MNHQ here: are you interested in the issue of medical consent during childbirth?

[RowanMumsnet]

Hello

One of the charities we work with, MASIC, is holding an event in London (sorry!) on Thursday 29 November to discuss the issue of medical consent in childbirth, and how that issue ties in to obstetric anal sphincter injuries (third or fourth degree tears that damage your anus, with often life-changing consequences) and the provision of elective caesarian sections.

It's a day-long event (9.15 to 4.30) with panels and debates on topics including:

an explanation of the Montgomery vs Lanarkshire ruling (a landmark case that established a legal standard for women's right to information about risk in childbirth);
a panel on anal injuries in childbirth and what the risk factors are (and what might be the effect of offering more caesarian sections by maternal request);
a panel entitled 'How much do we inform mothers beforehand without scaring?' [imagine there will be some strong MN views on this one...]; and
a panel called 'does consent mean anything when you're exhausted and in pain?'

Throughout the day, people who come along will be able to contribute and ask questions and generally make their views known.

Tickets are £40, or £25 for students or women with obstetric anal sphincter injuries. You can book tickets and see more info here.

We thought this would be of interest to some of you - and of course the issues being discussed are likely to interest lots of you whether you can attend or not - we at MNHQ are thinking about doing something in this area (what does it mean to give meaningful consent to procedures in childbirth, and what's the best way to ensure that women have all the information that they need to give meaningful consent) - so as ever please let us know what you think.

A member of MNHQ will be going along to represent your views, so give us a shout if you buy tickets and would like to have a coffee on the day.

Thanks
MNHQ

[ABingThing]

And as for the experiences of the doctors involved, not one gave me the risks of an induction or vaginal delivery in my circumstances. But they were very keen to tell me about their 'magic hands' and to ask me 'don't you want to feel like you've tried?'.

7 years of medical training is apparently insufficient to put logic over culture

[Lovemenorca]

I have two children
I had one very dangerous birth. The other fine.
I am a legal professional. Consequently I have absolutely no medical knowledge beyond google and no practical experience whatsoever.

I had a preference for a natural birth. I have a very strong desire not to have an episiotomy. However these were “wants” rather than needs.

I was happy to leave medical decisions in hands of professionals. Similarly, when I recently went sky diving, I was willing to leave decision making to professionals!

[Lovemenorca]

* 7 years of medical training is apparently insufficient to put logic over culture*

That doesn’t make sense

[Lovemenorca]

But we will never agree so I will leave the thread as I’m in the minority

[ABingThing]

@Lovemenorca

What I meant was that I wasn't given rational information and asked to make my choices on the basis of logic, I was asked to make it on the basis of 'try this, I have magic hands' and 'don't you want to feel like you've tried'. Two different consultants, two different births. Neither suggestion made sense in the circumstances.

We may not agree, but it's still good to share these opinions - it does give me pause that I feel I got better advice from Google than I did my consultants. Is that arrogance or hindsight? Probably the first appears increased due to the latter, because I didn't feel arrogant at the time, just frightened.

[Bearfrills]

A few hours googling puts you on the same level as a doctor, even the most junior of which will have studied for 7 years?

A life time of living in my body gives me more knowledge than the doctor about when something isn't right or when something isn't wanted. A lifetime of having to live in this body afterwards gives me more rights than the doctor to decide what condition I want it to be in.

When littlest DC was born and I was still numbed from the spinal, I was trying to feed her. I knew what I was doing, I'd BFd my previous DC for two years so it was not new to me. I had hold of DD having a little jiggle to wake her as she was very sleepy. I had a MW standing over my bed chatting to a second MW standing the other side of my bed doing my blood pressure. The first MW, without breaking off her conversation or asking me or even acknowledging my existence took hold of DD, opened my gown and took hold of my breast and then pushed DD towards it. I said "I can do it myself" and was ignored as she continued trying to push a sleeping baby into the breast she was holding. I told her to let go of me and was still ignored. She carried on her conversation with the other MW this entire time. I ended up having to raise my voice and very bluntly say "Let go of me!" There is no amount of training in the world that gave her the right to treat me that way when consent could have so easily been sought, it would have been denied as I could do it myself but she didn't even try.

[Weathergirl1]

Blimmin' heck @lovemenorca - as a legal professional are you not capable of realising that those of us who have done research didn't rely on googling random internet sites but may have actually looked at the scientific literature around this?

[Lovemenorca]

@Weathergirl1

Genuinely curious. What scientific journals have your drawn upon in your research?

[Notnowokay]

@lovemenorca, sometimes doctors/ midwifes are hard pressed for time they don't see taking the time explaining what they want to do worth it, so they just hurry up do it. Because they 'know better'. But they don't know our specific body better do they? They only general information based on the average person and the odd exceptions. Explaining what or why you want to do something, unless during a true emergency situation can only be beneficial. Why don't women deserve to hear the justification form a stranger (hcp are mainly as you never met them strangers) doing an intimate procedure on them?

