Decision-Making: Teaching Informed Choice

In my last post, I talked about 4 steps of teaching informed decision-making: Values Clarification, Communicating Values with Birth Plan, Key Questions to Ask, and Informed Decision Making. This post is all about that last step.

Note: we prefer the term Informed Decision Making to Informed Choice for a few reasons: 1) Choice sounds like there was a clear black and white list of options, and we check a box… decision-making is often murkier than that. 2) Choice sounds a little entitled (my four-year-old likes to shout “It’s my choice so I get to do this!” I tell him that’s not really the case…)  Decision-making sounds more like a discussion between the parents and the caregiver and a careful evaluation of the options.

So, how do we teach informed decision-making?

Teaching Method 1: The Five Finger Method
I say “Before your caregiver made the recommendation to you, they already did a risk-benefit analysis. They already thought of what the options were, and thought about the balance between which would be most effective and which would be lowest risk. Let’s say they considered 5 options. [Hold up one hand, five fingers spread.] This option [touch pinkie] would definitely work – it’s very effective, but it’s too high risk – your health situation is not dire enough to need that level of intervention. This option [touch thumb] is really low risk, but it’s not clear if would be effective… it’s benefits are not good enough to offer. This option [touch middle finger] is the best compromise – that’s why your caregiver offered it. But remember, it’s the best compromise for any non-specific person in your situation. That doesn’t mean that it’s the best compromise for you! When you look at those options, you might find that this one [touch index finger] feels like the best answer to you. You understand it might not be effective, and that you might then have to escalate to one of these, but you’d like to try it first. Or, you might be exhausted and done with labor, and ask to do this one [touch ring finger] because you just want to do something you KNOW will work to solve the problem.”

I then give an example: I start with a non-birth-related example. I want to take them out of the realm of birth (where some may feel like this is all complicated and only experts understand it) into some different field where they feel like they have all the info they need.

Two examples I have used: the air conditioner and the loose shelf. I kind of like the air conditioner example better because it brings up the idea that maybe before we ask an expert for an intervention, we should think about whether something is really a problem. But if I’m working with mostly low income clients, it could come from a place of privilege to be able to consider all five options there…

The air conditioner example. “So, the air conditioner broke in my friend’s car last August. Now she knows even before she asks someone what her options are likely to be – she could do nothing and just live with it [touch thumb]- after all, this is Seattle – how many days do you need A/C?  she could repair it [touch middle finger], or she could replace it [touch pinkie]. Now, if she goes to the mechanic and says ‘what should I do’, is the mechanic going to offer ‘do nothing’ [thumb]?? No! He figures that if you came to him asking for help, you want him to do something! He might say ‘well, I could repair it. That’s cheaper than replacing (lower cost = lower “risk”) but it might break again. Or I could replace it. Higher cost, but we know it’s effective.
“So, she’s asked her key questions. She’s gathered all the data from the mechanic’s point of view. Now she needs to look at her values and also at her budget, which the mechanic knows nothing about. If she’s trying to save money for something that’s much more important to her, she may decide either never to fix the A/C [thumb] or to tough it out through August, and save money between now and next summer to repair it then [index finger]. If she’s tight for money but can afford it she may start with a low level repair [middle finger]. If she can afford it and she REALLY hates being hot she might try a more comprehensive repair [ring finger.] If she’s got plenty of money, she might go straight to replacement so she doesn’t have to deal with it again.”

The loose shelf example: I won’t detail it here, because i include it as the example in the quadrants tool I describe below.

