Informed Consent

by Dr. Alisa Murli, ND 

Congrats, you’re pregnant!

Pregnancy is such an exciting time as you’re preparing for your newborn to arrive, but it can also be confusing or overwhelming. Whether this is your first pregnancy or subsequent, there is often so much to learn. In this article, we focus on informed consent and will go through all of the choices you may be faced with during pregnancy (and perhaps didn’t know you had?). By the end of this article, you should feel educated and empowered to seek out more information about your pregnancy and labour options.

What is informed consent?

Informed consent is when a healthcare provider presents you with all of the pertinent information necessary to make an informed decision. This means that they educate you about the benefits, risks and alternatives to any intervention or procedure. For informed consent to be valid, the patient must also be in a fully competent state and able to make a voluntary decision about said intervention (1).

Think back to a time you went to a medical provider; do you recall being given all of this information? You have the right to have all of the information clearly explained to you in a manner that you can understand, and you have a right to be given ample opportunity to ask questions and consider your options before making a decision (time may be limited in the event of an emergency).

Although this is something that all healthcare providers are aware of, in reality, informed consent is really lacking. This is particularly true of the interventions and procedures used for pregnancy and birth. This can be for many reasons, and more often than not healthcare providers are acting in your best interest and believe they are offering choice. What the lack of informed consent truly results in is the birthing person having a limited role in decision making of not only
their health but their baby’s as well. What this really means is the birthing person is void of basic human rights and bodily autonomy (2).

Informed consent is when a healthcare provider presents you with all of the pertinent
information necessary to make an informed decision.

Choices during pregnancy

Every choice during your pregnancy is ultimately up to you. Healthcare providers, whether it be your OB, family doctor, midwife, naturopathic doctor or doula, are there to guide you to make the best decisions for your health and safety. It is important to take their recommendations into consideration, however it is equally as important to understand that you have a choice and are provided with the benefits, risks and alternatives to each medical decision.

Let’s dive a little deeper into the choices you may be faced with during pregnancy and labour.

Birthing environment

Choosing your birthing environment is dependent on how you view your labour and birth and your choice of practitioner. If you would like a home birth or to give birth at a birthing centre near you, a midwife would be your best choice (TIP: apply for a midwife as soon as you know you are pregnant). If you’d prefer a hospital birth, you’re often able to choose between your family doctor, an OB or a midwife.

Did you know you have the right to manipulate your birthing environment to suit your comfort? For example, you are able to ask them to lower the lights, use essential oils and music, bring your own blankets/pillows from home.

 

Physical examinations

Consent for physical exams might look something like this, “I would like to perform a cervical check for you right now in order to assess the progress of your labour. I will be checking for the effacement (how thin your cervix is), the dilation (how wide it has opened) and the position of baby. This will help us to determine the best next steps for moving forward. The risks of a cervical check would include bleeding, discomfort, vaginal infections and premature rupture of membranes. If you do not wish to do a cervical check, we can proceed without one. Here are the alternatives…”

Interventions

Interventions during labour are used to start, support or assist with the progression of labour. Interventions can be anything from pain management to induction/augmentation methods to episiotomy to assisted birth techniques (ie. vacuum or forceps) and caesarean section. Believe it or not, you have a choice as to whether any of these interventions are used on you. For more information on alternatives to pain medications, visit https://yourdowntowndoula.com/alternative-options-to-pain-medications/

Labour positions/pushing

During labour, we often recommend various positions that can help with comfort and progression of labour. Here are some positions that are recommended for the various stages of labour.

People usually believe that the only way to birth is by laying on your back. While this may be the preferred option for some, it’s not necessary. There are several options for pushing positions and you may even use multiple positions. Some positions are better suited for your perineum and may lessen the effort needed to push (thank gravity). These are positions that tilt your pelvis in such a way that the birth canal is perpendicular to the ground rather than parallel.

Keep in mind that getting an epidural will limit the positions available to you, but that is okay! You can still use the peanut ball, sit up, turn from side to side and even try a supported squatting position for pushing.

 

Eating and drinking throughout labour

Contrary to popular belief, you are allowed to eat and drink through labour, even with an epidural. In fact, eating and staying hydrated through labour is necessary for increasing endurance. Imagine running a marathon without snacks and hydration! Of course it is not recommended to eat heavy meals, as this can increase risk of nausea, vomiting and increase your needs for digestion (and thereby shutting blood flow to your intestines).

The hospital might offer you jello and clear fruit juices for nutrition during labour, but here some great options you can bring yourself:

● Smoothies
● Bone broth
● Fresh fruit juices
● Natural electrolytes in water
● Coconut water
● Fruit
● Cheese
● Nuts
● Dark chocolate
● Protein bar
● Honey

Placenta delivery

Delivery of your placenta is often a passive experience that happens after your baby is born. Your doctor or midwife will be monitoring your placenta delivery and their job is to ensure it is completely removed.

