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

Ps a doctor is not allowed to act in the best interests of the baby when a labouring mother has refused consent. "Heightened emotional states" definitely don't negate capacity! Flipping heck if they teach that in medical school it explains a lot.

Take your phones in and don't be afraid to call for help if you need it.

@bearfrills your experience resonated with me - I've not got as far as birth yet, but had to go to assessment for suspected leaking waters about 2 weeks ago. I refused an internal examination when speaking to a midwife and was passed over to a registrar for alternative options (monitoring, etc). I then had to go through the whole discussion again, including being pressured to consent to the examination, which I again declined. The (male) registrar tried to get my DH to talk me round by suggesting we needed time to discuss options and didn't really know what to do when my DH calmly told him that he didn't see how that would help any as I clearly knew my own mind - DH was clear that he wasn't about to do the doctor's dirty work for him. Anyway, I managed to stand firm (although I do feel pretty traumatised by it - never want to see the inside of the delivery unit again!) and they confirmed PPROM by observation of pads instead. I now have an ELCS booked for next week as the baby is also frank breech.

I do think it helped us that we're both late 30s and well read up on this sort of thing, so we're able to stand out ground. It makes me angry though that others might not be as well informed about it and end up being forced into things they very much don't want.

I'm on the fence on this. I was given an emcs without consent 5 years ago. In fact it was worse than without consent as I begged them not to. I asked afterwards at my birth debrief about it because I didn't remember signing anything and I thought you were meant to. The midwife said it was an emergency so they didn't need consent. I can't really complain because thanks to my emcs ds and I are both alive, even though we have both suffered damage that I assume is going to be permanent.

MNHQ, your use of the word ‘often’ is misleading, as the majority (up to 80% of women) will have no long lasting symptoms from a third or fourth degree tear.

A very worthwhile topic certainly, but exaggerating helps no one. The RCOG has a helpful guide which quotes some of the statistics.

I do agree with PPs that the issue of consent is incredibly difficult, and it would be interesting to see what alternative ideas people have in regards to both education and consent prior to delivery.

Following with interest as had a horrible 4th degree tear and I don’t even know such a thing was possible
I knew you could tear mint not to the point of destroying your arse
So I do feel v pissed off oregannt woman are not told of the risk

itssoooofluffy I would like to see the risks of a vaginal delivery listed as clearly as the risks of a CS, and I would like that from your first appointment with the midwife. I don't want to have to go trawling the RCOG website to create my own comparison list.

Items on my list included: CS - 4x riskier for mother but reduced risk of stillbirth by half. Vaginal birth - risk to 38 year old in first time delivery is c.18% chance of anal tearing. Those were from papers on the website at the time, the figures may have changed since.

I would like all women to be told about consent - that it still counts during pregnancy and childbirth

I would like all women to be told about the likelihood and risk of each procedure. Up to 80% may have no long lasting damage but (1) define 'long' in this context, e.g., 6 months, 1 year, 5 years?, because that matters to the (2) more than 1 in 5 women who will have long lasting injuries and (3) tell them where they can access help afterwards

I would like figures put on interventions - success rates, failure rates, what happens next

I would love for antenatal sessions to stop glossing over inductions and CSs as though they only happen to a few or that inductions rarely go wrong. 10% fail to progress, that's not a 'few', nevermind however many end in a CS due to other factors.

I would like risks to be put into age categories

I would like women to stop being treated as incapable of making their own decisions about the risks before birth. I've been told that women will be frightened if you give them too much information - that's fair enough though, because some of the information is frightening but, believe me, being thrown into frightening without prior warning ramps it up to terrifying.

I would like to not have to fight for a CS because I've balanced the risks and chosen the ones I'm prepared to take and the consequences I'm prepared to accept

I believe that if midwives and doctors are honest with women from the start, and give them agency in decisions about their care, then it may have a positive impact on the mental health of pregnant and post-partum women because things weren't just done to them and/or they only found out afterwards that alternatives were available. The what if/if only/l wish I'd known scenarios could be avoided.

Ultimately, birth is about women's lives - their physical and mental wellbeing - not just during birth but in the years that follow. Women deserve better than they're getting at the moment.

Thank you @IonnaS I think it will take me a little longer yet but I'm determined to see it through. By the time my DD is old enough to have babies of her own I want things to have changed for the better

My experience was that there is no information whatsoever on the risks of a VB but as soon as you ask about CS doctors need to tell you every minuscule risk and expect you to go away and reflect before accepting that you know what you want. The risks of VB are somehow assumed to be part and parcel of being pregnant, the baby has to come out somehow, so what do you expect? It is also widely assumed that one must not scare pregnant women with facts about VB and it is best to keep quiet and hope for a good outcome.

MNHQ, your use of the word ‘often’ is misleading, as the majority (up to 80% of women) will have no long lasting symptoms from a third or fourth degree tear.

It’s actually 60-80% of women who suffer one will have no symptoms a year later.

In other words, 1-2 out of every 5 women who suffer a third or fourth degree tear will still have symptoms. So I don’t think the word ‘often’ is an exaggeration.

