Consent in maternity care

[Nimnuan]

I just read a post on MN from a woman who said no multiple times to ventouse/episiotomy, and the obstetrician did it anyway. Obviously she did not consent. That is assault.
Around 70% of the comments were variations of "it's not assault, the obstetrician wouldn't have done that unless your baby was in danger so you should be grateful".
I am horrified! In what world is it acceptable to cut a woman's genitals when she is telling you to stop?!
Also, do these commenters somehow think that everything done in maternity care is based on good evidence?? Are they not aware that obstetricians were doing routine episiotomies until the 2000's?
When I was in labour with my daughter the midwives forced me onto my back and pulled my legs open despite me physically resisting for about 25 minutes (according to the notes) and me verbally telling them to stop. They called an additional person into the room to help overpower me. They told me husband to help them do it. Because I eventually gave in, they claimed I consented. Later, when I told them I had not consented, they claimed I forgot that I consented.
If I was in a sexual situation with a man, and he kept trying to pull my legs apart while I physically resisted, and he didn't listen when I told him to stop, and I eventually gave in and let him do whatever he'd decided to do to me - nobody would say that I consented to having my legs pulled open or anything that followed.
Why do we excuse midwives and obstetricians who violate women's bodies?

No, it's not high. But it's a risk that can be reduced and medical professionals have a duty to spell that out to women. If women start refusing induction more, as they obviously have every right to do, on a population level that's going to be x number of extra dead babies who didn't need to die.

Okay, but that's a different problem. Whether the decision is right or wrong that doesn't give you or anyone else the right to impose your will over hers.
And encouraging medical professionals to override women's consent is not going to lead to more trust.

My ob for my first was brilliant. He asked before doing anything. Offered me options. I ended up ventouse, no cut, no stitches necessary. Quick recovery.

He was away for my 2nd so I had his new practice partner. Who shoved a local anaesthetic needle up.. well... It hurt more than the entire birth. No warning, no consent. He had to stop half way through as DD was in a hurry. Later DH told me he saw the ob laying out what looked like cutting tools. He'd intended to cut, no consent, no informing me, no medical reason. DH told me he would have stopped him (I'm unsure he would have, tbh). I could have had permanent scarring, longer recovery & issues, when it was completely unnecessary.

Consent has a long way to go. I still feel angry, and violated, when I think about it.

YANBU OP. The session on obstetric violence at FiLiA 2023 was harrowing & very thought-provoking. The gist was that patriarchy encourages women to dissociate from our own bodies, tells us birth is necessarily a process led by authoritative medical experts, obfuscates that obstetric violence is normalised sexual violence, routine all over the world.

My own experience of this was being examined by a student midwife while in early labour. I told her she was hurting me; she laughed dismissively, saying "if you think this hurts wait until you're in full labour". I was like, you're saying any pain you inflict on me that doesn't compare with baby crowning is OK then? but didn't feel able to say that, as I felt I had to focus on baby & as the whole interaction had triggered memories of being raped.

See from my experience midwives don't examine enough! I went from 0-10 with my first two births really quickly and was dismissed when I asked how much I was dilated and told them the pain I was in. I honestly don't think they examine unless they feel they need to. They definitely aren't doing it just to annoy you or cause you pain. But it is sad that you feel that way and we all have different experiences. I hope you are recovering well and you and baby are good 🥰

Turned out that her doing that exam was not only unnecessarily painful & unnecessary even if it hadn't been painful, it endangered my life & my baby's life. I had told them I thought my waters had broken & they'd decided I was wrong about that & it was OK to examine me.

Relatedly, I always thought smears were inevitably very painful for me (maybe I was a wimp or had a very tight vagina or something as nurses always seemed to think I was being ridiculous) until I had one that wasn't, & realised the difference was the nurse's attention. She wasn't like hyperfocused or anything, just paying attention in the way I would expect anyone who cared about their job to, & following the shape, the way anyone with intelligence puts their fingers inside a woman they care about not hurting. I was so depressed to realise my previous experiences had been down to institutionalised not caring about / normalisation of women's pain.

To me the problem is that they dismissed you when you told them how much pain you were in! I know they're under a lot of pressure but you deserve to be listened to!
I'm glad you're happy with your experience though. Me and my baby are really good, thank you :). Being pregnant again has really brought everything back up again but I'm feeling pretty good going to into it this time xx

Embarrassed to admit I hadn't heard of FiLiA. Thank you for sharing.

I am a former midwife. I left because of how much birth trauma, lack of informed consent, medical misogyny, and unnecessary interventions I had to witness. I went on the become a campaigner against birth-based violence and train midwives and obstetricians on women’s rights in birth and how to provide safe, respectful care.

