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.

Why should childbirth be treated differently from other physical/medical events? Genuine question - if you HAVE to have a procedure, like a VP shunt or an appendectomy (well - you could of course refuse both of those, but you see the point) -

Do medical folk say 'no point telling them about the risks as they have no other option'?

There is also a huge irony here in the way the choice is being phrased as 'give mothers partial information about the risks of childbirth - or risk scaring them'.

Btw, one of the things you hear a lot from women who have had 3rd and 4th degree tears was 'I didn't realise it was as common as it is'. Now you can argue that 3 or 4 out of 100 isn't common (I'm happy to be corrected, but I think thos3 were the RCOG stats), or you might think that's actually quite a lot....- but if someone goes into childbirth thinking it's a one in a million chance, won't they feel differently about it if it happens to them?

I genuinely think that because CS is surgical and VB is 'natural', then we have a blinkered view of risk. Women are frequently left with the impression that there are tons of risks with a C section, and virtually none with a VB. This just isn't true.

I had two home water births. I still think women should be able to choose a c section if they want one. I would, if there was ever a next time.

Of the 8 babies born to my antenatal group 4 years ago, one died at two days due to complications with his delivery. We had a reunion with the group leader and the parents of the baby who'd died a few weeks later and it became a bit of a debrief. We asked why it was never mentioned that things could go so horribly wrong (I suppose we assumed , wrongly, that in 21st century Britain, that neonatal death was a thing of the past). The course leader said that they did used to cover it, but that no one ever believed it would happen to them.

Sorry - rambled a bit there - the point I meant to make was -

is childbirth different to other physical/medical events in terms of how much information about risks and complications should be given?

I am trying to think of a good analogy, because if I compare birth to an operation, then people who want birth demedicalised will resist that -

But menopause is natural and inevitable, isn't it - so do doctors decide to withhold information about what might happen during menopause because they don't think women need to know, or can't handle it?

PS reminds me a bit of my breastfeeding group. There was a bit of mutiny one week - women who had experienced various problems asking health visitors why they weren't warned about it beforehand (and those of us who had no specific problems pointed out we all found it much more overwhelming and constant then we'd been led to believe).

The health visitors said they 'weren't allowed' to tell people 'what it was really like? beforehand as it might involve mentioning 'negatives' and that would put women off!

We were all gobsmacked. I said that if women were only prepared for 'positives' and then ran into problems, weren't they much more likely to be demoralised and give up?

Apparently not.

I strongly think that the stastics of stillbirth/neo natal death should be mentioned. I was blisfully igrnorant when I had my eldest and only became aware as I got to know more mums. A friend who recently had a stillbirth had absolutely no idea how common it really is - 17 per day in the UK.

I think generally what needs dispelling is the myth of perfect birth etc that for some people it is a difficult time, it's not like in the movies/TV/Media. Some babies die, some babies end up damaged, some mothers end up damaged, some women end up emotionally distraught by the experience and the focus needs to be on the birth being as safe as possible for Mum and baby.

Sorry it sounds so negative, I never got my "dream" birth experience, it was only after a horrendous 6 months with screaming dc #3 that I didn't really care about my birth experience for #4 - as long as it was healthy and didn't scream for 6 months I didn't care - turned out to be my far the best birth experience of lot, mainly because I was relaxed about it!!!!!

I very much agree about the stats re: still birth, and neo natal death.

It is awful, but it does happen, and it feels almost as if it gets swept under the carpet somehow. It must make it so much worse for the mothers who go through this.

Flo, you talk about risks, "so that women can choose whether or not to take that risk." In most cases, the mother DOES NOT have a choice, even if she knows about certain risks.

My waters broke and I was in labour for 3 days. By the second day, I was begging for a C section, I was sure this baby wasnt coming out normally. But no one took any notice because "guidelines" said they could wait for 72 hours after waters broke. Hospital treated the guidelines as law set in stone instead of judging individual mothers circs. Ended up with EMCS and cord prolapse.

A little off topic, but a significant percentage of complications arise BECAUSE OF an assembly line attitude to labouring women.

I am a secretary for a midwife who acts as a expert witness in potential negligence cases. Obviously the cases she deals with are the serious complications/maternal/baby deaths but she is in constant demand and l often wonder if this is a result of the increasingly litigious society we live in or more informed choice and therefore women expectations increasing.

From my personal point of view, my DS's birth resulted in an emergency section and it left me in a state of shock. Naively l never really expected to have anything other than a normal labour and l was terrified enough of that - the c section was even worse! Although having a section was covered in the ante natal classes, there was more emphasis on 'normal' labour with intervention, than just how awful/hard having an unplanned section can be!!

I had two mostly uncomplicated births. I had pethadine for the first and a very little G&A for the second, 2nd deg tear and no tear.

I wouldn't have minded knowing everything but think there is a risk of diverting attention away from the important/more likely issues with talk of very serious but very unlikely complications. For example at NCT we were only really told about cord prolapse as a 'serious thing you don't want to ignore' - I spent a lot of time finding out everything I could about it; too much time in retrospect.