Now that I’ve taught the five finger theory and given a quick example, now I want to apply this to birth. AND I want them to practice decision-making. I present a scenario, and tell them they have to ask me questions about benefits, risks, and what other options I considered. Then they have to think about their own values and priorities and what choice they would make

Slow Labor Progress example (you’re past 6 cm, but have gone 4 hours with no progress). Recommendation: Try Pitocin and position changes for an hour or two to see if we can speed it up. [Point to your middle finger to show that is the middle-of-the road recommendation that caregiver made. Note: it’s important that you hold up all five fingers and point to the middle one. Don’t just hold up your middle finger. 🙂 ]  Parents can ask: what are the other options: pinkie – we could do a cesarean now – that would get the baby out, but there’s risks to a cesarean, and your situation is not that big of a problem. Ring finger – could also break your bag of water. Index – could start with really low dose Pit. Thumb – Could just try position changes and maybe some nipple stimulation, but I’m not convinced that’s going to do anything. So, now parents have all the info. They need to reflect on their goals and values. Let’s imagine one family who had originally planned a home birth and wanted as low of interventions as possible. They might say to the caregiver: “Thank you for all that information. We understand that your recommendation is the most likely to be effective with the least risks. But, our original hope was to be as low intervention as possible, so let’s start with a low dose Pit [index finger] and see if that’s enough.” Another family, who has always been open to whatever interventions were needed to help labor progress well, and who are now very tired and just wanting to hold their baby might say “Let’s move this along – let’s do the Pitocin and break my bag of waters… I’m ready to rock.”

Teaching Method 2: The Quadrants
In this PDF: Decision Making Quadrants, I describe the full process of this method. But basically, you’re asking people first to consider their

  • intervention style: are they quick to intervene or are they willing to let something be a problem for a while before they intervene?
  • Self-Help or Expert Help: Do they like to solve things with their own skills, or do they prefer to turn it over to an expert?
  • Benefits vs. Risk: Do they choose the most effective thing even if it comes with more possible risks? Or are they very cautious about risks and more likely to try lots of less effective options first?
  • In a particular decision-making moment, how do they balance their normal decision-making style with the urgency/severity of the current situation while taking their values into account.
  • Examples include: the loose shelf, pain medication preferences

Teaching Method 3: The Values Clarification / Decision-Making worksheet

Can be done in class or as a take-home assignment. Check out the details on how it’s used here and find the worksheet here: Values Clarification.

Teaching Method 4: Help Students Learn More about their Decision Making Style

Check out this post on Medical Mindsets, and this worksheet, which gets into both medical mindset and other decision-making styles.

Decision-Making Values Clarification

In teaching informed decision-making, it’s not just about teaching birth plans, or just teaching key questions. There need to be at least four steps:

  1. Figure out your goals and preferences first (values clarification)
    1a. Choose the care provider and birth place that are most in alignment with your goals, preferences, and unique health needs (caregiver choices)
  2. Articulate those priorities for care providers (birth plan)
  3. Then if an intervention is proposed that is outside your birth plan, gather data on it (key questions).
  4. Then take that information and weigh it against your values to make the decision that is right for you. (informed decision-making)

And teaching these things is not just about Theory – we also have to Practice!

A quick note about step 1a: Ideally, this would always be the process. If I was talking to someone in early pregnancy who hadn’t yet chosen, I would absolutely cover that step. But, in childbirth classes, when I’m speaking to people in their third trimester, that choice was made long ago. So I won’t cover 1a. (But some of the other steps may lead students to question for themselves whether the caregiver choice they made was the right one.)

Let’s look at options for teaching each of those.

1. Values Clarification: The goal is to talk about what they want their birth to look like – what kind of labor support do they want, what are their views on interventions and pain medications, how involved they want to be in decision-making, and generally: what would help this birth be satisfying for them. There are many ways you could do this. I created a worksheet that could be used in class, or as a homework assignment, that would be one way of exploring these questions. The pregnant parent fills out one form with their values, the partner fills out a slightly different form with their values. Then they compare their answers and discuss them. How do they come to have a common vision of their goals and priorities? (And if they can’t, with birth, the pregnant parent’s priorities need to win in the end, so they may need to agree to that.) They can also discuss here whether their caregiver and birthplace share those values. Here’s the Values Clarification worksheet.

1a. Choose the caregivers that match that. (Check out the quiz at the beginning of the Great Starts Guide for one approach to this step.)

2. Articulate those priorities in a birth plan. (See Pregnancy, Childbirth, and the Newborn for our approach to birth plans.)

