forced consent to vaginal examinations

[terrifiedmummy]

Hello,

This is my first post and I'm posting as I really need help.

I'm going to have my second baby soon. My first labour was horrific, abusive and traumatising. Before that I had a history of sexual abuse. I've also subsequently had a traumatic botched coil fitting which ended up requiring hospital treatment.

As a result this time I'm refusing:

• all vaginal examinations
• any medical staff to touch or look between my legs
• assisted third stage of labour (I'm want the physiological option)
• post labour examination for tearing.

I've been seeing a midwife councellor and I have a consultant because this birth will be a VBAC. All staff at the hospital are adamant that my consent will be sought before any proceduce and that they will make it as comfortable as possible but that I am not permitted to not consent. Does that make sense? In effect I have to do it! Finally today, after much harrasment from me and from the staff they have agreed to my wishes but say I must come in to hospital and sign a document saying all negative outcomes (ranging from maternal and/or fetal death to tearing) are a direct result of my choices. I've also had one midwife tell me that labours without vaginal examinations usually result in dead babies.

I've provided the hospital with NICE, WHO, Lancet and Cochrane Report papers to support the safety of my decision and provide information on how to make things safer but they won't read them.

I'm glad they've finally agreed not to force me (this happened with my first labour) but I stilll need support to help find alteratives to make things actually safer and make me feel safer, calmer and less under seige. My baby will need NICU observations after birth so I'm keen to give birth in the hospital with the NICU. My babies consultant says her complications won't effect the actual birth.

Please help. Does anyone have similar experiences or information.

pommedeterre, yes, they are. The majority of ventouse/forceps happen as a result of epidurals and lack of correct rotating of the baby/malposition due to prone position and lack of movement (commonly known as "failure to progress" or sometimes "arrested labour").

Or also failure to push under epidural, forgot to add.

aruynne I wouldn't know whether my ventouse was necessary. But I was having no pain relief as I had a silent labour. I was up on my feet walkin around the ward. I was told mine rotated from back to back to front/side (can't remember) when I mentioned the back pain was gone. No one checked my progress with VE. I was being given a sweep to speed things up when they found me fully dilated already. I couldn't push because I had no urge to push.

I felt angry so many jumped on the no pain relief = natural birth bandwagon. As if keeping active will always miraculously give you a natural birth.

I went to a afterthoughts session and the MW there said basically they couldn't tell how long I have been in active labour at all. I was to be sent home that day they were to give me a sweep. The consultant has put a note in my notes saying I should be given VE this time because I had irregular and infrequent contractions through out 1st and 2nd stage first time. (1 to 2 in 10 FYI).

Not everyone has a text book labour.

Great posts Auruynne

whoops - sorry mispelled name.

OP, I'm really sorry to hear about your traumatic experiences. I'm afraid, though, that there is no getting over the fact that babies are either born through their mothers' vaginas or removed via CS from very near their mothers' vaginas. So unless you solo birth (which would be so dangerous given your circumstances) at least one medical professional is going to at least see your vulva.

I had a relatively straightforward delivery but because my waters went early I was told by the consultant to make sure no one gave me an internal exam to reduce the risk of infection. I only had one internal to confirm I was fully dilated, and that was performed with consent by a very lovely, gentle midwife.

aurynne to reiterate, VEs are NOT the same as 'no touching / looking between legs'. This is why people are mentioning things like shoulder dystocia. I think I mentioned significant PPH - knowing whether this originates (for example) from a perineal tear, uterine atony or retained placenta would guide management of it, which could be life saving. (And incidentally, emergency c section does not guarantee no touching unless you are prepared to accept much higher risks of bladder laceration without catheter or infection due to no cleaning. It is also not a treatment for retained placenta.)

What the OP needs is a team of maternity care healthworkers meeting together with her to try to adapt to her needs and wishes for her labour and birth, whichever those are.

This is very true. I fully agree. But the hospital are not being outrageously mean to make sure she understands the potential risks / benefits associated so she can make genuinely empowered decisions about what she is and isn't comfortable with. This is needs to be a sensitive discussion or process of discussions (because ideally you would want the OP to have a chance to go away and think about things and come back with questions etc). It isn't good enough to ignore the implications of an undiagnosed / unrepaired tear and what she treatment she could be offered, whether having a trusted HCP do / present for examination might be acceptable. (And not all 3/4 tears are instrumental related - 2011/12 stats suggest about 4% in primips for SVD and 1.5% for multips.). Have you ever seen the consequences of an unrepaired 4th degree? having worked in Africa where they are relatively common (as are fistulae from obstructed labour, or failure to progress) I can assure you that permanent faecal leakage and associated infection doesn't lend itself to a good physical or psychological recovery. But these discussions don't have to be a doom and gloom confrontational experience, and has to be proportionate to both the chance of a problem and its severity. There is no excuse for adding to the trauma of someone in the OPs position. But informed consent does require, well, information, otherwise it is just as patronising as ignoring consent altogether.

