Can you say NO to tests and treatments in pregnancy and birth?
What can you say no to during pregnancy and birth? Well, you can literally say NO to everything.
Ethically a health care provider can’t force a woman to accept any sort of treatment, even if they strongly believe their treatment plan is in the best interests of the mother and/or her baby.
You have choice in your pregnancy and birth, your consent needs to be given and you are your own best advocate. The trick is knowing from an informed position what is worth advocating for.
This episode talks about:
How to feel empowered about decision making during pregnancy and birth
How to advocate for yourself
The key to informed decision making
Different ways of communicating with your healthcare provider
How trust is crucial for good outcomes
Brigid [00:00:36] Welcome, everyone. This is episode 16, and what we're covering today is can I say no to tests and treatment during pregnancy and birth? And we thought this would be a really good topic because, you know, there's so many women that we know or on the Internet. Oh, you know, when I was in my mum's groups that say that they felt that they had no choice during their pregnancy or birth and that things were done to them that they didn't agree to. And I just thought that would be just something simple for us to cover. But I was pretty naive. It's opened Pandora's box. It's really huge. It's it's huge because ethically, a healthcare provider can't force a woman to accept any sort of treatment, can they?
Patrick [00:01:16] No, no, no. Absolutely not. And not nor can you. And even in pregnancy, it does make it any easier. You can't force things on people for the good of the baby either.
Brigid [00:01:25] No. Well, that's right. That must be really difficult as a health practitioner. So if you've got a situation where you know that decision is harmful, what's going on in your head when that happens?
Patrick [00:01:37] I think it's it's very, very challenging. Thankfully, it doesn't happen too often. Most people most people will put themselves out for something that they didn't really want if they're being advised that it's strongly in the best interests of their baby. But sometimes it happens. And sometimes I've certainly been involved in some incidents in my career where I very, very strongly thought that that woman in labour should have a caesarean section for the well-being of the baby. But she didn't want to do that. And yeah, it's it's it's one of the most challenging parts of the job.
Brigid [00:02:12] What I hope from our grow my baby program that will do is help women to be empowered and help them to advocate for themselves, but also knowing in an informed way what's worth advocating for. You know, if it's skin to skin contact after they've given birth, of course they should be doing that. But knowing the difference between if they've been given advice that perhaps is potentially life threatening to them or their baby, that that's advice that they should heed.
Patrick [00:02:38] Yeah, I think a really good example is, you know, when you're formulating a birth plan, one of the reasons I like people to do a birth plan is so that they can come back with it a week later and say, what? What do you think? And it gives us an opportunity to iron out some misunderstandings, because some of them sometimes there is genuine misunderstandings about why I might recommend something. And the reason I might recommend something might vary from it's actually not that important, you can go one way or the other, but I think this right up to something that's been, you know, beyond a shadow of a doubt proven to be highly beneficial. And I strongly recommend it. The patient might not know which it is. So if they can make their birth plan, they say that they want, you know, delayed cord clamping so that we let a blood come out according to the baby before we clamp the cord. Highly supportive of that. Fantastic. That is a genuine choice. You can have that or not have it. And if you feel strongly want to have it. Right. Right behind you. Fantastic. Someone might think that it's just as optional whether you will have an injection for the in the third stage of labour to prevent post-partum haemorrhage. And I will tell it's still optional, it is still up to you. This is your body. I'm not going to attack you by giving you an injection you don't want. But actually, the evidence behind doing that is overwhelmingly in favour of doing it. And the problem, if we don't do it, is that postpartum haemorrhages are a much, much, much harder to treat than they are to prevent. Yeah. And if we wait until the haemorrhage is up and going, it doesn't go nearly as well as if we just give everyone the injection and prevent them in the first place.
Brigid [00:04:22] And it really depends on, you know, why she formed that opinion in the first place. You know, it could have been from I don't know, her family or friends, her reading of the million online blogs about pregnancy. There's a lot of information out there is really hard to sort of nut out what it is that you want to take on board or not.
Patrick [00:04:42] Yes. So some of it's about looking at someone's motivation and in saying why, why? Why are they saying no to this treatment?
Patrick [00:04:49] And I think that really useful things to establish in this sort of scenario is communication. Yeah. As a private obstetrician, that's pretty easy because I see people who wanted to come and see me in the first place. I see them tons during the pregnancy and we build up a rapport and the communication is there.
Brigid [00:05:10] Yeah. And that's saying if if someone, you know, they're not seeing a private obstetrician or or a private midwife or whatever. And so they don't have that one on one communication with somebody you can still request to talk to somebody else within your your pregnancy or your birth can't you. So let's say, you know, if you are not getting through to somebody or they're not getting through now, you're just not communicating well. Yes. Then, you know, you might communicate well with the next doctor or the next nurse.
Patrick [00:05:36] So the next midwife. That's right. So. So that's part of of advocating for yourself within a public system or within a system where you don't see the same person every time.
Patrick [00:05:46] Yeah. It's just plain old true that if you're not seeing the same person every time, a lot of the quality of your experience is going to be up to you.
