OB-GYN and maternal fetal medicine specialist Dr. Brad Bootstaylor talks with Adriana Lozada about the ins and outs of shared decision-making with your care provider– plus practical advice on how to implement your birth plan.
How did shared decision-making (or a lack thereof) impact your birth experience? Let us know how you had a say your birth experience @birthfulpodcast on social media.
Related Birthful episodes:
- Family-Centered Cesareans, with Dr. Pamela Berens
- Know What You’re Up Against When Giving Birth at a Hospital, with Dr. Mimi Niles
- Informed Consent, with Cristen Pascucci
- Delayed Cord Clamping, with Dr. Mark Sloan
- Eight Questions to Ask Your Care Provider
- Shared Decision Making: Bring Birth Back Into The Hands Of Mothers Vol1, Book by Dr. Brad Bootstaylor
- Mode of Term Singleton Breech Delivery Committee Opinion, ACOG
- If Your Baby is Breech, ACOG
- Breech Baby at the End of Pregnancy, Royal College of Obstetricians & Gynaecologists
- One thing you can do for you is to embrace the reality that if you are pregnant, no matter how far along, you’ve already started to parent! Be an active participant in your pregnancy and birth choices, and take the responsibility of participating in shared decision-making.
- The one thing you can do for the rest of us is to take it one step further and actually take a pledge that you will demand shared decision-making from your provider. Using our collective voices is one way to be part of the systemic change we need. To help out with this, we’ve created a webpage where you can learn more about SDM and take the pledge to receive a handout to take to your appointments. Take the pledge at birthful.com/shared-decisions!
Why You and Your Care Provider Must Decide Everything Together
Adriana Lozada: Welcome to Birthful. I’m Adriana Lozada.
Dr. Brad Bootstaylor:
So, that’s why I don’t view mothers as high risks. They have risk elements they were given in some context, but they are accepting responsibility for the choices. I’m a “medical provider” able to hopefully outline what those choices are.
Lozada: That’s OB/GYN and maternal fetal medicine specialist, Dr. Brad Bootstaylor, talking about the basis of how he approaches shared decision making with the families he serves. During the episode, you’re gonna hear us talk about Dr. Bootstaylor’s B score to help determine if your care provider practices shared decision making, and some of the questions that inform that B score. We also talk about how breech birth is a variation of physiological birth and why no one should roll their eyes at your birth plan.
Make sure you stay on till the end of the episode for my two things to do, one for you, one for the rest of us. You’re listening to Birthful, here to inform your intuition.
You have a new book called Shared Decision Making: Bringing Birth Back Into the Hands of Mothers. If we need to bring birth back to the hands of the person giving birth, right now it means that it’s on somebody else’s hands. If it’s not the person giving birth, who’s holding the birth right now in the U.S.?
Bootstaylor: So, when you’re talking about bringing birth back into the hands of mothers, she is now really having to navigate a landscape where there truly are roadblocks and maybe mine fields, it depends on how you look at it, along the way. Where they are, the institution, family, friends, so there’s a lot of input coming in and appropriately, so it creates some anxiety, because there’s some uncertainty to it, and so to be able to navigate that to bring birth back into the mother’s hands really is gonna take look at different arenas and having a collaboration.
Lozada: Because it feels like the pendulum has swung very much to take the power away from the person giving birth and I think you’ve found a tool, something to help bring that back, in shared decision making. So, why don’t you tell us a little bit more of what is shared decision making?
Bootstaylor: So you do it all the time, actually. But when you enter into the realm of maternity, birth, you no longer are sharing in the information. You’re almost being told and directed what to do. So, shared decision making in and of itself is trying to appeal to an intuitive process that mothers go through daily.
I always say a mother shouldn’t have to have a PhD in birth in order to ask the right question and I describe something called the B score, where there are nine very simple, low ball questions that a mother should be able to ask their provider. The questions are as simple as do you believe in ACOG recommendations? Especially if they support VBAC. Do you support childbirth workers, such as doulas, or not? And they’re given a grade of 10 points apiece, and you can get 90% if you and your provider are in alignment.
