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Evidence On: Letting Labour Begin On Its Own

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Evidence On: Letting Labour Begin On Its Own

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WHO Recommendations & The 6 Healthy Birth Practices

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WHO Recommendations & The 6 Healthy Birth Practices

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Research on The 6 Healthy Birth Practices (Lamaze)

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Research on The 6 Healthy Birth Practices (Lamaze)

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Lamaze childbirth education offers healthy birth practices, teaching healthy pregnancy and safe, natural birth.

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Informed consent rights are extremely important to women's experience during birth. One of the biggest factors in whether you remember your birth as a positive or negative experience is the degree to which you feel informed and involved as decisions are made in terms of your maternal health.

You will remember the experience you have birthing your baby. It is a pivotal, intense event in any birthing woman's life, and has important physiological and psychological implications for you and your baby.

By understanding informed consent, you will be better able to actively engage in your maternal health decisions and be much more likely to have the birth of your baby be a positive experience.

Claim ownership of your birth. Make sure you are informed & take the opportunity to consider your options before consenting or refusing procedures during your birth.

Your doctor or midwife's job is to make recommendations during the course of your pregnancy and birth. Your job is to ask questions about those recommendations and make informed decisions about the treatments you choose or decline.

Take a look at our most recent birth rally video. Something that comes a lot from both birth professionals and mothers is how important informed consent is during childbirth. It's a long video, but worth watching the whole way through!

What Is Informed Consent?

Informed consent is your health practitioner's (ie. doctor or midwife's) obligation to give you as much information as possible about proposed care options so that you can make decisions about your health and birth.

Informed consent practices require your maternal health practitioner to facilitate the following:

Your Rights In Giving Or Refusing Consent To Health Care

By law, "A care provider must not provide health care without an adult's consent" (section 5 (1), Health Care Consent and Care Facility Admission Act).

cause consent to health care is so important, there are legal protocols set in place to encourage its practise. The following are your legal rights in terms of giving or refusing consent to health care procedures:
1. The right to give consent or refuse consent on any grounds, including moral or religious grounds, even if the refusal will result in death; 2. The right to select a particular form of medically appropriate health care on any grounds, including moral or religious grounds; 3. The right to revoke consent; 4. The right to expect that a decision to give, refuse, or revoke consent will be respected; and 5. The right to be involved to the greatest degree possible in all case planning and decision making *From A Health Care Providers' Guide To Consent to Health Care, Ministry of Health, 2011
Some Important Points About Informed Consent:

Although consent can be implied by cooperation movements such as offering your arm for an IV, cooperation should not be confused with consent, according to guidelines set forth by the Ministry of Health. If you have not been provided with information about a health care treatment, behaviour cannot be assumed to imply consent.

How To Make Informed Decisions During Childbirth:

I recommend asking the following questions when considering any proposed treatments during childbirth:

What are the benefits, risks and alternatives of the proposed intervention / treatment?

What is the risk of not taking any treatment at all?

How urgent is this decision: Is this something that need to be decided in the next few minutes? Next few hours? Next few days?

What are the risks of holding off on intervention at this point?

Tips for feeling fully informed:

Ask for numbers. If your midwife / doctor explains, for example, that no treatment increases your risk of a poor birth outcome, ask by how much. 40%? 10%? 1%? 0.05%?

Whenever possible, always take time to reflect on your options before making a decision, even if it's just for a moment or two. You can always ask to be left alone or with your partner to discuss and weigh your options

Your partner & doula can help you ask questions about proposed treatments so you have as much information as you'd like before making an informed choice about your care. However, they cannot make decisions on your behalf.

My Advice For Successfully Receiving Appropriate Opportunity For Informed Consent:

Please choose your birthing team and location carefully. Make sure they know how important it is to you to play a leading role in your health care decisions, and that you plan to fully embrace your right to informed consent or informed refusal. Understanding informed consent gives you a leg up in receiving the care and birth you want if you've chosen to birth within the maternal health care system.

But the best thing you can do for yourself is choose to surround yourself only with people you don't feel like you need to protect yourself from during your birth. Just like with any profession, there are practitioners that will be more in line with your philosophy than others. Choose wisely, and make it a priority to choose a health practitioner who also values your role in making decisions.

As many of you know, informed consent is one of the big priorities of the Vancouver Birth Rallies. If you want to rally with us for improved informed consent practices and accountability, please join our facebook group. We're planning a big event for Labour Day!

The latest birth rally video shown above has sparked a LOT of controversy. You can read more about it in Hoping For Dialogue: Vancouver Birth Rally Update.

Think this information is important? Share it! Every woman deserves to know her rights in maternal health care..
Jessica Austin, Vancouver Doula: Childbirth Services in Vancouver, BC

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Informed consent rights are extremely important to women's experience during birth. One of the biggest factors in whether you remember your birth as a positive or negative experience is the degree to which you feel informed and involved as decisions are made in terms of your maternal health.

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Latent stage of labour

The latent stage of labour is where your cervix starts to soften and open (dilate) so your baby can be born.

You may begin to feel irregular contractions, but it can take many hours, or even days, before you're in established labour. It's usually the longest stage of labour.

At this stage, your contractions may range from being slightly uncomfortable to more painful. There's no set pattern to how many contractions you get or how long they last.

During the latent stage, it's a good idea to have something to eat and drink because you'll need energy for when labour is established.

If your labour starts at night, try to stay comfortable and relaxed. Sleep if you can.

If your labour starts during the day, stay upright and gently active. This helps your baby move down into your pelvis and helps your cervix to dilate.

Breathing exercises, massage and having a warm bath or shower may help ease pain during this early stage of labour.

Established labour (1st stage of labour)

Established labour is where your cervix has dilated to about 4cm and your contractions are stronger and more regular.

When to contact a midwife

Call your midwife or maternity unit if:

your contractions are regular (every 5 minutes or more often)

your waters break

your contractions are very strong and you feel you need pain relief

you're worried about anything

If you go into hospital before your labour has become established, they may suggest you go home again for a while.

Once labour is established, your midwife will check on you from time to time to see how you're progressing and offer you support, including pain relief if you need it.

You can either walk around or get into a position that feels comfortable to labour in.

Your midwife will offer you regular vaginal examinations to see how your labour is progressing. If you do not want to have these, you do not have to - your midwife can discuss with you why she's offering them.

Your cervix needs to open about 10cm for your baby to pass through it. This is what's called being fully dilated.

In a 1st pregnancy, the time from the start of established labour to being fully dilated is usually 8 to 18 hours. It's often quicker (around 5 to 12 hours), in a 2nd or 3rd pregnancy.

When you reach the end of the 1st stage of labour, you may feel an urge to push.

Monitoring your baby in labour

Your midwife will monitor you and your baby during labour to make sure you're both coping well.

This will include using a small handheld device to listen to your baby's heart every 15 minutes. You'll be free to move around as much as you want.

Your midwife may suggest electronic monitoring if there are any concerns about you or your baby, or if you choose to have an epidural.

Electronic monitoring involves strapping 2 pads to your bump. One pad is used to monitor your contractions and the other is used to monitor your baby's heartbeat. These pads are attached to a monitor that shows your baby's heartbeat and your contractions

Sometimes a heart monitor called a foetal scalp electrode can be attached to the baby's head instead. This can give a more accurate measurement of your baby's heartbeat.

You can ask to be monitored electronically even if there are no concerns. Having electronic monitoring can sometimes restrict how much you can move around. Your midwife can discuss this with you.

If you have electronic monitoring with pads on your bump because there are concerns about your baby's heartbeat, you can take the monitor off if your baby's heartbeat is shown to be normal.

A foetal scalp electrode will usually only be removed just as your baby is born, not before.

Speeding up labour

Labour can sometimes be slower than expected. This can happen if your contractions are not coming often enough, are not strong enough, or if your baby is in an awkward position.

If this is the case, your doctor or midwife may talk to you about 2 ways to speed up your labour: breaking your waters or an oxytocin drip.

Breaking your waters

Breaking the membrane that contains the fluid around your baby (your waters) is often enough to make contractions stronger and more regular. This is also known as artificial rupture of the membranes (ARM).

Your midwife or doctor can do this by making a small break in the membrane during a vaginal examination. This may make your contractions feel stronger and more painful, so your midwife will talk to you about pain relief.

Oxytocin drip

If breaking your waters does not work, your doctor or midwife may suggest using a medicine called oxytocin (also known as syntocinon) to make your contractions stronger. This is given through a drip that goes into a vein, usually in your wrist or arm.

Oxytocin can make your contractions stronger and more regular and can start to work quite quickly, so your midwife will talk to you about your options for pain relief.

You will also need electronic monitoring to check your baby is coping with the contractions, as well as regular vaginal examinations to check the drip is working.

2nd stage of labour

The 2nd stage of labour lasts from when your cervix is fully dilated until the birth of your baby.

Finding a position to give birth in

Your midwife will help you find a comfortable position to give birth in. You may want to sit, lie on your side, stand, kneel, or squat, although squatting may be difficult if you're not used to it.

If you've had lots of backache while in labour, kneeling on all fours may help. It's a good idea to try some of these positions before you go into labour. Talk to your birth partner so they know how they can help you.

Find out what your birth partner can do.

Pushing your baby out

When your cervix is fully dilated, your baby will move further down the birth canal towards the entrance to your vagina. You may get an urge to push that feels a bit like you need to poo.

You can push during contractions whenever you feel the urge. You may not feel the urge to push immediately. If you have had an epidural, you may not feel an urge to push at all.

If you're having your 1st baby, this pushing stage should last no longer than 3 hours. If you've had a baby before, it should take no more than 2 hours.

