As you now know, your informed consent is required for every procedure that takes place in hospital. That means any time an intervention is offered or suggested, no matter how minor or major, it is a legal obligation for you to give your informed consent. Without your consent, anything that happens to you could be considered assault. This makes the issue of ‘giving consent’ a serious one (for women and caregivers alike) and an important topic to get to grips with.
Ideally you’re now feeling confident and empowered, knowing that you are in charge. That’s all well and good, but what happens if things do become challenging and medical professionals are sharing their recommendations? How do you ensure you’re not just sitting on that conveyor belt of care? How can you ensure it is you who is making the decisions and calling the shots? Most importantly, how can you ensure that you are fully informed and in a position to make those important decisions?
In this chapter I’m going to teach you a very easy but invaluable framework that you can use to ensure you have all the information to make informed decisions. This framework can be used for absolutely everything and it’s a good idea to make sure your birth partner is familiar with it as well, as they are more likely to be the one using it when you are in labour.
Remember, not only are you responsible for making the decisions that need to be made, but the responsibility to ensure you’re fully informed before making any decision is also yours. This is important stuff!
So how can you ensure you’re making the right choice for you and your baby?
You just need to remember to use your B.R.A.I.N. This handy little framework isn’t just useful for navigating birth but, as I said before, it’s great for all of life’s big decisions. It’s another life skill.
So let’s run through what B.R.A.I.N. stands for:
B is for BENEFITS
R is for RISKS
A is for ALTERNATIVES
I is for INSTINCT
N is for NOTHING
These are the things you need to establish before making any big (or small) decision. By working your way through this list and understanding each element, you’re ensuring you have all the information available and are in a position to make a properly informed decision that is right for you and your baby.
So let’s dig a little deeper.
What are the benefits of the proposed action/intervention? Essentially these are the ‘pros’ of accepting and giving consent. If an action or intervention is being offered, it’s likely you’ll have been told the ‘pros’ already, but if not, just ask: what are the benefits of saying yes and doing this? Once you’ve established these, you move on to the next point.
What are the risks of the proposed action/intervention? These are the ‘cons’ of accepting and giving consent, which you may not have been informed about. Essentially, you need to weigh up the pros and cons in order to make a decision. Do the benefits outweigh the risks? Or do you feel the risks are too high?
As much as we’d like to believe that there will always be a straightforward, clear-cut answer here, the likelihood is that most decisions are a little more complex. Occasionally there will be an obvious answer, where the benefits far outweigh any potential risks, but, more often than not, it’s a much closer call and people will come to different decisions.
And that, by the way, is totally fine. Your friend, your colleague, your own mum might make a different decision in the same set of circumstances, but what’s important is that you go with what’s right for you and not what someone else would do. Remember, we are all individuals: we have different thresholds for what is acceptable to us, we want different things – or at least different things matter more to different people – and we have all had different life experiences. We are not going to always make the same choices. That’s the beauty of being an autonomous individual.
This nugget of advice extends well into parenting and all the debates that you will have to navigate: breast vs bottle, co-sleeping vs a standalone crib, baby-led weaning vs purees. Being a parent means facing a never-ending series of seemingly serious and important decisions that need to be made, decisions about which everyone has a strong opinion. But the only opinion that ever matters is yours. Remember: your body, your baby, your choice! Learning to not be influenced by others, but rather feeling sure of your own decisions, trusting you know best for your baby is another life skill.
So, ask explicitly what the risks are of saying yes and consenting to what’s being offered. There are always potential risks or ‘cons’ when making decisions. Nothing is so straightforward in life that it can be guaranteed to be 100 per cent safe and without any chance of negative implications. Life isn’t so black and white. Understand what the potential negative consequences could be, and weigh this up against the benefits to decide what course of actions feels best for you.
What are the alternatives to the proposed action/intervention? This is an important one to ask and consider within the pros vs cons mix. Are there any alternatives? Often there are. And it might well be the case that these are preferable to you.
As I said before, what’s usually offered by the NHS is a course of action that is considered safe, first and foremost, but one that is also cost-effective. This means there are often alternatives that are not offered up as the first option, because perhaps they cost more, take longer or use more resources.
