The delivery room is not the place to be worrying about your rights. When you’re squatting or lying down, you don’t want to have to worry about standing up for yourself. Unfortunately, if you don’t, who will? For a lot of reasons (from being overworked to buying into paternalistic medical practices), helping you maintain control over your care may not be at the top of your care provider’s priorities. Which means you need to be thinking about your wishes and rights during labor and delivery long before your water breaks.

Enter, this Childbirth Bill of Rights. It’s a template for talking to your health care provider in the months ahead of labor, suggested questions to ask when pregnant, so you know what to expect when you’re done expecting (barring any emergencies). It allows you to confront hospital rules and care provider preferences early and decide if you’re willing to accept them or if you want to seek different care. It guides you in exercising informed choice over your body and treatment while planning your birth – because you are the only person who should be making the final decision about your care.

Your Rights during Labor and Delivery

You have the right to know your care provider’s qualifications and birth experience.

These are some of the most important questions to ask when pregnant, because a care provider’s answers can give you a general sense for how their interactions with you will proceed. Ask about their degree, how many years of clinical experience and what type of clinical experience they have. Ask for the numbers: If you are trying to have a vaginal birth, then ask how often your care provider assists vaginal births versus C-sections. If your care provider has an 80% C-section rate, they might not be the best person to ensure a vaginal delivery (or vice versa).

Similarly, if you’re interested in a vaginal birth after Caesarean (VBAC), ask your care provider about his or her experience facilitating them. Evidence-based guidelines consider a VBAC an appropriate choice for women who wish for one, but many care providers have yet to catch up and lack experience.

It may be difficult to ask these questions, but (a) you don’t have to ask in a combative, disrespectful way; and (b) asking can save you hassle and worry later on. For instance, if your care provider is reluctant to share their qualifications and expertise with you, it might be a red flag that an informed patient is not their priority.

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You have the right to know whether, at what point, and why labor will be induced.

While giving birth in weeks 39 or 40 is linked to the best health outcomes (and some care providers support waiting even longer for labor to start spontaneously), inducing labor before full term pregnancy, that is, in the 37^th or 38^th week of pregnancy, is not uncommon in India. Inducing labor before full term pregnancy comes with risks: Babies born before 39 weeks are more likely to experience complications that require a stay in the NICU. (Globally, complications from premature birth are the leading causes of death for children under 5.) Preterm birth is also associated with learning disabilities, vision and hearing problems and more.

In general, the best time for your baby to be born is when your body naturally goes into labor. However, your care provider may recommend an induction based on what he or she considers to be medically necessary – which may be influenced more by his or her experience, ability and approach than by evidence. Many care providers, either because they lack experience or because they are trying to mitigate risk, will suggest early induction/C-section in the event of: a “big” baby; decrease in amniotic fluid; twins; the 40-week full-term date has passed; or the water has broken before labor starts. These scenarios may warrant more careful observation, discussion and facilitation, but there are care providers who can help you navigate them without inducing labor early or performing a Caesarean. The key thing is to decide what is important to you, and find a care provider who is able and willing to support your wishes.

You have the right to know and understand what medical interventions might be performed on you during childbirth, why and at what point.

Natural, also known as physiologic, births — births that start, proceed and end without medical interventions — are very rare in Indian hospitals. Some of these interventions are routine and harmless (though not necessarily helpful). Others are unnecessary and annoying; still others are unnecessary and come with risks. It’s common for any of these interventions to be presented as necessary, but per evidence-based best practices, it is rare that they would actually be so. Regardless, none of these should be performed on you without your informed consent.

Let’s go through them one by one:

Routine birth interventions

Regular vaginal exams during labor

Vaginal exams during labor are a pretty accepted, albeit uncomfortable, part of labor care anywhere. Vaginal exams can help the care provider assess the baby’s positioning and the dilation of the cervix, however, there is little evidence they affect birth outcomes. Some care providers may be willing to forgo or minimize these invasive exams  if you discuss your birth plan preferences beforehand.