I was devastated when my medical team completely ignored my explicitly given 'no consent' and then when I tried to follow it up later denied all knowledge. However, it was a decade ago and didn't involve tearing.

And that reported symptoms. How many women out there are just quietly living with the after effects and not going to their GP about it because "its embarrassing" or "it's just the way it is after a baby" or "they wont be able to fix it anyway"?

@ABingThing has nailed it for what I'd like to see. All of the risks need to be discussed at an early stage of the pregnancy and again at a later stage (e.g., 10wk booking-in appointment and 32wk antenatal appointment) so that the woman can make properly informed decisions about her delivery and care. There is a page in the handheld maternity notes for the woman to write a birth plan. There should be an accompanying page with birth options on it, completed alongside the woman's midwife. It should have a checklist for the most common births, risks, and interventions (e.g., VB, ELCS, EMCS, episiotomy, risk of tearing, forceps, ventousse, haemorrhage, etc) with risks discussed and yes or no ticked then details of the woman's preferences based on the discussion of those risks (e.g., would rather a CS than forceps, would rather tear than episiotomy, etc).

CS needs to be presented as a perfectly normal birth choice rather than something to be afraid of, like the pregnancy bogeyman. CS delivery can be a very positive experience and is not a sign of failure, stop presenting it as such with terms like "failure to progress" or "failed spontaneous labour" or "failed induction".

Consent in childbirth is a largely artificial attempt to avoid liability in the event things go wrong.

In an ideal world contingencies for problems that may arise should be discussed before the labour starts and provisional consent obtained to be supported by the usual consent procedures when the time arises.

As for fear, we’re women not children. There is no need to infantilise us and ‘protect’ us from feeling bad by keeping us ignorant.

@itssoooofluffy

MNHQ, your use of the word ‘often’ is misleading, as the majority (up to 80% of women) will have no long lasting symptoms from a third or fourth degree tear.

A very worthwhile topic certainly, but exaggerating helps no one. The RCOG has a helpful guide which quotes some of the statistics.

I do agree with PPs that the issue of consent is incredibly difficult, and it would be interesting to see what alternative ideas people have in regards to both education and consent prior to delivery.

Ah sorry - in my head I was talking about OASI injuries (anal sphincter injuries) for which I think the rates of long-term effects are higher? But I see I didn't make that clear (and I might be wrong about that too!)

@Velveteenfruitbowl

Consent in childbirth is a largely artificial attempt to avoid liability in the event things go wrong.

In an ideal world contingencies for problems that may arise should be discussed before the labour starts and provisional consent obtained to be supported by the usual consent procedures when the time arises.

This is something we'd like to have your thoughts on - what would a proper consent process look like if it were conducted antenatally - and how can it be delivered without simply adding to the existing burden of midwives (who are already required to deliver a lot of antentatal information in a few pretty short pregnancy appointments)

MMHQ, third and fourth degree tears are anal sphincter injuries. So rates are the same.

@Monkeynuts18 to me ‘often’ means the ‘majority’ or at least more than 50%, hence I felt it was misleading. Sorry if this means something different to you.

Well said by @ABingThing, they should at the very least provide statistically correct information early in pregnancy regarding all methods of delivery in conjunction with the birth plan.

@itssoooofluffy

MMHQ, third and fourth degree tears are anal sphincter injuries. So rates are the same.

@Monkeynuts18 to me ‘often’ means the ‘majority’ or at least more than 50%, hence I felt it was misleading. Sorry if this means something different to you.

Well said by @ABingThing, they should at the very least provide statistically correct information early in pregnancy regarding all methods of delivery in conjunction with the birth plan.

Thank you - had plainly failed to get my head around that previously

I think consent in childbirth is a huge issue and there needs to be change. Pregnant women legally have the same human rights as any other patient, they can accept or decline any procedure- yet often they’re treated completely differently.

IME a lot of this even begins during pregnancy and before birth- being ‘told’ things are going to happen to you during consultant or midwife appointments. Eg ‘So we will induce you on this date’- no regard that you’re human being with autonomy who can decline and should have the full range of options (including doing nothing) and the risks/benefits explained.

So many women seem to believe they lose their basic rights in pregnancy and that other people are now in charge of their body and can decide what happens to it and who touches it.

I think one way to help overcome issues of consent when a woman is in labour is to make sure she is as informed as possible before birth. How many of us underwent a procedure (eg forceps) during labour and only learnt AFTER what it actually was, the risks, the other options.

When I had my first child, I had no idea that consent existed in a maternity care/childbirth context. With the second, I knew and was informed but ignored. With the third, I knew there was 'consent' but no such thing as consent.

I'll pay for my DD to go private when the time comes for her, whenever that may be. I'm not sending her knowing what I know, to be assaulted and ignored when she's at her most vulnerable.

