Thursday, 28 February 2013

Stop Googling Your Birth Options, And Hop Up On The Bed, Dear

Here's something every pregnant woman might like to know: during labour, you will be given a routine vaginal exam every four hours, and this will be used to check your cervical dilation, and to chart your progress. Your midwife might mention this at your antenatal appointments, but here's what she probably won't tell you - the exams are optional, you can refuse them, and unless there seems to be a problem or you actually want to know how dilated you are, it's probably better that you do, since this invasion of your privacy can actually bring you out of your Labourland trance, making your 'mammalian self' feel threatened and slowing or halting the very progress they are trying to check.

Learning about the various procedures, such as 'V.E's', that are likely to take place during your labour and birth can help you to make truly informed decisions about whether to accept or refuse them. It can allow you to think about the kind of labour you really want, and empower you to know your rights and take control of the experience, giving you a feeling of ownership and satisfaction, regardless of the way you ultimately birth your baby. There is a wealth of information available now to pregnant women, in particular thanks to the internet, and at the touch of a button you can inform yourself, and discuss your plans and concerns with other women who have 'been there, done that'.

Brilliant, right? What's not to like about this? Surely those concerned with the care of birthing women must be thrilled that some of them are actually taking an interest in what happens to them, and - often literally - getting off their backs and taking an active role in their labours? You would hope so, and yet Terri Coates, a practicing midwife, lecturer in Midwifery, and clinical editor to Call the Midwife, doesn't seem to be in favour of it in this interview from Tuesday's Mail:

"A lot of young women in the 1950s didn’t even know where babies came from. They were happy to have someone lead them and were more deferential. Now women are far more savvy, have apps on their phones, mum-and-baby books, better education. They know what they want and how to get it. Managing their expectations is like walking a tightrope. They expect the perfect birth, the kind they see in magazine pictures. Some feel that if they have anything but a drug-free birth, they’ve failed. But if they end up with a healthy baby, they’ve done extremely well."

So - the modern and informed woman is making life difficult for the professionals who have to 'manage her expectations'. Terri Coates seems to suggest that our access to information is encouraging us to set our sights too high, and she trots out the patronising and tired old idea that we should all be happy with a healthy baby. This attitude completely dismisses the mother's birth experience, and is often most painful to those of us who experience birth trauma, making us feel that we should stop complaining and be grateful that everyone simply survived.

As Elizabeth Prochaska, founder of Birthrights, the new UK organisation dedicated to promoting human rights in childbirth, puts it:

"What's worrying is an increasing tendency for healthcare practitioners to view the mother as simply a vessel for the production of her foetus, and to say “as long as you get a healthy baby and a live mother out of it that's all that matters". But it's not all that matters. Look at the cost to the healthcare system of women with serious disorders post-childbirth...The rise of post-traumatic stress disorder and post-natal depression are problems, too."

Women who have been traumatised are finding their voice, as in this recent article, in which several women, including Toni Harman from One World Birth, speak about the terrible treatment they suffered during labour and birth, including being shouted at, having their wishes ignored or belittled, and feeling as if they were being raped. 

However, commenting on their stories, Dr Gedis Grudzinskas, a former professor of obstetrics and gynaecology at St Barts Hospital, London, seems unmoved. It seems he agrees with Terri Coates - we women are getting our hopes up too high:

"There's a world of diminishing resources but increasing expectations from mothers-to-be. Labour is an all-consuming process, and discussion can be very difficult because you might only have one-and-a-half minutes between contractions. So there may be a perception of doctors and midwives being too assertive - therefore bullying - but they have the patients' best interests at heart."

Our hopes are too high - we expect silly things like a decent shot at the birth we really want, and if that turns out not to be possible, for professionals to talk to us and touch our bodies kindly and with respect.

Grudzinskas also echoes Terri Coates yearning for the good old days, when women - apparently - just did what they were told without question, and the dangerous technology of the internet was not at their disposal:

"In the old days, women referred to doctors as experts. Now, many women think they're well-read because they've done research on the internet. But much of that information isn't correct."

