So you’re expecting a baby. They’ve given you a due date, sent you for tests, scheduled your prenatals… So many decisions are being made…
Wait…
Who should be deciding about the particulars of your pre-natal care? Your birth experience? Your post-partum course? Who, ultimately, is in charge of your physical health, mental health, sexual health, and the health of your baby?
…Let’s try that again: REWIND<<<<
So you’re expecting a baby. You’ve determined your due date, chosen what tests to take, scheduled your prenatal visits. There are so many decisions for you to make…
Do you want to be a passenger or the captain? The first mate or the private? Not sure? Consider this:
Wait…
Who should be deciding about the particulars of your pre-natal care? Your birth experience? Your post-partum course? Who, ultimately, is in charge of your physical health, mental health, sexual health, and the health of your baby?
…Let’s try that again: REWIND<<<<
So you’re expecting a baby. You’ve determined your due date, chosen what tests to take, scheduled your prenatal visits. There are so many decisions for you to make…
Do you want to be a passenger or the captain? The first mate or the private? Not sure? Consider this:
What about Covid-19? YOU are still in charge. See below.
Who has made the biggest metabolic and physical investment in this pregnancy so far? YOUR BODY.
Whose body is going to carry the impacts of pregnancy, labor, birth and postpartum for the rest of your life? YOURS.
Who has made the biggest emotional investment in this baby so far? Again, YOU.
And who’s future emotional well being will be most impacted by how this pans out? YOURS.
Who has spent the most time thinking, dreaming and planning for this birth and this baby? YOU again.
You, the person who is pregnant, are the one who cares the most about the outcomes of this pregnancy, by a HUGE margin! You will carry the long and short term impacts with you forever.
What about the professionals you have chosen to monitor the medical aspects of your pregnancy? Where does your obstetrician (OB), Certified Nurse Midwife (CNM) or Certified Professional Midwife (CPM) come in on this continuum of responsibility? As humans, it’s certain they care about the outcome a lot. As licensed medical professionals, they are also liable for the outcomes you experience. Still, the most compassionate medical provider you’ve ever met can’t possibly care more about you and your baby than you.
So when push comes to shove… and certainly when time comes to push… who should be “the decider”?
Who should decide if an amniocentesis, a quad-screen, or a stress test are needed or even wanted?
Who should have the final say about scheduling an induction vs. waiting for labor to start on its own? Who should decide what position you should be in to labor, or push, or birth?
Who should decide if it’s time for a c-section or if continuing to labor is OK?
You wouldn’t be alone in assuming the doctor makes these decisions. Sometimes they do: In a true emergency, one where there is no time to discuss options, you WANT them to make decisions, and quickly. You also want to have chosen a medical professional who shares your values and would make a decision in an emergency that aligns with what you would have chosen, given the time. But let’s talk about other times; situations where there is time to weigh and discuss options. For the vast majority of the decisions you make about pregnancy, labor and birth, and indeed for the rest of this child’s life, there is plenty of time to step back and discus, weigh options and get expert opinions, before you decide.
In all of these cases, consider: Who is MOST invested in the outcome?
Whose body is going to carry the impacts of pregnancy, labor, birth and postpartum for the rest of your life? YOURS.
Who has made the biggest emotional investment in this baby so far? Again, YOU.
And who’s future emotional well being will be most impacted by how this pans out? YOURS.
Who has spent the most time thinking, dreaming and planning for this birth and this baby? YOU again.
You, the person who is pregnant, are the one who cares the most about the outcomes of this pregnancy, by a HUGE margin! You will carry the long and short term impacts with you forever.
What about the professionals you have chosen to monitor the medical aspects of your pregnancy? Where does your obstetrician (OB), Certified Nurse Midwife (CNM) or Certified Professional Midwife (CPM) come in on this continuum of responsibility? As humans, it’s certain they care about the outcome a lot. As licensed medical professionals, they are also liable for the outcomes you experience. Still, the most compassionate medical provider you’ve ever met can’t possibly care more about you and your baby than you.
