In this episode of The Pulling Curls Podcast, Hilary welcomes certified nurse midwife Juli Pyle to dive into the topic of informed consent in labor and delivery. Together, they break down what informed consent really means, the key components every patient should know, and how it plays out during childbirth. Juli and Hilary share personal stories from both sides—provider and patient—highlighting why these conversations matter and how they can empower you to make the best choices for your birth experience. Whether you’re planning your first delivery or looking to better understand your options, this episode provides practical tips for having more effective, respectful discussions with your care team.
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Big thanks to our sponsor The Online Prenatal Class for Couples — if you want to learn to communicate better, it is the class for you!
Today’s guest is Today’s guest is Juli Pyle (she/her) a certified nurse midwife who practices at a community hospital in rural Pennsylvania. Juli was a stay at mom for many years to five children before deciding to return to school to pursue a degree in nursing. She graduated from Colorado Mesa University with a bachelors of science in nursing degree in 2016 and then began her nursing career as a labor and delivery nurse. She quickly discovered that this was her true passion (as she had suspected since having her own children) and quickly gained a reputation for professionalism, compassion and expertise among colleagues and patients. She then returned to Frontier Nursing University to complete a Master’s degree in Nursing with an emphasis in midwifery. In 2020, she graduated and began as a certified nurse-midwife at a small community hospital in central Pennsylvania where she has been since that time. Her focus as a CNM is to provide evidence-based education to all birthing families, give true autonomy and informed consent throughout their time with her and to share love, understanding, empathy and true shared-decision making. When not immersed in the birthing world, she enjoys spending time refinishing furniture, gardening, raising and breeding different types of chickens, hiking and vacationing with her family.
Links for you:
Julie’s previous Episodes:
The Best Providers for Your Baby’s Arrival: A Deep Dive with CNM Juli Pyle — Episode 204
What Your Providers Think When You’re in Labor with CNM Juli Pyle – Episode 189
Timestamps:
00:00 “Informed Consent Importance in Medicine”
04:20 Balancing Patient Communication and Time
09:24 Respectful Informed Consent Dynamic
10:29 Patient Choice in Labor Induction
14:06 Informed Consent for Episiotomy Decisions
18:17 Informed Consent for Induction
22:31 Labor Induction and Position Choices
25:56 Documenting Risk in Patient Decisions
29:16 Holistic Prenatal Care Approach
32:33 Nurses’ Role in Informed Consent
35:45 Patient Communication with Providers
37:21 Importance of Informed Consent
Keypoints:
- Informed consent in labor and delivery is a crucial and often misunderstood part of medical care, emphasizing the patient’s right to understand and make decisions about what happens to their body.
- There are five main components of informed consent: patient understanding, absence of coercion, full disclosure of risks/benefits/alternatives, the right to decline, and documentation of the discussion.
- Time pressure, provider biases, and regional/cultural differences often affect how effectively informed consent is communicated in hospitals.
- Patients are encouraged to ask, at any point, for the risks, benefits, and alternatives to a procedure—it’s their right, even for routine interventions.
- Some medical staff may overwhelm patients with information, while others may inadvertently minimize discussion; finding the right balance to suit each patient is key.
- Regional culture, age, language, and personal preference play huge roles in how much information patients want or are comfortable with during labor and delivery.
- Informed consent isn’t just for major decisions like C-sections or epidurals—it can and should apply to things like cervical exams and labor positions, even in less formal, conversational ways.
- Declining a recommended intervention (e.g., breaking water, episiotomy, induction) is absolutely an option for patients, and the birth experience should support their decision, barring emergency situations.
- The benefits of midwifery care are highlighted, including a more holistic and consistent approach to informed consent and labor support, but ultimately provider style matters more than title.
- Good communication and shared decision-making between providers and patients help prevent birth trauma and litigation, reinforcing the importance of patients feeling informed and respected during their birth experience.
Producer: Drew Erickson
Transcript
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[00:00:00] Hilary Erickson | The Pregnancy Nurse®: Hey guys. Welcome back to the Pulling Curls Podcast. Today we are talking about informed consent in labor and delivery, so let’s untangle it.
[00:00:06] Hi, I’m Hilary, a Serial overcomplicator. I’m also a nurse mom to three and the curly head behind pulling curls and the pregnancy nurse. This podcast aims to help us stop overcomplicating things and remember how much easier it is to keep things simple. Let’s smooth out those snarls with pregnancy and parenting untangled the Pulling Curls Podcast.
[00:00:36] Today’s guest is a certified nurse midwife in Pennsylvania. She actually had five kids of her own, then went back to school, became a labor and delivery nurse, and then became a midwife. I wanna introduce today’s guest, Juli Pyle.
[00:00:48] Hey Juli, welcome back to the Pulling Curls Podcast. I’m so excited to have you here.
[00:00:52] Juli Pyle CNM: Hi Hilary. It’s good to be back today.
[00:00:54] Hilary Erickson | The Pregnancy Nurse®: Yeah, so we’re on this longer form content, and when I was thinking about who I wanted to have a guest, Juli definitely came to mind because I think you have a lot of great information as someone who’s had multiple babies, someone who’s been a labor nurse, somebody who’s a midwife of things that people are actually thinking about as they deliver their baby.
[00:01:12] And of course it’s, it’s sort of different like locationally. ’cause I’ve delivered in the west, you’re in the east. So I’m just excited that you’re here, and today we’re gonna talk about informed consent. So let’s first define. What is informed consent?
[00:01:24] Juli Pyle CNM: Yeah, I think informed consent is really a hot topic right now in the medical world, and especially in labor and birth, because really once we define it, you’ll understand why, but it’s super important for us to have a grasp of what is going on with our bodies in any sort of medical scenario.
