You will have many opportunities to opt-in or out of interventions in your pregnancy, birth, or with your newborn. In a perfect world, every procedure comes along with informed consent, and you have all of the information you need to make an informed decision confidently. In the real world, constraints like limited time available for appointments make proper informed consent a challenge. One of the most versatile tools that you can apply to anything is your brain. Not the three-pound organ in your head, the acronym BRAIN. This article has five simple questions you can ask to help determine whether any procedure or intervention is right for you.
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In this article, we are talking about using your brain. In this case, we are talking about your brain as 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 have many opportunities to opt-in or out of interventions in your pregnancy, birth, or with your newborn. To intervene means to come between to prevent or alter a result or course of events. An intervention is an action or process of intervening or an action taken to improve a situation, especially a medical disorder. When you apply these definitions to pregnancy, an intervention is any action taken to alter the course of your pregnancy or birth. This article has five 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. The results of a test could alter your prenatal care or your birth plans. Some invasive tests come with risks to you and your baby and the benefit of getting a more precise 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. Other routine procedures are 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, some minor and others could be significant. You will find yourself constantly deciding whether you want to opt-in or opt-out of these procedures and interventions.
Any intervention or procedure should always come with 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:
1. The diagnosis (when known)
2. The nature and purpose of recommended interventions
3. 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 also have guidelines on informed consent. 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 American College of Obstetricians and Gynecologists updated their official opinion in 2021. It was previously acknowledged that there are practical difficulties with ensuring the kind of communication necessary for informed consent. The statement updated in 2021 does not discuss limitations. The revised opinion does focus on shared decision-making, similar to the North American Registry of Midwives.
There is a shift to more evidence-based practice in the pregnancy and birth community. This is mainly due to demand from patients and expecting mothers. This change is not happening overnight, but the ball is rolling. ACOG moving their opinion on informed consent to shared decision making is evidence of this. Still, there are a lot of procedures and interventions done during pregnancy and birth that are typical, routine, and are not evidence-based. It takes a lot of time for attitudes to shift, for new doctors to be educated and trained, and to get existing practitioners to see and do things differently. I acknowledge this is not a simple problem, and it is a big reason I started this podcast. I know I can help you educate yourself to make informed choices, even if you are not getting the time and attention that every decision deserves from your doctor or midwife.
The Challenges of True Informed Consent
Proper 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 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 challenging because they, and the entities like hospitals they work for, have policies about what is “required” and routine. From even my personal experience, I know that it doesn’t always feel like you have a choice, but you must know you do. You always have a choice, which is a crucial component of true informed consent.
Some constraints that can make it challenging for care providers to give proper informed consent are:
- The time set aside for each appointment
- The number of patients your doctor or midwife see in a day
- How knowledgeable your care provider is 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
In practice, all of these constraints can make it challenging for doctors and midwives to provide proper 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. It can be especially difficult to take the time to discuss procedures at length and answer patient questions when you are limited to 15 minutes or less for an appointment. If you ever feel like you are not getting the information you need, please advocate for yourself and ask questions, even if that means your appointment will run longer than expected.
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, including 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. Not the three-pound organ in your head, 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 concrete examples.
What are the benefits? You may be debating whether or not you want to do a NIPT screening test or a cell-free DNA test. One of the things you need to weigh with this is the benefits. 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 advantage 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 covers every aspect of the pros and cons of a procedure or intervention. Once you know the benefits of the cell-free DNA test, you would ask about 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 care providers often overlook. Vaginal exams are in that category. For many expecting mothers, this comes up during an appointment near your due date, and 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, which 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 will find out there are some risks like 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 what the risks are, you can weigh those against the benefits to make an informed decision. Any intervention or procedure has risk. That isn’t necessarily a reason to opt-out, but any risks are something you should weigh 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, an excellent question to ask could be, what are the alternatives? 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 an unmedicated birth, or you could have the option to use nitrous oxide, a TENS machine, or other medications. By asking what the alternatives are, you can explore your options to better understand 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 having a tough time sifting through the pros and cons to make a decision, it can be easy to overlook your intuition. Of course, you listen to your care provider’s advice and ask 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. A nurse comes in to check on you and asks if you would like to give your baby a bath. Perhaps you have asked questions about the benefits, risks, and alternatives. What does your intuition say? If your intuition says yes, you are okay with it, and you would enjoy a short break, that is perfectly okay. On the other hand, you can absolutely decline if your intuition says that you aren’t ready for your baby to have their first bath and you want to keep them close.
What happens if you do nothing? This is a great question to ask for something like inducing labor. Often the answer to this question is nothing. If you have a low-risk pregnancy and are at your due date, your care provider may offer 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.
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 your doctor or midwife offers a procedure does not mean it is mandatory, and you can always opt-out. Asking what happens if you do nothing is an excellent tool to help you evaluate any procedure or intervention.
The power of the BRAIN acronym is that 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 confidently.
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