WHY IS HOW WE TREAT WOMEN IN LABOUR MORE IMPORTANT THAN WHAT WE TREAT THEM WITH ?

There is one thing that is absolutely undeniably pivotal when it comes to caring for pregnant and birthing women. Whether you are a friend, loved one, doula, midwife, nurse or obstetrician-this one thing is really the the most influential concept you need to keep at the forefront of your mind. This notion that I am talking about is the concept of RESPECT. Sounds easy-right? Let me break it down for you…

According to Webster’s Dictionary, Respect is:

“A feeling of admiring someone or something that is good, valuable, important.”

“A feeling or understanding that someone or something is important, serious, etc., and should be treated in an appropriate way”

I think all of us can agree that pregnant and birthing women deserve our respect. These women deserve the respect of the general public, but most importantly, they deserve respect from their care providers. So why is this often so difficult to find in healthcare these days? Why are women and their families often up in arms about the way they are being treated? Or even worse, why are women suffering in silence? This is because our behaviour as care providers and the general public is often anything but respectful. I’m going to break it down even further to help elucidate my point. RESPECT…

Real

Empathy

Silence

Patience

Encourage Autonomy

Compassion

Talk

“R” stands for REAL. We as birth workers and care providers need to be real. This applies to everyone. It doesn’t matter how much schooling you have or how many births you have attended- you must meet the woman at her level. This means that you need to talk with her and her partner like they are on the same playing field as you are. Sometimes this means sharing a personal story about your own birth, or discussing something completely unrelated at her prenatal appointment because that is where the conversation took you. It’s about showing the woman that she can tell you anything; her fears and her desires. Opening yourself up by being real can make a world of difference for the labouring/birthing woman. In practice, I’ve heard many preceptors/ mentors tell students not to do this because it is unprofessional. In fact, I find that transparency and being authentic builds trust. You want women to feel at ease around you so that their stress levels drop and their oxytocin levels rise (so their uterus contracts and they have the birth they wanted!). So- be genuine and kind!

The first “E” stands for EMPATHY. I’ve mentioned in previous posts why this is so important but I cannot stress this enough. If you cannot empathize with the pregnant/labouring/birthing vulnerable woman then birth work is going to be a tough road for you. You have to sit with that woman and her family, be totally present (I know this can be hard to do some days), and treat her like you would want to be treated. Would you want someone to come in and perform a vaginal examination without asking for permission? Would you want someone to tell you “how this is going to go.” Maybe you would, but I know most women don’t. They may not speak up at the time, but having a care provider who is cold, disconnected and clearly demonstrating a “business as usual” demeanour is not going to express empathy and therefore not be conducive to labour or birth.

“S” stands for SILENCE. Sometimes we need to shut up! Sometimes we need to say nothing and just listen. The care providers that say “hey, how are you really doing?” and stop and let the woman tell her story uninterrupted, not hurried or rushed, can leave the most lasting impressions. I can remember many times the need for silence and active listening. For example, at a birth, when things were happening quickly there was a woman agreeing to have a c-section because she was “stuck at 8 cm for too long.” I remember saying, “Okay stop, we need a minute to discuss this because I am getting a sense that she doesn’t feel this is a good idea, or she is holding something back from us.” Just giving the woman that extra minute to process, breathe and explain what she was thinking and feeling can set the stage for a COMPLETELY different birth. I understand care providers are busy and there isn’t always time for this, but we have to consider whether there is time for this and we just aren’t using it.

“P” is for PATIENCE. Patience and Silence go hand in hand. For anyone who knows me as a midwife or has been in my care, you know that my clinic appointments are almost always behind. Usually on average 20 minutes or so behind. In the world of midwifery that is a long time. That is because I do my very best to sit, listen and to be patient. I need to understand what the client is telling me so that I can help them find a way forward with whatever their concerns are. I need these women to feel heard. Sometimes when the birthing unit has a ton of inductions booked and you are being pressured to intervene (break her waters etc), you need to wait until SHE is ready. This makes a huge difference in how she approaches her birth. If we can do this more on her time (but before she is really exhausted of course) then we have shown her respect. The other aspect of patience  is that if you are so incredibly busy as a care provider and can’t spend sufficient enough time with the patient to listen to her needs, then we need to listen more to her midwife, nurse or doula (whoever is watching over her) because chances are they have been listening when we couldn’t and will know better what she wants and needs.

The final “E” is for ENCOURAGING AUTONOMY. Respect for autonomy is a key component of biomedical ethics. Respect for autonomy is usually associated with allowing or enabling patients to make their own decisions about which health care interventions they will or will not receive. Some health care providers spend a lot of time educating women and their families so that they can make use of their autonomy and make fully informed decisions. Other care providers gloss over autonomy and find it easier to tell patients what to do. It is true that while some women do want to be told how, when and where to have their babies, I find the majority of women do not. Many women aren’t even aware that they can refuse and decline interventions. This can set them up for a tremendous amount of guilt later on when they say things like “I should have known or I should have spoken up, I didn’t know I could have refused.”

