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

a bit of knowledge can be a dangerous thing if you suffer with anxiety

True. But if you know that staff have lied to you or straight up refused to answer your questions, or done things to you without consent, and you can no longer trust those staff, that's pretty bad for anxiety levels too. How am I supposed to feel safe with staff who won't be honest with me?

5zeds I agree. But labouring without a drip in place was met with horror - and when I mentioned considering monitoring instead of inducing at 37 weeks, you'd have thought I'd asked them to murder someone.

The fact of the matter is, a trial of labour should be available to ANY woman - even if they have a very dangerous condition that will almost certainly lead to death. It's the law. If an informed decision is made to decline treatment, it must be upheld, even when it risks the patient's own life.

Spanneroo I have a friend who recently had IVF twins. She had a rather unpleasant meeting with one consultant who wanted to book her an ELCS. She asked to be referred to another consultant who turned out to be much more supportive and in the end went into labour basis spontaneously and birthed her babies with gas and air. It can happen.

I hope you get the birth you want.

Don't know where the "basis" came from.

I had a 4th degree tear and then some nearly 9 years. The consultant after 2 hours at 10 cms at home, transported blue light ambulance, then 2.5 hours trying to push with no contractions, threatened me with forceps by waving them at me. She accused me of not trying whilst not listening to to the fact that my contractions were next to nothing or very short.
I was cut with no consent, to give the baby room, who did not budge a millimetre. I then had to push, with no contractions or pain relief and I tore apart. It was the arrogance of the Doctor who couldn't see that my daughter had and still has massively shoulders. I was told DH and baby could stay when they stitched me. They changed their minds and wheeled me down to theatre for reconstruction straight away leaving poor DH with the baby and I still suspect PTSD.
They had to call for a Senior surgeon to put me back together again, around an hour of stitching and I know they fucked up. How? I was in for 4 days and I saw every Doctor, midwife, paediatric Dr, nurse, everyone. Absolutely everyone in and NHS hospital.

I did a debrief with Head of Gynecology, it came to naught. The Consultant Midwife looked at my notes, scant as they were and said from my description, I'd had a near death in birth experience . Her words not mine.
It robbed me of my MH for months, it robbed me and DH of further children, it terrifi
ed him thinking of doing that again and mostly no one listened.

4th degree tears do heal but despite all the physio, I can just run for a bus, I can't run around the park without peeing my pants, lift heavy things, get constipated and it's a life long birth injury to manage. I am dreading the menopause because these symptoms will be amplified. Still angry about it now.

I saw a quote from a midwife which was ‘the woman does the allowing’ Now, legally and morally this is so true- you have to give your permission and decide whether the HCP is allowed or not allowed to give you a vaginal exam/sweep/drip/induction etc etc. Anything they do is with your permission only.

Yet in reality the language is shifted and switched to make women feel the opposite- like suddenly their body is hospital property, other people can tell them what is going to happen to their body, do as they please to their body and telling the woman what SHE is ‘allowed’ or ‘not allowed’ to do in reference to her own body.

and elect a section.

Forceps can be used at a section too.

If the decision was a clear cut medical emergency one, you'd expect to see very similar figures.

My point is that you can't have the information to make an informed choice about forceps vs emcs until you're in the moment. It isn't like going into labour vs elcs where you are weighing up theoretical risks of both. You can't know how risky a forceps will be until you know exactly where the baby is and what position their head is in so you cant compare that to the risks of a caesarean at fully dilated. There are so many variables in that situation which could sway the potential outcomes that you simply cannot rule out forceps on the basis that they are "more dangerous" before that moment.

My research and study in this area has led me to conclude that I'd want the most senior person available to do the VE and tell me how easy the forceps delivery will be.

I’m a doctor and was a trainee in O&G when I had my first child. What I found deeply wrong was that the information shared in antenatal classes completely failed to cover complications of delivery. No mention of risks, or of what happens in the situation where emergency CS is indicated; at the point where things could be calmly covered, they just glossed over everything.
Don’t know if it’s got any better. But I bet not.