So when push comes to shove… and certainly when time comes to push… who should be “the decider”?
Who should decide if an amniocentesis, a quad-screen, or a stress test are needed or even wanted?
Who should have the final say about scheduling an induction vs. waiting for labor to start on its own? Who should decide what position you should be in to labor, or push, or birth?
Who should decide if it’s time for a c-section or if continuing to labor is OK?
You wouldn’t be alone in assuming the doctor makes these decisions. Sometimes they do: In a true emergency, one where there is no time to discuss options, you WANT them to make decisions, and quickly. You also want to have chosen a medical professional who shares your values and would make a decision in an emergency that aligns with what you would have chosen, given the time. But let’s talk about other times; situations where there is time to weigh and discuss options. For the vast majority of the decisions you make about pregnancy, labor and birth, and indeed for the rest of this child’s life, there is plenty of time to step back and discus, weigh options and get expert opinions, before you decide.
In all of these cases, consider: Who is MOST invested in the outcome?
There are plenty of medical professionals who believe they should have the ultimate and final authority. But the American College of Obstetricians and Gynecologists (ACOG) disagrees. Here’s the first recommendation from ACOGs Committee Opinion Number 664 published in 2016 titled: Refusal of Medically Recommended Treatment During Pregnancy (a position reaffirmed by ACOG in 2019)
“Pregnancy is not an exception to the principle that a decisionally capable patient has the right to refuse treatment, even treatment needed to maintain life. Therefore, a decisionally capable pregnant woman’s decision to refuse recommended medical or surgical interventions should be respected.”
It is your right, and indeed your responsibility, to make decisions about your pregnancy, labor and birth. Just as it’s your responsibility to raise this child. The medical professionals you choose for your pregnancy and birth care team are people you hire to provide expertise in their field. Their job is to advise and explain - and then to respect your decision. They are the experts about medical conditions as they pertain to pregnancy, labor and birth: like diabetes, pre-eclampsia, neonatal resuscitation, reading a monitor strip… and so much more. They may even be the experts on your specific medical condition. But they are not the experts about whole, holistic, YOU. You know you! You know your values, your future plans, your history. All of these can and should impact your decisions. That’s why different birth givers might make different decisions even when faced with the same exact medical situation.
For example, when faced with deciding to have or refuse a c-section, how many future babies you plan to have is important. Each c-section raises your risk of having another c-section with your next baby. The more c-sections you have, the greater the risk to your health, to future pregnancies, and to your future babies. (A great resource for information about C-sections and vaginal births after C-sections, VBACs, is ICAN). So, if you are not planning to have any more children, choosing a c-section carries fewer risks than if you are planning more pregnancies. Different birth givers will make different decisions.
And the same is true for different medical professionals: In fact, it is common for medical professionals to look at the same information and situation and still recommend different courses of action (or inaction). I had a client once who was diagnosed with Gestational Diabetes (GD). Because of this, her OB told her that she would be induced (labor started artificially) early to avoid the risk of a big baby associated with GD. But this mom ate a terrific diet and had no problems with her blood sugar. When she reached the end of her 3rd trimester, she came in for her 38-week appointment and they did an ultrasound. The OB was now concerned that the baby was too SMALL and suggested an induction. This client refused and left. Soon after, her OB called and suggested she switch to a different practice saying they could not continue to care for her if she refused their advice. Her new OB looked at the SAME data and said “we use this information to keep the baby in as long as possible”. Several days later she went into labor on her own and had a healthy 6 pound 15 ounce baby! It’s totally normal to seek out a second opinion. People do that all the time with medical decisions. This family did so at 38 weeks’ gestation.
Shopping for a medical professional to accompany you through pregnancy and birth early in pregnancy will give you more time with a person who might share your values and match your personal expectations more closely.
“Pregnancy is not an exception to the principle that a decisionally capable patient has the right to refuse treatment, even treatment needed to maintain life. Therefore, a decisionally capable pregnant woman’s decision to refuse recommended medical or surgical interventions should be respected.”
