Tuesday, 30 October 2012

Not saying yes.

I was going to write about yoga today, but a conversation on a certain high profile parenting forum inspired me to bring forward a post I wanted to write in the wake of the release of the film Freedom for Birth.

The discussion, like the film, was about bodily autonomy, a woman's right to decide what happens to her body, specifically during birth, and a woman's right to refuse or withdraw consent for any procedure.

A common response to the fact that a birthing mother does have the right to say "no" was a concern that the procedure she is offered may well be life saving for her or her baby, and perhaps that no caring mother would refute the recommendations of her medical carers. There seems to be a confusion here, that a woman not following the policy of her health service trust is wilfully and ignorantly endangering her health and that of her child. There also seemed to be the impression that to refuse consent to a procedure, was to refuse all medical intervention.

The standard policy of your maternity unit may be exactly suited to your situation, and explaining your right to follow another route, is not intended as a critique. These policies must be based on a combination what is best for the "average" mother and baby, and what is best for the hospital (in terms of resources, legal fallout etc). Not all mothers are average, sometimes what's best for the hospital is not best for the patient. Sometimes an individual hospital has yet to update their policies to meet with NICE guidelines, so not take into account more recent research evidence.

So this post is not, as planned, about your right to "say no", it is about what you can say instead of "saying yes".

Before we start though, I should make the key fact clear, that even when in a life threatening situation, no medical intervention can happen without the informed consent of the patient, or their next of kin if they cannot give informed consent. To continue with a procedure without consent is a criminal act on behalf of the medical professional, they will always seek consent (even if it as phrased as "I'm going to examine you now,OK?"), and you have the right to respond as you see fit.

So what measures can we take to ensure our right to choose the circumstances of our childrens' birth (as confirmed by the European Court of Human Rights) is exercised, without putting ourselves and our children in harms way. I'm going to break it down like this:

Before the birth-
1) Take preventative measures to reduce the likelihood of an intervention becoming necessary.
2) Inform yourself of all the options when you make your birth plan.
3) Plan in advance for all eventualities so as not to be put on the spot.
4) Have an informed, birth partner ready to objectively support you in your decisions.

During labour.
5) Ask your health care professionals to fully inform you about the intervention they are suggesting.
6) Ask your HCP why they are suggesting this intervention over an alternative.
7) Ask for an alternative intervention.
8) Ask to wait and see if the situation changes.
9) Ask for a second opinion.
10) Have the intervention on your own terms.

Before labour, your toolkit for avoiding the question...

1) Take preventative measures to reduce the likelihood of an intervention becoming necessary.

There is a lot of research evidence linking certain practices in pregnancy and labour to reduced levels of intervention, usually by encouraging the natural processes and having patience and faith to allow them to unfold. When making your birth plan, try to be positive about what you will do to improve the birth process, rather than simply listing the things you don't want to happen.

In brief, you need to promote the production of oxytocin. If birth isn't progressing in hospital, it is often recommended that you supplement with synthetic oxytocin, which has a range of side effects, including reducing your natural oxytocin production, and is often the beginning of the cascade of intervention*. Oxytocin is "the hormone of love" you produce it when you feel safe, relaxed and loved, when you look someone you care about in the eye and when you feel a caring touch. Dim lights, comforting sounds and smells, keeping strangers away from you, massage (if you feel like it), kissing (ditto), hugs, your birth partner in the pool with you - all this will promote oxytocin and keep your contractions strong. Some alternative therapies, such as clary sage oil on a sponge to inhale, will also help.

It is often said that a baby's position is more important for a smooth delivery than their size. It is certainly true that the dilation of the cervix depends upon an even pressure being applied from the baby's head. It is well known that OP (back to back) labours tend to be longer and more painful, increasing the likelihood that you will be offered augmentation (a drug to speed up labour) or want pharmaceutical pain relief. Optimal Foetal Positioning (OFP) uses various exercises and lifestyle changes to improve the chances of your baby engaging in a good position for birth. In a good pre-natal yoga class you will be taught exercises to help guide your baby into position. Moving around, changing position and moving your hips during contractions will help position your baby in early labour. If you know your baby is in an unfavourable position Spinning Babies has a range of techniques to help encourage them into a better one.

Water birth encourages all the good things in birth, you are upright, supported, comfortable, you can easily change position, and it is quite hard to interrupt a woman in a birth pool for interventions or superfluous checks. Water is excellent, soothing pain relief. You don't need to deliver in water, but I would thoroughly recommend it during labour.

