Informed Consent

During your pregnancy and while giving birth, you will face the topic of “informed consent.” The basic definition is that you must be informed of the procedures offered to you, their risks and benefits, as well as the risks and benefits of all other options, including doing nothing. Implied in the very phrase is that once you are informed, you will consent, but this is not necessarily the case. Just because your doctor recommends a certain choice does not mean that that is the one for you. You have rights (as well as intellect!) and can make the best choice for yourself and your baby. The plain truth is that there are no guarantees in life. There is no amount of technology, no number of tests, that will ensure that your life will be “happily ever after.” Almost every single procedure that can be done during pregnancy, labor, birth, or postpartum has trade-offs—pros and cons. You must decide for yourself whether the benefits outweigh the risks. Your choice may be different from mine, and that’s just fine because it is your choice, your body, and your baby, not mine.

Unfortunately, there are many cases in which the woman will be given just enough information to consent, without really knowing all of the risks, nor any of the potential benefits of other courses of action. I attribute this to two main reasons: 1) not having or taking enough time to fully explain everything; and 2) doctors are human, too, and want you to agree with them. (After all, if you were trying to talk a friend into going to a particular restaurant, you wouldn’t tell her about that time you had bad service, would you? Of course not. You’d talk about how good the food was and how many times you’d gone there when everything was just perfect.) But what if you end up having a bad outcome from a procedure—an outcome that the doctor knew about but didn’t tell you could happen? Ideally, you should never say in retrospect, “I would never have done it if I knew that could happen.” Rather, you should say, “I knew the risks, and chose that course of action as the best at the time.”

In addition to simply knowing what all of the risks are, you should understand the likelihood of the negative side effects. This issue is important to understand because some doctors will try to persuade you with the “worst possible scenario” if you don’t follow their medical advice or opinion. For instance, there is a current nation-wide trend against allowing a woman to have a VBAC (vaginal birth after Cesarean) due to the increased risk that a scarred uterus will rupture under the pressure of labor contractions. Uterine rupture sounds scary, and can be dangerous, but it is usually handled quite quickly with an emergency C-section, and only rarely results in a hysterectomy or the death of the baby. So the actual risk of serious injury to mother or baby is in reality a fraction of the risk of uterine rupture. The risk of uterine rupture for VBAC is about the same risk as that of miscarriage if you have an amniocentesis, yet doctors will actually promote this invasive prenatal test and minimize the potential risk. Does this make sense? Doctors will promote a prenatal test of uncertain benefit with a certain risk of death to the baby; but will deny women the right to attempt a vaginal birth because of the equal risk of uterine rupture which only rarely threatens the life or health of either mother or baby.

And what if you disagree with the doctor’s opinion? (It is allowed, you know.) There are few cases in which all medical people will agree as to the best course of action. You can always seek a second opinion. What a doctor or midwife may think is the best, and what they would do if they were in your position, may not be what you want. Let me give you a radical example of this. A woman who has endured sexual abuse may have a morbid fear of having a C-section. Being unable to move and unable to see what is happening to her lower half while a bunch of men are on the other side of a sheet doing who-knows-what may be the worst possible scenario to her. Just the thought of it may nearly send her into a panic attack. Now let’s say that the baby’s umbilical cord prolapses (it slips down into the vagina), and without a C-section the baby will die from lack of oxygen since the head will compress the umbilical cord. You may think that losing a child would be the worst thing that can happen. She may find it preferable to mourn the loss of a baby than to submit to a terrifying operation that evokes all her worst fears and nightmarish memories of a lifetime of abuse. Few cases are this extreme. But what about whether to have a C-section just because “labor is taking so long”? Your doctor may think it is preferable….but then he won’t be the one recovering from major abdominal surgery while trying to tend to a newborn who doesn’t sleep longer than a few hours at a stretch.

Sometimes, though, you won’t even be asked for consent. It may be that when you sign the admission form there is a statement to the effect of, “I give my permission for any procedure deemed necessary by my medical team.” (You can cross through this and write that you retain the right to informed consent before any procedure is done.) But it may just be that the staff at the hospital are so used to a set protocol that they don’t even think they need to obtain your consent before doing something. Take amniotomy, for example. It has become standard protocol in many places to artificially break your bag of waters once you reach a certain stage of dilation. Many nurses will just come in and say, “We’re going to break your water now,” and then do it. They may not even realize that you might not want this done. Or they may say, “We’re going to break your water now, because it will speed up labor.” Though giving more information, that’s not asking for your consent—it’s telling you what they are doing, and how much choice do you really have when you’re already on your back with your legs spread? What true informed consent looks like in this scenario goes along these lines: “I’d like to break your bag of water now. This may help speed labor up a bit because the baby’s head can press directly on the cervix which tends to make it dilate faster. The procedure itself is painless, but many women say that the contractions feel stronger once the fluid is out, and many request pain medication afterwards. Once we do this, it can’t be undone, and there is the possibility that the baby may not tolerate labor without the cushion of the amniotic fluid around him and the cord, thus increasing your risk of C-section. Would you like for me to do this, or leave the bag of fluid intact?” If there is this much to say about the risks and benefits of a “simple” amniotomy, imagine what is often left unsaid about such procedures as epidural, Pitocin augmentation, continuous electronic fetal monitoring, episiotomy, forceps or vacuum-assisted delivery, C-section, etc.

Before you accept any procedure, make sure you fully understand all the risks and benefits of the procedure as well as any alternatives. If you are not told of them, ask. There are always benefits and risks to any procedure, as well as alternatives (even if it is just doing nothing—which often is the best and safest thing)!

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