how much control do you really have in childbirth

[bumpybumps]

I recently had a baby, and whilst i was pregnant a community midwife told me that there was no point putting anything about not wanting forceps/ventouse in my birth plan because if they need to get the baby out they will use whatever necessary.

My birth plan was open anyway, just go with the flow basically. However a friend of mine was saying that in her birth plan she wrote she didn't want a doctor to use forceps/ventouse on her. Luckily her birth went well and she didn't need it, but it got me wondering, how much control do we actually have when it comes to that? Do midwives disregard your wishes in your birth plan if they want to use forceps or should they be offering you the alternative knowing your wishes?

I needed forceps but i was ok with that. However withmy next pregnancy it would be interesting to know my rights a bit more i guess.

They need your permission to carry out any medical procedures, although in extreme cases (you are unconscious!) your dh could give permission.

I put no forceps on both of my birth plans. Now, obviously I understand that there could have been situations where they needed to be used, and I would have consented, but I wanted it to be a last resort. I think that so much depends on your midwife - SOME are imo a bit intervention happy and would go down the epidural-monitoring-forceps route too soon, before trying other things. And since I didn't know who my midwife would be, I wanted to make my feelings clear in advance.

You've every right to refuse forceps. However, in some circumstances (albeit rare), "the alternative" doesn't bear thinking about. Sometimes the baby can get stuck but be too far descended in the birth canal for a c section. So forceps may be the only option for a safe delivery.

Having said that, this is rare and you should always be asked for your consent before forceps are used. Good questions to ask at this stage include:

• what alternatives are there?
• what would be the consequences of doing nothing?

The answers should help you work out whether the forceps are necessary and then give informed consent.

In my many years of working with MWs both in hospitals and at community levels, I can safely say that 99% of the time your birth plan is a waste of paper and ink. Occasionally, a lovely student midwife will try to follow a plan because they are new and enthusiastic, (this doesn't last!).

MWs will do what ever they can to make sure your baby is born safely. This means that you may think that you are in control of the situation but the MW is. You may think you are giving consent to exams and procedures but you are being gently coerced.

Procedures, including VEs, catheters, pain relief, blood tests etc are "done" to you because you will eventually accept the authority of MWs and doctors. If you try to refuse you will be browbeaten and talked down to until you agree to whatever procedure to make sure your baby is safe. They know you will do anything to keep your baby alive.

Unless you "free birth" ( not recommended!) you will nearly always be in the position were you think you are in control but you most definitely are not!

CoconutRing I have to say this sums up exactly how I feel I was treated in the last stages of pregnancy. After initial positive discussions about home birth, they tried everything to get me to birth in hospital including telling me that my son had a potential life threatening kidney problem. I did give birth in hospital. My son did not have a life threatening condition. It was a good birth but 2 years later I am still angry about coercion that led to me giving birth in hospital. It is a particular sore point for me as I knew it was likely to be the only time I could afford a home birth as I was soon to me to a country where home birth is a costly option.

Bumpybump Sorry for the hijack. In terms of birth plan mine was really really detailed I did not intend for the midwives to read it but it was so my partner and I were on the same page in case of extreme problems. For example if I required a GA I didn't want a hysterectomy performed and that baby should be given skin to skin contact.

I did feel in control of my body but not necessarily the situation around.

Hazchem = For example if I required a GA I didn't want a hysterectomy performed and that baby should be given skin to skin contact.

My Birth Plan was pretty detailed too & flowed off in different directions including a C-Section under GA too! But emergency hysterectomies at C-Section are done as a last resort life-saving procedure - I'm intrigued as to whether when you went through the Birth Plan with the healthcare professional they suggested you seek legal advice? Birth plans are not the same as advance directives for life-saving treatments & I think most Obstetricians would ignore on the basis of a birth plan alone & prefer to then be in court against a live patient without a uterus than have a dead one (with possibly a bereaved family taking them to court!).

