Choices about first trimester ultrasound scans: A decision aid for pregnant women

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1 Choices about first trimester ultrasound scans: A decision aid for pregnant women

2 If you have any concerns about yourself or your baby/babies and want to talk to someone, please call: your family doctor 13 HEALTH telephone line ( ) Lifeline counselling service ( ) Stillbirth and Neonatal Death Support (SANDS) helpline ( ) Pregnancy, Birth & Baby Helpline ( ) What is this decision aid about? The research and development of this decision aid was conducted by Natasha Hayes, a health researcher, and Rachel Thompson, a health psychology researcher at the Queensland Centre for Mothers & Babies. The Centre is an independent research centre based at The University of Queensland and funded by the Queensland Government. The Centre does not stand to gain or lose anything by the choices you make after reading this decision aid. This decision aid has been developed to be consistent with International Patient Decision Aid Standards criteria for quality decision aids whereever possible. This decision aid is not meant to give you medical advice or recommend a course of treatment and you should not rely on it to provide you with a recommended course of treatment. It is not intended and should not be used to replace the advice or care provided by your midwife, your doctor and/or your obstetrician. You should consult and discuss your treatment options with your midwife, your doctor and/ or your obstetrician before making any treatment decisions. The University of Queensland, its employees and affiliates have made reasonable efforts to ensure the content provided is up to date and accurate. However, it does not guarantee and accepts no liability or responsibility for the accuracy, currency or completeness of the information contained in this decision aid. To the extent permitted by law, The University of Queensland its employees and affiliates exclude all liability including negligence for any injury, loss or damage caused by or arising out of any reliance on the content contained in this decision aid. Unless otherwise indicated, the content of this decision aid is the property of The University of Queensland. All content is protected by Australian copyright law and, by virtue of international treaties, equivalent copyright laws in other countries. No material contained within this decision aid may be reproduced or copied in any way without the prior written permission of The University of Queensland. Last updated: March 2010 This decision aid has been written to support pregnant women to know what to expect and to have a say in making decisions about first trimester ultrasound scans. An ultrasound scan is when a small handheld device is used to create a picture of a woman s uterus (womb) and baby during pregnancy. A first trimester ultrasound scan is an ultrasound scan done in a woman s first trimester of pregnancy (the first 14 weeks of a woman s pregnancy). This decision aid provides information about two options: 1. Choosing not to have a first trimester ultrasound scan 2. Choosing to have a first trimester ultrasound scan This decision aid will answer the following questions: What is an ultrasound scan? Why might a first trimester ultrasound scan be offered? What are my options? What happens if I choose not to have a first trimester ultrasound scan. What happens if I choose to have a first trimester ultrasound scan. Will I always be able to choose? How might I choose between not having and having a first trimester ultrasound scan? What are the differences between not having and having a first trimester ultrasound scan? 2012 The University of Queensland, Brisbane Australia. ABN , CRICOS provider No B What do the symbols mean? The information in this decision aid has come from the best scientific studies available to us. Numbers in brackets [1] indicate a reference to a study that is listed at the back of the decision aid. We use this symbol when there is something you might like to ask your care provider about. How can I make the decision that s best for me? How can I ask questions to get more information? Women may also be offered an ultrasound scan at other times in pregnancy. This decision aid provides information only about ultrasound scans in the first trimester of pregnancy. You might like to ask your care provider about ultrasound scans at other times. e-version 1.3 2