So, if you’re at a 90% alignment in your understanding of the processes that you may be going through, then you know when things occur that you could never plan for, you can have conversations about that and what the options are. And if you’re at a 10 to 20% alignment when you evaluate your team, then you know as you go through the pregnancy, especially into the birth, there’s gonna be some friction points. So, if you can get into alignment with your birth team, then you can enhance or apply a shared decision making model to your care.
Lozada: Because doing all those things, taking the childbirth education class, having the doula, those things won’t “buy you” the birth experience you want. There’s no guarantees in birth whatsoever. But things like delayed cord clamping, the pulsation, those are things that you can, to an extent, have more say in.
Bootstaylor: The one thing I’ll say to that, though, is to go to that point of delayed cord pulsation, you may not think anything of it. The mother’s like, “Hey, I got other things to think about.” And then somewhere down the road you’re thinking, “Oh, maybe I should have a Lotus birth because my cousin had one.” If you are not in alignment with your provider, when you mention Lotus birth or delayed cord pulsation for 30 seconds, there’s gonna be an interesting exchange.
Lozada: For listeners who don’t know what a Lotus birth is, can you explain it?
Bootstaylor: Yeah, sure. It’s a beautiful thing, I will say. Having said that, it’s where the umbilical cord is not clamped and cut. So, after the baby’s born, you let it pulsate until it’s not pulsating anymore. It’s usually about 10, 15 minutes. And then the placenta’s delivered with the umbilical cord attached to the baby. And a true Lotus birth is actually to let the cord kind of involute and dry up and break off on its own. That takes about 10 to 14 days. You can put herbs and decrease certain aromas, if you will. Or right at that time you can cut the cord, because the placenta and the cord and baby have been delivered together. I call that a quasi-semi Lotus.
But the concept of Lotus birth is if you can imagine this unit of placenta, umbilical cord, which is the lifeline, and the baby attached all as one. Beautiful pictures. About 95% of my births that I do are Lotus births, by the way. And I’m educating the moms about a Lotus birth and she’s like, “What is that? That was cool.” So-
Lozada: Well, and it also turns everything up on its head, because we’ve got these cultural beliefs that the first thing that you need to do as soon as this baby is born is clamp and cut, separate, right.
Lozada: And you are providing a different way of doing things and also a curiosity for exploration of like, “Wait, I didn’t think… Huh.”
Bootstaylor: So, even if you thought that through and had not thought about it before, when you are in birth or beforehand and you bring up that thought, if you are in alignment with your birth team, you should be able to explore that. And even to the point where the provider can say, “I appreciate what you’re saying. I have learned a few things. I know it’s something that you thought about and I don’t feel comfortable in doing that.” That shared decision makes the provider better and more sensitive to their preferences.
So, it doesn’t have to be the mother having her way 110% of the time. It has to be where there’s low friction, and there’s alignment, and there’s communication, versus you’re the enemy, I’m the provider, what I say goes. So, the provider doesn’t have to support a Lotus birth or delayed cord clamping, but there’s communication about that.
Lozada: What are some ways that people can evaluate? And you mentioned the B score of the nine questions, but are there other ways that they can also see if their provider is in alignment with this process? Because what I see happen sometimes, when people are interviewing their provider and asking them questions, everything sounds wonderful. And then as the process continues, these friction points show up, or I sometimes call them red flags. That type of conversation is no longer aligning.
Bootstaylor: Yeah. You’re right. Because one of the questions, question number nine, I’ll read it back to you, is it says, “At or near the end of your pregnancy, do you sense a change in your provider’s temperament towards you or an overemphasis of their preferences?” At the end of the pregnancy, when things pop up that you weren’t even sure of or heard about, you just… You still should be able to have some dialogue with that provider.
What unfortunately happens on the other end, the provider begins to or that group begins to label that person as being somewhat high friction point, maybe recalcitrant, so they start almost marginalizing that individual. It can’t be one or two mothers coming in there wanting shared decision making. So, if shared decision making is part of your everyday life in every arena, every mother before you and after you has to also bring that to that relationship with that provider.
