Informed consent, birth support, doula, edinburgh

Informed consent – protecting mothers and babies rights through birth choices and practices

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Informed consent is a practice provided by medical teams during the birth of a baby or babies – mums may consent over the use of interventions such as for induction, pain relief, surgery.  However, what is it that they are consenting over? Often it’s the side effects of any given drug or procedure.  But is it informed?

Here’s a scenario.  Mum has had a previous, possibly necessary caesarean section.  She’s is adamant for her subsequent birth to have a natural VBAC delivery.  A meeting is organised with her consultant.  She is ‘informed’ that she MUST have the birth in the hospital and that she will NOT be induced with syntocinon due to previous section due to potential of scar rupturing.  At 41 weeks post a further meeting with the consultant, mum is booked into hospital where EITHER they will break her water or give her another  section (the choices presented to her).  At 42 weeks baby is still happily inside mum, mum has been told they think this is a big baby, medical team can’t access mums water as there’s no dilation or effacement of cervix and mum is presented with a form asking for her signature as informed consent on the medical procedure – ie the risks of the actual intervention. Informed consent?

Imagine instead the following scenario – Mum has had a previous section.  She is adamant that her subsequent birth is to have a natural VBAC delivery.  She has an informal chat with her midwifery team who will provide continuous care.  The midwifery team go through options including:

  • Delivery – discuss what the benefits and risks are of both a VBAC and a section including what are the statistics so the risks are measurable, some positive stories and what are the scenarios should it all start to go wrong
  • Location – what would be the pluses and minuses to a home and hospital birth – is home birth an option?
  • Induction – under WHAT scenarios would the hospital team recommend induction of labour and WHY including discussion around gestation
  • Discuss what pain relief options would be available in a VBAC birth – would water births be an option in or out of hospital?
  • Discuss what monitoring is suggested/needed throughout pregnancy and during birth
  • What support would mum like in place – including midwifery team, partner, doula/friend/sister
  • Identify what atmosphere mum would like the baby born – lighting, sounds, smells, other
  • What about post birth – where will baby be placed, what will happen to cord/placenta – does mum have a choice around cord clamping, will baby be given Vitamin K (what’s the evidence), what about the birth of the placenta – can mum birth this unaided should she choose too – if not, why not.
  • Inform her that ultimately it is her choice to birth as she chooses

With each option – each of the benefits, risks, alternatives and doing nothing/wait and see approach should be discussed and addressed.  What are mums instincts saying?

So what would the outcome be of the VBAC mum? It COULD be the same outcome, Mum may decide the risks are too high for her to consider.  It COULD be easier to have another section as this is something she is familiar with.  It COULD be a section because something goes wrong.  But she COULD have had a home birth, vaginal delivery, at 43 weeks following spontaneous labour with love and care around her and have a gentle, peaceful birth – if she had known that was an option to her as her midwifery team had walked her through the options available to her.

Many people have births without having the understanding that they have choices – and the choices are theirs to make – they are allowed to birth as they choose.  Armed with information they might still choose to have interventions at birth as they have weighed up specific risks.  We don’t know if mums have previously suffered trauma or just don’t believe that they have the power to go through the pain to birth peacefully.  However, for the majority of mums, they are keen to have access to the information and choose to birth peacefully and naturally.  Mums also aren’t aware what the intrinsic importance of space is – including low lighting, small spaces, feeling safe, secure and loved are in birth (both Michel Odent and Ina May write widely about this).  Maybe if more mums knew that something so simple could have a huge impact on birth, the whole birthing landscape would change fundamentally and permanently. Maybe more antenatal support providing this information as opposed to the ‘cascade of interventions’ there would be more positive birth stories in place.

We as birthing women are provided with so much information about risks and interventions which pull on every fear nerve we have and ultimately don’t want to risk the loss of our babies or ourselves.  Yet many of those risks are actually tiny or unquantifiable.  Much of clinical practice is out of step with any research and the reason why is that it is impossible to undertake clinical trials of big enough sample sizes with robust methodologies to ascertain good enough statistical significance (as addressed in many of the AIMS publications).  So clinical practice isn’t always informed by research, it’s informed by the evolution of practices over time, some of which are acknowledged to be life-saving, and often hospital policies that are designed to ensure that they can cover staffing and facilities rather than putting gentle birth at the heart of the agenda.  Understandably at times, practices and policies are born out of fear of litigation from our changing society and it is important we remain mindful of this.

Some of the practices, however, are a violation of our human rights.  We are put under the knife, leaving life-long physical and psychological damage to ourselves and potentially our babies, without being presented with full, evidence-based information and given choices.  The risks are often so tiny.  We aren’t often presented with this.  We hear information such as ‘previous scar rupturing’ and immediately think that’s going to happen.  If instead we heard the chances of scar rupturing (not losing our baby) were somewhere between 0.09% and 0.8% (AIMS publication VBAC) we might be able to make a decision on that, that the risk is tiny.  There are also times where medical teams fell that they are ‘helping’ the birth along – it could be such as when doing a vaginal exam they ‘stretch’ the cervix (sometimes without pre-warning/consent) – this helpful procedure can cause pain and huge psychological damage and in some cases stop the birth. It could be giving syntocinon which could have a number of unknown post-birth effects (read Michel Odent’s work).

Without doubt, medical teams are trying at all times to do their best for each patient with the information they have been taught.  However, what about if the information they have been taught isn’t necessarily the right information that will enable women to birth – that is ensuring that a safe and loving physical and emotional space is created.  So there’s definitely a dialogue to be had around positive birth and making it a better experience for both the medical team and the birthing women.

Here are my rights for all mothers and babies:

The birth rights of a mother

  • Every mother is aware of her rights to birth as she chooses
  • Every mother is supported to have choice over her birth – including location, delivery mode, pain relief, induction and support in place
  • Every mother has access to clear, evidence based, information about birth given her own specific situation, values and choice – clear statistics should be presented on risks posed including risks of intervention and risks of doing nothing
  • Every mother is given ample space and time to consider and options, including having the choice to do nothing and “wait and see”
  • Every mother is asked and listened to before any intervention is done and given space and information
  • Every mother should have access to positive birth stories and group
  • Every mother is given support to feed her baby as she chooses
  • Every mother is asked about what she would like done with the placenta

The birth rights of a child

  • Every baby is brought into a world of calm – including dim lights, little sound and minimal interference
  • Every well baby is placed on their mother’s tummy or chest before any intervention is done, regardless of birth
  • Every well baby is left attached to their placenta for as long as is comfortable to mum and baby

In addition, it’s important that the health care team also get support and their rights are valued.

The rights of the health care professional

  • Every member of the health care professional is treated with respect at all times
  • Every member of the health care professional is provided with budgets and time for training and information sessions
  • Every member of the health care professional is not expected to know every outcome or every risk but will have the time to go away and find out and provide balanced information

Every scenario and birth is different but the support every family needs is the same – steady, gentle, informed, nurturing support. To book Birth Support for you and your family – get in touch.

Much love, Tricia xxx

This was prepared for my Red Tent Training Coursework, submitted November 2014