3 What is an ultrasound scan? Why might a first trimester ultrasound scan be offered? An ultrasound scan is when a midwife, a doctor or a sonographer (a person trained to do ultrasound scans) uses a transducer (a small handheld device) to create a picture of a woman s uterus and baby during pregnancy. The transducer is usually moved across the woman s abdomen (stomach) and sends out soundwaves to create the picture of the uterus and baby on a computer screen. This type of ultrasound scan is also called a transabdominal ultrasound scan. Another type of ultrasound scan is a transvaginal ultrasound scan. A transvaginal ultrasound scan is when a midwife, a doctor or a sonographer inserts a long and narrow transducer into a woman s vagina to do the ultrasound scan. This type of ultrasound scan allows your care provider to get closer to the uterus and may be used to get a clearer picture of the uterus and baby. Ultrasound scans can be 2-D (two-dimensional), 3-D (three-dimensional), or 4-D (four-dimensional). A 2-D ultrasound scan gives a still black and white picture showing the outline of the baby in the woman s uterus. A 3-D ultrasound scan gives a still brown picture showing the baby in the woman s uterus in three dimensions. A 4-D ultrasound scan gives a moving brown picture showing the baby in the woman s uterus in three dimensions. A first trimester ultrasound scan creates a picture of the pregnant woman s uterus and baby that can give the woman and her care provider information about her pregnancy. First trimester ultrasound scans don t always provide information that is accurate. The accuracy of the information from the ultrasound scan depends on different things including the timing of the scan, the position of the baby, the skill of the person who does the ultrasound scan, and the skill of the person who looks at the pictures from the ultrasound scan and prepares the report on the results [1,2]. The most common types of information that can be found out from a first trimester ultrasound scan are explained below. Different women like to know different things about their pregnancies and some women prefer to not know any of these things. For each type of information given, we have included space for you to tick whether the information is important to you. Ticking these boxes might help you to make decisions about whether or not to have a first trimester ultrasound scan. If you choose to have a first trimester ultrasound scan ticking these boxes might also help you to make decisions about what information to find out from the ultrasound scan. Ultrasound scans can be done at different times in pregnancy during the first trimester (up to 14 weeks of pregnancy), during the second trimester (from 14 weeks to 26 weeks of pregnancy), or during the third trimester of pregnancy (from 26 weeks of pregnancy onwards). This decision aid is about ultrasound scans done during the first trimester. e-version 1.0 3

4 Why might a first trimester ultrasound scan be offered? Continued To see whether a woman s pregnancy is viable A first trimester ultrasound scan can be a way of confirming a woman s pregnancy and finding out in some circumstances whether it is viable (will continue). For example, a first trimester ultrasound scan can be used to check whether the woman has an ectopic pregnancy. An ectopic pregnancy is when a fertilised egg implants and grows outside of the uterus rather than inside the uterus. In most cases, an ectopic pregnancy is not viable. A first trimester ultrasound scan cannot always confirm whether a woman s pregnancy is viable. You might like to ask your care provider more about the accuracy of first trimester scans and other methods for finding out whether a woman s pregnancy is viable. You might also like to ask your care provider for more information about your options if you have a first trimester ultrasound scan and find out that your pregnancy is not viable. These options can include counselling to give you support and help you make decisions. Important to you? Yes No Unsure 2. To see how many weeks pregnant a woman is A first trimester ultrasound scan can be a way of estimating how many weeks pregnant a woman is, that is, how long she has been pregnant. Care providers estimate how many weeks pregnant a woman is by looking at the size and development of the baby. For example, care providers can look at the baby s crown-rump length. The crown-rump length is a measure of the distance in centimetres from the baby s crown (the top of the head) to the baby s rump (the bottom of the buttocks). The estimate of how long a woman has been pregnant is used to work out her baby s estimated due date (EDD). The estimated due date is the date when it is thought that a woman will be 40 weeks pregnant. However, it is very common for babies to be born before or after the estimated due date. A baby born when a woman is anywhere between 37 and 42 weeks pregnant is said to be full term [3]. The estimate of how long a woman has been pregnant is also used to work out when best to schedule any other tests or scans a woman chooses to have during pregnancy. Some tests and scans offered to women can only be done at specific times in pregnancy [1]. The estimate of how long a woman has been pregnant is also used later to work out whether she has a prolonged pregnancy. A prolonged pregnancy is a pregnancy when the woman has not had her baby by the time she is 42 weeks pregnant. Women with a prolonged pregnancy often have different considerations and decisions than women who have their baby before 42 weeks. A more accurate estimate of how many weeks pregnant a woman is results in a more accurate estimate of whether or not she has a prolonged pregnancy. More information for women who have a prolonged pregnancy is provided in Choosing how your labour will start: A decision aid for women with a prolonged pregnancy. You can also find out how many weeks pregnant you are by counting forward the number of weeks since the first day of your last menstrual period (LMP) or by having an ultrasound scan later in pregnancy. You might like to ask your care provider about the accuracy of these different ways of finding out how many weeks pregnant you are. More information about the whether there are differences between women who don t have, and women who have, a first trimester ultrasound scan (eg the chance of having other pregnancy tests and scans at the right time, the chance of being told you have a prolonged pregnancy, the timing of the baby s birth) is provided later in this decision aid. Important to you? Yes No Unsure 4

