How much should women be told about complications in labour or birth?

[Flomaba]

Hello I am a midwife who does ante-natal classes and am studying medical law. I would really appreciate any feedback on whether or not women think we should tell them all of the risks all of the time, some risks all of the time, or any other variations so that women can choose whether or not to take that risk. Many thanks and best wishes.

As you are studying medical law, where does informed consent extend to? I think women should be told all potential risks. My first birth was before I discovered the joy of MN, and I knew very little about labour and birth, although ensured I researched pregnancy thoroughly as I would not be seen very often, this taking some responsibility for my own health and wellbeing. I trusted the professionals to keep me informed during the actual birth. Sadly I was greatly let down, and had an extremely traumatic birth. Had I been told more by friends, family and professionals, things may have been very different. Not wanting to scare a mother-to-be is a crock of patronising shit IMO. If we are old enough to get pregnant, we are old enough to be told the truth.

Ideally potential risks would be known before a woman gets pregnant.

Thanks so much EVERYONE for your responses. I have been a midwife for 20 years but have never had any children yet feel passionately about doing the best by women. At the same time I don't want to scare women and give them nightmares. I'm looking at consent problems in legal cases and worried that we do not pay enough attention to it. Your comments about giving real statistics and explaining them is great - I will definitely apply this to my ante-natal classes from now on. I actually started compiling a table the other day but am really having to search for some statistics which I imagined would be freely available. Wow you have really given me something to think about. Thanks again and look forward to continuing debate.

PS There is probably a line on this already but an obvious followup question is how do you feel a lack of preparation/information impacted on you?

That's precisely what I'm asking myself...the law just seems to want to avoid answering it. It also seems to be denying women the opportunity to decide what it should mean and sidestepping the issue. My instinct (bearing in mind that I'm not and never will be a mother now) is that women have a right to be told all potential risks.

Re:
As you are studying medical law, where does informed consent extend to? I think women should be told all potential risks.

Yes the stillbirth stats pose a real dilemma

Yeah I think it's really important to talk about it before you are in labour...it's the last thing you want when you're in the midst of it

Personally, I would want to be told about all of the risks, with information about the likelihood of the risk being given at the same time.

My problem with this is that elective section is not (really) available on request. I think if we really start talking about the risks of vaginal birth, for which emergency sections, forceps, 4th degree tears, prolapse, incontinence, coccydynia, etc etc are all possible outcomes and are frankly not that rare, then some women are quite rationally going to decide they would rather take the risks that go with a planned section. This seems a reasonable choice to me (as someone with coccyx pain and waiting for a pelvic floor repair op after two vaginal births). But there is still a big push for natural birth in the uk.
I know this is controversial, but I can't see the point of telling women all the things that can go wrong with a vaginal birth if they don't really have any other options. Some evidence suggests some bad outcomes are lower with homebirth or MLU but these often aren't realistic options for a lot of women due to units closing etc.
Telling women symptoms to look out for which are indicative of problems e.g. Reduced movement or headaches or swelling is course very important.

Although having read my post again, I am going to contradict myself and say I think it probably is important to know about different complications so it isn't such a shock when they happen. Also to know a bit how they are handled. For example letting women know that if they have an emergency section there will be a whole ton of people in the room, and letting them know in advance what people they will be (e.g. Anaesthetist, paediatrician etc etc).

Something that comes up in legal cases is the question of whether it is the risk of occurrence (that the 'potential' risk actually happens) that is most important or is it the risk of a bad outcome such as shoulder dystocia/Erb's palsy/stillbirth that ought to be discussed or both. What do you think? I think both so that women can weigh things up and if she is carrying a big baby she can decide not to take the risks and opt for an elective caesarian.

I'm not sure I understand the distinction, flomaba?

My problem with this is that elective section is not (really) available on request...

Yes I have a problem with this too. Even though I actively promote normal vaginal birth as an ideal, nature is not always so cooperative through no fault of a woman. I think that women with 'risk factors' ought to have the option...it's their body

What you're saying is that the % risk for the event happening should be given, and the % risk for bad outcomes if the event occurs should also be given. The only problem with this is the proliferation of information which would occur, given that risks are different in different women eg. Those who are obese, diabetic, hyper mobile, etc.
You'd need a book to give each woman with all the possible risks, or an individual consultation for each woman to honestly give her her individual risks based on statistical evidence. Not sure the NHS is up to that.

Do you mean women should know risk as expressed by likelihood x severity of consequences?

I think they should be told both. Individual perception of risk is different. They may view tearing as a high risk because the occurrence is high, but Erbs palsy a low risk because it doesn't happen as often even though the consequences of the latter if it occurs are probably more serious than the consequences of the former.