Possibly helpful birth interventions

Inducing labor with membrane stripping or sweeping

Care providers may recommend a membrane sweep, which is when they insert a finger into the vagina and sweep it in a circle around the opening to your cervix. This is a widely accepted practice – with conditions. First, membrane sweeping should never be done without discussion and your consent. Nor should it be done before your 40-week due date. Because it does carry some risks: Membrane stripping can reduce the chance of an overdue pregnancy and can be a more natural induction of labor than using induction drugs (which carry their own risks, see below); however, it can be very painful, may cause bleeding, and, in 10% of cases, causes the water to break, which increases the risk of infection and may make a C-section more likely.

Unnecessary and annoying birth interventions

IV during labor

For most women, having an IV during labor is unnecessary, not to mention restrictive, and sipping water can maintain proper hydration. Hydration via an IV during labor can lead to oedema, that is, swelling from excess water retention, which can complicate breastfeeding. (An IV during labor can also give the impression that a mom-to-be is a patient in need of treatment, which can further encourage intervention.)

Continuous electronic fetal monitoring

Devices for continuous electronic fetal monitoring may be strapped to the mother’s stomach in order to track her contractions and the baby’s heartbeats in real time. Sounds amazing, but research shows these devices aren’t associated with better birth outcomes for women with low-risk pregnancies; periodically checking the baby’s heartbeat is just as good as continuous fetal monitoring during labor. Instead, these devices restrict movement and often provide inaccurate data due to their sensitivity, which may make care providers more likely to jump to conclusions and recommend an unnecessary C-section.

Unnecessary and potentially harmful birth interventions

Inducing labor with Pitocin (synthetic oxytocin)

Pitocin, the brand-name for synthetic oxytocin, does have a time and place for the informed and consenting mother, generally when labor fails to progress. However, “failure to progress” is a highly subjective diagnosis; most labors progress slowly and unevenly. Inducing labor with Pitocin or generic oxytocin comes with trade-offs: required hydration via IV during labor; required continuous fetal monitoring during labor, (potentially, a bladder catheter too); and sudden and greater pain, as inducing labor with Pitocin makes contractions go from 0 to 60 and inhibits your natural pain-relieving hormones. Using oxytocin to induce labor also risks hyperstimulating the uterus, which can stress the baby or rupture the uterus, necessitating a C-section.

Performing an artificial rupture of membranes, i.e., an amniotomy

Assuming a labor is progressing smoothly, with no fetal compromise, then performing an artificial rupture of membranes — also known as an amniotomy (you can think of it as artificial water breaking) — isn’t necessary and may create more problems: The risk of infection after water breaks increases as time passes; there is also a risk of cord prolapse (when the umbilical cord falls through the cervix before the head), after artificial rupture of membranes, which can endanger the baby’s oxygen supply, among other issues.

Performing an episiotomy

An episiotomy — that is, a surgical cut to your perineum (your vaginal opening) — is a very outdated practice that is still unfortunately very common in India. Contrary to previous thinking, the recovery time for episiotomy is longer than for a natural perineum tear during childbirth. And while it’s true cuts are easier to suture than tears, that is an argument to make the care provider’s job easier, rather than the mother’s recovery. In fact, if your perineum tears, you may not even require perineal stitches (it’s 50/50) – but with an episiotomy, you will 100% require suturing, as an episiotomy cuts through skin and muscle and typically does more damage than tearing.

Some care providers in India justify episiotomies by saying South Asian women’s perinea tear more than Caucasian women’s during birth. There may be a shard of truth to that — one study found Indian and Filipino women in the US were more likely to have severe perineal tears than other ethnicities. Regardless, the risk of severe perineal tearing is very low for all women, no matter what skin colour or nationality, and does not warrant routine use of episiotomy.

Discuss your care provider’s and the hospital’s policy on these practices ahead of time to avoid any unnecessary, outdated cuts and a longer recovery after giving birth.

You have the right to know what options for pain management during labor are available to you, when, and until what point, and the right to request and receive those options until that point.