I know I want to trial a vba2c, I have already been told a consultant won't let me, by the midwife. I just let it slide, as it was during booking appointment and I got a lot of time to think about birth and discuss a birth plan with an obstetrician. It is weird being told what you can and can't do. Apparently I can do a home birth without telling anyone, it wouldn't be illegal. However, I won't do that as that is a risk I'm not willing to take. But if an obstetrician gives me good enough reason to abandon any hope for vba2c then I will. I won't let Google decide and tell me the best course of action. I want to make an informed decision with my doctor. Is that bad?

[RhubarbCricket]

Ha! I'm reminded of when I had a hysterectomy and a few days later had profuse rectal bleeding. The doctors, both men and women, sneered at me and said it must be vaginal bleeding and it was normal, as if I was incapable of realising which orifice it was coming from. Eventually my gp took me seriously and I'd had a gastrointestinal reaction to one of the anti inflammatory drugs they'd given me.

Seven years plus at medical school didn't help much there did it?

Surely medical training and the patient's own views should be complementary.

[TimeTravellingDiamond]

This is simplistic I suppose and I wish I were more articulate but people choose to have 'unnecessary' surgery all the time and know the risks. Cosmetic surgery being a prime example. Ok may be private and not NHS but doctors are still agreeing to the surgery. So in plenty of situations it is 'I want therefore I get' as @Lovemenorca put it. NHS is not free- we all pay in to it.

People should be allowed to make informed choices about the medical care they receive. And choose how they give birth without obstacles being put in their way, and without judgement.

[Commonreader]

I agree with Time. And a pp who stated that there are two issues involved, those of being informed and giving consent. With respect, Love, I don't really understand why you seem so reluctant to respect other posters' decisions. Because even if you disagree with them, and even if medical opinion is against them (which I think, btw, varies depending on who you speak to), autonomy over your own body should be a basic human right.
In fact, I do not understand your preference for a natural birth, given the possible complications ( my consultant agreed with my reasoning when I requested an ELCS- I know others may not), but I absolutely defend and respect your right to choose what is best for you. I do not understand why this seems such an invidious position to take in our society.

[Booboostwo]

Many medical decisions involve the subjective assessment of risk, so someone has to make the subjective judgement. The US and UK healthcare systems leave this subjective decision in the hands of the informed patient as she is the one at the centre of the decision. Other healthcare systems operate on different principles, for example the French health care system (and relevant laws) are much more paternalistic, medical professionals have more power to make best interests decisions on behalf of patients. What is grating is that even in the US/UK patient centered system, pregnant women are treated like children and not afforded the same rights to decide as male patients.

For consent to matter it has to be valid. Valid consent has to meet three requirements: be given by a patient who has the rational capacity to consent, who has a choice and who is informed. Nowadays all medical students, doctors, nurses and healthcare personnel know this. Some chose to ignore it.

[Lovemenorca]

@TimeTravellingDiamond

Yes but the cosmetic surgeries are only going to impact on the person making the decision.

Childbirth involves another person

[TimeTravellingDiamond]

@Lovemenorca

As people have mentioned on here planned ELCS are often safer for the baby. Safer than instrumental vaginal birth. Don't insinuate that women choosing Caesarean sections are making some grave choice for the health of their babies.

[Bearfrills]

Childbirth involves another person

Except legally it doesn't as the baby is not a person until it is born. Professionals can advise on the best course of action based on what they believe to be the least risky option but the decision ultimately comes down to the woman because it is her body and she is the patient therefore she is the priority.

Caesarean section and vaginal birth both carry risks that are comparable in commonality and severity. Woman should be informed of the benefits and risks of both options personalised to their own circumstances so that they can make an informed choice of how to deliver.

[TimeTravellingDiamond]

@Bearfrills I did think that too. I didn't bring it up as imagined it would be interpreted as not caring about the baby's welfare (untrue).

@Lovemenorca I'm curious, would you class mental health reasons as a medical reason for a caesarean?

[Booboostwo]

Childbirth involves another person
A rather ironic comment considering CS is safer for the baby than a complicated VB and the level of complication of a VB is one of the unknowns that makes giving birth risky.

And you still need to account for decisions where risks affect both mother and child but disproportionately; how do doctors decide in those cases? And how do doctors who do are not treating the foetus decide? E.g. an oncologist who wants to treat a pregnant woman with chemo but the process will kill the foetus, should he consider what is best for the other person and force the woman to carry through with the pregnancy at the risk of her life?

[Lovemenorca]

@Lovemenorca I'm curious, would you class mental health reasons as a medical reason for a caesarean?

Good heavens yes. And I include mental health in that.

[TimeTravellingDiamond]

The thing is @Lovemenorca huge swathes of the NHS don't see mental health reasons as a reason for a c-section. I have incredibly severe tokophobia, it still annoys me that my maternity notes state 'maternal request ELCS on them for the reason. I don't understand how if 'maternal request' is such a dirty thing in their eyes, why they don't choose to give the actual medical reason, mine being tokophobia which is a recognised mental health condition.

