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

Are these general classes about pregnancy and birth? Or designed for people who are pregnant?

No consent for asked for or given for the sweep I underwent. Midwife was just examining me and I felt pain and shouted ouch. She withdrew and as she took her gloves off said 'just done a sweep for you' is if I should be grateful. She left the room and I cried and hobbled to the loo to find out I was bleeding. I can't imagine any other scenario were someone could just injure you like and tell you as if you should be grateful.

@ChilledBee they're for expectant mums and their birth partners.

The "hospital education" experience I had was everything from "when to come in" to emergency section and everything in between. Water, gas and air, pethadine, epidural, forceps, the works. It was informative whiteout being frightening. The classes were free. They offered a few different options taking place over a couple of eves/a Saturday/consecutive days/a couple of weeks.... it was as accessible as they could make it. It was offered to all women at their booking in appt and still the classes weren't full. NCT has a waiting list (THAT's the ultimate in "denial of real life" classes!) but the hospital had free spaces in their free classes. The classes included a tour of the wards and NICU too. Instructions for partners where to park when you come in. Literally no stone left unturned.

My thoughts are that (and this is a general sweeping statement but seems to fit)

The medical personnel who attend us during pregnancy and birth perceive us to be ignorant of what's happening in our bodies, naive of our options and rights and so treat the majority of women like small children, telling them what they can or can't do. They don't expect you to be intelligent and willing enough to be informed, to question.

To be fair, most women going in to pregnancy, labour and birth are ignorant and uninformed. There's seemingly a lack of education or want to learn. Why? I couldn't say with certainty but I would guess that it boils down to "women's issues" so will never be made a priority in any policy.

@SpaceDinosaur

I think pregnancy is too late to learn these things. What I was suggesting is that our general education about pregnancy and childbirth starts a lot sooner and outside of pregnancy. Once you understand the general physiology of birth,itgives you a foundation for informed choice

Can't I'm afraid.

I'm currently studying a Masters in Bioethics and Health Law; the issue of whether a woman can consent in labour formed part of my Bioethics submission. Consent requires the ability to receive information, weigh it up (come to a reasoned choice) and communicate that choice. All women in labour are presumed to have the capacity to make choices regardless of pain or presence of analgesic drugs in the system. What few studies there are on this seem to corroborate that view.

The level of capacity required is related to the risk of the decision, so a high stakes decision requires a high level of capacity.

Generally these situations - epidural insertion, forceps, caesar, intervention in general - would be better discussed in the antenatal setting with minimal emotion attached to the conversations but relevant facts and information. However there isn't the ability for everyone to be seen in clinic beforehand and we rely on midwives to transmit this type of information prior to labour (particularly when the woman is writing her birth plan).

Something to be aware of is that even if you write something on your birth plan that you categorically refuse, if you later ask for it anyway then you are deemed to have exercised your autonomous right to change your mind - it's a bit of a minefield with epidural insertion in particular, which is often ruled out by first time mums antenatally who then ask for one when they arrive in labour.

However if you categorically refuse something and don't change your mind then that procedure cannot be performed on you.

New Zealand (where I practice now) has the Patient Code of Rights where one of the rights is the right to be fully informed, one is that a provider cannot provide treatment unless it is consented to and another is the right to care of an appropriate standard. It's something the UK should think of looking at.

(there are loopholes that allow treatment provision without consent if the patient does not have capacity to consent, and if it is in the patient's best interests, and their views on whether they would consent or not have been obtained if at all possible)

That’s really interesting hicdraconis

This follows on from what other posters have said about how women are informed of the risks of VB vs CS, but I really think doctors and midwives should stop telling women that VBs have a faster recovery time. The truth is that straightforward VBs with minimal tearing have a faster recovery time. For less straightforward VBs or bad tears, the recovery can be frankly brutal.

Put it this way - I’m 16 weeks PP and still recovering, and I’m going in for a third round of surgery to address the damage from my VB this week. My friends who had sections are skipping round at buggy fitness classes.

I completely agree Monkeynuts18. My friend had a third degree tear and suffered for six months after the birth. She had trouble sitting, much less doing anything else. She's a professional horse rider so she was completely off work. I got back on my horse at 6 weeks after both my ELCSs. Best of luck with your surgery.

When in labour with DS2, I had an assisted birth with ventouse. 2 Dr's, one junior and on supervising were carrying out the procedure, when I felt a sharp pain, and the supervising Dr looked at me and said, I've just cut you to help the delivery'. There was no concent and even now, all those years since I feel uneasy about it. I understand it was a pressured situation but she should have asked, I would have said yes, whatever it took, but instead she did it without consent, and it frightened me.

And yes, I agree. I have had three labours. 2 EMCS's and the one vaginal delivery with Ventouse, and that was the one I found most difficult to recover from, the stitches hurt much more, they were in a much more uncomfortable place and I felt worse from is psychologically

@Booboostwo

Exactly! Women are often told that sections are ‘major abdominal surgery’ (so patronising, as if women think they’re a trip to Disneyland!) but third and fourth degree tears - and in fact episiotomies - can be really serious injuries (and involve some pretty major surgery to repair!)

It has been a comfort to know I'm not alone, reading other people's experiences, although I wish it weren't the case. I'll add mine.

After my second baby's CS (premature due to pre-eclampsia) I refused to consent to an internal examination. I'd discussed consent in depth prior to the CS due to history of trauma/sexual violence. I'd even been assessed by a psychologist to confirm I had capacity to refuse consent, including to treatments that would potentially save my life. Following these discussions, it was agreed I could wear pyjamas during the CS rather than a gown, and other than having the catheter put in prior to going to the operating room, nobody was going to be touching or examining other than literally for the incision and CS itself if that makes sense. Pyjamas were to remain on throughout. I'd had the exact same arrangement with my first child's birth, no issues.

