advocacy from partners during hospital labour... what is the legal position?

[BreastmilkDoesAFabLatte]

I'm planning a home birth with an independent MW, but am aware that this carries the inevitable risk of an emergency transfer to hospital, which is what happened last time, and I'm trying to get my head around preparing for it.

At one point I remember becoming so anxious I utterly lost the ability to communicate, and I remember asking (probably not entirely coherently) if the staff would just allow DH to speak on my behalf. They said that they couldn't, as they'd not be able to ensure I was providing informed consent (not that they asked my consent for most of it anyway) unless I spoke directly to them.

Legally, given that DH is my husband and next of kin, is that really the case? Or were they simply explaining a hospital policy used to avoid embroiling themselves in domestics between couples? Either way, would a signed advanced directive suffice to allow DH to advocate/make decisions on my behalf? Or what else might I need to do or say?

If you are conscious & of sound mind the HCPs will always approach you for your consent.

Imagine a situation where you instructed HCPs to accept your DH requests for your treatment but at the time of said treatment you didn't want to go ahead with a procedure that your DH wanted you to have? I am not saying this could happen in your case but hypothetically you can see why consent has to come from the patient whenever possible.

Hope you don't have a repeat of last time & that everything goes well for you.

I understand the hypotheticals. But it isn't helpful. I'm not a hypothetical patient, I'm a real woman...

It's a situation you could find yourself in though but more likely the reverse - say you want an epidural at the time but up until then you'd been v vocally opposed, hadn't told DH you'd changed your mind, MW offers you one, your DH says no, they take his word for it. Everything is hypothetical until it happens. The whole situation is predicated upon the scenario where you are unable to communicate, which is still hypothetical.

What kind of situation are you thinking of where you would want your DH to make the decision?

I seem not to have explained this sufficiently.

I'm not asking to be able to delegate any decision making to DH. I'm simply asking that, in the event that I am unable to speak for myself (ie through anxiety) that DH is permitted to explain what I would want to be saying.

The situation I fear is that my inability to speak leads to decisions being taken by medical staff on the basis of what they think I would want, rather than what DH thinks I would want. And whereas there is a chance that DH could misrepresent my views, I would expect after several years of marriage for DH to stand more chance of knowing what I would want than a doctor I had met five minutes previously and had not yet managed to speak a word to.

FWIW when I had been transferred to hospital after 45hrs of labour, I was delirious with exhaustion and couldn't communicate with more than a word due to contractions. The midwives, consultant and our doula was in the room, cons was recommending trying for forceps, doula was blindly trying to stick to our birth plan of no interventions (bearing in mind baby was distressed) and was obstructing the HCPs (she hadn't actually ever asked us what we would want to do in such a situation) - DH literally chucked everyone out of the room, we had a calm conversation and agreed we were both happy to go into theatre, and then he let everyone back in and informed them! Is that a strategy that might help you?

I'm glad that worked for you. But in the scenario you experienced, the hospital staff did allow your DH to represent/advocate/express your views. In the scenario I experienced, the hospital staff didn't. I really can't foresee ever being left alone with DH during labour (we tried it during a non-emergency outpatients appointment, and a midwife insisted on popping her head in at 30 second intervals), and TBH I don't think even that would calm me down sufficiently to be able to speak to hospital staff.

I'm trying to think of a better way to explain this...

OK, if I am in hospital during labour, I will lose the ability to communicate to such a degree that decisions will be taken without my input or consent, and that those decisions will need to be taken by someone, be that my DH or a staff member. Given that such decisions will have to be taken regardless of my ability to communicate, I am simply asking that DH is permitted some involvement in the decision-making process.

Does that make sense?

No one else can give consent for you. If you are unable to give consent generally the medics are obliged to act on what they believe are 'your best interests' which may or may not tally with your wishes (and I understand a bit of what you mean, having gone down the minimal intervention/HBAC plan route in the past, and I am a HCP)

I would suggest clearly documenting in your birth plan that you have discussed all your wishes with DH and in the event that you are temporarily unable to communicate your wishes, you request they consult him.

He would simply be ensuring they know what you want, rather than giving permission on your behalf, IYKWIM? They still make the ultimate decision, but they would need a bloody good reason to go against it if your DH has clearly said , 'No BMDAFL absolutely DOES NOT WANT a scalp monitor put on the baby', for example.