So, it’s not new to them if everyone is coming there with an expectation to be part of the birthing process, sharing in the information, then it won’t be these surprises.
Lozada: And so, for that one person that’s going in and speaking to their provider today, and is feeling like there’s friction points, there’s red flags, that the conversation is changing, that they’re not getting shared decision making, what can they do?
Bootstaylor: So, it’s gonna be chipping away at something. That individual may not get what they need, but it’ll wear down or build up the provider. The challenge that I see is the mother who’s traumatized, who doesn’t even know she’s making a change or not, but if she maintains her voice, she can make it better for somebody else. And then collectively, the collective will and economics, I’m afraid, will change it.
Lozada: And I also want to give that person permission to decide whether they’re going to chip away at that specific provider or they’re gonna say, “Listen, I fought my fight, but I’m not gonna… This is too much for me and I’m gonna change and find a different provider.” And in that walking away, you’re also making a stand and a statement.
Bootstaylor: I agree. You are making a stand and a statement. But that gap is filled with a lot of other people, and I see moms, I see at least one person a day who’s changing her provider to my practice, who’s like 39 weeks. I’ll tell you that she’s making a change, she’s telling that provider, that group, “Hey, listen. Not me. I’m not gonna do this.” But when it’s one or two people, the provider probably doesn’t even miss the conversation. Glad the pain body is gone. Don’t have to deal with delayed cord pulsation.
So, I think when it’s one or two, it’s kind of… It’s good for that mom individually to have that power and to do it, but a mom has to feel empowered enough en masse to make that provider group change. And that way, you’ll see people do breech births, VBACs without questioning it, Lotus birth if you need to, have doulas.
Lozada: So then, I mean, my questions are all related. It’s about all these things that culturally we tend to view as “high risk” and a lot of providers are reluctant to do them, like you’ve been mentioning. VBACs, breech births, and it’s we’re taking away the idea that you are an expert in yourself. If something’s up, you’re gonna know.
Bootstaylor: That, and here’s the thing, it’s okay not to know. But if you’re in an unstress worthy, high anxiety relationship, then when something occurs, because you resisted some information, then you now fault yourself for that. It’s okay to be wrong, actually is what I’m trying to say. But the relationship is poisoned that you dig in. And I hate to say it, you have to dig in, because you heard that your cousin got an emergency C-section for no reason, you heard that everyone is induced at that hospital, this person, so you end up digging into your sensibility with what you feel comfortable with, and intuitively, things could be fine.
Lozada: And what you’re saying, it also is the other end of the coin in that shared decision making, is I think parents need to own their birth and take more responsibility in the process. Because there can be a, “Well, then it won’t be my fault if I’m not the one making decisions.”
Bootstaylor: Right. That’s where the finger pointing comes in. I did everything you told me to do and see what happened? Ooh. Your fault. But if you had shared responsibility, then there’s no finger pointing.
Lozada: And I find that provides, that lessens trauma, as well, because the trauma’s in the eye of the beholder, but it’s the experience that causes trauma, of how if it’s done to you versus you participated. You had a voice. You felt your agency was present. It’s when we take away the agency that trauma can come up. And most of the time, not 100%. I’m not generalizing. But I see a lot of that.
Bootstaylor: I agree. I’ll give you an example that comes to mind. I had a mom traveling from two states away because she wanted a VBAC. Her first birth was a story to be told, but she wasn’t gonna have a repeat cesarean, and which the community that she was in, they didn’t support VBAC, so she was driving six hours for prenatal care and all that stuff. So, at the end of the pregnancy, she opted for an elective family center cesarean, because she was able to think freely about it. The traumatic first birth, walking through that and realizing it wasn’t so much fighting to have a vaginal birth, it was fighting to have a say in the birth journey.
Lozada: I find that at the end, if we really look at it, that’s what every birth plan is about. People create birth plans just because they want to have a say, not because they’re-
Lozada: Do or die, married to the line item in the birth plan.
Bootstaylor: Correct. Correct, correct, correct.