Epidurals and spinal anesthesia are common medical options for pain relief during labor. But most women don’t know there are conditions around their use. For instance, epidurals require an anesthesiologist to administer. Ask your caregiver: Is there an anesthesiologist always available, or on-call at your place of birth?

Also, some hospitals have “cut-off points,” after which getting an epidural during labor is not allowed, typically because the labor is too far along or is progressing too fast for her to remain completely still for its administration. These cut-offs vary (though always before the urge to push/full dilation) between hospitals and care providers, so be sure to ask yours beforehand. (Conversely, you can always refuse an epidural if one is offered or insisted upon.)

Also, consider what non-medical options for pain management during labor are available to you. Continuous one-on-one support from a doula, hot compresses and water birthing are all alternative methods of pain relief during labor – ask your care provider: Does the hospital allow doula attendance? Can the hospital facilitate a waterbirth or water labor? Can you get hot compresses throughout labor?

You have the right to the most private birth experience possible.

Some care providers require the assistance of a team; others are fine working alone or with just one or two supporting staff. In teaching hospitals, it’s typically hospital policy that any medical staff be allowed into the delivery room at any point; in other hospitals, it may merely be practice, but not necessarily policy. Find out your caregiver’s preference and hospital policy/practice ahead of time so you can make your own preferences clear and switch caregivers if you are not aligned. Labor is much more likely to progress normally in situation where mothers feel unobserved and safe.

You have the right to know if, how and why your movement, actions and company will be restricted during labor.

Freedom of movement during labor is probably the simplest and most effective tool pregnant women have. According to a literature review of normal birthing practices published in The Journal of Perinatal Education, “women who use upright positions and are mobile during labor have shorter labors, receive less intervention, report less severe pain.”

This doesn’t mean you have to be doing push-ups or yoga during labor, but walking during labor, swaying your hips, getting on your hands and knees can help bring a baby down and out. Continuous fetal monitoring during labor, having an IV during labor and hospital policies can restrict women’s movement, however. Ask your caregiver ahead of time how much freedom of movement you’ll have.

Your rights during labor and delivery also include not being alone. Many women want their husband in the delivery room, or their partner, doula, other family member — or all of the above. Decide which of your people are indispensable to your birth plan and ask ahead of time whether the care provider and/or hospital will allow them to keep you company during labor and delivery — including in the event of an emergency C-section.

You have the right to know if and why you may not be allowed skin-to-skin contact after birth, and to request it outside those scenarios.

The benefits of skin-to-skin contact after birth (also known as kangaroo care after birth) are many, and range from emotional to physical for both mother and baby. While rare emergencies may make immediate skin-to-skin contact after birth impossible, your rights during labor and delivery include a delay of routine post-birth baby care like weighing, measuring or cleaning, which may unnecessarily take your baby out of your arms. Ask if your hospital supports doing these assessments an hour or two after the birth.

A C-section can make immediate skin-to-skin contact after birth challenging, but not impossible. If it’s important to you, ask your care provider if a loved one or nurse can hold the baby as close to you as possible, or, if immediate skin-to-skin contact with the baby is possible for your partner. Find out what a hospital’s post-C-section policies are and if they can accommodate immediate skin-to-skin contact after birth. And if anyone tries to take away the baby for a non-emergency reason, stand your ground!

You have the right to know if and why your baby may be top-fed, and to decline it in favor of breastfeeding.

Breast milk is uniquely suited to infants’ needs and is universally recognized as the best diet for newborns. That said, feeding formula to a newborn right after birth (often without asking the parents) is routine in many Indian hospitals; it’s a practice called a top-up or top-feed. If you don’t want your baby given formula, discuss your preferences, the hospital’s policy and your plan for breastfeeding right after birth (Don’t have a plan? Make one here!) with your care provider as thoroughly as you discuss your other rights during labor and delivery listed above.

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Good luck, moms-to-be! Remember, this is your birth, your body, and your baby. Choosing a care provider whose experience and approach aligns with your wishes goes a long way to making sure your rights during labor and delivery are respected and your birth experience is a happy one for you and your child. And isn’t that the best start to life?