Thanks. I think you have understood me. I'll have another go at wording my birth plan, and will try and strengthen my request that they consult with DH.

Where I may be getting stuck is, I think, in the perception of 'best interests'. Whenever hospital staff see my medical history they tend immediately to dissolve in panic and terror, and they often then lack the capacity themselves to recognise how they are worsening my own anxiety, which they have already by default dismissed as trivial in comparison to their anxiety. And thus they end up acting in their 'best interests' rather than necessarily mine...

Would you find it easier to confirm things, rather than express detailed opinions? I kind of understand what you mean as I was a bit like this in my first labour at times. As others have said, HCPs will always want your consent if you are concious, so I don't think that there's much you can do legally, but could you put something in your birth plan like:

"During my last labour I found it extremely difficult to communicate clearly with medical staff as a result of pain and anxiety and this limited my ability to make informed decisions about my treatment. I have fully discussed my wishes with DH and would appreciate it if you had the detailed discussions with him first. He will be the best person to communicate things to me (as I find it much easier to take in and respond to his explanations) and I can confirm my decision and give any necessary consents. This is extremely important to me and my ability to be involved in decision making, so I would really appreciate it being followed."

Your DH can then wave that around when you get to the hospital ("look, I just want to highlight something about BDAFL's birth plan because it's really important to her."), but hopefully it addresses the concerns that the medics will have by ensuring that you make the final decision. It also puts down a little marker that, if they don't follow this, they are limiting your ability to take treatment decisions, which is a pretty big thing to ignore.

Does that help at all???

Sorry, I think I have cross posted with you.

Is it worth also putting something directly into your birth plan about your medical history and basic preferences, so that it's clear you understand - e.g. "I have a history of X which I know often leads to a recommendation of Y. However, having considered this matter in detail and looked at Z, I am likely to prefer to do A". That would give them some comfort that you understand the implications of any underlying health issues so that when your DH says "BDAFL understands this", they know you really do.

Yes, it's helpful, and I like the wording you suggest. I think that, however anxious I was feeling, I would probably always be able to give a yes/no answer to DH even if I couldn't give one to a doctor or midwife. And from the point of view of the hospital staff, I'm sure it's usually much easier to deal with a coherent partner than a panicking woman...

I know what you mean. In my first labour, I kind of lost the ability to 'hear' anyone who wasn't DH. I just couldn't take it in. This type of approach would have really helped me. DH kind of did it anyway - repeating what the doctors said - but it wasn't the most efficient method!

Just posted before I saw your second response.

What you suggest might be a bit tricky as the medical problems in question (a rare and potentially extremely serious form of heart disease) are virtually unheard of in women young enough to even be pregnant... so there's not enough knowledge out there on which to base any official guidelines or recommendations. Which is why, I think, everything can get driven by panic rather than by best clinical practice.

So how do I ask them, without come across as rude or disrespectful, simply to calm down before considering any intereventions which may be needed?

Hhhm, tricky. Sorry to hear about your heart condition.

How about something like "As you will see in my notes, I suffer from X. As this is a rare condition in someone my age, I understand I understand and appreciate that the HCPs are working with limited information on how to best protect my best interests and those of my baby. However, I felt during my last labour that this sometimes resulted in an assumption that interventions must be in my best interests and also in an atmosphere which created more anxiety and panic in me. I would really appreciate it if we try and create a calm and quiet atmosphere this time round. In particular, it may be helpful if (taking account of my request above) for initial discussions between medical staff or between medical staff and DH to take place outside the room, or otherwise out of my earshot"

You probably won't get far telling them not to panic, but at least they could panic out of your way! I realise it's a bit wordy, so I think the rest of your birth plan would need to be quite short and your DH would need to flag these points when you got to the hospital. Obviously, I'm not a medical expert, but hopefully this is more about communication style than anything else.

"You probably won't get far telling them not to panic, but at least they could panic out of your way!"

Yes, that would be a start I suspect that our midwife and the GP have occasionally got on the phone for a good out-of-my-earshot panic, and I'm very grateful for not knowing the content.

I'm sitting here trying to rework/summarise a birth plan. I think I'd probably try and omit any references to my last labour as I'm keen not to come across as critical or pejorative but simply emphasise my request for an atmosphere of calm reflection which minimises my panic and ensures that no hasty decisions are made. But I think good to point out that the issue is not my heart problems in themselves as much as the lack of guidance on how to manage them during labour.