[00:01:41] So informed consent really has five components. The first one, which seems pretty obvious, but does the patient or do you understand the information? That doesn’t seem like something we’d have to define, but sometimes as medical providers we get talking and talking and we don’t have the right words so that the person understands what we’re talking about. So patient has to understand the information.
[00:02:04] The second part of that is it needs to be without any sort of coercion or undue influence. So you have to be really objective in the information you’re giving and not try and sway somebody because of what you think should happen as the provider.
[00:02:18] Really, all the information should be disclosed about the risks, the benefits, the alternatives. The right to decline whatever treatment we’re talking about and knowing what the potential complications are either way. That’s not always a simple conversation, but a really important one when we’re talking about informed consent and the right to refusal is really the fourth point.
[00:02:39] And then the last piece of all that is documentation that it’s happened some way, shape, or form. Sometimes that’s an already like pre-printed form that people just fill out and sign. Sometimes it can just be documented in the medical notes. Somehow there needs to be something written that informed consent was discussed and what the outcome was.
[00:02:58] Hilary Erickson | The Pregnancy Nurse®: That’s actually one of the first things I learned as a nurse. Back when we had paper charting, we had a little stamp about informed consent, and then the provider would sign it before a C-section, and I think they did it before an epidural. Now people. It is tricky because they’re like, well, we wanna informed consent on everything and let, let me just remind you, like if we did an informed consent in our lives, like I don’t know if our car would ever get going.
[00:03:20] Right. If it gave us like all the things that could happen to us in the car. So we as providers tend to like keep informed consent to the important things. But you’re always welcome to ask for informed consent, right?
[00:03:32] Juli Pyle CNM: Absolutely. If I think that’s a big piece of, as the patient or as the person receiving care.
[00:03:37] You know, anytime you feel unsure about what’s happening, just a simple question of can you explain the risks, the benefits, and the alternatives to doing this to me, because then that should give the provider the clue that like, okay, this person needs to understand more.
[00:03:52] Hilary Erickson | The Pregnancy Nurse®: Yeah. Why? Why do you think we’re not good at giving it in the hospital?
[00:03:55] ’cause I’ll say, Juli, my mom was just in the hospital having ankle surgery, not having a baby, thank goodness. And it’s surprising, like it’s just they people aren’t great at it. I think they think this is obvious, right? For her, it’s been a long plan of care. Several, several things. And so they’re just like, this is obviously the best option for you.
[00:04:15] But it, it is annoying that they aren’t like, this is why.
[00:04:19] Juli Pyle CNM: Yeah, I think we are in a hurry. Always. Our lives are busy, right? And so to think about taking. Five to 10 minutes with every single patient to explain Every single procedure can feel overwhelming from the provider side, but that, that doesn’t mean it’s not important to do so.
[00:04:33] But I think that, I think busyness and time is a huge part of it. I think there’s a, there’s a component that if we explain too well that people may not choose to do the treatment or may not choose to have the surgery if we’re really honest about what could happen. And of course as a provider, we sort of obviously count on people doing these, these things as part of our jobs.
[00:04:53] Not counting on it like they have to do it so that we make money, but just, just like, obviously if our schedule doesn’t have procedures on it, then we wouldn’t have a job. Right. And I do think it comes down to. We don’t do a good job of like really explaining things in a way that doesn’t include our values and preferences, you know?
[00:05:13] Like, oh, I would do that, so you should do it. And we just leave it at that. But that’s my perspective on, on what’s going on.
[00:05:19] Hilary Erickson | The Pregnancy Nurse®: Yeah. Two thoughts. Oh, so we used to have an anesthesiologist who, they come and they give informed consent. Nobody seems to remember, which, I can’t blame you because you’re in pain when you get the epidural informed consent.
[00:05:29] But they always come in the room and they say, there’s a risk of a really bad headache. There’s always a risk of infection, or blah, blah, blah. And then he always ended it, or you could die. I would see the patient’s eyes get really, really big, and so I started to like cut, like before he came in, I said, just so you know, his informed consent will end or you could die.
[00:05:48] I’ve never seen anybody die from an epidural, but he’s just giving you like all the things. Not every anesthesiologist… do you ever hear that?
[00:05:56] Juli Pyle CNM: We, we have a couple that go so in depth with their informed consent, which again, should not be considered a bad thing that even the patients are like, yes, whatever.
[00:06:03] I’m just, I’m ready. Like give me the epidural. Like, I don’t care what you’re telling me right now. So I think there’s both ways, like. You can do too much and people stop listening, you know?
[00:06:12] Hilary Erickson | The Pregnancy Nurse®: Yeah. And you have to remember that if your oven or your car gave you informed consent, the full informed consent it would end with, or you could die.
[00:06:19] Because obviously ovens could be very unsafe, especially in the hands of me or my car with my teaching. My 15-year-old how to drive it should yell that at me, right when we get in the car. So sometimes patients are overwhelmed and some patients do not want it at all. They do not want to hear all the risks and the benefits.
[00:06:36] They don’t wanna make a choice. They literally just wanna hear whatever the provider thinks is best. That’s what they wanna do, and I think that’s valid and I think you could even stop them and be like. Whatever you think is best I’m on board with, if it’s really starting to freak you out. Because a lot of patients will be like, maybe I don’t want an epidural.
[00:06:52] And I’d be like, are you sure? Like the risk was always there. You knew that there was a risk of dying with anything we are doing today. And then they’re like, I guess, and then they’re just freaked out, right?
[00:07:01] Juli Pyle CNM: Yeah. You know, it’s funny you mentioned that I did a small little couple of months in the South as a nurse and there was very much a mentality regionally like.
