Informed Consent for Childbirth
Does informed consent for childbirth differ from any other medical informed consent?
Recently my patient presented with a birth plan requesting no routine medication interventions. As a midwife, I'm comfortable with such requests but not everyone is. Both the physician on-call and the labor nurse assigned to the patient didn't understand why this couple chose to have a hospital birth.
In spite of the simplicity of this issue, it's surprising how many find it difficult. The parents chose not to have routine medical interventions. That is, they didn't want to be treated for conditions that might arise, but as of yet had not.
#1 Treat the Patient, Not the Risk FactorsEveryone realizes there are certain risks that can occur with childbirth - and certainly everyone who works with laboring families and newborns knows it. Certain policies and procedures have developed to lessen certain risks or provide treatment for them if they occur.
There are two down-sides for most routines. One is that every procedure itself carries a certain risk, though generally routine ones have been researched and determined to be worth it in light of their benefits. The second disadvantage is that the procedure may hinder her ability to move and labor naturally.
Hence, many birth plans request no routine interventions.
These are generally individuals who want medical treatment for illness and complications that do arise. They want oxygen administered if breathing is impaired, competent hands to unwrap a tight nuchal cord, resuscitation ability if meconium is in the lungs, pitocin for a postpartum hemorrhage, etc.
There is a difference between a recognized complication and a potential risk.
#2 Informed Consent: the Right to Say Yes OR NoHospitals state that patients have the right to care and the right to refuse care. The fact that someone refused certain procedures does not mean they get NO care.
By law we are required to get consent to perform a procedure on someone. Consent is not consent unless they have the right to say "yes" or the right to say "no."
If they only have the right to say "yes" - that is coercion.
#3 Coercion is Not ConsentOur expectation is often that a pregnant patient will accept all medical routines. There is a certain indignation towards patients who make our jobs a little harder by not going along with the routines.
It would be unethical, of course, to state that one must accept all our recommendations, otherwise they get no care at all. Not only is that unethical, it's also illegal.
But isn't that what the health care provider above was - silently - advocating? If you don't take our whole package, don't bother coming at all.
#4 INFORMed consent requires INFORMationI know you didn't want this induction, but if the pregnancy continues I can't guarantee you won't have a stillbirth. You don't want your baby to die, do you?
I wish I could say such statements never happened, but they do. Fairly frequently, actually.
Unless we give the decision-maker (ie, patient) the best-known statistics on the rate of death with and without our recommended procedure, this is not adequate INFORMation.
A classic example is telling families the risk of vaginal birth after cesarean and the advantage of repeat cesareans without telling them the risks of cesarean.
#5 Patients are not PrisonersHealth care workers often recoil when the statement "Patients are not prisoners" is made. Of course, we all know they aren't prisoners. It's an insult to our professionality to even suggest we would think such a thing.
But have you ever considered how patients feel in our care? They have to wear the ugliest gown possible. In some places, they are told they HAVE to put that thing on.
Want to go off the floor for a smoke? No way is that allowed! I'm not advocating for smoking, but do you see how they start to feel like a prisoner? Apart from being in a hospital, when was the last time you weren't allowed to leave a building?
In some places they aren't even "allowed" out of bed! Even prisoners have more freedom!
#6 Life and Death Scenarios Don't Negate Patient's RightsIt is interesting that oncologists who treat cancer patients are more comfortable accepting patient choices than are obstetricians and midwives. A much higher percentage of the oncologist's patients will die.
Giving statistical evidence for different treatments is part of their day-to-day job. They don't take it personally when a patient choses an treatment plan that differs from the "gold standard."
But in maternity care, where the statistical probability of a bad outcome is far lower, providers are often personally insulted that a procedure is declined.
#7 We Can't Demand TrustThis one is hard for us. I don't like it when someone doesn't like me or doesn't trust me. Obviously, if they don't trust ME than THEY have got some real problems. Right?
First, some people don't trust medicine. Period. Take it personally if you want, but it's a fact. And often, these are the patients who live the most healthy lifestyles. (But not always.)
Second, some people don't like you. That's worse. But it's also true.
Third, some people don't know who to trust. And this is a lot of the people who come to the hospital. And they aren't wrong or crazy. Talk to any nurse and she/he can tell you which people they want to take care of them. Those who don't work in hospitals don't have that inside knowledge, but they do know that it exists.
Document Their Decline, Then What?There is a little snafu that even the most flexible physicians and midwives run into. Once you have documented that the laboring woman has declined a routine practice, what comes next?
If she progresses quickly and has the baby, there is no issue. But what if labor stalls?
That's where care providers began to feel vulnerable. They feel like it is their job, in fact it may even BE their job, to promote the routine procedure or recommended treatment as the hours continue to tick by.
It may be helpful on admission to let the family know how often to expect that you will discuss their labor with them, and the discussion may be include their assessment of discomfort, labor progress, available procedures and alternatives. It is their right to continue with their original plan or change plans as things unfold.
By Karen Newell Copyright 2003 - 2012 Better Childbirth Outcomes - All Rights Reserved
Camp Hill, Pennsylvania, USA