There are some very passionate, dedicated HCPs out there who recognise that this is a massive issue, but sadly they are in the minority. People don’t go into health care to hurt people, but unfortunately the way the system treats its staff and forces them to work in overly pressurised environments within a defensive blame culture means many of them can’t provide the level of care they want and suffer from compassion fatigue. They begin doing whatever needs to be done to suit the system, not the women, and become perpetrators of harm.

There are many complex layers to why and how obstetric violence occurs, but I wholly support all of those who have been harmed or traumatised by their experiences. You were failed and did not deserve what happened to you, nor should you be shamed or told to get over it because you got a baby at the end.

Jesus fucking Christ. If a woman said a man had dragged her down an alley way, forced open her legs and stuck his fingers in her, would you describe that as being poked and prodded? It’s so goady and dismissive.

Being assaulted is absolutely not part of the process. If you want to consent to a VE it can help to inform midwives of your progress, but it’s only a snapshot in time and things can change very quickly. They are virtually meaningless for me because I don’t dilate ‘normally’.

Of course, if you are going to give birth vaginally there may be times where they get a bit up close and personal (assessing after birth, stitches etc) but consent is always sought. The only time in either of my births that being ‘poked or prodded’ felt genuinely necessary was when they wanted to check if DS had the cord wrapped round his neck.

Thank you for giving your perspective on this thread, and thank you for the work you have done to shed light on this.

I had a midwife after my second baby was born who was genuinely like the Mary Poppins of midwifery. She was exactly what I needed and thankfully she spends a lot of time training other midwives on best practise.

This thread depressingly proves why this is still a commonplace issue when other women accept obstetric violence and condone it for other women.

Its the entire "as long as the baby is safe and healthy". Doesn't fucking matter if the mother is left permanently incontinent, with permanent back pain, low self esteem, no bonding with the baby, severe depression, suicidal thoughts etc etc. Nah fuck her shes just an incubator who can be forcefully dragged around like a rag doll, cut up, injected, tortured because shes not a human in her own right and if she dares express upset at it we can call her selfish and evil and tell her she doesn't care about her baby.

But then again these same people are anti hypnobirthing/natural drug free births and refer to them as dangerous and ridiculous and tell you theres no medals. There may be no medals but the fact they are proven to cause less damage and promote better healing and mental health after is testament to understanding how physiological birth works.

Thats not to say sometimes things can go wrong. And things do. As with anything. Anaesthesia for example is routine and used thousands of times a day and is deemed safe enough for tiny babies, elderly people etc, yet a small minority of people will die from it.

The NHS over promotes dangerous interventions that are proven to cause a cascade of interventions that women arent informed of. Look up your local maternity hospitals birth stats per month and be horrified by how C-sections now make up more than 50% of births per month, as if 50% of women couldn't birth naturally without them or their baby dying. Patently something is very wrong with that number. Yet women are so brainwashed into being told they have to have an induction from 39 weeks and not told that by doing so they risk a 50% intervention of forceps/ventouse/emergency C-section delivery by doing so.

One could argue that a woman making decisions that put her baby at risk of death is not behaving with full mental capacity. If a full term baby requires an assisted birth and the mother refuses because she is feeling overwhelmed one would be right to question if someone refusing treatment due to feeling overwhelmed is demonstrating a behaviour of a disregulated emotional state is in a state of full capacityy to be making decisions that would result in a living or brain damaged or dead child

I’m glad you had such a lovely midwife who helped you have a positive experience, that’s wonderful 🥰

Not at all. Previous case law has been very clear about this. There is a particular landmark case dating back to 1998 where a pregnant woman with pre-eclampsia was advised to have a section and refused. They detained her under the mental health act and performed it against her wishes. She challenged the lawfulness of that decision.

The court of appeal established that an adult with capacity has the absolute right to refuse medical treatment even if that refusal may result in their death or the death of their unborn child.

Capacity should always be assumed. A woman making a decision that isn’t rational is not indicative that she has lost capacity. If she has demonstrated that she understands, can retain the info long enough to make a decision, weighs that information as part of her decision and is capable of communicating that decision (either written, verbal or even with gestures) then she has capacity.

‘Being overwhelmed’ will not cut it. Most women become overwhelmed at some point during their labour, it does not mean they have lost their autonomy.

