‘Tell The B*s**rds Nothing’

Essentially Birth is almost five years old now and that means that I am starting to see clients come to me for a second time around.

Because of the intimate way in which I work with my clients, particularly those clients who see me regularly throughout their pregnancies for massage and birth preparation, there is a real sense of sisterhood.

Now that I am free from any kind of legally instated regulatory system I can relax into the relationships that are inevitable in this kind of setting. I can talk freely about the limitations of the maternity system as well as its strengths. I can offer perspective and help women be conscious in deciding which interventions they want and which ones they'd rather pass on. I help women understand routine care versus acute care and I can help them get clear on what the evidence says. I can affirm to them that it is not selfish to prioritise their own and their baby's experience of birth, that the longing they feel to let birth unfold freely is shared by many women I meet and that I myself am no stranger to it. 

Unfortunately far too many women who desire a physiological birth are subjected to unnecessary interventions and experience trauma as a result. I can help those women who are trying to work through disappointment and sadness over their first experiences of birth make sense of what happened and why it might have occurred so that they can avoid the most common pitfalls this time around. 

And so I found myself talking about birth trauma with one of my long standing clients this week. The first time I met her she was preparing for a homebirth after a poor experience of her first birth, a story that is all too common within industrial maternity systems. We were talking about the mess in the maternity system and about what it means to stand fully in awareness and in responsibility. Not many of the individuals who make up 'the system' are ready for women who see pregnancy and birth as *just* pregnancy and birth. Quite often those women are dismissed by members of the public and, indeed, by 'professional' midwives as naive.

They just don't know about all the things that can go wrong in birth. 

I shared that during my own pregnancy and birth I was searching for connection from my midwives and couldn't find it. Remembering my daughter's birth still brings up such a mix of emotions. Though I feel that I have healed, there are still some remnants of guilt and shame surrounding her birth. The knowing that Lena and I missed out on the potential of what birth can be still makes me sad on occasion. 

For a long time I wondered if this would stop if I had another child and gave birth in the way that I wanted to. Up until a few years ago there had always been the possibility of another child should we choose it.

We never did. 

Our family seemed complete for now, maybe down the line we'd want a baby. Since my fiftieth birthday I have been feeling that this is wholly unlikely to happen now; though I can, on occasion, be seen in a panic in the pregnancy test isle of my local supermarket.

My client told me that, even though she has had a second baby, she is still feeling sad about how her first baby was born. Despite the fact that her second birth was all she could have wanted and more, she can't help but regret that her first baby didn't get the start that she had wanted for him. Like me, she has such mixed emotions about it all, still!

We agreed that you can heal, accept and 'do the work' but that it is like any other experience in your life. It integrates in who you are but you never forget. We chatted some more about how good it feels to just talk about this and about how so many people aren't open for this conversation.

'Sure, he's here, isn't he?', for many people this is how far this conversation will ever go. We wondered if this reluctance to talk about unfulfilling or even traumatic birth experiences was connected to women's own experiences of birth or was it really just that simple for them? 

Hard to tell, my money is on generational trauma. 

Thankfully more and more women are talking about this and it is those women who are showing us a different way. My client is lucky to have some amazing midwives in her corner for this upcoming birth of her third child . The baby will be born at home and my client is taking full responsibility for those aspects of the routine care pathway she is choosing to decline.

That's how it should be. 

She noted that despite all this there seemed to be such a difference in approach, that some midwives seemed to be really focused on telling women what could go wrong.

'I know that babies can die', she said, 'They can die in hospital or at home', and she is right. She's also right in observing that the same conversations about 'the risks' are never had when women just go to hospital to give birth, even if they engage in risky procedures such as inductions of labour. It's just when you want to wait for a spontaneous labour past 41 weeks that 'the risks' are laid out to you and yet we know that, statistically speaking, homebirth is safer for giving birth to a second or subsequent baby when compared to hospital birth. 

My client was wondering why there was such a difference in how midwives approached their conversations with her and I explained how hard it is for midwives to walk the line between showing up for the women as well as keeping themselves right with the regulators, 'it's in fact impossible' I said,  and  thenI remembered the best piece of guidance I ever received as a registered midwife. 

‘Tell the b*s**rds nothing!’

One of my most esteemed colleagues and mentors of all time used to utter these four words to me on various occasions over the years and it was our way of being ‘with woman’ within our framework of NHS pregnancy and birth guidelines. 

