AIMS Journal, 2005, Vol 17 No 4
Alice Charlwood volunteered to play the mother in a workshop on whether women are allowed to exercise informed choice, and learned first hand how difficult it can be.
A recent flurry of email correspondence about assertiveness in labour brought to mind a most disturbing experience I had at the Birth International conference in Reading last April, in a workshop to do with exercising informed choice. In a room packed with delegates apparently keen on promoting this principle, we were asked to work in small groups, volunteer for various roles to act out various mother/midwife scenarios and to explore if/how women can really exercise informed choice very often in hospital births.
As I am the birth educator who is usually trying to encourage anxious or doubtful women to be more active and assertive in their dealings with midwives and doctors, I asked if I could roleplay the "mother in labour" in my group. Everyone was agreeable to that, a few others elected to take turns to role play the midwife, whilst the rest of the group were supposed to observe objectively and interject as the mother's advocates, actively going through the BRAINS exercise, and so on.
Then every group was given a series of envelopes, each one with a different labour scenario in it to work through with everyone playing their part. My first "midwife" (who really was a midwife, as were most of the participants) read out the card in the first envelope
"You have arrived in hospital in labour and are found to be 5cm dilated. You'll need to get up on the bed so we can monitor the baby for a while" (or something along those lines).
So I began by asking her why I must lie on the bed. I said I'd prefer to be avoid being monitored in this way. Barely are the words out of my mouth than another of the 'midwives' (the one who became my 'bete noir' as it turned out) jumped in, very annoyed I'm questioning what they're suggesting. We somehow got into a fairly bitter dispute until it became clear that she'd interpreted what I'd said as a blanket refusal to be monitored at all. I tried to soothe her (she was really quite frightening!) by saying I understood the importance of monitoring but preferred hand-held intermittent monitoring and maintaining the freedom to move and be upright to lying down for continual CTG monitoring. She drew herself up to her full height and said
"Oh but this is intermittent monitoring. We just want to listen in for half an hour or so, then we'll probably take it off".
I had to ask that we temporarily come out of our roles so I could ask the group if, in real life, this is how they would normally interpret "intermittent monitoring". Some looked blank, some looked dubious, a few said no. Anyway, we got back to the scenario, I managed to assert my wish to have hand-held monitoring and stay off the bed and we got on to the next card. Afterwards I realised there were many realistic elements to this exercise, not least that I was having to deal with a different 'midwife' with each new scenario, so it was another 'midwife' who read out:
"You have been in labour for four hours and you are still only 5cm dilated. Its time we got things moving so we're going to break your waters".
I demur, and asked if there is any other reason, apart from time passing, she thought it necessary to speed things up. I asked if they are worried about the baby. 'Bete noir' jumps in with a sour remark that they can't be certain of the baby's well-being because I won't let them monitor properly. I ignore her and say to the midwife
"I'm worried that breaking the waters might mean sudden intensification of pain that will be difficult to deal with".
Before she can reply, another midwife took it upon herself to tell me
"we don't like letting things drag on too long. You know, a lot of the other women have already had their babies and are up on the ward".
At the same time, another was chipping in with another spurious reason why I should agree to an ARM.
So in the interests of what I thought was really likely to happen with all this pressure, I said OK to the ARM. The group who were supposed to be objectively observing seemed to have become frozen and silent so no-one had attempted to explain the benefits, risks, or alternatives at all and I was already feeling too overwhelmed to ask.
"Breaking the waters has not had the effect of speeding things up. We need to put up a drip. You'll need an epidural because you won't be able to manage the pain."
Suffice to say that there was no question of exercising informed choice, no-one listened to my fears, concerns, arguments and it was like watching a pack of jackals closing in on their prey - me. I wasn't having a conversation with just one midwife but about six of them at the same time, all badgering and absolutely determined to make me comply. I remember one saying (only half jokingly, because remember we're only role-playing here)
"Its your own fault you know. If you wanted to avoid this sort of thing, you should have had your baby at home"!
So needless to say, before long I'm hooked up to a drip and an epidural, and 'bete noir' announces with a triumphant gleam in her eye that I'll
"HAVE to be on the bed and have constant monitoring now".
We went on through a couple more scenarios until ultimately, surprise, surprise, I ended up with everything I would have wanted to avoid if I was writing a birth plan, culminating in a caesarean. (How many times have we heard women say this - I ended up with this, that or the other?) If it had been real life, the sheer stress of trying to negotiate with this lot would have made this outcome a foregone conclusion as my adrenalin levels would have been sky-high. There was a real midwife tutor amongst the 'midwives' and it was only at this juncture that she said to me, when it was far too late of course
"You do have the right to refuse this operation you know".
Afterwards I told her I was quite aggrieved that she hadn't told me something similar several scenarios back, because by the time she did say it, it would clearly have put the baby in danger to refuse a caesarean, and there was no way back.
In the debriefing afterwards I observed that I was absolutely shocked at the way my 'midwives' had all ganged up on me. As far as the exercise was concerned it was clear to everyone that informed consent was completely out of the question, but what was creepy was that not many of the midwives seemed concerned either personally or collectively about the implications of this because they'd become so carried away with their role and were dedicated to following the notional hospital policy. Far from demonstrating any real interest in facilitating informed choice, it was almost like they were on automatic pilot, even though we were only play acting. I asked if, in real life, they work like that, and a few were honest enough to admit that sometimes they do. One real-life midwife from another group said that, where she works, if they can't get the woman to agree to what they want to do, they just persuade her husband to make her do it. I said I thought they should all be ashamed of themselves.
This was a salutory experience for me and a real wake-up call about the kind of bullying women are having to deal with in real life. I see myself as a pretty assertive person generally but quite quickly crumpled in the face of this concerted attack on my person and my values. I know all the alternatives and the risks and the value of doing nothing like the back of my hand yet my perfectly reasonable wishes were discounted or ignored! What hope is there for ordinary women? I was as frustrated as hell that there was insufficient time in the workshop to get down to addressing the implications of this honestly.
Final insult. The following day I found myself sitting next to 'bete noir' at another workshop and we eyed one another a bit frostily. Then she said to me
"You know I've been thinking about what happened yesterday and I think your treatment stemmed from the aggressive way you were behaving".
I couldn't believe my ears! I was outraged but kept my cool (I hope) and said,
"Not at all. I was simply trying to exercise choice and talking about my worries and concerns in a way a lot of women might in a similar situation."
What I didn't say was that I felt totally disempowered, ignored, and desperate as I was effectively forced into submitting to a cascade of interventions which the exercise, rather cleverly, had devised. I began by trying to stand my ground and discuss my options. She saw this as aggression. For me, quite quickly, it felt more like simply trying in vain to defend myself from assault from all sides. What continues to trouble me is that she'd satisfied herself that the 'midwives' behaviour to me was my fault.
A purely theoretical exercise I know, but has anyone got any suggestions about what I should have done differently? I know, I know - have the baby at home!
BRAINS is an acronym for an exercise to ascertain
the BENEFITS of what's being proposed,
what your INSTINCTS tells you is right,
what might happen if you do NOTHING?
Lastly, according to the NCT, it helps to SMILE!
This is what should happen theoretically for women really to have informed choice.
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