I'll take another 24 hours please...

Women have the right to make choices about what happens to their bodies in pregnancy and childbirth. The Government says so. The NMC says so. Our national clinical guidelines say so. UK law and the European Convention of Human Rights say so. Birthrights offer this simple fact sheet on human rights in maternity care for those of you who want to read a bit more.

As a final-year midwifery student, I spent months writing a dissertation on informed choice in pregnancy and childbirth - specifically, on what maternity professionals felt and thought about it. I trained at a hospital where Julie Frohlich, Consultant Midwife and passionate advocate for personalised maternity care, ran a clinic dedicated to women whose choices fell outside the guidelines (if you have access to MIDIRS, you can read one of Julie’s articles here). 

Put simply, maternal informed choice has always been ‘my thing’. So why, when I hear a story of a woman calmly and ‘successfully’ implementing her right to choose, am I still surprised?

Anna, a brilliant first-time mum called me when she was 36 weeks pregnancy to tell me that a scan had confirmed her baby was breech. Over the next couple of weeks, she sought advice from her carers and tried every safe means to turn her baby - moxibustion, yoga, hypnotherapy, external cephalic version (ECV) (when a doctor or midwife attempts to turn a baby by placing their hands on the abdomen)… All to no avail - it seemed her baby was very happy bum down.

During this time, we spoke a number of times on the phone and discussed the advice and evidence available on breech birth. While we were talking, I was struck by how neutrally she received the information I gave her. She listened, and asked more questions, but rarely responded with emotion or, more specifically, expressed any fear. For her, it seemed, this was a true information gathering exercise. Her local hospital had recommended an elective caesarean at 39 weeks; Anna requested to wait until 41 weeks to see if her labour started naturally (I had the impression that, even then, she hadn’t totally decided what she would do if it did!)

For a while, things went quiet. Then I received a text from Anna telling me that her waters had broken at 38 weeks and, after choosing to wait for 48 hours before any further intervention (apart from IV antibiotics), she had gone into labour naturally - Anna’s birth story, in her own words, can be found here.

What impressed me about Anna’s approach to the whole situation was that she really seemed to take things one calm step at a time, all the time listening to advice, gathering information, and paying attention to her own instincts. When her waters broke, she asked to wait for 24 hours to see what happened. When that time was up, after discussing things with her carers and assessing the risks, she decided to wait another 24. A plan was made for an elective caesarean if things did not progress naturally in this time - both mother and father were happy with this plan.

Now Anna is a very smart woman. But so are many of us, and we have unique insight into what we feel and want in pregnancy. So why is it so difficult for us to make our own decisions at the time of birth?

Well, firstly, let us not underestimate the power of fear. More than anything, parents want what is best for their babies - the thought that we could inadvertently put our child at risk is enough to deter many of us from questioning the advice of healthcare professionals, even when we might have good reason for doing so. The feeling is often that, if a particular course of action is recommended, it must be the right thing. However, a somewhat daunting truth about childbirth is that, sometimes, there is not one right course of action - in these instances, the best route must be determined by considering available evidence and resources and, of course, the mother’s preferences. And, often, there are practical difficulties to following a certain course - one hospital or practitioner might feel confident, for example, supporting vaginal breech birth, while another does not. By the end of a long pregnancy, many mothers are tired and more than ready for their baby to be born. Women rarely want to change Trusts at this time, or lock horns with hospital seniors, in order to pursue their choices. 

So how do we move forward? Well, in an ideal world, we work together. Just because individuals might differ in their approach to childbirth doesn’t mean that their aims are fundamentally opposed. Far from it, we all want the same thing - a healthy, happy mum and baby. 

Hypnobirthing prepares partners to help the mother communicate their wishes at the time of birth. One aim of hypnobirthing is to reduce stimulation of the labouring woman’s neocortex (the more ‘civilised’, intellectual part of the brain) so that they can turn their focus inward and not be distracted by worldly problems, such as when the next vaginal examination is due or how many centimetres dilated the cervix is. In my practice, I have seen that, sometimes, partners interpret this role as an almost combative one - they feel they must defend their loved one from the unwanted interference of midwives and doctors. This attitude is not conducive to a peaceful birth, and I cannot imagine it is at all relaxing for partners to feel that they must cram sufficient information in the lead up to the birth so that they can determine which, if any, interventions are necessary at the crucial moment. But we have already acknowledged that there is not always one *right* course of action. So how do you know what is right for you?

My advice is this: befriend your midwife! Ask questions! Be curious, not confrontational! And make your preferences absolutely clear! It is a sad truth that Midwives sometimes feel limited in the extent to which they can make you aware of your choices because of the protocol at their particular Trust. By asking what your options are, you might well make her feel bolder in supporting your informed choices. And one question that is always wise is, ‘Can we have some more time?’ If you are being asked to make an important decision, ask ‘Is it safe for us to wait another hour and see what happens?’ Or, ‘Can we just have some time alone to talk about it?’ Let there be no doubt, if it is unsafe for you to wait any longer, your carers will let you know, and sharpish! 

Informed choice is an important part of your pregnancy journey, and hypnobirthing aims to provide you with information that will help you understand the context in which you give birth, and make choices - in partnership with your carers - that are right for you. If you can, like Anna, remain calm and curious when confronted with unexpected events, ask questions and listen to the answers, there is no reason why you, too, cannot be a wise and active participant in your own care.