Planning a home birth. Rates of intervention are much lower in planned home births, even when the mother transfers to hospital. The Homebirth Reference Site is full of information and links to relevant studies, anyone interested in informing themselves about birth (even hospital births) should check it out. At home it is much easier to have an active birth, and maintain an oxytocin friendly environment. As you are on "your territory" it is often easier to stand firm on your decisions, the dynamic of power between you and the midwives is very different. Women who have previously had caesareans are more likely to have a vaginal birth if they stay at home longer before going to hospital (VBAC facts is a helpful resource of you are in this position, as is the homebirth site above). If a home birth is not suitable, consider a midwife led unit (MLU). When choosing a hospital, statistics are available which give an indication of the intervention culture of the unit (but be aware that a consultant led unit will have a higher proportion of high risk births, and therefore a higher rate of intervention if it is close to or associated with an MLU. as the low risk women will attend the MLU, and any complications there will transfer to the CLU). Tour your intended place of birth, and ask plenty of questions.

It is worth considering that some interventions that you may not object to, may increase your risk of needing other interventions, for instance continuous electronic foetal monitoring is associated with an increased rate of emergency sections (but no change in outcomes for mothers or babies), this is often referred to as a cascade of intervention*, and you may wish to avoid an apparently benign intervention for this reason.

That was a long one, but a good birth really does begin in good, positive preparation.

2) Inform yourself of all the options when you make your birth plan.

Birth is a bit like playing poker, you can't really help what cards you are given, but with the right  knowledge and skills you can make the best of the hand you get.

You don't need to become a self made expert, but do talk through your birth plans with a sympathetic midwife, ante-natal teacher or doula. You need to be aware of the options available to you, and the pros and cons of various routes. If you are offered an intervention, it is well worth knowing the alternatives so that you can ask for them specifically. If you aren't going to follow the standard policy you need to understand why, and your HCPs will be a lot more understanding and supportive of your choices if they are reassured that you have good, educated reasons.

3) Plan in advance for all eventualities so as not to be put on the spot.

It's good to be positive about birth. Hypnotherapy for birth often involves visualising your ideal birth experience, making it real in your mind and inspiring you with confidence.

If, however, you some up against an unexpected hitch, it is worth having considered how you might tackle it in advance, and even including that in your birth plan.

For example, you may not want continuous monitoring, but if a complication arose that indicated it were necessary, you could ask not to be sat on the bed, but on a birth ball instead. If the birth pool were unavailable, what would your back up natural pain relief be?

In my birth plans, despite planning home births, I also had a section on how I would like things to be handled if I transferred to hospital, and another in case I needed surgery. It's OK to have a Plan B, and a Plan C, going off your original plan doesn't have to mean automatically reverting to the default.

4) Have an informed, birth partner ready to objectively support you in your decisions.

Support is absolutely key. During birth your higher brain takes a step back and your primitive hindbrain takes over. You may find it hard to process questions posed to you, or understand explanations, the effort of doing so will take you out of your birthing frame of mind and disrupt the process. No matter how intelligent and strong in your convictions you are now, in labour you are vulnerable. Besides, you have more important things to focus on than asking questions.

Your birth partners need to be completely supportive of your choices, they don't have to agree to them, but must be committed to following them through with you. They should be familiar with your birth plan, and have their own copies for reference. Should they have to advocate for you, it is easier if they have a written version of your wishes to hand. They should be capable of following the points below, asking questions on your behalf, and "translating" the situation to you should it become busy or overwhelming.

A doula is a good option, as she should be well informed and be able to direct you towards information and options you may not have heard of otherwise, and as an objective servant to your needs, she should support you regardless of her own opinions or emotional involvement. You may have a friend or relative who can do this for you.

It is also worth having 2 people whose sole responsibility is your care. They can also support each other, take breaks and fetch and carry for you without leaving you on your own. If you are having a home birth, and have older children in the house, it is worth having a 3rd person to take care of them, especially in case you need to transfer to hospital, as you can then have both your birth partners with you in hospital.

With all this in place you should be fully prepared for your own tailor made birth.

During labour, alternatives to saying "yes".

5) Ask your health care professionals to fully inform you about the intervention they are suggesting.

To give informed consent, you need to be informed, all HCPs are familiar with this, and will be very happy to explain the situation if you ask. I would not suggest at all that you argue with your HCPs, expect them to be open to a frank discussion of your care.

A good thing to remember here is to "use your BRAIN":
What are the Benefits of the suggested course of action? Why is it being suggested?
What are the Risks or side effects of the intervention?
What Alternatives are available to me?
What does my Intuition tell me? Birthing mothers are often incredibly good at knowing what they need, if they listen to, and trust their body.
What would happen if we did Nothing? Not necessarily forever, but it is perfectly reasonable to ask to wait 20 minutes, and reassess the situation, go through this process again, and see if you feel differently then; if not, wait another 20 minutes. There are very few situations in birth where such a wait will cause an issue, and if you are experiencing one of them, your HCPs will tell you.