[00:07:11] If the provider comes in and says, this is what should happen, I’m gonna do it. Like they didn’t ask questions, they really didn’t care about informed consent. The provider knew best and I’m gonna follow it, which has risks in and of itself. Right. So it was very interesting that just regionally, that can vary quite a bit of how much information people even want to know.
[00:07:30] Hilary Erickson | The Pregnancy Nurse®: Yeah, and overgeneralizing a whole bunch. It definitely varies depending on your age. Sometimes your nationality, I feel real bad when we’re trying to give informed consent and we’re giving it through the translator line, and I’m never sure that the people are really, truly understanding what the informed consent is.
[00:07:46] You know, they’re trained interpreters like, it’s like that’s all we can do, but sometimes those language barriers just not interested in maybe learning about their own care because they have so much going on in their own life at home. Things like that can really affect it.
[00:07:58] Juli Pyle CNM: Interestingly, when you look at acog, which is the governing body for obstetricians and also A CNM, which is the governing body for certified nurse midwives, they have very clear statements and very clear information on what informed consent is and that it should be happening in every instance humanly possible. That we should be providing that education. And that it’s really being much more recognized and taught in the coursework for these up and coming physicians and midwives as well. And, and that should tell us that it’s an important topic.
[00:08:29] Hilary Erickson | The Pregnancy Nurse®: And some people call it different things. I noticed, like when I was at the AWHONN convention, they have a different word that they use. And I cannot remember what it is, but it’s basically the same thing.
[00:08:38] Juli Pyle CNM: I know we talk about shared decision making. I don’t know if that’s what you’re talking Yes. Shared about shared decision making. Yeah. Um, and really that’s the process of the informed consent and making the future plan. Is that shared decision making.
[00:08:49] I do feel like they are used synonymously sometimes, but both are components for sure.
[00:08:55] Hilary Erickson | The Pregnancy Nurse®: Okay, so what should people be looking for informed consent on? Because I know a lot of people are like, well, you should give informed consent before you get the iv. You should be giving informed consent before you take a blood pressure.
[00:09:05] And I was like, okay. I don’t know that I can do it for a blood pressure. Also, if I was giving it for every single little thing, sometimes they might skip the like really important things. Right. I think we should be giving it briefly for maybe an exam, like an ex, a cervical check, just to be like, you know. ‘Cause a lot of times the alternative is that we wait.
[00:09:23] Juli Pyle CNM: There’s this weird. I think dynamic because like some of that. I think for us that do it well, it’s, it’s respect. Like I am respecting this person I’m taking care of and I’m gonna let them know I’m gonna put the blood pressure cuff on. You know, just telling them that like is a type of informed consent.
[00:09:40] Right? Because they may not know that that was your next step, you know? So you don’t wanna freak somebody out or like with a cervical exam, you know, giving a little bit of warning and a little bit of. Notice about what’s going on. I think that’s just respect. But it also can fall into the category of type of informed consent.
[00:09:54] Hilary Erickson | The Pregnancy Nurse®: Yeah, and you know, like she said, it’s not always gonna be like, today I am gonna assess the risks, the benefits, and the alternatives of this circle exam. It could just be like, Hey, you know, your provider was wanting us to check you every couple hours. What do you think about doing it now? If you wanna wait, we could do that too.
[00:10:11] We just kind of wanna see what your cervix is doing. We’re inducing you. We, we wanna make sure we’re doing our job. You know, that is an informed consent. It just didn’t be like, I’m gonna go through the risks and the benefits. Yeah. Because it’s awkward. Like we wanna just have a conversation with people.
[00:10:25] We don’t wanna be like checking boxes all the time through our care.
[00:10:29] Juli Pyle CNM: Yeah. And I think, like, I had a good example. In the last couple weeks of an induction that I was managing. And we know as labor nurses and providers, like if we get to the point that breaking the water is a good option, like it’s gonna make labor faster for somebody, especially that’s had a baby, right?
[00:10:44] But I gave that informed consent and that patient did not want water broke. And I said, great, you let me know when you’re ready for that. I’ll ask again at some point, you know? And instead of a baby, probably in one to two hours from that point, it was like seven hours from that point. Is there anything wrong with that? Probably not, you know, and she can fully say that she was in charge of that decision and, and was able to make the plan for herself that way. Looking back, I think she would’ve probably liked me to break the water earlier, you know? And we would’ve known that she could have had a baby sooner, you know?
[00:11:15] And that’s a good example of like, she chose to decline. And it, that was okay.
[00:11:19] Hilary Erickson | The Pregnancy Nurse®: Yeah. I did that same thing with my last baby. I didn’t wanna have my water broken ’cause I was sure I would end up with a c-section if they broke my water and then they broke my water finally at like six centimeters and I had the baby like half hour later, you know?
[00:11:30] Yeah. But I had made the choice, I had driven the car and I had drove the car very, very slowly up until that point. Uh, yeah.
[00:11:37] Juli Pyle CNM: And on the flip side, if you had been forced into a decision, you know, of like, or this patient, if she had said. I don’t want that. And I said, uh, we’re gonna do it anyway. You know then that her whole experience is different and then it becomes birth trauma or it becomes like.
[00:11:53] You know, a potential lawsuit potentially, right? Like, those are things that can happen if, if that doesn’t go correctly.
[00:11:59] Hilary Erickson | The Pregnancy Nurse®: Or my favorite, the doctor doesn’t even say anything, he just goes hand me the Amni hook. And I go, oh, did you wanna have your water broken Jane? And he glares at me and I’m like, don’t you think we should ask her?
[00:12:11] Juli Pyle CNM: Yep. Absolutely. And that, that still happens. Yeah, I think, I think it’s happening less, but it still happens.
[00:12:17] Hilary Erickson | The Pregnancy Nurse®: And I… Pro tip for everybody out there who’s gonna have a baby. When they go to do a cervical exam or a doctor or a midwife, because labor nurses officially are not allowed to break water. You can always ask, are you thinking about breaking my water while you’re in there?
