Would you like an ARM with that?

question markWhen is consent not consent?

That’s not intended to be a trick question, though I’ll admit it is a bit of a leading one in the context of this post because, although there are several possible answers to this, which are all more than worthy of debate, I am really only wanting to write about one today: the kind of so-called consent that is sought when someone is halfway through performing a vaginal examination which a woman has consented to and, out of the blue and before removing their fingers, asks the woman if she would like to have another procedure performed at the same time; usually the breaking of her waters or (in countries where intervention in pregnancy is even greater than average and vaginal examination is carried out during pregnancy) a stretch and sweep.

I was horrified to receive several emails about this when I asked for feedback on what kinds of things readers of this blog would like me to write about.  Because, try as I might, I can’t see how that is justifiable.  It bothers me on so many levels, and I can’t find a single angle to look at it from which doesn’t lead to my concluding that it flies in the face of the notion of informed decision-making.

Firstly, both of the procedures given as examples above (ARM and stretch and sweep) might sound innocuous, but they are means of attempting to induce and/or augment (speed up) labour.  Some women might well decide they want to have them, after they have had a chance to think about them and weigh up the risks and benefits, but they are interventions and women thus deserve to have that time to think about them, seek more information, consider their options and discuss them with loved ones.  small_6869336880None of which is possible or practical while one is being examined in that way.  Most of which might not even be possible or practical for some women while they are in the company of a waiting professional, though I acknowledge that this depends a lot on the relationship between the woman and her attendants and that there are times when this might be unavoidable.

Generally, though, neither of these interventions is carried out as an emergency procedure or in a situation in which speedy decision-making is necessitated.  Many – perhaps most – women find vaginal examinations uncomfortable, embarrassing and/or painful.  For some women, they are physically and/or psychologically excruciating.  Women will not always tell their attendants if that is the case, though; in some cases because they do not know the attendant well enough to trust them, or because the only possible response for them is dissociation.  Either way, they want each one to be over as soon as possible.  In some cases, a woman might agree to anything in order to get the examination to stop.

That is not informed decision-making.

From the blog www.stuckincustoms.comI don’t think that practitioners who do this are necessarily setting out to coerce or harm women.  I can see how, from their perspective, they might genuinely think that it’s kinder to save women from having an additional examination, or they might not have thought about the ramifications of this.

Please, if you attend births and have ever done this, think about what it does to the women you care for.

I am concerned from the emails I received – which are not, by the way, limited to particular types of professionals or particular countries – that this is something which needs to be said.  I cannot see how this is an appropriate time during which to discuss whether or not a woman wants to have an intervention which may have significant implications for her and her baby’s experience, and I certainly do not think that it is a kind or ethical context in which to ask someone to make a decision.

If you are a woman, and if this happens to you, you are completely within your rights to tell the attendant to finish examining you before discussing any further decisions.  You can say no or stop at any time.

A friend of mine who just called while I was writing this, asked what I was doing with my morning and thus received a full discussion of the issue(!) wondered if it might also be good to suggest to women that they are very clear with the attendant before they consent to a vaginal examination that they are not consenting to any related intervention and that they do not want to discuss further interventions during the examination.

That isn’t a bad idea at all.  But women should not have to be proactive in this way.  Surely, given the enormity of the interventions and the invasive nature of some of the examinations carried out in maternity care, the emphasis should be on attendants to initiate such discussions only at appropriate times?

photo credits: hands by Alex E. Proimos and pathways by Stuck in Customs via photopin cc and cc

4 comments for “Would you like an ARM with that?

  1. Helen
    June 22, 2015 at 4:40 pm

    I was pressurised into being induced with my first child, which was supposedly late. I did not think he was late as I didn’t agree with their dates. I was given 2 pessaries one in the morning and one in the afternoon. When I was examined I was asked what my pain theshold was like and my waters were broken without my consent which was excruciating. I was left virtually alone for the next 2 hours in a birthing pool and was sweating but told I was not in labour as it was just pre contractions. When I got out of the pool I was screaming in agony and given pethadin to shut me up. I was then out of it for the next while then suddenly felt the urge to push. The upshot was fast labour, an unwanted large episiotomy and a huge amount of internal tearing. I was still in pain when they stitched me up and the two of them were stood at the bed debating where to put the stitches. I saw my notes when I had my next child and they had justified the episiotomy as delay in second stage. the whole labour was over in less than 4 hours. (i was given the second pessary some time in the afternoon and I had my child by 8.15. I was in pain for several days and passed a blood clot the size of a grapefruit a few days later. I bled so much overnight I soaked the sheets. I continued to bleed quite a lot for 6 weeks later. My baby was healthy but I was traumatised by all these unnecessary interventions. I was a fit and healthy 32 year old. I had swum 30 lengths the night before my labour and was quite happy to wait for my child to be born naturally.

    • June 23, 2015 at 12:55 pm

      I’m so sorry to hear that you had such a traumatic experience, Helen 🙁 x

  2. Jo
    December 13, 2017 at 12:18 pm

    I was not in labour and was a day or so after my due date. Went to a health centre/docs surgery for a sweep. I consented to a sweep but didn’t really understand details of how it was performed. The lady used an amniotic hook not her fingers which I thought nothing of. I was wetter than usual after but didn’t expect my waters as she said I would have more discharge if the sweep worked. Niggles started which progresses into contractions but over days. It was only when I wanted to find out more info about a sweep during my second pregnàncy. I wanted to see if it could have contributed to such a long delayed labour until I was established, to still have 24 hours in established labour. Majority was at home as I attempted home birth (midwifes couldn’t feel my waters).
    I was very distraught when I realised a sweep was not the procedure I was given. I met with my new midwife quite distressed and told her everything and she said she would look into it. Not due to see her again until mid January.
    I’m glad my husband was with me for the so called sweep as my midwife tried to say I must be confused. She said that ARM would only be carried out at hospital or during home birth, not a doctors surgery then sent off home none the wiser.

    I feel there is definitely an issue with consent.
    Reading more into ARM and waters going before labour starting and being left too long puts mum and baby at risk. I was unknowingly put at risk for no reason.
    She had told me just before the procedure that I would be going into hospital x date to be induced which I replied No it’s my choice, do not book me in. I believe this ticked her off and resulted in her deciding to do the ARM instead of the sweep without my knowledge.

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