Peachy Keen Birth Services Blog

Are you a childbirth conspiracy-theorist?

Every so often as I’m teaching a childbirth class and covering informed consent, I’ll have this moment where I wonder if I just sound completely insane and paranoid. This is about how it goes down:

Me: “Technically, unless it’s a dire emergency, before performing any procedure, no matter how big or how small, your provider is supposed to obtain informed consent.”

Students: “Okay, good. So they can’t do anything before we give them permission?”

Me: “Not exactly. They’re not supposed to. Most providers wouldn’t. But a small percentage do perform interventions against their patients’ wishes. So you have to choose carefully when picking a provider, and be aware of what is happening at all times.”

Students: [shocked] “Wait, so even if they know you have refused, some will still do something against your wishes?!?!”

Me: “Yes. MOST won’t. MOS’T are honest, upright people. But some do, usually because they are convinced they are doing it for your own good.”

Students: “Give us an example.”

Me: “Okay. I have had more than one student talk to me about their birth, and even though it was discussed beforehand that they didn’t want AROM, the doctor broke their water during a vaginal exam and only told them as he/she was doing it. It was all done by the time they had a chance to protest, and there’s no un-breaking it.”

By this point their eyes are huge and a shocked hush has fallen over the class. I’m not sure if it’s due to this new information that a small minority of providers don’t bother to ask permission or respect their clients’ previously expressed wishes before performing an intervention, or because they are wondering what kind of a paranoid nutball they have signed up to take classes from.

I can tell you from the universal gratitude I get at the end of class and after the births that it is the former… but I can’t help but have that twinge of self-doubt sometimes. Am I a childbirth conspiracy-theorist?

I have decided this week that I am not.

Last week, one of my students told me, quite upset, that her midwife had stripped her membranes not only without her consent, but (get this!) after her telling the midwife “no!” What I gathered was an attitude of “Calm down, it won’t hurt that bad…” and then proceeding to do it anyway.

This prompted me to ask on my Facebook page:

“Have you had a care provider do something without your consent, or even after you expressly declined? What did they do? How did you react?”

I was horrified by some of the responses. Please keep in mind that this was from only SIX different people responding. SIX!

• One mom was told that she was being given saline, when in fact it was Pitocin.
• Several had their membranes stripped without their consent.
• One had an internal fetal monitor (scalp electrode) inserted without bothering to ask for consent. This was when the baby’s heart-rate had been fine the entire time on the external monitor.
• A few episiotomies without consent.
• A couple AROMs without consent.

This is just from the the six on that Facebook post! I can tell you that I’ve verbally heard of many more stripped membranes, AROMs and coerced inductions from my students. And keep in mind that my students are EXTREMELY well prepared! They have far lower intervention rates in every category because they are prepared to ask questions, and decline interventions if there is not a medical benefit. So you can imagine how much worse it would be for a first-time mom who has taken only a hospital “here are our policies” class.

So no, I am not a birth conspiracy-theorist… because even though I believe MOST providers would not directly defy their client’s refusal of a procedure, I know that some will. And you really never know for certain which category your provider truly falls under until game day. So you need to be knowledgeable, aware, and confident enough to ask a hell of a lot of questions.

Technically, in any area of medicine, no matter how big or small a procedure may be, a provider is supposed to obtain your informed consent – except in the case of an absolute dire emergency, or when a patient is non-responsive. Obstetrics does not get a pass from this little requirement, contrary to modern customs. This means that your provider should OFFER certain information about any proposed procedure (as opposed to only telling you after you have grilled them for 3-hours, good cop/bad cop style).

Unfortunately, in regards to birth, full benefit/risk information is very rarely freely offered in a real practice setting. So the only other alternative is for you to know what questions to ask.

I teach the easy-to-remember acronym BRAINS. As in “Use your BRAINS“

• B – Benefits – What are the benefits of doing this procedure? What are we trying to achieve? Why?
• R – Risks – What are the risks of doing this? What other accompanying interventions will come with this? What are the side effects?
• A – Alternatives – What are my other options? What are the benefits and risks of those?
• I – Intuition – What is your intuition telling you? Does this make sense? If no, research independently and ask more questions, or ask for a second, independent opinion.
• N – Nothing – What if we do nothing? What if we wait a while?
• S – ‘Scuse Me – As in, please give us a moment to discuss and decide. Unless it is an absolute emergency (which it rarely is), you should be able to take a few minutes to discuss and decide alone. You can image that it’s harder to make an honest decision if the doctor’s staring right at you, waiting for an answer.

Use your BRAINS.

How would this play out in real life, you may ask?

Nurse: “The doctor has ordered a little Pit to speed up your labor.”

You: [B - Benefits] “Why does he feel we need to speed up the labor? What would be the benefit of speeding it up?”

Nurse: “He just feels like it’s going too slowly, and your water has been broken for a while now.”

You: [R - Risks] “What are the risks of Pitocin?”

Nurse: “None.”

(Mandi: This is a lie. If anyone ever tells you there are no risks to doing something, call them on their BS. There are drawbacks to everything. Sometimes the benefits outweigh the drawbacks, so just because there is a drawback doesn’t mean you should automatically refuse. But you deserve [and have the legal right] to know the risks.)

You: [R - Risks - Seriously, I would like to know the risks.] “I have read that it can increase the odds of fetal distress, and can make labor much more painful, increasing the odds of an epidural.”

Nurse: “Oh, that. Yeah, most Pitocin moms get the epidural.”

You: [R... still! This is an important category!] “Since I would be more likely to get the epidural, what are the risks of that?”

Nurse: “Drop in blood pressure, increased chance of fetal malpositioning due to limited range of maternal motion, shaking, and increased chance of cesarean due to fetal distress/aforementioned malpositioning and inability to effectively push due to loss of muscle control.”

(Mandi: The nurse is never going to tell you this. But I could really turn this into a 12-hour string of [R] questions. So for the sake of my sanity, the nurse is just going to very clearly come out and tell you the risks. This is why it’s important to take a comprehensive childbirth class so you are already somewhat familiar with the risks of different interventions.)

You: [A - Alternatives] “What are the alternatives? I’ve heard walking is fabulous at speeding up labor if time is truly a concern.”

Nurse: “Walk? What is this walking of which you speak? We’ve never had a patient walk here. I would have to call a board meeting to see if that’s a possibility.”

You: [I - Intuition] “That sounds ridiculous. Women have been walking during labor since the dawn of time. My intuition is telling me it’s fine to walk. But I would love to get a second opinion on that.”

Nurse: “I’ll see what I can do about that.”

You: [N - Nothing] “Seeing as this isn’t an urgent situation, would there be any risk to NOT starting the Pitocin right now?”

Nurse: “Um, no, I guess there wouldn’t be any risk.”

You: [S - 'Scuse Me]: “Okay. Thank you so much for your help. We’d like to have a few minutes alone before deciding how to proceed.”

Easy -peasy? Not exactly, especially not in the midst of labor. But I can darn-well guarantee you it’s better than getting steamrolled into unnecessary interventions. And again, I’d like to clarify that sometimes these questions help you to conclude that an intervention IS the safest, smartest option for your particular birth. But every woman deserves to have this information so SHE can make the decision that is best for her and her baby.

Use your BRAINS.

Mandi
Peachy Keen Birth Services