“Showing women RESPECT means that we honour their wishes and understand that coercing them to consent (or bringing the same recommendation up over and over again after they’ve declined or refused treatment) is not helpful. It doesn’t derail birth PLANS, it derails BIRTH- plain and simple.”

So what do we do instead? We honour their decisions, document carefully and support them in their choices.

“C” represents COMPASSION. Compassion is key! Whether it’s drying a tear, holding someone’s hand, asking a student/colleague to leave the room knowing that their presence is making her uncomfortable (unable to birth). Compassion is treating someone like they are human, and not another number. Compassion is dimming the lights and covering their vagina up until it is absolutely necessary to view. Compassion is avoiding a vaginal exam unless it is necessary, and I mean REALLY necessary! Compassion is calling the anesthetist back again and again when the epidural is taking a long time to come. Compassion is telling the woman what you are seeing and feeling as you work, to keep her in touch with what is going on. Compassion is explaining exactly what you are doing during a vaginal exam even though you know she has an epidural and can’t feel it. Compassion is explaining what is going on when the baby is being carried to the infant warmer for a much needed examination. It is reminding the neonatal team that the baby doesn’t need to be bundled in two blankets because he’s going straight onto her chest for skin-to-skin contact. All of these little acts of compassion are what women will remember. These are the things that can make what is remembered positive instead of negative, things that help her enter motherhood without unnecessary guilt.

Finally, “T” is for TALK. This might be one of the most influential of all the characteristics I’ve discussed. We as care providers and the general public need to understand how our words pierce the ears of women. What we say can shape a woman’s pregnancy and birth like nothing else. Let me explain:

Sometimes a care provider says “ Your cervix is ONLY 2–3 cm dilated, we have a loooooooong way to go, you aren’t even in labour yet.” What she hears is “Oh no, these contractions really hurt, and if you are not even in labour yet, how are you going to be able to cope when you are in labour?”

Your care provider says: “You’ve been at this for a really long time and it’s just not working, your baby is probably too big for your pelvis.” What she hears is “This is all taking an abnormally long time, and it’s your fault that your baby got to be so big. You got the epidural and now you can’t birth vaginally.” Sure, we don’t come out and say this to women, but we have to remember that women don’t always know the in’s and out’s of why labour slows down so we as women naturally assume it is something inherently wrong with us.

“Let’s pretend for a second that maybe some babies really are big and don’t fit easily, do we think that telling women this outright will increase the odds of a successful vaginal birth?”

I am supportive of laying it out for women- in terms they can understand. If I don’t think a baby will fit out of her vagina- I will say so but I have to understand that by saying so, I have just changed the entire course of the labour and birth- because I have now put fear and doubt in her mind (So I better be sure!). This changes the equation out of favour of a vaginal birth. If she ultimately doesn’t end up birthing vaginally- well then I was right! ( Or I just made her feel like crap, her stress level sky rocketed and her uterus slowed down). All of these questions or concerns could have been re-framed to instill confidence instead of chip away at what little confidence she has left.

If you tell a woman after 24 hours of labour that she is “still only 3 cm and despite our best efforts, you just haven’t been able to get into labour”, you are going to crush any chance of her ever having confidence at birthing. Even though she hasn’t met the textbook definition of labour does not mean that we should dismiss the back-to-back, oxytocin fueled, grueling contractions that could make any woman fly through the roof. So to say that she hasn’t experienced labour is complete non-sense and needs to be corrected. More importantly, to imply that the labour was “our best effort” is to take away from her contribution to her own birth. We as care providers aren’t doing the hard labour work. At her birth, it is she that is labouring and birthing her baby.

I would say that providing respect to women can even make some of the biggest babies come out of smaller pelvises. The thing is, we know that if we provide women with RESPECT, they will often birth with decency and confidence. If you are a left-brained person, it looks like this:

RESPECT (Increased Oxytocin Levels + Decreased Cortisol (stress) levels)= Increased likelihood of straightforward labour and birth and healthy transitioning newborn!

The equation is simple really. When providing RESPECT, we get a better working uterus, less stress and therefore a better likelihood of a straightforward labour, birth and a healthy newborn. I’m not saying that even if you provide the deepest RESPECT for women, there won’t be complications or traumatic births. I think that we must have a bigger conversation about why so many women and their partners are left feeling traumatized and start taking responsibility for our part in all of this.

I’m asking birth workers to consider humanizing birth and thinking about MORE than just our day-to-day jobs. Birth is so easily manipulated and it’s time that we started reflecting on the way we provide care and examine whether we are truly providing the RESPECT that women deserve.

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