This stage of labour is hard work, but your midwife will help and encourage you. Your birth partner can also support you.

What happens when your baby is born

When your baby's head is almost ready to come out, your midwife will ask you to stop pushing and take some short breaths, blowing them out through your mouth.

This is so your baby's head can be born slowly and gently, giving the skin and muscles in the area between your vagina and anus (the perineum) time to stretch.

Sometimes your midwife or doctor will suggest an episiotomy to avoid a tear or to speed up delivery. This is a small cut made in your perineum.

You'll be given a local anaesthetic injection to numb the area before the cut is made. Once your baby is born, an episiotomy, or any large tears, will be stitched closed.

Find out about your body after the birth, including how to deal with stitches.

Once your baby's head is born, most of the hard work is over. The rest of their body is usually born during the next 1 or 2 contractions.

You'll usually be able to hold your baby immediately and enjoy some skin-to-skin time together.

You can breastfeed your baby as soon as you like. Ideally, your baby will have their 1st feed within 1 hour of birth.

Read more about skin-to-skin contact and breastfeeding in the first few days.

3rd stage of labour

The 3rd stage of labour happens after your baby is born, when your womb contracts and the placenta comes out through your vagina.

There are 2 ways to manage this stage of labour:

active - when you have treatment to make it happen faster

physiological - when you have no treatment and this stage happens naturally

Your midwife will explain both ways to you while you're still pregnant or during early labour, so you can decide which you would prefer.

There are some situations where physiological management is not advisable. Your midwife or doctor can explain if this is the case for you.

What is active management?

Your midwife will give you an injection of oxytocin into your thigh as you give birth, or soon after. This makes your womb contract.

Evidence suggests it's better not to cut the umbilical cord immediately, so your midwife will wait to do this between 1 and 5 minutes after birth. This may be done sooner if there are concerns about you or your baby - for example, if the cord is wound tightly around your baby's neck.

Once the placenta has come away from your womb, your midwife pulls the cord - which is attached to the placenta - and pulls the placenta out through your vagina. This usually happens within 30 minutes of your baby being born.

Active management speeds up the delivery of the placenta and lowers your risk of having heavy bleeding after the birth (postpartum haemorrhage), but it increases the chance of you feeling and being sick. It can also make afterpains (contraction-like pains after birth) worse.

Read more about preventing heavy bleeding after birth.

What is physiological management?

No oxytocin injection is given, and the 3rd stage of labour happens naturally.

The cord is not cut until it has stopped pulsing. This means blood is still passing from the placenta to your baby. This usually takes around 2 to 4 minutes.

Once the placenta has come away from your womb, you should feel some pressure in your bottom and you'll need to push the placenta out. It can take up to an hour for the placenta to come away, but it usually only takes a few minutes to push it out.

If the placenta does not come away naturally or you begin to bleed heavily, you'll be advised by your midwife or doctor to switch to active management. You can do this at any time during the 3rd stage of labour.

Read more about what happens straight after you give birth.

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Find out what happens during labour and birth, including the 3 stages of labour, contractions, dilation, birth positions and monitoring your baby.

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Using B.R.A.I.N To Make Informed Choices

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Using B.R.A.I.N To Make Informed Choices

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National Partnership for Women & Families

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Many things in life have unintended consequences: they may or may not have the effect that we want, and sometimes they have unplanned and possibly unwanted effects.

Many maternity care interventions have unintended effects during labor and birth. Often these effects are new problems that are "solved" with further intervention, which may in turn create even more problems. This idea that using one intervention can lead to the need for more interventions is called a "cascade of intervention."

The maternity practices that can lead to a cascade of intervention include:

Using various medications to induce labor.

Artificially breaking the membranes surrounding the baby and releasing amniotic fluid before or during labor.

Using synthetic oxytocin medicine ("Pitocin") to make labor move faster.

Giving medications for pain relief.

Laboring in bed versus being upright and moving about.

In many instances, these practices cause problems because they disrupt the normal physiology of pregnancy, labor and birth by:

Interfering with hormones that move labor and birth along.

Creating opportunities for infection.

Having undesirable effects on your baby.

Making it harder for you to push your baby out.

When these effects happen, women may feel that their bodies have failed them, not realizing that the things that went wrong could have actually been triggered by maternity practices themselves.

Limiting the Cascade of Intervention

Almost every intervention has some potential to cause harm. You should use care in deciding whether to have an intervention. We encourage you to accept only those interventions that are more likely to offer benefit than harm. In weighing possible benefits and harms, it is important to rely on the best available evidence about potential effects, and to consider how you feel about the possible outcomes. It is also important to learn about other options that may be available. You will find a lot of this information in the Giving Birth section of this website.

Unfortunately, it is impossible to predict in advance exactly what may happen during your labor and delivery, or how a given intervention may affect you or your baby. The best way to limit a cascade of intervention is to become informed, get all of your questions answered, and put plans in place in advance that will help avoid potentially harmful interventions.

Here are some tips for avoiding unnecessary interventions:

Choose a care provider and a birth setting that have low rates of using common interventions.

Become familiar with the best available research about interventions that are most likely to trigger a cascade of intervention, including induction of labor, epidural analgesia and other pain medications and cesarean section.

Have an open and respectful conversation with your care provider about why you need any recommended interventions. It's ideal to have this conversation well before you may need the intervention so you can express your wishes and discuss plans.

Talk to your care provider about options like "watchful waiting" (doing nothing and waiting for labor to move along or for issues to resolve on their own) or using simpler, less invasive alternatives.

Learn about the benefits of continuous labor support and consider engaging a doula to help you achieve your objectives.

Clearly communicate your wishes to your care providers, and get the support of your spouse, partner, doula or other companions to reinforce your wishes throughout labor and delivery.

Know that you have the right to accept or refuse procedures, drugs, tests and treatments, and to have your choices honored.

The Cascade of Intervention in Action

Epidural analgesia is a good example of the cascade of intervention. It can provide very effective pain relief during labor, but it also increases the risk of experiencing a sudden drop in blood pressure, a longer labor, difficulty moving about, difficulty urinating, difficulty pushing the baby out, fever and other negative effects.

Interventions like electronic fetal monitoring and intravenous fluids are often used with epidurals to monitor, prevent or treat these effects. And others become more likely (synthetic oxytocin to strengthen contractions, catheter to empty the bladder, vacuum extractor or forceps to help move the baby out). These in turn may have side effects that lead to the use of yet more interventions.

Babies can also be affected. For example, epidurals increase a woman's likelihood of developing a fever, which can make doctors worry that the baby has a fever. This leads to blood tests and antibiotics for the baby after birth. They may also be observed in a special nursery, which can interfere with mother-baby bonding and breastfeeding.

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The Cascade of Intervention | National Partnership for Women & Families

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Many things in life have unintended consequences: they may or may not have the effect that we want, and sometimes they have unplanned and possibly unwanted effects. Many maternity care interventions have unintended effects during labor and birth. Often these effects are new problems that are "solved" with further intervention, which may in turn create [...]

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National Partnership for Women & Families

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Download the PDF

You (and your baby) are born with the ability to start labor, labor and give birth, breastfeed and become deeply attached to each other. The flow of hormones in your body drives these well-organized, finely tuned processes.

It is important that you and your maternity care providers understand how to work with - and avoid disrupting - these processes.

While you don't need to be taught how to give birth, it is fascinating to learn about the amazing capabilities of women and newborns. For example, a newborn who was not exposed to pain medications and is placed skin-to-skin on his or her mother right after birth can crawl to mom's breast and begin nursing!

The Role of Birth Hormones

Birth hormones are chemical "messengers" that your body makes. Your baby makes birth hormones, too. These hormones work together to guide important changes in your bodies - changes that help make labor and birth go smoothly and safely for both of you.

Birth hormones help guide you and your baby in many ways, including:

Getting your body ready to give birth

Starting your labor contractions

Preparing your baby for labor and life outside your body

Telling your breasts to make milk and getting your baby ready to breastfeed

And when you and your new baby fall in love, birth hormones are part of those feelings, too!

Here we discuss four hormones that are important for reproduction: oxytocin, endorphins, adrenaline and related stress hormones, and prolactin. These hormones play a major role in regulating labor and birth. Learning about them can help you understand what will happen during labor and birth. Decisions you make about your care can support or disrupt the way hormones work, so understanding how they work and how they are affected is important for making informed decisions.

Oxytocin

Oxytocin is often known as the "hormone of love" because it is involved with lovemaking, fertility, contractions during labor and birth and the release of milk in breastfeeding. It helps us feel good, and it triggers nurturing feelings and behaviors.

Receptor cells that allow your body to respond to oxytocin increase gradually in pregnancy and then increase a lot during labor. Oxytocin stimulates powerful contractions that help to thin and open (dilate) the cervix, move the baby down and out of the birth canal, push out the placenta, and limit bleeding at the site of the placenta. During labor and birth, the pressure of the baby against your cervix, and then against tissues in the pelvic floor, stimulates oxytocin and contractions. So does a breastfeeding newborn.

Low levels of oxytocin during labor and birth can cause problems by:

Causing contractions to stop or slow, and making labor take longer.

Resulting in excessive bleeding at the placenta site after birth.

Leading health care providers to respond to these problems with interventions.

You can promote your body's production of oxytocin during labor and birth by:

Staying calm, comfortable and confident.

Avoiding disturbances, such as unwelcome people or noise and uncomfortable procedures.

Staying upright and using gravity so your baby is pressed against your cervix and then, as the baby is born, against the tissues of your pelvic floor.

