INFORMED CONSENT AND THE PROCEDURAL PAUSE: Three questions the midwife taught me

“We should break your water to move your labor along,” directed the labor and delivery nurse during the birth of my daughter. In my laborious stupor I recall her holding what appeared to me at the time was a 2-foot spear with a hook on the end, a sort of uber-crochet hook pointed at my–let’s put this politely—birth canal. Declining this unwanted intrusion, and after our friend escorted that nurse out of our hospital room in place of another, more “natural birth-oriented” one, we realized that part of the delay was due to improper positioning of our daughter. Instead of preparing to arrive face down, to exit the birth canal like a breast stroke swimmer coming up for air, our daughter decided that back stroke was her plan—not the ideal position for exiting the womb. The preferred face-down, or “occiput anterior” position (OA, where the back of the baby’s head—occiput—is facing the front—anterior—of mother) engages the baby’s head into the mother’s pelvis like a hat with a perfect fit. The “occiput posterior” position (OP, where the back of the baby’s head is facing the back of the mother) is an ill-fitting crown, prolonging labor and causing increased back pain for the mother. OP babies are a frequent cause of the all-too-common indication for cesarean section (C-section)—“failure to progress.” This was clearly in my future as we approached the 20th hour of labor. Then, as if the birthing instructor herself was in the room, we noticed while I was on my back that the shape of my belly was pointed, our daughter’s knees were pointing towards the ceiling—she was an OP baby. Having gone the way of natural childbirth, ignoring an old friend who summed up her advice for delivery in 3 words, “Get The Epidural,” I remembered the cat-cow stretches we practiced in our birthing class that could pop the baby out of the pelvis for repositioning. I jumped off the bed, got on all fours, and did several of these, as my partner turned our daughter’s knees in the right position, and lo and behold, our daughter turned upside down like a proper OA baby! Labor proceeded rapidly afterwards, and all was well, my only dismay being the lack of full disclosure from my long-postpartum friends–many of whom had memories dulled by anesthetics–that labor approximates the feeling of one’s rear end being engulfed in flames.

Childbirth was the most exhilarating experience of my life, the crescendo of this other-worldly pain disappearing in an instant. Much of what I cherish about childbirth stretched beyond the magic of that day, however, but also includes learning the importance of preparing for that day. In medical school, we rotate through different medical specialties, including obstetrics (“O.B.”).  ‘O.B’ among medical students and residents is described as “hours of boredom followed by seconds of terror,” meaning that there is always an element of the unknown when bringing a baby safely into this world—and one’s preparation for all that could go wrong makes the difference between a happy and a tragic outcome.

My birthing class was taught by a former labor and delivery nurse turned mid-wife. As my classmates and I approached our respective due dates, our instructor thoroughly informed us of the potential procedures that may be offered or recommended throughout the course of pregnancy and delivery. I have referred to her wise words many times over the past 16 years with my own patients, and encourage my patients to ask these 3 questions, whenever any medical provider, including myself, proposes an invasive test or procedure:

1) What happens if I do it?

2) What happens if I don’t do it? and

3) What happens if I wait?

In medicine we have many tests and procedures at our disposal, and when we advise our patients, we look to different sources to guide us—from published “standards of care” by professional organizations, to “expert opinion,” to one’s own experience guided to the best of our ability by research and common practice. Physicians frequently balance what they can do versus what they should do in the treatment of any individual patient, with the patient always being the vulnerable variable in the equation.

So whether it’s a crochet hook, an x-ray, or an operation, please ask your doctor to answer the 3 questions my midwife taught me. It’s a great way to inform—and protect–yourself.


Melissa Lim, MD

Pulmonary, Critical Care, Sleep specialist

Redwood City, CA

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