5 Why might a first trimester ultrasound scan be offered? Continued To see what position a woman s placenta is in While it is not usually offered for this reason, a first trimester ultrasound scan can be a way of finding out the position of a woman s placenta. The placenta is an organ that connects to the wall of the uterus and is also connected to the baby by the umbilical cord. For some women, the placenta is down low in the uterus and is near to or covering the cervix. When a woman has a placenta that is near to or covering the cervix, she is said to have placenta praevia. When a woman has placenta praevia, the placenta can block the baby coming out of the vagina during birth. Women with placenta praevia often have different considerations and decisions than women who do not. If a care provider knows that a woman has placenta praevia, he or she can give the woman information and care more suited to her unique pregnancy. Frequently, a placenta that is down low in the uterus in the first trimester can change positions and move away from the cervix as the uterus grows during pregnancy. If a first trimester ultrasound scan shows that your placenta is low in the uterus, near to or covering your cervix, you may be offered another ultrasound scan later in pregnancy to see if your placenta has changed positions [4]. 4. To see whether a woman has a multiple pregnancy A first trimester ultrasound scan can be a way of finding out if a woman has a multiple pregnancy. A multiple pregnancy is when a woman is carrying twins, triplets or more babies. Women with a multiple pregnancy often have different considerations and decisions than women who are carrying one baby. If a care provider knows that a woman has a multiple pregnancy, he or she can give the woman information and care more suited to her unique pregnancy. You may be able to find out whether you have a multiple pregnancy in other ways. For example, if your care provider listens to your baby s heart beat during pregnancy, more than one heart beat may be able to be heard. You might like to ask your care provider about the accuracy of a first trimester ultrasound scan and other ways of finding out whether a woman has a multiple pregnancy. Important to you? Yes No Unsure You can find out what position your placenta is in by having an ultrasound scan later in pregnancy. You might like to ask your care provider about the accuracy of ultrasound scans done at different times during pregnancy. You might also like to ask your care provider about your options if you find out that you have placenta praevia. Important to you? Yes No Unsure Photo courtesy of Little Posers Photography 5

