Informed Decision Making: “No Thank You” – A Guide to Informed Decison Making

Your experience of labour and birth should be exactly that – YOURS. Every birth is unique as each woman will approach childbirth in her own way. It is important that you have the information you need to decide what is right for you and your baby, and that your experience of labour and birth reflects these wants and wishes.

Being informed will help prepare you for birth and help you make decisions on what is important to you in labour. It can also help you make important decisions should changes arise in your labour. Your care providers should present you with information but many women also like to read up on options at home first. It is important that information is from a reliable source and based on evidence.

Do you have ALL the information?

You will have lots of decisions to make throughout your pregnancy, labour, birth, and caring for your new baby. Being involved in the decision process ensures that your care is specific to you and your baby. You know your needs best! You will be required to make choices – to either accept, or decline, or do nothing – for all tests, treatments, and procedures in your pregnancy, and during labour and birth.

In order to make the best choice for you and your baby, you need to have all the information from reliable sources.

Including:

* the benefits – positive ways in which accepting or declining a test/treatment/procedure will affect you and/or your baby, as shown by high quality research

* the risks – the ways in which accepting or declining a test/treatment/procedure will harm you and/or your baby, as shown by high quality research

* implications – any associated risks of a test/treatment/procedure to you and/or your baby

* any future consequences of the action

Opting in – Opting out – or None of the above!

It is up to each woman to consider all the information in order to make the best choice for her and her baby. Information should be from reliable sources and presented without bias. It is essential to ask questions if you feel you need more information. Its also important to ask for a second opinion if you feel that the information is being presented in a biased way; to influence how you make a decision.

Informed decision making consists of two main areas: informed consent and informed refusal.

Informed Consent

Informed consent is when you decide to accept or “opt in” to a test, treatment, or procedure after weighing up all your options and considering all the information.

Example of informed consent:

Susan is 6 days overdue on her first baby. She is feeling heavy and tired and her consultant offers her a sweep to get things going. Susan isn’t sure what a sweep is or how it is performed and asks her consultant for more information. Susan’s consultant explains that a sweep is performed internally and that he would use his fingers to sweep along the cervix in the hope that it might stimulate the start of labour for Susan. Susan’s consultant explained that it generally works for 1 in 8 women who are close to starting labour themselves and that it may just be what Susan needs to get things going. He also explains that after the sweep, many women experience a show and have lots of cramping which may or may not be the start of labour. He explains there can be a risk of infection or accidently breaking her waters. He also tells Susan that there is no guarantee that the sweep will start labour. Susan asks her consultant if a sweep will hurt and he tells her that the less favourable a woman is (if her cervix is still hard and posterior) the more likely a sweep is to be uncomfortable. Susan consents to a sweep but asks her consultant to only perform the sweep if her cervix is soft and favourable for labour.

Informed Refusal

Informed refusal is when you decide to decline or “opt out” to a test, treatment, or procedure after weighing up all your options and considering all the information.

Example of informed refusal:

Mary has just given birth to her third baby. Throughout her pregnancy she has read information about managing the third stage of labour by injection. Mary has requested in her birth plan that she deliver the placenta naturally and for the cord to finish pulsating. Mary’s midwife has mentioned that the routine practice in the unit is for the third stage to be managed. Mary asks the midwife what the risks of having a natural 3rd stage would be and discusses the benefits she had read about during her pregnancy. After a discussion with the midwife, Mary refuses a managed 3rd stage of labour and delivers the placenta naturally some time later.

Do Nothing

Doing nothing is when you decide to neither accept nor decline to a test, treatment, or procedure at that time after weighing up all your options and considering all the information.

Example of doing nothing:

Jen is encouraged to have a GTT at her booking appointment. She has no current risk factors or history from her previous babies which she feels warrants a GTT. She is worried about having an unnecessary test and is not satisfied with the information she is being given on why it is being recommended. Jen decides to hold off having a GTT at this time and explains to the midwife that should she change her mind in the pregnancy, or if any risk factors appeared, she would revisit this issue.

Coercion, Implied Consent, Complete Disregard of Consent

Unfortunately, sometimes women are not given all the information when they ask questions or the information is presented in a biased way, making women feel pressured to give consent.

“Its not consent if you make me afraid to say no”

Coercion is when consent is sought but a woman is given no choice or information to refuse – or she feels pressurized to give consent. Coercion is often used when a medical professional sites ‘hospital policy’ or accuses the mother of putting her baby at risk when asking about her choices or information on refusing a procedure.

Implied Consent is where consent is implied but not actually sought by care providers.

Disregard of consent is where there is a complete disregard to the fact that consent needs to be sought and obtained. The woman is given no information or choice in the decision process and procedures are carried out specifically against mother’s wishes or without informing the woman of what is happening.

