Obstetric violence - legs forced open against my will

[NibliaBiblia]

When I was in labour with my daughter, the midwives spent twenty minutes trying to force my legs open to get me flat on my back with my legs up. There was no emergency. It was so they could get a better CTG reading. I physically resisted for as long as I could and verbally told them to stop. They didn't stop until I gave up. After that they did other things without my consent, but I did not they to stop them again.
I complained to the hospital and they have done nothing. I complained to the police and they told me there must have been an emergency. I've complained to the NMC and the CQC. I hope they will do something but it's a long process so I won't know for a long time.
The police used to say that domestic violence was a private matter. They used to say that if you got in the car/went into the apartment/were drinking then you must have agreed to it. I think this is exactly the same type of justification, applied to equally criminal behaviour.
I don't think my experience is abnormal. I think this is fairly routine. They thought that when I gave up that meant I consented.

A lot of women probably feel the same, they'd rather have a high chance of unnecessary surgery than a tiny chance of a catastrophic injury, but there are risks to the baby from unnecessary surgery, and increased risks to your subsequent children too. Anyway, point is it's not always clear cut that's best and it always needs to be the mother's decision.

We seem to be obsessed with short termism in obstetrics without looking at the very real long-term effects of an intervention. The increase in inductions and subsequent cascade of interventions is one such reaction. I'm not on about medically indicated inductions, more so those for post dates. We used to offer induction at 14 days, it's currently at 7 days. Usually offered as "I'll book you on for your induction then" without any discussion around risks or alternatives and usually with a nice little sweep on the side (again no informed consent). The woman then goes into hospital, has prostins because her cervix is what we class as unfavourable, then we put her on the syntocinon drip for hours until baby has had enough, the heartrate crashes and we end up with a crash section. Woman is grateful that she was in hospital because her baby needed saving even though it was probably being in hospital that caused the issue in the first place.

Those women who decline induction are spoken about very negatively, treated as if they are stupid and want their baby to die. I remember a woman who had declined post dates induction and was coming up to 42 weeks, and the way she was seen as a trouble maker, someone who couldn't be reasoned with. Yet when you spoke with her she was very aware of the risks of declining, was very happy to have scans and CTGs regularly to monitor baby's wellbeing and had said any concerns she would want to have baby born.

I'm not saying induction is bad, there are times when it is very recommended and this should be discussed in detail. However induction does carry a risk of increased morbidities and this are very rarely spoken about or asked about.

"We seem to be obsessed with short termism in obstetrics without looking at the very real long-term effects of an intervention. The increase in inductions and subsequent cascade of interventions is one such reaction."

I think there is a global problem when it comes to any decision-making in birthing (and pregnancy and feeding), including decisions to not take an action (which can also have severe costs). I think it has to do with patriarchy, the heavy pushback from women in the last 30-50 years, and medical staff grappling trying to find a unified approach in the face of these (and their own) tensions.

When I read the medical literature - before I met any midwives/obs in NL - I was struck by the number of studies that watered down their findings in favour of the pro-vaginal birth "party line" in their Abstracts and Discussions. For example, a large study in the late 1990s showed clearly that babies were protected by elective CSs compared to emergency CSs, they were similar to successful vaginal birth. These data weren't mentioned in the Abstract and the Discussion tried to argue that it must be a problem with the elective CS data. I'm a scientist, this is bad science. I had at that point not encountered anything like this.

It became clear that this was all a REALLY HOT area.

I also noticed that a lot of things that are really important to women in the long-term, like urinary and faecal incontinence, sexual function, and just not being completely traumatised by the medical system when you're young and this is the first time you've had to deal with it - none of those things were being addressed around 2000-2008, which was when I was birthing and regularly checking the medical literature.

From my sporadic forays into the literature, things have somewhat gotten better but I still don't see that non-"political" balance emerging. There is more room for voices that go against the "party line" but you can still see the party line. And that party line is still founded on disrespect for women.

