Consent: A Progression of Decision-Making in Birth - a podcast by Sara Pixton

In this episode, I tackle the hot topic of consent in the birth space.

TRANSCRIPT:

Before we jump into the content on today's episode, I wanted to encourage you to head on over to www.birthwords.com, check out the new website and all the features there. You'll notice a few things. There's a Classes tab, where you can sign up for one-on-one video consults. And I'd love to meet with you that way, either for expectant families or birth professionals. Stay tuned, in a while those will turn into full fledged online courses, but for now, you can have the one-on-one if you sign up there. You can also check out the Shop tab which has birth affirmations cards that you can choose from the ones that speak to you or customize your own and order from there. And, if you use the promo code podcast for either of those purchases, you can get 15% off, so head on over to www.birthwords.com. Come and check it out.

 

 Hi, welcome to today's episode about informed consent. This is a big phrase in the birth world. I know doulas who have T-shirts that say “informed consent is my jam.” And it's important and people are passionate about it, because it doesn't always happen the way that it should. I've talked a little bit about this topic previously. I'm thinking about my conversation with Rebecca Dekker that was aired on October 28. Go back and check that one out if you haven't. We talked a little bit about informed consent or informed choice in that episode. And it's a really important topic that we'll continue to touch on and dig into in upcoming episodes. Today I want to talk about this progression from no consent, to consent, to informed consent, to informed choice.

So, no consent, unfortunately happens in the birth space more than people would like to admit. Occasionally it makes headlines, but most of the time it doesn't. And most of the time, this looks like things like the nurse saying: “Okay, the doctor wants me to turn up your Pitocin," so she turns it up, not waiting for any sort of consent, not waiting for a verbal “Yes, that's okay.” So, I'm thinking of when you fly in an airplane, if you're seated in an exit row, they tell you the roles and responsibilities of being seated in that row and what you would need to be able to help with in the event of an emergency and the plane will not take off until each person and an exit row has given a verbal “Yes.”

And sometimes, in the birth space, that verbal “Yes,” is not waited for and it can have traumatic, long-lasting effects. I'm thinking of unconsented episiotomies--have a huge effect.  And, just other things that are done during the birth process that don't recognize and honor a woman as a life-giving agent, engaged in a praiseworthy work, right? Somebody who's bringing new life into the world, who has carried this life within her own body for nine months, and is now emerging, and is now inviting that baby to be born, the birthgiver is playing a critical role in the ongoing drama of life. And, acting for her, acting upon her, without her consent is completely counter to the truth of the work that she is doing, and the beauty of it.

So let's talk about consent, then.  We talked about no consent, let's talk about consent: "compliance in or approval of what is done or proposed by another." That's Merriam Webster, there: "compliance in or approval of what is done or proposed by another.” So still here, that agent, the actor is the care provider.  Saying: “Hey, I'm going to do this,” but it does in this case, wait for that “yes. That's okay. You can proceed with that."

Still, with the power in the hands of the care provider, with the nurse or doctor or midwife being the one proposing or doing a course of action, and then leaving the role of the birth giver to be simply to consent, again, I argue does not honor the beautiful, life-giving, life changing work that she's doing in bringing that baby into the world. And of course, people will argue, and I will not disagree, that in some emergency situations, this is appropriate for the care provider to be the one really proposing the course of action. And, then we'll go into the next step of informing as much as possible, as much as emergency allows, and then moving forward with it. 

In some cases, that's appropriate.

But in most cases, as I talked about in episode one and episode three, birth is typically emergence, not emergency, and sometimes we act as if it's the other way around. So, let's take another step forward into informed consent. Google says that informed consent is “permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits.” So, with this model, who is granting the permission? The patient. It's a step up in that the patient is supposed to fully acknowledge and be made aware of all the risks and benefits. That's great when this happens. Again, I think there's another step that we can take beyond that. But often it doesn't.

 Often what we call informed consent is really just taking that step back to consent. Oh, your doctor wants me to break your water. Oh, your doctor wants me to turn up your Pitocin. And sometimes there's an opportunity to ask questions. A lot of times the assumed authority of the doctor is the reasoning given, and there's no conversation for risks and benefits in that space. 

But really, truly for informed consent to truly happen, what that means is that there's the informed portion of conversation in which the birthgiver has a conversation with their care provider about the possible risks and the possible benefits of proceeding forward with the proposed action. And the birthgiver should make the decision that they make in full knowledge of both sides.

And again, I don't often see this happen to this full extent.  And, it's also worth noting that Google's description says informed consent is “permission granted in the knowledge of possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits.” You notice I paused there this time on patient. This is one of my ticks--one of the things that makes me tick?-- No, this is one of my issues that I have sometimes in the birth world is that we say “okay, you are a patient in the hospital setting." A patient according to, again, my good friend, Google is "a person receiving or registered to receive medical treatment.” Let's stop there for a minute, “receiving or registered to receive medical treatment.” Okay, so we're giving birth and there is some medical treatment that will most likely come along with it.  Or maybe stitches. After the birth, there may again be medications administered throughout labor, then there's medical treatment given to the child after it’s born.  But you notice a person receiving medical treatment really puts the birthgiver in this passive state of receiving treatment. A birthgiver, I use that phrase a lot, right? It's my favorite, because they're giving birth.  Maybe we should call them a lifegiver. Maybe that would help us recognize that they're not there to receive treatment. They're there to bring new life into the world.