6 Why might a first trimester ultrasound scan be offered? Continued To see how a woman s baby is developing A first trimester ultrasound scan is a way of checking how a woman s baby is developing. A baby s development can be checked in different ways. For example, the baby s head, abdomen, spine, arms, legs, hands and feet can be measured by the woman s care provider. The baby s organs, such as the heart and kidneys, can also be examined. Checking how a woman s baby is developing can allow a care provider to see whether a baby has, or might have, any abnormalities. An abnormality is when a baby is not developing in the usual way. There are different kinds of abnormalities that can be found by looking at a first trimester ultrasound scan. You might like to ask your care provider about the different types of abnormalities that can be found during a first trimester ultrasound scan. 6. What gender a woman s baby is While it not usually offered for this reason, a first trimester ultrasound scan can be a way of finding out what gender a woman s baby is. Care providers can only work out the gender of the baby if the baby s genital region (external sex organs) can be seen on the ultrasound scan. Sometimes, women are told the wrong gender when having a first trimester ultrasound scan. You might like to ask your care provider about how accurate a first trimester ultrasound scan is for finding out the gender of the baby. Important to you? Yes No Unsure A first trimester ultrasound scan, if done at a specific time, can be combined with other extra tests to check whether a baby might be more likely than usual to have a chromosomal abnormality [5]. A chromosomal abnormality is when there are problems with the baby s chromosomes (parts of the body that contain the baby s genes and influence how the baby develops). Down syndrome is one type of chromosomal abnormality. You might like to ask your care provider more about screening (checking) for and diagnosing (confirming) chromosomal abnormalities during pregnancy. Different abnormalities can have different consequences for babies and their families. Sometimes, a first trimester ultrasound scan can show that a baby has an abnormality that ends up fixing itself before the baby is born. At other times, a first trimester scan can show that a baby has an abnormality that means that the baby may not survive. A first trimester ultrasound scan can also miss some abnormalities or show an abnormality when the baby does not really have one. You might like to ask your care provider about how accurate a first trimester ultrasound scan is for finding different types of abnormalities. You might also like to ask your care provider about your options if you find out that you baby isn t or might not be developing in the usual way. These options can include counselling to give you support and help you make decisions about your options. Important to you? Yes No Unsure 6

7 What are my options? When thinking about first trimester ultrasound scans, there are two options: Option 1 Choose not to have a first trimester ultrasound scan Option 2 Choose to have a first trimester ultrasound scan 7

8 What happens if I choose not to have a Option 1 first trimester ultrasound scan? Option 2 What happens if I choose to have a first trimester ultrasound scan? If you choose not to have a first trimester ultrasound scan you can still choose to have an ultrasound scan later in pregnancy. If you choose not to have a first trimester ultrasound but are interested in some of the information described previously (eg how many weeks pregnant you are), you might like to ask your care provider how else you might find out this information. If you choose to have a first trimester ultrasound scan, the ultrasound scan might be done at the place where you are receiving your pregnancy care (eg at a clinic or hospital) or might be done somewhere else (eg at a special ultrasound clinic). You can usually bring a support person or people with you to a first trimester ultrasound scan. If you are having a transabdominal ultrasound scan, your care provider might ask you to drink a large amount of water and/or fast (not eat) for several hours before the time of your scan. This is so you have a full bladder and/or no food in your stomach during your ultrasound scan. During the ultrasound scan, your care provider puts a small amount of gel on your abdomen and moves the transducer across the gel on your skin. A picture of your uterus and your baby then appears on the computer screen. Some women like to ask to look at the screen to see the picture while they are having the ultrasound scan. It is sometimes possible for the ultrasound picture to be printed out as a photo for you to keep, but not all places offer this. If you are having a transvaginal ultrasound scan, your care provider will not usually ask you to drink a large amount of water before your scan. During the scan, your care provider will ask you to remove your underwear and will cover you with a sheet. Your care provider will then cover the long, narrow transducer in plastic (like a condom) and insert it in your vagina. A picture of your uterus and your baby will then appear on the computer screen. When you have a first trimester ultrasound scan, the results are usually ready straight away. Sometimes, the pictures of your uterus and your baby are examined by a radiologist (a specialist doctor) after the ultrasound scan. The radiologist then interprets the ultrasound pictures and prepares the results report for you and your care provider. There may be a cost involved in having a first trimester ultrasound scan. You might like to ask your care provider for more information about whether there is a cost for a first trimester ultrasound scan, how long the scan will take, how you can prepare for your ultrasound scan and what to expect. 8

