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ACOG Reaffirms the Need to Respect Women’s Choices

1 Jun

The American College of Obstetricians and Gynecologist Committee on Ethics just published Refusal of Medically Recommended Treatment During Pregnancy. The update to the 2005 Committee Opinion Number 321 reaffirms in no uncertain terms that a woman has the right to refuse any recommended treatment or intervention despite the fact that it may create an ethical dilemma for her obstetrician–gynecologist.


With regard to pregnancy and childbirth, a physician may feel strongly that not following through with his or her recommendation may put the expectant mother or her baby at risk but, ACOG emphasizes that it is the caregiver’s ethical obligation to “safeguard the pregnant woman’s autonomy.”

A U.S. national survey of healthy, low-risk pregnant women with a prior cesarean reported that almost 9 out of 10 physicians strongly recommended a routine repeat cesarean to their patients rather than laboring for a VBAC.  Many women felt they had no choice but to comply.  Healthy pregnant women’s informed decisions to refuse routine hospital policies such as continuous fetal monitoring  and restricting a woman’s movement to the hospital bed have often been denied.

Evidence in the California Maternal Quality Care Collaborative  Toolkit to Support Vaginal Birth and Reduce Primary Cesareans indicates that when used routinely, without evidence of improved outcomes, both labor and delivery policies can increase the risk of an avoidable cesarean.

The following are highlights of the Committee on Ethics recommendations:

Informed refusal is the corollary of the doctrine of informed consent; it is an ongoing process of mutual communication between the patient and the physician and enables a patient to make an informed and voluntary decision about accepting or declining medical care.

Pregnancy is not an exception to the principle that a decisionally capable patient has the right to refuse treatment, even treatment needed to maintain life. Therefore, a decisionally capable pregnant woman’s decision to refuse recommended medical or surgical interventions should be respected.

Obstetrician–gynecologist’s actions should be guided by the ethical principle that adult patients who are capable decision makers have the right to refuse recommended medical treatment.

Forced compliance—the alternative to respecting a patient’s refusal of treatment—raises profoundly important issues about patient rights, respect for autonomy, violations of bodily integrity, power differentials, and gender equality.

Obstetrician–gynecologists are discouraged in the strongest possible terms from the use of duress, manipulation, coercion, physical force, or threats, including threats to involve the courts or child protective services, to motivate women toward a specific clinical decision.

Intervention on behalf of the fetus must be undertaken through the pregnant woman’s body. Thus, questions of how to care for the fetus cannot be viewed as a simple ratio of maternal and fetal risks but should account for the need to respect fundamental values, such as the pregnant woman’s autonomy and control over her body.

(The) patient should be reassured that her wishes will be respected when treatment recommendations are refused.

ACOG’s document also outlines various recommendations to improve physician/patient relationship, develop patient trust and communicate effectively. Refusal of Medically Recommended Treatment During Pregnancy reinforces existing national and international policies and human rights protections to include all patients in the decision-making process and respect their individual values and cultural beliefs.

The concepts of respectful maternity care, and childbirth rights specifically are two of the most prominent issues that expectant women and birth advocates are currently talking about.



Human Rights in Childbirth

Improving Birth


World Health Organization 

The White Ribbon Alliance


Professional Midwives Provide Excellent Care for Mothers and Babies

5 May

In honor of the International Day of the Midwife 2016, let’s celebrate the excellent and compassionate care they provide to mothers and babies.

Compared with physicians caring for similar healthy women, professional midwives offer women more prenatal visits and spend more time counseling and educating expectant mothers about pregnancy nutrition, childbirth and sexuality. Their patients are less likely to develop prenatal or intrapartum hypertension and are less likely to be hospitalized for prenatal complications.

Midwives recommend fewer inductions of labor. During childbirth, midwives  socialmedia-English-IDM2016-skyscraperencourage and support freedom of movement, walking during labor and upright positions for birth. Mothers are free to eat and drink.