If some of them can't cope with not being able to do what they want, instead of what the OP requires, then they should abstain from being involved in the OP's care. This is clearly not feasible. If (heaven forbid) OP has a massive PPH, there will probably be one anaesthetist on call for obstetrics. They're not going to say "oh no, I'm not taking her to theatre because I disagree with her previous choices". If the patient is conscious, they'll say "what do you want to do now?" and if the answer is 'theatre' they'll get on with it. If the answer's no, they'll do their best within the woman's wishes while thinking "should we have done more to explain? Could I have said something different? Should I have? God I hope she makes it". I have been involved in a maternal death via PPH in a woman who declined transfusion for religious reasons (not in UK). Watching a new mother die (probably) preventably is deeply traumatic. However much one supports informed consent and personal autonomy, it is still traumatic. You don't bounce off home and think "well, at least we did what she wanted, ooh I wonder what I'll have for tea tonight?"

Thankfully, we live in a country that has incredibly safe obstetric care compared to much of the world, so catastrophic complications are very rare. But please do not suggest that medical professionals might struggle with severe restrictions on intervention only because they "can't cope with not doing what they want" as if it's a toddler tantrum.

She doesn't want to be asleep for the birth of her baby. You aren't asleep with an elective section.

I asked for GA with #2 (#1 emerg section under GA) & they said no, it is only used in an emergency, (as it makes the baby groggy), where they don't have time for an alternative to work. I had a spinal & it was a fabulous experience.

IMO, op is more likely to be sedated if her VBAC fails to progress, or if her previous scar ruptures & she doesn't have any anaesthetic already in (epidural/spinal) they will completely sedate her!

I support OPs right to decide but also think the Midwifes should get the right to not assist a birth with these stipulations. I cant imagine having to standby and watch unable to help if something starts going wrong. I think you either need to go private and find a willing midwife or perhaps change 'the rules' so help may be given if a life or death situation arrises.

Exactly youbethemummy I couldn't imagine having to stand back and not do anything if I knew there was a shoulder dystopia happening, and ve's often detect things like ot position, where the head is facing sideways, which can result in a deep transverse arrest which can be fatal. Many times women seem to be progressing really well, only to find on the next examination that the cervix is thick and swollen because the woman has been pushing on a 8cm dilated cervix. This would not be known just by observing.
In a normal, low risk birth (which this isn't, we wouldn't want it to be prolonged due to pressure on the scar), all that many people on here have said makes perfect sense, however it's not always as simple as that.

OneLittleToddleTerror are you sure you were responding to my post? I don't remember saying anything related to "no pain relief = natural birth bandwagon", talking about text book labours (the OP is not going to be one, to start with, being a VBAC) and definitely did not say anything about your particular labour and birth, just a general comment that the majority of assisted births come as a result of failure to progress/push with epidurals. Why anyone I don't know and who doesn't know me would think that means "your specific ventouse was unnecessary" is beyond me!

And where exactly did the OP say anything about no one doing anything if a shoulder dystocia developed?? people are making huge assumptions here!

Aurynne - genuine question - is it possible to detect shoulder dystocia if you're not permitted to look between the legs or do a VE?

Get a doula or a birth partner you trust - you need time to build a relationship, keep on for the counselling and as sappy as they sound hypnobirthing lessons might really help you.

Really explore the elcs option, giving birth virginally (sorry if I used natural before wrongly - personally think you either have a natural birth or a cs -either being fine ) is not the be all and end all especially if you have such trauma around it - but if you go ahead you really have to plan for the emergencies and try and be in a good place mentally with a good support.

If you go for elcs it makes you no less a mother than anyone else.

Can you look at a home help for the 6 weeks post elcs that you need to recuperate - and an elcs is more likely to heal quicker than an emcs as it is a planned operation.

aurynne - she said she didn't want anyone looking or touching between her legs. I'm no expert but is it actually possible to resolve a shoulder dystocia without doing that, and do it quickly and safely?

With my 2nd and 3rd labours my midwife did not do any internal examinations as she did not feel it was necessary - "I can see you're in labour so don't need to examine you!"
So the following statement...

I've also had one midwife tell me that labours without vaginal examinations usually result in dead babies.

Is a load of bollocks and sounds like it's based more on fear of litigation.