I had to do a lot of my own research but I had my DS in France where there is a big culture of 'doctor/medical professional is the keeper of all knowledge and you will feast on what crumbs they deign to give you'. That is a very unhelpful approach and it wasn't enough for me. I wanted to know not only the risk (based on both components) but also how to actively minimise the risk by reducing likelihood of occurrence or reducing severity if the complication arose.

I think a lot more data should be available for women who want to make up their own minds about what risks they individually face. A blanket risk management approach is all very well but if something doesn't ally to me I want to know just as much as if it does.

Risk occurrence is the chance that a particular complication could happen but all turns out well no harm done; risk of bad or adverse outcome is the chances of harm resulting to mum or baby. In legal cases they split hairs and see one or the other as the basis for determining whether or not there has been negligence by the doctor/midwife for not telling them about the risk so that the woman could have decided to choose another treatment option. Hope that makes sense...I'm still trying to get my head around it.

The only problem with this is the proliferation of information which would occur, given that risks are different in different women eg. Those who are obese, diabetic, hyper mobile, etc.

Yes that's the down side and what the courts/doctors/midwives say too...

I think a lot more data should be available for women who want to make up their own minds about what risks they individually face. A blanket risk management approach is all very well but if something doesn't ally to me I want to know just as much as if it does....

I agree

I'm all for informed choice.

I prefer to know the risks tbh.

Watching One Born Every Minute was the best preparation for me. It made me realise intervention is very, very common. My birth experience was nothing like any I saw on OBEM (it was harder!!) but it probably helped me stay calm when the room was suddenly flooded with doctors when DD's heart rate was failing - having seen this happen on TV.

What does anyone who had a problem and intervention-free vaginal birth say?

I would have appreciated someone being one hell of a lot more honest about the risks of VB - to continence, pelvic floor integrity - and in terms of long-term health as well as the short-term immediate risks. I would also have appreciated a more individualised assessment of risk - e.g. a 40-year old primip is likely to fare less well than an 18-year old giving birth for the first time. Instead, we're all lumped together as one. And it just doesn't work like that!

I had a pretty straightforward birth ( although it did not feel like it at the time) - g&a, pethidine, second degree tear. I feel strongly that women should be told the risks, for two reasons.

1. We are not children. A lot of antenatal care seems to treat women as such, e.g. Overly rosy view of breastfeeding. Again, I breastfed successfully, but I had been well primed by my sister about how hard the first few weeks would be. A lot of people don't get that. This is not a criticism of midwives - mine were all great. But I think the overall strategy is wrong.

1. Being more open about risks would also make stillbirth, birth trauma, prolapse etc. less of a taboo. This might help people who've been through it. It might also make society appreciate just what a risky and valuable thing pregnancy and birth is.

In my view, pregnant women should be trested like soldiers going into battle. Give them respect, tell them the risks. The aim should be to make women feel proud and empowered.

I think there is a difference between talking about various risks in an antenatal class and in a one-to-one situation with a particular woman.

Within a class - why not focus on straightforward birth and the common situations where help might be needed. And answer questions with honesty as they arise. We all have very different, individual attitudes to risk - there is something like a 1:250,000 risk of serious injury as a result of having an epidural - now for some women that is a risk they are prepared to take, for another it's a no-no. But once they are in labour their attitude to risk - and their ability to take in and process information changes!

One-to-one - I believe women should absolutely be given information including risks so they can make an informed decision.

I think the most interesting aspect is to what extent can a woman in full-blown labour actually make an informed decision?

You asked about "problem and intervention free vaginal births", so for background, I had two straightforward vaginal births, one in a home from home unit of a major teaching hospital and one in a MW unit in a small town. I used only G&A and a birthing pool each time, as that was all I felt I needed at the time, but was happy to be guided by MWs as to what was necessary.

I personally wanted to know about things that could go wrong, risk levels, symptoms to look out for etc etc (I'm a scientist by background) I can think of one experience with MWs explaining risk levels: I am rh-neg, and was offered anti-D injections. I was given a leaflet telling me about the injection itself and the risks attached as it is a "blood product". I looked at the stats and commented that the risk (of contamination) as stated in the leaflet was miniscule. The MW looked relieved and said that it was clear that I actually understood the concept of "risk" / probability.

It seems to me that if you are talking to reasonably well-educated / well-informed mothers, then most are probably able to understand the concept of risk, and make an informed decision as to whether the level of risk of a certain course of action is acceptable to them as an individual. But I don't think there can be a one-size fits all approach, as there are going to be a proportion of mothers for whom the concept of risk is not easy to understand: how "informed" is their consent (or non-consent) if they are not really able to weigh up the different risks of alternative courses of action? On the other hand is it really up to the MW to decide how much information any person is "allowed" to have?

Oh yes, and one's feelings about risk might be entirely different in the middle of labour!