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.

Edgar Allan Pond - when I referred to the risks of vaginal birth, I meant things like cord prolapse, shoulder dystocia (for the baby), vaginal prolapse, 3rd and 4th degree tears, urinary and faecal incontinence (for the mother). Those risks. Which are still risks whether you give birth in hospital or somewhere else.

It is thoroughly negative about all aspects of hospital care and especially C-sections, but seems to suggest that childbirth is made risky by those things, as opposed to being inherently risky. Which I think is dishonest and undermines the argument.

The thread has ebbed and flowed since the original question but I think this point (which I've made previously on other threads) is relevant:

In relation to informed consent, I would love to do a detailed comparison exercise between (1) the information provided on risks of certain interventions/procedures antenatally and (2) those given during labour (ie: on the consent form you have to sign) / the ACTUAL reality.

My personal example is the NHS leaflet which matter-of factly states you may need forceps and that the dr would tug gently and the baby would have red marks which would fade. In the horrendous pain of labour as I was being told baby wasn't budging (found out after the event she was in deep transverse arrest) and I couldn't really go straight to CS as my birth plan stated. I had to sign something which mentioned paralysis, lacerations, incontinence. The "gentle tug" was the full body strength of the middle aged male consultant with his foot up against the table in theatre and DD is facially scarred (which is becoming more noticeable with age as it's growing with her). That leaflet was fking fraudulent.

Needless to say, after struggling with the physical and mental affects of that Keillands forceps birth on both me and DD, including a breakdown on my part, I successfully secured an ELCS (after the predictable fight). That exorcised so many demons for me and DH and was the most perfect and blissful experience on earth.

herethereandeverywhere -

That's a damn good point. Has anyone anywhere in the medical or academic world 'joined the dots' between the risks mentioned in nhs antenatal info and the actual consent forms you sign for various procedures?

As others have said, in the middle of labour, or a birth emergency, no one gets to study these things in detail like a lawyer. Are women in effect being misled by being partly or badly informed about various risks/procedures in advance?

And I totally agree about the NHS leaflet on forceps. There is such a thing as tactful wording - and then there's out and and out lying. I have friends who have suffered very much after a forceps birth, and have been left with ongoing problems. And my own (minor but very visible) permanent facial paralysis was caused by forceps.

Very good point. I have had 2 emcs, and signed 2 consent forms (1 spinal, 1 GA). I was in no fit state either time to read or understand what either said. For one, I asked if DH could sign and I was told not, as I was still conscious. I've always been cross about this, being made to be responsible for something when i am not in a situation where I can pay any thought to it. Fortunately both babies were fine, so no actual repercussions, but it does occur to me from time to time, what come back I would have had if anything had gone wrong, I'd challenged it and been told "but you signed a consent form..." (with my second birth, the GA one, the pain was so constant and intense I only stopped screaming to breathe, it was a uterine rupture).

treats, most of the things you list may have different rates at home and in hospital. female morbity is much higher in hospital (with 8% forceps vs 2.3%, i don't think its unfair to speculate the risk of urinary incontinence is higher in hospital).

but yes, if you think people should know all the facts then you will get comparative stats for ELCS vs Hospital VB (inc EMCS) vs home VB (inc transfers and EMCS) vs MLU VB (where available) - a proper basis for a decison.

I experienced a stillbirth earlier this year and one of the hardest things about it was that I was totally unprepared for the fact that this could happen. I consider myself to be an intelligent person who read up on a variety of issues in pregnancy/birth and did my own independent research about risks of certain things. As a starting point I used the pregnancy literature that I had available to me e.g. NHS publications and books like 'what to expect' to inform me about the kind of risks and decisions I should research further - I was prepared and understood the risks of interventions such as forceps etc and knew how I would deal with them. However none of this literature contained anything about stillbirths. It is only after the event that I discovered the statistics of how common stillbirths actually are - I think the last statistics I read were 11 stillbirths a day in this country alone (8000 parents affected annually).

Having knowledge of stillbirth statistics would not have made the experience any nicer but it would have made it easier for me to deal with. That is how I feel about all risks and complications. I personally don't care about being frightened or be subject to additional worry because of too much information. Ignorance is not bliss in this situation and a positive mental attitude can be achieved even armed with all of the facts and realities.

