In recent years, increasing numbers of women in the Republic have been expressing dissatisfaction with their treatment in labour. Women complain repeatedly of bullying, yet the bullying of women in labour has yet to become part of what is known about maternity care.
The concept of informed consent to medical treatment appears to be less well established in obstetrics than in other medical specialities. There is mounting evidence to suggest medical interventions in labour are being carried out against women's wishes. Women complain of being coerced, or duped, into procedures that seem to be driven by hospital policy rather than by medical necessity.
"My experience has put me off having another child," says Susan, a senior management consultant. "I would be afraid."
Peter is the managing director of a software company. His son was born in a Dublin hospital last year. He believes informed consent is not a requirement in maternity care. "The hospital can stay in control if they don't need your permission to intervene."
Women express a fear of unwanted intervention again and again. "I was like a little child," says Caroline, an airline pilot. "I was afraid they might do things I didn't want, that I might be hurt."
Amniotomy, or breaking the waters, is clearly a routine procedure in labour, although no statistics are available on its use. Women's views on amniotomy have never been established, but anecdotal evidence suggests many women loathe it.
Louise, a counsellor who works with women post-natally, says: "If a woman decides she doesn't want to have her waters broken, then she has a battle on her hands with hospital staff."
Women are not allowed to have any control over their bodies in labour, she maintains. "Women don't speak up. We need to look at the parameters of consent: where do they begin and end?"
Peter and Margaret had wanted a natural birth, but as Margaret suffered from extreme nausea and vomiting during her pregnancy, they decided to go to hospital so that she could be assessed for induction. A doctor told her she needed to be rehydrated and that it would be a day or two before she could be induced.
Margaret fell asleep after being given Stematil, an anti-nausea drug. When she awoke, she recalls, she was still in a haze. "They knew I was doped up, and they just came in and said: 'okay, we've discussed this with the consultant. We'll break your waters now.' "
She went into another room, as instructed. "I was exhausted by then, out of it. When I got back, I said: 'what's happened?' It was like I was five years old. If they'd said, 'we'd like to break the waters,' or, 'we think it's a good idea to break the waters,' but there was no consultation."
The couple had a birth plan. Peter believes a birth plan is a source of conflict between the hospital and the patient. "They're under pressure. They haven't got the resources. They go on about safety, and they don't want you to ask questions." Natural birth, he believes, is in conflict with hospital policy.
Active management is practised in every maternity unit in the Republic. Devised in the mid-1960s at the National Maternity Hospital at a time when resources were stretched, the policy lowers the "unit cost of production", calculated by dividing midwives' salaries by the number of babies born.
A 1970 report found that birth cost three times less at the National Maternity Hospital (NMH) than at any other maternity unit surveyed. Since then, the average length of labour has been halved, to its current figure of six to eight hours. As many as 50 per cent of all first-time mothers at the NMH had their labours speeded up in 1998.
Written by Kieran O'Driscoll, Declan Meagher and Peter Boylan, three former masters of the hospital, Active Management Of Labour (1993) does not address issues of patient choice or personal autonomy. Active management excludes the possibility that a woman might choose to decline amniotomy or oxytocin, a hormone that induces labour.
According to the Medical Council's Guide To Ethical Conduct And Behaviour (1998), "people have the right to refuse consent for investigation or treatment. Their decision should be respected and documented".
Susan recently had her first baby at the NMH at the age of 34. "I knew I didn't want the waters broken. I spoke to my consultant about it and we agreed to differ. I assumed that my consultant would discuss it with me in labour, and that the staff would let me go for as long as possible, and only then, if it was absolutely necessary, would they consider breaking the waters.
"I showed my birth plans to everyone, including the consultant. The plans were in my hospital notes, and we brought a copy into the hospital with us. The plan said that we wanted the labour to proceed at its own pace, and that I didn't want the waters broken.
"When we got to the hospital, they said I wasn't quite in labour, and that they'd come back in an hour to do another vaginal examination. Internal examinations are so invasive.
"I was still one centimetre . Then they came back and said: 'we were onto the consultant, and the consultant said we were to break the waters.' I said I'd prefer if they didn't, and they said they'd be back in an hour.
"They kept on saying: 'we want to break the waters. We need to see if the baby is okay.' It was really intimidating They did a second internal. It was extremely painful. I believe the midwife was trying to break the waters.
"There was a student with me. Two more senior midwives came in, the one who had done the internals and another one. 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.'
"When I was having a contraction, they would stand there, saying nothing, and wait for the contraction to pass, and then they would ask me again if they could break the waters. I lost track of time.
"Then they told me they had phoned the consultant again, and 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.
"I'd wanted the birth to be as natural as possible. They were in control. The psychological bullying was the worst. It was intimidation. To me, breaking the waters was a physical assault. It was like being raped."
Susan was given oxytocin; she had an episiotomy and a forceps delivery. Her daughter had an Apgar score of two at birth - of a maximum 10 points - her mother says, and spent several days in intensive care. After the birth, Susan suffered from panic attacks, nightmares and flashbacks. Her GP diagnosed post-traumatic stress syndrome. Now, nearly seven months later, she is still taking antidepressants.
Susan and her husband wrote a letter of complaint to Dr Declan Keane, the master of the NMH. The labour-ward manager wrote back. "All procedures performed during your labour were done in the best interests of you and your baby. They were also done with the full consent of your consultant obstetrician."
The midwives, Susan says, had written in her chart: "waters broken at patient's request."
In his reply to Susan and her husband, the master said: "the midwife who was looking after you has clearly documented that your waters were not broken at your request and were eventually ruptured at the request of Dr ---, presumably for some medical reason . . . Although the National Maternity Hospital is famous for the active management of labour . . . although we are a hospital associated with intervention, we are the hospital which attracts more patients with birth plans than any other . . . This all serves to reflect our belief that patients should have an active choice in their mode of delivery and I would refute any claims to the contrary."
Active management increases throughput in what its architects referred to as "the bottleneck" of the modern delivery unit. With midwifery shortages threatening to disrupt services, and a continuing baby boom, the bottleneck looks set to continue - and, with it, women's lack of control over their medical treatment in maternity hospitals.