@ChilledBee

Surely the use of forceps in caesarean is not the same thing as having your perineum sliced open and having them shove up your vagina? Surely the risks to the mother are not equivalent?

Most people I know who have concerns about forceps cite the risks to the baby rather than themselves. Sometimes alongside but people usually prioritise the baby over themselves. I'm not saying they should by any means. Just they do.

But that's not even my main point about forceps. What I'm getting at is that women are equally likely to make sweeping statements about childbirth as doctors. A doctor might say that it is always more dangerous for a woman to have a vaginal birth after 2 caesareans but fail to consider the woman who turns up in labour with the baby drowning (or at least a good way through the 1st stage). Is it really more dangerous for her to continue to labour at that point? Always? Even most the time?

It's the same as a woman who says she will never consent to forceps because it is always more dangerous for baby or herself. It isn't a decision you can make absolutely on that basis without knowing the exact situation.

Both essentially inhibit good communication if either party comes in with absolutes based on limited hypothetical information.

Not drowning, crowning* OMG.

I slightly resent the comment about most women prioritising the baby. I did prioritise the baby above myself which is why I consented to the forceps even though I knew full well the damage they could cause. I was told they were necessary to safely deliver the baby. I am still living with the consequences 18 months later.

Of course women consider the risks to baby of forceps but the point is that forceps in a caesarean delivery may pose some risks to the baby but they do pose the same risks to the mother as vaginal forceps. Comparing the use of them in vaginal and caesarean births is erroneous.

Most women are more than capable of considering different scenarios though. I knew I wouldn’t consent to a trial of high rotational forceps if a c-section could be done just as easily, but would agree to forceps in other scenarios. Part of preparing for birth is going through different eventualities and what choices you may have in those situations.

If you ask a woman in labour in absolute agony if they want an epidural, the first thing they ask are the risks to the baby. Even though they know it must be mostly harmless to exist. They might speak about the limited mobility but not because it will shorten the length of their own labour and mean less pain, but because it will be better for baby. It's a cliche but women are very selfless when it comes to birth. Often to their own detriment as you well know.

Away from pregnancy/birth, they speak about epidurals and long term back pain/paralysis but in the moment, they prioritise the baby. They make whatever choice because they think it will be better for them in the long run.

But anyway, back to forceps. My point about them is that people make sweeping statements about whether or not they want it.

On the whole I've been surprised and impressed that my doula training has incorporated this side of informed choice. For example, the hormone they offer to deliver the placenta, many women will write that they don't want it but it would probably be more helpful to consider when they would have it and communicate that. More people would feel their wishes were adhered to that way.

I knew I wouldn’t consent to a trial of high rotational forceps if a c-section could be done just as easily

That's a subjective in the moment decision though. To me,you just said categorically that you WOULD consent to a forceps if the doctor felt it would be harder/(I'm guessing more dangerous) to do a section. So if you wrote that down and you couldn't communicate for whatever reason and I was advocating for you, I'd ask the doctor what they thought would be "easier" to use your term,and go with what they said.

I see what you’re saying, during my 2nd labour the crash team came in briefly due to baby’s heart rate dropping. Once the dr had given me an exam and was considering what to do he asked my DH if there was anything I wasn’t willing to consent to and my DH replied no high/rotational forceps which was taken into account without question. The fact I had researched beforehand and had a birth partner who knew my wishes and could advocate definitely had influence on how decisions were then made during the labour.

Interesting article here....

blogs.bmj.com/bmj/2019/07/24/laura-downey-childbirth-in-the-uk-its-time-to-be-honest-about-what-the-nhs-can-deliver/

ChilledBee I also get what you are saying. In relation to forceps, I guess my own feeling on it would be that if there was no other choice, because of the baby needing to be out fast and it being riskier to do a section at that point (and I'm presuming the forceps used aren't the same as the high or mid forceps) then I can understand why it would be necessary and I could consent to it (tokophobia asides- I would never want to be in that position). This is why all the eventualities need to explained beforehand imo.