[00:12:29] Especially for the hospital. They’re not gonna do it in their office, hopefully. But yeah, I think sneak it in. We don’t like to sneak things.
[00:12:35] Juli Pyle CNM: I think that for labor and birth specifically, a really classic example, and one again I hope is happening less, but it still occurs, is the episiotomy. Right. That becomes like a big topic of debate and like if a doctor or provider or midwife says, oh, we’re just gonna make a little extra room to help baby get out faster.
[00:12:56] That’s not informed consent, right? That’s not explaining what’s happening. That’s not giving the patient a true option to decline or accept, but that still happens, you know, versus like, Hey, this is what I’m seeing. I can do this procedure. These are the risks, these are the benefits. Would you like this?
[00:13:12] You know, to to be part of your care. That’s a really classic one that we’re gonna continue to see. But I think as labor nurses, you really have seen that a lot more. And it makes you nervous when that’s happening.
[00:13:22] Hilary Erickson | The Pregnancy Nurse®: So that is tricky because there are points in time where they’re like, I need to give you a cut when the crap is really hitting the fan or whatever.
[00:13:29] And hopefully providers have talked to you while you’re in the office about it. I don’t do, do people do this anymore. When I had my first baby, they went over like probably 30 weeks. They went over, are you okay with blood products? We might need to do an app episiotomy. We might need to do an emergency C-section and we might need to take your uterus.
[00:13:45] Like they went through all three of all like four of those things. Just to kind of let you air your thoughts on all those different kinds of things. Right. Do do any providers do that anymore?
[00:13:54] Juli Pyle CNM: I think it’s really like provider and facility dependent. ‘Cause I have seen that still happening and then other places that like literally nothing’s talked about ever.
[00:14:03] So varies quite a bit, unfortunately.
[00:14:06] Hilary Erickson | The Pregnancy Nurse®: Yeah. And if you’re having that discussion with your provider, I think it’s akay to say, you know what, if me or my baby’s life is obviously in jeopardy, we’re akay with a, an episiotomy. But everything up until that point, I would really like you to stop and say, do you want me to do this?
[00:14:20] And that? I’m just here to say that that does happen. Sometimes they’re like, you know, you could keep pushing for another half an hour, or I could give you a little cut and we, and we could have this baby sooner. And I think that’s valid. I mean, I think that’s true in form consent. ’cause maybe the woman really values just getting that baby out.
[00:14:36] She’s so tired and miserable and if that provider, experienced provider knows that a cut will help get the baby there sooner, she’s like, do it. I’m over this. Right. Or Yeah. She’s like, no, I really love my perineum. I wanna try and keep it as intact as possible. I wanna push until my eyeballs fall out before you cut me.
[00:14:53] Juli Pyle CNM: Right. Everybody, there’s two different people. Truly, I think that’s the part of informed consent we don’t often talk about is that somebody may want the more invasive thing, you know, and they may really feel like that’s better for them. And sometimes we don’t even talk about it, you know? So then we really haven’t given them all of the information.
[00:15:11] To make a decision. We’ve talked about this previously on induction podcast that we did. Right? That like, yeah, somebody may have a lot of really valid options for desiring that higher intervention induction at 39 weeks as soon as humanly possible, even though that might not be what the majority of the people would choose.
[00:15:28] Hilary Erickson | The Pregnancy Nurse®: Yeah. And I actually have a super conservative friend who home births, and she was like, I don’t even understand why they give women the option. And I was really taken aback by that because that just makes me feel like, okay, it has been proven to be safe, at least. For the most part, it may increase C-section rates, whatever we wanna talk about.
[00:15:44] The arrive trial, it has been proven that it really doesn’t ultimately hurt mom or baby to have an elective induction at 39 weeks. And we as sentient people who get to make choices for our own bodies really should be able to make that choice, not just the provider doesn’t make that choice. Now, of course, if the hospital’s too busy or things like that, then then we don’t get to make that choice.
[00:16:05] I have people all the time that are like, no, they will not induce selectively before 41 weeks, which I’m like, whoa. It’s crazy how different some hospitals are, but what do you think on that? About like 41 weeks? Well, no. Oh. What do you think about, uh, the 39 week induction? Like, don’t you think we should all be?
[00:16:22] Sometimes I’m like, well, if somebody really wants to be induced at 37 weeks, it is kind of weird that we don’t even give them the option. Of course, we’re having to balance the pro, the thing of. Prior to 39 weeks, it has been proven that maybe your baby could have a NICU state or have ultimately bigger problems.
[00:16:37] And so we’re really trying to push that off. But it does sort of bother me that if people are begging for an induction at 37 weeks, we’re just like, nope, nope, nope, nope.
[00:16:45] Juli Pyle CNM: Yeah, I think that 39 week discussion again gets really heated. And if you have 10 different providers, labor nurses are gonna get all 10 different perspectives.
[00:16:54] And again, this is part of my informed consent when somebody’s asking about it, it’s like. There are things that start to increase your risk by not having a baby after 39 weeks. You know? So we know that definitely after 41 weeks, right, placental function declines, other things start happening that will not help a baby on the outside.
[00:17:12] But even after 39 weeks, that risk of stillbirth, the risk of preeclampsia, the risk of fluid around baby going down, like all of those start to get more risky, not significantly. So we’re not talking about 50% between 39 and 39 and two days, you know, but it is start to go up. And so some people even use the term risk reduction as far as like what happens after a 39 week induction.
[00:17:37] You know that, that you’re reducing the risk of somebody by inducing. So there’s certainly a lot of discussion that happens, but we just have to respect that somebody can understand that information and then make the decision of yes or no for themselves.
