Birth Preferences (Part 1): The Importance of Informed Consent and the "Overdue" Baby
Photo by Jonathan Borba
(Originally posted on September 29, 2016)
If you have a healthcare provider who you trust is capable of recommending the best treatment for you and your baby, who are you to question their advice?
An informed patient and diligent parent, that's who you are! Taking an interest in the healthcare decisions being made for you and your child is your right.
According to this article, published in the Journal of Perinatal Education,
"in the United States, federal acts and regulations, as well as professional guidelines, clearly dictate that every pregnant woman has the right to base her maternity care decisions on accurate, up-to-date, comprehensible information. Despite these efforts, evidence suggests that informed consent within current health-care practice is restricted and inconsistently implemented."
This lack of informed consent could take the form of omission of information, unannounced intervention, or a declaration that an intervention will be necessary (rather than a conversation including the patient in shared decision making).
Shouldn't we just leave the decision making to the experts? Not necessarily. While it definitely makes sense to consider your provider's professional opinion based on their knowledge and clinical experience, it certainly shouldn't be the last word. There are benefits and risks to be carefully considered, and unfortunately, there are still widespread practices in obstetrics that are not based on evidence.
Of course, there are legitimate reasons interventions may be suggested by your provider. In certain situations, interventions can be essential and life-saving, or the clear choice most likely to result in a favorable outcome for mother and baby; however, many times there is no clear cut "right answer". In many cases, there are different risks and benefits for each choice that need to be weighed, making the "best way" to go truly a judgement call. It is especially during these situations that the opinion and desires of the birthing family should be a major consideration. One such scenario is the decision of when or whether to induce labor for an "overdue" baby.
Photo by Camylla Battani
Full Term/Late Term Options
The best evidence shows that the average length of a normal pregnancy is closer to 40 weeks and 5 days from the start of the last menstrual period (or 40 weeks and 3 days for women who have given birth before) (Smith 2001, Jukic et al. 2013). Half of all pregnant women will give birth by 40 weeks and 5 days, and the other half will take longer. Longer pregnancy is often determined by genes, including the baby's tendency to gestate longer, and a woman's tendency to carry a pregnancy longer.
In any case, if you end up going past your estimated due date, you'll likely fall into one of two categories, as determined by the American Congress of Obstetricians and Gynecologists:
Full Term: Between 39 weeks 0 days and 40 weeks 6 days
Late Term: Between 41 weeks 0 days and 41 weeks 6 days
It is during this time, that the topic of induction will likely come up. Inducing labor is known as "active management." Waiting for labor to begin on its own, while monitoring the baby's status is known as "expectant management". There are risks and benefits to consider when deciding whether to induce labor, or wait to go into labor naturally, and there has been a lot of discussion over this comparison.
In 2014, ACOG released their latest recommendations on post-term pregnancy. Although their guidelines are not freely available to the public, ACOG recommends that induction of labor should take place between 42 weeks 0 days and 42 weeks 6 days, and that induction at 41 weeks can also be considered. If a woman planning a VBAC goes post-term, this does not mean she has to have a repeat Cesarean.
Research has shown that complications do increase for both mother and baby in pregnancies continuing beyond the estimated due date; however, there are also risks involved with induction. Most research articles and guidelines say that because there are benefits and risks to both options, the women’s values, goals, and preferences should play a part in the decision-making process.
According to Evidence Based Birth, one of the lesser known benefits to expectant management, and avoiding induction is the established hormonal benefit of experiencing spontaneous labor. In her book Hormonal Physiology of Childbearing (free full text available here), Dr. Sarah Buckley reviewed the research on the hormonal benefits of spontaneous labor. Based on the available evidence, Dr. Buckley concluded that: “Overall, consistent and coherent evidence from physiologic understandings and human and animal studies finds that that the innate, hormonal physiology of mothers and babies—when promoted, supported, and protected—has significant benefits for both in childbearing, and likely into the future, by optimizing labor and birth, newborn transitions, breastfeeding, maternal adaptations, and maternal-infant attachment”.
With so much information out there on this topic, and no definitive answers on which course of action is superior, it can be a very hard spot in which to find yourself. If your estimated due date has come and gone, it is a good idea to talk with your healthcare provider about the risks and benefits of both active and expectant management, your unique preferences, and possible alternatives to medical induction (natural induction methods).
In addition, your doula or birth class may be a good resource as you explore your preferences and weigh your options. They can provide general information, support and help you to explore what questions you may want to ask your provider.
Disclaimer: The content found on this blog is meant only to provide general information and is not a substitute for professional medical advice.
Stay tuned for upcoming posts in this series: Birth Preferences (Part 2): Vaginal Exams, Birth Preferences (Part 3): Birthing Environment and Choosing a Care Provider, Birth Preferences (Part 5): Fetal Monitoring