Anyhow - as people have said - they need your consent to perform procedures. Writing/signing something is not in itself fixed consent - it can be given or restracted verbally at any point. No one (not even your DH) can consent/'give permission' on your behalf - but if you are judged to lack capacity to make a decision (i.e. unable to understand, weigh up, retain information & communicate the deision) e.g. unconscious, then in the absence of a specific advance directive then doctors will act in your 'best interests' this might include looking at indications of your previous wishes when you did have capacity e.g. a birth plan or talking to people close to you like a DH. (More controversial aspects of not having capacity might be if in severe pain/fear, under the influence of drugs - including prescribed, concerns about your weighing of information due to overvalued ideas/delusions etc.!)
A principle of ethics when applying 'best interests' is to go for the least restrictive option - so the thing that will give the person the most possible choices when they regain capacity - e.g. trying to save both the life of a mother and baby (then she would have choice as to whether to care for it or e.g. adoption) or going for conservative options (like different suturing techniques, other methods of haemostasis, blood transfusions, major obstetric haemorrhage protocols) over a hysterectomy.

I did still think a Birth Plan was worth doing though - for some of the things I saw more as optional extras rather than the mechanics of getting the baby out! E.g. delayed cord clamping, physiological 3rd stage, skin-to-skin, discovering sex ourselves, Father cutting the cord etc. & my team did try to facilitate it as much as possible. I tried to think flexibly though & the language probably reflected that it was all very 'aim for' 'try' 'if X then try for Z' etc.
At one point I got to see lots of birth plans in a place that used a template & found it fascinating that people only ever filled in the early parts - often ignoring the whole forceps/C-Section parts, like if you don't think about it, then it won't need to happen?

With DD my birth plan was totally ignored - it was very simple (things like I would like to be in the pool if possible, DH to cut cord, delayed cord cutting) but I don't mind as DD is here safe and happy!

MorganLefrey I'm not sure if you meant for your post to sound so completely patronising. It's in the same vein as the OBGYN's that think birthing women are unable to give consent.

I included the hysterectomy so if asked my partner could say something like "we would like to have more children and that should be taken into account during any procedures" so the the operating team can make decisions based on a full picture. Your final paragraph implies most people don;t deal with those type of thing and they should.

My post included the line I did not intend for the midwives to read it but it was so my partner and I were on the same page in case of extreme problems. This was so my partner knew my wishes and if asked could respond accordingly.

Discussing the scarier side of birth and birthing practices made me feel safe and enabled both of us to have understanding of my wishes. My partner and I come from very different backgrounds and my knowledge and understanding of birth and the birthing process was quite different to his. For example the first birht my partner attedned was the birth of our son where as I attended and assisted (by hold a torch for the Doctor) a birth at 2.5years.

I was railroaded and made to feel foolish and like I didn't care for the life my my unborn child on a number of occasions. The practice for speaking to pregnant women as if they are unable to balance risks or benefits must end

I didn't bother, and my paediatrician friends think they are often useless in labour, as they neither (a) say quickly what really matters or (b) adequately express views on risk on what they di express (eg the "I want a natural birth" or "no forceps" but --- most mums wouldn't take a risk that could be reduced that my baby was brain damaged and (c) births and plans don't often flow. But on the positive side they think thinking about labour is good.

This is very interesting.
After being induced, three days of labour, couple if failed epidurals (when on full strength hormone drip), thousabds of contractions, hours of pushing & then being told my baby's position was back to back, I felt like I'd really been though the mill.

I'd written a simple birth plan but the main thing I didn't want, & specified, was forceps (unless as PP explained there was literally no other way). I know it can work fine but I'd heard so many horrendous stories, in RL and on here that I knew it was something I wanted to avoid.

One of the midwives started to mention forceps so I kept telling DH to look at the birth plan. When the consultant / surgeon came in, she glanced at it. Then sort of humoured the midwife by 'agreeing' about forceps & winked at me!

As they wheeled me to theatre she basically said to the midwives that forceps wouldn't work & I should have an EMCS. To me she said I'd been through plenty & it was time for it all to be over.