9 Will I always be able to choose? How might I choose between not having & having a first trimester ultrasound scan? During your pregnancy, your care provider might suggest that you have a first trimester ultrasound scan. If this happens, you can ask your care provider about the reasons for their suggestion and make decisions as a team. You can choose to follow their suggestion or you can choose to say no. You will usually be able to choose to have a first trimester ultrasound scan. You can also choose what you would like to find out from the ultrasound. For example, you can choose to find out some things, and choose not to find out other things. It may not be possible for your care provider not to find out something during an ultrasound scan (eg whether you have a multiple pregnancy). However, you might be able to ask them not to tell you, if you would prefer not to know. You might like to talk to your care provider in advance if there are some things you would prefer not to know. Some care providers choose not to offer or are not comfortable offering all options to women. If you are not offered all options or the option you prefer, you can ask to have another care provider. When choosing between not having and having a first trimester ultrasound scan, you might like to consider how important it is to you to know the things that can be found out from the scan, as described on the previous few pages. You might also like to consider how you may feel if you find out certain things from the first trimester ultrasound scans (eg if you find out that your baby is not developing in the usual way). A number of studies have also looked at what happens when women don t have a first trimester ultrasound scan compared to when women do have a first trimester ultrasound scan, regardless of whether they have an ultrasound scan later in pregnancy. We have included some of the results of these studies in the next few pages. Only high quality studies have been included in this decision aid. Studies can t say for sure what would happen if you choose one option or another. However, the results of studies might give you an idea of the possible outcomes of each option. The studies we use in this decision aid give you the best possible estimates of how likely different things are to happen. Some of the studies we talk about are better quality than others. Whenever we talk about the results of a study, we give you some idea of the quality, using the following rating: is given to studies that are high quality. level studies tell us we can be very confident that choosing to do something causes something else to happen. studies are the very highest quality of studies. is given to studies that are medium quality. level studies can tell us we can be moderately confident that choosing to do something causes something else to happen. is given to studies that are low quality. level studies can tell us when things tend to happen at the same time. But level studies can t tell us that choosing to do something causes something else to happen. Will the results of these studies apply to me? In the next few pages we talk a lot about the chance of different things happening. If you would like help understanding what this means, please visit The studies we ve included are studies of women who were described as low risk (eg women who were not thought to have any complications with their pregnancy). However, every woman s pregnancy is different, so the possible outcomes of each option might be different for you. You might like to talk to your care provider who can give you extra information that is suited to your unique pregnancy. 9

10 What are the differences between not having and having a first trimester ultrasound scan? Studies have found there is a difference between not having a first trimester ultrasound scan and having a first trimester ultrasound scan in: The chance of feeling worried about the pregnancy [1] Women who don t have a 1 st trimester ultrasound scan 40 out of every 100 women were worried about the pregnancy Women who have a 1 st trimester ultrasound scan 32 out of every 100 women were worried about the pregnancy Women who were worried about the pregnancy Women who were not worried about the pregnancy The chance of being told you have a prolonged pregnancy [6] 16 out of every 100 women were told they had a prolonged pregnancy 7 out of every 100 women were told they had a prolonged pregnancy Women who were told they had a prolonged pregnancy Women who were not told they had a prolonged pregnancy 10

11 What are the differences between not having and having a first trimester ultrasound scan? Studies have found no difference between not having a first trimester ultrasound scan and having a first trimester ultrasound scan in: The chance of feeling excited about the pregnancy [7] The chance of having other pregnancy tests and scans at the right time [1] The chance of the baby dying before, during or soon after birth [1] How many weeks pregnant a woman is at birth [7] The chance of having an induction of labour (when labour is started off artificially) [1,7] The chance of having a caesarean section [1,6,7] My Notes The chance of having a caesarean section before labour starts [7,8] The chance of having an instrumental birth (where forceps (tongs) and/or a vacuum (suction) cap is used to help pull the baby out of the vagina) [7,8] The chance of the baby having a low birthweight (weighing less than 2500g) [1] The baby s birthweight [7] The chance of the baby having a low APGAR score (a score to assess a baby s well-being after birth, a score lower than 7 means that a baby might need help breathing) five minutes after birth [1] The chance of the baby going into to the Special Care Nursery (a unit in the hospital for babies who need special medical care) [7] The chance of the baby going into to the Neonatal Intensive Care Unit (NICU) (a unit in the hospital for babies who need a high level of special medical care) for three days or more [9] 11