I was delirious during my labour with DD1, very anxious, stressed and in general, very shocked about the level of pain, which I know sounds stupid, but as someone with a very high pain threshold, I didn't realise the level of pain I'd be going through. I didn't want pain relief though. After 25 hours of contractions, I was exhausted and woozy. I remember a midwife saying something to me, asking me if I was allergic to anything, I said no. Next, my husband came through from the loo to find blood dribbling out of my leg. He asked what was going on and she told him they'd given me pethidine to help me sleep. It was an awful experience, the first midwives on entering the unit and the first one who 'looked' after me. They were walking around muttering they were going to kick me out of the room etc in earshot of my husband. I wanted to BF but they gave me no help at all and of course, the pethidine made my DD very sleepy and reluctant to feed. It was almost 24 hours before she'd take a feed and 21 hours until she even made a sound. Honestly, I think that was what kick-started my PND. Thankfully my 2nd and 3rd experiences were far better and I was supported and consulted in those labours.

So so so unfair how this is an issue for so many women.

For me, I had an unconsented sweep by a MW that left me feel totally vulnerable and taken advantage of - to have been forced into that situation and held down was terrifying - the MW waited until my birthing partners had gone to get some food before launching that attack on me.

In my most recent birth, my placenta was thrown away without my consent - the hospital at least apologised for this when I asked where it was

*I would like to see the risks of a vaginal delivery listed as clearly as the risks of a CS, and I would like that from your first appointment with the midwife. I don't want to have to go trawling the RCOG website to create my own comparison list.

Items on my list included: CS - 4x riskier for mother but reduced risk of stillbirth by half. Vaginal birth - risk to 38 year old in first time delivery is c.18% chance of anal tearing. Those were from papers on the website at the time, the figures may have changed since.

I would like all women to be told about consent - that it still counts during pregnancy and childbirth

I would like all women to be told about the likelihood and risk of each procedure. Up to 80% may have no long lasting damage but (1) define 'long' in this context, e.g., 6 months, 1 year, 5 years?, because that matters to the (2) more than 1 in 5 women who will have long lasting injuries and (3) tell them where they can access help afterwards

I would like figures put on interventions - success rates, failure rates, what happens next

I would love for antenatal sessions to stop glossing over inductions and CSs as though they only happen to a few or that inductions rarely go wrong. 10% fail to progress, that's not a 'few', nevermind however many end in a CS due to other factors.

I would like risks to be put into age categories

I would like women to stop being treated as incapable of making their own decisions about the risks before birth. I've been told that women will be frightened if you give them too much information - that's fair enough though, because some of the information is frightening but, believe me, being thrown into frightening without prior warning ramps it up to terrifying.*

Agree wholeheartedly with all of this, particularly what you say about age categories - the risks look very different for a 20 year old and a 40 year old giving birth for the first time. But at present women are given no individualised information.

I would add that I would like to see the risks presented clearly and not misleadingly. For example, conflating the risks of emergency and elective caesareans to make elective caesareans appear more dangerous than they are is misleading.

I would like to see women allowed the individual agency to decide what risks matter most to them. So, just for example, when discussing caesareans, a woman will be warned of the risks of repeat caesareans. And of course we should be provided with that information. But if a woman only wants one child, that risk is likely to be unimportant to her, whereas if she wants four children, it might be very important to her.

I also think there need to be retrospective agreement from mothers that consent was sought and things done right.

I won't go into the details as have told this story on MN before, but during my twins' birth in 2018, I was repeatedly not listened to and refused control over basic things like students in the room, extra staff, epidural, etc. I ended up having a panic attack, locking myself in a toilet, and delivering Twin 1 without assistance or pain relief - he was not breathing and I had to carry him, naked from the waist down, into a corridor and another room and shout for help. Then a team came and did resus on him but they'd forgotten to restock the room with cord clamps so the MW had to clamp his cord with her fingers to try and stop the bleeding whilst someone ran to get some more. As we do not know what time he was born as no one else was there, we do not know how long he lacked oxygen for. He has some (thankfully it seems minor) ongoing issues.

I saw my notes when I was still in hosp. Know what they said? Something like: 'standard vaginal delivery following IoL [induction of labour], EBL [estimated blood loss] such and such a figure, Twin 1 delivered 8.33am, Twin 2 delivered 8.46am, mother given xx drug [an anti haemorrhaging thing]'.

As far as I'm concerned, it's lies. It in no way reflected what actually happened in that room. It did not mention the unassisted birth, the delay in getting help, it even made up a time when Twin 1 was born, because how could anyone know? It didn't even say 'estimated time of birth', they literally just made it up.

But that's my medical records, now. So it's 'true'. What bollocks.

I would like to see the risks of a vaginal delivery listed as clearly as the risks of a CS

Could not agree more.

I did a Law degree and my third year dissertation was entitled: "Doctors vs lawyers - where does the balance of power lie in cases of emergency obstetric intervention?"

@JohnnyMcGrathSaysFuckOff how could they ignore your wish to decline students being present? That’s surely such a basic and easy request to follow. Plus the fact it is the law to have the woman’s permission to have students present. Disgraceful. Did you ever raise this issue afterwards?