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.

Arse. Lost half my post there....

OP, you need an independent midwife, or a doula. You really do. And also to talk to the supervisor of midwives and possibly change hospital.

I was trying to say that upon reflection last night I a couple of things stuck out from this thread:

Terrifiedmummy, you posted this:
explained that I've felt suicidal and considered DIY abortions.

followed by this:

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).

I wanted to stress the fact that if you are feeling like that YOU ARE URGENT AND IT IS UNACCEPTABLE THAT YOU CAN NOT GET A SOONER APPOINTMENT.

What you are doing is expressing thoughts of harming yourself or your baby; I would strongly advise you to push your GP for a sooner appointment or to bypass them and seek out your local mental health crisis team as you need support sooner.

You are not being difficult or awkward by doing this. You are trying to access the appropriate care at an appropriate time.

Also I notice this line:

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.

And it rang a bell with me.

Now I could be barking up the wrong tree here, but one of my concerns when I spend a long time looking at my options was the fact that in order to have an epidural or other forms of pain relief its standard procedure to insist (force?) a woman to have a VE first.

I found this quite upsetting to find out, though I do understand now why its done. I just wondered if pain relief options were one of the things that were really making you very anxious and not in control.

Like I say, I could be wrong, but its just a feeling I got from the language used and my own experiences.

How far along are you anyway? It might help people here be able to give you better direction.

aurynne Sat 30-Aug-14 10:55:57
"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?

I REALLY don't know what planet you are on, but if you ask any woman with an anxiety about HCPs I'm pretty damn sure they would all say that a midwife is a HCP.

I have to say, I am with other pps. I had an elective cs and didn't have a single vagunal exam. Vaginal exams aren't done unless/until they are completely necessary due to the risk of infection. So when one is suggested it is usually for a reason. Of course you are well within your rights to refuse one, but it is better to go with the option that will safely avoid them, which is an elective cs. I am sure the hospital would prefer this option.

OP, I had EMCS under GA with my first, and ELCS with spinal with the second exactly because I was afraid of being asleep again, if the same thing had gone wrong. It really was very different.

Wrt having the catheter fitted, my mw have me the option of having it done before I went in to theatre, or after I had had the spinal in theatre. I opted for after I'd had the anaesthetic as I was worried it would be uncomfortable, but in a way wished I had had it done before as there are a lot of people in the room when you have a cs, whereas it was just me and dp and mw (who was lovely btw) in room beforehand. Mw still did the catheter in theatre, but obviously lots of people would have seen down there in theatre - not that anyone was really probably looking. I also found I felt more supported having an elcs. Midwife and anaesthetist were at head end checking I was ok and explaining everything. As midwife was less actively involved I guess they are more on hand to talk and support rather than primarily concerned with the birth bit.

So it depends on what worries you most. Pain/discomfort or privacy. I am not sure how uncomfortable catheter fitting is without anaesthetic as they do use numbing gel. Certainly would have been a bit more private/dignified getting it done by mw beforehand.

I would feel very uncomfortable at the prospect of caring for you in labour op. That is not to say that I think yabu - you have a right to give stipulations, regardless of whether they make your mw feel uncomfortable

In particular a section - will you accept it if indicated? For example if you go overdue? As an induction would be impossible with your stipulations, and often not recommended with VBAC (varies between hospitals).

I do personally feel that vaginal birth is not suitable for you. I think it is unrealistic to approach it with such a long list of stipulations - some flexibility is always required. I really think the issue is that you need to be able to trust your mw, and you will need to have met her several times antenatally in order to build that trust. It is a disgrace that there aren't more caseloading teams available for women in your circumstances, so they can build trust with a small team of midwives knowing one will care for you in labour.

What you have been through is horrific, and totally understandable that you feel as you do. However, birth is an intimate process, I personally feel there is no getting away from that, and when avoiding VE's in labour it is useful if the mw can occasionally observe down below for signs of progress. That is not to say it cannot be done with preserving privacy and dignity - there is no need to have your legs up and bottom uncovered for all to see. There is no reason not to stipulate female carers, minimal people in room, no VE's etc.

However I would be concerned at you resisting any visualisation of the vaginal area and the checking afterwards for trauma or assistance with the placenta. Worldwide, PPH is still a real cause of maternal death, and you are putting yourself and great risk with those stipulations. It is no longer a leading cause of maternal death in the UK because procedures are in place to minimise the risk, however it would be most difficult to manage those without being able to view the vagina, or assisting the delivery of the placenta if needed.