12 What are the differences between not having and having a first trimester ultrasound scan? Continued Studies are not clear about whether there is a difference between not having a first trimester ultrasound scan and having a first trimester ultrasound scan in: The chance of having an induction of labour because of a prolonged pregnancy [6,8,9] My Notes Studies haven t looked at whether there is a difference between not having a first trimester ultrasound scan and having a first trimester ultrasound scan in: The chance of finding out that a woman has a non-viable pregnancy before she has symptoms The chance of finding out that a woman has an ectopic pregnancy before she has symptoms The chance of finding out that a woman has a multiple pregnancy before birth The chance of finding out that a woman has placenta praevia before birth The chance of finding out that a baby has an abnormality before birth The chance of having a postpartum haemorrhage (losing more than 500ml of blood after birth) The chance of the baby having development problems or disabilities in childhood The chance of the baby having difficulties with vision during childhood The chance of the baby having difficulties with hearing during childhood How satisfied women are with their pregnancy care 12

13 How can I make the decision that s best for me? At the Queensland Centre for Mothers & Babies, we understand that the right decision for you may not be the right decision for others. When making decisions about their maternity care, some women prefer to get the information and make decisions by themselves or with their families. Other women like to make decisions as a team with their care providers and some women like their care providers to make decisions for them. This decision is yours to make. You might change your mind about previous decisions if you get more information, if your circumstances change or your preferences change. For all decisions before, during and after your birth, you are entitled to know your different options, know what happens if you choose different options and choose the option that is best for you. Following these steps might help you to make the decisions that are best for you: Think about the reasons for choosing each option When making a decision about which option is best for you, it can be helpful to think about the reasons that you personally might choose each option. We have included a table in this decision aid where you can write down both the reasons you might choose not to have a first trimester ultrasound scan and/or the reasons you might choose to have a first trimester ultrasound scan. You might have come up with your own ideas or have found information somewhere else. Think about which reasons matter to you the most Some reasons might matter more to you than others and you might want to give these reasons extra thought when making a decision. There is room in this decision aid for you to mark how much each reason matters to you in a box. Doing this can also help you talk to other people about what matters to you. You might like to use a simple star rating like this to mark how important each reason is: Matters to me a little Matters to me quite a bit Matters to me a lot Think about whether you re leaning towards one option or the other Once you ve thought about the reasons for choosing each option and how much each reason matters to you, you might feel that one option is better for you. Or, you might still be unsure and want to think about it some more or ask questions. There is a place to mark what you feel about your options within this decision aid. You can also show this table to your care provider to help you make decisions as a team. 13

14 My reasons for choosing each option Reasons I might choose not to have a first trimester ultrasound scan... Reasons I might choose to have a first trimester ultrasound scan... At the moment, I am leaning towards Not having a first trimester ultrasound scan I m unsure Having a first trimester ultrasound scan 14

15 How can I ask questions to get more information? Asking your care provider questions can help you get the information you want and need. Below are some questions you might want to ask your care provider to get more information before you are offered a first trimester ultrasound scan. My Notes When would you normally offer a woman a first trimester ultrasound scan? Would you do a first trimester ultrasound scan if I asked for one? How would you feel if I declined a first trimester ultrasound scan if it was offered to me? Below are some questions you might ask your care provider to get more information if you are offered a first trimester ultrasound scan. How long do I have to think about this decision? What are the possible outcomes in my unique pregnancy if I choose not to have a first trimester ultrasound scan? What are the possible outcomes in my unique pregnancy if I choose to have a first trimester ultrasound scan? When, where and how would the first trimester ultrasound scan be done? What could I find out from this ultrasound scan? Could I choose to find some things out and not find other things out during this ultrasound scan? Is there a cost involved in having a first trimester ultrasound scan? Below are some questions you might like to ask if you choose to have a first trimester ultrasound scan. How can I prepare for my ultrasound scan? Can I bring support people with me to my ultrasound scan? Is it possible to have a print out or DVD of my ultrasound scan afterward? 15

