Consent & Informed-Decision Making in Labor
Picture this: A birthing person has been laboring for hours— contractions coming in endless waves. They are exhausted. Their doctor comes in and says, “you’re still just at 5 centimeters. You’re really not progressing. We’re going to need to speed things up.”
Now, here’s two truths and a lie:
Truth: A laboring person’s “progress” is defined by more than just centimeters that their cervix is dilated (more on that in a second).
Truth: A laboring person and their partner have the right to ask questions, gain more information, and have A CONVERSATION with the provider before decisions are made.
Lie: You should not ask questions of your providers. There is no time for questions.
So, how did we get to this point? And how do we avoid it in the future?
Since 1955, medical professionals have used “Friedman’s Curve” to determine how long it should take for the cervix to dilate (1 cm/hour being the optimal pace for labor). The curve was based on a sample size of 500 white laboring women and quickly became the gold standard. If laboring people did not “progress” according to the curve, they were likely to have interventions like an induction or cesarean birth.
Truth is, “labor lasts different amounts of time for different people and with different circumstances. Dilation does not tell us how much longer we have until we’ll give birth.” (The Educated Birth).
American College of Obstetricians and Gynecologists redefined the markers for typical labor progress in 2012. Still, you may encounter providers who use Friedman’s Curve, which can lead to deficit-based thinking, interventions started without full consent of the laboring person, and a sense that the laboring person has lost their autonomy.
It is 100% your right to ask questions during prenatal and postpartum care and while in labor. It is 100% your right to get consent for procedures. It is 100% your right to surround yourself with a care team-- OB/midwife, partner, doula-- who supports shared and informed decision-making. And when consent and informed-decision making happens, you’re more likely to feel safer, more heard, and empowered during your pregnancy, labor and birth.
In fact, the American College of Obstetricians and Gynecologists updated its recommendations for “Informed Consent and Shared Decision Making in Obstetrics and Gynecology” in February 2021. ACOG writes,
Meeting the ethical obligations of informed consent requires that an obstetrician–gynecologist gives the patient adequate, accurate, and understandable information and requires that the patient has the ability to understand and reason through this information and is free to ask questions and to make an intentional and voluntary choice, which may include refusal of care or treatment.
Shared decision making is a patient-centered, individualized approach to the informed consent process that involves discussion of the benefits and risks of available treatment options in the context of a patient's values and priorities.
During the shared decision-making process, patients are encouraged to share information, express value-based preferences, and provide input on a treatment plan. A shared decision-making approach facilitates meeting the highest ethical standard for the informed consent process.
This practice has been shown to improve patient knowledge around their care, allow for better understanding of risk, and improve patient outcomes and satisfaction.
Redefining “Progress” in Labor:
Pregnant/birthing people, please remember:
Progress in labor is not always linear.
Your body may be making progress even if it’s not being reported by doctors.
Ask your medical providers “What is my bishop score?”
Your “bishop score,” which tells you how ready your body is for labor and birth, includes:
centimeters your cervix is dilated (0-10)
station of the baby in your pelvis (-5 to +5)
level of effacement/thinness of your cervix (0-100%)
consistency of your cervix (firm, medium, soft)
position of your cervix (moving from posterior/point towards back to anterior/towards the front)
Questions for Informed-Decision Making
Questions* to ask your provider when a treatment or intervention is suggested while you're in labor:
What is the problem and how serious is it?
How urgent is the need to begin treatment/the intervention?
What is the treatment and how is it done?
How likely is it to solve the problem?
If the treatment/intervention fails, what are the next steps?
Are there any side effects to the intervention/treatment?
Are there any alternatives (including waiting, doing nothing, or other treatments/interventions)?
Questions* to ask your provider when a test is suggested at a prenatal appointment:
What questions will this test answer?
How is the test done?
How accurate or reliable are the results? What is the margin of error? In other words, might the test miss a problem that exists or indicate a problem that does not exist?
If the test detects a problem, what happens next (for example, further testing or immediate treatment)?
What will this test cost the pregnant person, if anything?
*from Penny Simkin’s seminal text, “The Birth Partner”
There are also 5 simple and powerful questions** that laboring people can ask their providers to get consent:
Am I okay?
Is my baby okay?
Is this an emergency?
What are all my options?
Do I have 5 minutes to process?
**from China Tolliver, birth doula and midwife, who created “let’s taco bout consent” cards
Dr. Nicole Lee Plenty, a double board-certified OB/GYN and Maternal-Fetal Medicine Specialist, urges all pregnant persons to “advocate for yourself, You are your biggest advocate and no one knows what’s going on with your body except for you.”
Surround yourself with providers and a care team who will listen to you and help you advocate for yourself. Reach out to Boston Area Doulas to learn more about how we support pregnant, laboring and postpartum people.
About the Author: Kathleen Stern is a certified labor, postpartum and infant care doula and founder of Boston Area Doulas. She had a postpartum doula with her second child, which inspired her to start Boston Area Doulas. Kathleen believes in the power of support, connection, increasing access to resources and increasing one’s confidence in parenthood. She lives in Boston with her two girls and husband.
