Saturday, February 16, 2013

Informed or mistaken?

Informed choice
Informed decision
Informed refusal
In my world the adjective 'informed' is often used in an attempt to declare that the person who is making the 'informed' choice/decision/refusal/whatever is intelligent, and has carefully considered options.  My question is, often, who's kidding whom?

A woman who wants to make an informed choice about who provides her care, and other aspects of the model of care, can only choose from what is available to her. 

A woman who wants to make an informed decision, particularly about an aspect of natural, physiological birth, may say she does not want to be treated as the next number on the production line.  She does not want standard care, whatever that is.  She wants to be treated as an individual.

A woman who wants to make an informed refusal of, for example, pre-labour caesarean surgery for a baby presenting breech, can find herself up against a system that does not support or understand her intentions.

In the often complex and demanding journey that a woman takes in giving birth to and nurturing her baby, the information available can be only marginally relevant to the individual situation: the choices and decisions can appear as shades of grey, rather than good and bad.  The constant juggling of the interests of the woman and her child, within the multiple contexts of a marriage, a family, a maternity service, and a community, can change the options for decisions in a moment.  In fact, a woman who considers herself well informed, and who is intentional about proceeding with an unmedicated physiological birth, has very little choice when some person with authority says "We need to get your baby delivered now."  A woman in labour who is confronted with even the suggestion that her baby's condition may be compromised, without whatever intervention is being offered, can suddenly find herself submitting to something that she would otherwise have avoided.

Health care, and especially maternity care, has changed in recent decades, from a "doctor-knows-best"-no-discussion model, with a hierarchical knowledge-based framework, to a system that attempts to include and respect the wishes and values of the patient/client.   This is, I believe, to be encouraged in principle.  But, in practice, I am often frustrated at the absence of an appropriate conversation about decisions or choices that need to be made.

At present the Melbourne Coroner's office is inquiring into the circumstances around the death of a baby whose mother intended to give birth at home.  Newspaper reports of this inquiry highlight the fact that the mother had refused caesarean surgery a few days before she came into labour.  In a news paper report of the proceedings, a medical specialist is reported to have said that: 
the "inadequate, incomplete and at times misleading information" available, particularly on the internet, made it difficult for women to make an informed decision about their birth plans.
There is little doubt from the reports that the mother believed she had made informed decisions.  Yet, in the tragedy of loss of the life of a baby, it's easy to argue that there were seriously mistaken decisions that led to the events of that day.

Women who have had previous caesarean birth(s) may make choices and decisions about their carers, and their planned place of birth, early in their pregnancies.  By way of contrast, women who find that their baby is presenting breech as they approach Term are suddenly confronted with a bewildering array of decisions.  As they obtain information they become aware that there is no right way (eg elective caesarean) and wrong way.  There is increased risk in breech birth, regardless of the actual method of birth. At each decision point, they can feel exposed and uninformed, even misled - but decisions must be made and there is no turning back.  Each decision places the participants in a new context, which may lead to more decision-making.

A woman who had planned to give birth naturally in a hospital birth centre found that her baby was frank breech a couple of days after her due date.  The special set of decision points that she encountered after the breech diagnosis were:
  • attempt external cephalic version (ECV): the decision was made on Saturday that this baby was not suitable for ECV, and the mother was informed that she would be booked for a Caesarean on Monday.
  • spontaneous onset of labour: Mother laboured at home Sunday night, and called her midwife for support around midnight.
  • progress in labour: After several hours of established labour, the mother's cervix was dilated 6-7cm, and the presenting part was high.  The decision was made to go to hospital.  Labour continued strongly.  The obstetrics registrar at the hospital agreed that progress was good, but advised a caesarean birth.  The mother declined, and stated that she was intending to give birth vaginally.  All maternal and fetal observations were within normal range.
  • review of progress in labour: After several more hours of labour, full dilation of the cervix was confirmed, but no progress of the presenting part.  Once again the mother was advised that she needed caesarean surgery, and this time she agreed.  Her baby was born in good condition, and the hospital staff facilitated early skin to skin contact and breastfeeding in the recovery area of the OT. 

In discussion a week after the birth, this woman commented to her midwife, "You know, it's a totally different outcome, having a caesarean birth after labour, knowing that I couldn't do any more myself, than if I had agreed to it the first or second time I was told I needed it."

The midwife agreed.  The decision making process included an ongoing review of the progress of mother and baby through uncharted terrain.  The decisions were made on the best information available.  There was ultimately only one *choice* - for the woman to do it herself, or not.  This is the only informed birth plan a woman can make, and follow through with.

related posts:
decision making for breech
breech vaginal birth
messages about breech births


Tine Oudshoorn said...

Great message. Thanks. Tine Oudshoorn, the Netherlands.

Tine Oudshoorn said...
This comment has been removed by a blog administrator.
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