Stimulating your nipples or clitoris before birth, and giving your baby a chance to suckle (breastfeed) shortly after birth.

Avoiding epidural analgesia.

Endorphins

When you face stress or pain, your body produces calming and pain-relieving hormones called endorphins. You may have higher levels of endorphins near the end of pregnancy. For women who don't use pain medication during labor, the level of endorphins continues to rise steadily and steeply through the birth of the baby. (Most studies have found a sharp drop in endorphin levels with use of epidural or opioid pain medication.)

High endorphin levels during labor and birth can produce an altered state of consciousness that can help you deal with the process of giving birth, even if it is long and challenging. High endorphin levels can make you feel alert, attentive and even euphoric (very happy) after birth, as you begin to get to know and care for your baby. In this early postpartum period, endorphins are believed to play a role in strengthening the mother-infant relationship. A drop in endorphin levels at this time may contribute to the "blues," or postpartum depression, that many women experience for a brief time after birth.

Low levels of endorphins can cause problems in labor and birth by:

Causing labor to be excessively painful and difficult to tolerate.

Leading health care providers to respond to this problem with interventions.

You can enhance your body's production of endorphins during labor and birth by:

Staying calm, comfortable and confident.

Avoiding disturbances, such as unwelcome people or noise and uncomfortable procedures.

Delaying or avoiding epidural or opioids for pain relief.

Adrenaline

Adrenaline is the "fight or flight" hormone that humans produce to help ensure survival. Women who feel threatened during labor (for example, by fear or severe pain) may produce high levels of adrenaline. Adrenaline can slow labor or stop it altogether. Earlier in human evolution, this disruption helped birthing women move to a place of greater safety.

Too much adrenaline can cause problems in labor and birth by:

Causing distress to the baby before birth.

Causing contractions to stop, slow or have an erratic pattern, and lengthening labor.

Creating a sense of panic and increasing pain in the mother.

Leading health care providers to respond to these problems with cesarean surgery and other interventions.

You can keep adrenaline down during labor and birth by:

Staying calm, comfortable and relaxed.

Being informed and prepared.

Having trust and confidence in your body and your capabilities as a woman.

Having trust and confidence in your care providers and birth setting.

Being in a calm, peaceful and private environment and avoiding conflict.

Being with people who can provide comfort measures, good information, positive words and other support.

Avoiding intrusive, painful, disruptive procedures.

Prolactin

Prolactin is known as the "mothering" hormone. The role of prolactin around the time of birth has been less researched than the hormones described above. It increases during pregnancy and peaks when labor starts on its own. As has been shown in other mammals, continued prolactin production during and after labor appears to be readying a woman's body for breastfeeding. It may also play a role in moving labor along and helping the newborn adjust to life outside the womb. Prolactin is central to breast milk production. High levels of prolactin with early breastfeeding may foster women's caretaking behaviors and adjustment to being a mother. This hormone may also support the infant's healthy development.

Low levels of prolactin may cause problems through:

Poorer transition of the baby at the time of birth.

Poorer growth and development of the baby.

Poorer adjustment of a woman to motherhood.

You can likely promote your body's production of prolactin by:

Waiting for labor to start on its own.

Minimizing stress during labor and after birth.

Keeping woman and baby together after birth.

Breastfeeding early and thereafter on cue from the baby.

Maximizing the Role of Birth Hormones

As you can probably tell from the information above, some features of typical hospital childbirth settings, like noise or medical interventions, can interfere with your body's natural processes. To avoid this and maximize your body's ability to follow its natural processes, it's a good idea to seek out a birth setting that supports this. Out-of-hospital birth settings and one-on-one continuous labor support, such as doula care, can help create conditions that enhance your body's natural production of helpful hormones and keep disturbing hormones in check.

You can read more about the role of hormones in childbirth in the Pathway to a Healthy Birth booklet.

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The Role of Hormones in Childbirth | National Partnership for Women & Families

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Featured Resource This informative booklet reviews the role birth hormones play in guiding you and your baby on the path to a healthy birth and how you can help your birth hormones do their wonderful work for you and your baby. Download the PDF You (and your baby) are born with the ability to start [...]

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Knowing your rights and the law in pregnancy and childbirth is important. Our factsheets provide you with the latest information on your rights, where they come from in law, and how they are backed up in guidance.

Each link below goes to a new page where you can read the information or download a printable PDF document.

We do not deal with maternity-related employment or benefits issues. Maternity Action provide comprehensive information on your rights at work, access to benefits, breast-feeding and chest-feeding rights.

Birthrights is a UK-based organisation and our factsheets cover the law in the UK, except where stated. They were last updated in August 2021 (written in May 2021).

Read our legal statement and copyright for terms and conditions of use of these factsheets.

If there's an area we've missed that you would like to see covered, please get in touch.
We are grateful to Looseleaf Productions, the Hollick Family Foundation, the Baring Foundation and the National Lottery Community Fund for supporting our factsheets.
Do you work with pregnant women and birthing people?

Our training equips doctors, midwives and other birth workers with knowledge of the law and human rights principles, an understanding of how to apply it in practice, and the ability to communicate effectively with women and birthing people in a way that upholds their human rights. We offer a 10% discount to multidisciplinary teams.

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Knowing your rights and the law in pregnancy and childbirth is important. Our factsheets provide you with the latest information on your rights, where they come from in law, and how they are backed up in guidance. Each link below goes to a new page where you can read the information or download a printable ...

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Consent means saying yes. You have the right to make your own decisions about your body, just as you do at any other time.

It is against the law to give you medical treatment unless you agree to it. It is also against the law for treatment to be given to your baby without your consent or the consent of another person with parental responsibility.

Agreeing to treatment is known legally as giving consent. In law, your consent must be genuine. This means you must understand the treatment well enough to make a decision. It also means that no one, including your family or healthcare professionals must put pressure on you or bully you into agreeing to have the treatment.

If you are a surrogate you have the same rights as any other woman or birthing person to make decisions about your body.
You cannot be treated unless you agree
No one can treat or touch you against your will. Even if health professionals don't agree with your decisions about your body, they must respect them. Health professionals must ask if you agree to any medical treatment. For example, they must ask before examining you, before taking your blood pressure, and before giving you pain relief. This is the law.

If you do not agree to treatment, but health professionals still treat you, they may have broken the law.

The only time health professionals do not need your consent to treatment is when you are not able make a decision. It is very rare in law for someone to be unable to make their own decisions.

It could be because it is an emergency and you are unconscious. In this situation healthcare professionals must only give you treatment and care that you need to stay alive and safe.

Very rarely, you may not be able to give consent because you cannot understand the choice you need to make even when it is very clearly explained. This is called not having mental capacity. Our factsheet Mental capacity and maternity careexplains.

If you have particular communication needs or are worried about communicating, talk to your doctors and midwives so you can plan the best way for you to give or not give consent.

A healthcare professional must ask you before they examine you, investigate anything, or give you any care or treatment. You must be asked whether or not you agree to every medical procedure, even if it is as minor as taking your blood pressure. You don't have to speak to show that you agree. You could simply hold your arm out for the blood pressure cuff.

Remember that you do not have to agree. It is not your role to please healthcare professionals. It is their role to look after you in the way that you want. They must ask you every time they carry out a procedure (this includes things like blood tests, monitoring your blood pressure, internal examinations or offering you medication). Even if you consented to this examination or treatment before, they must ask you again. They must be clear about what they are asking.

For example, if your midwife wants to carry out a vaginal examination, they need to tell you in language that makes it clear that they will be putting their fingers inside you. Saying something like, 'Can you just hop up on the bed and we'll have a look and see how you are doing' is not clear. In addition, it is wrong for a healthcare professional to carry out further interventions; for example, I just did a "sweep" while I was there'. They should ask your permission in advance. (A sweep is an internal procedure which is intended to start labour.)

Making a birth plan and having respectful conversations with your healthcare professionals early in your pregnancy can help you think about the treatment and care you may be offered. You can specify in your birth plan any treatment you do not want.
For example, if you do not want vaginal examinations during your care, talk to your midwife about this during your antenatal care. Make sure your choice is written in your notes and birth plan. You do not have to say why you do not want to have vaginal examinations. If you are comfortable explaining why, this can help your midwives suggest care that may work for you.

If y ou do not think your healthcare professionals are listening to you when you refuse consent, you can contact us for advice.

At some point in your pregnancy and labour your healthcare professionals may think your care or treatment should change. If anything changes, they must tell you what is different and ask you again. If the treatment could now bring new risks or new benefits, they must ask your consent again.

You need to know who is giving you maternity care and agree. You must be asked before a medical student can be part of your care.

In some cases you might be asked for consent ahead of time. You can still change your mind afterwards.

If you are going to have an operation such as a planned caesarean section, the doctors should offer you a proper conversation about the risks and benefits ahead of time. They cannot do anything during the operation that you haven't agreed to unless it will save your life or prevent serious harm.

Even if you have discussed your care in advance, you should still be offered another discussion at the time of the procedure in case things have changed or you have changed your mind.
For example, if you have been booked for an induction you can change your mind and decline the induction at any time, including on the day of the procedure.
You do not have to agree to procedures simply because they are standard in this particular hospital or birth centre.

Before you decide about any care or procedure the healthcare professionals must give you information about what will happen.

The information should tell you about any risks that will be important to you. It should tell you if there are other treatments you could have instead and the risks and benefits of those. It should tell you what could happen if you don't have the treatment.

Your doctor should listen to you and find out what matters to you. For example, if a treatment or procedure might make future pregnancies complicated, they need to talk to you about how important it is to you to have more children so that you have the information you need to make a decision.

