Photo: iStock/Blue Planet Studio
When Emily Boros-Rausch began reading and attending birth classes while expecting her son, now eight months old, the Moncton, NB mother of one was surprised at the number of choices involved in the care she was to receive during her pregnancy, birth, and immediately afterward. “There are so many decisions to make—at times I did find it quite worrying,” she recalls. The amount of agency you're given over your care can often depend on whether your primary care provider during your pregnancy is a midwife or an OB/GYN.
However, being able to make an informed choice that fits with your values about whether to undergo any medical procedure—and still be treated with respect and dignity—is your right. “It’s a health human rights issue,” stresses Kathrin Stoll, a senior research associate at the Birth Place Lab in the University of British Columbia’s Faculty of Medicine, who focuses on respectful, patient-centred maternity care.
Very little research has looked at what happens when birthing people decline care. (Most studies have examined this phenomenon “from the perspective of the care providers,” Stoll says.) So she and a research team, including professor Saraswathi Vedam, lead investigator at UBC’s Birth Place Lab, recently conducted a study looking at what was declined by the birther, why it was declined, and how the care provider reacted, from the perspective of the childbearing people themselves.
Some respondents reported they hadn’t been fully informed of their options, and then later, “they felt cheated, like they hadn't been able to fully participate,” says Vedam. Others told stories of feeling powerless and in pain while providers pressured them into having procedures they didn’t want. And if they still declined, “very often, they were made to feel guilty, and like they were not a good parent,” Vedam says.
Unless you’ve given birth, you may not know what Vedam is talking about. Even if you’re fully clothed, and in familiar surroundings, you might feel intimidated by doctors and other health professionals, especially during your first pregnancy. Add a new-to-you healthcare setting, unfamiliar faces, overwhelming (and sometimes contradictory) amounts of information, having your intimate parts on display, and the bodily sensations of labour, and the result can be uniquely disempowering. (Often, for racialized women, there’s an even larger power differential.) It can seem as if these people can go ahead and do whatever they deem necessary to your body at a time when some women find speaking up for themselves difficult, if not impossible.
Molly Hope, a new mom in Moncton NB, experienced such a power dynamic during the birth of her daughter, now 21 months. Nearly every request she made was rebuffed. For example, when she asked to wait more than a few hours for contractions to start after her water broke, “they said, no, you need to have an induction right away, because they didn’t want my labour to stall,” she says. “You get to a point where you’re too exhausted to argue.”
Different hospitals, OBs and midwives may have different guidelines on policies like this, depending on the presence of other risk factors, the health of the mom and the health of the baby.
Ideally, patients should have conversations during pregnancy ahead of time about what to expect during labour, “so they don’t run into these conflictual, unplanned situations where you have to do a lot of discussion about interventions and procedures during a hectic time,” Stoll says. This can help prevent unexpected surprises, and hopefully, feelings of being disrespected or coerced. It also helps you build a relationship with your provider. "If early in your prenatal appointments, there’s a real disconnect between what you want and what the provider is willing to offer, you might want to seek a different provider, if you have a choice,” she adds. (Depending on where you live, this may not be an option. In some areas, waitlists are months long for maternity care providers of any kind, and some communities lack any practicing midwives.)
While care providers generally need to obtain your consent before going ahead with a test or procedure, some will simply present certain things as routine, while others will go through a much longer, more detailed discussion of the risks and benefits before asking for your permission.
“In Ontario, there are certain things midwives are bound by our professional college standards to do, and one of them is informed choice,” says Kathi Wilson, an assistant professor in the Midwifery Education Program at McMaster University in Hamilton, Ont., explains. This means laying out the potential consequences of both abstaining from, or going ahead with, a particular test or procedure. A patient shouldn’t feel like they’ve been “railroaded into a certain kind of care and haven’t been given adequate information,” Wilson says. While there certainly are obstetricians who practice informed choice and shared decision making, it historically hasn't been baked into their training in the same way it is for midwives.
So how can you sort out what’s a must-do, a should-do, or something you can safely skip, without spending endless hours researching?
Here are a few of the most common prenatal and postnatal interventions that first-time parents might be surprised they can choose to opt out of—and what experts recommend.
An internal (aka vaginal) exam in late pregnancy (usually around 38 weeks) to see if the cervix is starting to soften, “is not universal, but is very common,” says OB/GYN Vanessa Poliquin, associate professor of Obstetrics and Gynaecology at the University of Manitoba in Winnipeg.
This practice can provide some information, such as if the cervix has begun to soften and dilate, and, sometimes, even whether the baby is head- or bottom-down (aka breech). And if you’re eager to go into labour, it’s also an opportunity to potentially hasten that along with a maneuver called a stretch and sweep. (More on that in a minute.)