I can understand a situation like that. But I could never understand the high forceps being used, or a forceps delivery being attempted when a c-section would still be an option. Unless a woman chose it instead of a c-section- my own mother was far more scared of having a c-section than of any kind of vaginal birth.

The 29th November is a Friday.

it is very important to distinguish two different issues:

One is informing women before labor. At the moment information is pretty biased. CS risks are always presented, often in an exaggerated manner, while VB risks are often missed out at all. This means t.hat women cannot make an informed decision between CS and VB.

The other issue is what happens during labor. As many women’s stories show, their choices are ignored during labour WITHOUT the excuse of emergency intervention. Medical professionals simply take over and perform procedures without asking for consent or against the woman’s explicit consent.

During some labors it is possible to have a genuinely emergency situation with no time to get informed consent but this possibility is used as an excuse to override women’s autonomy in many other situations where there isn’t the justification of a medical emergency.

I think that what we need is :

1. Unbiased, comprehensive information on all birth options, risks, benefits and complications of uncomplicated VB, complicated VB, ELCS and EMCS as standard across NHS trusts to avoid individual bias by doctors and MWs.

1. Retraining medical personnel to respect birthing women’s autonomy in non-emergency situations.

I agree with pp about the and answer lying in general education outside of pregnancy and childbirth.

My husband's sister had IUGR in 2017. She didn't want a section and was keen to avoid one from the start but as she approached term, the doctors didn't think her placenta would withstand an induction.

She couldn't understand this and felt forced into a caesarean but it was because she truly didn't understand how the placenta works and why an induction would be extremely risky. She also has a BMI of 40+ and a clotting issue so they REALLY weren't keen on doing an EMCS and would much, much prefer to plan it in advance. Her midwife was great though and found her some videos which explain. She was going to refuse the section and request an induction which they would have given her because doing nothing and something happening to the baby would be put on them if they didnt even try an IOL.

But I could never understand the high forceps being used, or a forceps delivery being attempted when a c-section would still be an option. Unless a woman chose it instead of a c-section- my own mother was far more scared of having a c-section than of any kind of vaginal birth.

I was very anti forceps because of everything I'd read. Then after 75 hours of labour, pushing and a baby stuck mid pelvis, I agreed because they told me it was the safest option for both of us. My heart rate wasn't great, my blood pressure was rubbish, I had a fever and they didn't want to operate unless they had to, they were worried about me bleeding heavily, told me it might come to a hysterectomy if I needed a c-section. They were also concerned about dc1 being wedged and harder to access from the top than the bottom.

Forceps failed but apart from bruising (me) neither of us sustained any damage from them. I didn't tear and neither was I cut.

Apart from me passing out, having first had a bunch of horrible hallunications, the emcs went fine too. In the end I lost 400 mls of blood according to my notes but from everything I'd read, we were quite lucky.

From an emotional perspective for various reasons, I really struggled with the c-section. I don't know if I'd have felt worse if they hadn't tried forceps or better.

My hospital runs free education classes.

Anyone can go. They're run by a midwife. We covered all aspects of pain relief, the content of the consent forms, everything people are saying they "didn't know"

It didn't cover the main consent issue. But it did mean that during my hypnobirthing trance, of my husband said "space they want to talk about xxxxxx" I could respond.

Anyone can go. They're run by a midwife. We covered all aspects of pain relief, the content of the consent forms, everything people are saying they "didn't know"

I think that would be great if it was standard but it's not. Our ante-natal classes (the NHS ones) were all about the positives. We weren't allowed to mention c-sections or forceps. We couldn't see a consent form, it was all about straight forward vaginal birth. We didn't even get to talk about NICU.