I personally feel your choices are more of a risk to yourself than your baby. It is a disgrace that this has not been discussed with you in a calm and evidence based manner. I would request a meeting with a supervisor of midwives (contact the hospital for details). They must talk through your options in an evidence based way. I would also prioritise finding a birth partner, I think it is a big mistake for you to not have one - a doula will do if you really have no one. Could you also consider an independent midwife? They are expensive, but you can get to know them and they are not restricted by NHS guidelines and policies in the same way as hospital midwives.

I would also recommend looking at Sheila Kitzinger's website and book 'birth crisis'.

terrified, my heart goes out to you, really, it does.

You've had lots of very knowledgable and technical advice on here by people with lots of experience.

What jumps out to me is that your relationship with your obstetric team seem really adversarial and that it very much sounds like you feel your fears are not being heard.
I cannot imagine anything more counterproductive in a vulnerable position like the one you are in.

I second/third/fourth ad infinitum the need for you to have a calm, experienced and knowledgable birth partner - a doula would seem ideal.

Is there any chance you can change hospitals? You know, start with a clean slate etc? I get the impression even if you get everybody to agree to your choices (which come from a position of fear, rather than positive selection), you'd remain distrustful and terrified that somebody would not stick to your stipulations.

If feel very strongly that the main issue here is not how you end up labouring and delivering, but your mental health. You need highly specialised counselling and treatment to hopefully find a way to make your peace with your previous experience AND make a positive one out of this one. I am not sure how much your GP can do for that, however the Supervisor of Midwifery or your consultant should be able to refer you for specialist assessment (?do you have PTSD or a birth phobia) and therapy.

Truly, I am wishing you all the best in the world and hope that you will have a healthy and happy labour and delivery experience.

Stone, just as an example, the catheter I had was an absolute doddle and I love not having to worry about going to the loo after my emCS. I was also v glad of the Voltarol/Diclofenac suppository I was given in theatre and had plenty of VE in my 4 deliveries, but I have never had the horrendous issues that the OP is facing.

Which reminds me, terrified, I had an induced VB, a premature emCS and 2 VBACs thereafter. I always felt supported and as part of the decision making process.

Please address how cornered and defensive you are feeling - I really would have hated to go through what I did without the absolute trust I had in the HCP who were looking after me/us.

MissDuke Sat 30-Aug-14 11:49:36
I would feel very uncomfortable at the prospect of caring for you in labour op. That is not to say that I think yabu - you have a right to give stipulations, regardless of whether they make your mw feel uncomfortable

I dislike the implications of that. It puts 'blame' for the way the OP is feeling on her, and I think one of the most important things for a woman in this situation is to stress that her previous experiences are not her fault and that she should be put in a position where she feels like she is being awkward or difficult or somehow penalised because of her previous experiences.

The onus should be on those caring for her, to rebuild that lack of trust and to put her in control as much as possible taking time to listen to what her fears are. The application of pressure is the single worse thing that they can do. They have to explain things in a way so she fully understands and appreciates where they can compromise, but this also relies on making concessions else where to prove that their intentions are to put her first and are based on her individualised needs rather than what is convenient to her. If all she is meeting is resistance at every turn and alternatives are not suggested then it will make her feel as if she is being forced into things that can not be done.

This is essentially a medical issue in its own right, so it needs to be treated accordingly. Its not about whether the MW feels uncomfortable or not. The MW can make herself feel comfortable by good preparation and active involvement in the decision making process by the woman.

I do dislike the fact that people keep pushing the idea of an ELCS on the OP, when she has said she doesn't want this - especially when she already feels in a situation where she is feeling pressured to do things she doesn't want. An ELCS isn't for everyone and I think in terms of treating women with anxiety like this, other options need to be available and promoted too which I feel currently aren't been. The updated NICE guidelines for CS have been enormously helpful in recognising anxiety as a health issue in pregnancy, but this has also led to people having something of a blinkered approach and not seeing that there may be more appropriate treatments for different women. And I say this as someone who has actively sort out having an ELCS for anxiety myself.

Ultimately, women need to be listened first and foremost and the system be more accommodating to those with special needs. Instead, its still being seen as method over individualised care.

I am struggling to see how OP's request to not have "any medical staff to touch or look between my legs" can be complied with except by an elective cs unless she is 100% sure the birth will go swimmingly well with no help.

Phaedra, it wouldn't be complied with even if she had an ELCS either though.

Its a fundamental point that everyone seems to be missing.

And because of that, I do think you have to consider why she feels like that and how that feeling can be minimised, because its going to have to be tackled however she has the baby.

The method is not the problem, its how she feels and how she is being treated.

Elc seemed the option likely to have the least looking and if she refused the catheter no touching. I don't think I even had a catheter after mine.

I couldn't see what they were doing as the bottom half of me was screened off but presumably given where my scar is the bit they were looking at and working on is higher up.