3. Key Questions. Here’s what we teach:
Whenever a test or procedure is offered, first ask how urgent / severe the situation is and whether you have time to ask questions, discuss options, and consider the information you’ve learned. Then, ask:

  • Benefits: What’s the problem we’re trying to identify, prevent, or fix? How is the test or procedure done? Will it work?
  • Risks: What are the possible tradeoffs, side effects, or risks for my baby or me? How are they handled?
  • Alternatives: What other options are available? What if I wait? Or do nothing?
  • Next steps: If the procedure doesn’t identify or solve the problem, what will we need to do next?

It would be all too easy to stop with the key questions, thinking we’ve done our job, but we just missed they key point of decision making: MAKING THE DECISION!

We need to remind them that although their caregiver is an expert source of information and advice on benefits and risks, that only they can take into account all their goals and priorities and make the choice that is best for them. We also need to acknowledge that sometimes the choice we need to make is NOT something we wanted. But we want parents to feel in retrospect, that the choice they made DID line up with their values, and WAS the best decision available at the time.

4.Teaching Informed Decision-Making. Check out my next post for this one…

Big Changes in Maternity Care 2010-15

I am a co-author of the book Pregnancy, Childbirth, and the Newborn. (We call it PCN for short.) We have been working on a revision – the 5th edition of PCN will be released in March 2016. You can pre-order it here (affiliate link.)

This post is a summary of all the changes we have made to the book. It is not really meant to be a stand-alone post for someone who is not a birth professional and who hasn’t read PCN. However, if you ARE a birth professional (especially a childbirth educator) and HAVE read PCN, this summarizes what we think are the most important changes in maternity care and birthing culture since 2010 when our last edition came out. I have highlighted with ***asterisks*** the ones that I believe are essential for childbirth educators to be aware of and essential to incorporate these ideas into their classes.

Here you go… all the changes… Note, when I say we’ve “made a change to the website”, that will be upcoming changes to our companion website – those will appear live online after March.

Throughout the book:

  • Gender: Have made the language more inclusive of gender-non-normative families. Have changed many incidences of “pregnant woman” or “women” to “pregnant person” or “people” or “expectant parent.” Where we could, we re-phrased the sentence to avoid pronouns, but when pronouns are needed, we use she or her to refer to the pregnant person. As always, partners are gender neutral, and for babies we alternate male and female by section.
  • Microbiome: Added a section to the cesarean chapter discussing the microbiome in detail (also added an even more detailed discussion to the website.) Included references to this information in pregnancy complications chapter (when discussing antibiotics for GBS) and in the newborn care chapter when discussing diarrhea and again when discussing colic. See this blog post to learn more
  • Chapter Order and Division: In this document, I refer to chapters by their chapter number in the old edition. For new edition, the breastfeeding chapter will be divided into two, the pain medication information will be made a separate chapter from Labor Pain and Options, and chapters in the birth section will switch order to:
    • When and How Labor Begins (chapter 9); What Childbirth is Really Like (formerly chapter 12); Labor Pain and Options (formerly first half of chapter 10); Comfort Techs for Labor (11); Pain Medications (formerly second half of chapter 10), When Childbirth Becomes Complicated (13)

Intro: Added some notes about “how to use the book” that address some of the concerns that Amazon reviewers have expressed about the book. Added a note at the end about gender-inclusive language.

Chapter 1 – You’re Having a Baby: no major changes

Chapter 2 – So Many Choices: Updated health insurance info to reflect Affordable Care Act (see details on health insurance). Included notes about ACOG/SMFM levels of care recommendations, which include birth centers and then define level 1 – 4 hospitals. Also added brief note defining “high risk” pregnancy vs. low risk, saying that a high risk mother should choose a high level of care (OB and level 3 – 4 hospital) vs. a low risk mother can choose anything.

Moved the lists of questions to ask (at a birthplace, of your caregiver, etc.) to website.