I think if you do share all potential risks (and I think that's preferable) - just do it unsensationally and perhaps in separate groups according to likelihood. I don't even know what Erb's palsy is...

I agree talking will lessen any 'sensationalism'. I really hate it when things go wrong and people feel as though whatever's happened is somehow their fault; their body has fucked up. If we all knew how quickly and unexpectedly complications can present themselves it will hopefully stop judgement by others and, more likely, self.

You are right SnowWide...the rhetoric of 'choice'. Occasionally I have come across women who know and I know they'll have a CS and have challenged the system without success then ended up with a CS after a long, arduous, sometimes traumatic induction. Various bodies are very concerned about the rising CS rate yet arguably by not making it a matter of self-determination they are transgressing this legal right and the law, in effect, condones it. In the same way that women are campaigning for non-intervention, the right to homebirth, etc, maybe women also need to start campaigning for the right to decide for themselves as far as possible if 'intervention' is right for them. Currently the law dictates that while a woman can refuse consent to a CS she cannot demand...as many of you have seen there is a huge contradiction there. Do we have an action group evolving here??!!!

Yes the strong implication that having had a CS is equivalent to have failed at a vaginal birth is very damaging to women who have had their babies this way and those mothers-to-be who feel pressurised to live up to the ideal.

Breastfeeding... arrgh. Still have a chip on my shoulder about failing with that both times. I do so wish that NHS could fund a tongue-tie specialist who'd look at every baby before discharge from hospital. Still don't know if I failed with DS because he had it... he was at least shitting yellowy poo after a week unlike DD, who was diagnosed & cut at 6 weeks.

With DS my nipples were like bloody canyons; I was in agony and permanently tearful; I quit for my sanity. With DD by 6 weeks my supply was nonexistent and having a toddler (and therefore no time to sit around for hours with a child on my boob)/ no knowledge of what good breastfeeding is like, no skill at getting a latch... in short I gave up.

I can't believe that by sharing the reality HVs think they'll put people off. I think desire to BF is either there or not - information will only help. I've had a little cry writing this; it still affects me that much! Is that healthy?!

Yes the breastfeeding conspiracy is a real problem. Most women find it painful to start with yet have almost invariably been told before birth that if it hurts you're doing it wrong - not true. The WHO guidelines have now helped set in place a fascist regime across the NHS bullying everyone in to breastfeeding.

Watching One Born Every Minute was the best preparation for me. ... 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.

This. It was much easier cope with being rushed to theatre for an EMCS (same reason) having seen it all on OBEM, DH said the same thing about being left in the delivery suite alone. DS ended up being a normal birth because he arrived so quickly but it was very much 'OK, EMCS, no it's too late for that, you push and we'll pull, oh baby has arrived'. It was only when I read my notes late that I realised 'you push and we'll pull' was them asking my consent for a forceps delivery. But I had a 10 minute second stage, most of which took place as I was pushed from the delivery suite to the theatre so it's not like there was a lot of time to consider my choices.

yep to the 'veiled' consent. I had that with my first (ventouse).
it wasn't presented by midwife or consultant as something I had any choice in.
and the fact that the language used is so downputting. 'failure to progress' sound like I didn't study enough for maths a-level, not like something I didn't have any influence over.

I hate the "Let's not tell them all the risks in case we scare them" attitude. Surely women who have complications during labour are more likely to get panicky and scared if they've been led to believe that all births are lovely uncomplicated textbook births?

Agree about the consent issue. I nearly got a forceps delivery because DS's heartrate was dropping with contractions - consent question was basically "Baby needs to be born because he's not happy, we're going to use forceps, let's just wait a few minutes for this local anasthetic to kick in before we give you an episiotomy, okay?"

But luckily it turned out that labour was more advanced than they realised, and DS was almost crowning at about the time the local anasthetic kicked in.

At the time, I didn't have a clear understanding of what forceps might involve or what any after-effects might be. Granted, under the circumstances, I'd have consented anyway, but some prior information about intervention and forceps deliveries would have prepared me for what might have been involved if DS hadn't turned up as quickly as he did.

I agree with Jules125, people (not just women) should be more aware of what to look out for and think about, and what needs urgent attention.

My thinking when pregnant was heavily influenced by my sister who gave birth in a birthing pool, kept to her birth plan and only had gas and air as pain relief. There was so much emphasis about that kind of thing being a woman's right when I gave birth that I felt like a fraud and a failure as a woman to have pre-eclampsia, and all that it led to!

There is only so much advice and influence a midwife has, unfortunately, and I was lucky to have some excellent midwives, and happy to say they were not exceptional in their profession.

I think we are more fearful of the unknown, so don't overburden people with things that are going to be unavoidable; there's no point in worrying about every rare and unlikely complication. Do equip them with the knowledge they need to seek help when needed.

