Sunday, September 23, 2012

What If We Could Have Honest Conversations about Birth with Our Care Providers?

Imagine if, at a regular prenatal appointment, your midwife or OB said to you, "Let's talk about your birth options." Imagine that she or he went on to ask you what you would like to know about giving birth, what you already know, and if you have any particular ideas or plan as for how you'd like to give birth. Imagine if, taking it a step farther, she or he then gave you information such as the following:

"If you would like to avoid a cesarean section, stay home as long as possible once you think you are in labor. The sooner you come into the hospital, the more likely your labor will be augmented with Pitocin, and the more likely you are to end up with a c-section."
"As long as your pregnancy is otherwise healthy and normal, we will not induce you without your express consent. Induction before the body and baby are ready to be born increases the chances of complications, negative outcomes, cesarean section, premature birth, and birth trauma."
"If you would like to discuss the possibility of a scheduled cesarean section, let me first tell you about the risks of doing so, both to you and to your baby. We can then discuss whether the benefits outweigh the risks."
"Unless medically indicated, we do not induce or deliver surgically any baby before, at minimum, 39 weeks' gestation."

And so on.

The point is, women are expected to do research for themselves in order to make informed decisions about childbirth. What's surprising, I suppose, is that more women don't inform themselves. (I didn't, with my first pregnancy.) If I were going in for just about any medical procedure, I would probably be scouring the internet for information about that procedure before agreeing to it. But childbirth? It's natural. The body knows what to do. The nurses and doctors know how it should go. Why do I need to research?

But it's this very problem, that many women (and their partners!) don't know that there's anything to know, that can be rectified by the care providers we trust to deliver our babies. Give us a fact sheet on various birth methods. Discuss risks and benefits. Give us strategies to cope with labor pain, to decide when to come in, to manage our labor process. Help us understand what Pitocin is and what it's for and how to refuse it if we don't think we need it. Talk about induction and scheduled c-section with us, realistically.

When I was pregnant with my second, I had a doctor tell me that babies delivered at 39 weeks via scheduled c-section, 99% of the time, don't have lung issues. She was busy trying to convince me to schedule a c-section, because I was still wavering on whether to attempt a VBAC. What she didn't bother to tell me is about all the risks associated with repeat cesarean sections, such as placenta accreta in future pregnancies, infection, "imposter babies" (those babies who appear to be full term but still aren't quite ready to face the world), etc. (See my post about c-sections for more information.) A second doctor, whom I saw later in the pregnancy, did tell me some of these things, and also told me I was a very good candidate for VBAC and that there wasn't any reason not to try. Obviously, he was right!

Let's move on to the hospital setting. Imagine showing up a little too early, say, at 3cm, and being told, "You should really just go home. It will be a while, and if you stay here, we may end up trying to speed things along, which will increase your chances of complications and possible c-section." Or, perhaps they would say, "Feel free to stick around, but it's still quite early and could be hours or even a day or more before your baby is ready to come. Would you like to speak with a member of our birth support team or a doula on duty to help you cope with these contractions without medication?" (Wouldn't it be amazing if hospitals employed staff doulas to provide labor support?!)

But what if a woman comes in and just wants her pregnancy over with, if she's swollen and in pain and past her due date and horribly uncomfortable and just can't be pregnant another day, and she has called her doctor and requested an induction? Shouldn't her doctor at least discuss the risks of induction? Shouldn't she know that her chances of complications and c-section are dramatically higher than if she waits to go into labor on her own? She shouldn't be "bullied" into waiting any more than she should be bullied into a procedure such as induction or c-section, but she should make the decision fully informed.

A woman isn't "wrong" or "bad" for choosing an elective induction or c-section. A doctor isn't "wrong" or "bad" for suggesting one, especially if a woman is really suffering in her last days of pregnancy. (And, of course, medically-indicated inductions and c-sections save lives.) My concern is that many women show up at the hospital in early labor, sure they'll be holding their baby in their arms in the next few hours, and, 18 hours later, they're under the operating room lights, scared out of their wits, undergoing an emergency c-section because the Pitocin caused fetal distress. Was she fully informed that this was a strong possibility when she decided to come into the hospital?

There's room for change, here. We can work from the bottom up, educating women one at a time about their birth options, which is, in part, what this blog is about. But we can also work from the top down. Hospitals, doctors, midwives, and other care providers throughout pregnancy can help to educate and inform their patients. Indeed, these care providers themselves may need to be more educated and informed about the latest research, evidenced-based care practices, and ways to improve maternal and neonatal mortality and morbidity. Working from all directions to improve birth outcomes - at the hospital administration level, at the care provider level, and with each individual laboring woman - will create a culture of birth that is more powerful, more open, and safer for all involved.

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