Thank God. First time I fell in love with a woman

I wonder firstly, what would have happened without the birth plan and secondly , what would have happened with another (esp male) surgeon.

Hazchem - Nah, I didn't set out to try to be completely patronizing - more factual (i.e. the earlier thing about 'DH's permission' is inaccurate, capacity is decision and person specific so blanket things of 'birthing women can't give consent' aren't appropriate either) but balanced - recently having been on both sides of the birthing process! If you do feel patronized by it then perhaps that's related to your previous experiences..? (Although I'm aware you'll probably think that's a patronizing thing to say too! Perhaps it comes naturally to me... )

There is a HUGE whopping great difference between writing 'I didn't want a hysterectomy performed' and 'my partner could say something like "we would like to have more children and that should be taken into account during any procedures" so the the operating team can make decisions based on a full picture'.

Obstetricians are pretty aware that fertility is important to many women (keeps them in business!) & non-elective hysterectomies at C-section are incredibly rare - I listed some of the other things that would be tried as conservative clinical/best interests measures before that, irregardless of whether a specific patient explicitly verbalizes that they want more children as part of a 'full picture'.

If someone absolutely wouldn't want a hysterectomy (or any other procedure) even if all those measures were unsuccessful & the operating team deemed it to be lifesaving then I would think they'd need legal advice in advance because there wouldn't really be the chance to rediscuss with the patient if they're under GA or time to call in lawyers while someone is on the operating table bleeding out - though sometimes they're called in labour.

My birth plan basically stated that I wanted the baby to come out safely, have skin to skin, and delayed cord clamping and that I have a narrow sub pubic arch.

In the end I was induced as overdue and had an EMCS because the baby got into distress. When all the doctors came into the labour room I just got asked if they had my permission to do a csection and of course I said yes and they rushed me into theatre. I already had an epidural for when they broke my waters so didnt need to be put under.
The medical team were fantastic I just wanted a healthy baby and I have healed really well so its a positive experience for me especially as I had concerns about delivering naturally due to my narrow sub pubic arch.

Morgan I didn't mention permission anywhere.
My birth plan did take into account that at the time there had been several cases where OBGYN had decided women were incapable of giving consent and then were taken to court and found they were wrong.

Because of the time we spent researching issues and scenarios I was able to to consent to having managed 3rd stage rather then delayed cord clamping because of hemorrhaging.

Just to be clear the birth plan the midwives had from me was one page and said

"Hi My name is Hazchem You pronounce it Haz-CHEM Thank you"

I have an unusual name and knew I wouldn't want to explain it or have chit chat about it's origins.

I had a long 60 hour labour with all sorts of complications. Birth plan went totally out the window although my midwife did advocate strongly for me.

I ended up with forceps despite clearly stating i didn't want them and begging for a C-section instead. I was terrified. The Obs SpR was a total knob and told me I didn't have a choice I'm a HCP so know my rights but was obviously not able to think clearly at the time.

The consultant that delivered DS was amazing & a pro with forceps. They rotated him and I pushed him out myself. Tbh I think I think the SpR just wanted to gain more experience with forceps but was utterly clueless, so the consultant said no. Thank fuck. Horrible experience that left me feeling traumatised.

The birth plan can also include who you want/ don't want present, whether you would like delayed cord clamping, the vitamin k injection etc. I saw. It more as a 'I would prefer' plan, rather than a set in stone one.

But mine ended up just saying 'I would like only my OH present'

I had a long 'I would prefer' and 'if X then Y over Z' (so EMCS over high forceps.

It was followed very well, but at the sane time at the top in big letters it said 'safety of baby and mother is the top priority'. In a country where standard practice is to hook you up to a drip and give you an epidural I was clear on what all the intermediate stages and options were, and my birth plan was okayed by the head MW and my obgyn, who happened to be on duty that day but I only saw her once because she popped her head round the corner and other than that I was happy for her to keep her distance.

Ugh pressed post.

