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Whose Choice Is It Anyway?

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    “It isn’t informed consent unless the patient has the ability to choose an alternative other than the one that the provider recommends.” 
     ~ Hermine Hayes-Klein (Pathways: issue #40)

 

There are some people who stand out from the crowd. They dress differently, they have striking looks, a bellowing laugh, shoot arrows at you letting you know they are there under duress (most likely thanks to her – the one sitting next to them).  Andi was notable because of her eclectic dress sense, long copper hair, shining green eyes, and the intensity with which she seemed to listen to the words I spoke. 


Here we were on night four of their antenatal course.  Supper time, and the group had gelled well so the noise of their chatter rose above the ‘antenatal playlist’ I had on in the background.  I was preparing for the second half of the evening, gathering the relevant materials.  Infant feeding was on the agenda and I had my bag of knitted breasts, leaning against the suitcase of baby dolls, ready to go.  I
 glanced up from my notes as Andi spoke.

“I just thought I’d let you know that I’ve been telling everyone that you’ve created a monster, SJ” she said, her eyes crinkling at the corners.

I laughed. What had I said?  And how had it been taken?  Most importantly had it made a difference?

“Yep, since that second session I’ve been using my brains left, right and centre! It was so good to realise I DO actually have choices and I’ve managed to negotiate the water birth I wanted from the beginning,”she finished with a mixture of pride and relief.


 
My first beautiful son was born 14 and a half years ago. The pregnancy was uneventful.  I was fit and well.  I didn’t really have a birth plan beyond “I’m not having an epidural”.  For me the thought of lying like a stranded beetle on my back, unable to move was horrifying.  I expected labour to hurt but I also expected to handle it.  

My waters broke at home and contractions began shortly after.  My husband and I headed into hospital where I was seen by a hospital midwife.  I asked for a birth pool to be run and it was the most heavenly sensation to sink my body into that warm water.  The pool room was quiet and dark. I laboured well and without fuss for a couple of hours.  I didn’t want anyone to speak to me or to touch me.  My husband was simply behind me, I was aware he was there and that’s all I needed.  I have little memory of the midwife during this part of the birth.


 
I’m big on people using their ‘brains’. 

Benefits
Risks
Alternatives
Intuition
Nothing/not now (what if I do)
Second opinion
 
By running through each of these steps, I tell my antenatal groups, you should be able to get the information you need in order to make decisions that sit best with you depending on your values and beliefs.  The old line that is flung about by almost everyone if things turn pear-shaped, ‘healthy baby, alive mother’ is not enough.  It’s not how a birth turns out, it’s how a woman feels about that birth that counts.  She’ll almost always feel okay about it if she was an active part of all processes.

Informed consent underpins everything childbirth educators cover in antenatal courses. In fact, the cornerstone of health services in New Zealand, it’s laid out quite clearly in the Code of Health and Disability Services Consumers Rights (such a mouthful!)  Essentially the code consists of the 10 rights of consumers of health care in New Zealand.  Rights 6 and 7 are particularly relevant here – 6: The right to be fully informed, and 7: The right to make an informed choice and give informed consent.  The reality is very different with women frequently reporting that they feel coerced into making decisions.


 
My labour was short – five hours total - so it wasn’t long before I felt the urge to push and began to work with my body.  It seemed like a very natural process and I just went with the sensations.  I didn’t say anything.  When the midwife realised what was happening she told me I had to get out of the water.  I said no.  She insisted.  I didn’t move.  I couldn’t move.  I couldn’t talk.  I was busy.  “I’ve never done a water birth!” she said. “You have to get out. Now!” Before I knew it I was being hauled out of the water by her and my husband.  I was naked and wet and suddenly felt as though I was being pulled apart.  I crawled towards the toilet.  They grabbed at me again and dragged me into a wheelchair.  I was pushed, screaming silently, into the delivery room and ‘helped’ onto a bed.


 
In February 2015 Waikato midwife, Carla Sargent, carried out a survey looking at birth trauma.  A total of 319 respondents took part anonymously with 47% citing poor care from a midwife and/or doctor as a contributing factor to their trauma. In the report, Elise is quoted as saying that she was, “stripped of all choices and had no opportunity to consent or refuse.”  Another woman, Daisy, was left “feeling completely overruled in decisions relating to [her] body,” while Kerry’s birth trauma resulted from, “feeling bullied by protocol.” 

On this last comment Sargent writes,  "This is an interesting statement as it highlights the potential conflict between hospital policies and informed decision making. Are women who birth in hospital made aware that policies do not override their right to informed decision making? And are maternity practitioners supported within the hospital environment to uphold their clients’ right to such, or are there institutional pressures that hinder their ability to enact this obligation?"

Consider the language used by women who have experienced the maternity system: “I wasn’t allowed”, “they let me”, “I was told I couldn’t”, “it went against policy”. It certainly sounds like the majority are completely unaware of their rights.  Or perhaps it’s a case of feeling unable to challenge or question ‘authority figures’.

