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.

Yeh good luck RedToothbrush

The only thing an internal exam will determine is progression of labour. There are other ways to determine progression without an IE that an experienced midwife will be able to see, eg your behaviour, other physical signs (eg your tailbone will push out as the baby enters the birth canal) etc. What these things depend on though is you not being left alone, because someone needs to watch for the changes. Can you afford a doula?

Aurynne, you haven't answered my question as to whether it's possible to detect shoulder dystocia if you can't look between the legs?

YY to everything redtoothbrush has said. OP, my heart goes out to you.

You've been traumatised and your experience of medical staff during birth has not been positive. It sounds like you're hearing your current medical staff (I hope at a different hospital!) as saying that your consent won't be taken seriously and basically they'll do what they damn well please and you'll just have to deal with it, so no wonder you are feeling very, very triggered.

This needs to start from a position of listening and trying to find points you can work together on - for example that they take your choice NOT to have VEs very seriously, that they know exactly what happened at your last birth that was so traumatising to you and are aware of exactly what needs to NOT happen at this one, and for you to know and trust the people involved and make a plan with them of how, should they feel you or your baby are at risk during the birth and that a VE or other procedure that you've chosen not to have is now necessary, they will explain this to you and enable you to make an informed choice as to what you want to do. It sounds like you've considered that in an emergency you might be able to bring yourself to permit them to do more IF they were taking the trouble to show they take your concerns very seriously, and that things were done in a way you might find easier to cope with. For example who is allowed to be in the room at the time, who you want to do it, may they look but not touch, there are many things that might give you a feeling of greater trust and control.

Essentially your medical team need to get you through this and in good emotional condition. If you can change hospitals and teams and find one a bit more professional in supporting women with traumatic birth experiences it might make this much easier on you.

Very best of wishes to you and to redtoothbrush

I am Dr (obs)

I am surprised that you have been told you don't have the right to refuse an examination, as this is absolutely not the case. You have the right to refuse any examination or investigation.

The medical staff/midwives do have a duty to inform you of the purpose of the examination/investigation, the benefits of what is proposed and the potential consequences of not having it (e.g. not having a vaginal tear picked up and repaired, can lead to longer term complications such as incontinence), then you are free to make whatever decision you chose.

Examination during and after labour is not mandatory. It can mean we don't pick up on something, or pick up on a complication much later than we might have otherwise (especially if you are also refusing fetal monitoring). On the other hand, it may not have any impact at all. Nevertheless, you do have to be aware of the risks.

However, I can understand why the hospital want you to effectively sign a disclaimer.

That said, I do think you need to have a plan (which you have signed) stating what you want in the event of an emergency. For example, if you have a postpartum haemorrhage sometimes bimanual pressure (pressure on uterus from both internally and externally) can be life saving. Would you allow that? What if there is a problem at delivery e.g. shoulder dystocia? Or baby in distress at a late stage of labour? You need to think about these, and perhaps seek advice as to what these would involve and the potential consequences of refusing them in an emergency.

You are going to have to be very specific about what you will and will not allow staff to do in an emergency situation- prevarication in the emotionally fraught and time-pressured situation like an emergency can be catastrophic.

I am not saying this to "coerce" you into anything- I am coming from a medical point of view though. If you were my patient, I would try to accommodate your wishes, but I'd need you to be very clear as to what those wishes were- including in an emergency situation- and be sure you understood any potential risks as a result of your choices. For both your sake and mine.

I hope this helps. Good luck and I hope it all works out well for you.

verylittle sorry, but that is not the only thing a vaginal examination will do, it can also determine the position if the head by feeling along the suture lines of the skull, and to feel for any caput or moulding of the head.
We don't do them simply to assess progression.

Red, I made it very clear that my being uncomfortable did not make the op unreasonable, in other words that is my problem. My point was that my job is to facilitate a safe birth for mum and baby, and I would be really on edge because the stipulations would be making me very worried that I couldn't achieve that. As I said, the no VE request wouldn't worry me as I have other ways to monitor progress and fetal and maternal well being, but not even being able to look down below would compromise their safety - which for sure would make me uncomfortable. I made it clear that is my problem, not the op's however she needs to understand the point of view of those caring for her.

