“In case you sue us”. A discussion on consent.

Guest blog by Emma Ashworth

I had a mole removed yesterday.  Just a simple procedure, done in the GP clinic on a smooth running, efficient weekly service.

Before the doctor went anywhere near me with a scalpel, I was asked to sign a consent form because, of course, even when I ask someone to cut a piece off me, we all need to be very clear about what exactly I have requested, and what they have agreed to do.  I’m quite fussy about consent forms.  I like to know what I’m signing.  I like to read all of the details and to ensure that I clearly understand what is being offered and what the potential risks may be.

Consent forms can often be long and complicated.  This one wasn’t – it was a small piece of text on an A5 sheet of paper and the consent wording was along the lines of, “I agree that I have been fully informed of all of the risks, which may include bleeding, pain and scaring”.  It reminded me of a self-discharge form that I was asked to sign in hospital once.  It stated that, “I have been made fully aware of all of the risks of self-discharging”.  However, the reason that I was self-discharging was that I had been in the hospital for two days without seeing a doctor once, my symptoms had gone and I was clearly low priority, as otherwise I would have already have had a discussion with the doctor, which would have meant that I was, in fact, fully aware of any risks of leaving.  I hadn’t, so I wasn’t.  I declined to sign that form and left anyway.

In AD 579, Emperor Justin II was in need of emergency surgery.  No surgeon would even attempt the procedure because they were too worried about being blamed for it if it went wrong.  Emperor Justin handed the surgeons the scalpel himself to clearly show his request for the surgery, and promised that there would be no retributions if they failed.  In fact, he died, so it’s a good job that they did!  This very early example of consent being gained for the surgeons’ protection rather than the patient’s, is now being repeated time after time in our hospitals and clinics.  The time pressures on clinicians is such that it is extraordinarily difficult for them to walk us through the pros and cons of different options, and so often reduced to the effects of the paternalism endemic throughout history, where the likes of Henri de Mondeville in the late 13th Century stated, “patients […] should obey their surgeons implicitly in everything appertaining to their cure”, and even the Hippocratic texts which recommend, “concealing most things from the patient, while you are attending to him.”

While the lack of information sharing nowadays is almost always for entirely different reasons (a lack of time, not desire for control), we do see responses from medical staff when we ask for more information which perhaps many might get huge value from reflecting on. In my experience, impatience is the usual reaction, which again is likely to be because of time constraints, but sometimes there is perhaps a paternalistic throw back. For instance, I was once in a meeting with a consultant who was in discussions with a doula client.  She had plenty to ask after much preparation between us.  After she had gone through a number of her questions, the doctor asked in rather frustrated tones, “You seem to know an awful lot about this. Who have you been talking to?”

My client responded, “Well, my doula”

To which the doctor snapped back, “No, I meant which professionals?”.

So, to go back to my own minor surgery yesterday. I read the consent form and I pointed out that to sign to say that I was fully informed of the potential risks, without them all being laid out, was not full consent. The doctor replied that there was a list, look, right there, and anyway it’s just, he said, so that you won’t sue if there’s any issues.  I explained that I meant that the wording itself implied that there were other risks that weren’t listed – I couldn’t blanket consent to say that I know everything – and, importantly from his perspective, he was unlikely to be protected if, say, he hit a tendon and caused me to lose function in my hand.

The next day I happened to be in the same GP surgery again for a physio appointment. Because my wound had bled quite badly, I asked the receptionist if she would be able to get me a replacement dressing from the nurse.  “Oh no”, she replied, “you’ll have to have an appointment for that”.

“Why?” I asked. “It’s basically like changing a plaster, I can just do it myself”.

“Well,” she responded, “you might sue us if it’s been bleeding so I need to make sure that the nurse sees you to protect ourselves.”

Is this really where we have gone with obtaining consent? I cannot change my own simple dressing because I might sue for some minor bleeding that I’d already signed to say that I understood might happen?.  On the one hand, are health professionals trying to desperately cover themselves with extensive notes, and consent forms which may or may not be adequate, and on the other hand completely unable to give people in their care the time to actually talk things through properly? What does obtaining consent mean? When women in the throes of labour are bullied in caesareans with long speeches about the dangers of continuing with their vaginal birth, and then they are given complex consent forms with risks such as “death” as they’re being wheeled towards the theatre, can we really say that they’re consenting?  And in the end, who, if anyone, is being protected here?