It is your right, and indeed your responsibility, to make decisions about your pregnancy, labor and birth. Just as it’s your responsibility to raise this child. The medical professionals you choose for your pregnancy and birth care team are people you hire to provide expertise in their field. Their job is to advise and explain - and then to respect your decision. They are the experts about medical conditions as they pertain to pregnancy, labor and birth: like diabetes, pre-eclampsia, neonatal resuscitation, reading a monitor strip… and so much more. They may even be the experts on your specific medical condition. But they are not the experts about whole, holistic, YOU. You know you! You know your values, your future plans, your history. All of these can and should impact your decisions. That’s why different birth givers might make different decisions even when faced with the same exact medical situation.
For example, when faced with deciding to have or refuse a c-section, how many future babies you plan to have is important. Each c-section raises your risk of having another c-section with your next baby. The more c-sections you have, the greater the risk to your health, to future pregnancies, and to your future babies. (A great resource for information about C-sections and vaginal births after C-sections, VBACs, is ICAN). So, if you are not planning to have any more children, choosing a c-section carries fewer risks than if you are planning more pregnancies. Different birth givers will make different decisions.
And the same is true for different medical professionals: In fact, it is common for medical professionals to look at the same information and situation and still recommend different courses of action (or inaction). I had a client once who was diagnosed with Gestational Diabetes (GD). Because of this, her OB told her that she would be induced (labor started artificially) early to avoid the risk of a big baby associated with GD. But this mom ate a terrific diet and had no problems with her blood sugar. When she reached the end of her 3rd trimester, she came in for her 38-week appointment and they did an ultrasound. The OB was now concerned that the baby was too SMALL and suggested an induction. This client refused and left. Soon after, her OB called and suggested she switch to a different practice saying they could not continue to care for her if she refused their advice. Her new OB looked at the SAME data and said “we use this information to keep the baby in as long as possible”. Several days later she went into labor on her own and had a healthy 6 pound 15 ounce baby! It’s totally normal to seek out a second opinion. People do that all the time with medical decisions. This family did so at 38 weeks’ gestation.
Shopping for a medical professional to accompany you through pregnancy and birth early in pregnancy will give you more time with a person who might share your values and match your personal expectations more closely.
Another example of how doctors differ is in when they choose to do episiotomies. There was a time when episiotomies were performed on 90% of people giving birth to their first baby. Then, a systematic review of the research on routine episiotomies was published in 2005 and concluded:
“Evidence does not support maternal benefits traditionally ascribed to routine episiotomy. In fact, outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury, instead had a surgical incision.”(1)
Since then, some OBs have essentially stopped doing episiotomies, some do fewer, and some may not have changed their practice at all. When not doing episiotomies, techniques to support your perineum as the baby’s head emerges are critical for avoiding tears. Small tears heal easily, more severe tears and episiotomies that tear deeply, heal more slowly and can impact your short and long term sexual health. So, who decides when an episiotomy is necessary? Whose call is it to have one or to tear instead? When should this conversation happen? Whose vagina is it anyway???? Remember, YOU are the one who will be living with the short term recovery and the long term impact on your sexuality.
(Read my blog post about avoiding perineal tears.)
“Evidence does not support maternal benefits traditionally ascribed to routine episiotomy. In fact, outcomes with episiotomy can be considered worse since some proportion of women who would have had lesser injury, instead had a surgical incision.”(1)
Since then, some OBs have essentially stopped doing episiotomies, some do fewer, and some may not have changed their practice at all. When not doing episiotomies, techniques to support your perineum as the baby’s head emerges are critical for avoiding tears. Small tears heal easily, more severe tears and episiotomies that tear deeply, heal more slowly and can impact your short and long term sexual health. So, who decides when an episiotomy is necessary? Whose call is it to have one or to tear instead? When should this conversation happen? Whose vagina is it anyway???? Remember, YOU are the one who will be living with the short term recovery and the long term impact on your sexuality.
(Read my blog post about avoiding perineal tears.)