It is not enough just to give you a leaflet or a link to a website. You should also have a personal discussion with your healthcare professional.

You might want to use the BRAIN framework to help you get the answers you want:

B - What are the B enefits?

A - What are the A lternatives?

I - What does your I ntuition (gut) say about what's right for you?

N - What would happen if I said No or N ot now?

Your healthcare professional must not give you misleading information. The information must be up to date and based on the most recent evidence. They should give you as much information as they can to help you need to make a decision.

They must make it easy for you to ask questions, and they should answer your questions properly. If there is a question that they cannot answer, they should explain why (for example if the information isn't available). They may be able to help you find out information you need if it is available or point you to where that information might be.

If you need an interpreter or support to communicate the Trust should provide this.

You can ask for things to be explained again. It is ok to ask questions about what you were told and why during a previous appointment or during a previous pregnancy.

You have the right to request care but healthcare professionals do not always have to offer care if there is a good reason why they should not.

You should be listened to and taken seriously when you ask for care.
For example, if you ask for pain relief or for your pain relief to be topped up, it should be given unless there are good reasons against providing it. If there is a medical reason for refusing pain relief because it could cause you harm ('a clinical contraindication') then your doctor or midwife should explain this to you and document the discussion.
You can write a birth plan to tell people what care you want during labour and after. Your midwife or doctor should help you to make a birth plan that will be included within your maternity records.

You may also want to think about what is important to you and what you would like to happen in various situations. It can help you think about any boundaries you have, for example if you never want to be naked or be examined internally.

You can give your preferences, for example that you want your baby to be placed skin-to-skin with you after the birth.

Making your birth plan should be a collaboration between you and the health professionals supporting you, sharing information and finding out the best way to care for you and meet your wishes.

Your birth plan has no legal status, but if it has been agreed with your midwives and doctors then this should indicate that they are happy with it and will follow it. Even if you have chosen care that is not what they recommend, they should respect it and try to meet your wishes. A birth plan can be used in court as evidence of your wishes and the informed decisions you had taken at the time it was made.

If you have a disability any reasonable adjustments should be recorded in your notes/ birth plan. This could include, for example, room for your wheelchair in the birthing suite, lighting that lets you see better, a quiet or dark room to help with sensory overwhelm, or time after the birth to recover from fatigue. If you need reasonable adjustments under the Equality Act 2010, the Trust has to provide these.

No matter what you say in your birth plan you can change your mind and consent to different care at any time.

Your birth plan can include the role you want a birth partner or doula to play.

After giving birth, you can challenge the treatment you received. Your birth plan can be evidence of the consent you gave or did not give.

If there are medical reasons not to give you the treatment in your birth plan, your healthcare professionals should explain them.

Healthcare professionals have a duty to prevent suffering that can be avoided. They must not refuse you pain relief or other support simply because of a hospital guideline or policy.

Your healthcare professional's job is to explain the risks of treatment to you. They can recommend one treatment over others and give you their reasons for this. But they must not put pressure on you to choose a particular treatment for yourself or your baby.

If your healthcare professional puts pressure on you to make you choose a particular treatment, this is called undue influence.

Undue influence could mean that your healthcare professional keeps discussing risks even when you have made a decision.
For example, you may have decided that you do not want an induction. You discuss the risks and benefits with the midwife, who is worried about your decision. They call in the senior midwife, who repeats their concerns. Then the consultant obstetrician comes to see you and repeats them again. Unless the risks have changed and your health professionals want to give you new information, this may comprise undue influence.
It may also be undue influence if your health professional threatens to stop caring for you.
For example, if they said, 'Once you are 42 weeks pregnant the home birth team won't be able to come out to you and you will have to give birth in hospital' or 'If you don't agree to giving birth on the labour ward you will have to find another Trust to look after you.'
It may be undue influence if your healthcare professional tells you to make a decision by a certain time even when there is no clear medical need.
For example, they might say, 'You need to decide in the next twenty minutes' without explaining why.
They must not put pressure on people in your family to persuade you to change your mind.
For example, they might say to your partner, 'Try and talk them round. If it were my partner I wouldn't want them to do this. We only want what's best for your baby.'
They must not restrain you physically.

If your healthcare professional threatens to refer you to social services if you do not make the treatment decision they want, this is undue influence. They must never do this. If they do this, you may not legally have given consent. They could be taken to court if they went ahead and treated you.

If you have a disability or long-term illness, you may be worried that social services will take your baby away if you talk about any concerns you have about caring for your baby. They must work with you to find solutions, and you should never feel threatened.

If you are involved in the criminal justice system, you may feel worried that something you say could be used as an excuse to take your baby away. You have the same rights as everyone else and should never be threatened with social services merely because of your circumstances.

If you are in, or may go to prison during your pregnancy, the charity Birth Companions has a guide to pregnancy and early motherhood in prison.

If a woman is being treated for a mental disorder under the Mental Health Act 1983, or the Mental Health (Care and Treatment) (Scotland) Act 2003, that does not necessarily mean that she lacks capacity in relation to decisions about her maternity care. She should be treated in the same way as any other woman unless she has been assessed to lack capacity.

No. You can tell your healthcare professional that you agree to treatment. Or you can agree with a gesture, for example by holding out your arm so they can check your blood pressure.

Usually you will sign a consent form before surgery. Before you sign, you and your healthcare practitioner should talk about the treatment, the risks and the benefits.

It is important that you understand what you are consenting to, and the risks it brings.
For example, if you have a visual impairment and need to read in large print, ask for the form in large print and for plenty of time to read it.
A signed form and medical notes are evidence that you gave consent but not proof. Other evidence may show you did not have enough information or were put under pressure.

Royal College of Obstetricians and Gynaecologists guidance and guidance on consent from the Association of Anaesthetists of Great Britain and Northern Ireland state that special care must be taken when obtaining consent from women who are in labour, particularly if they are under the influence of narcotic analgesics (opiate-derived painkilling drugs).

If you can't give consent in an emergency, for example because you are unconscious, you can be treated to save your life or stop your condition getting much worse. In a situation like this, if there is time, the healthcare team should talk to your next of kin about any decisions.

It is very rare that you would be unable to give consent even if you did need emergency treatment during pregnancy or labour.

Even if healthcare professionals think your baby's life is at risk, they cannot perform procedures, such as assisted birth (forceps or ventouse), without your agreement.

If it feels like an emergency and you feel under pressure to make a decision it can be useful to ask the healthcare professional something like, 'Am I in immediate danger? Is my baby in immediate danger?' This allows you to have a conversation about what the actual risk is, and how urgently you need to make a decision.

Yes. You can refuse treatment even if your doctors or midwives think you are wrong.

If you can make decisions, you can say no to treatment for any reason. Your reason does not have to make sense to other people. You can say no to treatment even where it might lead to your death, or your baby's death.
You can say something like 'I don't want that treatment' or 'I do not consent to this treatment'.

If you need advice on refusing treatment you can contact us.

Yes. Even if you gave consent you can change your mind. This is called withdrawing consent.

You can do this at any time. If your healthcare professional suspects you may no longer want the treatment, they must stop as soon as possible. They should talk to you and only carry on if they are sure you consent.
For example, you can say 'Stop'. If you want some time to process what is happening you can say 'wait a minute, please'. You can move away, if you are able to. If you are in labour, you can ask for the healthcare professional to wait till your contraction has finished before they carry out a vaginal examination. It is always ok to say no.
Mental capacity means that you can understand the choice you need to make about treatment and can make a decision.

In law, everyone has mental capacity unless it can be shown that you do not. It is very rare to not have mental capacity.

The people caring for you cannot say you do not have capacity simply because you do not agree with them.

If you are 16 or 17 then the law presumes that you have the capacity to consent to medical treatment.

If you are 16 or 17 and you wish to decline care, then in rare and serious cases someone with parental responsibility or the Court could override your decision. This should only happen if declining care would be likely to lead to your death or severe permanent injury.

If you are under 16 then you can consent to treatment if your healthcare professionals believe that you fully understand what is involved. This is called having Gillick competence. Otherwise someone with parental responsibility can consent for you.

Labour can be tiring and hard work but it is very unlikely that giving birth will make it hard for you to give consent.

During your pregnancy you should be supported to think about what you might want during labour. You should be given plenty of time and opportunities to discuss decisions that might come up in your case.

If you are in labour your health professionals must take extra care to be sure you have consented to treatment. They must take even more care if you are given painkillers called narcotic analgesics. These are opioid drugs and can make you sleepy.

If you know you will find it hard to communicate during labour, talk to your healthcare professionals early.
For example, this could be because you use British Sign Language and need an interpreter. Or it could be because you are autistic and pain can make it very hard for you to speak or use your assistive technology.
Providing communication support is called a 'reasonable adjustment'. The Trust or Board must make sure that anyone who is disabled has equal access to all of its services. This applies throughout your pregnancy, labour and postnatal care. It includes making sure you can communicate and give informed consent when giving birth. This applies to written as well as spoken communication.

You are the expert in what you need in order to communicate and your healthcare professionals must listen to you.

Only you can give consent to your treatment or care.

You can ask a birth partner, including a doula, to support you during labour. You can ask them to communicate on your behalf to express the preferences you have made in your birth plan.

If something changes in your labour and you need to give consent to something that isn't covered in your birth plan, only you can make that decision.