Although on paper women have a 'right to informed choice' this doesn't always translate into reality within a guideline driven culture. I remember a number of occasions when I went to tell a manager that a woman was declining aspects of care only to be told that that was against guideline and that I needed to go back to her and explain properly, or better still, a senior member of staff had to go and explain properly. Though this doesn't always happen, it gets tedious after a while and so some things are best kept under your hat, TTBN - tell the b.... 

I am increasingly wondering if this could be the best policy for women themselves. Like every other approach this has its disadvantages. You might miss out on potentially crucial information. On the other hand you won't find yourself in the surreal situation of having to defend your bodily autonomy for telling people ahead of time that you intend to decline aspects of routine labour care for example. 

The things that are said to some of my clients are unbelievable. I have one client whose husband had to step up during a meeting with a 'senior' midwife who was trying to 'negotiate a compromise' around vaginal examinations by suggesting that a homebirth was 'not possible' if she declined them. Unbelievably he had to point out that the territory of his wife's vagina was not up for negotiation; that she alone held authority over who got to touch her most intimate body parts let alone let alone enter her vagina.

This is after his wife had had to state repeatedly that she would aim to avoid routine VEs in labour as he sat quietly.

She had even printed out some evidence around the topic and brought it along to the meeting to share with the midwife. The meeting didn't go how the parents had imagined at all. There were repeated attempts at coercion and her questions remained unanswered.

'Do vaginal examinations improve the outcome for me or my baby?'

There isn't any evidence to say that they do and there are plenty of studies out there that would support a different approach to assessing labour progress and reserve vaginal examinations for when there truly is a concern about the mother or the baby. This is what my client wanted to discuss. She wanted to share that the authors of a Cochrane review on the topic (Cochrane is considered the gold standard for evidence) concluded in 2013 that 'It is surprising that there is such a widespread use of this intervention without good evidence of effectiveness, particularly considering the sensitivity of the procedure for the women receiving it, and the potential for adverse consequences in some settings.' (Cochrane, 2013). When the authors reviewed their findings in 2022, they upheld their initial recommendation for further study and emphasised that 'relying on cervical dilation alone to determine whether progress is normal can result in the use of interventions such as oxytocin and emergency caesarean section to expedite birth, where this may be unnecessary' (Cochrane, 2022). The authors also point out that vaginal examinations legally require valid consent from women and that women have the right to decline them (which should go without saying!).

Unfortunately there was absolutely no attempt at engaging with this couple about the actual topic at hand or even at explaining any kind of rationale for routine VEs other than the fact that avoiding them is out of guideline. Personally, I feel that there are situations where a VE might be indicated even in a spontaneous labour. If a woman opts for an induction of labour, declining VEs isn't compatible either, so declining VEs might be better suited along with declining induction of labour. That's something to explore with women who decline routine VEs together with the assertion that, of course, they will be respected in their decision at each occasion a VE is offered to them. Instead, my client was met with an 'I'm the expert' attitude and told off for 'undermining' this midwife's 'expertise'.

So he stepped in, calm and assertive.

'My wife said no, it's her decision!'

Sexy or what?

I really love to see how things are shifting. Women are finally claiming back the territory of their own bodies sometimes with the help of their partners. They are trusting themselves to make decisions and when they choose interventions they do it consciously and confidently. 

The experience of this couple with the senior midwife is not unique to them. I have heard this story over and over and this idea of there needing to be compromise. I recently saw the term 'cascade of coercion' and I wish I could remember where I saw it so I could credit it properly. It describes the phenomenon that you can't just decline an intervention with one practitioner. Quite often you have to speak to a senior midwife and then if you still decline, you have to speak to a doctor. It wears people down and in the process they finally agree to the very thing they didn't want. For more and more people this is a matter of 'fool me once' and their policy in subsequent pregnancies is TTBN aka keep your head down and do your own thing!

What's your policy? Send me a message to [email protected] or via DM through @essentiallybirth on Instagram.

References:

Downe S, Gyte GML, Dahlen HG, Singata M. Routine vaginal examinations for assessing progress of labour to improve outcomes for women and babies at term. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD010088. DOI: 10.1002/14651858.CD010088.pub2. Accessed 02 May 2024.

Moncrieff G, Gyte GML, Dahlen HG, Thomson G, Singata-Madliki M, Clegg A, Downe S. Routine vaginal examinations compared to other methods for assessing progress of labour to improve outcomes for women and babies at term. Cochrane Database of Systematic Reviews 2022, Issue 3. Art. No.: CD010088. DOI: 10.1002/14651858.CD010088.pub3. Accessed 02 May 2024.