A good example of this is induction. The NICE guidelines state that a woman should be offered increased antenatal monitoring at least twice weekly as an alternative to induction. This is rarely offered in practice and, unless you know about this or think to ask about alternatives, you won’t even know this is an option available to you. This means you might potentially agree to an induction without understanding its associated risks, and without knowing you had any other options – that there were alternatives. I’ve heard this so many times and, indeed, lived this experience with my first.
So always ask, are there any alternatives? Sometimes when it comes to things progressing slowly, you might be offered an intervention to speed things up. However, if baby is well and you are well, you might well decide that a good alternative course of action would be to dim the lights, remove unnecessary people from the room, do a little relaxation practice and get your natural oxytocin flowing again.
There’s a great quote I always mention at this point when teaching and that’s:
‘If I don’t know my options, I don’t have any’ (Diane Korte).
Do not be afraid to ask and establish what your options are. There are always options and it’s always your choice.
What is your instinct telling you? Your instinct is a powerful thing and is part of the reason we are all still here today! All mammals behave instinctively and although we have, of course, evolved, we are still mammals with this powerful intuition within us. The problem is we tend to forget and ignore our instincts because we have been conditioned to process everything and make decisions with our heads rather than our instincts!
In birth, when you are deep in the zone, your instinct will be even more powerful than it has ever been before. It will take over. It will be almost tangible. You will feel your body do amazing things and know what is happening within. Midwives should encourage you to listen to your body and do what it needs to do. Nothing is more powerful than a mother’s instinct in birth. It’s highly tuned. So tap into it and don’t be afraid to do so.
Remember, you may be surrounded by experienced birth professionals with years of experience working on a labour ward, you may be a first-time mum, you may never have done this before, but you are the only person in the room who can feel what is happening! You can feel reassured and confident knowing that you do know what’s happening and you do know what’s best, because it’s happening inside you! You know your body better than anyone else, it’s your body after all. You will know what feels comfortable and right for you, and what doesn’t. Don’t be afraid to let your instinct guide you.
When it comes to making decisions, when you weigh up the pros and cons, when you consider the alternatives, remember also to listen to your instinct – what feels like the right course of action for you. You know you! What does your gut tell you to do?
Parental instinct is established in pregnancy and certainly it’s very active in birth. You know best. Listen to that powerful instinct of yours. Take it into consideration. Ask yourself: does this course of action or proposed intervention feel right for me and my baby?
What happens if we do nothing?
This final question always seems like a bit of a throwaway one – an afterthought. But actually, it can sometimes be the most important one to ask.
What happens if we do nothing . . . for five minutes? Ten minutes? An hour? Four hours? Twenty-four hours? A few days? Another week?
You see where I’m going with this . . . Depending on the situation you find yourself in, the timescales might shift. If things seem critical you might be asking for a few minutes to get yourself into the right head space; if your waters have broken and you’re feeling under pressure to agree to an induction because labour has not yet started spontaneously, you might be asking for a few hours; if your baby is breech and you’re considering a planned caesarean you might be asking for a few more days to make your decision and to give your baby the opportunity to turn; or if there are concerns about baby’s growth (big or small) you might ask to review the situation in a week and opt for monitoring in the interim.
There are too many potential scenarios for me to list here, but asking for a bit of time when making a decision (even just a couple of minutes) is almost always a good idea. I say ‘almost’ because we know that emergencies can happen, as they can in any area of life or any given day. And in the extremely rare event that a true emergency is unfolding, it might not be appropriate to delay. A true emergency, in which every minute matters, is the only situation where asking for some time might not be helpful. In all other situations, asking for time is hugely beneficial. If you feel you’re being put under pressure or rushed and you’ve established it’s not a medical emergency then you can always ask for some time – even if it is just a few minutes. In that time you can process the new information, ask any necessary questions, reach the right decision for you and your baby, and be in a position to give informed consent.
In the majority of cases, being rushed into making a decision or put under pressure results in more negative than positive feelings long term, leaving room for regret and what ifs. Nobody likes feeling that they were forced into something. We enjoy and value our own free will! Reaching a decision yourself, even if it means opting for whatever was initially proposed, will leave you feeling empowered and confident as you navigate your birth and any twists, turns and deviations from the initial ‘plan’ it might take. These feelings around your birth will stick with you forever, so make sure they are happy positive ones. Don’t be rushed into anything or pressured to conform to a one-sizefits-all approach.
