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.

Really interesting thread.

Answer has to be that it depends on the woman surely? Does anyone remember the 'Disney' couple on OBEM? They were convinced they were going to have a perfect pain-free waterbirth, everyone watching expected her to be screaming for the drugs 10 minutes in, but she actually did just that. It was almost as if she refused to consider anything negative might happen and so just viewed it as an entirely positive experience.

I have a friend who is similar although without any of the Disney schamaltz because then I'd have to kill her in that she is an athlete, was very confident she would know her body's limits, and so read virtually nothing, went to no classes, didn't panic when she went overdue, and, despite being nearly 10 years older than most of my peer group, had the best pregnancy and birth experience of any of us. I do wonder if for some women a positive, affirmative You Can Do This attitude works.

For me it was the opposite. I had twins and a tricky pregnancy so knew I was headed for a very medicalised birth. I went into labour 2 months early so I hadn't had a chance to get to any NCT classes as and turned up with no hospital bag, no birth plan and no DP. But I had read everything I could get my hands on, watched OBEM religiously, and requested the hospital protocol on multiple and CS births. This meant that when I was on the labour ward I could say to the midwife "I know X is in your hospital protocol, but I want Y&Z". SHe took it onboard and when there were other issues down the line she told the consultant "Twelve is very well informed and thinks Z" so even though I was off my nut on G&A with nobody there 'on my side' she knew I knew what I wanted and was confident putting that forward. Other midwives (and I had half the hospital around me ) followed her lead and deferred to me more than I expected, and made essentially a hellish experience much more positive than it could've been. I am very very glad I armed myself with as much information as possible.

With reference to those who have mentioned that the risks ought to be discussed earlier in pregnancy, where I work we tend to start AN classes at 32-34 weeks. What stage of pregnancy does anyone thinks we should start discussing the risks. My feeling at the moment is that maybe we ought even to be incorporating it in to sex ed at school (which amazingly midwives play no part in!!)

Really interesting to hear of women who have had the 'textbook' vaginal birth would also go for CS next time if they were given the choice. I suspect I haven't heard so many women say this before because it now seems so taboo and politically incorrect. The majority of you seem to advocate full informed consent of all risks and with direct reference to your individual situation.

What does anyone think about what we should tell very young/teenage mums-to-be and ethnic groups who need a translator with their midwife checks? I dread to contemplate the disservice we are giving them in terms of disclsoing relevant information.

Any thoughts or feelings about how not being given all the information you might want to know takes away your control?

I think women do need to be told (as I was) about how the doctors will handle common complications ie types of forceps, how they're used and to push when the doctors says, how an EMCS is likely to unfold etc. Possibly not the absolute worst-cases where complications lead to death, but how to handle the birth not following the perfect script. Maybe a few women don't want to know, and warn them that you are going to talk about things going wrong (this was second session for us and we were forewarned so we could choose to not turn up).

However when the doctors were called into my delivery room I made it quite clear I didn't want to know more detail than necessary and they got DH to ensure I didn't see anything. But at least I knew roughly how forceps worked and about being stitched up afterwards. The most helpful thing was that they made it clear that it wasn't my fault, it was just one of those things that can happen.

In relation to young mums or mums who require a translator. With equality as it is, they should have exactly the same information.

I am all for this being part of sex education. It might help cut down on unplanned teenage pregnancies a bit more effectively than being a parent to a bag of flour.

Lack of control and not being told what was happening were highly significant in my birth trauma.

Def think women need to be told the truth but also think women need to be given the information to help them make an informed choice all the way through and that is with regards to during their labour and what they can do to help it go smoothly.

Ie stuff in later preg to encourage baby to ger in a goid posituon and support to move around etc in labour.

My local.hospital has new birthing centre on same floor (opposite side of corridor) to the delivery floor where high risk mums now go. But the birth centre has all the facilities to cope with difgicult birth except c section. But its so much nicer than the delivery floor! The conditions of where woman births can maje a big difference to how well she labours.

Also with reference to being given information, in labour I couldn't process information, could not have made a rational decision about pain relief (other than that I wanted it) or comprehended the interventions we ended up needing. That I knew ahead of time I didn't want opiates pre-birth and what could happen meant that when I couldn't cope with the pain I could make it clear that I wanted to go straight to epidural and once the doctor said "forceps" I could say "yes, I don't care" whilst still understanding what would happen to my body. If I hadn't been told how forceps would work ahead of time I think I would have been more distressed and less able to focus during DS's birth.

As for sex ed, did no-one else see the video of a (biology teacher?) giving birth at school? I remember our teacher warning the next one what we'd seen and to watch out for fainters!

i think better information would be great. i definitely think more information about basic midwifery stuff like position and active labour would helpl

people go into hospital expecting a midwife to be with them whilst they are in labour. they don't expect to be turned away, or stalled from entry. they quite often don't know what the protocols will be (eg labour for x hours before induction, pushing stage 2 hours limit etc etc..), and won't be informed about the reasoning behind them even whilst subject to them.

they don't know that if you want an intervention free birth, not going to hospital is the best way to get it, or if they have to go to hospital, taking their own midwife/doula significantly increases their chances.

despite huge piles of evidence to the contrary, people still believe that everything that happens is inevitable, every intervention is completely unavoidable, and therefore information in advance is pointless.

Depends on the context.

I learnt that the risks of a managed 3rd stage was reduced iron for the baby and possible But unproven PPH risk.

The risk I SHOULD have been told is that opting for a physiological 3rd stage I was at a high risk of having an inexperienced mw that CAUSED a PPH due to using cord traction.