Consent is not as simple as signing a consent form. Food for thought for both health carers and the people in their care.



Why we couldn’t wait for Kate – the induction and the Duchess

Our blog this month would not be complete without some discussion surrounding the birth of the Royal baby.  Welcome to the world, baby Charlotte.

Much speculation surrounded Kate during the final moments of her pregnancy regarding her due dates and possible induction. My hope is that she banished the entire furore from her home and read not a single article published by the mainstream media.

The Telegraph wins the unofficial Born Stroppy award for Worst Media Outlet after browbeating us with stunningly misinformed headlines like “Kate Middleton, Duchess of Cambridge overdue with second child”, and this very disturbing leader

“The Duchess is thought to be a week overdue, suggesting the latest she would be allowed to wait by her doctors would be next Thursday, the day of the General Election. Some reports have claimed her due date was April 25, which would mean the Duchess may not be induced until a week on Saturday, as doctors treat two weeks after the due date as the cut-off point for allowing labour to come on naturally.”

Yes, you read it right. The Duchess (and her baby) would not be allowed to wait beyond election day.  No pressure, then?

to induce or not to induceLet’s get this straight.  This is the Duchess of Cambridge.  Revered, powerful, selected as one of the most influential people in the world by Time magazine, being told vicariously through institutions such as the BBC and the Mail when she’s no longer allowed to be pregnant.  It seems laughable in that context, but it’s not. It’s not laughable because she is now the latest poster girl for all that is wrong with our views on pregnancy and birth and women’s rights to make informed choices for themselves and their babies.  We wouldn’t let someone tell us how much milk to pour into our coffee, and yet when it comes to the matter of birth we are expected to blindly follow a set of arbitrary rules imposed by people we don’t know, for purposes we don’t understand.

So, in repost to the Telegraph and all the other ill informed journo’s, here is my jargon busting selection of facts and evidence based articles on the final weeks of pregnancy.

Myth 1: If your pregnancy lasts over 40 weeks, you are ‘overdue’.
The truth: 80% of labours begin between 38 and 42 weeks. It is quite normal for a woman to gestate up to and even beyond 42 weeks, particularly in a first pregnancy, whose average duration is 41 weeks. Due dates are estimates. No more, no less.

A study by the US National Institute of Environmental Health found that the length of pregnancy can vary naturally by as much as five weeks, with only 4% of babies born on their 40 week ‘due date’.

Myth 2:  If I allow my pregnancy to continue beyond 42 weeks my placenta will stop working and my baby will die.
The truth: Placental function in an otherwise healthy woman does not simply cease.

Nature is far cleverer than that. It is true that placental function decreases at the end of pregnancy, when the placenta has more or less fulfilled its purpose.  This is a normal feature of a healthy pregnancy, but is used by some as a means of frightening women into accepting intervention that may not be necessary.

A fascinating Cochrane review of 22 studies including over 9,900 women found that if we induced every woman’s labour at 41 weeks, the risk of a baby dying is 0.03% (or three in 10,000). If every woman gave birth at over 42 weeks the risk would gradually increase over time in a reasonably linear fashion to just 0.3% (or 30 in 10,000).  So a doctor or midwife may tell you “you are 10 times more likely to lose your baby” if you go over 42 weeks, but they should also be pointing out that this 10 times risk is actually 10 times a value of 0.03, which is minute.  Putting it another way, 410 women would have to undergo induction (with all its risks and pitfalls) in order to save the life of one infant.  A baby is more likely to die from a cord prolapse (cord prolapse affects approximately 60 in in 10,000) but we don’t evacuate babies before they are ready for that.

To make matters more confusing, some of the data collected doesn’t rule out confounding variables, such as the lifestyle choices of the women in the study.  Some of those women will have had other risk factors, such as smoking (which damages the placenta) or previous known/unknown health conditions.

And there’s more! The researchers at Cochrane state that many of the studies they reviewed were quite old and some of the evidence was not of the best quality, and many of the trials were also considered at moderate risk of bias.