Midwives are less likely to use medical interventions during childbirth. To augment contractions with pitocin, break the bag of waters, use intravenous fluids in labor, continuous fetal monitoring and pain medication. Their approach to childbirth therefore results in fewer complications for mothers. Less need for an episiotomy, instrumental birth (use of vacuum or forceps), and 3rd or 4th degree lacerations.

With the midwifery model of care, women have fewer cesareans and more VBACs.

Perinatal outcomes are excellent with midwives. Compared with physicians caring for similar healthy women, mothers have fewer or comparable numbers of preterm births and low-birthweight babies. During childbirth, fewer babies experience fetal distress, birth trauma and require admission to a neonatal intensive care unit (NICU). At birth babies are more likely to have skin-to-skin contact, more likely not be separated from their mothers and to be exclusively breastfeeding after birth and at 2-4 months later.

Expectant mothers who choose midwives as their primary care provider really value the continuity of care, participation in making decisions and the empathy and the close relationship they develop during pregnancy and birth. They feel confident, respected and supported. Mothers also appreciate the lower cost of midwifery care.


Normal Healthy Childbirth for Women & Families: What You Need to Know

Choosing a Caregiver

Midwives Model of Care

The Mama Sherpas (video)


Reducing the Complications of Cesareans Is Finally Getting the Attention It Deserves

25 Apr

In 2014 the U.S. national cesarean rate was 32.2%, 1.3 million U.S. women gave birth by cesarean.  According to the World Health Organization, “cesarean section rates up to 10-15% at the population level are associated with decreases in maternal, neonatal and infant mortality. Above this level, increasing the rate of cesarean section is no longer associated with reduced mortality.” Medical, business, insurance and hospital associations are finally beginning to take this issue seriously.

Happy Young Attractive Mixed Race Family with Newborn Baby.

One of the scheduled sessions at this year’s annual American College of Obstetricians and Gynecologists meeting in Chicago will address the “cesarean epidemic.” A popular OB/GYN online newsletter is questioning the necessity of 1 in 3 surgical births and is recommending more patience by physicians before calling a cesarean for failure to progress.

A study of severe obstetric complications in the United States from 1998 to 2005, found an increase in renal failure, maternal respiratory distress syndrome, shock, the need for ventilation, pulmonary embolism, and blood transfusions. The study concluded that the increase in complications paralleled the increase in cesarean sections during those years.

According to the California Maternal Quality Care Collaborative (CMQCC), cesareans in the U.S. have risen by over 50% in the last 15 years without any benefit for mothers or babies. The rates for cerebral palsy and neonatal seizures have not changed since 1980. However, maternal and neonatal complications from the surgery have increased. žOver the last 15 years OB hemorrhage increased by 50% žand blood transfusions during birth increased by 270%. ž The CMQCC found that both complications correlate with the rise in cesarean sections.

The National Institutes of Health has set a goal of reducing first cesareans for low-risk women to 23.9% by the year 2020. California’s health insurance exchange, Covered California, has set a policy of excluding approved provider networks with a cesarean rate higher than 23.9% beginning in 2019. The state wants to reduce the number of medically avoidable cesarean births to reduce complications and costs.

Research shows us that repeat cesareans may do more harm than good for low-risk mothers who can labor for a VBAC. Mothers and babies experience these harms both in the short- and long-term. Cesareans put mothers’ next pregnancy and fetus at risk for complications. Downstream complications include difficulty becoming pregnant again, an embryo that implants in the cesarean scar (ectopic pregnancy), and an increased risk for preterm birth and low birth-weight.