Chapter 3 – Common Changes of Pregnancy:

  • Added a recommendation to subscribe to an email newsletter like Lamaze or Baby Center’s if they want detailed week-to-week information (“this week your baby is as big as a kumquat”)
  • Made changes to ***how we talk about “the 41st week and beyond”*** given ACOG’s 2014 statement on Preventing the Primary Cesarean, where they recommend that all women be induced at week 41 because of the increasing risk of stillbirth beyond that point and the fact that cesarean rates increase for prolonged pregnancies. We state that some caregivers will recommend that pregnancy continue, with some extra monitoring to ensure that placenta/baby continue to do well, and some will recommend induction at week 41.
  • Updated section on pregnancy after age 35. (Trivia note: when PCN first came out in early 80’s, average age of mothers having their first births was 22.7, and just under 4% of all births were to women 35 and older. In 2013, the average age at first birth was 25.8. 15% of births were to women 35 and older. 22% of those were the first baby born to the mother.)
  • Added a section on “If you’re transgender or genderqueer” that gives resources for finding a supportive caregiver and suggests preparing a detailed birth plan to explain things like preferred pronouns and family terms (e.g. pregnant father)

Chapter 4 – Having a Healthy Pregnancy

  • Added a new section on prenatal screening for birth defects, which includes: first and second trimester blood tests, nuchal translucency screen, second trimester ultrasound, and cell-free fetal DNA testing. Explains that these are all screening tests and none are 100% accurate, so shouldn’t be used as the sole basis for irreversible decisions like termination. If screening tests reveal high risk of birth defects, diagnostic tests (CVS or amniocentesis) are recommended. Although we don’t cover these topics in birth classes, it would be good for all educators to be familiar with the newer testing options. (See my blog for more)
  • Added signs of prenatal depression to pregnancy warning signs
  • Added new resource on effects of infections, substances, and environmental hazards: Mother to Baby website, from the Organization of Teratology Information Specialists.
  • Addressed e-cigarettes: Effects on pregnancy has not been studied. MAY be safer because fewer chemicals and no smoke, but still contain nicotine, which is harmful to babies.
  • Addressed marijuana since some states have legalized recreational marijuana use and several have legalized marijuana for medicinal purposes. (It is still illegal at the federal level and this may come into play in child abuse or neglect rulings in those states.)Some studies show that marijuana use in pregnancy does not increase the risk of birth defects. Others indicate that babies born to mothers who regularly used marijuana had a higher risk of premature birth, low birth weight, small head circumference, and cognitive and attention deficits. These studies were generally done when marijuana use was illegal, and thus difficult to get accurate reporting on. Plus the women who regularly used illegal marijuana were also more likely to use alcohol, tobacco and other drugs, and less likely to access prenatal care, so that may influence these outcomes. Until more research is done, it is wise to avoid recreational marijuana use, and only use it medicinally with the supervision of a caregiver.

Chapter 5 – Feeling good and staying fit: Made changes to ***pelvic floor exercises***, saying there’s not a one-size-fits-all recommendation. Recommend they check strength of pelvic floor muscles (by stopping flow of urine or by tightening around two fingers or partner’s penis.) If they seem weak, then do kegels (note: 10 second kegels are best). On the other hand, these symptoms may suggest the muscles are overly tense: pain in vagina, rectum, tailbone, straining with bowel movements, pain during intercourse, urinary issues such as hesitancy, incomplete emptying or pain. In this case, instead of kegels, she could do pelvic bulging, conscious relaxation, or perineal massage to release tension.

Chapter 6 – Eating Well

  • Added info on gluten free options
  • Changed discussion of non-fat dairy items. Research actually shows that people who consume full-fat dairy are less likely to be obese than those who consume non-fat dairy.
  • Starting with a 2011 medical update of the 2010 edition, we have updated discussion from the Food Pyramid to the new “My Plate” guidelines:
  • Added recommendation for 600 IU per day of vitamin D in pregnancy
  • Added a section under special circumstances on “Pregnant and Considered Obese” which encourages them to learn more at or by reading the series “Maternal Obesity: A View from All Sides” on

