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

Thanks Carabello

I often wonder if teaching it in schools would also help. We're seem lacking in general when it comes to information on our anatomy. Biology matters so much, failing to educate women particularly does them a great disservice

@AnneElliott Yes this kind of language in prevalent in maternity care everywhere. From the very first appointment women ‘told’ what will happen to them as matter of fact, ‘allowed’ and ‘not allowed’ used frequently. Often when discussing things that women should actually have the ultimate say and upper-hand, the language is switched so that the HCP is ‘in charge’. It’s no wonder so many women don’t realise they have the same human rights as when they are not pregnant. You only have to look at countless threads on here to find examples of ‘Oh didn’t realise you could say no to induction/sweep/vagina examination’

Will you offer the cheaper ticket to members of MVPs please?

Just to comment on the ‘I’m going to cut you now’ type comments; I’m a hospital doc (not obstetrics but I do ICU so I’ve seen a lot of Maty emergencies), and the few times I’ve seen midwives do that they’ve literally seen a tear starting in the ‘wrong’ direction, so one they know will likely be a third degree, and so have to cut quickly and efficiently to stop that in its tracks. They haven’t had time to say literally anything else to the patient.

However I have also had 2 heinous deliveries resulting in both my children going to NICU, and I feel extremely strongly that much of the carnage could have been avoided if the midwives would have just LISTENED to me. I remember actually sitting up whilst trying to deliver my daughter, who had turned back to back during labour and shouting at them to listen, that I wasn’t consenting to anything else, that I wasn’t pushing and that I wanted a spinal and into theatre now, because I knew something had changed and it was all very wrong. They just poo-pooed me off saying I was simply agitated like lots of women get during transition, and when I eventually pushed my totally flat, lifeless baby out (who’s now fine but will have long term issues due to prolonged resus) face up, with tearing that has now required two gynae and one plastics reconstruction, the attitude was all ‘ooh look how well you’ve done to get her out like that’ rather than ‘we are so sorry that should never have happened’. I did receive a formal apology from the obstetrician who completely agreed with me, and I did feel MUCH more listened to from the doctors involved in comparison with the Midwives, but I’m not sure how much of that was because I’m a medic myself.

I found the midwives quite rude to me on that aspect, kept talking about how we doctors are terrible for ‘medicalising out births‘ and that they are the ones experienced in the natural way and to just let them get on with it. But as has been mentioned many times in this thread it’s not for them to be ‘getting on’ with anything that the patient doesn’t want really, is it.

I think the way forward is that consent should be sought as far as possible in advance for as many eventualities as possible; in every patient. So yes; you may not want an epidural now. But at your clinic app you will be chatted through the procedure and the risks anyway and be familiarised with the consent form. The same with forceps (and we need to make more women aware that if the baby is fully descended a section can be EXTREMELY hard and often all vagina methods really do need to be exhausted first.). The same for sections, and any other procedures and pain relief we can think of.

The rub however is that this would require doctors to be involved in cases where a women may wish for only midwife led care; but it’s how they do it in other countries...South Africa in particular. They have a very high section rate but their outcomes in both survival and satisfaction are leagues ahead of ours

Jeezypeepers that's awful I'd always assumed that having a medical background would be an advantage in this situation, but clearly not

Your post had reminded me of the other big factor in all of this, which is the midwifery obsession with natural deliveries.

Once I'd refused consent for anyone to touch me again about 100 hours into my induction the head of midwives was sent in to talk me round at about 0500 when I hadn't slept at all for more than 24 hours. The crux of her argument was not about what was best for me or my DC, it was that I could be 'seen to have failed' and would 'regret' not trying to deliver vaginally because I'd have to have a CS 'if they'd even allow it'.

When I requested a CS with DC2 the response was "don't you even want to try?"

Vaginal isn't always best, for lots of reasons, and I am furious about the number of women and babies whose wellbeing has been sacrificed for this doctrine.

Apologies for the lack of punctuation in there. Angry typing and grammar didn't mix

My Labour was only 3 hours, my second stage was only 12 minutes and baby was not in distress - the dr tapped on the midwifes shoulder and said ‘if it’s not out on the next contraction I’m going in’ ... she then gloved and gowned next to me and has a table with all the equipment out.
They did not tell me anything - they just carried on. They were going to start an equipment delivery for (in my opinion) no reason.
He came out on the next push.

It’s crazy isn’t it? ‘Natural’ births have been killing women and their babies for millennia. I absolutely cannot understand the obsession with a natural birth at all costs, especially in situations like the poster above who was clearly asking for pain relief but was fobbed off because the midwife felt a birth without analgesia was some kind of achievement.