Examples of coercion, implied consent, and complete disregard for consent:

Sarah presents herself at her maternity unit in spontaneous labour. This is her first baby. Sarah has expressed the desire to be active in labour and to have the option of the bath for pain relief. She is coping really well, her baby is happy. On admission, Sarah is told she needs an admission trace with a CTG which means she cannot move around or use the bath. Sarah tries to keep upright with the CTG but the belt keeps slipping and Sarah is asked to lie on the bed to get a better reading. Sarah finds it very difficult being on the bed. Sarah asks if she can have intermittent monitoring but is told that it is hospital policy to use the CTG. Sarah explains to the midwife that she would like to move around and use the bath, again asking for intermittent monitoring. Her midwife tells her that her baby is what is most important and that the CTG reassures everyone that her baby is healthy. Sarah agrees as she does not want to be seen as a troublemaker or annoy her midwife. She also doesn’t want to do anything which could make her baby unsafe.

 

Aoife has presented herself to the labour ward at 3cm dilated. She is having good regular contractions and has been admitted. On admittance to the labour ward, the midwife asks Aoife if its OK to examine her, which Aoife agrees. As the midwife performs the vaginal exam, she says “we are just going to break your waters now” as the waters break. Aoife is confused, had she consented to have her waters broken?

 

Louise has been pushing for half an hour. She has had an epidural and she and her baby are both doing fine. On the next push Louise’s doctor says, “I am just going to make a little cut,” and performs an episiotomy. Louise’s baby is born shortly after but Louise wishes that the episiotomy had been discussed with her before it was performed.

 

Lisa arrives at her appointment at 40+4. Her doctor discusses the plan of care as she is now over-due. Lisa tells her doctor she would prefer not to be induced in any way. Her doctor agrees and then suggests he do a quick exam to see if Lisa is favourable or likely to go into labour soon. Lisa thinks it would be good to know if anything is happening, and agrees to an exam. Lisa’s doctor performs a vaginal exam and a membrane sweep. Lisa feels very upset, having a sweep was never discussed with her and she did not want one.

What women say about informed decision making

“I had a planned Caesarean Section for a transverse lie on my first baby and a relatively straightforward VBAC on my second. The only thing I would have changed was the continuous monitoring as I found it really disturbed my labour. On this baby I brought up monitoring early on with my doctor, I had done a lot of research on it and we had a good discussion. He told me it was policy to have continuous monitoring with VBAC but as I was making an informed decision he supported my choice. He wrote that I was to have intermittent monitoring during labour as expressed by me, and this was to be respected assuming the labour went normally. I had a fabulous birth, with intermittent monitoring”

And:

“I feel that every woman needs to have access to all information. I was very informed but it was due to research done by myself. However when you are in the hospital there is a subtle pressure put on you saying you want your baby to be safe “

And:

“I was admitted to the labour ward at 9cm on my fourth baby. She was in a slightly off position and my contractions only felt productive when I was upright. I explained this to the midwife but she told me I had to have an admission trace, which required being on the bed. When I was on the bed, the contractions started spacing out and one of the midwives decided to order oxytocin. My baby was doing fine and I was OK so I declined oxytocin. I got the CTG off and up off the bed and the contractions started back up again. My baby was born an hour later while standing by the bed”

And:

“In some instances I was given the option to refuse, in others, I was not, I was told it was “hospital policy” and I had to agree. E.g., having continuous fetal monitoring in labour”

Tools to Use in Decision Making

A supportive care provider is an essential part of a positive and healthy birth experience. Your care providers are there to work for you – to support you and ensure that you have the best birth for you and your baby. It is important to have regular discussions with your care team on any worries, your options, or questions you may have. Any concern or question you have is worth raising, and you care team will be happy to discuss it with you! Birth is not the right time to go over your options, its best to have these conversations early. A birth plan, or birth preferences can be a great way to initiate discussion on your care options and the preferences you have for you and your baby. Your preferences are not ‘demands’ or set in stone, but are simply a way to discuss with your care team what is important to you, what you would like to avoid, your preferences should complications arise, the use of tools or options available to you and more. Many hospitals have a sample ‘birth plan’ tick-box of preferences – or you can write out your own.

The majority of us will not meet our main health care provider until we are booked into labour. As in all workplaces, there are good health care professionals and bad health care professionals. Or someone could be having a really bad day! There can also be personality clashes. If you feel that your health care professional is not a good fit, request a new one! A supportive care provider is an essential part of a positive and healthy birth experience. Birth is not the time to ‘make do’ with something or someone you are not happy with.

If you still aren’t sure, these tools can help provide you with the information you need to make a decision about what to do next.

Asking simple questions can help you make a decision.

Is my baby OK?
Am I OK?
What other suggestions do you have?

Another helpful tool is to “use your brain”.

B – what are the Benefits involved?
R – what are the Risks involved?
A- what are the Alternatives?
I – what does my Intuition tell me?
N – what would happen if we do Nothing?

Example:

Tina has been in labour for 5 hours and the midwives are not happy with her progress. It is suggested that her labour be accelerated. Tina asks the midwife, is my baby OK? Am I Ok? And she is told that they are all doing well but that labour does not appear to progressing as quickly as it should be. Tina asks the midwives if there is anything she can suggest which may get things moving on their own. The midwife suggest that sometimes getting up and moving about may help. Tina suggests to the midwife that she go for a walk for a half an hour/hour and then they can reassess the situation then. Midwife feels this is a good idea.

Finally, never feel that you are trapped into a decision once you make it – you can change your mind at any time!

If you would like more information on informed decision making or would like to access AIMS Irelands private and confidential support services please see  support@aimsireland.com