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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!


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.


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.


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

DR. ALISA MURLI, ND
Hi, I’m Alisa! I am a Naturopathic doctor, birth doula and pelvic floor therapist. Pregnant womxn are my favourite population to work with, both as an ND and a doula. Being a doula is exciting and meaningful to me. I love being able to share such a memorable time in your life with you. I pride myself in providing personalized care and supporting you in the ways that you need. Education about the birthing process is key, and providing parents-to-be with informed healthcare is an integral part of what I do. I have experience with various types of births and birthing practitioners (OB, midwives) and am there to advocate for you.
Background and experience: I am a licensed Naturopathic Doctor, who graduated from the Canadian College of Naturopathic Medicine. Prior to this, I achieved an Honours Bachelor of Science in Life Sciences (minor in psychology) at McMaster University. I completed my naturopathic internship with a focus in pediatric health, where I gained experience treating infants and children. I have additional training and certifications as a birth doula, in prenatal acupuncture, and in pelvic floor therapy. This allows me to help you with preconception to postpartum and beyond. Pregnancy and birth is beautiful and meaningful and it brings me joy to be a part of your journey!

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

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Postpartum Chills

by Dr. Ailya Patel, ND 

Giving birth is one of a person’s most transformative and profound experiences. However, it is also an intense and physically demanding process that can lead to various postpartum symptoms, including postpartum “chills.” While it is a common and expected side effect of childbirth, many women are surprised and confused when they experience it.

 

What are postpartum chills?

Postpartum chills, also known as postpartum tremors, are a common and temporary side effect of giving birth. It typically occurs in the hours following delivery and is characterized by uncontrollable shivering or trembling. Some women may experience mild shivering, while others may have more severe symptoms.

Why do they happen?

Several factors contribute to postpartum chills. One of the leading causes is the rapid drop in hormones that occurs after delivery. During pregnancy, the body produces high levels of hormones, such as estrogen and progesterone, which help regulate body temperature. After delivery, these hormone levels drop rapidly, which can cause a drop in body temperature and trigger the body’s natural response to generate heat through shivering. Additionally, the physical exertion of labour and delivery can cause fatigue and dehydration, contributing to shivering. Women who receive epidural anesthesia during delivery may also be more likely to experience it as a side effect of the medication.

Are these chills typical?

Yes, postpartum chills are a common and temporary side effect of giving birth. It typically lasts for a few hours or days after delivery and does not usually require treatment. However, if you are experiencing severe or prolonged shivering, it is always best to consult with your healthcare provider.

How can you manage it?

While postpartum chills are not usually a cause for concern, they can be uncomfortable and sometimes alarming. So here are a few tips to help manage them:
  1. Dress in warm, comfortable clothing and use blankets to keep yourself warm.
  2. Drink plenty of fluids, such as water, coconut water, electrolytes or warm tea, to help prevent dehydration.
  3. Rest as much as possible and avoid overexerting yourself.
  4. If you experience severe or prolonged shivering or have other symptoms such as fever or chills, it’s essential to consult your healthcare provider.

Postpartum chills are usually a common and temporary side effect of giving birth. While it can be uncomfortable, it is usually not a cause for concern. Always consult your healthcare provider if you have concerns about your postpartum symptoms. Remember to take care of yourself, rest as much as possible, and seek help and support when needed.
Dr. Ailya Patel, ND
Dr. Ailya Patel, ND
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Considering a VBAC*? You Need to Read This!

Dr. Ee Von Ling, ND

*There is a shift towards using the term TOLAC (Trial of labour after C-section) instead of VBAC (Vaginal Birth after C-section). In many ways this term is preferred, less emotionally loaded and less cumbersome than using VBAC. Thus, I will be using both VBAC and TOLAC interchangeably in this post. 

One of the very first births I attended as a new doula was a home VBAC. The parents had taken my HypnoBirthing classes and requested me to be their doula. At the time I was just so excited to be going to a home birth that I didn’t even think about the significance of this being a TOLAC.

The mother told me her birth history and the events that had led up to her c-section – “failure to progress at 9cm”. I took all her info and simply reassured her, “every pregnancy is different and so this will be a different experience than your first one”. And it was different. Amazingly different. The labour and birth progressed just like any other normal labour and birth and the mother had her successful home VBAC!

This VBAC homebirth imprinted on me that VBACs were no big deal and they were just like any other birth.

It wasn’t until I started having more conversations with pregnant clients and doctors and reading comments in mommy forums and news articles that I would realize that VBAC’s were seen as A. BIG. DEAL. Words like “highly risky”, “uterine rupture”, “endangering baby”, “dangerous for mom”, “irresponsible” almost always accompanied the VBAC discussion. It was bad enough that women had fear of normal labour and birth itself, but having a past c-section somehow put a whole other layer of fear and worry on top of that.

So I double checked the evidence and the statistics around VBAC and risks and benefits.  Contrary to the conversations, the numbers showed that a vaginal birth after a previous c-section was a reasonably safe and healthy choice for most women. The absolute risks were very low and the success rates for attempted VBACs were actually quite high. In fact, the risks for a planned repeat c-section were worse. If you’d like to learn more about the pros, cons and risks around attempting a VBAC, you can read this very excellent handout created by the Ontario Association of Midwives here.

Over the last several decades VBAC rates have gone up and down. According to US statistics, In the 1990’s about 30% of those who had a previous C-section attempted a VBAC. Today that number is about 13%. These numbers have fluctuated because of changes in the practice guidelines of obstetricians. VBAC births themselves did not become more dangerous, but practice guideline updates recommended more medical requirements in order to offer them. These changes influenced the perception and accessibility of attempting VBACs – OB’s became less supportive of them and the public developed a bigger fear of them. Understand that the risks and outcomes for those who attempt VBACs did not change in the last 40 years. 

