Pregnant women who are going to give birth at a hospital may feel like will receive the most appropriate care, and have the safety net of modern medicine to ensure a good outcome. They may also, however, feel like they are on a conveyor belt of births where their own needs and wishes matter little.
Knowing what informed consent is, and is not, will help you have the best possible birth and the best possible agreement with your healthcare provider.
What Is Informed Consent?
Informed consent is a legal phrase that has been around since the 1950s. It reaches far beyond simply submitting to whatever your doctor or other members of your medical team suggest — giving informed consent means fully understanding whatever medical interventions you will undergo before consenting. According to the American Medical Association, informed consent requires:
- You know your diagnosis
- Details of the proposed treatment — what it involves and what purpose it serves
- Knowing the benefits and risks of the procedure
- Alternatives to the proposed procedure, and knowing the benefits and risks of any alternative procedure
- Knowing what will happen if you opt not to undergo any treatment
The American Medical Association goes on to advise physicians to allow the patient to ask plenty of questions in order to be able to understand proposed procedures properly before agreeing to them. It also suggests the use of consent forms, which is common practice in hospitals. Consent forms will be often be presented in a template format. It is important for patients to understand that they don't have to sign consent forms as they are handed out, and that you can cross out parts or make additions before signing — in consultation with your doctor(s).
How does this apply to a labor and delivery? Many medical conditions that require treatment are not quite as urgent as labor and birth (which doesn't have to be a medical situation at all, of course). Because labor and birth can move very fast, and complications can arise quickly, you usually don't have as much time to ask questions and discuss treatment options.
Some of the issues that may come up for laboring women are:
- Labor induction or augmentation with medications such as Pitocin
- Artificial rupture of membranes (AROM), or the breaking of your bag of waters
- Pain relief, including epidural anesthesia — which can, keep in mind, facilitate a speedy emergency c-section if necessary
- Electronic fetal monitoring
- Episiotomy, or making a cut in the vaginal wall
- Cesarean section
- Assisted delivery with forceps or vacuum
- Interventions for your baby following birth
Obstetricians/gynecologists and other medical professionals working on maternity wards see all kinds of often dangerous complications every day, as well as many smoothly proceeding labors and births. They may have settled into a routine that is comfortable to them, and may not pay as much attention to informed consent (and refusal) as they should. You, as the laboring mother, may not have time to make informed decisions.
To facilitate informed consent to some of the more common issues that crop up in the course of a labor and birth, I suggest that all pregnant women read up on complications in advance. The internet will certainly help you with this, but it is (as always!) important to stick to proven, scientific sources of information.
Women who already have a good idea of what they do and do not want during labor and birth can express their preferences in advance by creating a written, one-page birth plan for their doctor. Let's say that you would prefer a natural birth without induction, augmentation of labor, or episiotomy. You can write this down and discuss the situations in which your preferences would not be able to be honored in advance. During labor and birth, it is usually the mother's wish to have a natural childbirth that presents a problem. Those women who would like a fully medically managed birth will usually (but not always) end up with that by default.
In Which Cases Does Informed Consent Not Apply?
Informed consent and refusal applies to non-life threatening, non-emergency situations. Remember that the doctors caring for you during labor have two patients — you and your baby (and more if you are carrying twins or multiples). In emergencies that threaten any of the patients' lives or permanent physical well-being, doctors are not required to obtain informed consent, and can carry out procedures that you do not agree to.
Placenta previa physically excludes the possibility that a baby will be born alive through a vaginal delivery. If the woman refuses to undergo a c-section, she will have one carried out despite her refusal — because her baby would die without one.
There are many other situations that are a little more in the grey zone. A hepatitis positive mother may refuse to consent to immunoglobulin treatment for her baby, a woman whose membranes have been ruptured for longer than 24 hours may refuse to be induced, or a 30-week pregnant woman comes in to hospital demanding a c-section.
Then, there are situations that are legally sticky but clearly not life-threatening. Some woman refuse electronic fetal monitoring, insist on giving birth to a breech baby vaginally (this may be risky, but can also be done safely), or do not see eye to eye with an OBGYN about labor induction at 42 weeks.
What will happen in these situations? Doctors are legally and morally bound to attempt to provide the best care possible to all patients. What is clear is that they don't have to proceed with interventions that they deem to be dangerous. What is also clear is that they cannot allow mothers to make decisions that may lead to the death of their babies. Where time allows, doctors will engage in conversations with the mother and her support people (usually the baby's father).
In some cases, doctors and hospitals will even take matters to court. Take one case, Pemberton v Tallahassee Memorial Regional Center, where a woman who had previously had a c-section could not find a doctor to assist her in a vaginal birth after cesarean section (VBAC). The mother had decided to have a homebirth. When a doctor whom she consulted for another pregnancy-related matter found out, she was sued and successfully forced to undergo a c-section.
What this situation life-threatening? Not necessarily. This case shook the natural birth community, largely because c-sections carry risks just as VBACs do. It is debatable whether a c-section was truly the safest choice here. Yet, this mother's decision to give birth at home was deemed risky enough to discount the mother's refusal.
Choosing Appropriate Healthcare Providers During Pregnancy
As already mentioned, issues surrounding informed consent and childbirth mainly focus on women who wish to have a natural labor and birth, while the hospital and medical staff see medical management of childbirth as preferable. In this section, I'd like to address how to avoid disagreements with medical professionals during labor. Being a mother who had two low-risk pregnancies followed by homebirths, I certainly understand an expectant mother's wish to be in control of her medical situation.
I am not, here, talking about situations that are obviously dangerous. Instead, I am talking about situations in which doctors simply prefer to follow their usual course of action and have an irrational skepticism toward natural or physiological childbirth. Labor and birth can turn into emergency situations — something that can happen rather quickly in some cases — and there are births during which “natural” would equal “fatal”.
If you would like a natural birth in normal circumstances, you are most likely to achieve this by finding a midwife or OBGYN who has similar views on childbirth as you do — in a hospital that is supportive. You can assess healthcare providers' attitudes toward maternity care in various ways:
- Checking the hospital's rates of common interventions that you would prefer to avoid, such as c-sections, inductions and augmentations of labor, episiotomy and epidural anesthesia.
- Asking whether relatively controversial points are welcomed in a given hospital or with a given healthcare provider. Think walking around during labor, waiting for the natural delivery of the placenta, or having showers during labor.
- Talking about interventions with your healthcare provider. What do they think about episiotiomy and when it is necessary? How about vaginal breech delivery? How about no vaginal exams during labor?
- Making a birth plan and discussing it with your healthcare provider. If your healthcare provider welcomes your suggestions, they are likely to be a good partner. Some doctors will sign mothers' birth plans to signify they are able to accommodate their wishes. Some hospitals have “banned” birth plans outright. That is a great signal that the hospital is probably not a good choice for women who want to play a proactive role in their care.
It is also, on the other hand, helpful to remain somewhat flexible. Women who have low-risk pregnancies and wish to have a completely natural birth may be better off at a birth center or at home. If you want to deliver at a hospital, it is only natural to keep in mind that you will end up following at least some of their protocols.