So I was doing a 36 week birth talk, discussing said choices…

I’ve done many birth talks. They’re kind of my thing. I go a bit theatrical, I’m afraid, but I pride myself on giving the woman all the information she’ll need to be fully prepared for the marathon that is birth. Make sure she knows all her options. So she can choose what’s best for her. Girl power, you get me? Except that recently, I’ve been having niggling doubts about this whole informed choice concept. Don’t get me wrong, I’m fully in favour, of course I am but… what my birth talk boils down to, if I’m honest, is this:

1)If you are lucky and the gods are with you, will be pushing a baby out of your vagina with minimal help.

2)Should you require our help (which comes 100% recommended by me if circumstances dictate that you do), chances are that you’re not going to like it.

3)It’s gonna hurt. There’s no Stork.

So I work hard to make these unpalatable truths a bit less hideous. Emphasis on healthy baby. Talk up the epidurals.

The truth is that all of us midwives and doctors and anaesthetists, sonographers, baby doctors (yes, there a myriad others) work really hard to make sure that neither mother nor baby ever sees the inside of an Intensive Care Unit. It’s a no-brainer, right?

We’ll scan baby with a thoroughness that will blow your mind to make sure there are literally zero surprises. Even do intrauterine surgery in some extreme cases. At the very least we know if we’ll need a team of baby doctors at birth, and we can make sure that birth happens in an appropriately resourced hospital, in theatre if need be. Which is fab, unless you wanted a home birth.

If you so much as threaten to develop high blood pressure (as an example), we’ll see you pretty much every week, give you life-saving drugs, we’ll induce you early to make sure those readings stay reasonable and you don’t die of an eclamptic fit. Which is great but what if you don’t want an induction? We induce for all sorts of reasons now-a-days, and every body has heard the horror stories. And there goes your lovely drug-free home birth… But because your blood pressure is so well controlled, and because your baby is monitored with unbelievable vigilance, you will both do really well. Even though there’ll always be a part of you wondering if it wasn’t overkill, after all, you never felt ill and your blood pressure was never that bad… I guess it’s like buckling up and obeying the (ever decreasing) speed limits. You hate it, but you know it makes sense.

Of course, fewer and fewer women now have to live with the consequences of us NOT having taken over your uterus. That’s a good thing, I believe that. But there’s a cost. The feminist in me has to accept that if we go down the medical model of childbirth where we practice very high surveillance on every single woman because we believe that maternal and neonatal mortality should be consigned to history, then informed choice is no longer a thing. I mean, it’s a thing, but only up to a point. Oh dear gods, has this feminist been institutionalised?

Soooo, I’m talking to my client, let’s call her Anna, and I’m explaining how we plan to help her if things don’t go according to plan A. Bottom line, the pain might be a bit much, she might find that the TENS machine and the gas are beyond useless, she might need an epidural. In my mind, that’s an easy one: take the epidural, Anna, it’s safe and it works. But no, Anna has heard terrible things about epidurals. Seriously Anna, epidurals are the least objectionable ways we can help you, I can promise you that. No, you won’t be paralysed, no, it won’t slow things down (in fact you are having it because things aren’t progressing too well, you’re exhausted, you need to sleep then you stand a chance of pushing this baby out). And yes, you can push with an epidural. I’m not saying Anna must have an epidural, she might cope just fine. But she should know that it’s a safe and effective option. Informed choice.

OK, now it gets more complicated. Anna, you might get to second stage (with or without an epidural) but although you’ve been pushing like a woman on a mission, nothing is happening. That baby hasn’t read the birth plan and she’s got herself stuck. Worse, she’s beginning to show signs of distress. She needs to be born. We can help, but we’d have to use the suction cup or the forceps. Anna disagrees. It’s right there on her birth plan: she does not want that. And who can blame her. But here’s the crux of the problem with informed choices: how can she reasonably refuse? That’s a rhetorical question: she can reasonably refuse because that baby has zero rights until it’s born. So sure, Anna, you can refuse, but what then? The situation is time sensitive and the consequences of leaving it too late to deliver that baby are not great. I mean sure, babies are resilient, and sure, we’re all trained to resuscitate a flat baby, but do we want to risk it? Does Anna really understand what’s at stake? And it’s not just the integrity of her perineum (it will heal). The brutal reality is that when push comes to shove (pun very much intended) Anna will undoubtedly ‘choose’ the instrumental delivery. Let’s be honest, she’d give up a kidney in a heartbeat for this baby, so what’s the big deal? We will endeavour to make the experience as dignified and as painless as possible. She will push, the obstetrician will pull, and Anna will have a healthy baby. It’s a bittersweet ending to Anna’s dreams of childbirth, emphasis on bitter. It’s not what she wanted.

Somehow, during my birth talk, I have to spin this in a reassuring way so she goes home feeling empowered. That’s a midwife’s job: making the unbearable bearable; the unfeasible feasible. I’ll spend 45 minutes (technically I only have 30, but who’s counting) going over all the possibilities. There will be sound-effects. Some pretty terrible mum jokes. Against all odds, I’ll make Anna laugh. The words ‘just in case’ are grossly overused. As is the phrase ‘you’ll be fine!’ Because she will be fine. Maybe not immediately, but I make sure she knows that too. Birth is a big deal, it’ll take some recovering from. And we can’t all be Princess Catherine.

The thing is, we all want the same thing. We all want that healthy baby. And you know, Anna did (probably) choose to get pregnant, so she kinda has to deal with the consequences, right? So what’s the problem? Maybe I’m overthinking it but it seems to me that Anna doesn’t really have any meaningful choices if her baby is considered at risk of harm. Maybe that’s not such a bad thing, but perhaps we ought to be more honest about it from the outset. We could say: Anna, you’ll resent us for intervening in truly unpleasant ways, but you’ll sue us if we don’t because you will be left holding the (disabled) baby. Your partner can walk away when it all gets too much but you, Anna, are the woman, the mother. You have two choices: frying pan or fire.

Of course I don’t say that. None of us do. All I can do is prepare her. Emphasis on healthy baby. Because pregnancy and birth, that’s just the beginning of Anna’s journey into motherhood. The next 18 years are going to be gruelling. One of her biggest challenges: getting her daughter to understand that we don’t always get what we want; if we’re lucky we get what we need. For the record, despite my valiant attempts to impart it, none of my 3 kids have on-boarded that important message. I won’t tell her that either!