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.

more about choice, decisions, and 'the birth you really wanted'

From time to time, as I read social media sites used by mothers, midwives, and others interested in the whole childbirth package, I come across messages such as:
"I was prevented by ... from having the birth I really wanted," or
"I'm so glad you got the birth you really wanted."

Women who feel physically and emotionally traumatised by experiences in previous births declare that they won't go near the hospital, because that's where and why it all happened the way it did.

More and more women are telling me that they are planning to give birth at home without professional support for various reasons - can't afford a midwife; no midwife or publicly funded homebirth program in the area; too 'high risk' for the midwives in the area ...  This really concerns me - it's scary!

Homebirth has resurfaced in the local media recently, with an article by Sydney midwives, Karol Petrovska and Caroline Homer, Beyond the “homebirth horror” headlines: some wider questions for the health system (and media).  This article was responding to a 'news' article on the mamamia blog, titled 'A hospital birth would have saved Kate's baby'.

The Coroner had identified internet-based research of risk as being central to the mother's choices and decisions in this instance
‘‘[This is] an example of the danger of untrained users utilising raw data or statistical information to support a premise as to risk, without knowledge and understanding of the complex myriad of factors relevant to the risk’’.[report]

The Coroner also found that delay in transferring care from home to hospital, after it should have been apparent to the midwives that Kate's baby was in distress, contributed to the death.

Midwives hold to a theory of 'partnership' with each woman in our care.  The midwife-woman partnership has been incorporated into the ICM International Definition of the Midwife.
This partnership, when correctly applied, places the woman at the centre of all decisions, with the intention of protecting the wellbeing and safety of mother and child.

Today I would like to briefly comment on the midwife-woman partnership, especially as it applies to choice, decisions, and achieving 'the birth you really wanted'.


Independent midwives, employed directly by women for birth in their own home, are in a privileged position because we are able to apply midwifery skill, knowledge and expertise directly without being hampered by the levels of bureaucracy and policy and protocol that exist in hospitals.  Women who are low risk and who plan to give birth at home with a midwife in attendance are in the most optimal maternity care situation that exists today.  A large study (de Jonge et al 2013) comparing maternal outcomes from (low risk) homebirths with a comparable group of (low risk) women giving birth in hospitals in the Netherlands concluded that:

"Low risk women in primary care at the onset of labour with planned home birth had lower rates of severe acute maternal morbidity, postpartum haemorrhage, and manual removal of placenta than those with planned hospital birth. For parous women these differences were statistically significant. Absolute risks were small in both groups. There was no evidence that planned home birth among low risk women leads to an increased risk of severe adverse maternal outcomes in a maternity care system with well trained midwives and a good referral and transportation system."

Independent midwives practising in Australia are often asked to attend births that are not in the low risk category.  Women who are older, fatter, who have had a lot of children, or caesarean births, or who have been traumatised in previous births often seek a midwife who will plan homebirth with them, particularly those who want to avoid the hospital.

There is no calculation table that lists risk factors against chance of having an uncomplicated vaginal birth - and if there were, I doubt that it would be of any use.  The current 'odds' for serious adverse complications (such as death of a baby, or serious maternal haemorrhage from uterine rupture) in vbac is estimated at 1:2000. [for more on safety of vbac, click here]   There is no comparable statistical estimate that ordinary people face in daily living.  People who bet on horse races may have some understanding.  1:2000 seems remote, and meaningless.

A more useful guidance would be to define at what point in time does actual risk, rather than theoretical risk, escalate.  This appears to me to be a question that was not thoroughly explored in the tragic case referenced at the beginning of this post. This clinical judgment is within the scope of a midwife's practice.  Spontaneous, unassisted birth becomes less safe if there is anything that indicates compromise of the mother or the fetus: complications of pregnancy, including raised blood pressure or impaired glucose tolerance; prolonged pregnancy; antepartum haemorrhage. Complications of labour including poor progress over time; and fetal heart rate decelerations or other abnormalities.

When 'the birth I really wanted' focuses on place of birth, or even on the process of birth, a significant number of mothers are going to be disappointed.  A midwife cannot become so committed to homebirth, or natural birth, that she forgets to keep a keen, critical eye on what is actually happening.  There are a couple of significant hurdles that a woman needs to get over before the spontaneous, unmedicated homebirth can even be considered. These are:

• spontaneous onset of labour, and
• spontaneous progress in labour - to the point where natural expulsive forces can be applied.

As it happens, there is no safer way for most babies to be born, than for the mother to do it herself - spontaneously - irrespective of place.  Not with herbal stimulants or acupuncture or coaching or hypno/calm birth education or pelvic manipulation or olive oil being rubbed into the perineum, or the best midwife in town.  Spontaneous is from within.  As labour progresses, a mother's capacity to judge progress and safety decreases, as her calculating, educated mind closes down to permit intuitive activity from deeper brain structures.  As this altered state of consciousness becomes strong, her midwife maintains a skilled, watchful vigil.  A mother cannot do this for herself.

The midwife's role is clear: if the mother and baby are coping well with spontaneous labour, no interruption or interference is permitted.  On the other hand, if warning signs are present, the midwife's ongoing clinical judgment and assessment throughout the birthing process protect the interests of her clients, both mother and baby.

You might have a birth plan for 'the birth I really want'.  Please check that birth plan, and check with your midwife, to ensure clear decision points.  While you are able to spontaneously progress through labour and birth, the physiological process is magnificent.  But, if there is a valid reason to interrupt the natural process, be ready to get the best birth possible, using the best and most timely intervention that is accessible at the time.

'The birth I really wanted' is above all, one that protects my baby and myself.   

Thankyou for your comments.

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