As much as
you may not like something, there is some comfort in knowing what you are up
against. You can work towards change. You can acknowledge it – face it head on.
You can rally in a united stance. But this week finds pregnant women and
maternity advocates in a strange limbo. We now face the unknown. A High Court judgement has changed everything - setting a terrifying precedent with broad implications for birthing women in Ireland.
High Court
On Friday
last, a woman who sued Kerry General hospital over the care she received while
giving birth to her second child, lost her case in the High Court. The woman
had her waters artificially ruptured – ARM- (also known as “breaking the
waters”) and needed an emergency caesarean section due to a cord prolapse. Further
details have emerged that the woman was a known carrier for Group B Strep
(GBS). (Mind the Baby Blog) The woman has indicated that she did not consent to
the ARM and that it was allegedly performed by a midwife during a routine vaginal
examination without discussion and without the woman's knowledge that the intervention was about to take place. Justice Ryan ruled that the woman did not make a case against the
HSE and is responsible for full costs.
From the
Examiner:
“Mr Justice Ryan said the midwife at Kerry General
Hospital and the hospital
responded in a competent manner to the situation which arose when Ms Hamilton
was having her second baby.”
“Mr Justice Ryan found
that it was reasonable for the midwife involved to seek reassurance with an artificial rupture of the membranes. The midwife was the person entitled,
authorised and qualified to make the decision, the judge said.”
“He added that the
management of Ms Hamilton accorded with a practice supported by a responsible
body of expert opinion.”
“The midwife was the
person entitled, authorised and qualified to make the decision, the judge
said.” Read that again.
And again.
It will come to haunt you as the reality drips in.
In that one
statement, Justice Ryan has eroded every right of birthing women in Ireland. Where
we once thought we knew where we stood, with the National Consent Policy, we
now are fighting a ghost. A notion of entitlement over birthing
women’s bodies. An unapologetic exemption to use medical intervention where a
midwife sees fit. And seemingly regardless of best practice or evidence! The midwife is the person entitled,
authorised, and qualified to make the decision. Not the birthing woman. Not
the woman in labour. The midwife. Not the woman who has to live with the
consequences. The midwife. Because a judge says so.
This
judgement is a ruling for Active Management of Labour. It laughs in the face of
evidence based practices and high quality research. It mocks science. Who are
these ‘responsible body of expert opinion’ who disregard international best practice?
This is a ruling in favour for
Active Management of Labour. This is a ruling for routine admission policy. This is a ruling for speeding women up, intervention, interference. This is also
a ruling which contradicts the Irish National Consent Policy, leaving a Nation
of women without clear understanding of our rights.
Rights
Every
Irish citizen has the right to informed consent during medical treatments. This means tests, procedures, and interventions are to be discussed clearly with an individual, both the benefits and risks, in order for them to make the best decision for themselves at that time. This
includes the right to informed refusal. For pregnant women in Ireland, these
rights are diluted and challenged by the Irish Constitution and Article 40.3.3,
both of which are enshrined in the National Consent Policy.
The
National Consent Policy states:
Page 41:
7.7.1 Refusal of Treatment in Pregnancy
The consent of a pregnant woman is required for all health and social
care interventions.
However, because of the constitutional provisions on the right to life of the
"unborn" (12), there is significant legal uncertainty regarding the
extent of a pregnant woman's right to refuse treatment in circumstances in
which the refusal would put the life of a viable foetus at serious risk. In such
circumstances, legal advice should be sought as to whether an application to
the High Court is necessary.
Citation: (12) Article 40.3.3 of the Irish Constitution (1937)
Relevant factors to be considered in this context may include whether the risk
to the life of the unborn is established with a reasonable degree of medical
certainty, and whether the imposition of treatment would place a
disproportionate burden or risk of harm on the pregnant woman.
AIMSI have been vocal in
our condemnation of the National Consent Policy, and article 40.3.3, both used
to violate women’s rights in pregnancy and childbirth. We have supported women threatened
with the High Court. We have supported women who have been doorstepped by Child
Protection. We support the survivors of symphysiotomy, brutally maimed in childbirth, in their quest for justice. We have supported women in their right to continue pregnancy, or not, and to decide how and where their baby is born - from planned caesarean section to homebirth after caesarean. We support women. We have actively campaigned on all these issues - all of which are bound by the same constraints. This is the reality of what
Ireland
has collectively signed up for, and as a result, pregnant and birthing women
live with the consequences of restricted rights. From Symphysiotomy, Neary, Mother
and Baby homes; all examples of rights lost.
Despite all this, there
was some slight reassurance that a birthing woman’s right to consent and
informed refusal was recognised at all in a National Consent Policy, despite
these limitations. The Consent Policy
stating a pregnant woman could consent or refuse treatment unless refusal “would put the life of a viable foetus at
risk”.
But Friday’s judgement
completely contradicts this rational.
In fact, Friday’s
judgement does the complete opposite.
We are now in a situation
where a woman can refuse a procedure, (or indeed even have a procedure done with no opportunity to consent or refuse), which is shown to increase risk to her
baby, but the midwife can over-rule her and do it anyway.
This woman says she did not
consent to have her waters broken. The woman says she didn't even know that this was about to happen, but that the midwife did it anyway. Despite the
woman having known risk factors in which an ARM would put her baby at risk. And
Mr Justice Sean Ryan says this is OK. He has essentially enshrined Active
Management of Labour into Irish law. He has handed women’s decisions and bodies
over to health care providers to do as they please.