Your birth partner or doula can support you in this situation. You can ask for some time to discuss the decision alone with them if you want. Or, for example, they can assist you by asking on your behalf for more information about any new risk the midwife raises, how urgent a treatment really is, and how important it is.
Some autistic people can find it very difficult to communicate during labour and to give or refuse consent. It can be hard for autistic people to show that they are in pain, and it can be hard for them to speak when in pain or experiencing sensory overload. If you are autistic, you can ask an advocate to support you from the start of your pregnancy. During labour, if your advocate recognises your personal signs that you are distressed they can ask the health professional to stop by saying, 'Stop', or 'I don't think they want you to continue'.
Yes. Before treating a baby, healthcare professionals must ask consent from a person with 'parental responsibility' for the baby.

In law, the mother always has parental responsibility for her baby. The father has parental responsibility if he meets certain criteria.

A trans man who has given birth will legally be described as the mother under current law. Non-binary birthing people are also described as mother at present.

If parents decline treatment for their baby, healthcare professionals should respect their decision.

No one should threaten parents with a referral to social services to make them consent to treatment for their baby.

A baby should only be referred to social services if health professionals think ('have reasonable belief') that the baby is at risk of significant harm.

In rare and serious cases, including if parents disagree about treatment or doctors feel that the parents' decision is not in their child's best interests, healthcare professionals may ask the High Court to decide. They can ask the High Court to declare that the treatment should be carried out, or not carried out, because it is in your baby's best interests.

Law and guidance

Everyone has the right to make decisions about their body for themselves. This is called the principle of autonomy.

The principle of autonomy is protected under Article 8 of the European Convention on Human Rights and common law of England and Wales, and common law in Scotland. You can read more on our factsheet Human Rights in Maternity Care.

The law says that pregnant women are entitled to make autonomous decisions in the same way as any other person. Even if healthcare professionals disagree with their decisions they must respect them.

The principle of autonomy creates a legal requirement to seek a person's consent whenever they are given any medical treatment.

The only exceptions are rare cases: when a person does not have the capacity to make their own decisions; or in an emergency when a person cannot consent because of their physical condition (for example when they are unconscious).

If a person's consent is not obtained, the medical treatment will be against the law. It will be negligent, and in England and Wales, it will also constitute the crime of battery, and a civil wrong of trespass to the person.

Failure to obtain consent also violates Article 8 of the European Convention. If the harm that occurs as a result is serious, it will breach Article 3 of the European Convention prohibiting inhuman and degrading treatment.
Consent includes knowing who is providing healthcare
In the case of Konovalova v Russia (2015), the European Court of Human Rights held that women's consent must be sought for all medical care provided during labour and this included consent for medical students to be present during a birth. As a result, any person who is providing maternity care should be clear about their status and explain if they are a student, so that the patient can decide whether they wish to receive care from them or to have them present.

The healthcare professional must give the person the information they need before seeking consent. The information should cover any material risks, any alternative treatments that are available, and the risks of doing nothing.

In the Supreme Court case, Montgomery v Lanarkshire Health Board (2015), the court stated that the test for whether a risk is a 'material' one is whether a reasonable patient would attach significance to the risk, or whether the doctor should be aware that the particular patient would attach significance to it. This means that there must be an honest conversation between doctor and patient and the assessment of risk must be sensitive to the individual's characteristics.

When thinking about how significant a risk is for a particular patient, statistics are only one factor. For example, the risk of complications for future pregnancies after a C-section might be statistically small, but it would be more significant for someone who wished to have multiple children than for someone who did not. Every person perceives risk differently.

Hospitals cannot only rely on printed leaflets or online material to provide relevant information; there must always be a personal discussion between the patient and the health professional ( Montgomery v Lanarkshire Health Board (2015)).

Leaflets and online material can form a useful starting point for an informed conversation. Health professionals must make sure that people have time and any support they need to understand the information, to make notes, and to think about the information. When someone finds spoken communication difficult, it is important to give support and to be flexible about their preferred means of communication, for example using a pain scale or assistive technology.

Giving misleading information about someone's medical condition or the proposed treatment, or not giving them relevant information, may mean that consent was not valid. The failure to provide appropriate information may also leave the healthcare professional open to a successful claim of negligence if the person suffers harm as a result of the treatment.

If the patient asks specific questions, a healthcare professional must give full, honest and objective answers. They should take the time that is needed to do this.

General Medical Council guidance on consent sets out how doctors should support people to make decisions about their care, including how consent should be recorded.

The Royal College of Obstetricians and Gynaecologists also provides advice on consent, and on specific procedures and the risks associated with those procedures, including caesarean section, operative vaginal delivery, and participating in research while in labour.

The National Institute for Health and Care Excellence (NICE), which makes guidelines for health and social care, has guidance on improving the experience of care for people using adult NHS services, which includes information about how healthcare professionals should communicate with patients and how to present information about risks and benefits, to enable them to make decisions about their care. NICE guidance is not law, but a hospital has to give good, clear reasons if it does not follow the guidance.

Consent does not need to be recorded in writing. It may be given verbally or with a gesture. Someone might move away from a healthcare professional, shake their head, or simply say, 'No'.

It is usual practice to sign a consent form for surgical procedures, but this does not reduce the need for a fully informed dialogue between the patient and their health professional ( Montgomery v Lanarkshire Health Board (2015)).

A signed consent form and/or medical notes are evidence of consent but do not prove it was obtained: they may be contradicted by other evidence that consent was not well-enough informed or freely given.

The GMC's guidance, Department of Health's reference guide and the Scottish guide on consent contain further information on the form consent should take.

The courts in England and Wales have upheld the rights of patients to make important medical decisions affecting their lives for themselves.

A mentally competent patient has an absolute right to decline medical treatment for any reason, rational or irrational, or for no reason at all, even where that decision may lead to his or her own death.

A mentally competent pregnant person may decline treatment during pregnancy or labour even where that might lead to death or serious harm to them or their baby.

Royal College of Obstetricians and Gynaecologists guidance states that special care must be taken when obtaining consent from women who are in labour, particularly if they are under the influence of narcotic analgesics (opiate-derived painkilling drugs).

If someone has difficulty understanding spoken English, NHS England sets out how Trusts should obtain language support. This could include hiring a professional interpreter or translating written material. Everyone needs to be able to communicate fully and understand what consent they are being asked for.

The GMC guidance on consent says that doctors should use an interpreter or translation service.

If someone's illness or disability means that they need support to communicate, this is called reasonable adjustment. The right to reasonable adjustment is set out in the Equality Act 2010.

The principle of reasonable adjustment is that the Trust must make sure that everyone has equal access to all of its services. They must put in place the support that someone needs to understand the treatment they are being offered, and to communicate their consent. This could include large print information materials for someone who needs this, lighting that enables someone to lip read, or an advocate to support understanding and communication.

The NHS has been trialling Reasonable Adjustment Flags, a way for people's needs for extra support to be highlighted to healthcare professionals every time they use the health service.
About Birthrights
Birthrights factsheets give you information about your human rights when you are pregnant and giving birth.

Birthrights champions respectful care during pregnancy and childbirth by protecting human rights. We provide advice and information to women and birthing people, train doctors and midwives, and campaign to change maternity policy and systems.

We are a charity, independent of the government and the NHS.
Disclaimer: Our factsheets provide information about the law in the UK. The information is correct at the time of writing (May 2021). The law in this area may be subject to change. Birthrights cannot be held responsible if changes to the law outdate this publication. Birthrights accepts no responsibility for loss which may arise from reliance on information contained in this factsheet. Birthrights has provided links to third party websites where these may help provide relevant further information. Birthrights takes no responsibility for the contents of linked websites and links should not be taken as an endorsement.
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Consent means saying yes Consent means saying yes. You have the right to make your own decisions about your body, just as you do at any other time. It is against the law to give you medical treatment unless you agree to it. It is also against the law for treatment to be given to ...

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The AIMS Guide to Your Rights in Pregnancy & Birth

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The AIMS Guide to Your Rights in Pregnancy & Birth

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2020

Principal Author Emma Ashworth

(This book has replace the AIMS Book 'Am I Allowed?')

How many times during pregnancy and birth do you hear the phrase 'am I allowed to...?'
How often do you think that you must be given 'permission' by the maternity services?

The AIMS Guide to Your Rights in Pregnancy & Birth changes that thinking - because you don't have to ask permission. You have the legal right to decide what happens to your body. And you have always been allowed. You might find you have to make a difficult decision, so you are likely to listen to the information given to you by family and birth workers, midwives and doctors but the decision is yours to make - nobody else's. Most of the time, it is the maternity services that need to ask your permission about the care that you would like for yourself and your baby, and this is done through a process of informed consent which is an on-going, up-to-the-minute dialogue.

This book offers a comprehensive examination of how to get what you want in your pregnancy and birth journey - it helps you to understand the issues and offers you the tools to help you to make your decisions. It is a vital resource for partners and for those working in any part of our maternity services and for all birth workers.

This book is also available as an e-book. Please see AIMS Kindle Books for further details of all the AIMS Kindle books

Read a review of this book

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AIMS Guide to Your Rights in Pregnancy & Birth

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2020Principal Author Emma Ashworth (This book has replace the AIMS Book 'Am I Allowed?') How many times during pregnancy and birth do you hear the phrase 'am I allowed to...?' How often do you think that you must be given 'permission' by the maternity services?

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Supporting you, Campaigning for all

* Campaigning for better births for all

* Protecting human rights in childbirth

* Independent information about pregnancy and birth

* Raising awareness of research

When's your due date?

What does your "due date" mean? How long is a normal pregnancy? How might being given a due date affect you and your baby? Enter the first day of your last period to discover when you're most likely to give birth.... and to find out more about due dates, induction and "post date" babies.

Date of the first day of your last period

The date of your last period allows an estimation of when you ovulated and conceived your baby.

