You will have many opportunities to opt in or out of interventions in your pregnancy, birth, or with your newborn. You always have options when it comes to your prenatal care and birth as long as you know what your options are. In a perfect world, every procedure comes with informed consent, and you have all the information you need to make an informed decision confidently. In the real world, constraints like limited appointment time make proper informed consent a challenge. There are five simple questions you can ask. When used together, these are one of the most versatile tools you can apply to any decision, whether navigating prenatal care, choosing interventions to employ during labor and birth, or making critical choices for your newborn.
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You always have choices when it comes to your prenatal care and birth as long as you know what your options are. You will have many opportunities to opt in or out of interventions in your pregnancy, childbirth, 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.
Examples of Interventions
An intervention could be a prenatal test. The results of a test could alter your prenatal care or birth plans. Some invasive tests come with risks to you and your baby and the benefit of getting a more precise diagnosis of potential issues. Inducing labor is an intervention that can alter when your labor starts and potentially change some aspects of your labor and birth. Many other procedures are interventions, although we may not traditionally think of them that way. This includes routine procedures like an ultrasound or a vaginal exam. Any procedure has risks and benefits, some minor and others could be significant. From the start of your pregnancy through your parenting journey, you will constantly decide whether to opt in or out of procedures and interventions.
Any intervention or procedure should always come with informed consent. According to the American Medical Association, 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 following:
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, and 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 its 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.
The pregnancy and birth community is shifting to more evidence-based practice. 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 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 that this is a complex problem and 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, are made aware of all of the risks and benefits, and can 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, and testing for Group B Strep. For a doctor or midwife to honestly 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. It doesn’t always feel like you have a choice. You always have a choice, which is crucial to true informed consent.
Numerous constraints can make it challenging for care providers to give proper informed consent. Many care providers have a tight schedule with non-stop appointments throughout the day. Limited time for each appointment can make it challenging to discuss procedures and take the time needed to have in-depth conversations.
A midwife or OBGYN are experts in prenatal care and birth. A wide range of knowledge is needed within the niche of caring for expecting mothers. How knowledgeable your care provider is about particular topics can affect their ability to assist you in navigating interventions. On top of their profession’s demands, it takes time to stay current on the latest research and evidence. If your care provider is not consistently educating themselves, there may be areas where they do not have the most up-to-date information. While every procedure should come with informed consent, many care providers gloss over procedures they consider routine.
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 need more information, 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, including your partner, doctors, midwives, nurses, doulas, family, and close friends. Thank you for allowing me to be a resource for you as you navigate these decisions. I do not take that honor lightly and want to give you the best tools in your toolbox.
One of the most versatile tools you can apply to anything is the BRAIN acronym.
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 and your baby. The power of asking the questions in the BRAIN acronym is asking all five. While each one is helpful, together, they cover every aspect of the pros and cons. Let’s explore these questions and explain how you can apply these 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 genetic abnormalities.
What are the risks? There are so many routine procedures that carry risks that care providers often overlook. Vaginal exams are a fantastic example of this.
For many 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, 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 discover 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 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 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, an epidural is the most commonly used method to manage the pain of contractions. If you are unsure whether that is the route you want to go, an excellent question could be, what are the alternatives? One alternative is to go without any medication and have an unmedicated birth. If you want an intervention to manage pain, you could have the option to use nitrous oxide, a TENS machine, or other medications. You can explore your options to better understand what is right for you by asking what the alternatives are. You almost always have options when it comes to anything pregnancy or birth-related. The caveat is that to have options, you have to know what they are.
What does your intuition tell you? If you are having difficulty sifting through the pros and cons of making 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, holding your beautiful newborn 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 would enjoy a short break, that is perfectly okay. On the other hand, you can 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 nothing happens. Or, hopefully, you will go into labor naturally on your own. If you are nearing 42 weeks and ask this same question, the answer may be that your doctor is uncomfortable 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. You can always opt out. Asking what happens if you do nothing is an excellent tool to help you evaluate any procedure or intervention.
Show Up Prepared
Not every doctor or midwife will be patient and supportive if you question every procedure. I hope you are working with a care provider who takes time during appointments to answer your questions thoughtfully. You can do a little bit of homework before your appointments so you show up informed and prepared. I have resources to help you and make this as easy as possible.
Listen to the 40 Weeks podcast. This is a separate podcast with a short episode (about 6 minutes) for each week of pregnancy. Each episode covers how your baby is growing, what is going on in your body, what to expect at your upcoming prenatal appointments, and a tip for dads and partners. Visit this page to enter your email address and due date, and each week will be delivered to your inbox at the perfect time. You will get a link each week to the episode and transcript on the website, or you can listen to the episode in your favorite podcast player. The 40 Weeks podcast will keep you ahead of what is coming up and where you should focus your attention.
If you want to educate yourself or have questions about a procedure, intervention, or your options, there is likely an episode of the Pregnancy Podcast that covers it. You can use a search bar on the website to search by keyword. There is also an episode guide where you can browse by topic. There are hundreds of episodes in the back catalog. Each episode is a masterclass on a specific topic. I have had so many listeners say that their doctors were impressed by how much they knew. Listeners have said that they learned more from this podcast than from a birth class.
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When you educate yourself ahead of time, you already have a base of knowledge on a subject and will be so much more prepared to have a conversation with your doctor or midwife. It reduces the time needed to explain the procedure because you already have a basic understanding. You will already know the medical terminology your care provider is using. Most importantly, you will already know your options and can focus your time on discussing the course of action that is best for you and your baby.
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