And it's tricky because a hospital where most babies are born, is set up to provide treatment for those who need it. And there are many benefits that the hospital provides for those giving birth there. My perspective is that they are far too many and overdone. And that, whatever your opinion about how many interventions should or should not happen during birth, still, when a patient goes to a hospital to receive treatment for an illness, that's a very different thing that we're dealing with than when a birthgiver arrives at the hospital to bring new life into the world. Okay, so here's the other nugget that came along with Google's description of patient. It has some similar words listed down below some synonyms. Here they are: “sick person, case, sufferer, victim, invalid,” and the list goes on. 

Now, if I was a sick person receiving treatment, some of those I would still squirm about being called. I don't love the term invalid, though I've sometimes been an invalid at a hospital receiving treatment. I hope that I never go to a hospital as a victim. And I hope that the number of people who have the experience of being a sufferer while giving birth can decrease and decrease and decrease over time, as they're made more aware of their options, their choices and as they're given compassionate care that really considers their perspectives. 

Okay, so perhaps that was a little bit of a side soapbox about the word patient, but let's not think of those giving birth as sick people, victims, invalids. Okay, moving on, interesting, another gem the Google Gods bestowed upon me as I was looking on Google for informed consent, and oh, and then patient as followed, so the first definition I read to you just a minute ago. The second definition is a linguistics specific definition of patient, “the semantic role of a noun phrase denoting something that is affected or acted upon by the action of a verb.” And we're not going to get too into this, but did you notice affected or acted upon by the action of a verb we're using that word, patient? And it means in linguistics, when you're grabbing the structure of a sentence, or in the case of people, it means being acted upon. And, I think that is something we really need to step away from in the first place. 

So, let's talk about informed choice. We have arrived at the end of our progression from no consent, to consent, to informed consent, to informed choice.  I love, for this idea of informed choice, the BRAIN acronym. BRAIN stands for Benefits, Risks, Alternatives, Intuition and Nothing. And I think that this acronym places the birthgiver, and again, I use that word purposefully, it puts the onus of agency on the person giving birth. As the actor, the decision maker, the researcher who is consulting medical experts, and others as needed, to inform that choice. It puts that birthgiver in the position of informed decision maker, benefits, risks, alternatives, intuition, nothing. Whenever there's a crossroads a choice to be made in the birth space, ask: “What are the benefits of constant fetal monitoring, as opposed to intermittent fetal monitoring?What are the risks? What are the alternatives? What does my intuition say? And what if we do nothing?”

 Again, this could happen in the case of labor augmentation. “Let's get you on some pitocin, your contractions haven't really been picking up and you haven't made any cervical dilation progress in the last three hours.

Okay, let's pause. What are the benefits of starting some Pitocin? 

What are the risks of starting some Pitocin?

And you'll have those conversations with your care provider and they'll lay those out. What are the benefits and the risks?  And, do your research to find out the risks that may not be mentioned in that conversation, benefits that may not be mentioned in that conversation.  Alternatives: What else could I do to speed up labor? Is there something besides pitocin that can have the same effect? Intuition: What do I feel right about? And nothing? What if I just continue to labor as I'm doing and we don't intervene right now what would be the consequence of that? Again, I love this acronym putting the birthgiver in the position of informed decision maker.

So, what does informed choice informed decision making look like in real life?  It looks like choosing a care provider who recognizes that you have unique situations, perspectives, preferences, intuition, and desires and who supports them to the ultimate extent that they can. It looks like referring to yourself, in your mind, in conversation with others, etc. as an informed decision maker, avoiding phrases like “my doctor won't let me.” Choose one instead who supports you as a decision maker and informs you of the unique responsibilities related to your specific situation.  Or, it also looks like avoiding the phrase: “I can't because I'm high risk.” Instead, we could say, “because of my unique circumstances during this pregnancy, I'm choosing x,y, & z."

You see how we reframed that, we didn't say “I can't because I've had This Label put upon me and other’s authority dictates my actions.” Instead, I say, “I recognize that in this pregnancy with this baby, at this time, there are some unique circumstances. And because I'm aware of them, I'm going to make specific choices that will be beneficial for me in this situation.”

What else does this look like? What does being an informed decision maker look like? It looks like finding the support you need, family members who are supportive, a doula, supportive care providers, etc. to help you find a situation in which you feel empowered, confident, capable and respected as you do the magnificent work of bringing new life into the world. 

Thank you for joining me on today's episode. As we wrap up, I just want to extend an invitation if you are liking what you hear on the podcast if you feel like you've learned something or it has given you a new perspective, that has been helpful, if it has given you power or confidence, or helped you reflect on the language that you use, please leave a review. I'd love to hear your thoughts. I'd love to hear what's helpful and what's working for you. And please share with your friends, colleagues and neighbors so that we can spread the influence of Birth Words.

Further episodes of Birth Words: Language For a Better Birth

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