Brigid [00:05:55] Yes, that's right. And I think there's a lot to be said about being polite in this situation. So you say that woman is politely asking for more information or politely asking for somebody else. I know it's a bit unrelated, but just this week I was listening to the radio and they're talking about the Melbourne Shop Keepers Union. They released a report saying the abuse of shop assistants was just so high. I can't rember the percentage like it was 18, 20 percent or something like that. And it's a bit for the health professionals, too, isn't it? Like you guys do cop a fair bit of abuse?
Patrick [00:06:28] I think so. So I think someone trying to advocate for themselves should be polite because you don't want to have your birth in a hospital where you've fallen out with the care providers. That's for sure.
Patrick [00:06:38] So we're talking about a constructive discussion.
Brigid [00:06:41] And hopefully the person on the other end is also being constructive and not.
Patrick [00:06:45] Well, it absolutely worth works both ways. And that's for sure. Like, for example, if the patient says, I don't want to have a vitamin K injection for my baby or vaccination for my baby, then I don't think it's adequate just to tick the box saying refused. Yes. I think that we shouldn't be ticking the box saying refused until we've perhaps gone escalated the clinical question up to some more seniority. Some education has gone on. Yeah. This is why I think you should have those things. And then if we're still refusing, then you tick 'refused'. Yeah.
Brigid [00:07:17] Yeah. It's a bit belligerent just to go straight to like tick the box for refuse. It's just not good care. It isn't. So you know, in your experience, what are some of the common things that women can say no to.
Patrick [00:07:28] Well, some people say no to just about everything and deliberately seek out a model of obstetric care that doesn't involve health care professionals. I don't just mean obstetricians. I mean midwives or or anybody. And they are well within their rights to do so. But we certainly think that in Australia and in 2019 that we can't just assume that we'll get the same good results as everybody else if we don't go to the same lengths that those other people went to to get those good results. Does that make sense? Yes. Birth is safe because we do it well. Yeah. Yeah.
Patrick [00:08:10] Not by accident. Not by accident. Okay. All right. So I think it'd be useful to say, well, what are some tools that a woman can use to make her and her partner feel like they're part of the decisions or the decision makers in this process?
Patrick [00:08:23] Well, I think one of the things that really comes down to is, you know, openness of the communication, trust in the people giving you the info, but also knowledge if you want to know what you're talking about. Yeah, that's right. So, you know, you asked a moment ago, what what can you say no to it? Well, it's anything you like. I don't think people set out to say no to things. But I think that they might start to think, oh, I've read something about I've read something about an injection in my thigh during the third stage of labour to prevent post-partum haemorrhage affecting the success of breastfeeding. Well, before basing our decision not to have that injection on that information, which I never looked back whether it was true. Yep, it was me. So so higher levels of education. And unfortunately, that reliable stuff like that can be hard to find. Yes. I think I think when it comes down to it, if there's a bit of a I don't say dispute, if there's a disagreement between what's being recommended and what's being received, then the patient, the pregnant woman should feel that she and her partner are allowed are absolutely allowed to say, can I have more time to think about it? Could you explain to me one more time? Could you get somebody else to explain it to me?
Brigid [00:09:42] Or even can you just give me my partner a chance to talk about it without you in the room? Yeah. Go out. So we can have a yack. Yeah.
Patrick [00:09:48] Yeah, absolutely. And then of course, a really useful tool that's in common use in Australian hospitals is encouraging patients to ask questions along the lines of what are the risks and benefits of procedure X and what of the what are the risks and benefits of not doing procedure X.
Brigid [00:10:09] What happens if I do nothing? Yeah. All right. So that's that's tricky in some circumstances where the time pressure might be on. You know, if you if you've got to a point where you've you've felt like you've just been pushed from having this labour within a room to it being that there's a roomful of people sort of staring you down and you feel like you don't have a choice at that point in time. How would you help that woman feel good about decisions being made at that time?
Patrick [00:10:40] I think I would if we get to that point in the acute situation of the labour ward without ever having dealt with it. We're in a bit of trouble.
Patrick [00:10:49] Okay. Without you ever having talked to them about it before. I think that's a problem.
Patrick [00:10:53] Problem, isn't it? And one of the problems in maternity care, for example, is it might be brought up in an antenatal class that forceps are possible, but that's not the person who puts the forceps on three months later when you need the forceps.
Patrick [00:11:11] So the person doing the forceps in the in the acute situation where suddenly the fetal heart rate plummeted and we need to get the baby out straight away and everybody's stressed, to put forceps on. That person hasn't had a chance to talk to you about forceps. Yeah. Yeah. And so it is a complex situation where urgent things like that are not rare.
Patrick [00:11:31] And we're not we're not terribly good yet at really preparing people for the realities of childbirth. Yeah, people go to classes. I'm not convinced we learn enough and I'm not convinced we learn what we should do. Everything we should learn.
Brigid [00:11:45] Yeah. Yeah, exactly. We focus on normal situations and mostly it is a normal situation. But every woman within that normal situation has little sort of peaks and troughs of, you know, the boundaries of perhaps what isn't normal. And that can be a shock. Yeah. You know, for a woman who is expecting it just to be textbook. Yeah.