Also, I made it clear that current structures in maternity services are the problem here. When working in labour ward, I meet each woman for the first time when she arrives in labour. Therefore your suggestion of building trust beforehand is not possible - hence why I mentioned there needs to be caseloading teams for women in these sort of situations. Why should the op have to repeat her wishes over and over to each new midwife she meets? Continuity of care is the key here.

I had an emcs with my first ds, and it was very traumatic. I could not understand what was happening, and I was very ill afterwards, and it took me months to get over it physically and mentally. I also think it contributed to my pnd. I also felt like a failure for not getting the chance to give birth naturally.

I wanted a vbac with the second ds, but the midwives and consultant advised against it throughout my pregnancy, because of the risk of rupture. In the end I had an elcs and I was terrified. But it was a completely different scenario. Everything was far more relaxed. The actual cs was far better and more controlled, and I was up and about far quicker, and could deal with my toddler and baby on my own within the week.

I hope this helps a little. Good luck with whatever choice you make.

RedToothBrush in the country I am, half of the midwives work in the community, not in the hospital (they are autonomous), they visit you at home, they are with you for the 9 months of pregnancy, birth and week after birth. Midwives here are not "medical staff", they are not even paid by the hospital at all. That is why I was suggesting perhaps having her own independent midwife (you guys still have them in the UK? genuinely asking) could provide the OP with a person she trusts and does not see as "part of the system". I speak from the ignorance of the depth of the OP's condition, that's why it would help if she came back to the thread and was a bit more specific.

Everything I am saying is to try to help the OP and offer options, I have no idea why some people in this thread are trying to turn this into a bunfight.

*"and 6 weeks after birth", it should read (not a week)

Gosh, I didn't realise so many people would reply. Thank you to everyone, genuinely and sisncerly. In answer to some questions:

• I'm 24 weeks. I've started asking for help early as I want problems to be addressed as soon as possible.
• I'm scared of the midwives. They shout at me. They tell me, "rape victims are fine with VE's", "you're going to have a baby with cerebal palsey" and make me feel like I coward. I'm ashamed of not being stronger and able to put up with more. I am so under seige.

-I do not want discussions to be a confrontational experience. Rather I want discussions to be proportional to the likelihood of risks and their consequences. I understand that events which are less likely are often those where the outcome is most effected by prior discussion. I also want discussions to be actively problem solving and positive about what can go well.

I've come to the conclusion I don't have any choice in the first part of labour as I am not free to choose to risk my baby. I may make requests such as; please keep VE's to a minimum or please don't let students do it, but that ultimately I must accept what has to be done. It's not my life I'm risking, it's hers. The spectre of choice is an illusion.

As soon as she is delivered the situation changes. I am willing to risk my own life to try and save any shred of sanity which remains after the delivery. I am not mad, but I am on the edge of sanity and I fear being tipped over the edge. I have another appointment with my birth councellor in a week and one of the things I will ask is if I can be given any support after the birth.

In what a horrible place you are, emotionally. So sorry.

You do not have to plead with them for minimal VEs etc, you have to simply tell them. And they have to listen.
They equally have the duty to inform you of the risks - most labour and delivery risks are small, but may be catastrophic if they do happen IYKWIM.

I hope you have a trusting relationship with your counsellor and are able to be as honest and articulate them them as you are here.

I only wish you could feel more supported in your choices, whatever they end up being. Nobody should feel like they are 'under siege' - that's awful.

Your MWs sound like the ought to be reported to their professional body tbh - rape victims, cerebral palsy; what utter tosh

I hope you can find something useful in all these replies; some more technical, some more focussing on the MH side of things.

TerrifiedMummy I've never had a kid, I'm not a medical professional. But what I can tell you is that their threat "you're going to have a baby with Cerebral Palsy" is bang out of order.

CP is not always caused by birth trauma - my own CP was caused by prematurity not a birth accident. Yes maybe it puts you at a higher risk - I don't know - but it's completely wrong to say it will definitely happen. My suspicion would be that the additional stress they are putting you under increases the risk almost as much if not more than not have VE.

And it sickens me to think that the disability I live with everyday is being used as a shocking threat to force someone to consent to a medical procedure. Yes, I use a wheelchair all the time but having CP isn't the end of the world and my life isn't ruined. If having CP was meant to lead to me and my family leading a terrible life we obviously missed that memo. You aren't "choosing" CP by not having VE.