I do think, on that basis, you can exert a measure of control over things the situation allows you to control (so you can refuse VEs and you can refuse an epidural if you're coping and have prepared for the pain not having one will bring) but at the same time every birthing woman needs to accept there are some things you can never control and often there is one course of action leading from that situation for a safe outcome. That's what people who say 'no forceps or ventouse' don't appreciate. It's just closing your mind off to the real possibility you may end up needing them and consequently not educating yourself that not all forceps are created equal etc.

This has got me thinking and I wonder if what we need instead of birth plans is really proper continuity of care. SO having actual discussions with the same midwife the whole way through. So you don't need to have a piece of paper because they understand the type of things you are likely to want.

I was caseloaded so had the same midwives throughout pregnancy & birth. They really tried to stick with my birth plan, advocated and supported me as much as possible. They were great, couldn't fault them.

In the end, the medical team said 'listen, she has x, y, z going on, she really needs this'. And that's fine. I'm a nurse, you don't take risks with your patients.

What I do wish is they had discussed properly with me rather than this is what's happening, end of. If I had been more I formed about forceps, I wouldn't have been so terrified. I made a quicker recovery than if I'd had a C-section, I can have a normal delivery next time. It was the right decision.

A midwife once said to me that the most useful thing about a birth plan is that it lets them know a little bit about your personality a little bit quicker, so they can form a rapport with you before they have to go delving.

I agree hazchem, I think continuity of care is very important. I was lucky enough to live way out in the sticks, with a local birth centre (now gone), and saw the same midwife from start to finish. She was there when I arrived at the MLU in labour, and just seeing her there on arrival was the best thing. She left half way through my labour to do an antenatal class, and I really began panicking! Luckily, she came back an hour later, just in time to deliver the baby.
Having someone who knew me, and who I recognised, not a stranger was a massive help.

My mum thought having a birth plan was really strange but then she is still good friends with the midwife that was attending her during my birth (34 years ago) and the midwife who attended her during my brothers birth.

I only saw a couple of midwives more then once and the relief at not having to entirely explain myself each time was good.

In the show about midwives in England a few years back one of the older midwives was saying you used to be respected in your community because you knew the people and had seen them grow up where really part of it.

Miaowthecat I'm sorry you had to go through that with your first born. Its absolutely disgusting treatment.

I don't know if I'm just blanking parts of my labour (I don't think I am) but I don't recall being asked my consent to use forceps or do an episiotomy. They said it was needed as I had pushed for two hours, and proceded to call the doctors in so I just accepted that was what was happening and didn't say anything. I guess by not saying anything that was my consent.

If I ever have another baby I would like my birth plan to be more specific but I'm not convinced it will be taken seriously now.

Hi bumpybumps - congratulations on your new baby!

This is a big subject at the moment. Have you seen the film Freedom for Birth, currently being screened around the country this month?
Look up Birthrights, a new UK based charity dedicated to women's rights during pregnancy and birth. They are up to date on the subject, and have helpful and clearly written articles on the issue.

I think this a really good question to ask yourself. We may all think that we are aware of and in control of our bodies and our choices, especially regarding our births. And the MWs and doctors may be trained in the importance of genuine informed consent etc. But the reality, unfortunately, is often far removed from the lecture theatre and legal debate.

In regards to birth plans, I would recommend this article: Pitfalls of Going with the Flow. I, for example, found that writing '..only where absolutely necessary' on my birth plan just meant that the doctor just stood over me saying 'It's absolutely necessary' every time they wanted to intervene...

Remember: the medical staff are not allowed to tell you what you are allowed, or not allowed to do .

Finally, I would urge anyone who has given birth in the past 2 years to complete the Birthrights Survey, here on Mumsnet.

I had complete control over my 2nd and 3rd births.

My birthplan was adhered to. Ignored throughout most of my pregnancy and when finally read sent the midwives into a panic but given the plan stated that I refused to discuss my birth-plan after I was term, them reading it for the first time at 6 days overdue -it was too late.

The booked me an appointment with a consultant to 'talk it through'. I cancelled it on the grounds that again, it was too late.

They then insisted I probably had gestational diabetes but I wasn't having any of that.