But unless it’s being done for a specific reason—say, prior to an induction to determine whether or not you need medication to soften the cervix first—there’s no convincing evidence that routine late-pregnancy vaginal exams are either helpful or harmful. And as far as how soon you can expect to go into labour, “they have absolutely no predictive value,” says Wilson. In other words, even if your cervix has begun to soften and dilate, labour won’t necessarily start within days, or even a week or two.
Some care providers view this maneuver as part and parcel of the vaginal exam, and so may not mention it as something you can decline if you wish. Others will present it as an option and explain the pros and cons before going ahead with it.
Performed by gently stretching the cervical opening, and separating the amniotic sac from the lower part of the uterus, a stretch and sweep can sometimes help soften the cervix, and may even promote contractions and bring on labour within 48 hours. If it's time to get things moving, a stretch and sweep may help you go into labour naturally and hopefully avoid a medical induction.
"It's a reasonably efficient procedure, and for some it makes a big difference," notes Poliquin.
Boros-Rausch, for example, requested membrane sweeps at 38 and 39 weeks because she’d been having early contractions and felt her body was ready to go into labour. (While the procedure can sometimes be painful, Boros-Rauch only found it slightly uncomfortable.)
While care providers may not all agree on the value of internal exams in late pregnancy, virtually all consider performing cervical checks periodically during labour an important part of good, safe care. For one thing, they can help your provider tell whether the baby is head-down when labour starts. They’re also useful for gauging how much your cervix has thinned (effaced) and dilated, and how far the baby has moved down the birth canal.
When it comes to intervals between exams, practices and policies may differ from one provider and one institution to the next. Some women prefer to have as few vaginal exams as possible, for instance, because they can feel invasive during such a vulnerable time, and emotions such as embarrassment release hormones that may slow down labour. If you’d like to minimize the number, “I think you can make an argument for every four hours,” Wilson says.
“You shouldn’t have to do them a whole lot, but there is information to be gained that can help keep labour on the right track, as opposed to sitting and waiting,” Wilson says. For instance, if your labour stalls, your caregiver might suggest getting up and walking to help promote progress.
It’s also worth noting that even experienced nurses typically don’t have extensive time to observe labours from start to finish, because they often work in shifts and have to manage multiple patients. They may pop into the delivery room once an hour to do an internal exam, but may be unable to stick around to provide emotional support and build trust, which can feel impersonal and invasive—or like your wellbeing or labour progress is being reduced to one body part. Experience level may also affect their ability to swiftly read external cues, compared to midwives, for whom “labour-sitting” is a cornerstone of practice. (For instance, what midwives refer to as the ‘rest-and-be-thankful’ lull that typically happens during an unmedicated labour between the time the cervix reaches full dilation and a woman starts feeling the urge to push is something nurses may have had scant opportunity to observe.)
That said, “there can be very deep and profound reasons that people decline [cervical], such as a history of sexual abuse or sexual assault,” notes Vicki Van Wagner, a registered midwife and associate professor of Midwifery at Ryerson University in Toronto. In that case, since Van Wagner would still recommend cervical checks during labour, she suggests working with your care provider to see if together, you can find a way of doing them without causing you distress. “But you know, sometimes you can’t find a way,” she acknowledges. And some caregivers, like Van Wagner, “would want to accept people declining any procedure rather than having people give birth unattended.”
As you might imagine, being able to build a trusting relationship with one care provider may help increase your comfort level with vaginal exams: when they’re done by a stranger, or a provider you don’t know well, or someone who doesn’t appear to listen to you or see you as an individual, you may feel more like a body being worked on, and less like a human being with fears and emotions.
There are even more choices to make for your newborn post-delivery. Your health provider may ask you to consider many of these options well in advance of your due date (before you’re busy giving birth!).
One of them is the vitamin K shot. Babies are born with low levels of vitamin K—which is necessary for normal blood clotting. (This is because very little vitamin K passes through the placenta; newborns don’t develop the colonies of gut bacteria that produce the nutrient for several months, and their livers aren’t yet mature enough to extract and use vitamin K from food. And while formula is fortified with vitamin K, breast milk contains little.)
This puts newborns at increased risk for abnormal bleeding, which, if it occurs in the brain, can cause catastrophic damage and even death. On average, the chance of any vitamin K deficiency bleeding happening in the first week of life is somewhere between one in 60, and one in 250: it can still happen up to six months later, though this is much rarer, affecting one baby in 14,000 to 25,000. Giving an injection of vitamin K within the first six hours after birth protects babies until their own digestive systems start producing sufficient amounts.
While the Canadian Paediatric Society has recommended a vitamin K shot for newborns since 1988, at that time, providers were divided on the strength of the evidence supporting the practice. This was compounded by the fact that one study suggested it might slightly increase the risk of a certain form of leukemia (that is, until a large, later trial found no such link.) Consequently, some parents declined the shot, or opted to have a dose given orally instead. “This happened on a large enough scale that they actually did see the incidence of vitamin K deficiency bleeding go up,” Wilson explains. (While the absolute number was still small, this was significant because the extra cases were preventable, and the impact on the affected families can be so severe.)
