Active management and
the bullying of women in labour

Patient bullying is a relatively new concept. In recent years, it has surfaced as an issue in relation to care of the elderly. The bullying of women in labour, however, has yet to surface.

This is one woman’s story. She was having her first baby at the National Maternity Hospital, Dublin, at the age of 34.

"They talked about active management at the hospital antenatal classes: ‘Labour can be painful but active management ensures you won't be in labour for a long time. We will break the waters if they haven't already broken. If you haven't made progress within a reasonable space of time, we'll give you oxytocin.'

"I didn't want the waters broken. I knew the waters protected the baby's head by keeping it off the pubic bone. There was a higher risk of fetal distress with breaking the waters, and it could make labour more painful.

"My birth plans said that we wanted the labour to proceed at its own pace, that I wanted to be able to move around, to change position. That I didn't want electronic fetal monitoring, or the waters broken, or an episiotomies, or an epidural. That my partner wanted to be able to cut the cord, if possible. That the room where the baby was to be born was to be quiet. That I wanted to breastfeed.

“We arrived at Holles Street at about 3.30 p.m. I'd been in labour for about 14 hours. The contractions were now five minutes apart and lasting one minute. They said I wasn't quite in labour. After an hour, they said: 'We were onto your consultant and we would like to break the waters.' I didn’t want them to.

"They threatened me with monitoring, with repeated vaginal examinations. Two more senior midwives came in, the one who did the internals and another one, who might have been a sister. They stood at the end of the bed and said: 'We'd really advise you to let us break the waters. If you don't let us, we'll have to monitor you all the time, and we'll have to do hourly vaginal examinations.'

“They were in control. I wanted to be up, and they kept telling me to lie down. Then they said they would monitor me for 30 minutes, and let me walk around for 30 minutes. They kept on saying: "We want to break the waters". The second internal was extremely painful. I believe the midwife was trying to break the waters.

"It was really intimidating. When I was having a contraction, they would stand there saying nothing and wait for the contraction to pass, and then start again. I lost track of time.

"They said they were on the phone again to the consultant, that they wanted to break the waters. Finally I had to let them. I felt I had no choice. I found the procedure extremely unpleasant and extremely painful.

“By then, I'd been there five hours, and I was five centimetres. I was not dilating in line with their charts. They were doing continuous fetal monitoring. They wouldn't let me sit up.

“Then they started talking about oxytocin, saying the consultant said I should have it. I didn't want it because I knew that oxytocin makes the contractions stronger and more painful. Also because I wanted the birth to be as natural as possible. Oxytocin didn't fit the bill.

" I said I didn't want the oxytocin, but I finally agreed to let them put up the drip. I felt bullied into it.

"I was on gas and air by then. There were times when I didn't know what was going on - it must have been the effect of pure oxygen. 'I want to walk around', I said, but I couldn't get off the table.

"After I got the oxytocin, the contractions went out of control. They were hot and heavy. I couldn't get from the table to the shower. I found the shower great [for the pain].

"I got to ten centimetres. The midwife was shouting at me to push. I was pushing alright, but I knew myself nothing was happening. 'You're not pushing', they said. I felt like a slab of meat. They lifted me up, they lifted me down. The baby's heartbeat dropped.

"They said they'd have to do an episiotomies. The baby was in distress. The consultant then came in to do the episiotomies. I could feel the doctor cutting me. The midwives’ hands were on my shoulders, getting me to lie back down on the table.

"There were quite a number of doctors and midwives in the room by then. They used forceps. The baby’s head was turned slightly in the wrong direction.

"They lay her across me. I didn't know what was going on. She was lifeless. Once the cord was cut, they took her over to the table and resuscitated her. She woke up after a couple of minutes and opened her eyes.

"I had a sense of it being all over. The consultant delivered the placenta and stitched me up. The nurse brought me tea and cleaned me up.

"How did I feel? Relief - that it was all over. I didn't know what was going on. I just knew I had no baby and I was very tired.

"She was born at 1 o'clock in the morning. Afterwards, it felt very strange. I was, like, 'what was that all about?'

"She was in the Special Care Baby Unit. The nurse said she was on the critical list. It just didn't make sense to me.

" I was in a state of shock. She wasn't reacting. She was sleeping, not responding. They started tube-feeding her on the second day. She had a brain scan, but nothing showed up. Then she started to respond.

"The second morning after the birth, I woke up crying. The tea-lady saw me and came over and gave me a big hug. One nurse asked me how I was and she said to put it down to the 'baby blues'. Every so often, I would start crying.

"I was in for five days. The breastfeeding didn't work out. Two weeks later I was still in floods of tears. I was getting panic attacks. I was having flashbacks. The Public Health Nurse visited me.

"Twelve weeks later, the episiotomies still had not healed. I was in a lot of pain. I couldn't sit down properly. When I went to my GP, I burst into tears. I told him everything that had gone on. He talked about postnatal depression. He said I was suffering from post-traumatic stress syndrome stemming from the actual labour. He gave me anti-depressants. The plan is to stick with them for another couple of months.

"I never felt I couldn't cope with the baby, but I was having nightmares and getting panic attacks and flashbacks. Gradually the flashbacks started to decrease, and the panic attacks calmed down, and the nightmares. I started to sleep better. Now I can talk about it without having to rush out of the room [to cry[.

"But the episiotomies was like female mutilation, genital mutilation. There are areas down there, areas of numbness, where I can't feel anything, areas that won't go back to the way they were before. The area is all battered and scarred.

"The birth affected my whole life. Before that I was a very confident person. I have a fairly senior position at work and I need to be confident. Now I find myself taking everything personally. It's harder to deal with hassle. I wouldn't people at work to know [what I went through].

"My daughter is now six and a half months old. It has put me off having more kids - I would be afraid.

"What concerns me most about it all is all those other horror stories you hear from other women. But they feel they can't talk about it. They don't want to scare off women who've never had a baby.

"The psychological bullying was the worst. To me it was a physical assault. It was psychological intimidation. It was like rape.

"I wrote to the Master. He wrote back and said: 'Talk to your consultant.' "The consultant was very sympathetic but patronising. The midwives wrote back to me, saying: 'All the procedures were done in the best interests of baby and mother, and with the consent of your consultant.' They had written in the chart: 'Waters broken at patient's request.'

In his letter to us, the Master said: Although the National Maternity Hospital is famous for active management, we are the hospital which attracts more birth plans than any other…It is our belief that patients should have an active choice in their mode of delivery, and I would refute any claims to the contrary.'

Published in The Northern Standard
Thursday 20 March '03