A surprising number of women will have a bleed after they are pregnant, and although seeking advice from a doctor or midwife is recommended, usually this bleeding is not a problem.

Adjusted cycle length

Your menstrual cycle is counted from the first day of one period to the first day of the next. The average menstrual cycle is 28 days long, but many women will have longer or shorter cycles than this.

Ovulation usually takes place about 14 days before the next period. This means in a short cycle ovulation will be less than 14 days after your last period and with a long cycle more than 14 days after your last period. Giving the length of the cycle allows this to be taken into account in calculating your due date.

Many women have irregular cycles which make using the last day of their period less reliable for estimating due date.

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Birthrights: Protecting Human Rights In Childbirth

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Birthrights: Protecting Human Rights In Childbirth

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When is consent not consent?

That's not intended to be a trick question.

I'll admit it is a bit of a leading one in the context of this post because, although there are several possible answers to this, which are all more than worthy of debate, I am really only wanting to write about one today.

The kind of so-called consent that is sought when someone is halfway through performing a vaginal examination which a woman has consented to and, out of the blue and before removing their fingers, asks the woman if she would like to have another procedure performed at the same time.

This post is excerpted from my book, " What's Right For Me? Making decisions in pregnancy and childbirth. " I'm sharing it here as well because I think it's something that everybody needs to be aware of.

Non consensual intervention

This procedure is usually the breaking of her waters or (in countries where intervention in pregnancy is even greater than average and vaginal examination is carried out during pregnancy) a stretch and sweep.

I was horrified to receive several emails about this after I published the first edition of What's Right For Me?

Because it is not justifiable and it flies in the face of the notion of informed decision-making.

First, both of the procedures given as examples above (ARM and stretch and sweep) might sound innocuous, but they are means of attempting to induce (bring on) and/or augment (speed up) labour.

Some women might well decide they want to have them, after they have had a chance to weigh up the risks and benefits, but they are interventions which can affect the outcome.

Women deserve to have time to think about them, seek more information, consider their options and discuss them with loved ones.

None of which is possible or practical while one is being examined in that way.

Most of which might not even be possible or practical for some women while they are in the company of a waiting professional. But I acknowledge that this depends a lot on the relationship between the woman and her attendants and that there are occasionally times when this might be unavoidable.

Those are very rare though. (But before anyone asks, one example is a situation where a midwife or doctor finds a loop of cord and is concerned about the baby's wellbeing.)

These are not emergencies!

Neither membrane sweeping nor membrane rupture is an emergency procedure, though. Nor are they offered in situations in which speedy decision-making is necessitated. Many - perhaps most - women find vaginal examinations uncomfortable, embarrassing and/or painful. For some women, they are physically and/or psychologically excruciating. Women will not always tell their attendants if that is the case, though; in some cases because they do not know the attendant well enough to trust them, or because the only possible response for them is dissociation. Either way, they want each one to be over as soon as possible. In some cases, a woman might agree to anything in order to get the examination to stop.

That is not informed decision making.

I don't think that every practitioner who does this is necessarily setting out to coerce or harm. I can see how, from a technocratic perspective, they might genuinely think that it's kinder to save women from having an additional examination. Or they might not have thought about the ramifications of this.

But it's not okay, on any level.

Please, if you attend births and have ever done this, think about what it does to the women you care for. And never do it again.

What should you do if this happens to you?

If this happens to you while you are receiving any kind of health care, you are completely within your rights to tell the attendant to finish examining you before discussing any further decisions. Or to tell them to stop immediately.

If someone continues to touch you after you say 'no' or 'stop,' this is an assault, and you should report it.

Being clear about consent

Some people suggest to women that they are very clear with the attendant before they consent to a vaginal examination that they are not consenting to any related intervention and that they do not want to discuss further interventions during the examination.

That isn't a bad idea at all. But women should not have to be proactive in this way. Given the enormity of the interventions and the invasive nature of some of the examinations carried out in maternity care, the emphasis should be on attendants to initiate such discussions only at appropriate times.

But it is the reality that modern maternity care is fragmented, standardised, and often impersonal, which is why it's a really good idea to get informed ahead of time and to take responsibility for the decisions you make.

If you'd like more information on to support you in making the decisions that are right for you during pregnancy and childbirth, grab a copy of What's Right For Me: making decisions in pregnancy and childbirth.

You may also find a couple of my other blog posts useful, as they cover related topics:

Five questions to ask if you're offered induction of labour

Resources for questioning vaginal examination

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When is consent not consent? - Dr Sara Wickham

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When is consent not consent? That's not intended to be a trick question. I'll admit it is a bit of a leading one in the context of this post because, although there are several possible answers to this, which are all more than worthy of debate, I am really only wanting to write about one today.

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What is a stretch and sweep? - Dr Sara Wickham

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Many women are offered a ‘stretch and sweep’ in late pregnancy. But what is this, why and how is it done, does it work and can you say no?

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Cervical dilation is (now mathematically shown to be) unpredictable - Dr Sara Wickham

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Research has confirmed that, in spontaneous, naturally progressing labour, the rate of cervical dilatation is largely unpredictable.

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The Vaginal Exam in Labor - Childbirth Series

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Hands-off midwifery and the art of balance is an article that was published in 2009 (Wickham 2009). Now more than a decade on, we have reposted it here. Please be aware that new evidence is emerging all the time and some of what is in here may have been superseded by the time you read it.

A real challenge

Nita has been a community-based midwife for over twenty years, and has more recently moved into independent practice. She is well-versed in what has become known as 'hands-off' practice, is expert at knowing how women are progressing in labour by watching, listening and feeling their baby abdominally and only occasionally suggests vaginal examination [VE]. She always seems to know instinctively when a baby needs a little help to be born, yet feels no need to keep her hands on the baby or perineum at all times. Her outcomes are excellent, and women and student midwives love her.

Kiera is one of those students. She described her placement with Nita as " welcome relief " from some of her experiences in more medicalised areas of practice. Yet while Kiera's heart is with the kind of approach she sees Nita use, the practical reality of how she can reach that place herself is a different matter:

"You work with some midwives who do everything, they do VEs every four hours and have their hands doing all these things when the baby comes, and then you go out with the ones like Nita who are different ... and they hardly ever do those things, and you think, well that's great, and that's what I want to do ... but how do I learn when to do it and not? ... and how do I get the practice when I don't want to subject women to more VEs than necessary? ... I'm really conscious of that..."

Introduction

A wide variety of philosophical positions and practical trends have characterised approaches to health and birth throughout history. Early European medicine, for example, was characterised by the theory of 'humors', which healers attempted to rebalance with the use of cathartics, purgatives and bleeding. Later, Western medicine was revolutionised by the work of people like Semmelweis and Lister, whose work on germ theory and antisepsis helped prevent the transmission of disease and, from this point, the principles of Western medicine both expanded and gained a firm footing as the dominant approach to healing in the industrialised world through the development of bacteriology, vaccination, pharmacology and surgical techniques. Although a large number of other approaches to conceptualising, diagnosing and treating health and disease still exist, the principles behind Western medicine have continued to gain momentum and, as midwives know only too well, have more recently been applied to the care of women in childbirth as well as in the care of sick people.

The application of the principles of Western medicine during pregnancy and childbirth has not, of course, been universally popular. Nor has this been universally successful. The past few decades have been characterised both by increased medicalisation of pregnancy and birth and by the various responses to this from those who do not consider it appropriate, including the natural birth and midwifery movements. Perhaps inevitably, the exact nature and form of these movements varies geographically. New Zealand has a unique story of midwifery autonomy, while slightly differing political and practice stories have played out in Australia, the US, Canada, the UK and other countries. The trend towards the kind of hands-off approach practised by midwives like Nita, however, can now be found in midwifery practice in all of these countries - and others - and it is this trend and some of the questions it raises for us as midwives that I would like to explore in this article.

What is Hands-Off Practice?

There does not seem to be a clear theoretical definition of what 'hands-off' practice means, although it is a term whose meaning is fairly obvious to most people. In relation to midwifery, it appears to be used in at least two ways. Firstly, it describes a general attitude; a low-tech and individualised approach where the practitioner does not manually intervene unless there is a genuine need to do so, and a genuine desire from the woman that this happens, following honest discussion of the situation and options. This contrasts with the approach taken where systems of care and individual practitioners adopt the use of routine practices or interventions which are then applied to all women on a population basis, rather than according to individual need.

Secondly, the term 'hands-off' is used specifically in relation to a number of different aspects of midwifery practice, including;

An approach to facilitating breech birth which involves careful watching, waiting and manual intervention only as appropriate (e.g. Cronk 2005), rather than the medical approach of "delivering" the breech baby through a series of relatively standardised manual interventions while the woman lies in a lithotomy or semi-recumbent position.

An approach to attending women in labour such as that described in Lesley Dixon's (2005) research, which recognises that vaginal examinations can be both traumatic and problematic for women (e.g. Stewart 2005) and involves undertaking these only when truly indicated, rather than at regular and / or pre-defined, intervals.

An approach to attending the birth of a baby where the midwife will not automatically place her hands in a particular series of positions on the baby's head (and possibly the woman's perineum) and attempt to assist flexion and guide the birth in a relatively standardised way, but instead may either hold her hands 'poised' (as described by McCandlish et al 1998) and use them only if she perceives a particular need to do so, or will adapt her practice depending on the situation.

An approach where the midwife helps the mother to learn to breastfeed her baby without using her own hands to position and latch the baby on his mother's breast (Fletcher and Harris 2000), thus enhancing the woman's self-confidence in her ability to do this when the midwife is not able to be physically there to help her.