Birth guru Sheila Kitzinger takes on this attitude in her excellent new book, Birth and Sex:

"An obstetrician once snapped at me that he couldn't stand 'back seat drivers'. He meant women who had ideas about what they wanted in childbirth."

And, with the usual twinkle in her eye, she tells this story:

"One obstetrician in a major teaching hospital where one in four women had a Caesarean was pleased that there is 'increasing maternal input into childbirth'. It is not clear what he means by this. Women have always had a lot of 'maternal input'. Doctors could not produce babies without them."

Women - with the help of the internet and all of the information and communication that it brings, are taking back childbirth. Slowly, ever so slowly, the balance of power is shifting, and it is this that is causing some professionals to feel uneasy and long for a time when women would defer to their expertise, not ask so many questions, and comply.

If a woman declines vaginal exams in labour, this is likely to make things a lot easier and more enjoyable for her, but have the opposite effect for her carers. They will have to rely on other methods (and skills that they may not have) to make their assessments. They will not be able to chart her dilation on a partogram. If they can't do this, they won't be able to fully assess her 'progress' or lack of it, and follow their usual procedures and protocols according to the clock. They might even have to behave like the midwifes 'in the old days' as Dr Grudzinskas would put it, and, putting down their clipboards, turn their eyes to the woman as the most powerful and knowing figure in the room.

Water birth, pronounced risky by some doctors, has a similar effect of restoring power to the woman at the expense of those who attend her. As Marsden Wagner, director of Maternal and Child Health for the World Health Organisation for fifteen years, puts it in Water Birth Unplugged:

"Water birth like home birth is controversial. Why? Because the obstetricians are out of control. It's that simple. The water helps the woman, but it sure doesn't help the birth attendant. It's the opposite of the lithotomy position (on the back with feet in stirrups), which helps the birth attendant, but doesn't help the woman. With water birth, the birth attendant has many dilemmas, do I roll up my sleeves, do I get in the pool, do I take my clothes off, what do I do here? You can't really attend a water birth and keep your sophisticated control and dignity."

If you are faced with a choice about procedures and interventions in childbirth - ask yourself - who is this most likely to benefit, reassure, or make comfortable - me, or my carers? We must not be deterred from learning as much as we can about our rights and our options in childbirth, no matter how much it may inconvenience midwives or doctors. We do not have to comply with their suggestions, unless we wish to. We are allowed to be powerful in childbirth. Whatsmore, birth is not simply a means to an end - our birth experience matters, and is of primary importance, not just to us, but to our babies, our families, and the whole human race. 






27 comments:

  1. One thing I hate about the tired trope of "as long as the baby is healthy, that's all that matters" is that sometimes, a baby ISN'T healthy. So then what? Those mothers seem to just disappear.

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  2. I really like this post and completely agree with it. I know my midwives and obstetricians were a little frustrated with me when I wanted to know exactly why I couldn't have a water birth because I'd been induced. I wasn't their usual easy patient who took their word as gospel. I understand they need to cover their backs in the culture where everyone sues everyone but I had the complete opposite birth to the one I had dreampt of. I progressed VERY fast and the midwife didn't believe me and ended up with a 3rd degree tear from being on my back in the hardest birthing position. Despite all this it didn't traumatise me but very easily could have and put me off having another future child. I think its important for mums to be listened to as well as fully informed.

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    1. Yes, your final point is a great one, being listened to and respected is vital, as it isn't much use our being informed if we are then not heard! x

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  3. Great post!
    I just don't get this attitude that an informed woman is a hinderance to the birth process. Surely, if she can truly trust her birth attendant and there is open communication, an informed woman is the best thing that could happen to the medical professional.
    The problem is that in so many cases women distrust the medical professionals. And for good reason, as outlied in your post. If you are informed but don't trust your doctors or midwives, that might indeed make the job much harder for the profassionals. And in the end nobody wins. It is such a shame.