16 Where did this information Where has come this information from? come from? The information in this decision aid has come from the best scientific studies available to us. A list of these studies is included below: [1] Whitworth, M., et al., Ultrasound for fetal assessment in early pregnancy. Cochrane Database of Systematic Reviews, : p. Art. No.: CD [2] Efrat, Z., O.O. Akinfenwa, and K.H. Nicolaides, First-trimester determination of fetal gender by ultrasound. Ultrasound in Obstetrics and Gynecology, : p [3] National Collaborating Centre for Women's and Children's Health, Induction of labour [4] National Collaborating Centre for Women's and Children's Health (NCCWCH), Antenatal care: Routine care for the healthy pregnant woman. 2008, RCOG Press: London. [5] Nicolaides, K.H., M.L. Brizot, and R.J.M. Snijders, Fetal nuchal translucency: ultrasound screening for fetal trisomy in the first trimester of pregnancy. British Journal of Obstetrics & Gynaecology, (9): p [6] Bennett, K.A., et al., First trimester ultrasound screening is effective in reducing postterm labor induction rates: A ra ndomized controlled trial. American Journal of Obstetrics and Gynaecology, : p [7] Crowther, C.A., et al., Is an ultrasound assessment of gestational age at the first antenatal visit of value? A randomised clinical trial. British Journal of Obstetrics & Gynaecology, (12): p [8] Harrington, D.J., et al., Does a first trimester dating scan using crown rump length measurement reduce the rate of induction of labour for prolonged pregnancy? An uncompleted randomised controlled trial of 463 women. BJOG, : p [9] Ewigman, B., M. LeFevre, and J. Hesser, A randomized trial of routine prenatal ultrasound. Obstetrics and Gynaecology, (2): p In time, the technical report for the development of this decision aid will be available online. Technical reports are a record of the decisions the researchers made when considering which studies to include and exclude in each of the decision aids. 16

17 Acknowledgements The Queensland Centre for Mothers & Babies would also like to acknowledge the families in Queensland for their generosity in contributing many of the beautiful photos contained in these decision aids. We would also like to thank the following organisations and individuals for their contribution to the development of this decision aid, or other decision aids we ve developed. Organisations Australian College of Midwives (ACM) Caboolture Hospital Central Maternity & Neonatal Clinical Network Ethnic Communities Council of Queensland Friends of the Birth Centre Queensland Association Inc General Practice Queensland Griffith University Herston Multimedia Unit Mater Mothers Hospital Maternity Coalition Maternity Unit, Primary, Community and Extended Care Branch, Queensland Health Midwives Information & Resource Service (MIDIRS), UK Midwifery Advisory Committee, Office of the Chief Nursing Officer, Queensland Health Midwifery Advisor, Queensland Health Northern Queensland Maternity & Neonatal Clinical Network Preventative Health, Queensland Health Queensland Maternal and Perinatal Quality Council Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) Redland Hospital Sexual Health and HIV Service Southern Queensland Maternity & Neonatal Clinical Network Statewide Maternity & Neonatal Clinical Network Stillbirth and Neonatal Death Support (SANDS) Network The University of Queensland Individuals Lana Bell Dr Wendy Brodribb Deirdrie Cullen Rachel Ford Dr Glenn Gardener Professor Geoffrey Mitchell Rosalie Potter Dr Camille Raynes-Greenow Assoc. Professor Allison Shorten Hayley Thompson Assoc. Professor Lyndal Trevena Other decision aids Choosing your model of care Choosing how to birth your baby: for women without a previous caesarean section Choosing how to birth your baby: for women with a previous caesarean section Choosing how you labour will start Monitoring your baby during labour Choosing your positions during labour and birth Choices about epidural Choices about episiotomy Birthing your placenta Queensland Centre for Mothers & Babies The University of Queensland Brisbane, QLD 4072 Australia 17

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