This episode we are talking about using your brain. In this case, we are talking about your brain as being an acronym for some good questions you can run through when deciding if any intervention or procedure is right for you during pregnancy, birth, or with your newborn. You will come across a lot of opportunities to opt-in or out of interventions during your pregnancy or birth, or even with your newborn baby. In a perfect world every procedure comes along with informed consent and you have all of the information you need to make an educated decision you can be confident in. In the real world constraints like limited time available for appointments make true informed consent a challenge. This article has 5 simple questions you can ask to help determine whether any procedure or intervention is right for you.
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You will come across a lot of opportunities to opt-in or out of interventions. The definition of intervening means to come between so as to prevent or alter a result or course of events. An intervention is defined as the action or process of intervening, or an action taken to improve a situation, especially a medical disorder. When you apply these definitions to your pregnancy or birth I define an intervention is any action taken to alter the course of your pregnancy or birth. This article has 5 simple questions you can ask to help determine whether any procedure or intervention is right for you.
Examples of Interventions
An intervention could be a prenatal test, whether non-invasive or invasive. The results of a non-invasive test could alter your prenatal care or your birth plans. An invasive test like a CVS comes with risks to you and your baby and the benefits of getting a clearer diagnosis of any potential issues. Inducing labor is an intervention that can alter when your labor starts and potentially change some aspects of your labor and birth. Then there are other routine procedures that are really interventions, although we may not traditionally think of them that way. This would include an ultrasound or a vaginal exam. Any procedure has risks and benefits, whether those are small or major. You will find yourself constantly making decisions about whether you want to opt-in or opt-out of these procedures.
Any intervention or procedure should be accompanied by informed consent. According to the American Medical Association, the process of informed consent occurs when communication between a patient and physician results in the patient’s authorization or agreement to undergo a specific medical intervention. In seeking a patient’s informed consent physicians should:
(a) Assess the patient’s ability to understand relevant medical information and the implications of treatment alternatives and to make an independent, voluntary decision.
(b) Present relevant information accurately and sensitively, in keeping with the patient’s preferences for receiving medical information. The physician should include information about:
- The diagnosis (when known)
- The nature and purpose of recommended interventions
- The burdens, risks, and expected benefits of all options, including forgoing treatment
(c) Document the informed consent conversation and the patient’s decision in the medical record in some manner.
In emergencies, when a decision must be made urgently, the patient is not able to participate in decision making, physicians may initiate treatment without prior informed consent. In such situations, the physician should inform the patient at the earliest opportunity and obtain consent for ongoing treatment in keeping with these guidelines.
Informed Consent in the Birth Community
Organizations within the birth community have guidelines on informed consent. The American College of Obstetricians and Gynecologists opinion acknowledges that there are practical difficulties with ensuring the kind of communication necessary for informed consent. The first limitation they address is the limitation of time, which plays a big role in this. It is difficult to take the time needed to discuss procedures at length when you are limited to 15 minutes or less for an appointment.
The North American Registry of Midwives outlines the components of informed consent as Shared Decision Making and Informed Consent. I like their emphasis on shared decision making because that is what your prenatal care is. You are working with your doctor or midwife to make shared decisions. This is a two-way street.
The Challenges of True Informed Consent
My interpretation of true informed consent means that you fully understand the procedure, intervention or treatment, that you are made aware of all of the risks and benefits, and that you have the choice to opt-in or opt-out. The last part of that is really tricky. The truth is that you can opt-out of anything. This includes ultrasounds, vaginal exams, the glucose tolerance test, genetic testing, testing for GBS. For a doctor or midwife to truly give you a choice can be tough because they, and the entities like hospitals they work for, have policies about what is “required” and routine. I know from even my personal experience that it doesn’t always feel like you have a choice, but it is so important that you know you do. You always have a choice and that is a key component of true informed consent.
Challenges to Getting True Informed Consent
Some constraints that can make it challenging for care providers to give true informed consent are:
- The time set aside for each appointment
- How many patients your doctor or midwife sees in a day
- How informed they are about the particular topics
- Whether they are up to date on the latest research and evidence
- What they consider to be a medical procedure or something that needs informed consent
All of these constraints can make it challenging for doctors and midwives to provide true informed consent for everything with every patient. Some care providers make it a high priority to give true informed consent and others, unfortunately, do not prioritize it.