So you see, this is the vital perspective we are missing out on because many healthcare providers don’t have the time or inclination to inform us.  Why? I will let you gather your own conclusions, but I feel it is strongly to do with the culture of fear and forced compliance that surrounds the medical model of birth of which we are so fond in the UK.

If all women considering induction were party to this information, how many women would opt out of routine induction?

Myth 3:  Induction is risk-free.
The truth:  Whilst induction is not nearly as risky for women and babies as it once was, women who have inductions for post-dates (over 42 weeks) pregnancies are not exempt from injury, and there can also be implications for the unborn child, usually resulting from over-stimulation of the uterine muscle causing foetal distress.

This well researched article outlines the risks associated with induction in more depth, the main risks being as follows:

– Induction is slightly more likely to result in a Caesarean section, particularly in first births.
– Inducing labour too early can result in premature birth, which can cause issues such as breathing difficulties in the baby       (and for an individual it is impossible to tell when ‘too early’ really is).
– There may be reduced oxygen supply to the baby during labour, which can affect the baby’s heart rate.
– Increased risk of infection for both mother and baby.
– Increased risk of cord prolapse, a rare obstetric emergency which occurs when the cord slips into the vagina ahead of the   baby.
– Increased risk of uterine rupture, another rare but serious consequence of artificially stimulating the uterus (more common   in women who have 2 or more c-sections)
– Slight increase in risk of forceps or ventouse birth (often due to foetal distress caused by the hormones in the induction       preparation)
– Post-partum haemorrhage (bleeding after the birth), again caused by the over-stimulation of the uterus which can prevent   it from fully contracting after the birth.
– Prolonged stay in hospital (the pessary used to soften the cervix can take up to 24 hours or more to take effect, and can     sometimes be completely ineffective if the cervix is not ready to let the baby out.)

Myth 4: I’m not allowed to go beyond 42 weeks.
The truth: The simple answer to this is that you are allowed to do whatever you like.  Nobody can compel you to make a decision that isn’t right for you.  The role of a Midwife or an Obstetrician is primarily to inform you, and secondarily to advise you. What you choose to do with the information they impart is down to you.

If you find yourself being coerced or bullied by a healthcare professional into any situation you do not feel comfortable with, it is useful to ask them the following questions, based on a system known as the BRAIN acronym:

Benefits – what are the benefits of this procedure?  How will this help me and my baby?  Evidence?
Risks – What are the risks associated with this line of action?
Alternatives – What are my other options? Are there alternatives to this procedure?
Intuition – What is my gut feeling about this?  What is my instinct telling me?
Nothing – What is likely to happen if we do nothing?

Now, if you ask a healthcare professional, “what is likely to happen if we do nothing?” and they reply with something emotive like “your baby will probably die”, you know instantly that you are dealing with someone who is either very misinformed or is stretching the truth beyond its limits.  If you go through the BRAIN questions and get well informed answers with some concrete evidence to back those answers up, you are dealing with someone who is honest and at least reasonably objective.  I know who I’d rather put my trust in.

This helpful blog on informed consent by anthrodoula goes into more detail about how to implement the BRAIN acronym in a real life scenario.

Myth 5:  I cannot have a natural/normal/home/water/intervention free birth if my pregnancy lasts more than 42 weeks.
The Truth:
Yes, you can.  As a Doula I have supported many women in their 43rd week of pregnancy and all of these women have made a fully informed choice to refuse induction, for various reasons.  I highly recommend reading this article from the Homebirth UK website on ‘overdue’ babies, which is excellent reading whether or not you are planning a home birth.  In it, the author discusses the alternatives to induction and clearly demystifies the statistics and the guidelines used by the NHS. You will also find some empowering stories of babies born beyond their due dates.

A final note on the Duchess of Cambridge. Some of you may have noticed that she did not reveal her ‘due date’ to the press or public.  Any mention of dates in the papers was purely speculation.  And Kate is bucking a trend.  Many women are now choosing not to reveal their dates, instead favouring the option of a birth month. I believe this will work its way further into the public consciousness over time, as more women take back control of their choices, their bodies and their births.  Reader, I hope you are one of them.

This month’s guest blog has been written by Caroline Ward, Doula and birth rights campaigner.