Informed consent is one of those phrases that is becoming a signature phrase in birth circles. You might have read in a blog or on a Facebook post something like, “We support informed consent,” or “Every woman has the right to informed consent.” But what does that really mean? Informed consent is the concept that a patient has the right to be fully informed of the benefits and risks of any medical procedure or intervention, as well as the alternatives to the procedure prior to agreeing to undergo the procedure. The doctor, midwife, or nurse in charge of the patient’s care would take the time to explain these things to the patient prior to obtaining her consent. Do you notice something here though? The use of the term “informed consent” implies that the patient will in fact consent to the treatment being offered. Is assumed consent with adequate information really much better than assumed consent without it? What will be the repercussions if the patient chooses an alternative or to refuse all together? I submit, then, that what we actually are seeking and have the right to in the United States is informed choice, the right to making an educated acceptance or refusal of any procedure or treatment and for either to be accepted and respected without repercussions, coercion, etc. Informed choice also means that, if consent is given but later later withdrawn, the medical staff will cease treatment immediately. Informed choice is the right of every patient being treated medically, including prenatal care and labor and delivery.
That sounds so logical, doesn’t it? You might even be thinking, “Of course, that’s what doctors and nurses do all the time.” Unfortunately, that’s not always the case. Often, what happens is a professional comes into an exam room or the delivery room and says something like, “We’re going to schedule your Group B Strep test for your next visit,” or “We’re going to do a vaginal exam now to see how far you’ve dilated,” or “We’re going to get your IV started, okay?” Consent is assumed in all the cases, even the last one. There really isn’t an opening left for questions or alternatives. Have you heard this sort of language during your pregnancy or your birth experiences? I know I did, and I just kind of assumed I had no choices or that there were no other options. I certainly didn’t think to myself, “I can refuse this if I want to.” In fact, it wasn’t until I was pregnant with my third child and was seeing a midwife that I realized I had a choice about routine medical procedures. As we discussed a routine procedure I was not really sure about, she looked at me and said, “You know you don’t have to do that, right?” What an eye-opener! I had assumed that all these routines and procedures were just a given during pregnancy and birth. It was very empowering to realize that I did have options, and beyond that, to feel like a full participant in my medical care. The idea of informed choice is not about denying all interventions all the time, but rather having access to all the information and making an informed choice either way, using that information to make the right choice for you in your specific situation. It’s about being empowered in your care, an active decision maker, rather than a passive participant. So many women who report dissatisfaction with their birthing experiences list feeling like their autonomy was not respected as one of the main causes. The goal of this article is to help women find their power and reduce this occurrence.
Disclaimer 1: I am not at all talking about emergency situations here. I am talking about the right to decline routine procedures such as a cervical check if you wanted to, or to request a hep-lock instead of being tied to an IV pole in the case of a normally progressing labor, for example, or the right to ask questions and know your options in the face of interventions that you may be facing in a non-emergent situation. In a medical emergency where all the minutes and even seconds count, I absolutely advocate relying on the advice and expertise of the doctors and nurses in charge of your care; they want a healthy outcome for you and baby and are using all their expertise and best judgement to achieve that.
Disclaimer 2: The majority of doctors and nurses truly want what they think is best for their patients. In cases where informed choice is not pursued, I truly believe that it is not usually because the medical staff is trying to bully or control the mother or is pursuing their own convenience. These things have become routine and fairly expected, so I think it is often assumed the mother is in full consent or that if she is not, she would speak up. I realize there are cases when medical professionals were in fact not really pursuing the best care for their patients, but those are for the most part the exception rather than the rule.
So now that we’ve looked at informed choice and why it’s important, how do we make sure that’s what is happening in our own medical care and births? First, take a good independent childbirth education class—hopsital based classes often really just teach patients how to be a good patient and what to expect in that particular setting. An independent class is an invaluable source of evidence-based and unbiased information and will cover birth and birthing options in all settings and circumstances. Second, do your own research on what procedures are routine with your midwife or doctor and your place of birth and on common interventions. Find out the evidence for these procedures and interventions (Evidence Based Birth is a great place to start). Talk to your doctor or midwife about all of these things. Find out what options and alternatives you may have. Talk to your partner as well. It is so much easier to think clearly and make important decisions prenatally, before the intensity of birth hits. Third, consider hiring a doula to support you. She is there to help you find the information and research you need prenatally and to help you create a birth plan or list of what you do and do not want during your birth. She is also there to help you advocate for yourself during labor. Remember, a doula does not make decisions for you; rather, she facilitates communication between you and your birth team and can help you ask questions and get the answers you need. She will amplify your voice to be sure you are being heard and will advocate for you. And she’s there to support you if birth leads to necessary interventions that you did not want so that even in that case you feel empowered in making the right choices for your situation. Fourth, ask for a little time. If you need a minute to consider your options or to discuss a procedure with your partner, it is absolutely okay to ask for a few minutes alone to do so. Unless it is a truly emergent situation, do not feel pressured to make a snap decision on the spot.
And, finally, ask questions of the medical staff. Good, clear communication between everyone on the birth team is key. Do not assume that because you wrote something in your birth plan, everyone is automatically going to know what you do and do not want in each situation. Again, your doula can help you open this conversation, often by asking you questions such as, “Are you comfortable with this procedure? Did you have any questions about that before it’s done?” I love using the BRAIN acronym because it is short and memorable and helps you make sure you are asking all the right questions to get the information you need.
Benefits:
- What are the benefits of this procedure or intervention? What is the desired goal to be accomplished by pursing it?
Risks:
- What are the risks associated with this procedure or intervention? What possible side effects are there for the mother and the baby? What limitations might it impose on mom such as needing to remain in bed, not being able walk, having a catheter, etc.?
Alternatives:
- What other options for treatment are there? Different medicines, non medical options you could try, etc. ,such as positioning to help get labor going again rather than immediately starting Pitocin.
Intuition:
- What does your gut feeling say about this procedure? Mothers are gifted with strong instincts, especially when it comes to their bodies and their babies. Consider your intuition. Also consider your wishes for your birth. How does this align with those? Think through how this procedure might impact other things that might be important to you.
Nothing:
- What would happen if you simply did nothing in this instance? What is the evidence for doing and not doing something in this case? What if you do nothing for a period time? What if you never do anything?
Once you have gathered your information, be sure that you are very clear in speaking with the staff that you are or are not consenting. State clearly, “I consent.” “I want to proceed with_______.” On the other hand, clearly state, “I do not consent to that procedure.” Not, “I don’t really want…” “I’d rather not…” “I don’t like…” These statements are easily overlooked and dismissed as a woman being emotional or stressed in labor and not taken as serious refusal. Be open and plain about what you do and do not consent to, and be sure your partner and/or doula is ready to help you make your voice heard. You cannot be forced into any procedure or intervention against your wishes, nor bullied into not consenting to a procedure you do wish to consent to.
I believe in you and your ability to birth your baby. I believe in your ability to make solid, informed choices for you and your baby. Remember: It is your body and your birth. It is your right to be fully informed about the benefits and risks of every procedure and to make the choices best for your situation and to be fully supported in doing so.