Choice and Permission

May 8, 2014

I was inspired to write this after reading an article via Twitter about permission in pregnancy http://www.bestdaily.co.uk/your-life/news/a567116/i-was-not-allowed-the-words-that-steal-our-birth-power.html   Mili Hill


I feel sad that women still in 2014 do not feel empowered to ask about their care, to ensure they understand why things are being done to them. Yet they still allow care, that they don’t really agree with, to happen.  There was book I read a long time ago about how people psychologically take on the role of patient as soon as they enter a hospital.  They allow examinations and interventions that in normal life they would reject. But because they are in a hospital setting they allow staff to do all sorts of things to them.

Women must be doing the same within maternity  care – thinking that the professionals must know best, allowing themselves to be driven by the midwives/medical staff  they meet.  This puts us (the professional) in a particularly precarious position, where our judgement about what should be happening takes over from what might be best for that particular women.

One of the reasons why I came into the Midwifery business is because it is still an area of medicine where often we still don’t know all the answers. We still don’t know why women go into labour and why the gestation varies woman to woman.  We still don’t know why some types of analgesia work for some women and some do not.  Why the length of labour varies from woman to woman. Why some babies die in pregnancy despite all care being taken.

We have gathered recently lots of evidence that leaving women alone to do their own thing in labour, if they have a routine pregnancy, is better than accessing interventionist care in an obstetric led unit. But still some women will have good outcomes, others will not, wherever they are cared for.

I wanted to work in an area of healthcare where the individual woman and her family would be the centre of care and her not be a victim of cart blanche interventions. However I watch, and administer myself, prophylactic Anti D Immunoglobulin at 28 wks, when all the evidence suggests that giving it in response to a clinical bleed has been shown to have the optimum effect. Even if women have had the prophylactic dose she still needs the extra if she has a antenatal bleed.  This seems to me to have more to do with large drug companies making money out of the process rather than actual clinical need.

I also offer syntometrine for the third stage of pregnancy because it is my professional duty to share the evidence which shows that the placenta will be delivered more quickly and with less blood loss than physiologically.  It is only the rare woman who listens to the other evidence about the blood loss not making any difference to recovery after the birth and the possible effects on breastfeeding.  Most of the women I encounter hear the “quicker” and the “less” and opt for the drug.  Who am I to say they have not made the correct decision for them.  Even though my personal philosophy is, if you have managed the birth of the baby without intervention you are likely to manage the delivery of the placenta without medication.  But I don’t push my own philosophy, I trust the woman to make her own decision.

Some midwives will say that their women never have syntometrine.  I then have to think is that the woman’s choice or that of the midwife.  I cannot believe that all the women under the care of a particular midwife, if they were allowed to review all the evidence, would all opt for a physiological third stage.

So where are we in the modern, maternity world?  The internet offers vast information on the topic. The literature available is vast.  Professionals are ready to discuss the relevant evidence if necessary. But at the end of the day the choice has to be the woman’s and I do mean the woman’s choice.  The role of her partner is for a completely different blog I feel.


This is why I have some difficulty with the cart blanche approach of “normal birth” for all.  This will be appropriate for most births but for many it will not.  To make it a demand of the health service challenges the idea that for some, a normal vaginal birth would not be the best approach.  The “normal birth” fraternity tend to be middle class, vocal women who feel they are fighting against a system that is not “allowing” them to birth naturally.  I really have never ever been witness to anyone undergoing an emergency caesarean section, because it is what the surgeon or midwife wants.  It is always about what the clinical signs are telling them at the time and them wanting to achieve the best outcome for the mother and child.

I was witness many years ago to a mother declining a caesarean section, despite appalling fetal distress. She declined for so long that legal means; to prove her competency to make that decision; could not assist and yes the baby died. This was her choice. But how she will live with it for the rest of her life. I am not sure.  The professionals had a really difficult time after this incident coming to terms with what they had “allowed” to happen.


This month, this April 2014, my current stance is that I will work women to achieve the best outcome for her pregnancy and birth. We will discuss the various options, when decisions are required, but that I will abide by her choice. I will give her the benefit of my years of experience and my knowledge and skills acquired over 28yrs as a midwife. But at the end of the day I need to know that what is happening is understood by her and is what she wants in the circumstances that arise.

It is my opinion that if this philosophy were followed more we would have less incidence of claims for negligence  and poor care.  The woman would understand at all points and would know she had made the choice for whatever occurs so will live with the outcome.   So my personal fight is to support women in the choice they make for themselves, not playing politics with birth


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