Since almost 90% of women in the U.S. with a prior cesarean will have a repeat operation (most of them as a routine procedure), the CMQCC is set to publish guidelines in April to prevent low-risk first cesareans and support vaginal birth. The CMQCC Toolkit to Support Vaginal Birth and Reduce Primary Cesareans, a collaborative project, includes the contributions of multi-stake-holders such as ACOG, ACNM, AWHONN, AAFP, Blue Shield of California, California Hospital Association, California Department of Public Health, Pacific Business Group on Health, Kaiser Permanent, various university health systems, birth centers and birth professional groups including Lamaze International, Coalition for Improving Maternity Services and Doulas of North America.

Although national consumer advocacy and maternity care quality improvement organizations have brought attention to the risks of cesareans, the addition of the recent release of Safe Prevention of the Primary Cesarean and  increasing interest in lowering  maternal and infant complications of avoidable cesareans may finally move the country towards reducing cesareans in a significant way.


VBAC Education Project, Module 3: A Closer Look at Repeat Cesareans: Benefits & Risks

VBAC Education Project,  Module 5: Four Main Reasons for a First Cesarean: What You Can Do Differently This Time

Coalition for Improving Maternity Services, CIMS Fact Sheet: The Risks of Cesarean Section & Expectant Mother’s Checklist





Support and Encouragement from Nurses Can Help Mothers Achieve Their VBAC

27 Mar

Nurses play a significant role in helping women complete their VBAC labors. Women laboring for a VBAC may have more anxiety than women having first babies, and may need extra support. They are grateful for all the encouragement, validation, and labor progress suggestions that nurses can provide. Many times, mothers have said, “My nurse was wonderful. Just when I wanted to quit and ask for another cesarean, she told me things were going just as they should be. I couldn’t have done it without her.”

Friendly female nurse comforting worried pregnant woman who is having a contraction

The following is a list of suggestions to help nurses support women laboring for a VBAC:

  • During labor, while collaborating with her caregiver avoid formally admitting mothers to the L & D unit until they have a strong active labor pattern.
  • Encourage mothers to continue taking in clear liquids and light carbohydrate snacks in the early phase of labor and liquids in the active phase.
  • Support physiologic birth. Remind mothers to use a variety of positions and ambulate during labor as long as they are comfortable.
  • Suggest that the mother and her partner use a variety of comfort measures, such as heat or cold packs, lunging motions, a birth ball, a rocking chair, or hydrotherapy.

Psychological interventions

  • When meeting the mother for the first time, find out how she wants to labor this time. How does her partner or family feel about a VBAC? What concerns does she have? Why did she have a cesarean? Teach her how she can do things differently this time. Verbal support and encouragement are extremely helpful, especially when nurses help to identify signs of labor progress. Remind parents that 3 out of 4 women who labor for a VBAC have a safe birth. Help her to create the birth environment she prefers (low lighting, quiet, music, no visitors). Smiling nurse talking to pregnant woman lying on bed in the hosp
  • When laboring for a VBAC, some mothers may have anxious moments and flashbacks to their prior birth. Distressing memories of fetal distress or of laboring “for ever” and not getting anywhere. Help mothers to overcome these difficult moments and remind them that this is a different labor for a different baby and that they are strong enough to move through it. Most nurses know when a mother has gone as far as she can and that she needs to adjust to the idea of having a cesarean birth.
  • Give her time to think about what she would like for this birth. Does she want the baby skin-to-skin after birth? Does she want her partner to go with the baby to the nursery if it becomes necessary or stay by her side? Does she want her family to visit her in recovery? Involving mothers in their care and honoring their wishes will go a long way to help them adjust to the loss of the birth they may have planned for and anticipated for months.
  • Many mothers have said that they were left alone after the birth while their partner went with the baby to the nursery (when medically necessary). If a mother does not have a doula and if you can provide one-on-one care for this period of time and talk to the mother about how she is feeling, or how the baby might be doing, she is more likely not to feel abandoned.
  • Mothers, just like their newborns, need to adjust to their new life. Your support, guidance, and compassion will give mothers and babies their best start together.

To find out more about laboring for a VBAC download the VBAC Education Project

The VBAC Education Project