If the midwives are shouting at you and saying that OP, you need to contact PALS for your hospital first thing Monday, that is completely unacceptable, and ask to speak to the head of midwifery also.
Aurynne there are a few independent midwives here, but they are no longer insured anymore, so a lot have had to stop.

Please find a birth partner - maybe someone who can come to the mw appointments with you - it might make the mw buck up or just help you assert your wishes in a way productive to giving birth - and an extra pair of ears who can take in information when you are feeling anxious and possibly not taking everything in - it has to be a two way conversation - talk through the possible points at which internal or external checks may be required - you can have the opportunity to think about what and why they would be doing and take that in to your counselling - could they help you with coping or relaxation techniques - definitely tackling potential anxieties in advance so that if it happens you can avoid the anxiety getting in the way of a potentially positive birth experience - anxiety can reportedly slow labour and increase need for intervention.

You are doing the best thing preparing but just prepare for lots of possibilities and understand what options you may have at different points of the birth - you can always fall to elcs right up to the day - so have prep in place for post birth assistance, at what points you would say stop the labour please go for cs, what pain relief is available at which points in the birth and at what points do your wishes particularly clash with potential interventions and at which point do they go from advisable to unavoidable/ high risk - and what are you options at each point. You can't plan for everything but you need to work out what you feel can and can't consent to - and this may change with the counselling.

There is a wonderful vbac group on Facebook www.facebook.com/groups/149800885093152/?fref=nf who help women talk to HCPS and portray what they want and need. In particular a wonderful woman called Kath who will help.

I suggest you join, pm Kath, and post on there.
I would also complain about the midwife and refuse to see her/them again.
Once again, if you can afford it, hire a doula and hire them now. 16 weeks is ample time to build up a trusting relationship and you might get to the point where she handles any necessary exams pre delivery. They will also support you post birth.

You can completely decline VE's, sweeps, students, and anything of that ilk, you don't need a reason.

I wish I was near you as I feel so strongly about this and would happily come and support you. Perhaps if you pm me I'll see you on the Facebook group. It is so supportive and I think you'll find empowerment there.

terrifiedmummy, I feel ashamed I am going to share a profession with some of the nasty bullies that call themselves midwives in your hospital. I wish I could somehow bring you to New Zealand and could be part on helping you put together a group of people you can trust, speak to freely, and that would have your interests in mind. The system here considers the woman and her baby as a unit, not like two separate entities with different interests, and the woman has control over her labour and birth, even if she wants to go against medical advice. I really do not understand what all those "horrible risks" that your baby is supposed to be submitted to come from and it sounds like a tool to scare you and out pressure on you. Obviously they are succeeding. It makes me very, very angry.

By the way, many rape victims are SO NOT OK with VEs. How dare they say that to you. Fuming for you! Please PM me for any info you may need or just to chat.

If the midwives are shouting at you and telling you that not having a VE is going to cause you to have a still-birth or a baby with CP etc, then you need to complain. That is wrong (both morally, ethically and factually) and it is unprofessional- if true, it could well lead to disciplinary action from both the trust and the royal college. You should complain and refuse to be seen by the individuals who have acted this way towards you.

I am very surprised that this has been said by more than one HCP. You might get the odd one who is terrible, but a large number who would do and say such things is, in my experience, rare.

As to "having" to do anything, I don't think that's what many have said- I think most people who have professional experience have stated that you don't "have" to do anything. Nobody can force you to undergo any examination you do not want to have- performing an examination on any patient without their consent is deemed assault.

What I think we have been saying is that you need to be given accurate, factual information regarding the risks of not being examined during labour/after delivery. You also have to think about what you would want if an emergency arose, or what you would want if you went post-dates. Then you have to make your decisions clear to your midwife and consultant. You should also be asked to take full responsibility for those decisions if they go against medical advice. But that can, and should, be done without becoming adversarial. I am sorry that this appears not to have happened in your case.

Actually, it's more common than people realise I think.

I have had one midwife and one consultant play the 'dead baby' card so far this pregnancy, I'm sure it would have been more if I didn't discharge myself from hospital care. And this was in response to me telling them I was trying for a vbac, and that I was happy going full term. Hardly anything radical and following NICE guidelines.

And this is after I have had a stillbirth. Some HCP's are a disgrace to their professions.