 

 
Two midwives draped me in a stiff hospital gown, the bed was raised, the back of it brought up, and I was left semi-reclined, feeling unsupported yet the centre-of-attention. A blood pressure cuff was wrapped around my arm and pumped so tight my fingers began to tingle.  I was trying desperately to concentrate on the job of birthing my baby in a room full of noise and bright lights and activity. A man, in his early 40s wearing dress pants with his shirt tucked untidily into them, entered with huge grandeur and self-importance.  I half expected buglers to leap out from the walls to announce his arrival.


 
New Zealand midwives are required to meet 10 standards as part of their scope of practice.  These standards are laid out in the Midwives Handbook for Practice with the second standard stating, “The midwife upholds each woman’s right to free and informed choice and consent throughout the childbirth experience.” Criteria for this standard include the sharing of relevant information, facilitating the decision-making process without coercion, respecting the informed decisions made by women even when they are contrary to the midwife’s own beliefs, and respecting women’s rights to decline treatments or procedures. Midwives in New Zealand undergo a review process every two years where they meet with a midwife reviewer and a consumer reviewer to discuss how they have been meeting each of the standards.


Obstetricians are required to work within the framework of the Code of Health and Disability Services Consumers’ Rights. In a statement by the Medical Council of New Zealand released in March 2011, it is noted that:

 

Doctors have a statutory obligation to abide by [the Code]. Under the Code every patient has the right to make an informed choice and to give informed consent, except in certain circumstances. In addition, several pieces of legislation determine how consent should be handled and these requirements can override the requirements of the Code. This statement has been written to inform doctors of the standards of practice that are expected of them in meeting their legal obligations.
 

And:

In most situations treatment should not proceed unless the patient has received all the relevant information and you have determined that he or she has an adequate understanding of that information. In risky or innovative procedures it is recommended that the patient is given time to reflect and consider the options before making a decision on the treatment they wish to pursue.
 

Not to mention: 
Before providing information about treatments, you should make sure that you yourself are aware of all the reasonable alternatives.

 

 
He was the on-call obstetrician. He stood at the end of the bed I was on, with my notes in his hand. “You have to have an epidural to bring that blood pressure down,” he stated. [1] 
I said I didn’t want one. Again he said I had to.  I said I refused. “You have 10 minutes to get that baby out or you’re having an epidural.” He left, his white coat flapping behind him.


 
So why isn’t this happening?  We’re not talking a mere courtesy here.  This is basic and essential to how a woman perceives her birth experience.  When a woman feels that she had a say in what happened, that she had things explained clearly and in a way that was not patronising, that she had choices, then she is able to more easily reflect positively on that experience, however it unfolded.  And I really do mean ‘however it unfolded’.  A caesarean section, for example, is as much a wonderful birth as a vaginal one when done respectfully and with the woman always at the centre of care.

Tests, assessments and procedures are offered so casually by midwives and obstetricians right from the very first appointment that it hardly occurs to women to question them.  Ultrasound dating scan?  Well, okay… I know exactly when my baby was conceived but seeing as you offered, and didn’t discuss any risks or benefits, I’ll have one.  Gestational diabetes screening?  Sure… I have no risk factors but you haven’t disclosed the downsides to the screening, so why not? 

And so women are set up to be compliant.

Hospital systems are entrenched in policy, record keeping is paramount, time is money, and people are NHI numbers.  Hospitals are busy places, usually understaffed, and resources are severely stretched so it’s convenient to have a one size fits all approach to care.  There is sometimes a conflict between the two models of care that play out beside each other in that environment as well.  On one side are LMC midwives who have been trained to view birth as normal and on the other the obstetricians whose training has centred on the pathological.  Birthing women are unwittingly caught up in the politics.


 
Pick her foot up and place it on your hip,” snapped the midwife at my husband as she lifted my other leg.  Looking at me she said, “When you feel the next contraction you have to hold your breath and push.  Push hard. Let’s get this baby born.”
“I can’t!”
“Do you want an epidural?”
The threat was hanging in the air.  A deep pain rose within me. “Get this thing out of me!” I screamed.

I was terrified.  I was a stranded beetle. My 6lb 13 son was born within 10 minutes.  He was beautiful.  My pelvic floor was destroyed and later required surgery.


 
The idea of questioning Lead Maternity Carers (LMCs) can be challenging for many couples.  When raising the topic of informed decision making there are quite a few expectant parents who are not comfortable with this idea.  It seems to be the partners in particular who sit up straight, square their shoulders and lean forward slightly.  Then looking me directly in the eye say something along the lines of, “You’re suggesting we question our midwife who has done the training and knows more about birth than we ever will?” or, “We’re paying good money for an obstetrician with years of experience and a good education behind them.  We’ll be doing what they say.” 

Hard to argue with those thoughts, except that the birthing experience impacts a woman, her body, her mind, and her baby potentially forever.  There are very real life long consequences when birth is mishandled or poorly supported.  Women in this situation are at great risk of developing postnatal depression and post traumatic stress disorder (PTSD).  They may find it more difficult to bond with their babies and the relationship with their partner may be affected.