Each of these examples - and, indeed, the notion of being hands-off in general - illustrates a philosophy which I would suggest has arisen partly in opposition to the medicalised, intervention-heavy approach that has come under criticism from so many sources. I have heard a number of people speaking about how the roots of this approach also lie in related, woman-centred trends such as the use of water for labour and birth, which render the midwife less able to carry out hand manoeuvres and thus place her in a position where she is able to extend her own comfort zones around the need to be hands-on. These notions are supported by a body of research evidence, and by documents such as the WHO Principles of Perinatal Care, which states that, "...care should be based on the use of appropriate technology ... reducing the overuse of technology or the application of sophisticated or complex technology where simpler procedures may suffice or indeed be simpler." (Chalmers et al 2001: 203)

Hands-Off ~ A Personal Perspective

I should probably declare a vested interest in this topic sooner rather than later. I would consider myself a hands-off midwife. Although, like many of my colleagues who espouse this philosophy, I don't hesitate to ask for permission to use my hands or other tools when I feel the situation genuinely calls for it. For example, I attend breech births with the "hands off the breech" mantra uppermost in my mind, yet at some point I have, with permission, used almost every one of the manual manoeuvres known to midwife-kind when I have felt they were truly warranted. As Ina May Gaskin often mentions (personal correspondence 2003), there is a danger that mantras such as 'hands off the breech', if used on their own, can mean that we risk taking the hands-off approach too far and end up with sub-optimal outcomes.

Equally, if I am in a situation where performing a vaginal examination could give myself and the woman important information which we will be truly useful and which we cannot get any other way, I will discuss this option with the woman rather than ploughing on (but with my hands still off) in a situation where I have a concern that I cannot otherwise resolve. Very few women decline intervention when they are in circumstances which truly warrant this and, like so many of my colleagues who take a hands-off approach, my philosophy embraces the (admittedly paradoxical) notions that one should "never say always" and "never say never".

Instead of being an absolute rule, then, the hands-off approach for the midwives who practice this way seems to be the starting point from which the woman and midwife might decide to add in certain hands-on practices as and when they are deemed appropriate. This contrasts fairly starkly with the medicalised approach where the starting point involves regular manual, technological and pharmaceutical interventions which are only omitted if the woman particularly requests not to have them. The cornerstone of the practice of hands-off midwives doesn't seem to be about never using manual intervention, but about striving to achieve the art of balance. Like many hands-off midwives, I am by no means under the illusion that I have perfected this art! As I am sure is the case for most of the midwives who are reading this, I still spend hours talking with colleagues about whether I should have waited longer before I intervened in a particular situation, or whether, if I had done something earlier, the eventual outcome might have been different...

Exploring the Challenges...

I have wondered whether the misunderstanding that may arise where we use terms like "hands-off" when we actually mean "hands-off unless there is a real need to put hands on" means that we should re-think the terminology we are using to refer to this approach. However, it seems quite clear to me that, whatever we call it, this approach is what some women want, and that it will continue to be a feature of the increasing autonomy of women and midwives. Indeed, in areas where this kind of care is not an option, more and more women are voting with their feet for a totally hands-off approach by choosing unassisted birth.

However, if we believe that the hands-off practice movement is an important part of the development of twenty-first century midwifery practice, there are a number of questions that need consideration. Among them are the vital matters of how we learn, teach and expand our understanding of hands-off practice, in order that this approach remains central to the needs of women and babies and - given that we live in the modern world - that we can demonstrate that each of the decisions we make with women is clearly thought through within the context of the woman's needs and the wider picture.

The story at the beginning of this article illustrates the situation which has arisen where a good number of the midwives who have been at the forefront of developing the hands-off approach were already experienced in a more hands-on approach first. Nita's approach to practice seems to be rooted in a deep kind of experiential knowledge that Kiera and many of her colleagues are now struggling to gain. As a nurse who later became a midwife within the medical model and then gradually moved towards a hands-off approach, Nita has a great deal of practice experience upon which to draw. Not only in the assessment of when intervention is truly warranted, but in having used these interventions enough in the past to perform them when they are needed with skill and dexterity.

Midwives like Nita initially learned to perform intervention on a more regular basis. Perhaps they then gradually expanded their trust of birth and their own comfort zones to a point where they felt able to do less and less and 'downsize' from a more medical approach as their experience and knowledge grew. For me, this juxtaposition of the experienced midwife who has grown into the hands-off approach over time with the new midwife who so desperately wants to learn to work this way from the outset but who does not yet, in her own words, have the confidence to wholly do this, illustrates one of the very real challenges which has arisen as a result of the increased autonomy that women and midwives have gained.

Other challenges raised by this movement include the questions of how we develop individual and collective knowledge around this kind of practice, based as it is on a midwifery model rather than a medical model approach. (I am currently engaged in research which looks at these questions, not least because I feel there is such a great need to explore the principles by which experienced, trusting midwives make decisions). Perhaps even more important is the question of how we find safe ways in which we can openly discuss these issues - and review our practice - without falling prey to unwarranted criticism from outside, particularly from those groups who do not feel able to take an open and honest approach to the evaluation of their own practice.

Finding Answers...

How we continue to explore, expand, learn and teach the art of a balanced, hands-off approach are, I feel, among the biggest questions which face midwifery today. How do we ensure that student midwives have gained enough experience of vaginal examination to ensure that they really feel confident about what they are feeling when they do need to perform this, when we, their mentors, are also trying hard not to subject women to more vaginal examinations than are truly necessary? How do we enable students and newly-qualified midwives to feel confident with the manual manoeuvres which are rarely used in hands-off practice, yet which might one day be the very thing they need in a particular situation? Rather than removing the concept of labour assessment from our practice completely when we want to embrace hands-off practice and do less vaginal examinations, how can we continue to develop and share less invasive forms of evaluation such as auditory and visual observation using physiological signs like the purple line?

Perhaps most importantly of all, how can we explore and encapsulate the cognitive tools and criteria which experienced midwives are using to decide when an intervention is essential and life-saving, and when it is unnecessary interference, such that we can further our knowledge and share this with those who follow us? One possible starting point for this last question might be the conclusions that were reached by some of the midwives who joined me in a recent workshop exploring these issues. They decided that, as a rough guide, an intervention should be contemplated when the midwife and woman both agree that it is really necessary, because either:

1. There is a real concern that there may be a problem, and the intervention (which includes screening tests like vaginal examination) could give further information about whether this problem exists or not, or

2. The woman and her midwife are in a situation where the outcome of a test (like vaginal examination) or manoeuvre might impact upon an important decision (such as the decision to transfer from home to hospital in labour), or

3. The outcome of an action (like helping a breech baby to birth) is more likely to change the outcome of the situation for the better than it is to cause problems, risks or an unacceptable degree of discomfort for the woman and / or baby.

Ultimately, I feel that all of these questions are rather interesting ones, and a part of me is excited that we have reached a point where we need to explore them, because the fact that we need to ask them is indicative of the increasing autonomy experienced by women and midwives. Rather than seeking to balance the humors, as our ancient colleagues did, the challenge for modern midwives is not only to perfect the art of balance in our own practice, but also to find ways of expanding and sharing this art with those who follow.

References

Chalmers B, Mangiaterra V and Porter R (2001) WHO Principles of Perinatal Care: The essential antenatal, perinatal and postpartum care course. Birth 28(3): 202-7.

Cronk M (2005) Hands off that breech! AIMS Journal 17(1):3-4

Dixon, L (2005) Building a picture of labour: how midwives use vaginal examination during labour. New Zealand College of Midwives Journal 33: 24-28)

Fletcher D, Harris H. (2000) The implementation of the HOT program at the Royal Women's Hospital. Breastfeeding Review. 8(1):19-23.

McCandlish R, Bowler U, van Asten H et al (1998). A randomised controlled trial of care of the perineum during the second stage of normal labour. British Journal of Obstetrics and Gynaecology 105: 1262-1272

Stewart M (2005) 'I'm just going to wash you down': sanitizing the vaginal examination Journal of Advanced Nursing 51(6): 587-94

Wickham S (2009) Hands-off and the art of balance. Birthspirit Midwifery Journal 1: 22-24

Books to help you become informed and make the decisions that are right for you...

Thank you 💜

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Hands-off midwifery and the art of balance - Dr Sara Wickham

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Sara Wickham's 2009 article on hands-off midwifery and the art of balance, which discusses topics from vaginal examination to breech birth.

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10 Things To Know About Labour Induction

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10 Things To Know About Labour Induction

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Resources For Questioning Vaginal Examination

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Resources For Questioning Vaginal Examination

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"Do you know of any good resources on the subject of questioning/declining vaginal examination? I'm thinking of vaginal examinations in a number of contexts - well woman exams, vaginal examinations in labour and especially at the end of pregnancy, as women in my area are being told they need to have a vaginal examination in order to assess their cervix for induction and for the purposes of a stretch and sweep. I'm a childbirth educator and I'm looking for some resources to share via email and then discuss with my groups."
As with all my resource posts, these are just a few of the resources that I'm aware of, and there are many more out there. Please feel free to suggest others in the comments section and check for relevance before you share any of these, as the content can change without notice!

Well woman exams

In some countries, such as the US, healthy, asymptomatic women have long been advised to have regular pelvic examination (despite being healthy and asymptomatic) as part of an annual so-called 'well woman' examination. Many other countries don't have this recommendation and, instead, pelvic examination is usually offered only if a woman actively seeks medical examination because she is concerned that she may have a problem. Recently, however, this practice has come under question and in Doctors are examining your genitals for no reason, Amanda Hess reports on how several US bodies have changed their recommendations in this area in recent years. Her post might be a useful trigger for discussion with a group.

