Making Decisions during Labour

The more work you put into the decisions you make before labour begins, the less work you will have to do in this area whilst you're busy having your baby. The first decisions you make will concern who cares for you during labour and birth and where you plan to have your baby. During the birth, you may be asked to make decisions about which routine interventions you prefer to engage with and which you do not. Writing your preferences down and having these on hand during labour, will help those caring for you know what you would like without having to distrub you with questions. Asking your midwife or doctor questions about their recommendations during labour will ensure that you are able to make an informed decisions about what happens next. This will increase your sense of satisfaction with the birth process. Using the acronym BRAIN can help you to structure your questions, B - what are the benefits? R - what are the risks? A - what are the alternatives? I - what is your intuition? N - what are the risks of doing nothing?

What decisions need to be made about labour and birth?

During the birth of your baby, you may be required to make decisions about your care. The more you have thought about this before labour begins, the less decision-making you will have to do whist in labour. This is ideal, because during labour things unfold more easily the less you are disturbed.

The first decisions you make about birth will involve which type of maternity care best fits with your own ideas about pregnancy and birth. The choices you make about who will look after you during the birth and where to have your baby will have the single greatest influence on how you give birth. It's important to get this decision right for you.

During labour and birth, your midwife or doctor will offer you a number of routine interventions such as:

• continuous electronic fetal monitoring on admission to hospital;
• vaginal examinations;
• abdominal palpation;
• intermittent fetal heart rate monitoring with the Doppler.

Making decisions about these routine interventions whilst you are pregnant and recording your preferences in a written statement, will mean that you do not have to explain your choices each time the staff shift changes when you are in labour. During pregnancy, it can be helpful to take your written preferences statement into a antenatal appointment so that you can discuss your ideas with your midwife and doctor. You do not need your caregiver's approval for your informed choices. However, some caregivers will offer to sign this document for you, so that other members of the clinical team will know that it has already been discussed. Your Birth Preferences Statement can then be placed in your records at the hospital to be used by the midwife looking after you in labour.

You may have other preferences that are important to include on your Birth Preferences Statement. These might include:

• the role of any additional support people you might be bringing with you other than your partner;
• the kind of environment you would like to labour and give birth in and the help you would like from the hospital to achieve this;
• how you would like the medical team to approach you regarding drugs for pain relief in labour.

It is not necessary to detail your choices beforehand about all the different decisions you might be faced with in labour, because you will be able to make informed decisions as your labour unfolds. Whatever your goals might be for the birth of your baby, you are not intentionally in control of how it will unfold. You may may have strong feelings in pregnancy about a particular intervention or option for labour, but these could change whilst you are having your baby. Maintaining this type of flexibility in your preferences means that you will avoid setting yourselve up for feelings of failure, if your plans change. Birth is not something which you can fail at, you simply aim for the best birth you can have on the day. 

Why is it important to ask questions during the birth?

Whom ever you choose to look after your during pregnancy, your doctor or midwife want the best outcome for you and your baby. However some doctors and midwives are more able to focus upon caring for you as an individual due to the model of care they are practicing within, whilst for others this is more difficult as they are managing competing pressures as well as your care.

The more personalised your maternity care is, the easier your decision-making role becomes. The most personalised care a pregnant woman can receive sits within the Caseload Midwifery model of care. This is when one woman and one midwife are able to work together throughout pregnancy, labour and birth. The relationship this creates, leads to high levels of mutual understanding and trust. Being able to completely trust your midwife or doctor is important. Through this 1:1 relationship, the woman comes to understand the midwife’s values and attitudes around pregnancy and birth, and decides whether these are a good fit for her, choosing a different caregiver if she finds that the fit is not good. This close working relationship also means that the midwife develops a good understanding of what the woman wants for her pregnancy and her baby’s birth. She develops a confidence in the woman from their relationship and her detailed knowledge of the pregnancy to date. When decisions have to be made, the woman trusts the midwife’s recommendations because the level of her care is very personal and based on her needs and those of the baby.

Research from studies around the world are indicating that this is the Gold Standard in maternity care (Sandall et al. 2013). However, caseload midwifery is not yet the standard model of maternity care in Australia, though many services are beginning to move in this direction as research shows how good the outcomes of this model are for mothers and babies.

In models of care where women are looked after by a team of professionals, their doctors and midwives will also be juggling a number of other competing pressures whilst providing care. There will be guidelines and protocols which they are obliged to follow according to the hospital or clinic they are working in. Hospital protocols are not always based upon the best available evidence. Sometimes they are the way they are because that is the way it has always been done, or they are based upon what works best for the hospital in terms of managing the facility’s work load.

The individual doctor or midwife, may also be caring for other women and babies at the same time as providing your care, and so they may need to consider the needs of others as well as your own.

It might be useful to remember that your midwife or doctor are experts in the average pregnancy and birth, whereas you are the expert in the lived experience of your pregnancy and birth. When you collaborate, your decisions can include the best from both sources of experience and knowledge, the personal and the professional.

Sometimes decisions are not always presented as choices. Your midwife or doctor might present a course of action as the natural thing to do next in the circumstances. However, you are the Chief Executive Officer of your body and your pregnancy, and you have the right to decide what you would like to do.

It is not your doctor or midwife’s role to ensure that you follow their advice or the hospital’s policy. Your doctor or midwife’s role is to provide you with information so that you are able to make the decisions that are right for you and your family. Once you have made an informed choice, your caregiver should support you emotionally, whether you have consented to or refused a recommendation.

Making decisions

You have been making decisions all the way through your life. You gather information about the pros and the cons of each option and then make a choice. During labour, emotions can run a little higher than usual and so having a tool to support this process can be helpful.

BRAIN is one such tool. This is an acronym which stands for each element of information you might wish to include in considering your decision. The first step is to identify that you have a decision to make and then to apply the following questioning format:

B – Benefits ‘What are the benefits of this course of action for me and my baby?’

R – Risk ‘Are there any risks or negative consequences associated with this course of action for me or my baby?’

A – Alternatives ‘What other options are available to me?’

I – Intuition ‘How do I feel about the recommended course of action and the alternatives?’

N – Nothing ‘If I did nothing right now, what would be the benefits or risks of that course of action?’

You probably apply this questioning process every time you make a decision. BRAIN provides you with a structure for your questions, so that you can be sure that you have covered all the relevant information required to support your decision making process.

During labour, the task of using BRAIN really belongs to your partner or support person. Although labouring women are more than capable of making informed decisions when required, labour hormones then to create a zoned out headspace and so the mind in labour is not always sharp. If your partner is able to ask the questions, you can then discuss the information together once you are alone. This means that the partner's final task after having worked through the BRAIN questions, is to ask for 10 minutes alone to consider the information and make a decision.

BRAIN allows you to slow down the course of events. Unless you are in an emergency situation, you have time to make decisions.

BRAIN places you and your partner at the centre of the decision making process, rather than just being accessories to it.

If you practice using BRAIN during your pregnancy, you will not only become very skilled in the process, but also more comfortable in questioning your doctor or midwife, which does not always feel like an easy thing to do.

References

• Sandall, J., Soltani, H., Gates, S. et al (2013). Midwife-led continuity models versus other models of care for childbearing women. Cochrane Database of System-atic Reviews, Issue 8. Available online at http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004667.pub3/abstract [accessed on 31 October 2013].