I have many things in my life I consider achievements, but the luck of having a baby in the right position/size to come out my vagina really is not one of them. It’s like the whole breastfeeding/baby/toddler-rearing/general wife work stuff. Perfectly intelligent, capable women are forced into this world where we’re suddenly expected to see some of the most menial and mindless, thankless and downright painful tasks as ‘achievements’; rather than being able to take a decent step back and realise these are incredibly small moments in the entire life of having your child and why are we so fixated on them? ‘Proud’ of ourselves for a vaginal delivery, or breastfeeding, or being a stay at home mum; rather than seeing these things for what they often are, relentless drudgeries painted as ‘womanly achievements’ that we hold ourselves and others up to. It’s a big pile of shite and I’m sick of it.

As an additional to my last post - I needed some minor labial tears stitched, a lady entered and introduced herself by name, she sutured me and then afterwards the Dr came in and said congratulations to the STUDENT dr for a successful labial suturing. Seriously?
If I had know she was a student, I don’t know I would have allowed. (Previous errors with student care had made me very cautious)

I also then found from the Dr that they didn’t need suturing as they were very minor, but it was done without giving me the options. This part upset me more - as if I had been informed correctly beforehand I likely wouldn’t have consented and wouldn’t have had the suturing.

The trouble is that the alternative to asking for consent when you're exhausted and in pain, is asking for it beforehand when (if it's your first baby) you have absolutely no idea what the pain is going to be like. I'm very glad that the one coherent thought I managed to express in the throws of an exhausting 27 hour labour (that I did not want a water birth like I'd said beforehand and I wanted an epidural instead) was listened to.

I don’t think it necessarily comes down to ‘natural vs medicalised’ in those cases though- just a disregard for the woman’s wishes and needs, ignorance of consent/autonomy and placing the HCPs ideas about the ‘best’ kind of birth above the woman’s. I think this can work both ways- women who want an ELCS or a birth with an epidural being pushed into a ‘natural is best’ approach against their will but also women being pushed into a more medicalised birth by being told they ‘have to’ have certain things or threatened with unbalanced information. Beneath it lies the same ideas that women can’t be trusted to make their own informed choices.

I know the thread isn't directly about maternal request ELCS but I have seen threads on MN and newspaper articles about this particular hospital and its refusal to carry them out. Here is their leaflet on maternal request ELCS:

www.ouh.nhs.uk/patient-guide/leaflets/files/10405Pcaesarean.pdf

Very detailed information of the risks of CS in that leaflet- unsurprisingly little information on the risks of VB (and no mention of 3rd/4th degree tears and what they actually involve). Nothing is mentioned about faecal incontinence. Nothing is mentioned about perineal or uterine infections (they were quick to mention infection as a risk of CS).

I've had two maternal request ELCS due to tokophobia and am so glad I didn't have to go to this hospital. It's not an overstatement to say they would have destroyed my mental health.

This isn't a pro ELCS post but again highlighting the patronising attitudes towards women and our ability to make informed choices, and in this case an outright refusal of choice. This hospital is a regional centre in many areas and I find it shocking they take this stance.

I agree wholeheartedly with neonglow that this works both ways- not allowing things like ELCS (or certainly making women jump through hoops to get one), but also forcing overly medicalised births on women.

I agree with everything ABingThing has said. I believe so strongly that we should be allowed to make proper informed choices- the balance of control lies completely with HCPs and this isn't right. I can't believe for one second that men would be treated in this way.

@FullMoony that leaflet also doesn’t seem to tell apart ELCS and EMCS- the latter of which women AVOID by opting for an elective section. Such a horribly patronising and unbalanced leaflet.

@neonglow @FullMoony completely agree regarding the disregard for women's wishes. And I think some women are let down when they opt for physiological birth because they're not placed in the optimum conditions for that to run straightforwardly - and they end up being forced into medical intervention.

Regards ELCS and informed choice, there is a lack of separation of stats regarding different types of caesarians even nationally - they're all lumped together. The book 'Why Caesarian Matters' is really good and calls this out.

Really good point- I meant to mention that too and wondered myself if those stars were EMCS or ELCS as there is a huge difference between the two.

Age, general health, weight etc are also factors in the statistics.

I knew the chances of me, as a 24 yr old in good health, a very healthy weight etc, coming safely through an ELCS, and my baby being healthy too, were incredibly high. There was a much higher chance I would end up with birth injuries and continence problems with a natural delivery. Weighing it all up, the risks of ELCS were preferable to me. Never mind my tokophobia.

That leaflet is truly vile imo. I've also just noticed on the Birthrights website that the hospital where I had my second baby has changed its policy to no longer allow maternal request ELCS. I think I'm going to contact them and explain just how wrong this is.