If there’s ever any doubt as to whether or not the situation is an emergency one, simply ask the question: Is this a medical emergency? You should be able to trust that the team providing your care will be honest, and if they confirm it’s an emergency, then stand back and allow them to do their lifesaving work. In real emergency situations it’s normal for the mother to be put to sleep under a general anaesthetic and for the birth partner to be asked to leave the room. However, real emergencies are extremely rare. And if we got caught up worrying about every tiny risk that exists in life, then we might never leave the house. Life-threatening emergencies can, quite literally, happen anywhere – crossing the road for example. But thankfully they are rare and extremely so when it comes to giving birth.
The process of making the decision and using your B.R.A.I.N. is an important one to work through and is what offers long-term benefits from a mental health perspective. Often, we get so caught up in ‘the plan’ or focused on this single image of what our dream birth should look like that we start to believe any deviation from ‘the plan’ is a failing and means we didn’t get the birth we wanted. I encourage women to think differently . . . it’s not what birth looks like that matters – ultimately it doesn’t really matter if you’re at home, or in a pool or in theatre – what really matters most is how you felt during that experience. It’s the feelings attached to the memories that last a lifetime and not the mechanics of how a baby entered the world. You might well have created a set of preferences (and it’s definitely a good idea to do so) but they need to be adaptable: pregnancy and birth can be unpredictable. A positive birth, which is something we all strive for, is a birth experience that leaves a woman feeling empowered rather than traumatised, where the mother’s wishes are respected, she is listened to and feels calm, confident and informed. Water birth, caesarean birth, whatever – it’s not a particular type of birth.
Having helped hundreds of women prepare to give birth and seen them come out the other side, I know this to be true: it’s perfectly possible to have a positive experience wherever and however you give birth. You may have a dreamy natural water birth at home, you may have a planned gentle caesarean or even an unplanned caesarean, but all of these births can be positive, empowering and happy experiences. On the flipside, having spoken to so many women about their previous birth experiences, I know that it’s equally possible to suffer from postnatal depression and post-traumatic stress disorder after an unplanned caesarean as it is after a birth that might appear straightforward and uncomplicated on paper. Just because a woman had a natural water birth without pain relief doesn’t mean it felt like a positive experience to her. She may have felt frightened, panicked, unsupported; she may not have felt respected or listened to, and she might not have understood what was happening. These are the things that can make birth feel traumatic.
So, can we make sure we have a positive experience whilst remaining open-minded as to how that birth happens? Can all births really be positive? The answer is yes! If a woman feels in control as she navigates her birth experience, feels calm, confident and well supported and is empowered to be able to make the best decisions for herself and her baby then, even if ‘the plan’ changes, the woman can still feel that it was a positive experience because she knows in her heart that she brought her baby into the world in the best way possible on that day. And that is what matters. So, take your time to make the decisions that need to be made. Ask that vital question; what happens if we do nothing for x amount of time?
Let’s try out the B.R.A.I.N. method using internal examinations as an example. They might be routinely conducted, but . . .
• They’re invasive
• They can be uncomfortable
• They can hinder a woman’s relaxation and make her feel anxious
• They can cause the cervix to regress and close up
• They don’t give you any indication of how long there is left to go
• They don’t let you know anything about baby’s well-being
• The measurement is subjective
• There’s a risk of rupturing the membranes
• And a risk of introducing infection
If you apply the B.R.A.I.N. framework and weigh up the benefits (knowing approximately how many centimetres dilated you are and whether you’re making measurable progress) against the risks (outlined above) you might decide the risks outweigh the benefits. Or, you may feel the benefits outweigh the risks. You might choose to decline all examinations or just some. You could always opt to defer the initial examination, usually offered on arrival at a birth centre or hospital, until the point at which you feel settled into the new space and relaxed. It’s absolutely your choice as to when or even if you have an internal examination.
Remember, too, the ‘A’ from your B.R.A.I.N. framework. A is for Alternatives and there are other ways to assess progress. These include using a mirror so that the midwife can see what is happening without having to invasively examine you or even touch or disturb you. Also, through observation: are the surges coming more frequently, are they lasting longer, are they becoming stronger? What sounds is the woman making? All of these things are indicators that labour is progressing well.
