My doctor agrees with my birth plan...

Do you trust the practice you are with to provide evidence based support? 

As I sit here waiting for my clients to leave their doctor's appointment at 41 weeks gestation, I'm wondering if they will be asked to go to the hospital for induction. This couple is ready for this conversation and they have just had their second BPP ultrasound to ensure all is healthy and fine. Yes, I said second Biophysical Profile Ultrasound (BPP) within 24 hours because the first revealed oligohydramnios at 4.6 cm, just shy of the 5cm or less standard cause for concern. Turns out the new BPP ultrasound reveals 6.0 cm. Whew...they leave the office, and go home. 

Did you know that ultrasound quantitative data can have a standard deviation of up to +/- 15%? So within 24 hours my clients found themselves nearly fighting with their medical staff to keep from being induced due to the only piece of data that showed a "problem". All previous medical tests, blood work and low risk status gave them the ALL clear to wait for spontaneous labor up to 42 weeks of gestation. This was the promise their entire pregnancy. This practice advertised being low intervention and holistic. 

Let's talk about that visit just 24 hours before and how terrible that experience was for them. They felt betrayed. You see they knew the standard deviation of ultrasound results because they took an Evidence Based Birth ® Childbirth Class. But the nurse practitioner decided that 4.6 cm was enough to schedule an induction THAT very evening due to risk of still birth despite no other indicators of an issue with the BPP. The doctor was unavailable for consult so the clients called me to help review their options.

Me: What's the medical reason for induction?
Them: Slightly low amniotic fluid
Me: Do you understand the risks involved?
Them: Not fully and the NP was not comfortable sharing her knowledge, but asked us to sign paperwork that we are going against medical advice if we choose not to go to the hospital.

I sat back to ascertain what I was hearing. I restated the information they shared with me.

Me: So you have not been fully informed of the medical risks but you are being asked to sign papers that claim you don't agree with the medical advice?
Them: Wow, yes that's correct!
Me: Is there someone else who can provide you the information you need to feel comfortable with this "medical decision to induce?".
Them: No, we have been sitting here for hours.
Me: Do you feel ready to sign anything saying you are going against medical advice if you haven't been fully given medical advice AND informed consent?
Them: No, we were pressured and made to feel as if we don't care about our health but no one is providing clear reasons why this is a danger. 
Me: She mentioned still birth; here is the data I know concerning risk from Evidence Based Birth ®. The risk of stillbirth rises gradually after 39 weeks and then increases more rapidly starting at 42 weeks.
39 weeks = 3.5 per 10,000
40 weeks = 4.2 per 10,000
41 weeks = 6.1 per 10,000
42 weeks = 10.8 per 10,000
So yes your risk of still birth has increased at 41 weeks gestation, but you and your doctor were comfortable with this risk when you all agreed to wait for spontaneous labor up to 42 weeks according to your birth plan? Right?
Them: Correct!
Me: Is there anyway to redo the BPP and wait for the doctor's opinion? (LONG WAIT)
Them: Yes! The NP agreed to wait for the doctor to return in the morning. We don't have to sign anything and can go home.

The next day, less than 24 hours later the BPP results were very different...

• 4.6 cm was now 6cm; acceptable fluid levels
• baby's weight significantly changed from 8lbs 6oz to 7lbs 13oz. 

So why the hyperbole? Not everyone practices or in this case even understands evidence based information and TRUE informed consent. This scenario turned out well for this family who birthed their baby 3 days later spontaneously at 41.2 weeks with no issues or complications. But what would have happened if they allowed themselves to be frightened by the data? If they were forced into an unnecessary induction?  Chances are they just would have had their baby earlier or they could have gone down the road of a cascade of interventions forcing labor that may have ultimately lead to a caesarean they really didn't need. That was definitely not part of the birth plan. 

What makes providers or their staff seem to "go against their word" at the slightest change? To not realize that even due dates are guesstimates and no egg timer is going off, especially when scans indicate proper placental function. The reason...Evidence Based Gap problems. It takes 10-15 years for the latest evidence to get into the hands of the provider...to be used as part of daily routine practice and looking at every INDVIDUAL case and not just data known to have variability (which can be skewed by human error as well). 

When providers don't have a full grasp of the latest evidence pertaining to birth or choose not to follow it (..."because we have better results doing things our way!"..) it can feel like a 'bait and switch' tactic. Or that they were telling tales about this perfect birthing experience they were offering as a service. "Yes we love natural births here"; only to find out natural births mean vaginal and all first time patients are often coerced into receiving the epidural because "this could take forever and we want you comfortable". How about when you take a tour of the hospital and see all the beautiful tubs but once in labor you are told you can't push there, it must be on the bed on your back. Even though evidence suggests that water birth is safe and hydrotherapy is nature's epidural? Or, and this is my favorite, you can't eat or drink during labor because there is high risk of aspiration death if you are on or might need to use anesthesia. Did you know that "high risk" is less than the risk of being struck by lightning (one in 500,000)? Whereas risk of aspiration death is 1 in 1.4 million! And what does that say for the persons not using anesthesia...why can't they eat? These 'nil per os' or nothing by mouth rules date back to the 1940's when general anesthesia use was very different. Again evidence suggests it's a basic human right to eat when hungry, especially when doing some of the hardest work of your life.  

When discussing risk, it's so important to understand the difference between absolute versus relative risk. For example, if you are told you have a 45% chance of increased risk of still birth at 41 weeks of gestation compared to 40 weeks, that sounds super scary! But that's known as RELATIVE RISK, a mathematical relationship between two risk factors. However, when you see the ABSOLUTE RISK, your personal risk assessment, you see the true risk relationship of data.  So instead of a 45% increased risk you see 6.1 occurrences of still birth out of 10,000 births at 41 weeks when compared to 4.2 occurrences of still birth out of 10,000 births at 40 weeks.  It provides you better data to make better informed decisions without harmful scare tactics. 

Listen not all doctors/ medical staff are intentionally playing games with you, some are just out of their comfort zone when it comes to data or are truly doing their best to keep you and your baby safe. Just be mindful of what YOUR non-negotiables are when it comes to YOUR birth. As you can see it doesn't hurt to take a childbirth education class to understand the evidence and informed consent. Plus hiring a doula who can help you navigate these sticky situations and advocate for yourself and your family. You aren't just a vessel for your baby, your birth matters too. When you are heard and respected a satisfying, empowered birth experience is good for everyone! 

Michelle Gabriel-Caldwell
Certified Doula and Evidence Based Birth ® Instructor
Evidence Based Birth® Childbirth Class - Virtual Experience- Tickets, Tue, May 18, 2021 at 7:00 PM | Eventbrite
(Teaching Virtual Classes Through 2021)