Your Role in Decision Making
You are the commander in chief of your pregnancy and birth. You should have a team of people on this journey with you. Your team includes your partner, doctors, midwives, nurses, doulas, family, and close friends. A huge thank you for allowing me to be a resource for you as you navigate all of these decisions. I do not take that honor lightly and I want to give you the best tools to have in your toolbox. One of the most versatile tools that you can apply to anything is your brain. I am not talking about the 3-pound organ in your head, I am talking about the acronym BRAIN.
Each word in this acronym is the key to a question you can ask to help you figure out whether any intervention or procedure is the right choice for you. Allow me to explain how you can apply this to your decision making with some concrete examples.
What are the benefits?
This is likely one of the first questions you ask. Afterall, the goal of any procedure or intervention should be to improve something and benefit you and/or your baby.
You may be debating whether or not you want to do an NIPT screening test or a cell-free DNA test. One benefit of this test is that it is non-invasive because it only takes blood from you, it doesn’t affect your baby. Another benefit of this test is that you have more information about your baby. This includes their biological sex and whether they could be at an increased risk for any genetic abnormalities. The power of asking the questions in the BRAIN acronym is asking all five of them. This really covers every aspect of the pros and cons of a procedure or intervention. Once you know the benefits you would go on to ask the risks and so on. This will give a complete picture and clarify what you want to do. Asking what the benefits are is step one.
What are the risks?
There are so many routine procedures that carry risks that are often overlooked. Vaginal exams are in that category. For a lot of expecting mothers, this comes up during an appointment near your due date. Your doctor says, “I’m going to do a vaginal exam” and you say, “okay”. They do the exam and you get to find out if your cervix has started to dilate and efface. This could or could not be a sign you are close to labor. A good question to ask here is, what are the risks? If you ask that question you would find out that there are some risks. These include premature rupture of your membranes or an increased risk of infection. Depending on how you will use the information from this exam you may still decide to do it. At least if you know the risks you can weigh those against the benefits to make an informed decision. Any intervention or procedure has risks, that isn’t necessarily a reason to opt-out, but any risks are something you should consider against the benefits.
What are the alternatives?
Perhaps you are exploring your options for pain management or medication. If you bring this up with your doctor or midwife, the most commonly used method to manage the pain of contractions is an epidural. If you are not sure whether that is the route you want to go a good question to ask could be, what are the alternatives? Obviously, this is a conversation you would be having months before you are actually in labor. Some alternatives are to go without any medication and have a non-medicated birth, or you could have the option to use nitrous oxide, a TENS machine. By asking what the alternatives are you can explore your options to get a better idea of what is right for you. You almost always have options when it comes to anything pregnancy or birth-related.
What does your intuition tell you?
If you are sifting through the pros and cons to make a decision it can be easy to overlook your intuition. Of course, you are listening to advice from your doctor and asking questions, but what does your gut say?
Imagine you are through your labor and birth and you are holding your beautiful newborn baby on your chest, snuggling and enjoying getting to know your baby and a nurse comes in to check on you and asks if you would like to give your baby a bath. Perhaps you have asked some questions about the benefits, risks, and alternatives. What does your intuition say? If your intuition says yes you are fine with it and you would enjoy a short break that is perfectly okay. On the other hand, if your intuition says that you aren’t ready for your baby to have their first bath and you want to keep them close you can absolutely do that.
What happens if you do nothing?
This is a great question to ask for something like inducing labor. Often times the answer to this question is nothing. If you are at your due date, you may be offered a few different procedures to induce labor. If you ask what happens if we do nothing, the answer is often that nothing happens. Or hopefully, that you will go into labor naturally on your own. If you are nearing 42 weeks and you ask this same question the answer may be that your doctor is not comfortable with you going past 42 weeks. That is common, and you could be told you would need to find another person to attend your birth.
In some cases, you may ask this question about a different intervention and the answer may be that you or your baby are at a significantly higher risk for an issue if you do nothing. The bottom line is that just because a procedure if offered does not mean that it is mandatory. You can always opt-out. Asking what happens if you do nothing is a good tool to help you evaluate any procedure or intervention.
The power of the BRAIN acronym is by going through these five questions you cover all aspects of a procedure or intervention. This gives you all of the information you need to make an informed decision that you will feel confident in.
Thank you to Zahler for their support of this episode.
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