Chapter 7 – When Pregnancy Becomes Complicated

  • Updated miscarriage statistic – it did say 10 – 15%, increased to 15 – 20%. As more women learn about the pregnancy earlier in pregnancy, there has been an increase in recognized miscarriages. Also added a few more details on how a miscarriage is treated (observation, medication, or D&C)
  • Moved the chart on impact of infections out of the chapter and on to website.
  • Updated incidence of gestational diabetes. Was 3 – 5%, now 4 – 9%. Included note that in the days prior to (and day of) a glucose challenge test, mother should be well-rested and eat healthy, non-sugary foods to decrease her chance of a false positive.
  • Updated section on gestational hypertension and preeclampsia. Proteinuria is no longer required for a diagnosis of preeclampsia – if mom has high blood pressure plus either lowered platelets or impaired liver or kidney function that is sufficient. Mild gestational hypertension (BP 140/90) is treated with: reduced activity / stress, daily kick counts, weekly appointments for blood tests and possibly fetal monitoring. ***For those with mild hypertension or preeclampsia, delivery at 37 weeks is recommended.*** For severe cases (BP 160/110), she’ll be hospitalized and given hypertensives plus magnesium sulfate to reduce risk of seizures. If baby is past 34 weeks, they will deliver baby as soon as she is stabilized. If baby is under 34 weeks, amniocentesis to check for lung maturity and corticosteroids to prepare baby for birth, and then deliver as soon as mom is stable.
  • Added a very brief section on perinatal mood disorders to point out that depression in pregnancy is quite common (estimates range up to 20%, or 30% in women of low SES.) Amongst parents with postpartum mood disorders, a significant portion (up to a third) say symptoms began during pregnancy. (Interestingly, anxiety and panic attacks decrease during pregnancy due to soothing effects of hormones.) ***This info should be covered in childbirth education classes, and parents can be referred for more information to sources that address PPMD.***
  • Moved info on breech babies from “When Childbirth is complicated” chapter to here.

Chapter 8 – Planning for Birth and Postpartum

No major changes, except moved “What to pack for the hospital” list from chapter 9 to 8.

Chapter 9 – When and How Labor Begins

  • Replaced the old Events of Late Pregnancy “arrow” with a new graphic.

Chapter 10 – Labor Pain and Options for Relief

  • Divided into two chapters: Labor Pain Options and Pain Medications for Labor
  • In the section on Pain versus Suffering, added in ***the concept of “working with labor pain” ***(see Leap and Newburn. (2010) Working with pain in labour: An overview of evidence. New Digest 2010; 49:22–6.) Also added a brief note about it in the chart comparing pain relief options. If parents believe that comfort techniques are designed to take away their pain, they’ll be disappointed in labor. If they understand that the goal of comfort techniques is to make pain more manageable and help them feel like the pain is something that they can work with rather than something they are suffering through, they may be more satisfied with the experience.
  • In the last edition, under “Effectiveness of Pain Relief Options” we had cited mother’s experiences from the Listening to Mothers survey. We have kept that, but added info on research into the effectiveness of various methods. In the book, we summarize Chaillet, et al. (2014) Nonpharmacologic approaches for pain management during labor compared with usual care: a meta-analysis. Birth, 41(2): 122-37.
    • Gate control, defined as adding pleasant stimuli to the painful area. Users were less likely to use epidurals or Pitocin and had lower pain scores
    • ***Counter-irritation***, defined as creating pain or discomfort elsewhere on the body (with TENS, ice, birth combs) to cause the release of endorphins. Users less likely to use epidurals, had lower pain scores, and more satisfied with birth.
    • Central Nervous system control (attention focus, prenatal education, relaxation, hypnosis, continuous labor support). Less likely to use epidurals and Pitocin, less likely to need instrumental delivery or cesarean, higher satisfaction
    • Most effective is a combination of continuous support with other techniques
  • Added to website a chart comparing Cochrane summaries on individual non-drug techniques.
  • See blog at for more discussion of ‘working with pain’, counter-irritation, and research into the effectiveness of techniques