 
I was fiercely protective of the mewling, pink, wide-eyed creature who was suddenly my entire life-purpose.  For the first six months of his tiny life, I needed his distraction to draw me back from the depths of panic that would burst upon me several times a day.  I would shake, my heart would flutter and skip, I’d want to run and run and run and never come back.  I couldn’t think about his birth and I was desperate to feel normal again.  


 

The Trauma and Birth Support (TABS) group website lists the following as contributors towards PTSD:

  • Managed labour
  • Induction
  • Poor pain relief
  • Unnecessary trauma
  • Traumatic delivery
  • Impersonal treatment, overly professional, stand-offish or judgemental attitude of the staff
  • Multi handling
  • Shift changes
  • Staff related problems
  • Feelings of loss of control
  • Not being believed or listened to
  • Lack of attention to dignity, e.g. no coverings
  • True obstetric emergencies
  • Invasive procedures without explanations or consent
  • Forceps, suturing without adequate analgesia
  • Prolonged latent phase - resulting in demoralisation
  • Conflicting advice
  • Having baby/ies admitted to SCBU (Special Care Baby or Unit) or NICU (Neonatal Intensive Care Unit)
  • Severe postnatal anaemia
  • Postpartum haemorrhage
  • Old trauma
  • Unmet need to debrief, review or to understand what happened
  • Emergency caesarean section
  • Shoulder dystocia,
  • Poor postnatal care
  • Postnatal problems

 
PTSD doesn’t go away on its own.  Some women may be able to bury it deeply but inevitably there will be a trigger, perhaps years down the track that will bring the memories of that birth experience abruptly and terrifyingly to the fore.  I wonder if that’s why we hear so many horror stories when we’re pregnant from women who have birthed.  Perhaps they are simply being confronted with memories that have been too painful to process.


Well-known French obstetrician Michel Odent says, “It seems that many health professionals involved in antenatal care have not realized that one of their roles should be to protect the emotional state of pregnant women.”  This is a sad truth. 

Doula, Heather McCue, sums it up perfectly with this quote, “The whole point of women-centred birth is the knowledge that a woman is the birth power source. She may need, and deserve, help, but in essence, she always had, currently has, and will have the power.”
 

What does informed consent look like?  Human rights lawyer, Hermine Hayes-Klein, says it consists of three parts: inform, advise, support.  Women should be informed by LMCs about the alternatives, not just the one the LMC believes is best.  They should be advised of any risks as well as benefits, and the evidence for each.  Once a woman has made her choice based on the information and advice given she should be supported in that, even if it goes against what the LMC thinks is the most appropriate decision.  Informed consent is a conversation; it’s not just a signature on a form.

It’s no secret that obstetric care could be doing far better for women and babies.  The use of technology, pharmaceuticals, and surgical procedures are routinely used in most pregnancies and births.  From dating and anatomy ultrasound scans early in pregnancy to epidurals, episiotomies and caesarean sections in labour and birth.  But as obstetrician Henci Goer says in her book, The Thinking Woman’s Guide to a Better Birth, “When intervening becomes routine, meaning there is no reason for it, only risks remain.”


 
I look at him now, a tall, athletic, blonde headed young man, whose grey-blue eyes twinkle and shine.  He’s funny and kind, and also really good at winding up his 12 year old brother when he’s bored.  I thank him silently for turning out so perfectly despite my inability to fully be present for him in his early months.  How I wish his birth had been different.


               
I’m sad and I’m angry that women are still being treated with total disregard.  I’m relieved I don’t have daughters.  I hope to raise my sons to be strong advocates if they have partners who go on to give birth.  The Andis out there, the beautiful first-time labouring women in the world, deserve to be treated with compassion and respect.  They should not feel as though they are merely vessels to have a baby taken from.  They are living, breathing, feeling, knowing people who are not incapacitated just because they have a little human growing within them.
 

Bibliography
 
Goer, Henci. The Thinking Woman’s Guide to a Better Birth. New York: The Berkley Publishing Group, 1999. Print.
Hayes-Klein, Hermine.  “Informed Consent in Childbirth: Making Rights into Reality.”  Pathways 40 (2013), 36. Web. 21 October 2015.
Health and Disabilty Commissioner. “Code of Health and Disablity Services Consumers’ Rights.”  2014. Print.
Lentz, Sydney. Advanced Practice Nursing: Setting a New Paradigm for Care in the 21st Century. AuthorHouse, 2013.  Kindle file.
Medical Council of New Zealand. “Information, choice of treatment and informed consent.” (2011). Web. 18 October 2015.
New Zealand College of Midwives. Midwives Handbook for Practice 5th ed., Christchurch: 2015. Print.
Sargent, Carla. “Birth Trauma in New Zealand: Some Major Concerns” (2015). Web. 20 October 2015.
  

[1] Low blood pressure is the most common side effect of epidural anaesthesia.  This occurs because the local anaesthetic used acts on the nerves that lead to blood vessels, thereby creating a drop in blood pressure.  When a woman develops high blood pressure in labour it is sometimes recommended that she has an epidural placed to help bring this down.
 
 
 
 

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