Agreed that the NHS over-promotes intervention but let's not forget that it's equally important to respect women's choices when they're accepting or requesting intervention as when they're declining.
We all have different values and preferences. You don't have to be brainwashed to want an induction at 39 weeks. To some women an extra 2, 4, 6 still births per 10,000 pregnancies isn't worth risking. Some women just don't want to be pregnant anymore for whatever reason, or maybe forceps/C-section doesn't seem like such a big deal.
Over-emphasising the risks of epidurals/sweeps/induction/C-section and trotting out the patronising "no medals" line are two sides of the same coin.

The point is that the medical professionals weren’t guiding the patient the OP was talking about. Guidance requires consent. Forcing regardless of that consent isn’t guidance. It is assault.

The idea that any amount of time "researching" with Dr Google could put someone on the same playing field of knowledge as medical staff with professional qualifications and years (possibly decades) of relevant clinical experience is about as likely as anyone winning the lottery every week for a whole year.

Unless you are medically trained and experienced in the speciality for which you are being treated, you cannot be certain that you know what is likely necessary for an individual patient. (The medical staff won't be completely certain either but they know what is probably happening from all the data available to them allied to their experience of many other similar situations.)

I don’t think anyone is claiming to have as much knowledge as trained professionals, but the point is that the professionals are meant to explain and advise, not just decide for you. The way information is presented matters. You can’t obtain informed consent if you don’t do the ‘inform’ bit first.

Doing your own research enables you to ask the right questions so you can make the right choice for you, but it shouldn’t be like that - the information to empower you to choose should be freely given by the medical professionals. I learnt this the hard way in my first pregnancy. I was hospitalised several times due to hyperemesis. I couldn’t eat, drink or move without being sick and was severely dehydrated. None of the antiemetics I was prescribed worked. I kept being told ‘there’s a much better drug but you can’t have it until 12 weeks because it’s too dangerous / risky’. In my mind, that meant it could cause a miscarriage or serious birth defects. So I kept on lying in a dark room wasting away, being admitted to hospital every few days for fluids.

When I was 11 weeks pregnant a doctor prescribed me the drug. I panicked and was upset saying it wasn’t safe. He said it is safe - there’s a very very small increase in the baby developing cleft palate and even then, the study that showed it was not very robust. I felt devastated. I’d endured weeks of absolute hell thinking this drug was horrendous when actually, if someone had explained the actual risk I would have taken that drug and that risk.

After that experience I no longer had blind trust that the professionals always knew best or would make the best choice for me. I realised I had to get all the information, ask all the questions and challenge their recommendations to ensure their advice was the right choice for me and my baby. It’s not about thinking I know medicine better than them, it’s about it being MY choice and me needing the info in order to make that choice.

I agree but it is still highly unlikely that a cursory use of the internet (cursory compared to years of in-depth professional education, training and experience) will prepare anyone for every possible situation they might find themselves in, and so be equipped to ask, and choose to ask, the appropriate questions for the unique situation they find themselves in.

Unlike many other common medical situations, there are significant time constraints for the well-being of their own life and/or their potential baby which may preclude being able to DYOR at the time.

There are a lot of decisions that are not highly time-constrained. Accepting an induction, planning to birth at home birth/birth centre/labour ward, deciding whether you want routine vaginal exams or CTG in the absence of any specific medical concerns.
If you have an illness, then you probably want to be guided a bit more, but pregnancy and birth is not an illness. Most of the interventions applied routinely to healthy pregnancies/births were introduced without any evidence of safety or efficacy.
To take one small example, immediate cord clamping had no evidence of benefit, is now generally recognised as being somewhat harmful, but it took decades of research and education to stop it being routine practice.
But the important thing is, midwives and doctors should be honest about the reasons for their recommendations, provide explanations appropriate to the urgency of the situation and preference of the woman, and they should respect her decision.
Some women want to just do whatever is recommended without hearing all the details, and that's fine. Some women want to know the evidence base behind the recommendations, and that's also fine. Some women feel safest with all the tests and prophylactic interventions, some women feel safest at home and unmedicated, with the midwives quietly observing on the other side of the room.

I hate midwives too. A special kind of psychotic and stupid.

Part of the reason I don't have children.

Wildly inappropriate comment.
Midwives are wonderful. They are doing the best they can in a flawed system under extreme pressure.

While it’s a noble role and most will, no doubt, have gone in to it with the best of motives, investigation after investigation into failing maternity units, along with posts from midwives themselves suggest there are significant problems with work culture amoung midwives that are not isolated.

Problems in the work culture for sure. There's a former midwife in this thread who talked about compassion fatigue, for example.
But that previous comment is ridiculous. "Stupid and psychotic"?! Must be a wind-up.