In response to the question of shoulder dystocia, actually it is very possible to resolve without having to look at the woman's vagina. In fact nonme of the shoulder dystocias i have been involved in (about 7) have required vaginal visualization/contact (we did visualize the women's vagina, but because she did not have this phobia, so they were not covered). One of the most successful ways of releasing a dystocia is by changing the position of the legs, either using the McRobert's maneuvre (pusshing woman's legs up towards her chest, if she is lying in bed, can be covered with sheet for privacy) or the Gaskin's position (on all fours on floor, bum up, knees towards chest). In Gaskin's position, if the dystocia is not resolved a change into the Runner's position (same position but with one of the legs up "like a runner") can do the trick. These movements resolve over 60% of dystocias. The next step if it is not resolved is suprapubic pressure, which also does not require touching or looking at the woman's vulva (it is strong, constant or rotating pressure on the baby's stuck shoulder by putting pressure on the lower abdomen, right over the pubic bone).

If after these manoeuvres the dystocia has not resolved, the next steps would involve internal rotation of the baby, which would indeed require contact with the woman's vagina. At this point this is a life-death situation for both woman and baby and, most important, a C/S is not always possible, as the baby is too far out for it to be safe. It is also uncommon that a shoulder dystocia does not resolve with non-invasive techniques.

You can tell the woman to lie flat and bring her knees right up which could release the shoulder, but you would need help with pressure bringing the baby out, any problem that continues would need urgent help, involving looking between the legs which the op has said she will refuse. In my 16 years as a midwife I've never had this situation.

Added: usually during manoeuvres for dystocia, one of the midwives holds the baby's head (which has been partially born, so it is outside of the vagina) and applies gentle traction. I do not know whether this would trigger the OP's phobia or not, but not touching the head is very possible during McRobert's, Gaskin and Runner's positions.

Crazeeladee, the thing is, we do not have the OP coming back to tell us whether holding the baby's head/indirectly looking at her vagina by one trusted practitioner or simply during life/death emergencies she would consent on any of those procedures. Perhaps what she is so scared about is random people directly observing her vagina closely. That is why I think it is so important to discuss all this with her. Having been in a number of shoulder dystocias (and you have been in many more than me and can confirm this), at that moment the woman and her partner are in so much pain and confusion that I would imagine checking who is looking at her vagina would be almost impossible.

The OP's initial post seems to be all about her being in control. Perhaps if she could designate a trusted midwife/obstetrician to be the one doing any emergency interventions in which looking/touching her vagina was involved could be enough to reassure her.

"As a result this time I'm refusing:
(...)

• any medical staff to touch or look between my legs"

Perhaps she would be happy with a midwife doing it?

It's not just fear of litigation. It's fear of dead babies. Do you think we don't cry over every one of them? You just try not to do it in public.

Of course you don't need a VE in every labour. But the OP, for whom I have enormous sympathy, isn't just saying she cannot cope with VEs, but with anyone between her legs. So that does mean what if something did go wrong (cord prolapse, cord around neck, shoulder dystocia), what would she then feel able to allow to happen? If things started to go wrong, not being able to cope with a VE would increase the liklihood of needing (recommending/begging) to be let perform a C/S, as not only could dilatation not be checked, but no chance of fetal blood sampling or scalp electrode monitoring if the CTG monitoring showed a possible problem. So, not low risk due to the previous C/S, and if something went wrong (which it may not, it might all go smoothly, but you cannot rely on that) a significant barrier to retrieving the situation. So I'm afraid that you really would want exquisitely clear, written, signed consent (including documentation of what is not permitted) in advance. As without that if, heaven forfend, the result was a brain damaged or dead baby, or an injured or dead mother, then it isn't just that the hospital would be sued. The doctors involved would probably be struck off. So they're also risking their careers.

Oh, and the paediatrician stuck with trying to resuscitate the baby would probably be attempting to kill the obstetrician.

Which is why the consent process can end up feeling brutal. Because if someone needs the midwives/obstetricians to go against usual practice/recommendations, where 2 lifes are the stakes, then even if the risk of a bad outcome is low, it absolutely has to be clear. And the obstetrician will not just be able to refuse to get involved if they don't feel happy - sod's law says that these things happen out of hours, unless it's an elective C/S, so it will be whoever is oncall.

It is the mother's choice, and it has to be. But that choice has to cover every bad possibility, not just the hoped for good outcome. Or it is not informed, and is not fair on the mother who might have to live with the consequences.

(Conflict of interest - paediatrician. And I remember every single baby we couldn't save. In particular, the thankfully rare preventable baby deaths leave a scar on your soul. We're human too.)

So what are they supposed to do if something goes wrong? Stand and let her and the baby die because she does not consent to even have someone look at her public area?

She wants a free birth, but it's a VBAC with the baby known to need to go to NICU.

explained that I've felt suicidal and considered DIY abortions. However the result is always the same, I'm told I have to do this. I've asked for specific guidance on how to make specific treatments bearable but I'm just told I may be allowed gas and air.

I've made an appointment with my GP two weeks ago to discuss my psycological problems and ask for councelling but I stilll have a week before the appointment because I'm not urgent (very busy London practice).