Chapter 10 B – Pain Medications

Chapter 11 – Comfort Techniques

  • Lots of minor updates to wording and references
  • Added a section on counter-irritation: when the laboring person causes an uncomfortable sensation somewhere to distract her from pain (e.g. bites her lip, digs her fingernails into her palm, pulls her hair). Explained to partners that if this is helpful to her and not harming her, we reinforce it as her ritual. If it might be harmful to her, we substitute – like giving her a washcloth to squeeze in her hands. Addressed birth combs, TENS, sterile water injections as good options
  • Added peanut balls as a comfort item / item to aid labor progress, particularly in late labor for a mom with an epidural (she lies on her side with the ball between her legs – the pelvic opening gives baby room to descend)
  • Re-did some of the diagrams of breathing techniques, particularly light breathing – diagram shows fast breaths every second. Re-drawn as a breath every 2 seconds, with a brief pause between each breath. Slide breathing diagram had 5 or 6 exhales per inhale. Should be 3 – 4.

Chapter 12 – What Childbirth is Really Like

  • In the past, we had described early labor as lasting to 4 cm. ***Shifting to saying early labor lasts till 6***. We describe a “getting into active labor” phase from 4 – 6 cm to acknowledge that labor often intensifies there, and mom needs more support than she did before, but cervical dilation does not really speed up till after 6 cm
  • Added a sidebar about the 2014 ACOG/SMFM consensus paper as the source for that change, and the perspective of “***6 is the new 4***” (American College of Obstetrics and Gynecology and Society for Maternal-Fetal Medicine. “Obstetric Care Consensus: Safe Prevention of the Primary Cesarean Delivery.” Obstetrics and Gynecology 2014; 123:6093-711.)
  • Made even clearer our statement that prolonged early labor is not a complication. (But, of course, mom does need support with it, and we do give ideas for how to improve progress.)
  • Changed words used to describe fetal heart rate issues. New terms are ***normal, indeterminate, and abnormal***. Outdated terms include fetal distress, non-reassuring heart rate, and fetal intolerance of labor.
  • Fetal scalp sampling removed (apparently there’s not an FDA approved kit for doing it) But do recommend fetal scalp stimulation (scratching baby’s head) as a tool for evaluating an indeterminate heart rate – if you scratch baby’s head and heart rate speeds up, good sign
  • Added more on delayed cord clamping. (to learn more about it, see Penny’s video here: Note: cord blood CAN be collected for storage or donation after delayed clamping – it is collected from the placenta.
  • Added more on hormones of labor and on hormonal interaction during fourth stage. Included reference to ‘Pathway to a Healthy Birth’ by Sarah Buckley, available at
  • We are adding Penny’s Road Map of Labor (newly revised) to the back of the book, so have brought references to it into this chapter and chapter 13.