Lozada: So, you do family-centered cesareans in your practice. Can you walk us through what that looks like? Like what are those items in a family, what defines a family-centered cesarean?
Bootstaylor: Yeah. I’ll describe it briefly and give you some context with that. So, the family-centered cesarean doesn’t have to be planned. It could be during the course of labor. Labor has stilled, if you will, or you need to proceed to the OR. You can walk to the operating room, by the way, so there’s a sense of mobility with that. In the operating room, I put a mirror up so that mom can see the baby coming from her abdomen. She can actually see the birth and witness it. Oftentimes, I hear that, “I had a baby, I think. And they brought the baby and showed it to me for two seconds. It was all wrapped up in a blanket and they took it away.”
So, I want the mother to see the baby coming from her body. There is that visual connection that it has occurred. Her arms also are not restrained and when the baby is born, I let the cord pulse for about 60 seconds. And I tell mom it’s still pulsing, and she can see the baby in the mirror, and see the goo goo gagas and all that stuff, and then we’ll clamp the cord and let the pediatric team examine the baby for about five minutes. The birth partner can go over and see the baby. They can stay in the room.
And then the baby is brought back to the mother for skin to skin. And they can do breastfeeding in the operating room. They can just do skin to skin, take pictures, and all that stuff. So, I make it such that it’s a birth, as opposed to, “We need to get this baby out and save it.”
With that said, I’ll do a family-centered cesarean with an emergency C-section, because you’re doing the surgery. Not like… You know, you’re still doing, and once the baby’s born, if it needs to be managed differently, then the pediatricians can do that. But oftentimes, the baby’s kind of vigorous at birth. It’s like… And so, I try to make it a birth experience. So, the one more piece to the family-centered, to add to it, is that I will close the skin with a suture. No staples. And I want mom when she sees that incision, sees a nice, thin line. So, what she can say to herself in the whole process of this family-centered cesarean is that she had a birth. She didn’t have a failed v vaginal delivery. She didn’t have an elective cesarean. She actually had a surgical birth.
And when mom puts all that together, a lot of our moms in our service when they have a family-centered cesarean, they’ll go home in 24 hours.
Lozada: So, why do you think we are considering so many things high risk today, and why do you not consider breech birth, for example? Why do you feel breech birth is not high risk when most every other provider does?
Bootstaylor: I mean, science supports the fact that breech is a variation of normal. So, science supports that if a breech presentation meets certain criteria, it is reasonable and safe to support vaginal breech birth. That’s what science supports. So, then you have providers who may say, “I’ve never seen a breech birth. I never heard of a breech being born vaginally. How can it even happen on the planet Earth?” So, therefore it must be high risk, despite the American College of OB/GYN saying about 90% of breeches can be supported for vaginal birth. Because there’s certain criteria.
So, there’s scientific evidence to support a mom laboring to have a vaginal breech. It’s written. Provider is able to throw a label on that and get the mom to do something that she hasn’t maybe thought about. So, it’s more probably a comfort. I’m gonna say there’s some ignorance on the providers’ part, meaning they have never had the experience. Not ignorant as in totally ignorant or things, but not having the experience to do it. Having not seen it, then they will default to their preferences. And it’s easy to call it high risk, just to wrap it up in a couple words, as opposed to try to explain, “I’m not comfortable with supporting breach. I know it’s supported scientifically. In our group, we don’t support vaginal breech birth, therefore we would recommend a cesarean section.” Very nice, clean, versus, “You’re at high risk, your baby may become entrapped. It’s dangerous. How dare you even think about a vaginal breech birth?” So, now mother feels, “Oh my God, I was either gonna compromise my baby’s well being.” No, we don’t support vaginal breech birth. You understand the criteria. We’re happy to support you.
And that’s the same sentence, saying that we don’t do breeches.
Lozada: But I wish they would be honest like that.
Lozada: The question I keep coming back is how do we change that, and we have, we’ve answered this by trying to really get the word out there about the importance of shared decision making. And demanding from care providers.