Vaginal examination in pregnancy

The idea that vaginal examination is useful or necessary during pregnancy is also more common in some countries than others. However, as suggested by the question above, it is becoming more common within the context of earlier induction of labour, which many people do not believe to be an evidence-based practice. I already have a blog post on stretching and sweeping, so I shan't cover that further here, except to say that, as with all interventions, consenting to a vaginal examination does not automatically mean that a woman has consented to a stretch and sweep or to having further intervention, such as membrane rupture. See my post Would you like an ARM with that? for more on this.

Here's an article called The myth of the vaginal exam at the end of pregnancy. It is written within a US context, so not all of it applies to women in other countries, especially the bit about having vaginal examination early in pregnancy, but it could be a good starting point for discussion.

And Hey Doc, keep your fingers out of my vagina! is another article which might be useful for women in countries where vaginal examination in pregnancy is a more common occurrence, but it also highlights the very important point that vaginal examination is not mandatory, not always necessary and is associated with potential downsides as well as potential benefits.

Vaginal examination in labour

My all-time favourite piece on this topic is Vaginal examinations: a symptom of a cervical-centric birth culture, by midwife Rachel Reed. Rachel has actually referenced and linked to pretty much every other resource and paper that I know of on this topic, so there's no need for me to share more as her blog post is so extensive and well resourced.

What I will share though, are a couple of recent pieces on consent which relate to this. Firstly, birthrights has recently published a guide on women's legal rights during pregnancy and childbirth within the UK, and Rachel Reed has published a useful piece on information-giving and the law within an Australian context.

Please feel free to add your favourite resources on this topic in the comments section 🙂 I've also got a couple of quotes to share, but I'll save them for next time.

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Resources for questioning vaginal examination (1)

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"Do you know of any good resources on the subject of questioning/declining vaginal examination?

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Inducing Labour: making informed decisions

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Inducing Labour: making informed decisions

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Dr Sara Wickham PhD, RM, MA, PGCert, BA(Hons) is an author, educator and researcher who works independently.

Sara's career has been varied and includes more than twenty five years of experience as a midwife, lecturer and researcher. She is the author/editor of seventeen books, has lectured in more than thirty countries, edited midwifery journals and provides consultancy services for midwifery and health-related organisations around the world.

Sara can be found online at www.sarawickham.com

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Inducing Labour: making informed decisions

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When is it better to induce labour than to let a woman's body or baby decide the best time for birth? What are the pros and cons of waiting and of being induced? What about after the due date? When the baby is thought to be bigger than average?

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Woman Explains Contractions With A Balloon

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Evidence On: PROM (Premature Rupture Of Membranes)

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Evidence On: PROM (Premature Rupture Of Membranes)

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Failure to Progress - Signature Article (2022)

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Evidence On: Diagnosing Gestational Diabetes

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Evidence On: Diagnosing Gestational Diabetes

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Evidence On: Induction For Gestational Diabetes

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Evidence On: Induction For Gestational Diabetes

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Gestational Diabetes (Induction) - Signature Article

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Cervical effacement refers to the shortening and thinning of the cervix. It is part of the process that helps the cervix prepare for a vaginal delivery.

The cervix connects the lower portion of the uterus to the vagina. Normally, the cervix is around 2.5 centimeters (cm) and is firm and closed.

In preparation for childbirth, the cervix must thin and open up to allow the fetus to pass from the uterus through the vagina.

In this article, we look at cervical effacement, including how it relates to dilation and how to measure it.

Cervical effacement is the shortening and thinning of the cervix. This helps the cervix prepare for a vaginal delivery.

During the later stages of pregnancy, the fetus's head drops into the pelvis, pushing it against the cervix. This process stretches the cervix, causing it to thin and shorten.

Measurement of effacement is usually in percentages. For example, when the cervix is 100% effaced, it means that it is completely thinned and shortened.

An alternative is to measure the length in cm. As the cervix effaces, it becomes shorter.

As well as needing to thin and shorten, the cervix also needs to open up, or dilate, to prepare for vaginal delivery.

When the cervix opens up by 10 cm, doctors consider it considered "fully dilated."

Full dilation and 100% effacement both need to occur for the fetus to be able to pass through the birth canal. The process of dilation and effacement is called cervical ripening.

Image credit: logika600's / Shutterstock.com.
Certain signs and symptoms may indicate that cervical effacement has begun. These symptoms may include:

Passing of the mucus plug

During pregnancy, the mucus plug seals the opening of the cervix. This prevents bacteria from entering the uterus.

Cervical changes, including dilation and effacement, cause movement or loss of the mucus plug. However, not all pregnant women will notice this.

Bloody show

As effacement nears, tiny blood vessels near the cervix may rupture. This can cause a small amount of spotting known as bloody show.

This may occur with loss of the mucus plug or on its own.

Pelvic pain

Cervical effacement often occurs after the head of the fetus drops lower into the pelvis. This may cause pain, as the head puts pressure on the woman's pelvic ligaments.

The pain may vary. For example, it may cause a dull ache or intermittent sharp pain. However, some women may not feel any discomfort at all.

Contractions

Contractions involve the tightening and relaxing of the uterus to help cervical dilation and effacement.

Contractions can vary in severity and frequency. Usually, the more regular, frequent, and strong they are, the closer the woman is to delivery.

Braxton-Hicks contractions may occur during the second or third trimester of pregnancy. These are known as false labor, as they do not lead to delivery.

Braxton-Hicks contractions are less regular than true labor contractions and are often milder. According to March of Dimes, Braxton-Hicks contractions may play a role in cervical effacement.

A healthcare professional often performs a pelvic exam to measure cervical effacement. Wearing a surgical glove, they will insert two fingers into the vagina and feel for dilation, effacement, and the position of the cervix.

Pregnant women can check their own cervix, but if they are not familiar with how it felt before pregnancy, it may be difficult to recognize the changes. A self-check of the cervix is not a substitute for a cervical exam by a healthcare professional, however.

In some cases, a doctor may recommend a transvaginal ultrasound to measure cervical thickness and length, as this method is likely more accurate.

The amount of time it takes for complete cervical effacement during labor varies greatly. Some women may reach 100% effacement within a few hours. For others, cervical effacement may occur slowly over several weeks.

The same applies to dilation. It is not uncommon for a woman to be 1-2 cm dilated a couple of weeks before going into labor.

Although they may occur at different speeds, cervical effacement and dilation can go hand in hand. A study in the American Journal of Obstetrics & Gynecology involved 7,407 pregnant women.

Healthcare providers may monitor the length and thickness of the cervix to determine pregnancy duration.

The researchers analyzed how fast effacement occurred in relation to dilation. The results indicated that by 8 cm dilated, 95% of the women had complete cervical effacement.

Cervical effacement can start a few weeks before labor. Once a woman's cervix is fully effaced, delivery is likely to be close.

The length and thickness of the cervix at different stages of pregnancy can also provide useful insight for healthcare providers.

For example, the length of the cervix at mid-pregnancy may give a clue as to pregnancy duration. A pregnancy longer than 41 weeks can raise the risk of complications for both the woman and the fetus.

Assessing which women have a high risk of a prolonged pregnancy allows healthcare providers to determine the necessity of labor induction.

Cervical effacement refers to the stretching, thinning, and shortening of the cervix in preparation for vaginal childbirth.

Along with effacement, cervical dilation must also occur to allow vaginal delivery. Typically, healthcare providers measure effacement in percentages or by the length of the cervix that remains.

Symptoms such as the loss of the mucus plug and pelvic pain may indicate that cervical effacement has begun. The rate of complete effacement varies from woman to woman.

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What to know about cervical effacement: Measurements and diagram

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Cervical effacement occurs as the cervix prepares for vaginal delivery by thinning and shortening. Learn more about cervical effacement here.

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Fetal Station Assessment and Engagement Nursing NCLEX Maternity Review

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Fetal station is important to monitor. It helps doctors evaluate how labor is progressing.

Other measurements your doctor may take into account include cervical dilation, or how much your cervix has enlarged for your baby to pass through, and cervical effacement, or how thin your cervix has become to promote delivery.

Over time, if a baby isn't progressing through the cervix, a doctor may need to consider delivery by cesarean delivery or with the help of instruments like forceps or vacuum.

Pros

Cervical examination to determine fetal station can be a fast and painless. This method is used to determine how a baby is progressing through the birth canal. This measurement is usually one of many that a doctor may use to determine labor progression.

An alternative to cervical exam for fetal station is using an ultrasound machine, which uses sound waves to determine the baby's position.

According to a study published in the journal Ultrasound in Obstetrics and Gynecology, ultrasound is usually as effective as personal examination to determine fetal position.

Doctors might choose to use this imaging tool as an alternative or way to confirm what they identify as the fetal station.

Cons

One of the possible drawbacks to using fetal station is that it's a subjective measurement. Each doctor bases their determination of fetal station on where they think the ischial spines are.

Two doctors could both conduct a cervical exam to try to determine fetal station and come up with two different numbers.

Also, the appearance of the pelvis can vary from woman to woman. Some women may have a shorter pelvis, which could change the way a doctor would typically measure fetal station.

Another reason your doctor may want to use caution with using fetal station is that too many vaginal exams done while a woman is in labor may increase the chance of infection.

It's also possible that a baby could be in a position known as the "face" presentation. This means the baby's face, instead of the back of their head, is pointing toward the front of the mother's pelvis.

The shape of the baby's head at this position may cause a doctor to think the baby is further down the birth canal than they really are.

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Here's what you need to know about fetal station and why doctors monitor it during labor.