Belly Up

* bellies * birth * babies * breastfeeding *

Tuesday, May 17, 2011

Uninformed Consent

A laboring mom walks into the hospital.  After some speculation, she is declared to be in labor and is ready to be admitted as an L&D patient.  As part of her admittance, mom will be handed three consents to sign.  One for vaginal delivery, one for surgical delivery and one for anesthesia.  Mom, who is probably quite uncomfortable, is given all three, and told she must sign them in order be treated...and that is what counts as informed consent in most births.  The nurse does not go over these forms, an OB does not come in and explain each bullet point, mom is just expected to sign all of them, even if she is not planning anesthesia or a surgical birth.  If labor is advanced (and even when it is not) it is very likely that mom is not reading the fine print on these consent forms, instead she is merely scribbling her name on a piece of paper as quickly as she can between contractions.

Of course with labor, mom does usually know for around 9 months that it is coming and she can become informed during that time so that when she signs these particular consents it can truly be informed consent.  But what about the rest of labor, and what about the choices couples make throughout their prenatal experience?  Are women receiving informed consent, or are they even asked for their consent in most case, informed or not? 

Informed consent is based on two separate but parallel aspects.  One is the obligation in a non-emergency situation of a health care provider to disclose all information concerning a person's care.  The second is then the autonomy of that person to agree, or refuse, the suggestions or procedures offered.  At the same time, a person should have the expectation that if she chooses to exercise her right of refusal she will still be treated with dignity and her right to autonomy respected by her health care providers.  However, if a person is told she must comply to certain rules, or that certain procedures are routine and no discussion of their various risks/benefits takes place, that person has not had the option to exercise her informed consent. (It is also not informed consent if a health care provider does not provide factual or unbiased information but I am going to save that discussion for another day.)

Let me just list a few examples of what informed consent is NOT.

1) Mom has been laboring a while, she is thirsty and has a dry mouth so she asks for water,  However her nurse tells her that it is against hospital policy for her to drink anything.  This example can be applied to numerous routine procedures and policies during labor including fetal monitoring, rules about IVs, being out of bed etc.

2) Back at the nurses station, mom's nurse and OB have been communicating via phone and the OB has decided to give mom some pitocin to speed up her labor.  The nurse walks in mom's room and hangs a bag of pitocin with the comment, "your OB wants you to have some medication to increase your contractions." 

Mom has not exercised informed consent in either of these cases.  Instead, in the first example  she was told what hospital policy was with no discussion.  Hospital policy is usually based primarily on efficiency, costs, and risk management of the institution, not the health or well being on any individual person or group.  It is not necessarily designed to produce a better outcome for your labor, rather it is to save money or prevent lawsuits for the hospital.  However, hospital policy is also always inclusive of informed consent so a patient can ask why this policy exists, how it benefits her labor and then decline and accept responsibility if she feels it is not in her or her child's best interest to comply.  In the example where mom is hooked up to pitocin, mom has every right to talk to her actual careprovider if she has questions or concerns.  In most cases the OB is not on location but a couple may have their nurse have him call their room or they can ask that he come in to discuss care options.  The couple may decide to accept the recommendations, but accepting medical care without informed consent can be dangerous to mom and to baby.  It also can lead to a lot of second guessing and blame if things don't go as planned.

There is a difference between a health care provider (or hospital) who pays lip service to informed consent by meeting the legal requirements put in place to help protect agaisnt lawsuits and a careprovider that actually informs a couple about what may or may not be in the best interests of mom and baby and encourages them to educate themselves.  A care provider and a couple should be working together towards the best care and labor experience for mom and baby.

Tuesday, May 3, 2011

Your Cervix is Not a Crystal Ball

When is baby coming???
 It is around mom's 38th week of pregnancy, she's just had a vaginal exam and the OB declares,"you are 2cm dilated, baby will be here soon!".  The week passes and the next week and perhaps even the next week.  Still, mom is pregnant and still 2cm...perhaps even more.


It is around mom's 40th week of pregnancy and she just had yet another vaginal exam where the OB has declared,"you are not dilated at all". 

Let me let you in on a little secret, your cervix is not a crystal ball.  It cannot predict when you will start labor.  It cannot predict if you will deliver before, after or even on your due date.  The cervix can do many wonderful things, but let's not give the cervix more credit than it is due.  A cervix cannot read the future. 

Having the cervix examined can satisfy mom's curiosity and when something is happening that can be exciting.  Obviously each bit of dilation that occurs before labor is less that must happen during labor.  However if cervical change is found, and especially if the careprovider adds the comment that labor will be soon, it can make the last weeks of pregnancy the longest of her life.  Everyday she is on high alert for impending labor and each day that it doesn't happen will be a disappointment.  Mom may now feel each discomfort of late pregnancy more acutely and her family might even travel to be in town for the big day.  However, instead of holding a baby they are all just staring at mom waiting for her to pop.  These women are often encouraged to electively induce by their due date and they agree because they are mentally exhausted from being told the baby would be here any second.

On the other hand when mom has an exam and nothing is happening, mom may start to loose confidence in her body and feel that she will be pregnant forever, or at least longer than she was hoping.  Even though it is completely normal for dilation not to occur until actual labor, these women are often made to feel that their bodies are not and will not work correctly and are pushed toward elective induction. Mom is discouraged and when the OB starts looking at induction dates, mom agrees because obviously she will not go into labor on her own any time soon and in the back of her mind she thinks her body may not even be capable of spontaneous labor.

The cervix is a a unique creature.  Some will naturally dilate prior to labor, some will not.  Some will dilate and efface slowly over time; many will only do so with the advent of contractions and a cervix that has birthed before is different than one that has not.  The bottom line is that a cervical check only tells the story of what is going on at the time of that exam.  It tells nothing about what will happen...even later that day.  A cervix does not need to reach a certain point for contractions to start, just the opposite.  Contractions will open a cervix when the time is right no matter what that cervix has been up to prior to that time.  So a mom who is closed up tight as drum is as likely to go into labor that night as the mom who is 2cm dilated and has been for a week or more.  The lucky labor winner will be the one that starts having effective contractions and that honor could go to either mom.

So why do many providers do routine vaginal exams at every appointment those last weeks of pregnancy?  I have never found a justification besides it just being a routine part of managed care. A body part cannot be "managed" if it is not assessed, measured and commented upon.  However, there is no evidenced based medical reason for routinely doing these late pregnancy exams.  In individual circumstances a vaginal exam can be helpful, but for the vast majority of women a cervix check can provide no useful or predictive clinical information and it is an uncomfortable and invasive procedure that actually carries some amount of risk. 

The good news?  You can say no thank you if you happen to be using a careprovider who does these routine vaginal exams.  If you are really curious and want to know what is happening in there, go for it, but just don't give your cervix more credit than it deserves....whatever is found means nothing about what will happen.