Bootstaylor: One of the goals is to make the providers better. So, if moms could feel, “Okay, I may not be one who wants to do whatever.” I can make my provider better by practicing this. And so, the providers have to receive it, though. And this will be on the front of my biography, when I started at the beginning of this podcast, I was… And this may be critical, I think. I was also in the special forces for… I was in the Green Berets, on the A team. And before college, right out of high school, joined special forces. And in that, you learn to develop a risk tolerance of things based on facts. And as a team, 12 people on a team, everybody relied on each other. Your risk tolerances allowed you to get through crises.
Dealing with reality, basically. So, as someone who’s had that indoctrinated into my core, add to that the maternal fetal medicine specialty, and then add to that understanding I think science behind obstetrics. I don’t view things as, “Oh my God, I’ve never heard of this. This is a risk factor.” There’s plenty of factors about vaginal breech birth. There’s enough to fill up a vault, basically. I look at the facts and then where is mom’s temperament and disposition? I have many moms come to me with breech who ask for a cesarean, by the way. We have a conversation, we go through it, and they say, “You’re obviously comfortable not doing a cesarean with it, but I’m not comfortable with it.”
So, being with that background in the special forces, I’m able to look at information kind of objectively, but add a touch of humanity to it. So, to my fault, I try to have a balanced, respectful conversation with people, and then let them walk through what their choices are. And can that be passed onto other providers? I’m not sure. That’s why the mothers, one of the goals of the book is for the mother to make the providers better. And not just one or two of you guys at a time. You may do 20 births a year yourself. It can’t be 20 births a year between you and I. It has to be tens of thousands saying that we should have doula support.
Lozada: Yes. And the question that I forgot to ask you about the late transfer, 39 weeks, how are you able to create trust at such a late transfer?
Bootstaylor: Sure. Great question. Well, what I tell the moms who are having that, some of these are phone calls by the way to save them a trip, I tell them, “You’re probably not transferring to talk about the weather. You’re not transferring to talk about the nice wallpaper we have in the office.” When you transfer, are talking about it, I know it’s your partner, the grandmothers are a little bit concerned, your best friends, your coworkers, even you’re staring at the ceiling at midnight. Am I being selfish? Am I just overexaggerating my needs? So, when the mom is talking about transferring, I tell them, “You’re not here to talk about the weather.” So, this is… It’s a very serious psychosocial dynamic going on. So, I break the ice on that level, and then they realize, “Oh. I’m not just transferring because Dr. Bootstaylor can do a breech.” You’re transferring because of everything that’s happened to force the transfer.
And then I also tell mothers, “You should be able to go back to your provider today, tomorrow, next week, and have a conversation with them.” And if they cannot now have that conversation after we’ve had our conversation, then you probably need to seek a different place to have your birth, where you feel safest. And so, the ability to establish trust is the ability to have a conversation. I mean, you have it when you go to the restaurant. You don’t know the waiter. What do you recommend? Oh, I recommend the fish. Okay. Seems reasonable. Okay, trust you. I’ll have the fish. It doesn’t have to be complex thinking, right?
Lozada: But the stakes are different. If the fish is not good, well, you know.
Bootstaylor: Understood. But it’s the same human dynamic.
Bootstaylor: I mean, that stranger you’ve met on the bus, or at the school play, or the… You’re not trying to read whether they are… It’s that humanity.
Lozada: And you know, I think if a provider tries it out and has a good experience with shared decision making, which they will, right?
Lozada: They will feel less the burden of, “I need to scare you into doing. I need to practice fear-based maternity care because if something goes wrong you’re gonna point at me.”
Bootstaylor: I think that’s a great point. I think you’ve illustrated it clear and succinctly as one could. I think that’s a great description of it. I mean, they’re truly relieved from taking the responsibility of everything, so that’s why I don’t view mothers as high risk. They have risk elements they were given in some context, but they are accepting responsibility for the choices. I’m a “medical provider” able to hopefully outline what those choices are. And I’ll have recommendations, by the way, that are declined often. Appreciate your recommendation, Dr. Bootstaylor. I know you’re the one. I need to do this. And she owns it.