Serious question - what birth plan at all could be followed if medical staff aren't allowed to even look ?

Serious answer: I think people are looking at this the wrong way and its not about the birth plan as it stands, its about rebuilding trust, putting the OP more in control, making her feel more at ease, making some concessions and ultimately listening to what she is saying - which starts with listening to the fact that she does not want an ELCS.

I do believe it is possible to have a baby via VB without any examinations (a think a few MNetters have said they have). It is unusual and you have to be lucky, but it is possible.

I do believe that an ELCS still carries the risk of needing a VE in certain circumstances and a catheter is standard.

So you are left with trying to work out with the OP which risks/possibilities is she most comfortable with and trying to find ways to help her cope with those.

It is a VBAC, though. Does she have in place a plan if things go awry and she has, say, a PPH? Would it even be possible, in such a case, for medical staff to stand by and do nothing because she doesn't want anyone even looking at her vulva?

Red fair enough but , not even being allowed to look? Even in the most hassle free vb that's going to be almost impossible to comply with surely?

She could say she doesn't want a catheter. I honestly can't remember having one. If I had it can only have been there for a very short time. I don't recall at all not being able or not being allowed to go to the loo. Presumably if she refuses a catheter she can be assisted to the loo or offered a bed pan.

Red yy to that.

If trust were rebuild (or build with another team altogether) some stipulations may not be as important for the OP as they are now.

It's fear like this that makes people consider free birthing. And even unattended births are usually fine, but the risks are of course higher.

Rainbow I think its a contentious issue, and one that I don't think there is a definitive answer to. Without scaring the OP, in theory she could legally insist upon it, but there would be a case, that some doctors under certain circumstances would deem her incapable of making a rational decision because of her mental health.

It would be a very difficult call, and one that I don't think any doctor would want to make and one the OP would not cope well with either as it would ultimately be her very worst nightmare and feed how she is already feeling.

This is why any good HCP needs to see the issue in those terms and find any compromises they can and tailor care - without ANY pressure - because this scenario is just too awful to think about.

I know what has worked to help me, get to the place I am in now, and that has really relied on the attitude of the consultant and midwives who have dealt with me and to recognise my problems and take them seriously and put me in control. Its a place I didn't think I could ever get to...

So I don't believe it is an impossible problem, just one that the OP needs really serious support with. Support she is not getting and can't get access to. It does seem like she is being met with an attitude of "we can't" rather than "ok this isn't normal, but if we did x, y and z we might be able to this but we couldn't go as far as doing that".

More than anything else, the OP needs to know she is being listened to and respected rather than being told she is in wrong and she just has to suck it up.

More than anything else, the OP needs to know she is being listened to and respected rather than being told she is in wrong and she just has to suck it up

Agree.

Having read your update I think you need urgent access to counseling services. Call your GP for an emergency appointment or if you possibly can consider going private. I am not judging the appropriateness of your feelings, but given how you feel about CS and about vaginal examinations and the fact that babies have to be born somehow you need support and help to deal with some of your emotions before you get to the birth. I wish you all the luck in the world for a completely straight-forward VB but you do need a contingency plan.

PhaedraIsMyName Sat 30-Aug-14 16:33:40
She could say she doesn't want a catheter. I honestly can't remember having one. If I had it can only have been there for a very short time. I don't recall at all not being able or not being allowed to go to the loo. Presumably if she refuses a catheter she can be assisted to the loo or offered a bed pan.

My hospital have been exceptionally accommodating in everything they have done to help me - they have done a lot of things that are not standard. I have heard it is possible without a catheter, but the risks are significantly increased and there are a number of problems in doing so. It was one of the few things that has been made clear to me that is totally non negotiable. They have been very good in explaining this, and the background of helping in other ways has been enormously helpful in excepting this.

Plus, even if I didn't have a catheter on the operating table, you may still need to be cleaned up down there (you won't be wearing underwear afterall). They can do things to protect your dignity but only so much.

Also the OP, may not like the idea of being immobile anyway as this makes her feel out of control and at the mercy of medics - it depends on the nature of her fear which is very personal to whoever is suffering from it.

I think as Pacific says here, freebirthing ends up being the only thing that some women feel they can do and thats not in anyone's interest. It was certainly what I was told, and how I felt. I've read a lot of threads on MN over a number of years, and its a common feeling for women who are really desperate. Its not a rational choice, but this is the point - phobias make you unable to grasp things in a rational way. Unfortunately this isn't well understood, and women are given all sorts of labels that only add to the issue rather than making it better.

When I read these threads, I thank my lucky stars I found someone with a special interest in this type of fear and they have delivered (so far!) on promises. Ask me again in a weeks time though...

Red Good luck when the time comes.