• We need to start talking about consent in childbirth, writes Nicola Heath. (Getty Images)
“He told me he was going to cut me up, and that was pretty standard, and he was going to use forceps, which are like tongs.”
By
Nicola Heath

12 Jul 2019 - 8:04 AM  UPDATED 12 Jul 2019 - 2:45 PM

A grown man using all his might to wrench something out with force is how Melbourne mother Suganya remembers the moment her eldest son was born.

Nearly nine years after her son’s birth, she is still recovering from the psychological and physical trauma caused by his delivery.

Concerned that Suganya’s labour was progressing too slowly, a midwife administered her with induction drugs to speed up contractions. When her baby remained stuck in her birth canal, it was later discovered that his shoulder was caught on Suganya’s pelvic bone, a condition called shoulder dystocia. A obstetrician later arrived to perform an instrumental delivery.

“He told me he was going to cut me up, and that was pretty standard, and he was going to use forceps, which are like tongs,” says Suganya. “That’s all I heard."

“I didn’t know that something (like) a pair of tongs could do so much damage to me.” 

Her baby son was born with injuries to his eyelid and cheek from the forceps, a broken clavicle and partial Erb’s palsy, an injury that causes paralysis of the arm. His Apgar score - which doctors use to assess the health of newborns - was low. He soon developed jaundice, cephalhaematoma and a sternomastoid tumour - conditions associated with his instrumental delivery.

Her son was soon moved the special care nursery, and Suganya was unable to breastfeed him.

After his birth, Suganya struggled to care for her son. “I couldn’t look at my child for close to a month,” she says. His injuries were a constant reminder of her trauma. “We had to go through a lot of therapy for him, a lot of physio, and he had to get a special hearing test.”

Suganya initially suffered depression after the birth and later, when she became pregnant in 2013, experienced nightmares and PTSD symptoms. She also suffered serious physical injuries. A third-degree perineal tear that remained untreated until her second pregnancy left her with faecal and urinary continence. Nine years later, she still experiences stress incontinence.

At no point does Suganya recall being warned that the use of forceps could harm her or her baby, even though between 40 and 45 per cent of women who undergo an instrumental delivery suffer pelvic floor trauma.  The figure is one in 10 for suction and unassisted vaginal births.

“We treat women and their partners like children. We keep them in the dark over risks…because that might frighten them.”

“I didn’t know that something (like) a pair of tongs could do so much damage to me,” she says. “I wasn’t informed.”

Suganya’s experience is not uncommon, according to Bashi Hazard, a lawyer and advocate for human rights in childbirth and maternity care.

Hazard says there is little or no practice of informed consent in maternity care in Australia.

“The only time in New South Wales facilities that they ask for express consent is when they are about to perform a surgery because they know that the law says if you perform surgeries without consent, it’s assault and battery,” she says. “They bring out a piece of paper, it’s usually done at the last minute.”

Many hospitals have guidelines regarding how often vaginal examinations and foetal heart rate monitoring should be performed, as well as the rate of dilation, the length of first and second stage labour and induction. But Hazard argues that these are arbitrary guidelines designed primarily to protect hospitals and can harm maternal health.

When a vaginal exam reveals that a woman’s cervix hasn’t dilated at the recommended rate of one centimetre per hour, she may then be induced, which increases the likelihood of a forceps delivery and pelvic floor injury and trauma.

Yet women are rarely informed that there are policies governing labour management and don’t realise that they do not have to comply with them.

Hazard argues that it should be up to care providers to brief women on hospital regulations well before labour starts. She says obstetricians should treat forcep deliveries as interventions that require informed consent, in the same way caesareans do.

“If…well before she’s in labour she says, ‘you are not touching me with forceps’, then that is actually a very clear no, and contact with those forceps on her or her baby is assault and battery. That’s what informed consent looks like,” says Hazard.

“You can’t obtain consent in the moment,” she says. “These conversations need to be happening much earlier on.”

Experts say the lack of informed consent to interventions during childbirth is a significant contributing factor to postnatal trauma. 

“We treat women and their partners like children. We keep them in the dark over risks…because that might frighten them,” writes Professor Hans Dietz, a birth injury specialist from Sydney University. “Elsewhere in medicine, such paternalism ceased to be acceptable decades ago.”

Australian Birth Trauma Association chief executive Amy Dawes says interventions like caesareans and forcep  deliveries are often downplayed in hospital birth education classes, which means many women go into labour with rudimentary knowledge about forceps and their associated risks.

“You can’t obtain consent in the moment,” she says. “These conversations need to be happening much earlier on.”

Instead, consent is usually obtained when women have been in labour for an extended period. Dawes herself suffered an injury to her pelvic floor that resulted in a prolapse, after a forceps delivery in 2013.

Dawes had been awake for 48 hours when she consented to the use of forceps. “I’ve seen the form that I signed – it’s definitely my signature – but I have no recollection of signing that,” she says. “How can you possibly make an informed decision at that time?”

At that moment, Dawes thought she was doing what’s best for her baby, but six years later, she’s still living with the consequences of that decision.

“The effects of having a forceps delivery…don’t leave you,” she says.

Nicola Heath is a freelance writer. You can follow Nicola on Twitter @nicoheath.

Birth Trauma Awareness Week runs from July 7 to 14.

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