Lozada: Are you also seeing better outcomes? Because birth is not zero risk. It’s never been and as safe as we try to make it with technology, it’s never gonna be.
Bootstaylor: Yeah, and I try to be careful of saying the choices or the outcomes are healthier. No, the outcomes are what they may be statistically based on what the choices are.
Lozada: And that’s really, I find that being pregnant is the first step into parenting, like that’s… Having to make decisions for your children and for yourself throughout life. We are all weighing risk and consequences in our daily lives. It’s just there’s bigger stakes.
Bootstaylor: Well, I must admit this realm of maternity is probably the last frontier for humanity. I know I’m a little biased in that, but I’ve looked at how can you change the direction it’s going in? I say this often. Science, not science, but providers have said you can’t get pregnant without me, you can’t maintain your pregnancy without me, and you cannot have a baby without me. That relationship needs to change.
Lozada: Yes. Because the provider’s not the one having the baby.
Bootstaylor: Right. You have to be able to maintain your voice. If you can’t maintain your voice, then you can’t help others become better. So, maintaining that voice, and you see that in 2020. It’s when people’s voices are oppressed, suppressed, then you have frustration. And so, the same is in the realm of maternity, as far as I can see it. Mother’s don’t have choices. They can’t choose where they can birth, who they can birth with, and they got… You know, their voices are being silenced. And in that is frustration and I’m sure trauma. So, maintaining your voice helps with empowerment.
Lozada: That was OB/GYN and maternal fetal medicine specialist, Dr. Brad Bootstaylor, author of the book, Shared Decision Making: Bringing Birth Back Into the Hands of Mothers. You can access the nine questions to determine your provider’s score through the book or at his website, seebaby.org. And that’s S-E-E-BABY.org. Dr. Bootstaylor is also on Instagram @see_baby.
One thing you can do for you is to embrace the reality that if you’re pregnant, no matter how far along, you’ve already started to parent. Be an active participant in your pregnancy and birth choices and take the responsibility of participating in shared decision making. The one thing you can do for the rest of us is to take it one step further and actually take a pledge that you will demand shared decision making from your provider. Using our collective voices is one way to be part of the systemic change we need, so to help out with this we’ve created a webpage where you can learn more about shared decision making and take the pledge to receive handouts to take to your appointments. You can go take the pledge at Birthful.com/shared-decisions.
You can connect with Birthful on Instagram @BirthfulPodcast and to learn more about Birthful and my birth and postpartum preparation classes, go to Birthful.com. A new birth series starts January 11th.
Lozada: Birthful was created by me, Adriana Lozada, and is a production of Lantigua Williams & Co. The show’s senior producer is Paulina Velasco. Virginia Lora is the managing producer. Cedric Wilson is our lead producer. Kojin Tashiro mixed this episode. Alie Kilts contributed to this episode. Thank you for listening to and sharing Birthful. Be sure to subscribe on Apple Podcasts, Amazon Music, Spotify, and everywhere you listen. Come back next week for more ways to inform your intuition.
Lozada, Adriana, host. “Why You and Your Care Provider Must Decide Everything Together.” Birthful, Lantigua Williams & Co., January 4, 2020. Birthful.com.
About Dr. Brad Bootstaylor
Dr. B. Bootstaylor ascribes to a philosophy of “shared decision making” in maternity care based on his extensive training, deep experience and genuine belief in empowering your birth journey.
In practice in Atlanta, GA since 1996 as an Ob & MFM, Dr. B. has developed his shared decision making (SDM) model of care into an inviting process that encourages the birthing person to engage their maternity care and birth confidently and safely.
In working with many health care professionals such as doulas, midwives and childbirth educators, Dr. B. creates a healthy environment for the birthing person to discover their confidence about their birth preferences with a genuinely supportive team (a nod to his military background on a Special Forces A-team).
The concept of “guided discovery” gives a voice to the SDM model that many patients want to be a part of. Patients do not have to fight for this respectful process, as it is the expectation of your partnership with your care team, aka SDM.
Dr. B is married, has 3 children and lives in Atlanta, GA
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