[00:17:50] Hilary Erickson | The Pregnancy Nurse®: Yeah, it’s tricky and everybody’s like, oh, I’m gonna make that decision when I’m like 30 weeks pregnant.
[00:17:55] I’m like, no, you make that decision based on, you know what? What’s your cervical exam at that point? If you’re six centimeters and contracting every evening. You know, that’s a big difference between I’m close, thick and high, I’ve never had a baby before. These are very different situations that we’re looking at.
[00:18:11] Juli Pyle CNM: Absolutely. Yeah. And And that’s what makes it so tricky. ’cause there’s so many variables.
[00:18:16] Hilary Erickson | The Pregnancy Nurse®: Yeah. So what do you think, I think this is a big one that people maybe don’t get enough of an informed consent on because they’re just thinking. I want this baby out, right? Because I’m so tired of being pregnant. So what do you think are things that people should be talking with a provider so that they feel like they get a full informed consent?
[00:18:34] Because I so often hear online, my provider forced me to have an induction and I didn’t wanna have it. Or he scared me and said I should have an induction and then I ended up having a C-section or whatever like that. What do you think people should be going through before. For an induction so that they really feel like they have a handle on what’s gonna be happening to them.
[00:18:52] Juli Pyle CNM: I think you have to specifically ask what the induction protocols and like what the plan usually is at the facility and the provider you’re using, because the way I manage an induction may be completely different from somebody else, and that can make your whole experience very different. You know, evidence has proven that nurse midwives as.
[00:19:11] Providers, you’re gonna have more successful labor progress in general, and that includes induction. Part of that is because we’re, we are not, and this is a very general statement, but generally speaking, you know, we’re not as tied to really specific timeframes and milestones throughout. We’re gonna individualize that to exactly what your body’s doing, you know, so for example, you know…
[00:19:34] Hilary Erickson | The Pregnancy Nurse®: And a shout out for midwives because they’re there.
[00:19:37] So that’s how they can tailor it, right? Yes. Whereas an OB calls in maybe every four to six hours. They’re not there. They aren’t kind of watching everything every step of the way. Shout out for midwives,
[00:19:46] Juli Pyle CNM: guys.
[00:19:47] Yeah. Historically and generally speaking, we’re gonna be a little bit more present in the care and be able to kind of doing informed consent all along the way instead of like just this one discussion, you know, at 39 weeks right before your induction.
[00:20:00] And again, I think that’s a big conversation for people who desire that is like, okay, what happens if my cervix is staying the same for four hours? What are you gonna do? You know? And then getting that answer. And if you’re not happy with that, then you have to start, start making decisions along the way.
[00:20:16] Hilary Erickson | The Pregnancy Nurse®: Yeah, it is true. A lot of people are really upset with their Foley bulb inductions lately because it can be really painful. Some people that that. That’s the tricky thing, right? Some people get a fully bowl placed and they, they could care less. It doesn’t bother them at all. And then some people get a fully bowl placed and it is literally the worst thing in their whole lives.
[00:20:33] They want the epidural just for that fully bulb. And I think sometimes people forget that this is, it’s such a huge range. Just like IUD placements, like I got my IUD placed. I was like, when are you gonna be done? Right? And she was like, oh, it’s already in. I was like, oh. I don’t have any feelings down there apparently.
[00:20:49] And so there is a huge range of how people feel different things. And the best part of informed consent is knowing that you can, you know, you get that fully well placed and it’s absolutely miserable. You’re like, I wanna go home. This is, I want it out. I wanna go home. And that, that’s always an option.
[00:21:03] Juli Pyle CNM: Yep.
[00:21:04] I think that’s important. Like especially for fully bulbs, I tell people, I’m like, what? I think this is a good option if you absolutely hate it. It can come out. That’s the great thing about that process. You know, now water breaking, like we talked about earlier, can’t take that back. Right? So that’s one that you have to be pretty sure about.
[00:21:20] I’m all about giving people all of their options and allowing them to make a decision. And there are times when they will tell me, I have no idea, what do you think we should do next? And then that’s when my professional experience and opinion becomes, you know, probably likely to what’s gonna happen because they’re asking me that for that.
[00:21:37] Right. And that’s part of their informed consent is that they’re like, I don’t know. This is a lot of information. What do you think?
[00:21:43] Hilary Erickson | The Pregnancy Nurse®: Yeah, because it can feel like a deluge of information in labor and delivery, and it’s okay to be like, I’m not sure what I should do. What do you think? Or if this was your choice or your daughter or whatever like that, what would you be encouraging them to do at this point or something?
[00:21:58] I think that really helps is, you know, I really value. Aiming for a vaginal delivery, right? Like that is one of my highest priorities in this delivery. This fully bulb is hurting like a son of a gun. What do you think my best option is to try and not die with a fully bulb, but also get a vaginal delivery and then see what your provider has to say,
[00:22:17] Juli Pyle CNM: right?
[00:22:17] Absolutely. Yep. You should always be open for things to change throughout the process, especially when we’re talking about babies being born.
[00:22:26] Hilary Erickson | The Pregnancy Nurse®: Yeah. What other things do you think people should be looking for in informed consent on?
[00:22:30] Juli Pyle CNM: Well, induction, like we said, that’s a huge one throughout the labor process.
[00:22:34] Breaking water, that’s a big one. As well as, uh, a big topic right now is delayed versus immediate pushing. So, and then also positions in labor I think is always gonna be a big thing because there’s a lot of facilities and a lot of people that. That don’t want laboring people to move around because it makes our jobs harder.
[00:22:53] And so positions, I think throughout labor, I don’t know that that’s truly like informed consent, but like if, if you have a provider that says you have to stay in bed, the patient, you can ask like, why do I have to be in bed? What are my other options? What are my other alternatives? And, and why are we doing it this way?
