Maintaining Autonomy at the Hospital

Hospitals are designed to help, to save those in life-threatening situations and prevent deaths. Medical providers feel very out of place if they aren’t actively doing something for their patients. Doctors are used to birth being done a certain way. It sounds a certain way, it looks a certain way. If the mother seems like she’s in pain, they can offer her medical pain relief. If they’re unsure about something, they can check their machines. They want to ensure both mom and baby are safe and that they’re doing everything they can to achieve a safe labor and delivery.

However, this hyper focus on safety can come at the expense of a woman’s autonomy.

Autonomy Challenges during Labor

Routine Intervention.

One of the more pressing risks to a woman’s autonomy in labor is the prevalence of routine interventions that aren’t necessary for every woman. Most hospitals have standardized policies and procedures regarding continuous electronic fetal monitoring (EFM), IV fluids, and cervical checks. These interventions are designed to manage risks and prevent complications, but they also interfere with the natural progression of labor and restrict a woman’s autonomy over her birth.

• Continuous Fetal Monitoring: Studies show that continuous EFM can lead to higher cesarean rates without improving the outcomes for the baby. Despite this, continuous EFM is a common practice in hospitals, often without fully informing the mother of her right to intermittent monitoring or her right to refuse it altogether.

• IV Fluids and Restricted Movement: Administering IV fluids (or just the IV port) is a routine part of labor in many hospitals. This can, however, limit a woman’s mobility. This can hinder her ability to change positions, using gravity to aid labor, and do more active birthing techniques. According to a study published in Journal of Perinatal Education, women who are free to move during labor experience shorter labors and fewer interventions.

Time Pressure

Most hospitals have an unspoken time limit on how long labor should take. If your doctor thinks labor is “taking too long” or that it isn’t progressing “fast enough”, you might feel pressured to agree to interventions like Pitocin or a foley bulb. This time limit on labor could come from your doctor, a nurse, your partner or even yourself.

• Pressure to induce labor is also an area where autonomy is compromised. Women can be pressured to induce for a suspected “big baby”, her age, and going over her due date., which can all be unnecessary. Women are often not fully informed of the risks of inductions or alternatives.

Standardized Care

Hospital policies are often designed to care for the majority, a lot of the policies at hospitals are created with high-risk pregnancies in mind. They aren’t made for the individual woman or the more common low-risk pregnancies. This means your birth plan, preferences, and autonomy can be overlooked or not fully respected, especially in the heat of the moment.

Medical Legal Concerns

Hospitals and medical providers are often concerned with minimizing liability. They’ll recommend inductions, cesarean sections, and other interventions “just in case” to avoid any potential legal issues. They will even perform interventions without your consent so they can say they did everything they could, if something goes wrong.

Autonomy Risks During Birth

The Cascade of Interventions

Where one intervention starts, others follow. For example, an induction will often lead to stronger and more painful contractions, which can lead to the use of an epidural. The epidural can slow labor, increasing the chances of Pitocin, which in turn increases your chances of a cesarean.

• Cesarean Sections: While cesareans can be lifesaving, it’s a major surgery with risks and long recovery times. Many women feel that their cesareans were not necessary and that their autonomy was compromised.

Episiotomies and Coerced Pushing

American College of Obstetricians and Gynecologists (ACOG) recommends against episiotomies, yet they are routinely performed in some hospitals, often without explicit consent or under the false pretense of it being necessary to prevent tears. Coerced pushing is when the woman is told when and how to push, this can interfere with the natural birthing process and undermine a woman’s autonomy.

Immediate Postpartum Autonomy Risks

Separation of Mom and Baby

A significant risk to autonomy occurs immediately after birth, when hospitals sometimes separate the mother from her baby for routine procedures. Immediate skin-to-skin and breastfeeding within the first hour are crucial for bonding, regulating baby’s temperature and breathing. You have the right to delay or refuse non-essential procedures in favor of immediate contact with your baby. You also have the right for these procedures to happen with you in the room.

Routine Newborn Procedures

Hospitals will often perform procedures such as administering the vitamin K shot, eye ointment, and hep B vaccine to newborns shortly after birth. Parents have the right to be fully informed about each of these before giving consent. Unfortunately, parents have reported feeling rushed or pressured to consent without having time to fully understand the benefits and risks.

Breastfeeding Support and Policies

Hospital policies are 50/50 on whether they support or undermine breastfeeding. Some hospitals will offer formula to newborns without parental consent or medical indication, which can interfere with breastfeeding success. The Baby-Friendly Hospital Initiative aims to improve breastfeeding practices by promoting rooming-in, breastfeeding on demand, and not offering formula or pacifiers unless medically necessary. However, not all hospitals have adopted these practices and you may need to advocate for your right to breastfeed without unnecessary interference.

How to Protect your Autonomy in the Hospital

At this point, you might be feeling a little overwhelmed. Remember, protecting your autonomy is entirely doable. By being proactive and informed, you can navigate the hospital environment confidently while preserving the autonomy that is rightfully yours.

Know Your Rights

Understanding your rights in the birth room is the key to maintaining your autonomy. You have the right to informed consent and refusal for any procedure and intervention, the right to be treated with respect, the right to have continuous support during labor and birth, and more. If you feel that your rights are being violated at any point (and I do mean any point), you have the right to speak with a patient advocate or a hospital ombudsman and to request a new provider.

Choose the Right Birth Team

When looking for a birth team, you get to be as picky as you want. Having a supportive birth team that will advocate for you and ensure your birth preferences are honored is crucial to maintaining your autonomy. Consider hiring a doula, make sure your medical provider and everyone you want in the birth room understands your birth plan. Remember, you can change providers for any reason at any time.

Create a Birth Plan

A well-crafted, detailed birth plan is an essential tool for communicating your preferences for labor, birth and the immediate postpartum period. Be specific about your wishes regarding interventions, pain management, newborn care and labor positions. Share it with your healthcare provider in advance so you can go over it with them and bring copies to the hospital.

Empowering Your Birth

Birth is a sacred, transformative event. By empowering yourself so you can make informed choices and actively participate in decisions about your care, you can ensure that your birth experience is both physically and emotionally fulfilling. Autonomy is more than a concept, it's a fundamental right. You have the power to shape your birth experience, and with the right preparation and support, you can achieve a fulfilling and respectful birth that honors your autonomy and desires.