So, after being stitched up, the surgeon comes to my head end and asks for consent to do this internal exam. She said it was to assess blood loss. I said I was sure they'd see any blood loss without that exam and that I did not consent. She tried to persuade me and I said no repeatedly. She said ok and disappeared behind that screen thing that stops you seeing what they are doing. I then felt tugging and realised she was trying to pull off my pyjama bottoms, but they were soaking wet so difficult to take off. Went ballistic and pushed my hands down and hung on to the band of my pyjamas as she tried to pull them. I started shouting no and then flat out screaming, and the anaesthetist had to stop her, then escorted the surgeon out the room. I was having a panic attack so they took the screen down so I could see no one was touching me. They kept trying to put baby on my chest and I more or less told them to fuck off and give him to his father because I was hysterical. Afterwards the surgeon came to see me (about 2 hours later) and said she still needed to do the internal exam to check my blood loss. I asked what she'd do if I had excessive blood loss, and she said she'd give me a drug to stop it. I said so give me the drug just in case but she said she couldn't because it causes cramps. The midwife there said it was absurd because all my vitals, heart rate BP were perfect throughout.

I had nightmares and flashbacks and discharged myself against medical advice after 2 nights even though they wanted me to stay a week because of the PE. The day after I discharged myself I reported the surgeon to the police for assault. The police more or less told me that doctors didn't need consent for anything that they wanted to do, but requested the medical info from my blue folder. I went back to hospital to request the folder, and they said if I wanted to make a complaint I'd have to make a subject access request for the information then follow the complaints procedure. I explained it was for the police, and that if they didn't wish to provide it to me, the police could ask them instead.

That was on a Friday, and on the Monday I was asked in for a meeting with my consultant. Apparently there had been emergency meetings about it over the weekend. They suggested a meeting with the surgeon, which I did, but she was unapologetic and still adamant that she was correct in her actions. Prior to the meeting I had intended to pursue it with the police and ask to see a higher up officer, but at the meeting, the surgeon looked awful. She was white as a sheet and looked like she hadn't slept or eaten in days, so I just left it. I still made a formal NHS complaint and was told she was no longer working there.

The nightmares etc continued for weeks and I had bad PND. It was a very terrible time for me. Years later I'm trying for another baby through IVF and I'm already anxious about the birth if I do conceive.

Gosh fllinn you are brave. They also wanted me to have a meeting with the cons after my delivery but I couldn't face seeing her.

This was a few years ago, so maybe things have improved but the doctor holding a conversation with you whilst for example internally examining you while being induced, does not make for a conversation where you are able to express yourself as well as you would do otherwise.

fllinn that is just shocking!

Sorry not sure how this happened
Wrong thread obviously.

I think the whole consent thing is a really tricky subject during childbirth. Some women are calm, collected and able to think things through very well which many more will not be thinking logically and rationally but out of a place of fear, hormones and quite possibly pain.

Some women might even elect for a c-section just to avoid natural birth. That's not really sensible and doctors and midwives would probably consider it to be illogical and irrational but as long as they're competent, it's their choice. In the hospital where I work, we are always reminded that informed consent is what's needed and whether or not it seems sensible isn't our business.

My concern is that people are often made to make big decisions without any prior understanding, under difficult circumstances and with no time to consider the evidence for and against.

Triskelion choosing a CS is neither illogical nor irrational, it’s a subjective assessment of a variety of risks. That someone else would make a different choice is explained by the subjective nature of the risks and one’s attitude to which unknown outcomes might actuate. The whole point of patient autonomy is that all medical decisions involve a subjective assessment of risks and benefits, which the informed patient is best qualified to make. Plus you don’t see anyone rushing to call men’s health care decisions illogical and irrational - you are just feeding into the perception of women as incapable of reason and easily overwhelmed by emotion. There are grave risks associated with VB, such as the risk of brain damage from lack of oxygen, one has to decide what weight to give to that possibility and it’s chances of actuating.

@Triskelion I think you ought to ask MNHQ to remove your judgemental comments about who choose caesarean sections, there are a variety of reasons why women choose a caesarean section (read the thread maybe?) and it is never "just to avoid natural birth". Even your phrase "natural birth" is divisive as it feeds into the narrative that caesarean are not natural and women who choose them are therefore not natural. All births are natural, regardless of whether they are vaginal or caesarean.

In many circumstances the risks of a caesarean are no worse than the risks of a vaginal birth, both short term and long term, and women should be afforded the benefit of balancing one against the other to enable then to make their own best choice.

@Bearfrills I think you take my comment to mean ‘all women who choose C section’ which might be my fault for the way I worded it but that wasn’t what I meant. I meant that there are some women who opt for this route due to misconceptions around recovery and see it as an easier option. I’m well aware that there are a huge number of other reasons why a woman might want or need to have a c section and in many cases it might well be the best for mother and baby.

In my own experience of childbirth, I was well aware of the statistics for needing intervention after the use of epidural so I made the informed decision to write in my birth plan that I didn’t want them for each of my children. However midway through labour with all of them, I was begging for an epidural. Nature took its course quickly and I never got to have that pain relief. Looking back I’m glad I didn’t because I could have had more traumatic births (or not but we shall never know). What I’m saying is that we all can give consent to things from a place of fear rather than understanding. For me it was a fear that I couldn’t take the pain and there was no time for me to think that through.

I'm due to give birth in 3 weeks for the first time. Have taken the time to read my hospital trusts guidance on birth as well as NICE guidelines and relevant studies a number of times to ensure I'm fully informed of facts and to be able to cope if I'm pressured in certain situations. After a second miscarriage when I was given false information to pursue a course of treatment that suited them, it's the best I can do to protect myself from undue pressure and misinformation.