    If you get married, it is totally normal to make plans for the wedding, try to make the day as enjoyable and memorable as possible for the people involved. Imagine the celebrant just telling you to suck it up and do what you're told cause in the end all that matters is that you got married, how it happened is immaterial. Or even better, people saying: "Give me drugs, I just want ths over with as quickly as possible and don't want to feel a thing. As long as I have a healthy husband at the end, that's all that matters!"
    Crazy, right?
    So why is it so weird to want to plan and prepare for the birth of your child? Isn't that at least as big an experience as a wedding?

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    1. Ah there is a great blog post here saying just that:
      http://maddiemcmahon.com/2011/09/02/planning-a-wedding/

      You are right, we are often in a lose / lose situation, with a lot of mistrust all round.

      Let's be hopeful for improvement, there are so many people gunning for it! x

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  4. This is so true! My first birth was everything I had read about and wanted to avoid. Forced to lie on my back the entire time despite having back labour. Forced to have procedures I didn't want as it was taking too long, etc. The only time I was assertive though was when I woke to the midwife trying to insert a drip I'd refused to have. Surely she needed my consent? It was a hideous experience and put me off hospital births. Unfortunately, I was forced into hospital again for my second birth by the midwife's refusal to visit me at home. It was better but still against my wishes. I was certainly made to feel like I was inconveniencing them with my knowledge of how to have a good birth.

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    1. That sounds terrible, I'm really sorry to hear that. :-(

      Your point ties in with one made above - that it is pointless our being well informed if we are not then listened to.

      Thanks for your comment and sorry again to hear of your experiences x

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  5. I passed out during a VE in my first birth and was so traumatised by the pain that I asked to have an epidural, having got to 8 centimetres on my own at home! I chose a home birth second time round mainly because the midwife who would would be attending my birth promised not to do any VE's and assured me that watching and listening was all she would need to determine my progress. (I'm lucky enough to live somewhere where midwives case-load, which means there is a good chance of getting a midwife you have met and know well, bliss). She was true to her word and I didn't need any pain relief at all, trust is a very effective analgesic.

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    1. What a great point! - trust in our carers, trust in ourselves, our carers trust in us, in birth, and the system's trust in our carers - all significantly reducing the need for pain relief!!! x

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    2. 'Trust is a very effective analgesic'
      Wow wow and wow. This articulates something absolutely essential in understanding the effectiveness or the potential harm of a midwife/care giver. As a mother, and as a midwife, I thank you for this insight. May I have your permission to borrow this phrase? It has even set off a direction of research for me! Love Claire

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  6. I had my 3rd baby at home unassisted... my husband checked me once because I asked him... it was the most beautiful and peaceful birth. When I had my next baby, at the hospital, my baby was about to crown ( I was on my knees propped on the bed) and I said "she is coming!" The nurse standing next to me, said "I have to check you so I can call the doctor." I told her, "I don't need the doctor. She is coming." My husband smiled and told her, "if she says the baby is coming, the baby is coming!" The same thing happened with our unassisted home delivery. The nurse never checked, she ran out of the room to call the audience. :| the baby was born in the next 5 minutes, with 2 more contractions... the "student doctor" never caught my baby, and she was standing right there in front of the opening. I heard her say "What do I do now?" and a Philippino nurse, also in the room, snapped "put your hands out there and catch the baby." The baby flopped on the bed. :| She was fine though. :) Today is is 3 y.o.

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    1. That's great that you have such trust in your body - happy birthday to your child x

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  7. Hi, I couldn't agree more.

    I've responded here: http://bigbirthas.co.uk because not all health professionals agree with Terri Coates, and actually like seeing the status quo challenged.

    One thing is certain, though, we have to do our own research if we don't want to be herded into a birth experience that is more for others' convenience than our own.