I would have liked also to have known the very high risk of being denied a planned-for water birth and the subsequent impact this can have on a woman's ability to cope.

I would also have liked to been given decent information about the risks of induction rather than simply being told my baby was at risk for refusing.

I'd like to have been told that a sweep can risk infection, breaking waters and starting labour before the baby was in an optimal position.

Ultimately though i would have liked to have known the risks of agreeing to a SHO seeing me and subsequently performing fundal pressure without warning or consent.

Oh, and absolutely explain SD so that the woman can have some say in how it is dealt with which can be agreed in advance and put on the birth plan.

when it comes to BF - telling people that more than half of women that start off with the intention of Bf aren't doing so 6 weeks later would perhaps get more women to read up and get informed in advance rather than assuming it happens by magic and isn't hard at all.

The absolute main thing is that the woman is kept entirely informed during labour. It's good to be armed with information beforehand but I think for a lot of people it can be a bit overwhelming and you won't necessarily remember all of it when the time comes. Every main possibility should at least be mentioned in antenatal classes so it's not a complete bolt out of the blue if someone mentions an episiotomy for example. In the delivery room is the not the first time a woman should hear a word like that.

What annoyed me in labour was that the older midwife who came in after a couple of hours very much had the attitude that this was her show and I just had to go along with what she wanted. That was in complete contrast to the younger midwife I'd had up to that point, who just let me get on with it and listened to what I was saying. The older MW came in bleating about ventouse and episiotomy without ever once explaining why she was considering them. That sort of treatment is what contributes to a woman feeling out of control - the feeling that everyone else seems to be in on some secret that you're not aware of. In fact, I think it's just that some older midwives (not all of course) come from the era where what nurses and doctors said was law, and the idea that you work with a patient and actually listen to them isn't even on their radar.

When I asked three times why she wanted to use a ventouse she finally admitted it was because their monitor was faulty and they couldn't get a stable trace of DS's heartbeat. Given there was meconium in my waters they were understandably concerned but I didn't feel faulty equipment was a good enough reason to start intervening and I flat refused to consider ventouse. She then went on about wanting to do an episiotomy again due to lack of a stable trace. Note that there was no actual evidence of DS being in distress (beyond the meconium), she was just insisting on these interventions because it would make life easier for her as she wouldn't have to ask the other MW to hold the trace to my belly. I again refused that, but was forced to give in to her insisting I go on a bed (having laboured on my feet/knees up to that point) because I was so tired I couldn't argue any more. If she had just bloody well left me alone I could have had DS out in half the time, I'm sure of it!

The younger midwife subtly praised me afterwards for standing up to the older MW and criticised her decisions in a very roundabout way. I appreciated that as I was worried I had been foolish in not listening to her. DS was totally fine by the way - needed a little suctioning when he came out due to the meconium but that was it.

So what I would advise is that you let women know that they are in control in labour and that they should expect and demand that they are kept fully informed of what's going on at all times. I doubt you will tell women that though, because it seems easier to patronise them or as in my case, pretend their baby is in grave danger, in order to get them to do what the MW wants.

BTW I am having a homebirth this time round because I believe the dynamics will be very different in my own home. I'll be in my own space and so won't be so easily bullied and I'm hoping the MWs will have a bit more respect.

Yes I'm very 'interested' in the impact of having an inexperienced midwife generally in labour, risks of induction and of sweeps causing infection.

one thing that should be as common knowledge as how to identify meningitis - is how to handle a BBA - it isn't rare at all.

and i agree about SD resolution - again, it isn't rare and should be discussed.

i knew next to nothing when i gave birth the first time.

I actually tell women in my AN classes to trust themselves and their instincts, to write down in the birth plan what they really do not want including things they don't want people to say to them, and to ask for the senior midwife and/or a supervisor of midwives if they are not happy with anything in labour including the midwife looking after them as I think it can impact on labour progress. It's also good to have a really good friend/additional birth partner who will stand up for you.

Thing is Flomaba, you shouldn't need "someone to stand up for you" because it should be a fight! Poor DH was really caught in the middle during my labour - I had warned him in advance that I wanted minimal intervention but when the older MW was leading him to believe DS was in danger, what was he supposed to do? The fact was, she just wasn't honest with us. How can someone in the throes of giving birth deal with that?

Sorry that should say "it shouldn't be a fight."

I fully understand that MWs genuinely want the mother and baby to be well and safe. I don't doubt that for a second. I just think at times they become so focused on avoiding risk that they forget about the mother and what she's thinking/feeling and in the process make things worse rather than better. Does that make sense?

You're absolutely right and a big part of the reason that I'm researching this is to try and draw attention to all of these issues. Did you send in a complaint? I know it doesn't change things for you but does now force managers to investigate the midwife's behaviour. How long ago was it?

Yes I get what you're saying and some midwives do

Nearly two years ago. I didn't complain because I didn't even think to at the time, I was just so happy DS was there. To be fair she didn't do anything wrong as such she just wasn't interested in me in as a person, she had a completely business like approach to the whole thing. What irked me the most was that my desire to stay upright pissed her off a lot - she didn't care that lying down was absolutely excruciating for me, all she cared about was that it would make life easier for her. I can understand wanting to get the job done, but IMO in midwifery that's not the approach to take - you are dealing with people who are very vulnerable and you absolutely must take that into account. Her tutting and herding me along to the bed like a naughty toddler still makes me feel awful to this day. Luckily the younger midwife was there the whole time watching out for me or I'm convinced the older one would have done an episiotomy without my consent. Now, if she had done that you can bet your bottom dollar I would have made a complaint, and then some!