[00:23:07] Hilary Erickson | The Pregnancy Nurse®: Yeah, I think that’s a great one. And also sometimes as a nurse, I would go in and be like, okay, let’s, let’s roll you to the other side, or whatever, when they had an epidural and they’re like, oh, I’m just so comfortable right here. And so sometimes I would go into informed consent, not again. We’re not gonna be like, well, these are the risks of you staying on your left side.
[00:23:23] Right? Just saying, Hey, I have noticed that patients who move more during labor tend to progress a little bit better, and I would love to help you move, but if you wanna stay on your left hand side, then you can totally do that. What do you wanna do? Right. And that is an informed consent where I’m just saying, I think you might be better off turning, but if you wanna stay where you are, go for it.
[00:23:42] Juli Pyle CNM: Yeah. I think one that I hear a lot is people say, oh, I don’t wanna give birth on my back. Right? I don’t wanna have the baby come out in my back, but I often find that laboring people prefer that position. So I’m open to like any position, like if you feel like you can do a handstand and you wanna try pushing like that, I’ll try for you.
[00:24:00] You know, like, let’s go for it. But a lot of times people are trying to figure out what to do and I said, let’s try that position. A lot of people prefer it, and then they’re like, oh. I don’t wanna change outta this position, like I like this position and it’s the one that they thought that they absolutely didn’t want.
[00:24:15] Hilary Erickson | The Pregnancy Nurse®: Yeah, there are a lot of benefits to being on your back, most of them being that between contractions, you can chill out a little bit. And the other thing with informed consent is it’s okay if your provider says, you know, I feel. I think this is the best way I deliver. If your tile man came and you were like, well, I want you to tile the ceiling, wouldn’t you want ’em to say, I am not great at tiling the ceiling.
[00:24:37] You know, that’s not my skillset. And the same thing goes for your provider. They can say, you know, I’ve delivered 99% of my patients on their back. That’s delivery. That doesn’t mean you have to push the whole time on your back, and I’m best at that, but if you wanna try doing it squatting, we. I’m happy to try that.
[00:24:53] I just want you to know my A game comes when you’re on your back and I think people get mad that they’re like, well, why don’t you have a B game for squatting? But the reality is, I think it’s great when a provider says, this is what I’m best at. What do you want me to do?
[00:25:06] Juli Pyle CNM: Yeah. And I think that’s where you should be evaluating that relationship between provider and yourself before labor.
[00:25:14] Asking questions along the way so that you’re not blindsided by something, but also so that it’s a good fit and hopefully a good experience.
[00:25:20] Hilary Erickson | The Pregnancy Nurse®: I think it can be really tricky. And the other thing that I don’t think people understand is that in the hospital we can give you informed consent and you can still end up suing us it.
[00:25:29] So that ends up feeling really tricky for us because, you know, if we have a patient that we’ve seen is in trouble and they definitely don’t want a C-section, we are hands off and we’re like, okay. Baby ends up having a bad outcome and we’re like, well, we just informed consent the heck out of that lady.
[00:25:44] You know, nurse, doctor, second doctor have all come in and said, we see a bad outcome and yet they still come back and sue us. And so that is really tricky for us as providers. Do you have any thoughts on that?
[00:25:54] Juli Pyle CNM: Yeah, that gets really in the weeds of documentation and being able to show that there was real good conversations and if that can happen and the outcome was still not as expected or not great.
[00:26:07] That unfortunately gives us a little bit more clout on our side to say like, and I will make documentation, like if somebody’s declining something and their risk of stillbirth is really high, you know, for various reasons I will put in my note like discussion held about whatever it was, and that her risk of stillbirth is higher.
[00:26:25] If we do not do this thing, you know, because none of us can know if that would happen, that would be the worst outcome, obviously. But it has to be really clear, you know, on the provider side. And hopefully if we’re documenting that it was really clear. We really give the information clearly to the patients so that they’re getting the information that they really need.
[00:26:43] But that’s so hard because we can’t predict the future, especially in labor and delivery. It gets very, very gray in many situations.
[00:26:50] Hilary Erickson | The Pregnancy Nurse®: I just like people to understand that sometimes when we’re like going over things, maybe excessively, that’s part of the reason why is we’re all real worried about liability and I wish we didn’t have to be so worried about it.
[00:27:02] Obviously, I wish we could just give informed consent and that would be enough, and you get to make the choice that you want. But liability is a tricky part in labor and delivery especially.
[00:27:10] Juli Pyle CNM: And the other part that I’ll mention is that, you know, I’m talking about litigation because. We work in ob so we’re, we’re gonna have to have to talk about litigation ’cause it’s a high litigation area.
[00:27:20] But again, the research has beared out that one midwives are less likely to have litigation on them. And two, that a good relationship with the patient. So somebody who feels like they can trust you. You’ve given them information that you’ve respected them as a person are much less likely to even think about or pursue litigation even when there’s been really horrible outcomes.
[00:27:43] If the process along the way has been compassionate and respectful, it’s less likely that that’s gonna come to that.
[00:27:49] Hilary Erickson | The Pregnancy Nurse®: So Juli, you are a certified nurse midwife, and we have an episode that I’ll link in the show notes that we talked about, like the different people that can deliver your baby. And it is so confusing for people because some people think of a midwife as just like Joan down the street who delivers babies, like on Little House in the Prairie where Caroline would go sit with them, right?
[00:28:07] Versus somebody who, do you have a doctorate? Juli? We have to have a doctorate in, um, Arizona.
[00:28:12] Juli Pyle CNM: I don’t, I have a MA master’s degree, but yes, some states require a doctorate, but. It’s the equivalent of a nurse practitioner. Yeah.