Good points.

I also think there needs to be balanced information. For my first pregnancy I was told masses about the 'horrors' and 'risks of caesarean section and all the risks of vaginal birth were either absent or glossed over.

My actual experience of the risks was the complete reverse- blissful elective c/s but psychologically and physically injurious vaginal birth.

I felt totally betrayed by the poor information; choice is meaningless if the information you are given is one sided.

I think it is best to include all the needed information in written form, with sources cited, so it can be discussed from that stand point and digested over time, preferably early in the pregnancy. I found the later in the pregnancy it was and the more they relied on speech off the top of their head rather than written information, the more HCP relied on anecdote and emotional blackmail that facts.

The NHS's purple book on pregnancy that I got last year wasn't very good on this, particularly when it came to discussing after-birth complication. It has less than a quarter of the page for placenta delivery, a couple tiny paragraphs mostly convincing the reader to get the injection. Including information on the cord, when needs to be cut right away and when it can be delayed, retained placentas, adhered placentas, ways the midwife will encourage the placenta and why, causes and prevention of PPH , pros and cons on the after-birth injection (including how it works and include all options including after a period of time/trial of natural delivery or injecting just after the placenta is removed), manual placenta removals would have my own 3rd stage complications (in 3 out of 4 of my pregnancies) a lot easier to understand and come to terms with as it was the information I got on the fly was often contradictory and confusing as no one had information on it on hand so just went with what they had seen rather than any real studies on the issues.

I had an uncomplicated VB but I did end up with G&A which in hindsight I didn't need and wouldn't have asked for (as per my birth plan - if I need pain relief I will ask). It does make the issue of in-labour consent interesting for me personally.

Basically I think we just need more freedom of information and a serious chat on 'risk and reduction' early in pregnancy.

Pregnant women are not fragile flowers who shouldn't be worried. Women have a right to know.

" At the same time I don't want to scare women and give them nightmares. "

IF there is a reason for women to be scared because of information about birth - then they MUST be told this!

I totally agree with Valium that it is a croc of shite to pretend that natural birth is usually fine.

"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. "

Totally agree with this too - we are going into battle we need to be properly forarmed and forwarned!

Flomaba,

I had a so called text book first birth, 6 hours established labour and 23 mins pushing.

i had a small labial tear and it turned out - five years later going through the notes with a MW that baby was back to back.

I had homeopathy, massage, my DH did not STOP MASSAGING FOR SIX HOURS....I gave birth bent over a chair, I had the ball etc etc etc..I was mobile, I had G&A and Pethadine.

It was hell and torture, I was in no way prepared for the pain, I would have gladly got in the water birth pool but I couldnt move an inch let alone go to another room.

The MW consultant at the hospital I spoke to - was not able to look at me
" holisitically", inspite of her level as a consultant - she could not see me as a whole human being with emotions and a brain, she kept talking about " my bodied capabilites" and my " pelvis".

Three times she said " women just dont realise how much water can be a great pain reliver", she was not listening to me when I said I was open to water and would have gladly tried it could I have got in it!

My body was amazing, it birthed the baby without me doing anything which was fabulous, but its just a process of our animal side - and nothing to do with me - eliza regina. I do not feel proud of what my animal side did at all.

Therefore I also do not feel embarrased to say now I am having an ELC this time.

In my close personal circle of friends,

1. pre eclampsia - baby died just before birth, friend serioulsy ill.
2. placenta pravia, heomrorage - blue light to hospital, nearly died.
3. " failure to progress" , babies heart beat dropped/ ECS, under GA.
4. Heart condition not monitored, left to give birth alone on wrong ward.
5. Fibroids, EMCS after 12 hours, touch and go on hysterectomy.
6. 1st birth ended up on crutches.2nd, wheel chair
7. baby came out so fast tore undercarriage totally, severe incontinese issues
8. forceps in both births, so badly damaged after second, crawling for first week, couldnt hold baby.

Only myself and one other friend had so called straight forward labours and births!

I am amazed, and somewhat encouraged, that ladies on this thread report having textbook natural labours, yet would choose an ELCS next time. I am encouraged because I had a traumatic first delivery, and elected to have a section with no.2, and due to have no.3 via ELCS on Thursday.

If I had been better informed, I am utterly convinced I would not have been so traumatised by my first birth experience, and may well have chosen to give birth vaginally the next time, although at 10lb 3oz the consultant reckoned it was a good call.

In my circle of friends, one died after baby shot out so fast that it ripped her cervix - she died in theatre having it repaired. Baby was fine. Another friend went overdue, young girl, already had one healthy child. Baby died in utero. No reason identified. One friend had PE at 34 weeks and was very unwell. EMCS, both mum and baby fine, but scared to have more understandably. Another friend had her boy at 28 weeks. So traumatic she will never have another child, and cannot talk about it at all. One friend had three natural births with no interventions or drugs, and another who thought the birth was the best bit and would happily give birth every day.