Thank you.

From a legal perspective, another adult cannot consent or withold consent for you, however most HCPs would certainly take what your husband said into account unless it was truly a life or death situation. A birth plan is not a legal document, but it is a good way of expressing your wishes prior to labour

Glad I was some use. Really hope it all goes well for you and the birth plan for hospital gets to stay packed away in a bag for all time!

Definitely get them to panic away from you - not helpful at all to have that adding to your anxiety.

I recently lost it in labour and was prepared to consent to something DH knew was my worst case scenario; he intervened and asked them for alternatives, how much time there was to make a decision, what happened with different options etc and then told me what he felt was best (he was prepared to argue with me at this point!) and in line with my best interests and wishes. He got it right (although at the time, I was happy to side with whoever was going to get the baby out of me in the most pain free way) and I was able to try for a natural breach delivery - it didn't work out and I ended up with the EMCS but it made a difference knowing I'd tried everything I'd wanted to try.

I don't recall them leaving us alone, but DH was firm enough that they remained very much in the background and let him communicate with me.

This reminds memof my friend who I was birth partner for. She has a severe phobia of hospitals following cancer treatment. After 48 hours labouring at home she had to transfer. Baby couldn't come out because cord was wrapped round his neck so many times, so drs needed to do a cs. In between contractions, she had panic attacks, and everytime they thrust the cs form in front of her she screamed "no". It was horrendous and staff were really panicking, making her panic worse. I was only a friend, not a relative, and her dh a quiet chap who couldn't cope. But we asked forma few minutes alone with her, explained that the baby wasn't comic out any way except cs, so it was both of them die or her have the surgery, and she calmed down, consented and then themmedics came back in, Having had some time to
Calm down themselves.

So firstly, I think you're doing the right thing to cover the worse case scenario in the birth plan. My friends assumed, due to 2 previous hbs, that she'd automatically be fine for a 3rd. She also assumed that her community mw would explain her phobia if she did have to transfer (she went off shift at that time unfortunately.)

Ultimately, as well as what you write in your birthplan, your birth partner needs to be really geared up to actively advocate for you, and not take no for an answer if he needs to talk to you himself.

Good luck. Friends baby was fine after few days in scbu, and she's getting there with post trauma stress counselling.

There are several aspects of your post which really concern me, more than the legalities of taking direction from your partner.

Firstly, I cant imagine what must have happened to you to leave you incoherent with anxiety. Women can be very frightened by what is happening around them but I genuinely have never seen a woman in labour that could not communicate when the midwife is talking gently and quietly in their ear and using good eye contact. Its certainly possible to bring the person back to relative calm within a few minutes. This is very different to when women get into an almost hypnotic state through endorphins or hypnobirthing for example and dont want to be disturbed etc.

Also I find it very hard to believe that any medical or midwifery staff who see your medical history suddenly turn to quivering jellies! Im not naive enough to believe that with a rare few hcps that it may happen, but these are the exception rather than the rule. Whatever your heart condition, it should be dealt with professionally and calmly and even in the hospital where I work, we see life threatening medical conditions in patients who are also pregnant or labouring, and who may literally die in front of us at any moment, and this does not induce a meltdown in the staff. It is just dealt with as it is part of what we do. I have worked in many hospitals and it is the same in most places, we just get on and deal with it. Sometimes if something is happening like a major PPH or something, it may look like chaos and panic as there may be many people in the room and we have to work very fast and there may be a lot of noise etc. But that doesnt mean people are in panic, just that if we dont stop the bleeding fast then the patient will suffer, so we work fast and it may appear that people are panicking when in fact they are just doing their job.

Now if you turned up at a little cottage hospital in the middle of nowhere, I guess it might be different.

The other thing to think about is that if you get incoherent with anxiety and panic, how is that affecting your labour? Your body is not likely to labour well if you are fearful and anxious, so its very important to try to stay calm and focussed and relaxed as much as possible.

Finally, if your cardiac condition is very severe, or unpredictable, is home the best place to give birth? It may be safer to go to hospital but have your IM as an advocate for you. And as a midwife who does a lot of homebirths, I am certainly not anti homebirth in any way and if you were on my caseload, I would support you in what you want, but I would have genuine concerns for your safety at home (depending on what the heart condition is).