Chapter 13 – When Childbirth Becomes Complicated

  • Changed the order of the sections. In the past, they were roughly in order from most common to least common. But that didn’t lead to a logical flow of topics. New order:
    • complications of pregnancy that affect labor: multiples,  gestational hypertension
    • issues with transition from pregnancy to labor: premature birth, rapid birth, induction
    • challenges that arise in labor: prolonged labor, concerns about well-being
    • prolonged second stage
    • issues after the birth: third stage complications; premature or seriously ill newborns; infant death
    • Note: breech birth moved to chapter 7. Preterm labor divided up as follows: chapter 7 – warning signs and what to do if you think you may be in preterm labor; chapter 13 – when labor can’t be stopped and birth is inevitable
  • Induction – cite recommendations from ACOG that ***elective induction not be done before 39 weeks (and ideally not before 41). However, also mention ACOG recommendation that all women consider induction at 41 weeks.***
    • Shortened section on misoprostol, as current protocols do not appear to cause the severe health complications that happened when it was first used as an induction agent
  • Changed discussion of prolonged labor to match current ACOG recommendations. Prolonged labor should not be diagnosed before 6 centimeters dilation. After 6 cm, it still shouldn’t be diagnosed until she’s had not progress for 4 to 6 hours, even with AROM and Pitocin.
    • Note: ***this is a very significant change for childbirth educators to be aware of***. If more care providers start following these guidelines, labor will become longer on average, and students need to have expectations set appropriately! We need to talk more about not getting excited too early in prelabor, conserving energy in early labor, ways to aid progress in active labor but also not stress over a long labor. (e.g. it may take 5 – 7 hours to progress from 4 to 6 cm even if you’ve got contractions in the 5-1-1 pattern)
  • Childbirth educators used to talk about prolonged labor / back pain being mostly due to OP babies. Ultrasound studies have shown that isn’t always true (see Simkin 2010 – Fetal OP Position: state of the science), and that babies change position more in labor than we had thought. We can say that if you have any of these issues: slow labor progress, irregular or coupling contractions, back pain, or very severe pain, then there is something dysfunctional (“not quite right”) about your labor that needs to be corrected. It may be baby’s position, it may be something else. But whatever the cause, the things we’ve always recommended for slow labor and for back pain can help (e.g. positions and movement, counter-pressure and hip squeeze, addressing mom’s fears, hydration, etc.)
  • Prolonged second stage. Again, the ACOG recommendations have changed! There is no absolute maximum amount of time for pushing. ***Arrest of descent should not be diagnosed unless the mother has pushed at least 3 hours (2 hours if multip). Longer may be appropriate: for example, allowing one hour more if the mother has an epidural or if baby is malpositioned.***
    • Before instrumental deliveries are done, manual rotation of baby’s head should be considered. Before a cesarean is done, vacuum or forceps should be considered.
  • Previous edition said postpartum hemorrhage occurs in 20%. This was a typo. 😦 Should have said 2-5%. Updated this to say “about 5%” based on WHO and ACOG.

Chapter 14 – All About Cesarean

  • Updated “cesarean trends” section to address that rates have increased for all women across the board, and to address practice variations between birth places and how that influences cesarean rates at individual hospitals. Talk about the ACOG statement on need to reduce c-s.
  • Updated info on elective cesarean to reflect 2013 ACOG saying that if there are not medical reasons for cesarean, then vaginal delivery should be recommended. If elective is done, should be after 39 weeks.
  • Updated info on what counts as prolonged labor in need of cesarean (see chapter 13 notes)

Chapter 15 – What Life is Like for a New Mother Parent

  • Changed the order of topics for more logical flow
  • Replaced section on breast self-exams with new recommendations for long-term reproductive health care: Pap smear every 3 – 5 years. Under 40, clinical breast exam every 3 years. Over 40, may recommend annual breast exams and annual mammograms, or they may follow the USPFTF research-based recommendations for biennial mammograms starting at age 50

Chapter 16 – When Postpartum Becomes Complicated

  • Added brief info on PTSD after birth; noted that 5% of new dads experience PPMD; briefly address placental encapsulation (while noting research on its efficacy and safety is limited)

Chapter 17 – Caring for Your Baby

  • Tightened up some medical details to make room for some practical stuff like “how to hold a baby”, “dressing your baby”, “when and how to change a diaper” and typical wake-sleep patterns at 2 weeks, 4-6 months, and 2 years
  • Newborn procedures – removed silver nitrate and tetracycline from eye ointment options, leaving just erythromycin which is what is in current use. Changed hearing screening to note that it is now recommended for all babies. Added the pulse oximetry test. (learn more about this test:
  • ***Updated circumcision.*** New AAP guidelines say medical benefits outweigh risks, but not enough to recommend routine circ.; New CDC guidelines say circumcision reduces risk of HIV and 2 other STI’s, and given concerns over the spread of HIV we should do all we can to prevent, and it’s safer to circumcise a baby boy than an older boy or man However, AAP says parents need to weigh benefits and risks, and CDC says delaying circ allows child to participate in decision-making. Note: there is a chair that can be used during the procedure rather than strapping baby to a board on his back – this leads to less distress for baby
  • Increased information about newborn cues, particularly disengagement cues, and overstimulation as a culprit in colicky behavior. Cited research that probiotics may help colic.
  • Updated vaccinations. Old edition didn’t really talk about the benefits, just all the reasons people might choose not to. Update covers benefits to child and community. Says the CDC believes that for the population as a whole, the benefits outweigh the risks, but some parents may have concerns about the risks. States that research does not show a connection between vaccines and autism. Suggests that if they want to opt out of vaccines or adjust timing they should do so only after research into benefits and risks and consultation with caregiver.