Hiding statistics from women or presenting a rose tinted view of pregnancy and birth is not helpful. In fact I think hiding realities or omitting to discuss issues properly is gross negligence on the part of medical staff. This includes all risks - including risks of a hospital birth which seems to me to be presented as a cure all by many NHS professionals.

I wonder if we were all aware of how high the risk were of stillbirth, permanent damage to mum or baby, horrendous experiences etc would the loss of that rose tinted glasses be overall a good thing.

Would we be more grateful for a healthy child and ok birth, more able to support women for whom it did not go well, would there be less PND because our expectation of birth and early motherhood would be far less unrealistic?

rainbowbaby if you don't mind me asking, which facts would have helped most to know in advance? how do you think it should be presented?

in my first birth, i definitely didn't countenance the possibility of anything going wrong. I'm not sure what would have changed that.

RandomMess - one of the things that comforted me when I lost my DS was knowing that my grandmother had suffered a similar loss 60 years ago. But I think back then, there WAS more understanding of the risks and fewer rose tinted glasses about pregnancy and birth. Everybody knew somebody who had suffered the loss of a baby or a permanent injury after childbirth.

I remember reading a book about the start of the NHS in 1948 and one doctor reporting the flood of new patients through the door now that it was free. He records being most shocked by the female patients who were finally able to seek treatment for some of their childbirth injuries - he described women who had been holding up their prolapsed wombs with towels tied round their waists - for years.

EdgarAllanPond - I expect you're probably right (about home vs hospital). My point was that the AIMS document refers to the risks of C-Section, but not the risks of vaginal birth. If they DID refer to them, but emphasised that they were lower with a home birth than a hospital birth, then I think it would be more honest.

Also, I think it's impossible in retrospect to say what knowledge would have prepared you better for something going wrong. It's always going to be a shock.

I agree that acknowledging the risks would make us more grateful for a healthy baby and ok birth, and make it easier for people to support women when things don't go well.

I knew about stillbirth stats before having DS, but that's only because one of DH's colleagues had a stillbirth, for no apparent reason, shortly before I became pregnant. Until then I hadn't realised that stillbirths were still so common.

Agree that knowing the risks may help. I was very aware all through my pregnancy that I should have another SIL (stillborn) and my PIL still visit her grave.

Therefore even at the most brutal parts of DS's delivery I was just terrified he wouldn't be OK, and damage to me wasn't on the radar. And afterwards (once he started breathing) I was still so grateful they'd got him out that I still didn't care although I couldn't be parted from the G&A whilst they stitched me up.

In terms of stats, I want to compare outcomes of inductions to ELCS, because most horrific births I hear about are induced and I wonder whether it is worthwhile now. I may even do that as a returning to uni project.

In terms of stats, I want to compare outcomes of inductions to ELCS, because most horrific births I hear about are induced and I wonder whether it is worthwhile now. I may even do that as a returning to uni project.

Good idea MrsH - my impression is the same, but there seem to be no stats to back this up; I don't think they are collected even. You could include the reason why the induction is happening too - is it just because you are 40 +10/12/15/whatever the protocol in the local hospital?

Re information about risks - I have been puzzling over whether it's good to be informed or not. I'm not sure personally that I would want to hear a list of risks, some of which would be rare. I suppose one reason would be to know so that you could mitigate the risk, but afaik, stillbirth is still something of a mystery, so how could you realistically prepare for it?

Going back to the OPs question - I think if I had asked a question about a particular risk I would have wanted a straight answer.

This is slightly off topic but I was reading this tragic story in the DM (yes I know, I don't usually do DM links but this was linked to from a thrombosis charity I follow!) about someone who did after IVF complications and the family are now suing the hospital, saying "she would never have had IVF if she?d known that there was a chance she might die." I found myself thinking - really? Surely everyone knows that pregnancy is still risky, even in this day and age? But maybe that's not the case, and maybe there are people who believe completely in a guaranteed happy outcome?