I also know several vbac and post dates pregnant women who have been told the same.

verylittle. Vaginal examinations do more than assess dilation and position, they are also used to assist with determining fetal wellbeing. If a baby has a non-reassuring ctg trace but then responds to the VE, it tells us the baby is coping with the labour.

There are several other things vaginal examinations are necessary for, but I am not going to put them down, as I think OP is traumatised enough and doesn't need to read it.

OP I truly hope you manage to get some sensitive caregivers and have the least intervention possible birth.- can the hospitals clinical psychology department help you with that?

terrifiedmummy I'm going to go through a few things which I hope help...

- I'm 24 weeks. I've started asking for help early as I want problems to be addressed as soon as possible.
This is brilliant and what you need to do. But please, please be aware this can be a difficult process in itself.

I have been trying to deal with my problems for a number of years, and along the way have hit a few brick walls. I have had time on my side, so have been able to take things at a slower pace than most who only come to address issue whilst they are pregnant.

From what I know, the added pressure of the deadline of a pregnancy, makes the experience even harder and unfortunately, for many can be a real battle in itself.

At the very heart of the problem is a total lack of understanding of the issue, from probably the majority of HCPs you will come across. It is beyond the comprehension of many to fear HCPs because they don't see themselves as a threat; in fact quite the opposite. The paradox of fearing HCPs is that the only people who can help you are HCPs. Breaking the vicious cycle of this is exceptionally difficult to both do and understand.

Remind yourself every step of the way through this of a few things;
What happened to you is not your fault.
You are not being difficult, you can not help how you feel.
You are suffering from anxiety. It is a legitimate health care issue that you have a RIGHT to get the appropriate care for.
You can not 'just get over it'. A HCP would never say to someone suffering from severe depression, to "just cheer up".

The truth is, that the system in the UK does not properly recognise this issue, and as such, is not properly designed to cope with it. Nationally, staff are not trained properly to treat it and existing care pathways are often either inflexible, non-existent or simply not fit for purpose.

That is not to say that there is nobody out there who can help you; there is. The trouble is, it is not universal, it is widely known about and it can be difficult to access.

Keep pushing, seek out help yourself and do not rely on those caring for you to find it for you as often they don't know about it themselves.

- I'm scared of the midwives. They shout at me. They tell me, "rape victims are fine with VE's", "you're going to have a baby with cerebal palsey" and make me feel like I coward. I'm ashamed of not being stronger and able to put up with more. I am so under seige.

This is unprofessional behaviour which is more than worthy of being reported. It breaks every code of conduct with regard to consent.

As it stands the law is that consent is only consent if it is given without 'undue pressure'. I'm sure you are probably aware of this, but I think it needs to be stressed, because if you feel under siege this is affecting your mental health, and you need to know that you have a legitimate complaint and you have every right to challenge their behaviour. I think you are probably unlikely to do so, because you don't feel empowered or strong enough to do so, but if you do feel up to it, I would encourage you to do so.

You have absolutely nothing to be ashamed of here. You are being bullied and they are abusing their position of power over you. This does not make you a coward. You are simply in a vulnerable position and they are trying to exploit this. Lots of people have been in similar positions.

Rape victims are very commonly not fine with VEs. I've lost count of the number of threads on MN which state that. Research into women who have a clinical fear of childbirth (tokophobia) which you may be suffering from, highlights that it is a common feature of the phobia. If you need me to, I can probably pull some out, to reassure you, how you are feeling is perfectly normal and recognised.

-I do not want discussions to be a confrontational experience. Rather I want discussions to be proportional to the likelihood of risks and their consequences. I understand that events which are less likely are often those where the outcome is most effected by prior discussion. I also want discussions to be actively problem solving and positive about what can go well.

It does not have to be like this. But unfortunately, thats not the case everywhere. I wish I could say its different but its not. Care is so patchy across the country and is entirely dependant on which hospital you are at and which individuals at that hospital you see. The next hospital may have a completely different culture.

I have found that writing things down has helped me - as I can take time to explain things more clearly, in more detail and show that I am not an uneducated idiot at the same time, without getting as upset or emotional over it. (Though getting emotional is not always a bad thing in this as it shows how distressing you are finding things).

I would also say, if you have a close friend or family member who can go to appointments and help advocate for you, its a massive help. Having a witness to what these HCPs are saying and having someone to back you up, is a massive confidence boost.