Active vs expectant management of placental delivery:

In active management, the doctor or midwife may give you an extra push of pitocin to promote more contractions to help separate and push the placenta. The doctor or midwife may ask for a little push or may push on your uterus to help expel the placenta (and ask your consent first!). Active management was introduced to reduce the risk of postpartum hemorrhage, as the added contractions help to close off the footprint left by the placenta (3)

In expectant management, the practitioner will wait for the placenta to detach and deliver on its own, without the use of any added drugs.

Newborn management

After you give birth, there are several choices in which you may be faced with.

Cord clamping

The umbilical cord is meant to provide nutrients for baby in utero. Immediately after birth, the umbilical cord actually continues to provide nutrients until it stops pulsing (usually takes a couple of minutes). It used to be routine to clamp and cut the cord immediately. You now have the option of delaying cord clamping, which can be beneficial for the reasons stated above. The World Health Organization recommends delayed cord clamping in all normal birth outcomes (4). Keep in mind that you cannot do delayed cord clamping if you plan to donate or bank the cord.

Skin-to-skin

The World Health Organization recommends 90 minutes of uninterrupted skin-to-skin contact with mom after birth. This maximizes positive breastfeeding outcomes, fosters bonding and increases oxytocin levels in both baby and the pregnant person(5).

Vitamin K administration

Babies are born with very little vitamin K. Vitamin K is necessary for blood clotting and is not available in significant amounts in breastmilk. It is a regular procedure for babies to receive a vitamin K shot after birth to decrease the risk of a spontaneous bleed in the first 6 months of life. You do have options and alternatives for this, such as a preservative-free shot or an oral option.

Erythromycin eye ointment

This antibiotic eye ointment is given to every baby in the event that baby gets conjunctivitis (ie. pink eye). Most commonly pink eye can occur when the birthing person has an untreated infection with a sexually transmitted infection (chlamydia, herpes or gonorrhea), however other bacteria can cause this infection and can be picked up during birth or from exposures in the hospital or home (6).

 

Bathing of baby

The World Health Organization suggests wiping the newborn clean and delaying the first bath for 24 hours (7). This is because when babies pass through the birth canal, their skin is populated with beneficial bacteria that are needed for optimal health, including immune function, gut health and dermatological health. However, the decision is still yours!

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Evidence Based Birth is a great resource for learning more in depth information about these management practices. I encourage you to read through the evidence surrounding thesepractices before making your decision. It is recommended that you review all of these choices and have them made as a part of your
birth plan before labour.

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Informed consent and doula care

A lack of informed consent is one of the reasons that pregnant people seek out doula care. As naturopathic doctors and doulas, we truly understand the need for informed consent and see the negative effects of lack of informed consent in everyday life. Uncertainty can cause a lot of anxiety around pregnancy and birth. There is a universal lack of knowledge and education around pregnancy and labour. We are firm believers in evidence-based maternity care, and we strive to educate and empower our patients to remove this uncertainty and fear and make the best decisions for themselves and their babies.

Tips for prompting informed consent from your healthcare provider

Here are some ways you can ask for informed consent or more information from your healthcare providers (including your doulas!). Understandably, some patients are afraid to speak up because they are afraid of affecting the relationship. Don’t worry! There are respectful ways of asking for more information, and most often practitioners are happy to answer your questions.

● Can you please explain the benefits and risks of this intervention?
● Are there any alternatives to this?
● What happens if we do not do this intervention?
● How long do I have until I have to make a decision?
● Are you able to send me resources where I can find more information about this?
● Can you please ask my permission before doing physical exams?
● Are you able to explain the process of this procedure?
● I am feeling a bit nervous about this, can you please help me understand why it is
necessary for me/my baby?

Overall, the main takeaway from this article is that the choice is always yours! Advocate for yourself and never be afraid to ask questions about your body, your health, and your baby.

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This article is meant to provide information only, it does not substitute for personalized medical care.

REFERENCES

1.https://www.ncbi.nlm.nih.gov/books/NBK430827/#:~:text=Informed%20consent%20is%2
0the%20process,undergo%20the%20procedure%20or%20intervention.
2. https://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-020-03023-6
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6372362/

4. chrome://external-file/WHO-MCA-17.07-eng.pdf
5. https://www.who.int/westernpacific/news-room/feature-stories/item/skin-to-skin-contact-
helps-newborns-breastfeed
6. https://evidencebasedbirth.com/is-erythromycin-eye-ointment-always-necessary-for-
newborns/
7. https://www.who.int/tools/your-life-your-health/life-phase/newborns-and-children-under-
5-years/caring-for-newborns