FWIW I had a post-partum DVT after DD1 was born and was pretty shocked that although it's a reasonably common pregnancy complication, I still encountered lots of midwives who really didn't know anything about it at all, and didn't know that a post-natal woman presenting with leg pain should be investigated for DVT as a very likely cause.

yes branshott i saw that also,
though i think the thing about that story is she in particular due to her medical history ought to have been told to be very watchful for the signs of thrombosis and the warfarin not working -

a Fb friend had multiple clots in her lungs from taking the pill - so even avoiding pregnancy has risks.

given the limited time medical professionals have, possibly what they need to do is identify the most pertinent risks to that particular person and advise those - and respond as well as possible to questions.

To reply to a question from way up there ^

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.

I gave birth in France. It's very medicalised here - the expectation is epidural or CS. I felt that I was given an ok amount of information whilst pregnant. You have to sign up to a hospital very early on (when 6 weeks pregnant!), so there was a first introductory talk where they explained basic stuff about the hospital, AN classes etc.

Then there was a AN class at 4 months. This covered various problems which could arise during pregnancy and what to do if they occured, e.g. if baby moves more or less than normal to come in no matter what (although I wished they'd been nicer to me the two times I did come in in a panic! But hey ho, I'm glad I did it to be reassured), or if you bleed or leak water etc. etc.

I think that class also covered which baby products you had to buy (i.e. what the hospital wouldn't provide).

Then there was a BF talk. And an epidural talk. And from 32 weeks onwards you could go to the 4 AN classes which covered VB, CS, a visit of the labour rooms and maternity wards, bathing the baby and various other stuff.

Everyone was also obliged to meet an anaethetist to discuss your epidural even if you didn't want one. It was a "just in case" you needed one during the VB or emergency CS.

Having said that, they didn't cover risks a huge amount, which is a shame. I would have liked more information. I learnt mostly from MN.

In France you don't really have a lot of choice about the intervention. We were told about forceps and ventouse (and shown them with a doll and fake pelvis) but when a woman asked if you could refuse it, the midwife just looked at her and said "if we consider it's necessary then it's necessary. We won't have time to ask your permission". Same with the episiotomy.

"
Everyone was also obliged to meet an anaethetist to discuss your epidural even if you didn't want one. It was a "just in case" you needed one during the VB or emergency CS."

as 50% of first timers have an epidural in the UK, and many of those won't have wanted one at outset, ensuring everyone is aware of what is involved in advance would be no bad thing. Though i don't think obligation is the way to go, recommendation will do.

"Though i don't think obligation is the way to go, recommendation will do."

I don't know what would happen here if you refused to go. I went and it was just a few basic questions and looking at my back to check for something or other.

During the talk it was funny that one woman asked in a horrified tone why anyone would not want an epidural She was to find that some women prefer to try it without...

Very high rate of epidurals and CS in France. Over 60% of births with an epidural and about 20% with CS (I think - happy to be corrected!).

So that leaves very few with different methods of pain relief. In fact, the one big thing missing from our AN classes were other methods of pain relief! None were discussed! Even when I asked about gas and air they were dubious that it was possible to do it and you can just forget about TENS machines etc. Very few hospitals use them.

If I had refused to go to the (appallingly handled) anaesthetist appt the hospital would have refused to care for me. So I went and suffered 30 mins of how my fear of needles wasn't that bad and I was definitely going to need an epidural anyway because first time mothers have no idea how long and painful labour is. Riiiiight.

I think if it weren't obligatory some people wouldn't go, and then we wouldn't be any better off for those who didn't plan epidurals but did have one. But there does need to be a measure of sensitivity!

MrsHoarder great idea for a study! My first birth was induction for dates at 40+12. No idea what my bishops score was but even after 7 hours of (excruciating and unrelenting) hyperstimulated contractions (7 in 10) my cervix was closed and tucked back! Couldn't risk that again so insisted on ELCS for 2nd birth. If I'd have been able to guarantee going into labour naturally, I may have decided against the ELCS.

(Decided against expectant monitoring partly because my birth issues aren't just about induction and partly because I don't want to be one of the ones who ends up with a stillbirth/very poorly baby when they go over dates )