Chapter 18 – Feeding Your Baby

  • Split into two chapters. Feeding your baby and When Breastfeeding is Challenging. We did this because of feedback from students that it was overwhelming to see all the complications mixed in with the normal. Throughout the book, we separate typical from Complicated (chapter 7, 13, and 16) so that the complications info is there, but that it’s hopefully less anxiety inducing when it’s clearly labeled as the unusual circumstance.
  • In the past, lots of the information on general feeding practices no matter what they’re fed (when to feed, how much to feed, how to burp, spit-up, etc.) was in the midst of the breastfeeding content, so parents who were bottle-feeding might have skipped much of that important content, and only seen the info on bottles and formula at the end of the chapter. We re-organized the chapter a bit, to be: general feeding info, breastfeeding specific info, bottle-feeding (breast milk or formula) info, then a brief section on formula.
  • “Normal” breastfeeding challenges covered in Feeding Chapter: when your baby doesn’t get enough milk – ways to increase supply; breast fullness and tenderness, sore nipples and leaking
  • Issues covered in the “when breastfeeding is challenging” chapter: persistent sore nipples – causes and treatments; engorgement; plugged ducts; mastitis; persistent low milk supply; and situations that make breastfeeding challenging (cesarean, preemie / ill baby, multiples, nursing while pregnant / tandem nursing; working and nursing.)

Chapter 19 – When You’re Pregnant Again

  • Minor updates, including updated recommendations for books to read to older child.


  • We will be moving the chart about pain medications to the website
  • We will add “The Road Map of Labor” graphic to the book, and have updated the “Summary of Normal Labor” chart to incorporate ideas from the road map

The new book will be available in March. We encourage you to check it out! We are also revising the Simple Guide to Having a Baby, which will be out in May 2016. It is similar content to PCN, but whereas PCN is written at a high school / college reading level, Simple Guide is 6th-8th grade reading level. It’s a good match for students with less formal education, for those for whom English is a second language, or those who are too busy to read the much longer PCN.

Decision Making Style

Recently I posted about tools to help students / client’s understand their medical mindset and how it affects the decisions you make. I’ve since decided it doesn’t capture some of the other key components that affect our decision-making in labor: how much information we need to make a decision, how much time we need to make a decision, and whether we prefer to make our own decisions or just follow the recommendations of a trusted caregiver. So, I’ve added a second page to that worksheet which explores decision-making in more depth. Find it here.

Medical Mindset Tool

When making choices about medical care, are you a maximalist or a minimalist? A maximalist may use lots of tools to prevent and treat problems. A minimalist may try to use as few tools as possible, letting things run their natural course. What kinds of medical tools do you use? Natural remedies and self-help techniques or medicine and technology? A maximalist naturalist might prepare for birth by attending prenatal yoga, drinking raspberry leaf tea, and frequent love-making to get her oxytocin flowing. A minimalist technologist might choose a hospital birth with an OB, but ask for as few interventions as possible.

Helping your students or clients understand their medical mindset may help them in choosing care providers and birth places, and may also help them explain their decision making in labor to their partners and care givers. There are a few tools you can use to learn more and help your clients to understand this idea.

Jerome Groopman has written a book on Your Medical Mind: How to Decide What is Right for You. (He also wrote How Doctors Think and some other great books.) You can read an article which summarizes it here: or watch a video here that presents the idea to medical professionals:

Kim James and Laurie Levy discuss this in their childbirth classes and with doula clients. They designed a worksheet you can find here:

I liked their idea, but found the worksheet complicated and a little dense on information for my client population, so I made a simplified version of the worksheet. Click here for the PDF. If I were using this in a class, I might give one copy to the pregnant parent, and one to the support person to fill out separately, then compare and discuss.

[Added on 7/28/15: a 2-page version of the handout that looks at more factors that affect decision-making. Find it here.]