6) Ask your HCP why they are suggesting this intervention over an alternative.

This fits with the points above and below, but it is a key point. Is it safer? Is it quicker? More likely to succeed? Is it due to staff training, experience or preference? Is it because it is most suited to your current situation, or is it the default?

7) Ask for an alternative intervention.

The first option you are presented with is unlikely to be the only option. Rather than going into a lot  of detail here  on the pros and cons of each, I am going to present you with some alternatives to common interventions, that are worth researching or asking about:

Instead of forceps, ask about ventouse (it is often, but not always offered first), if you are able, ask to wait a bit to stand up and walk, sway your hips or shake your legs (yes really), or just turn onto all fours, a change of position often makes pushing easier.

Instead of an episiotomy "in case" you tear, you can ask to be left to tear, there is evidence that tears are often less serious and heal quicker, you also might not tear at all. You are less likely to tear in water.

Instead of an elective section at 38 weeks, you can ask to wait until you are full term, or the first signs of labour, to ensure your baby is really ready.

Instead of being induced when you are "overdue", you can ask for expectant monitoring, to check your baby is happy and healthy, and choose induction only if a problem is detected.

Instead of an elective section for certain "high risk" births such as twins, breech or VBAC, ask about vaginal delivery. It is worth knowing that although the consultant in charge of the unit may have a preference for caesarean delivery, other doctors or midwives on the unit may have the skills and confidence to support you in a vaginal delivery, but it is up to you to ask.

Instead of directed pushing (coaching) ask to be allowed to follow your own body's cues (this may mean waiting a while before you feel the urge), if you have an epidural, you can ask to let it wear off for the pushing stage.

Instead of continuous electronic foetal monitoring, ask for intermittent monitoring.

Instead of augmenting a slow labour with synthetic oxytocin, try moving around to help the baby descend, encourage oxytocin with cuddles, massage, dark, privacy etc. Use acupressure points to encourage contractions, clary sage oil and.... patience.

8) Ask to wait and see if the situation changes.

Birth is a dynamic process, and the situation changes constantly. If there is indication that an intervention might be beneficial, it may be worth waiting for a little while, and seeing if things change. If for instance early labour seems slow, you can take that time to withdraw to a calm, oxytocin friendly environment.

It is also worth having the time to carefully consider your situation without the pressure of an audience of medical professionals.

9) Ask for a second opinion.

If you are not happy with the dialogue between yourself and any doctor or midwife caring for you, you are always able to request the opinion of someone else. In the worst case you can ask that someone else takes over your care, but hopefully a fresh perspective in the conversation will clarify the outstanding issues.

10) Have the intervention on your own terms.

Sometimes, after exhausting the alternatives, a mother-to-be finds herself facing a birth very different to her plan. There is no need to completely throw away all of your plans, it is possible to maintain control and make the best of the hand you have been dealt. It is much easier to face these situations if you know that it is still your final choice.

Look at your plan and consider which key parts are important to you. Consider how they could be transferred to your new situation. Birth partners can help make your hospital delivery room homely, you can have your own music, low lighting, you can restrict the number of people that come into the room.

If you wanted to be upright and active, but need monitoring consider sitting on a ball or kneeling resting your upper body on the bed or a chair.

Even when there are major interventions, you can still insist on skin to skin contact immediately after birth (even in an operating theatre). Delayed cord clamping is possible, even after an emergency caesarean

Small changes like this will help you feel better about your birth, even if it doesn't go to plan.

There is far more I could say about alternative birth planning, but hopefully this overview has been enough to make it clear that choosing not to follow trust policy in your care plan, is not equivalent to forgoing all medical assistance; in fact what it is really about is starting a dialogue with your HCPs, saying "OK, I get why you want to do this, but can we discuss something else that I am more comfortable with?" It opens up a myriad of options, which may be better suited to you and your baby. Exercising your right to bodily autonomy is a gateway to choice.

*Cascade of intervention. Synthetic oxytocin produces strong, painful contractions without the high of natural oxytocin to soften it, many women find they cannot manage without an epidural, which means they will end up lying on their back. Even without an epidural, it is known to increase foetal distress, so electronic foetal monitoring is always used, which usually means lying down, and is associated with more emergency ceasareans. Unable to be upright and active the mother often needs instrumental assistance to deliver the baby, and the increased risk of foetal distress leads to a greater chance of needing an emergency caesarean.

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