Since it’s not possible to predict which babies will develop vitamin K deficiency bleeding, or to stop or reverse the potentially devastating effects, most care providers now strongly suggest giving babies a vitamin K shot at birth. “This is an example of a routine procedure for the newborn that I think the evidence has gotten stronger and stronger in favour of,” Van Wagner says. That doesn’t quite mean that a lot of babies used to die of Vitamin K deficiency bleeding in decades past—just that the risk linked with skipping the shot is small, but meaningful.
On the other hand, the reverse is true for routinely putting antibiotics in newborns’ eyes—there is very little risk in opting out of this common, but outdated, practice. The idea behind it is that the medication could protect a baby’s vision against infections such as gonorrhea, which can be transmitted during birth, and it’s still technically mandated by law in Alberta, BC, Ontario, PEI and Quebec.
However, a good deal has changed since preventive eye medication for newborns was introduced in the 1880s. For one, the agent used was originally silver nitrate, not antibiotics, which hadn’t yet been discovered. After gonorrhea (which carries the greatest risk of causing rapid damage, and endangering vision) became less prevalent, with chlamydia replacing it as the most common STI, silver nitrate—which isn’t effective against the former—was replaced by antibiotic ointment.
In recent years, though, the Canadian Paediatric Society has called into question the effectiveness of topical erythromycin for preventing (vs. treating) such eye infections. (Some strains of chlamydia, in particular, seem to have become resistant to erythromycin.) Consequently, “the emphasis has thus become more on making sure that people are offered testing for STIs during pregnancy,” Wilson notes. (Another favourable development: while this once required an internal exam with a speculum, it’s now a simple urine test.)
In fact, says Van Wagner, “the Canadian Paediatric Society has recommended that health professionals work together to change the law.” In BC and Ontario, the laws have been amended to allow parents to decline the antibiotic ointment in most circumstances, as long as they sign a form documenting their refusal. In practice, this is something many midwives have been doing for decades. But because medical cultures vary across different communities, and medical racism and discrimination still very much exist, some providers wouldn’t respect parents’ wishes, and would sometimes even report parents to child protection services for opting out. (That said, in communities with relatively high rates of STIs, some care providers continue to recommend routine eye ointment as a preventative measure.)
A jab of Pitocin for the mom or birthing parent is considered part of routine obstetrical care in the moments between the baby’s arrival and the delivery of the placenta. (Pitocin is what the hormone oxytocin is called when it’s made in a lab.) It’s usually administered to the thigh, though may be just added to an IV if you’re already hooked up to one. The medication causes the uterus to contract, helping to squeeze off bleeding from the wound that’s left when the placenta separates.
“Many professional bodies, including the SOGC, recommend a prophylactic dose of Pitocin or a similar medication to prevent postpartum hemorrhage,” explains Poliquin. (Even less severe blood loss can have consequences as impaired breastfeeding and an increase in the risk of postpartum depression, she adds.) And the amount required to reduce the risk of hemorrhage (vs treating it) doesn’t cause side-effects such as heart palpitations, though it may slightly increase the chance you’ll need medication to treat after-pains that follow birth as your uterus contracts.
Skin-to-skin contact with your baby immediately after birth may help accomplish the same thing as a shot, because it causes your body to release a large gush of oxytocin. This is becoming common practice at most births, especially at midwife-led births. (And of course, you could also do both! Hold your baby on your naked chest while getting the Pitocin shot in your thigh.)
Interestingly, a 2013 study of women in New Zealand at low risk of postpartum hemorrhage whose births were attended by midwives, found that while the overall rates of heavy bleeding were low, birthing people who got prophylactic Pitocin were actually somewhat more likely to lose 500 ml or more of blood versus those who didn’t get the jab. (Risk factors for postpartum hemorrhage include uterine fibroids and pregnancy-related high blood pressure.)
Because things like place of birth (home birth vs hospital birth) seem to influence the likelihood of hemorrhage, and many studies showing benefit from Pitocin are older, and weren’t done in higher-income countries like Canada, not all midwives are convinced of the need for the preventive shot in the absence of risk factors such as previous postpartum hemorrhage. (Still, clinical practice guidelines for Ontario midwives recommend an informed choice discussion on how to manage this stage of labour that takes such issues into account.)
However, unless your care provider will be remaining with you for a few hours after birth (which obstetricians typically don’t), “you may be better off having the Pitocin,” Wilson says. That’s because while a midwife or family doctor who’s on hand can administer a shot if you start bleeding heavily in that window, nurses don’t have the authority to do so independently.