Don’t forget to tap into your instinct. Will this examination aid your relaxation? Will it tell you anything important? Remember, internal examinations aren’t normally used to check on baby’s well-being; baby’s well-being is monitored by listening in regularly to their heartbeat. And an internal examination can never tell you how long is left! Which is what most women want to know. Women can dilate very quickly or slow down depending on so many factors – many of them external and environmental factors. So, knowing how dilated you are in this moment doesn’t indicate how long it will be until you are fully dilated. Also, it’s an estimate with someone’s fingers, and that someone may as well be blindfolded. It’s not exact.
And then, N for Nothing! Ask if there if there are any potential negative consequences to declining an internal examination at this time. You can always decline or postpone an internal examination. It is your choice. You have the absolute right.
Nobody has the right to put their fingers inside your vagina without your consent, or pressure you into saying yes. Not in a nightclub (where it would be considered sexual assault) and not in a hospital. It may seem obvious but so many women have told me they thought they had to have internal examinations.
No matter how seemingly innocuous or routine what’s being suggested appears to be, always engage your B.R.A.I.N. prior to making any decision, and, more crucially, before saying yes and giving consent. Do not be afraid to ask questions! It is your responsibility to ensure you are fully informed and the easiest and best way of getting informed is to ask questions of the experts. Never feel you’re being difficult by doing so, or that you’re not equipped to challenge medical professionals. I’ll say it time and time again: this is your body, your baby, your birth and most importantly your choice! You’re in charge! And just in case you’re having a wobble in confidence, always remember you are a strong, capable individual and well able to make the right decisions for yourself and your baby. You’re growing a human. You’re a walking miracle! And a bloody superwoman! Never forget it.
Finally, make sure your birth partner(s) are familiar with this B.R.A.I.N. framework too, because when you’re in active labour you might not be in a position to think clearly, ask questions, process the information and advocate for yourself. If you’re in the zone and breathing deeply through your surges, you’re going to need your birth partner to step up here and help you by gathering the information on your behalf. So, make sure they know to ask: What are the benefits? What are the risks? Are there any alternatives? What happens if we do nothing for the next ten minutes? They can then relay this information to you between surges and you can weigh up the pros and cons, consider the alternatives and check in with your powerful instinct to make the decision that’s right for you and your baby. Your birth partner cannot make any decision for you – you need to be the one to give informed consent – but they can help massively by stepping up, using their B.R.A.I.N. and asking the necessary questions. You can imagine how easy it would be otherwise – when in the midst of labour – to get swept along that conveyor belt of care, consenting to things without fully understanding the whole picture. When you are in active, established labour you are vulnerable, and this is when you need your birth partner most to advocate for you, ensure your wishes are respected and get the facts for you if new decisions need to be made.
Fold the corner down on this chapter and get your birth partner(s) to read it. I mean, ideally, they’ll read this whole book, but if that’s not looking likely, get them to at least read this bit!
Positive hospital birth – Hayley, second-time mum
My baby was born about two hours after arriving at the delivery suite after my surges started naturally at forty-one weeks and one day. He was born naturally with no pain relief and very little interference from the midwives (one student and one midwife), with en caul and weighing 7lb 2oz. He is absolutely perfect!
The midwives were so incredibly supportive and respectful of our wishes. I could feel early on that baby was back to back (as was my first baby), but they only told me after he arrived so as not to be in any way discouraging. They barely spoke, only offering encouragement towards the end of a surge. I must say my husband was an incredible support, and, together with the midwives, I felt so safe that I was able to keep my eyes closed and focus on listening to my music.
The biggest difference between this and my first baby’s birth was my taking control of my care throughout rather than relying on people to tell me what was going to happen. I’m not the most confident of women but the feeling of empowerment that Siobhan instilled in me is remarkable. I was able to communicate with my husband about the birth so he understood the importance of being calm and quiet and in control. I was able to communicate better and confide in my community midwives, who were all very interested in hypnobirthing (if not entirely experienced) and supportive, and I had the confidence to question the consultant (who was very kind but still from a very medical place, of course) and after using my B.R.A.I.N. avoided later growth scans which were causing unnecessary stress to me and my husband.
I’m so incredibly grateful. I feel confident and relaxed with my new baby and I’m thrilled to be home with my family. Hypnobirthing really has been a game changer. And babies really do come when they’re ready!’