Patrick [00:12:04] And one of the one of the other problems is that we come at it from a different perspective. As obstetrician, you know, we're very focussed on safety. Yes. So. Safety for mother, safety for baby. But there's another dimension which doesn't get much of a look in sometimes, which is the quality of the experience for the woman. And she might highly value that more than safety. Maybe not, but she might really highly value that. And if, for example, a woman has her birth experience where ultimately she's fine and so is the baby. She may not still consider that a satisfactory outcome. There might be a lot of health care providers standing around patting themselves on the back, but she may not be pleased.
Brigid [00:12:48] Yes, her she might be actually seeing some part of that delivery as being traumatic. Absolutely. Yeah. So on that point, what can someone do if they've had a birth where they feel that they weren't listened to?
Patrick [00:13:01] Yeah. So I think that happens all the time. And debrief is important and debrief gives an opportunity to go through what happened. One step at a time. And for caregivers to to cover again why doing whatever it was in vacuum or force as an emergency. Caesar was considered a good idea at the time. And who's doing that debrief? Yeah, it's a problem. It's in a in a sort of a public hospital system. It's often not the people who were there. And that's a problem for patients, at least in private sector. It is the people who were there. So the benefit of it is to try and help the patient work through the way they're feeling about it and to clear up any errors of fact.
Patrick [00:13:53] Remember this happening and we can go to the notes and say well actually it didn't quite happen in that order or it didn't happen in exactly the way that certain person might remember it. And then the idea, of course, is to try and is to try and help that person heal from whatever's going on in their mind about the birth afterwards.
Brigid [00:14:12] And hopefully people have sort of put steps in place beforehand. You know, they've they've they know what they can say no to. They know how to listen to information as it's given to them to help them make their decisions. And they've learnt the way to make those decisions. So they feel empowered so they don't get to the point where they, you know, are in this sort of post-traumatic period where they need this debrief or seek legal redress.
Patrick [00:14:38] Well, there's that. Yep. Yep, that's right. So there's an interesting phenomenon where somebody can have a birth that did not go according to plan. That where there were complications. And yet it's still described by the patient as a positive and empowering experience. And it's because they've been able through good self training or good luck to shift the goalposts of what a positive, empowering birth actually looked like. So, for example, it is empowering in some situations to accept expert advice and to and to go down, and to be flexible and to go down a path that you didn't imagine you would. And that's not necessarily disempowering.
Brigid [00:15:23] And so we don't talk about that that much, do we? You know that people perhaps have gone down. You know, the birth hasn't proceeded how they expect it. We hear the negative part of that. Or maybe I do. Maybe that's my personality, that that's what I'm listening to. However, you know, like you said, there are some women that go. Yeah, I am. I had a 26 hour labour wasn't wasn't what I was, obstructed at four centremetres and had a section and there you go, I had a baby.
Brigid [00:15:51] It's it's such a big topic. And we really do need your help on this. So what we're gonna do is when we release this podcast, we're gonna put up a post on our Instagram page and that's @grow_my_baby
Brigid [00:16:06] And we would love to hear from you. When was it that you advocated for yourself? How did that feel? What could you have done better? What could we you know, health practitioners have done better? How can we work collaboratively to have a positive birth experience?
Patrick [00:16:21] I think that it would be terrific to be out to build on some sort of bank of experiences, possibly even some sort of education tool, so we can work so we can do better on this.
Brigid [00:16:33] Yeah. Speaking of education to all this is this is probably a shameless plug, but we did actually talk about it already and that is the birth plan. And as part of the Grow My Baby program, we have a pretty in-depth birth plan template. And that sort of is something that, you know, everyone's encouraged to do. I think that's about in the second module. Yeah.
Patrick [00:16:54] Yeah. I said some people think that their obstetrician is gonna be against the birth plan because they want the obstetrician might want the couple to be as open minded as possible about how it's gonna go on the day. I don't think those things are mutually exclusive at all. I think if you don't have a plan for something, how can it go to plan? I think we should be planning for the best. Yes, but a good birth plan should also include how am I going to approach it if it doesn't go according to plan? Given that with your first baby, intervention is not rare. So a good birth plan has to be deeper than than here is the music I want playing? Yes. It's got to look into how is it gonna look for me? Yeah. If those if if if something like that happens.
Brigid [00:17:39] How do I consent for forceps delivery or, you know, all that sort of thing is important for somebody to know because they're often the things that women are blindsided by, isn't it? And that's what they feel like, that they've been railroaded into a decision that they weren't ready to make.
Patrick [00:17:52] That's right. So we don't want everyone. You don't have to become a consultant obstetrician worth of knowledge about these things. But I think you need more more knowledge than we've given people in the past. Yeah. All right.
Brigid [00:18:04] Excellent. Well, I hope that was useful, people and thank you once again for listening. We're getting very excited by everything that's happening with the podcast. And we love it when you come over to our Instagram page and follow us there. And please just get on and tell us what you think of this episode. That'd be great. Thanks for listening.