Tuesday, September 03, 2013

a pot of tea

my new enamel teapot
I am delighted with my new enamel teapot which my daughter found for me.

Today I would like to make a pot of tea, and talk with you about one of the challenging topics in maternity care: decision-making.

here are some of my questions:

  • Who is the decider?
  • What choices does a woman have?
  • Are there limits to personal autonomy?
  • How much information does a midwife (or obstetrician) need to give a woman when a decision needs to be made? 
You:  That's easy, it's my body, my baby, my birth.  I'm the decider.

Me:  Yes, but your decision can only be made from what is on offer at the time, can't it?

You:  What do you mean?

Me:  Let's take a very common decision that has big implications for subsequent events in birth, induction of labour.  Let's assume that you and your baby are well, that your pregnancy has continued a few days past the due date, and you are getting tired of being pregnant, of all the phone calls: "Are you still in one piece?" and waking up in the night with a half-full bladder, and half strength contractions that don't go anywhere.  Someone suggests that you ought to have induction of labour.  How would you decide?

You:  I would ask you as my midwife to tell me the pros and the cons, and I would make my mind up.

Me:  I need to declare a certain bias here.  As a midwife, by definition, I am committed to protecting and promoting the natural process unless there is a valid reason for interruption.  It sounds to me as though you are likely to come into spontaneous labour very soon, with all those runs of pre-labour contractions, and I see no clinical reason to induce labour at present, so I cannot encourage you to consider induction of labour.  I will list off some of the risks that are inherent in this procedure: a cascade of interventions, use of artificial stimulants that can lead to hyperstimulation of your uterus, and reduced blood flow to your baby; to increased perception of pain, and need for medical forms of pain management, possibly increasing the likelihood of assisted vaginal birth or even caesarean; separation of mother and baby at birth; difficulties with bonding and breastfeeding ... do you want more? 

You:  So, my decision is no.  I don't want induction of labour.

Me:  When I check you again in a week's time and you still haven't had your baby, I may want to encourage you to re-consider induction of labour.

You:  But you have convinced me that it's not a good idea.

Me:  That was last week.  We are now 10 days past your due date, and the guideline I am required to follow leads me to advise you to carefully consider induction of labour if you are past 40 weeks + 10 days.  There are pros and cons which you need to consider - some the same and some different from what we discussed last week -  as you make your decision. 

You:  I do want to have my baby, but I don't want to do anything that would hurt my baby.  How can I be sure?

Me:  There are no guarantees.  Each decision point is like a fork in the road: you must take one or the other, and there is no turning back.  I would encourage you to be reviewed at the hospital, where they can use ultrasound to check fluid levels around the baby, and the function of your baby's placenta, and do some monitoring.   If any of these tests result in non-reassuring features, there will be more 'encouragement' to proceed to the birth without delay, which could include surgical induction (breaking the waters - the membrane holding amniotic fluid around the baby), and possibly medical induction (IV syntocinon).  If all the tests are reassuring, I will encourage you to consider waiting for spontaneous onset of labour.

You:  So, although I get to make the decision, I need to trust the information and trust the person who is giving it to me.

Me:  That's right.


Another possible pathway in this scenario is that you, the woman, have made an effort to inform yourself, and decided that under no circumstances will you accept induction of labour.  You want to have your baby naturally, in your home.  You know your rights, and you decline any offer of investigations because you have no intention of being spooked by the medical system.  How much information am I required to give you?  Should I discuss all the possibilities, or should I give you my professional assessment based on my palpation of your abdomen, and my (limited) ability to auscultate and assess?

If there is an adverse outcome, am I culpable because I did not give you enough information?

Decision making is not a one-off choice; it constantly evolves as we move through a childbearing episode. The trump card that a woman has is 'Plan A' - her capacity to do it without assistance or education or coaching or therapies or any outside help. But it's the fine line between Plan A and Plan B, when intervention is likely to lead to better outcomes - that may call for expert and timely professional action.

My concern about naming a 'decider' relates to situations in which I have seen the professional treat decision making as a sort of lottery - "I can do this or I can do that - your choice" without giving sufficient information to help the person understand the choice they are making. It's an ongoing process that demands trust and reciprocity between the woman and the midwife.

Even if 95% of women who come into spontaneous labour could stay in 'Plan A', and go on to an unassisted birth, what happens to the 5%? How does a woman know? 

I hope you have enjoyed your cup of tea.
Your comments and further discussion are welcome.

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