This is NOT OK.
This month, the UN Human
Rights Committee had harsh criticism on the Irish Government in its failure to
secure civil and political rights. Ireland
was flagged on 19 areas with a heavy focus on the rights of, and, crimes
committed against pregnant women in Ireland. Ireland was publically and globally
dragged over the proverbial coals. Our dirty laundry out for all to see; a
unified call for the Irish Government to make good – demands for justice – send
a signal of change…… This judgement is Ireland’s answer. No, we do not
take women’s rights seriously and No, we will not change.
** Edit Note 5:30pm, Wednesday August 6th. AIMSI has received confirmation that the woman in this case has alleged that she was unaware the midwife was going to break her waters - ARM was performed during a routine exam with no discussion or opportunity for the woman to consent or refuse treatment.
AIMS Ireland have been inundated with support and offers of help for the Hamilton family following the loss of their case in the High Court against Kerry General. A fund had been established to help them with their legal costs. You can donate at the link below. Please share wherever you have seen discussion and support on this important issue:
http://www.gofundme.com/AIMSISupportFund
Further
Information on amniotic fluid, ARM, Cord Prolapse, and Group B Strep (GBS), and
AML
Protecting your baby – the important job of amniotic
fluid.
Amniotic fluid is a clear, slightly straw coloured fluid which surrounds
the baby in pregnancy. During pregnancy,
the baby is protected in the amniotic sac, which is in the uterus, and is made
of two membranes. These membranes seal around the baby and the amniotic fluid.
The baby floats in the amniotic fluid safely within the amniotic sac for the
duration of your pregnancy.
The amniotic fluid is constantly circulating and the amount corresponds to
the baby’s growth. At the beginning of a pregnancy, the amniotic fluid will
only be a few millimetres. At its peak volume, around the 36 week mark, there
may have around 800ml to 1000ml of amniotic fluid. This gradually decreases
until the baby is born. The baby uses the amniotic fluid to practice
‘breathing’ – swallowing fluid into the lungs and urinating it out. For this
reason, the fluid levels are constantly moving.
The amniotic fluid protects the baby in the following ways:
- acts as a cushion for any sudden blows, shocks, bounces received
- maintains the right temperature around the baby
- helps mature the baby’s lungs
- protects the baby from infection – such as GBS/Strep B
- helps the baby explore movements in pregnancy – to strengthen bones and
muscles
- helps mature the baby’s swallowing reflux
What is ARM?
One of the most
common forms of routine interference in labour is an artificial rupture of
membranes (ARM) – sometimes referred to as ‘breaking’ or ‘releasing’ your
waters. To do this, the health care professional, inserts a plastic hook into
the vagina and cervix to make a tear in the bag of amniotic fluid.
What the Evidence Says
Evidence does not support artificial rupture of membranes for women in
normally progressing spontaneous labours or where a woman’s labour has become
prolonged. The evidence shows that ARM does not shorten the first stage of
labour.
ARM is on the NICE “Do Not Do” list and is shown to increase risks to women
and their babies.
Despite this, most Irish units follow an Active Management of Labour policy
as routine.
Active Management of Labour (AML) is an approach to
labour which was created in National Maternity Hospital,
Holles Street,
in Dublin and
is now practiced in many obstetric led units. The principal of AML is to manage
the time a woman is in labour to prevent ‘prolonged’ labour. The definition of
‘prolonged labour’ has changed over time. In 1963, prolonged labour was defined
as 36 hours. This was changed to 24 hours in 1968 and was finally reduced to 12
hours in 1972. The main principals of AML are that you will have your waters
broken, be given frequent vaginal exams to track your progress, and that your
labour is considered to be progressing if you dilate 1cm per hour. Continuous
electronic foetal monitoring is also used. Women who are not dilating 1cm per
hour, have labour accelerated with a drug called syntocinon.
Risks of ARM:
* possible increase of caesarean section
* many women report ARM makes contractions stronger/more painful
* increases your baby’s risk of exposure
to infection in vaginal track (Group B Strep and others)
* does not shorten first stage of labour
* increases a risk of cord prolapse
* may increase risk of distress in the baby and cord compression
* your health care provider may introduce time limits to your labour once an
ARM is done
* introduces further interventions
* ARM may cause your health care provider to recommend continuous electronic
foetal monitoring
* ARM may cause your health care provider to restrict your mobility or from
using a birth pool or bath
What is Cord Prolapse? A cord prolapse is when
the cord is carried by the breaking waters before or beside the baby’s head
resulting in compression of the cord which cuts off the baby’s oxygen supply. Artificial
rupture of membranes (ARM) is a risk factor for cord prolapse.
What is Group B Strep?
GBS is a common streptococcus
bacteria which can cause illness which lives in the digestive system, rectum
& vagina.
* In the cases in which GBS is
transferred to the baby, it can lead to serious health implications and be life
threatening in about 1-2% of cases.
* The University
of Oxford suggests 3 out of every 10
adults carry GBP and about 1 in 2,000 babies a year in England and Wales are infected. 1 in 17,000
babies in the UK
will die of GBS a year.
* Babies are at increased risk of
being exposed to GBS if the waters are broken (ARM). The waters act as a
protective barrier for babies, keeping the baby away from the infection in the
vaginal tract.
* other risk factors include: baby
born before 37 weeks, previous baby born with GBS, high temperature of mother
in labour, prolonged rupture of membranes, urine testing positive for GBS.
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