I can say 'No'?
Once you are pregnant a whole new world opens up. Tests, checks, scans and appointments are all booked in and you will be hearing a whole new set of language.
You will find yourself navigating the maternity system, another unknown.
You might meet midwives, maternity support workers, maternity assistants and sonographers. You might see a Consultant or one of their team. Figuring out who is who and who does what can take a bit of research or asking some questions.
All of this can seem a bit overwhelming and if you are not familiar with the maternity system or with pregnancy and birth you might not be aware of the choices that are open to you. Because when it comes to it everything is your choice. You can say yes or no to any of those tests and appointments.
But for a lot of birthing people the concept of choice in their care, in their birth, in what happens to their body is a little alien.
We have become accustomed to being told what to do when we are pregnant. You are probably feeling a little less like yourself than usual and maybe even just a teensy bit hormonal. Plus this stuff matters.
You don't want to make the wrong choices - it's your incredibly precious baby, you do not want to mess up. You want to trust the people looking after you and be guided in the best way to be cared for, the best place to have your baby and the best way to do it.
So when someone says 'We'll just....' or 'At your next appointment I will....' or maybe even 'Then we'll decide on your birth plan'. We just go along with it.
But what if you stopped and asked some questions.
Everything that happens needs to be with your informed consent. That means that you need a full understanding of the pros and cons so that YOU can make a decision. Yes, no, later, if xyz. It's YOUR decision, your body, your baby, your choice.
Some of them you won’t give a second thought to – you might be 100% confident you want midwife care and regular checks but there are people who would prefer not to. Likewise you might be really excited for your first scan to see your baby and find out your due date. But there are people who choose not to have that scan.
The most important thing is that you are able to make an informed choice about your own care. Just take a moment to reflect on informed choice. What does that mean to you?
If you wanted to make an informed choice about something – let’s say you are thinking about buying a new car – you would want to make sure you had the information you needed to make a decision you felt comfortable with. You wouldn’t want to listen to a sales person telling you all the reasons you need the car. That’s just one side of the information. You might ask a few questions about the information you have been given, you might decide to go away and do some research of your own, maybe you look at what other options there are but what you are trying to find out will be what are the good and bad things about this car. You are weighing up the pros and cons, figuring out what will work for you and your situation and deciding for yourself if it’s right for you.
The decisions you make about your care and about your birth are important. You might be weighing up the safety of your baby or yourself (not something anyone wants to think about) and maybe you feel like you need the guidance of the professionals.
There are always risks and always what ifs. Informed consent means you understand and come to the decision you feel is right for you and your baby.
As you read through this you might be thinking it’s all about the big decisions, the ones where you are thinking about safety and interventions. But the reason I’m writing about this is something that isn’t quite on that scale. However it is something that is a huge deal for a lot of people and something that you might not give any thought to with regards informed consent.
So lets talk vaginal examinations.
This year alone I've taught several people who were anxious about vaginal examinations in labour. Very understandable! What they didn't know was that they could decline. I can't imagine feeling so anxious about something but not realising I could say no.
If I say that no one can put their fingers in your vagina without your consent you would certainly be nodding in agreement. Sitting reading this I’m sure you would think that’s pretty clear. But something happens when we are in labour and somehow we just expect that examinations will be happening and we need to just go with it.
First things first. You can absolutely say yes or no to examinations. At any time.
Why are examinations offered?
It is usual to be offered an examination when you are being assessed in labour. Either when you arrive at hospital or when a midwife comes to you at home. This is to see how dilated you are and is often used to see whether you are in established labour or not. This may well be presented as a necessity before being admitted .
In established labour it is usual to be offered an examination every 4 hours to assess your progress. You might like the idea of knowing your progress or you might prefer not to know!
You might also be offered an examination if there are concerns labour is slow or to check your baby’s position.
Whatever the circumstance it is worth considering the reasons for the examination and what you would do with the information. Would it impact your decisions? Will it help you? It is important you understand the purpose of the examination and what will happen because of the outcome.
From the NICE Guidelines
Your midwife will offer vaginal examinations during labour. These are done to check how far your cervix (neck of the womb) has opened (dilated) and the position of your baby's head. The midwife should always explain why an examination is being advised and what it will involve.
There is a common perception that the only way to assess labour is by vaginal examination and that without that knowledge you can be denied care such as pain relief or even admission to the hospital or birth centre.
If your preference is to decline examinations you might want to read a bit more about other methods of assessment and if you feel you need more support or information AIMS are a good place to go.
As ever my interest is not in whether you want examinations or not it is that you are aware of your options and supported to make your own decisions.
There are times when vaginal examinations are incredibly useful but it’s all about the informed consent so you know.
What is important to remember is that all a VE will tell you is what is happening at that moment in time. It won’t tell you anything about what has been happening or how long you still have to go in labour. Labour progress isn’t linear and plotting it on a graph doesn’t really tell you anything useful. We know that not everyone will dilate at the same rate, some are faster and some are slower but whether anyone needs interventions or help needs to be taken on an individual basis not just by looking at the numbers.
In 2013 the conclusion of the Cochrane Review into vaginal examinations stated
We identified no convincing evidence to support, or reject, the use of routine vaginal examinations in labour, yet this is common practice throughout the world. More research is needed to find out if vaginal examinations are a useful measure of both normal and abnormal labour progress.
It would seem we are still waiting for the research because, despite a lack of evidence, routine examinations are taking place every day in every maternity unit in the country and unless women are aware they can say no and that there are pros and cons, nothing will change.
If you want to read more about the history and science (including some of the risks associated with VEs) please read this article https://midwifethinking.com/2015/05/02/vaginal-examinations-a-symptom-of-a-cervix-centric-birth-culture/
Cochrane Review 2013 https://www.cochrane.org/CD010088/routine-vaginal-examinations-in-labour (accessed June 2021)