How to give informed consent: making choices in childbirth

There is just too much for any one person to know when it comes to obstetrics and gynecology. Not even all doctors stay up on all the medical information all the time. But being the wife of a medical student, I am more sensitive to the sublimity of the massive amounts of information that doctors are required to consume, internalize, and recall at the drop of a hat.

That being said, it can feel even more overwhelming when you are pregnant, and you begin to have medical decisions that you need to make almost on a daily basis. And usually they are not unimportant decisions to make either! They are life-changing, and can affect the lives and health of you, your baby, and your family. So, knowing that we can’t really know everything, and the doctors can’t even know everything all the time (research is always coming out with new information that challenges strongly-held medical beliefs all the time), how can we even begin to make medical decisions?

Informed Consent

The best any pregnant woman (or her doctor) can do is to gather all the information that is readily available to them, including their own intuition, and weigh the pros and cons. The best tool that doctors have to help patients achieve this is the process of informed consent. The American College of Obstetrics and Gynecology (ACOG) put out a committee opinion on ethical decision-making in 2007 (reaffirmed 2016). They defined it:

“Informed consent is the willing acceptance of a medical intervention by a patient after adequate disclosure by the physician of the nature of the intervention with its risks and benefits and of the alternatives with their risks and benefits.”

There are a couple of important elements that they say are necessary in order for a conversation to qualify as informed consent. The first is described as a patient’s capacity to understand, and the physician’s responsibility to present information in a comprehensible way:

“one of the most important elements of informed consent is the patient's capacity to understand the nature of her condition and the benefits and risks of the treatment that is recommended as well as those of the alternative treatments. A patient's capacity to understand depends on her maturity, state of consciousness, mental acuity, education, cultural background, native language, the opportunity and willingness to ask questions, and the way in which the information is presented. Diminished capacity to understand is not necessarily the same as legal incompetence. [which can only be established in a court of law]....Critical to the process of informing the patient is the physician's integrity in choosing the information that is given to the patient and respectfulness in presenting it in a comprehensible way. The point is not merely to disclose information but to ensure patient comprehension of relevant information. ”

The other crucial component is a right to informed refusal:

“A patient's right to make her own decisions about medical issues extends to the right to refuse recommended medical treatment. The freedom to accept or refuse recommended medical treatment has legal as well as ethical foundations… Voluntariness—the patient's freedom to choose among alternatives—is also an important element of informed consent, which should be free from coercion, pressure, or undue influence.”

There you have it: Respectful Informing+Consent=Informed consent.

The How-To:

The quickest, easiest, most effective tool in the moment, when you don’t have any references with you is the BRAIN acronym. It is great especially for when you feel you are being pressured into making a decision you’re not sure about, or your gut is telling you that you need more context or information to make a more informed choice. It can help throughout pregnancy as well, by helping you retrieve the maximum amount of information from your caregiver in regards to the decision, rather than just their recommendation for what THEY would do if they were you.

Cause here’s the thing: your doctor/midwife/doula/family/friend does not have to live with the consequences of the decision you make. YOU DO. It’s your decision, so it should be informed. If the person you are speaking with has more information than you do, it is your right to receive that information, for that information to be presented in a comprehensible way, and for you to make the decision yourself, rather than leave it up to them because they are the ‘expert.’ So here’s the acronym in a nutshell:

  • Benefits: what would be the benefits of the intervention/choice/direction that you are proposing?

  • Risks: What negatives would I be risking, and what are all the possible far-reaching consequences of making this choice in the way you want me to?

  • Alternatives: Is there any way I can attempt to achieve the benefits (even if they’re not proven to be effective), that might help me avoid the risks? If there is an alternative, what are the risks and benefits of that scenario?

  • Intuition: What would this course of action look like for me? Can I envision it, and get behind the idea? What does my gut say?

  • Now: How much time do I have to make this decision? Can I talk it over with my partner? Can it wait until later? What will happen if I do nothing? *

Keep in mind that in emergent cesarean situations, the time limit goal to prep and get you into the OR is 30 minutes or less, so that is usually enough time to discuss it with your caregiver and team - usually, not always. This time increases with the ability of your care provider to recognize the red flags of an emergent situation before it arrives.

Occasionally, there may be the need for a crash cesarean. These are rare situations in which there is almost no time to even get to an OR, such as a full uterine rupture or cord prolapse. In these situations, informed consent is STILL NECESSARY. The main difference might be that there might not be a form to document it, or a very detailed conversation. But, at minimum, the requirements of information and a right to refusal still need to be met.

Woman Vs. Baby

The most common issue I see come up as a concern among nurses and doctors is that, occasionally, the fetus’ well-being, and the mothers’ interests or preferences are in conflict. I’ve even heard nurses say that a woman can “create dangerous situations” for her baby. I think what’s important in these situations is not for a practitioner to take sides, but to recognize that there are some needs not being met. Quoting Harris LH in the same paper, the ACOG stance is:

“An ethic of care would concentrate on the implications of the virtue of caring in the obstetrician–gynecologist's special relationship with the pregnant women and with the fetus. In the process of deliberation, individuals using this approach generally would resist viewing the relationship between the pregnant woman and her fetus as adversarial, acknowledging that most of the time women are paradigmatically invested in their fetus' well-being and that maternal and fetal interests usually are aligned. If, however, a real conflict does exist, the obstetrician–gynecologist should resist feeling the need to take one side or the other. Instead, he or she should seek a solution in identifying and balancing his or her duties in these special relationships, situating these duties in the context of a pregnant woman's values and concerns, instead of specifying and balancing abstract principles or rights… To take one example, in considering a case of a pregnant woman in preterm labor who refuses admission to the hospital for bed rest or tocolytics, Harris combines a care or relational perspective with a feminist perspective to provide a "much wider gaze" than a principle-based approach might: The clinician would focus attention on important social and family relationships, contexts or constraints that might come to bear on [a] pregnant [woman's] decision making, such as her need to care for other children at home or to continue working to support other family members, or whatever life project occupied her, and attempt to provide relief in those areas….[Often] fetal well-being is achieved when maternal well-being is achieved.”

I think the implication here is not to assume that a woman is acting out of selfishness, or some other motive, but that she may have any number of unknown or invisible constraints that lead her to make the decision she does, and that the best way to approach this scenario is to try to identify and address those constraints, and run instead with the assumption that she wants what is best for her baby, but there may be something else keeping her from giving consent to a particular intervention.

This approach will most of the time lead back to informed consent, and the need to present information in a comprehensible and respectful way. Sometimes, women who want the best for their babies “create dangerous situations,” because they just have incomplete information, and ethically it should be the physician’s responsibility to identify this, and to fill in the gap.

Afterward

When all is said and done, the past needs compassion more than anything. With the fallibility of our memories, and the tendency to judge our past selves using our current knowledge, the most kind and loving thing we can all do for ourselves is to look on our decisions with an acknowledgement that we made the best decisions we could at the time, with the information we had available to us. Give yourself grace, because there is no such thing as having made a ‘wrong’ decision in the past, especially when you know that it was and is, impossible for you to know everything.