby.  When these waters flow out of the womb, the baby is subjected to more of the pressure resulting from contractions.  In extreme cases, the cord can become displaced and pinched, cutting off the baby’s supply of oxygen (cord prolapse).  Even when this doesn’t happen, some babies don’t respond well to the added stress of contractions without the cushioning water.  Their heartrate can become irregular or too slow, and they can descend into fetal distress.  Since these abnormal heart rates are one of the primary causes for Cesarean sections, it makes sense that women who have amniotomies are more likely to have Cesareans than women whose membranes rupture naturally.

Goer also cites several studies that link amniotomy to higher maternal infection rates (101).  Once the waters are broken, the bacteria that are always present in the birth canal can travel up into the womb, precipitating an infection in the mother, the baby, or both.  Vaginal exams, which are frequently performed in the hospital, can hasten this transfer of bacteria.

These risks to mother and/or baby, combined with the questionable nature of the benefits, might lead one to question the necessity of routine early amniotomies.  But what about breaking the waters for a specific reason later in labor?

Sometimes when a mother reaches 7 or more centimeters dilation and then doesn’t progress for a while, a practitioner may recommend amniotomy to remove “bulging forewaters” (a bubble of amniotic sac and fluid that is coming through the cervix before the head).  Again the thinking behind this recommendation is that breaking the waters will help to bring the baby’s head fully onto the cervix, allowing the cervix to dilate more effectively.  In my experience as a doula, I have seen amniotomy in this case to be effective for some mothers.  When labor is already well established, and positions and movement have been tried but haven’t been effective, amniotomy may be helpful to complete dilation and aid the baby’s descent into the birth canal.  However, I think a mother should always check in with her own body and intuition- if she feels like it’s not a good idea, then in the abscence of medical necessity, it’s her right to refuse an amniotomy.  If the mother’s first response is “Yes!  Anything to help move this along!” then it might be a good idea to go ahead with breaking the waters.  Each case of amniotomy at a late stage in labor is individual, and should be evaluated according to the mother’s and practitioner’s judgement.

The risks of late amniotomy are less than those of early amniotomy, because there is less time for the risks to develop.  This is especially true for infection, since the amount of time that passes after the breaking of the waters is a big factor in whether or not an infection will set in.  In regards to fetal distress, it can still occur at a late point in labor, but if the amniotomy is done closer to birth, the baby has less time to become exhausted and depleted.  And if the baby’s head is well engaged, there is less chance of a cord prolapse, although it is still a possibility.

As a doula, my personal birthing philosophy is that bodies are wise, and birth will generally proceed best if left undisturbed by interventions.  However, there are some isolated cases where I’ve seen a late-in-labor amniotomy help a mom to birth her baby more quickly and easily.

Whatever your feelings are about the breaking of your waters, it is a good idea to ask your doctor or midwife about their protocols concerning amniotomy.  As Goer says, “Many caregivers consider amniotomy so trivial that they may not think to advise you that they are about to do one” (102).  If your practitioner does suggest rupturing your membranes during labor, it is entirely reasonable to ask for five minutes to think about the procedure before making up your mind.  This will give you some unpressured time to check in with your body, or read a page in a book, and from there make the decision that is best for you and your baby.

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