Being able to go through a trial of labour after C-section might be a very significant and impactful choice. For some, being able to vaginally birth helps them to heal a previous birth trauma and reclaim the birth experience for themselves. As a medical industry, we should not take the personal decision to try for a VBAC lightly and we should provide unbiased information and support for that person. 


If you had a previous C-section and are now considering a VBAC for your next childbirth, here are 6 things you can do to help improve your chances of birthing your baby vaginally: 

  1. Choose a supportive provider: This might be the most important factor of all. Having a midwife improves your chances of giving birth vaginally and with fewer restrictions around VBAC. If you are not able to get a midwife, make sure your OB is VBAC supportive. How will you know if they are VBAC supportive, ask them outright: 

  • Are you supportive of VBAC?
  • What is this hospital’s TOLAC rate? How many of your own patients chose TOLAC and how many of those result in VBAC?
  • What would be your advice around increasing my chances of achieving a VBAC?

You will get a sense of their own attitudes and biases based on how they respond to these questions. 

  1. Learn techniques so you can labour at home for as long as possible: Choose a program that includes learning and practicing breathing exercises, visualizing, releasing past fears. Our clients who have been able to VBAC took HypnoBirthing classes, listened to positive birth podcasts, read books about empowered birth by Ina May Gaskin and Penny Simkin. From our own collective experience supporting our own VBAC clients, we teach a special condensed version of our  Confident Birth Prenatal Program that focuses just on the relaxation exercises and techniques to help you be calm and confident during labour.  

  1. Ensure the baby is in a good position: Head down is not enough!  Baby’s position with their back on the left side so you feel kicks or the big movements on the right (referred to as LOT) or baby’s back is in the front so you don’t feel a lot of kicks or movement elsewhere (referred to as OA) are the ideal starting positions for baby. A baby in the posterior position (or OP or “sunny side up”) may have a harder time being born vaginally. Perhaps during your previous birthing the baby was in this posterior position, which can lead to slow or arrested labour. 

There are ways to help encourage a baby to get into the ideal starting position for birth. Daily positional awareness, acupuncture, massage, chiropractic, osteopath and physiotherapy treatments may help. 

  1. Get your labour to start naturally: If you labour starts naturally, this will help you avoid further interventions that might increase the risks of a TOLAC. Speak with your midwife or doula about ways to start labour that are safe for those who’ve had a previous c-section.

  1. Try to avoid an epidural: An epidural can limit movement and slow down labour (if started early in labour). If labour slows down, then artificial oxytocin will be needed to help progress the labour. But using artificial oxytocin in someone who had a C-section increases the risk of having a VBAC (ie. scar separation). This is why learning good coping techniques and having a doula can be very helpful. That said, if you need an epidural to help you have a positive birth experience, then by all means, choose that for yourself! 

  1. If you have an epidural, use a peanut ball: Even if someone has an epidural, there are tips and tricks to help increase your chance of a vaginal birth. A peanut-ball is a peanut shaped exercise ball that can be used in a variety of positions to help open up the pelvis and positively influence the positioning of the baby as it’s being born. 


Beware the “VBAC calculator”! Recently, I have been hearing about care providers using a “VBAC calculator”. Different factors about the pregnant person are inputted into an algorithm that is supposed to predict the percent chance of having a vaginal birth. The use of this is a HUGE RED FLAG to me, and if this becomes part of routine OB and midwifery practice I fear that VBAC rates will decrease even further. 

What is wrong with these calculators? 

First, the database of information that these calculators use is from observational data of a specific patient population. The one that care providers in Toronto have been known to use is from a patient population in the United States. American birthing patients and American birth management practices are very different from the birthing patients and birth management practices in Canada. VBAC rates in the US are much lower than VBAC rates in Canada. A hospital with low VBAC rates will produce patients with low VBAC rates and vice versa. So you can already see a discrepancy in applying such a calculator on a random patient. 

These calculators are not evidence based, meaning no study has been done to test the impact of using these calculators to accurately predict actual VBAC success, we also need to study how these calculators impact decision making in both the OB and the patient. 

We are well aware that there is bias in the practice of obstetric medicine, meaning, if a care provider is personally biased in the management of a particular patient, it greatly influences the outcome for that patient. For example, if this VBAC calculator happens to calculate a low success rate, then that can influence the OB to assume that the patient’s attempted VBAC will end up in a c-section. 

Here is a link to an article that explains the research that critiques the use of VBAC calculators.

In any case, the American College of Obstetricians and Gynecologists had this to say about VBAC calculators: “… population-based statistics cannot accurately predict an individual’s VBAC success odds….It is ill-advised to use statistics as a primary indicator when making VBAC decisions.

The role of a doula in your plan to have a TOLAC: The good news is, a doula can navigate at least 5 out of 6 of the positive factors listed. Having the presence of continuous and on-going support from a doula is supported by research to help you avoid a c-section (whether it’s your first childbirth or an attempt at a VBAC). If you are interested in learning more about how a doula could be an integral part of your VBAC team, book a free meet and greet with us today!   

Dr. EeVon Ling, ND

Want to get prepared for pregnancy, birth and postpartum? Grab our free Bump to Baby Checklist! This clear and thorough guide walks you through everything to expect from your first trimester to past your 6 week postpartum check up.

  • What tests and screenings will be offered and when
  • When to sign up for prenatal education and what types to consider
  • Things you should think about that your care provider may not mention
  • Links to helpful resources