[00:28:19] Hilary Erickson | The Pregnancy Nurse®: Yeah. Where you’ve had like a residency plus you were a labor and delivery nurse before you were a midwife.
[00:28:24] Like it’s an extensive training. And the beauty about a midwife that I think a lot of people don’t understand is you always have an OB where you’re kind of like, you know, we’re starting to get in the weeds here a little bit. I’d like a consult with a little higher up. Right. I’d like to move this up. So what’s the best part of having a midwife deliver your baby Juli versus an open?
[00:28:44] Juli Pyle CNM: Yeah. The first part of that, I think is that. The understanding that, yeah, we’re not obstetricians, we don’t have a physician training. We can’t do surgeries. Right? Yeah. But we actually manage, not all of us. It depends on our training and our experience, but most of us manage high risk conditions throughout as well.
[00:29:01] It’s not just like the most low risk person is the only one that can have a midwife as a provider. So you know. I, I will manage people with hypertension, people with regular diabetes or gestational diabetes, like those are things that I can help manage. So we’re not just like the lowest risk people that can have a baby in a teepee, and that’s all.
[00:29:20] So we’re not exclusively keeping people that have high risk conditions out of our care. We can do that. Again, there’s much more of a holistic approach. So we’re looking at the whole person and like, you have five other children, how are we gonna get you to twice a week? Fetal testing appointments, right.
[00:29:36] How is this gonna work for you? Instead of just saying. If you need twice a week visits, figure it out. Like we’re gonna try and work through, you know, the whole scenario as well as looking past those points. You know, like maybe a C-section is recommended again, you have five other children. How’s your recovery gonna be?
[00:29:52] What are you gonna have in place for that? I just think we do a better job of being able to see, especially because we’ve been a nurse before, so our perspective is not as medical, it’s nurse and holistic person perspective. So I think that’s really valuable. And then depending on where you’re practicing, it’s not always this way, but hopefully a midwife can be a little bit more hands-on throughout the labor process and be able to give a little bit more support than the obs who are busy with surgeries, busy with a million other things that we don’t have to do.
[00:30:22] Hilary Erickson | The Pregnancy Nurse®: Yeah. Now, of course, I wanna caveat this, that there are obs who practice very similarly to midwives, I find, and there are midwives who practice very similarly to ob. Yeah. So I’m not saying that you just be like, oh, she’s an ob, or she’s this midwife.
[00:30:36] She’s gonna be amazing. ’cause some midwives I’ve worked with and I’m like, oh my gosh, we’re all gonna die today. Or, I’ve worked with obs and I’m like, oh my gosh. Like they wanna be here from six centimeters on. They clear their schedule and they just make it, and they really wanna be there for the patient.
[00:30:49] They love that part of it. So obviously you wanna find the provider that’s right for you, but I get so many people in my groups that are like, well, I didn’t wanna have a midwife because she, you know, what if something went wrong, I got diabetes or preeclampsia or something. And I’m like, no. Like, that’s not gonna preclude you.
[00:31:05] From using them. You know, maybe you go see an o, an OB for one appointment and then you go back to your midwives rights. I think a lot of people don’t understand that there’s like midwives, there’s obs, and then there’s perinatologists, right? Like there are always these different levels of care that we’re kind of like, you know, we’re kind of in the weeds here.
[00:31:22] Let’s get somebody higher. Is there anybody above perinatologists? I think that’s it. Or maternal fetal medicine is their new name. Similar?
[00:31:28] Juli Pyle CNM: Yeah. Yeah. Yeah. And that’s the thing is like a lot of these things I can just make a phone call and be like, Hey. Maternal fetal medicine, what’s our plan? But I can still implement that plan and be the primary person throughout the pregnancy journey, and that’s really, really helpful, I think.
[00:31:44] And that’s what it should be. We should try and keep ourselves connected with the people that we know and have our relationship with if we can.
[00:31:51] Hilary Erickson | The Pregnancy Nurse®: Yeah. And I see midwives doing informed consent. It tend to be, again, tend to be overgeneralizing all along the way. Right? Like they’ll, at 36 weeks they’ll be like, Hey, I am seeing that you might, you know, your blood pressure’s trending up a little bit.
[00:32:05] There is gonna maybe be a possibility of an induction. I just wanna put a little seed in your head so you can start to think about what’s important to you and how we’re gonna balance that with an induction. We’re gonna see you next week. Right? Absolutely. That’s exactly what I do. Yeah, because whereas an OB, all of a sudden your blood pressure’s high and you’re like, we’re gonna induce you tomorrow, and they’re just totally taken off guard.
[00:32:24] Juli Pyle CNM: Or they show up in labor and delivery. They’re like, I don’t know why I’m here. And nobody’s told them anything, you know? So yes, I agree with that completely.
[00:32:32] Hilary Erickson | The Pregnancy Nurse®: I should say that one of the trickiest things is officially your labor nurse is not the one to give informed consent for the big stuff.
[00:32:39] Obviously a cervical exam or putting your blood pressure cuff on, we can do stuff like that. Definitely not for a c-section. We shouldn’t be the ones really doing it for an induction. That should be a, a conversation that you have in the office or over the phone or something, but. A lot of people are like, oh, the nurses didn’t give me informed consent, but officially, that’s not really our job.
[00:32:55] We should be the ones who catch it. Where the we’re like, this girl doesn’t even know how or why she’s getting induced. I feel like maybe we should have a conversation today.
[00:33:03] Juli Pyle CNM: Yep, absolutely. I feel like the labor nurses are there to help facilitate, to make sure it’s happening. You have a little bit more time usually to, to give more of the background information that maybe the provider doesn’t spend as much time on.