I also want to post my experience.

When I was pregnant with my first baby, it was pure luck that my community midwife was understanding of my tokophobia. She was fabulous- she referred me to a specific consultant at the hospital who she believed would be more understanding (isn't it bad she knew others wouldn't).

I actually only had one appointment with him, he agreed to my ELCS immediately without making me go through the usual process of counselling (ie trying to convince me to have a natural birth). He saw it was my best interests to do this and even booked my ELCS date and I was only about 16 weeks pregnant. A truly compassionate and understanding man.

When I was pregnant the second time, part way through the pregnancy I moved to a different area and hospital. The consultant there hadn't read my notes at all and she immediately started talking to me about VBAC. I asked her to read my notes and the letter the previous consultant had written, stating just how severe my tokophobia is. She then assumed my phobia was about pain and said I would be able to have an epidural (the phobia is nothing to do with pain btw). I said I needed to have an ELCS- she told me I'd have to come back at 36 weeks to discuss it. I was devastated (I already had a date confirmed for the ELCS at the previous hospital)and absolutely petrified after this.

Luckily I had a fantastic community midwife in the new area who immediately arranged for me to see a different consultant, who was far more understanding and he booked the ELCS for me, I was about 23 weeks at that point.

I'm relieved and eternally grateful to the understanding HCPs who helped me. But the female consultant wasn't really interested in my wishes or understanding of my needs at all. It caused me so much additional stress, when I was terrified anyway.

One of the surrealest moments of my first birth was when after using instruments I hadn't consented to, cutting into me without my consent, literally wrestling with me to get me to do what they wanted, stabbing me with needles without even telling me what it was, etc, after that was all over, they then produced a little form with a clipboard for me to give my consent to them stitching me up again. And I just remember sitting there thinking really, NOW you need my consent?!?!

I would like to know how many failure to progress inductions are really failed indications & how many are because the labour isn't going fast enough for the hospital staff? Also giving consent to treatment after giving birth, I had emcs after failed induction, was in high dependency, drugged up to the eyeballs, fell asleep to wake up & find I was having a blood transfusion, at no time was I asked to consent to receiving blood, what if I had been a jehovah's witness or simply did not wish to have a blood transfusion? I always thought that any medical professional had to ask consent to even touch you? I woke during my drugged haze to a nurse groping in my nightlife for my breast to feed my son, again, without consent.

This is a topic I feel very strongly about. I requested a C-Section with DS1 as I have a chronic illness which affects my stamina levels. This was pooh poohed and I was told to ‘ give it a go’. Needless to say labour was prolonged and my illness kicked in to the point where I could barely deliver - I requested a section multiple times during the labour and was ignored. I suffered a severe 3rd degree tear which I still have issues with and it terrified me out of having any more children.

I would like to know how many failure to progress inductions are really failed indications & how many are because the labour isn't going fast enough for the hospital staff?

I would also like to know how many fail because the conditions were unfavourable to begin with and there was no real chance of success.

I wasn't told there's a scoring system they're supposed to use (Bishop's, I think). When I requested my notes recently there was a score of 0 on it. Presumably they should have gone straight to CS in the circumstances but decided to give it a go anyway, without informing me it was a pointless exercise.

@Nat6999 I was definitely asked about blood transfusions at my booking in appointment and it was clearly marked in my notes that I consented to that if necessary - and I guess they ask that then because if a patient is in ICU/high dependency then they have to act if it's needed without waiting for the patient to be in a state to speak to them about it. That said, I'm sorry that this happened to you.

Full Mooney that leaflet should be illegal
Someone should sue them for that

The leaflet is disgraceful. They are using the NHS to legitimize a very one sided view.

Lardlizard it's propaganda, so completely biased.

It makes me so upset to read women's stories on threads like this one. I'm so sorry for everyone who has suffered a traumatic experience. The fact that this is women doing this to other women in most cases is also shocking.

I'm going to contact the hospital where I had my second baby, given they (like the John Radcliffe) seemingly no longer offer maternal request ELCS and see what their response is. I'm not sure if this policy was in place when I had DC2- as I'd had one CS already it was a different scenario than asking for ELCS with first baby.

It will probably make no difference but as ever, and like in wider society, I've a feeling some HCP's and trusts want us to keep quiet.

My thought is, would you rather women and babies die ... informed consent works great for planned operations but when there's a medical emergency there's not time to fully explain often (same goes for a&e emergencies) drs need to be trusted to use their medical knowledge to get the best outcome. I'm not downplaying tears but c-sections also come with higher risks and different complications.

In the US they got me to sign all the consent forms around 28 weeks pregnant - this is also pointless because preauthorising a c-section or forceps means that the dr just decided