I've come to the conclusion I don't have any choice in the first part of labour as I am not free to choose to risk my baby. I may make requests such as; please keep VE's to a minimum or please don't let students do it, but that ultimately I must accept what has to be done. It's not my life I'm risking, it's hers. The spectre of choice is an illusion.

This is BULLSHIT. You DO have a choice. Many people here will tell you cling on to that thought and do not give up hope yet.

Personally, I really think your starting point should be to consider looking at other hospitals, and seeing they have better cultures which are more supportive. You have no trust in the people at this one, and thats always going to undermine how you go forward from here now. It can be difficult but it is possible.

The NHS is definitely not a universal entity with the same attitudes or policies throughout. I have chosen to go to a completely different Trust to have my baby, as I found out they had experience in my issues which my local one simply doesn't. Its a massive pain in the backside at times, but it was the right choice for me. It can be hard to find out this type of information, of who is more sympathetic to your needs, but it may well be worth the effort.

I am not mad, but I am on the edge of sanity and I fear being tipped over the edge.
You are not mad. You are NORMAL. You are acting in a way which is consistent with the behaviour of others who have been through similar. Please be aware that if you feel 'on the edge of sanity', there are services available to support you. As part of my care, I have been referred to the local mental health crisis team. I don't actually need it presently, as I'm happy and stable, but because of my history they wanted me to know it was there in case I didn't feel I was coping. However it is a service that you can self refer to as well. I obviously don't know what is available in your area, but these services do exist. This is separate from going through the GP and separate to my maternity care.

I have another appointment with my birth councellor in a week and one of the things I will ask is if I can be given any support after the birth.
In addition to the above, I have been put under the care of the local HV and they have said that both she and the community midwives will help me more than they usually would should I require it. In some ways I have mixed feelings about this, but I am glad they have offered. I have also been made aware that social services may be able to help me if I need it. This scared the shit out of me, as I have feared both the stigma and whether it means they think I am a potentially unfit mother. Its be categorically stressed that is not the case, and it is purely on my terms rather than compulsory. Again I have mixed feelings, but knowing that there are things out there is useful.

Sorry this post is so long, but I hope it helps, if only a bit.

Crazeeladee that's wrong. Independent Midwives have been battling to get insurance and achieved it July of this year. I have a group of IMs as clients so I'm well versed in their situation. I have also chosen to engage their services due to my previous traumatic birth. They refer to me as their client, not their patient, which puts me in a position of strength right from the start and everything they say and do reassures me that I'm in control.

I really really hope that you can find since care givers who offer you the peace of mind I've received from mine. Do take the advice of the women on here. Contact PALS. contact AIMS. contact Birthrights. You are being treated abysmally and you don't have to be.

Might the organisation PANDAS be any good? I know they more commonly deal with post natal mental health but they might be useful. .?

Good luck. You have a big team of us cheering you on from the sidelines here

Also, I made it clear that current structures in maternity services are the problem here. When working in labour ward, I meet each woman for the first time when she arrives in labour. Therefore your suggestion of building trust beforehand is not possible - hence why I mentioned there needs to be caseloading teams for women in these sort of situations. Why should the op have to repeat her wishes over and over to each new midwife she meets? Continuity of care is the key here.

I agree and disagree with this. The current structures in maternity services are only the problem here - IN SOME PLACES. Not all hospitals are running the same system.

I have been given great continuity of care as it was recognised that is what I needed. I do realise that not everyone at the same hospital gets it, but it is done in cases where there is an issue. Its stunned me a little as on the occasions I have seen someone else, they have been debriefed first.

Whilst I have opted for an ELCS so its slightly different, and my midwives won't be there, they have introduced me the person who coordinates theatre and they have carefully gone through things with me. I have been introduced to various postnatal staff too.

So building trust before CAN be done, in the sense that it is building a culture of trust and making a woman feel like her concerns and problems have been recorded and shared and the whole thing is about making it a team working together.

When I see threads like this, I do get frustrated as 'we can't do that' is commonly used; but my reality is that it can and it is being done in some places with enormous success. I get frustrated when the onus is put only on the woman to change her mindset when she is often a victim of the system and negative thought processes are frequently reinforced by the actions of those caring for her.

It all comes down to ignorance though and an institutionalised resistance to change.