Do you realise that actually the vast majority of women actually choose and would prefer a natural birth anyway? When the NICE guidelines on c-section were revised in 2011, they actually stated that they didn't anticipate a big rise in the number of people asking for them. The idea was to help women who really do want a c-section, for whatever reason. They need revising further imo but at least they are better than what came before. What is awful however is the number of hospitals completely ignoring this guidance.

And yes the risks with c-section are for the mother. And with an ELCS the risks are absolutely tiny in most circumstances. And arguably far more predictable. If you have a straightforward natural birth then great but 5 mins on mumsnet alone shows that this sadly isn't often the case.

If 'childbirth involves another person', if we are going to judge women who want a c-section, should we judge women over the age of 35 for having a baby at an age where there is a higher chance of Down syndrome? Or obese women where there is a higher risk of complications? (Please don't think I'm suggesting we should, I'm making the point we could tear apart everyone for the choices they make if we wanted to analyse things that much).

[AnnaCMumsnet]

Good morning, @RachelBosenterfer and anyone else who is attending the MASIC event today I'll be there on behalf of MNHQ I'm wearing a green dress and have a brown backpack, do come and say hello if you'd like. And thank you again to everyone for sharing your stories here. It's been really shocking to hear your experiences.
Anna

[AutumnCrow]

Hi @AnnaCMumsnet and @RowanMumsnet, I'd appreciate hearing your feedback from the event, as I'm sure would lots of others. Many thanks.

[AnnaCMumsnet]

It was a really interesting conference. I was really moved by the four mothers who spoke of their OASI (Obstretic Anal Sphincter Injuries) on stage, as well as those in the audience.

The section on language around birth was incredibly interesting. Being told you're doing great and having professionals ask for your consent led to a more positive birth experience (unsurprisingly). The examples of actual phrases mothers were told were appalling but for anyone on Mumsnet I don't think they were that surprising - things like 'you have awkward nipples', 'you're not allowed to push', 'we're just giving you an internal, 'be quiet you're scaring the other mothers'.

Everyone criticised the idea that because someone had signed a consent form they had consented. The lawyers, surgeons, midwives and mothers all said consent had to be a two way process. This has changed fairly recently (2015) when Nadine Montgomery (who was supposed to be the first speaker but couldn't get from Scotland because of train cancellations) won a revolutionary case. Her son Sam was born with cerebral palsy as a result of being deprived of oxygen for 12 minutes. Her consultant did not inform her that because of her small stature and because she had type 1 diabetes and a large baby she was a risk of complications and that a c section was an option. The ruling made it clear that doctors must ensure their patients are aware of the risks of any treatments they offer and of the availability of any reasonable alternatives, rather than the previous 'doctor knows best' view. (This is a very oversimplified summary so do look it up.) Her son is now at university (with the help of a full time carer).

The speakers were saying that all women should be informed while pregnant (maybe at a 36 week or earlier appointment of their personal risk profile and the pros and cons of various options including forceps, ventuouse, c-section so that if any of these become necessary during birth the woman isn't hearing about them for the first time and her consent can be informed consent.

The overarching sentiment is that birth is an individual experience. Some you won't know until the day - how you handle pain, exhaustion, the position of your baby etc - but professionals know your height, your build, the approximate size of your baby (the size of the dad's head!) and therefore know if you are at increased risk of an instrumental birth and other complications.

We ended with a vote on the motion that informing women of their risk profile will lead to a rise in c sections. Both sides actually had similar arguments in that whatever happens you must let women choose what happens to their bodies. One side said it wouldn't lead to a rise in c sections because most women wanted a natural birth if possible, the other side said it would lead to a rise but was that a bad thing if OASI injuries could be avoided. The issue of cost was brought up as c sections are often said to cost more (around £2k vs £1665 for a non instrumental birth) but the fact is many births do have added complications. Women with OASI injuries explained that they needed counselling, repairs for prolapse, sphincter repair operations, which cost tens of thousands of pounds (not to mention in some cases their jobs, relationships and mental health).

@RachelBosenterfer and other Mumsnet users who were there, is this a fair summary? (It was lovely to meet you BTW).

What do you think - would knowing your risk profile and the pros and cons of c section, forceps, ventouse etc make you more likely to request a c section, and is that such a bad thing?

[Dinosauratemydaffodils]

What do you think - would knowing your risk profile and the pros and cons of c section, forceps, ventouse etc make you more likely to request a c section, and is that such a bad thing?

I was told of my risk factors for anal tears with my 2nd baby. It was one of the factors that had me choosing another c-section (first was an emcs). I was given research papers by my SiL (Dr) and then discussed that with my consultant who agreed with my decision but wasn't going to mention those risks until I brought it up. I struggle with the smell of blood when it's my period and I also have an issue with public toilets due to previous trauma. I honestly don't think I could cope with incontinence.

Everyone will have their red lines. That was definitely one of mine.

[Booboostwo]

Thanks for the update AnnaMN. Sounds like a really productive conference, hope it leads to changes in practice.