Things are changing though. But not enough.

I don't really have any proper evidence for this, it's just my personal perspective/framing. To me the main problem is that the vast majority of routine labour management was introduced without a shred of evidence.

Things like immediate cord clamping, routine episiotomy, episiotomy when it looks like you're about to tear, pre-labour shave/enema, suctioning airways, the lithotomy position, the Friedman curve, coached pushing, active delivery, cord traction, syntocinon for dropping below the Friedman curve, going to hospital at all, vaginal exams, CTG monitoring, and so on. Some now abandoned of course, but many still practiced.
It makes sense to try something when there's obviously something wrong - that's how they developed safe C-sections after all and thank goodness for that - but just routinely doing a bunch of stuff to manage a physiological process that nobody really understood in the first place doesn't sound like a great plan. Why do they want to speed things up anyway? Is that actually helpful?
Now when they do big studies it's usually comparing a new intervention to "standard care". So for the most part they're comparing a whole bunch of non-evidence-based prophylactic intervention (standard care) to a whole bunch of non-evidence-based prophylactic intervention plus one more intervention (experimental).

I may be completely misunderstanding this, I'm not a research scientist and you are, but it just doesn't feel right to me that all of this stuff is just assumed to be beneficial for women who are not ill, just going through a normal physiological process.
To me the fact that more than half of women have their babies cut and pulled out of them either through a C-section or with forceps is pretty clear evidence that standard care is deeply flawed. I know you made a clear informed choice that an elective Ceasearean birth was the best option, but I would guess that's not terribly common as only 20-25% of births are planned Ceasearean and many of those are medically indicated or repeat after EMCS.

For me one really eye opening moment was when i looked at the Cochrane review on epidurals. I'd always heard epidural was safe and had just accepted that, but it turns out we only have moderate/good evidence that it's safe compared to opioid pain relief. I wouldn't have assumed opioids were safe, so why was I being told that epidurals are safe without mentioning the comparator?

Well, actually the main problem is not listening to women, but after that I think it's this 😂

And I'll bet it's common for a lot of patients to not be thinking clearly.

Another numbnut. And IRC a male numbnut ie a 100-fold numbnut.

"I may be completely misunderstanding this, I'm not a research scientist and you are, but it just doesn't feel right to me that all of this stuff is just assumed to be beneficial for women who are not ill, just going through a normal physiological process.
To me the fact that more than half of women have their babies cut and pulled out of them either through a C-section or with forceps is pretty clear evidence that standard care is deeply flawed. I know you made a clear informed choice that an elective Ceasearean birth was the best option, but I would guess that's not terribly common as only 20-25% of births are planned Ceasearean and many of those are medically indicated or repeat after EMCS."

You probably think I am at odds with you, since I chose elective CS and you chose homebirth for your second. And to some extent, I probably am (I trying hard to resist that reflex) because it was pretty bad being coerced by the die-hard vaginal-birth-at-all-costs system at the time I was going through my first pregnancy. That was NOT OK.

But we have in common more than sets us apart, namely opposition to the system that did/does not serve either of us.

I think that women who want vaginal birth should be facilitated and encouraged, as should women who want elective CS. The system should be better, more inclusive. I only recommend elective CS in *this climate, because it is a way to prevent the worst of this dysfunctional patriarchy-riddled system hitting women. But I also understand that many women want to give birth vaginally, and feel strongly that should be honoured.

With regard to the meta-analysis on epidurals you mentioned, which one are you referring to? There are several, and the comparator arm is not opioids alone. AFAIK opioids on their own are only given in limited settings?

I don't think we're at odds at all. We are both completely clear that the mother makes the decision because she knows what's best for her. Pressuring her and withholding information so she makes the "right" choice is absolutely wrong.

