Informed Consent

We all know that consent must be obtained from us before things happen to us and our bodies. And if you're a parent, you would know how prevalent consent education is for the next generation. In pregnancy and birth most commonly, consent is requested for something super simple like a blood pressure check. Most often this is offered to you through a sentence like 'I'm just going to take your blood pressure, rest your arm here'. In this situation if you comply, consent is assumed. But the truth is, that this is not consent, and it is so far from informed consent.

Informed consent means that you have been given a detailed description of what will happen, it has been explained why this may be helpful or recommended for you, and you are told of any risks or complications that could arise as a result. Additionally, you are given time to make the decision and the choice to decline without any further pressure.

So, if someone wants to take your blood pressure and they are providing informed consent, it would sound more like:

"It is recommended that all pregnant women have their blood pressure taken during pregnancy to assess for hypertension, which means high blood pressure. During pregnancy high blood pressure can reduce the flow of blood through your placenta and to your baby and it is often associated with pre-eclampsia which is a serious complication that sometimes doesn't have other obvious symptoms. To take your blood pressure a cuff will be placed around your upper arm, the cuff will tighten firmly for a few seconds and then release. It is not painful, but feels like someone firmly squeezing your arm. You can ask me to stop at any time. If you are diagnosed as having high-blood pressure this may change your birth plans as it may be recommended that you are more closely monitored, and you may be offered blood pressure lowering medication. Around 3-4% of women will develop gestational hypertension. Do you have any questions? Would you like me to take your blood pressure now, later or not at all?

And I get it, it sounds a bit ridiculous and over the top for something so simple, but that's the issue. For any midwife, OB or even the occasional GP you see during your pregnancy things like weighing you, taking your blood pressure, collecting a urine sample, palpating your tummy, and listening to your baby's heart rate are such mundane everyday tasks that its generally assumed everyone will do them and everyone knows what will happen. So, consent of often not gained at all, and informed consent is pretty much absent.

Consent for Invasive Procedures

The disappointing reality of our current birth culture is that nearly every woman will have an invasive procedure done during their birth experience. This may include:

• Vaginal Exams (performed routinely every 4 hours in all hospital settings, sometimes more frequently, not an evidence-based practice).
• Cannular placement (required for all inductions, recommended for all VBAC or high-risk women).
• Urinary catheter (required for all epidurals and caesarean sections, sometimes used when the baby is obstructing the flow of urine).
• Epidural (used by 42% of women).
• Perennial Assessment (recommended for all women who have had a vaginal birth to check for any tears to the vulva, vagina or anus. Includes an internal vaginal and rectal exam with clinicians' fingers).
• Episiotomy (a cut to the perineum, which is done at a rate of 22% for first-time mother in WA).

There are many more procedures that I would also consider invasive, but these are the really common ones.

Well just like taking your blood pressure is mundane and everyday task for your clinic midwife, performing a postnatal rectal exam is the same for your hospital midwife, and cutting your perineum for your OB. These people do these things every day, and sometimes they kind of suck at getting your informed consent. The reality is that:

It's your responsibility as the birthing mother to be educated on your rights and options and to ensure you feel confidence and well supported enough to advocate for your choices and stand your ground.

Am I Allowed To?

This is what my current Facebook feed from local Mums and Pregnancy/Birth Groups looks like:

• "Just found out I'm pregnant, my first baby was an emergency caesarean 12months ago, will I be allowed to VBAC?"
• "My OB said I need to be induced at 40+10, but I really don't want an induction, help!"
• "My last pregnancy I hated the CTG monitor because they kept losing the trace, so I had to lie down the whole time, can I decline CTG next time?"
• "Can I birth in the shower at the hospital?"
• "I don't want to do the glucose tolerance test, can I decline?"

What I have gained from reading hundreds of posts just like these, are that most women don't realise they don't have to do anything. Not a single thing. Every single test, screening, scan, procedure, appointment and interaction is optional. Just because you have a baby growing inside of your body does not mean you lose your right to autonomy and freedom. You get to choose what is right for you and your baby.

Questions to ask your care provider to Encourage Informed Consent

For tests and screening offered during pregnancy

• I understand you are recommending X, can you please tell me why that recommendation is being made, and do I have any pre-existing risk factors?
• Is the recommendation of X based on policy documents, evidence-based research and/or my personal circumstances?
• What will happen if I choose not to do X?
• What will this procedure/screening/test involve, how long will it take, and are there any other procedures or interventions that will be recommended as a result of the initial test?
• What will happen if I choose not to do X?
• What is the actual risk of X for my baby and for me?
• I would like a second opinion before making a decision. Can I speak with another midwife or OB?

For interventions during labour

• Am I or my baby in immediate danger?
• What will this procedure involve, how long will it take, and are there any other procedures or interventions that will be recommended as a result of the initial?
• I understand you are recommending X, can you please tell me why that recommendation is being made, and do I have any pre-existing risk factors?
• Is the recommendation of X based on policy documents, evidence-based research and/or my personal circumstances?
• Can I view a copy of the policy documents and/or evidence-based research to help me make a decision?
• What other options do I have?
• What will happen if I choose not to do X?
• What is the actual risk of X for my baby and for me?
• Will this impact future pregnancies and births, and in what ways?
• I would like a second opinion before making a decision. Can I speak with another midwife or OB?

Additional Thoughts

"Leave your dignity at the door"

Don't listen to anyone who tells you this. It's a load of crap to groom women into compliance and acceptation. If someone says this to you, ask them if they know what the word dignity means. The Merrian-Webster Definition is "the quality or state of being worthy, honoured, or esteemed". In my opinion dignified is the bare minimum you should be made to feel during birth.

You have as much right to stick your hand in your care providers vagina as they do to stick their hand in your vagina if consent is not given.

If it's not obvious, that's no right at all. At the end of the day, you and your care provider are both just people, no one less deserving of consent than the other.

Why is it "that's just how birth is" when you are in a hospital, but if you were anywhere else it would be sexual assault?

No one has any right to touch your body unless you tell them they can. No one has any right to continue doing something once you have told them to stop. No one has any right to look at or observe you nude unless you tell them they can.

So why are we not, as a society, in absolute rage about care providers performing procedures without consent, not immediately stopping a procedure when they are told to or not waiting for permission or an invitation to enter a birth suite. As mothers and women, we need to hold our care providers accountable, and we need to expect better.