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    1. Thanks for this, and thanks for your post, I've shared it via my FB page x

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    2. wow, thanks - lot of views today on my new little project thanks to you ;-)

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  8. LOVE this post. It's true; there's this territorialism around birth that means if mom is ultimately in charge, the provider is ultimately not, and that's a scary thing for many providers. It's even scary for many moms who have been taught all their lives that birth is something that's done to them or in spite of them, not something they actively do. Also, here's something I wrote about the last premise of this article: "A Healthy Baby Isn't All That Matters" http://www.improvingbirth.org/2013/02/06/a-healthy-baby-isnt-enough/

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    1. Hi Cristen, it's an honour to get your comment as I am a big fan of what you are doing with Improving Birth. :-)
      Here in the UK I have set up the Positive Birth Movement which similarly hopes to spread positivity and real evidence about birth to all women, in our current climate of fear. (www.positivebirthmovement.org)
      I like your post a lot and actually read it while writing this one! I will share it on FB.
      Thanks again for your comment x

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  9. Nearly 15 years ago my Doctor with my third (and final) child definitely felt like an observer. By the third baby I knew what I wanted and let him know in no uncertain terms, how it was going to go. To his credit he was never a jerk. He just accepted it meekly LOL

    He wanted to induce me, I remember him saying so at my 36 week check up, because my first baby tore me 4 degrees. Well, I told him, my first baby came out sideways and his shoulder did it. Also probably a clumsy OB who had to wiggle him out - but I was 20 and I healed up just fine. It wasn't "traumatizing" or anything of the sort.

    Anyway he was all "worried and scared" that I was going to have a ginormous baby that wouldn't come out so he wanted to induce me 4 weeks early and I was *appalled.* I flatly refused. I said there was no way I was going to do anything unnatural with regards to starting the birth. He flapped his gums a bit but said alright.

    My last baby was 9lbs 3oz. I got an epidural at 7cm (love that hospital that allowed that) and within 30 minutes was crowning. Pushed him out in 2 pushes.

    I think I made some snarky comment about a big baby to the Doc, I couldn't help it :p

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  10. Great post as always lovely Mule! :-) Was honoured to see you referring to my article 'planning a wedding' above - thank you!

    There's something in the air at the moment...so many of us blogging about birth rights. Did you see my latest post on www.thebirthhub.co.uk?

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    1. Yes, great one, very feisty! Will share x

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  11. I'm a midwife, but I also wrote a fictional story about a mother who's baby was injured by the birth. It's sad, but ulitmately uplifting. I wanted to create s story that would get women talking and thinking about reclaiming their trust in their bodies at birth, and understand why some people make non-mainstream choices.

    It's available on Amazon:http://tinyurl.com/cu2vrls
    You can read what other readers had to say about it here: http://tinyurl.com/d2ze4u6

    I believe change is afoot, there is definitely more awareness about birth these days, but we still have a long way to go.

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    1. Thanks Juli - so many people are working towards it - it IS happening! x

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  12. In my area cervical checks are generally done every 2 hours, or as often as every 30 minutes once the mom reaches 8 cm. It's INSANE. And they are rarely presented as optional.

    I hear so many complaints from medical professionals that "what you read on the internet isn't true" to which I reply "well there where is the ACOG blog for expectant women? Where are all the OB blogs for expectant women? I know there are a few OB blogs...but not many. If they aren't part of the solution...they need to stop complaining about the "problem."

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    1. Good point.
      There is one really awful Ob blog, not going to mention the name even! Apart from that I don't know of any. x

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  13. Oh Maddie, I felt so sad when I read this post. If Terri Coates actually said the quote above (and I couldn't guarantee it given editing freedom), I feel ashamed to be in the same profession. Her views are not shared by the majority of maternity workers in the NHS, who are trying, like you, to change the system so that women and families have the best birth experience. There are SO many constraints. I could talk about this for a whole week.
    Can I make a suggestion? Vaginal examinations are sometimes useful, and I find it's much better to use the word 'decline' rather than refuse. Refuse brings another tension, and often women are worried about that. Using 'decline' infers that the procedure is optional, and that there is a choice, whereas 'refuse' suggests it to be obligatory.

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