Birth Stool circa early 1900's Here’s a good way to think about medical decision making. Deciding what’s best for you and your baby rests on three equal legs of a stool. In no particular order (because they are equal, otherwise the stool would wobble or tip over), these are the three legs:
The medical professional you have chosen (or been assigned, if you have no choice) has the job of determining your medical condition, and advising you about it in clear and precise language.
You can look up the research, or ask your medical professional to show you the research, regarding the decision you are making. It’s also their job to help you understand this research, and how it relates to your specific situation and condition.
Then you get to weigh these three “legs” and make the final decision.
- Your personal values and goals
- Your medical particulars: is yours a low-risk pregnancy, or do you carry risk factors like diabetes or high blood pressure?
- The research pertaining to a specific situation or condition
The medical professional you have chosen (or been assigned, if you have no choice) has the job of determining your medical condition, and advising you about it in clear and precise language.
You can look up the research, or ask your medical professional to show you the research, regarding the decision you are making. It’s also their job to help you understand this research, and how it relates to your specific situation and condition.
Then you get to weigh these three “legs” and make the final decision.
Even during this time of uncertainty surrounding Covid-19, the medical professional you have chosen to advise you can present the current recommendations and hospital policies. YOU can seek out the current data. And in the end, YOU make the decisions.
A great resource for keeping up with the new research on Covid-19 and having a baby, as it comes out, is at Evidence Based Birth. You can sign up to get weekly updates here.
Currently, the recommendation is to labor normally, as planned, regardless of if you are Covid-19 positive or not. After birth, the CDC suggests "strongly considering" separating infected parents (even the birth giver) from the baby. However, they also state that "decisions about temporary separation should be made in accordance with the mother’s wishes." The World Health Organization suggests keeping the baby skin to skin while wearing a mask and washing hands. Read more from The WHO here.
Thus, parents still have the right and responsibility to make the decision after a conversation of benefits, risks and alternatives.
If you decide to keep your baby with you, and feel that your place of birth may not respect your decision, then download this Sample Informed Consent Form for Refusal of Separation from Newborn Infant and bring it with you.
A great resource for keeping up with the new research on Covid-19 and having a baby, as it comes out, is at Evidence Based Birth. You can sign up to get weekly updates here.
Currently, the recommendation is to labor normally, as planned, regardless of if you are Covid-19 positive or not. After birth, the CDC suggests "strongly considering" separating infected parents (even the birth giver) from the baby. However, they also state that "decisions about temporary separation should be made in accordance with the mother’s wishes." The World Health Organization suggests keeping the baby skin to skin while wearing a mask and washing hands. Read more from The WHO here.
Thus, parents still have the right and responsibility to make the decision after a conversation of benefits, risks and alternatives.
If you decide to keep your baby with you, and feel that your place of birth may not respect your decision, then download this Sample Informed Consent Form for Refusal of Separation from Newborn Infant and bring it with you.
In sum, the decisions made about your care throughout your pregnancy, labor and birth, will profoundly impact you and your baby. More so than anyone else, you are the one who will live with the consequences of these decisions. Therefore, they are YOUR decisions. When assembling your maternity care team, consider choosing a medical professional who recognizes and respects that YOU are “the decider” because ultimately, YOU are responsible for all this.
What have YOU done to take charge of your pregnancy and birth journey? Please share in the comments. Your actions can help empower and embolden others!
Research reference:
For a discussion on how to reduce your chance of tearing during birth, read my blog "Avoiding a tear "down there".
What have YOU done to take charge of your pregnancy and birth journey? Please share in the comments. Your actions can help empower and embolden others!
Research reference:
- Outcomes of Routine Episiotomy: A Systematic Review. K. Hartmann, MD, PhD, M. Viswanathan, PhD, R. Palmieri, BS, G. Gartlehner, MD, MPH, J. Thorp, Jr, MD, K. N. Lohr, PhD JAMA. 2005;293:2141-2148 https://pubmed.ncbi.nlm.nih.gov/15870418/
For a discussion on how to reduce your chance of tearing during birth, read my blog "Avoiding a tear "down there".
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