[00:33:15] And I think that that’s really valuable. And you have the perspective of, again, that whole person that you’ve been taking care of, you know, and you’ve been able to say, I don’t think that this is what they really have been telling me they want, you know, and you can communicate that to the provider a little better sometimes.
[00:33:29] Hilary Erickson | The Pregnancy Nurse®: Yeah. That part’s super rewarding for me. And also just because you give informed consent to be induced, like we talked with about, with a Foley bulb. If you get into it and it’s just miserable and you’re starting to be like, I just wanna have a C-section, my cervix isn’t even opening. You can make another choice.
[00:33:44] It’s not like informed consent. And then you are on that train forever. You can be like, I wanna get off this train. This train isn’t taking me where I wanna go. I can make a new choice. Obviously once your water breaks, there’s certain things we do that we can’t roll back, but there’s a lot of choices in labor and delivery where you can say, this is not working for me anymore.
[00:34:01] What can we do to change? And that’s a, that’s an opportunity for a new informed consent. Absolutely. It’s tricky because a lot of people are like, I do not wanna go home under any circumstances, but I, it’s hard for us because we’re like, two days at home could be a big difference for you.
[00:34:15] Juli Pyle CNM: I had a patient who we were sort of preemptively discussing like the need for induction, and she asked me that.
[00:34:21] She said, well, did people ever go home? And I said, great question. I said, most of the time that’s the patient that doesn’t wanna go home. Honestly. Yeah, they’re ready to, they’re ready for the baby to be on the outside. I understand that. But it can be an option of like, this hasn’t worked for 24 hours. Like literally nothing’s helping.
[00:34:35] Can I go home for a couple days? And there are scenarios that that is not a good option, but there are many scenarios that it could be.
[00:34:41] Hilary Erickson | The Pregnancy Nurse®: You know, Juli, I think one of the hardest parts of being a labor nurse is that it is, I give birth all the time. Right. As a labor and delivery nurse. So it ultimately, it doesn’t end up as big of a deal, but when you are coming in, you’re new, what do you do you have thoughts on that?
[00:34:54] Juli Pyle CNM: I just think as providers and nurses, you know, we do this. Every single day, multiple times a day. So, you know, an informed consent on induction, right? We might be like, oh my gosh, I’ve said this seven times today. And that might change, you know, the words we’re saying. But if we keep the perspective of like, for this person, this is their first baby, maybe first induction for this person, they have not experienced maybe ever being on the monitor.
[00:35:19] You know? And so explaining some of the things that we’re doing is important for me. I keep that perspective. I try to, that like. This is the most important day for them, even though I’ve maybe already caught five other babies today as a midwife. Like this is their time. And so that perspective helps me, uh, be able to like refocus and be like, okay, I, I need to explain all of this exactly the same way again. And that’s okay.
[00:35:44] Hilary Erickson | The Pregnancy Nurse®: Yeah. And as a patient, if you feel like your provider’s sort of running through it, think of your job and something you tell people constantly all the time. And how sometimes it’s more clear than other times, right? If you work at McDonald’s talking about this, the fry sizes or whatever, if you can always say to your provider, Hey, can we just slow down and have a quick conversation about this?
[00:36:02] Sometimes, you know, it’s been a long day. They’re kind of quickly going through it when, but if you say something like that, that triggers in them that. That you need a little bit more information. And I would say 98% of us are human. And when they hear something like that, they’re like, okay, she really wants more help with this decision and we are gonna slow down and really help you.
[00:36:19] But sometimes because we’re human and you’re human, we need that reminder that you would like a little bit more information and to slow things down. And that’s A-okay to say as a patient? A hundred percent.
[00:36:29] Juli Pyle CNM: Absolutely. Yep. We are, we are humans after all. We’re people just living the experience and getting through the journey, especially labor and delivery.
[00:36:36] That’s a whole separate life changing day, you know? Yes. So I agree with you. Absolutely.
[00:36:41] Hilary Erickson | The Pregnancy Nurse®: Yeah. Guys, informed consent is so important. I really want you to take it serious. I think providers are taking it seriously way more seriously than they used to because it really used to just be for a C-section and that’s it.
[00:36:54] Well, an epidural, but we really are doing a better job at it. But when you communicate what kind of information you want or things like that, I think it just helps everybody. End up having a better experience and can prevent a lot of birth trauma when you understand that you are really in the driver’s seat of this car.
[00:37:09] Thanks for coming on, Juli. Thank you so much. I know you’re a busy midwife. You gotta go catch some babies probably now. Or deliver. We catch, we don’t deliver. Yeah.
[00:37:17] Juli Pyle CNM: Yes. Thank you for having me today. It’s always great to see you.
[00:37:20] Hilary Erickson | The Pregnancy Nurse®: I hope you guys enjoyed that episode. I don’t think we stress how important informed consent is, and I think a lot of times when you’re in labor, you’re just overwhelmed and you don’t wanna hear about it. So I think this is a good one to have your partner listened to and to just think about how you’re gonna implement when you’re in labor, even when you’re tired and you don’t wanna hear about it.
[00:37:36] Because I think it can be really helpful in making the choices that you want when you’re in labor and helping you feel like you are in charge of what’s going on.
[00:37:43] Thanks for joining us on the Pulling Curls Podcast today. If you like today’s episode, please consider reviewing, sharing, subscribing. It really helps our podcast grow. Thank you.
Keywords:
informed consent, labor and delivery, childbirth, induction, epidural, c-section, certified nurse midwife, obstetrician, patient rights, shared decision making, medical risks, medical benefits, alternatives to treatment, refusal of treatment, documentation, birth trauma, labor nurse, pregnancy, patient-provider communication, cervical exam, water breaking, episiotomy, pain management, delivery positions, hospital protocols, regional differences in care, language barriers, birth plan, stillbirth risk, maternal fetal medicine
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