You said you have a bias because "it was pretty bad being coerced by the die-hard vaginal-birth-at-all-costs system at the time I was going through my first pregnancy." I completely agree this is NOT OKAY. The only thing I take issue with is the framing of the system as being vaginal-birth-at-all-costs. I didn't see that at all, but maybe that's because of changes over the last few years.
I have a bias because I felt pushed towards doing a bunch of non-evidence-based stuff just to be on the safe side, when I don't believe any of it made me or my baby safer.

I also know how good it can be to give birth somewhere safe, with people you trust, with no one trying to stick there fingers in your vagina or mess about with you. It was magical, and I desperately want that option open to every woman.
It's frustrating to see the options presented as major surgery or dangerous, painful vaginal birth where you're open to the worst of medical abuse, because there is a third option.
But if I'm really honest with myself, there isn't a third option. I only got to stay home and stay safe with my second because i was healthy and my baby was healthy. I think that the vast majority of "birth trauma" results from routine prophylactic management of labour, but even if you don't plan to have all of that stuff done to you, you are in a vulnerable situation. I planned to stay home with my first but wound up being assaulted in hospital when I transferred for a slightly elevated risk of serious infection. If I'd had a CS that wouldn't have happened.
Another thing that really gets me - not that you've said or think this but just a related point - is that obstetric violence gets lumped in with "birth trauma" instead of being named separately. It makes it sound like birth itself is the scary and dangerous thing. We don't call domestic violence "relationship trauma". We don't call sexual assault "sexual intimacy trauma". Why is medical assault of a woman in labour referred to as "birth trauma"?

It's this one:
https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD000331.pub4/full

But re-reading I'm not so sure. My comment was based on this: "40 trials, involving over 11,000 women, that contributed information to this review. The trials varied in the quality of their methods.
All but six studies compared epidural analgesia with injected opioid drugs." And this type of comment "epidural in comparison to opioids probably makes little or no difference to caesarean section rates, women with long‐term backache, effects on the baby at birth or the number of babies who were admitted to neonatal intensive care." Without any equivalent safety conclusions on epidural/no analgesia.
I think there were only around a few hundred women with neither? and the main comparison was opioids vs epidural.
There were definitely several where it was IV opioids vs epidural.
In another note apparently one of these (dickinson 2002) was randomising women undergoing induction to have no pharmaceutical pain relief?!

@LouiseMadetheBestBroccoliPasta

I'm off topic but what does this mean below? I kind of sounds like too many participants in comparison 2 decided they wanted epidural after all so there weren't firm conclusions drawn. Is that correct?

Comparison 1. Epidural versus opioids
Removing studies with unsatisfactory allocation concealment in Satisfaction with pain relief had an impact on the pooled effect size, resulting in no clear difference between the groups (average RR 1.42, 95% CI 0.70 to 2.92; 1372 women; studies = 4; I2 = 99%; Analysis 1.41), albeit with substantial heterogeneity. We noted a similar finding when studies with incomplete outcome data were removed (average RR 1.23, 95% CI 0.97 to 1.55; 923 women; studies = 3; I2 = 94%; Analysis 1.42).

Removing the studies with unsatisfactory allocation concealment (average RR 0.12, 95% CI 0.03 to 0.53; 3043 women; studies = 9; I2 = 75%; Analysis 1.43) and incomplete outcome data (average RR 0.15, 95% CI 0.05 to 0.45; 3740 women; studies = 9; I2 = 78%; Analysis 1.44) for the outcome Need for other pain relief made little difference to the meta‐analyses.

Comparison 2. Epidural versus placebo/no treatment
The sensitivity analysis for Need for additional pain relief widened CIs and the effect of epidural remained unclear, when studies with unsatisfactory allocation concealment (RR 0.33, 95% CI 0.01 to 7.91; 70 women; studies = 1; Analysis 2.25), and incomplete outcome data (RR 0.33, 95% CI 0.01 to 7.91; 70 women; studies = 1; Analysis 2.26) were removed. Only one study contributed to the analysis for Satisfaction with pain relief, so a sensitivity analysis was not appropriate.