Tuesday, January 29, 2013

Informed Consent

According to the American Medical Association, informed consent
is a process of communication between a patient and physician that results in the patient's authorization or agreement to undergo a specific medical intervention.
In the communications process, you, as the physician providing or performing the treatment and/or procedure (not a delegated representative), should disclose and discuss with your patient:
  • The patient's diagnosis, if known;
  • The nature and purpose of a proposed treatment or procedure;
  • The risks and benefits of a proposed treatment or procedure;
  • Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance);
  • The risks and benefits of the alternative treatment or procedure; and
  • The risks and benefits of not receiving or undergoing a treatment or procedure.
In turn, your patient should have an opportunity to ask questions to elicit a better understanding of the treatment or procedure, so that he or she can make an informed decision to proceed or to refuse a particular course of medical intervention.
A key factor in the case of labor and birth would be timing.  Be sure to ask if the situation is urgent or if the procedure can wait.  Consider what is being used to indicate timing.  For example, does an electronic fetal monitor indicate baby's heart rate is dipping?  Note your position.  Are you lying on your back?  This position cuts off oxygen to the baby which results in a stressed fetal response,  Try lying on your left side and see if this fixes the problem. 
Continuous monitoring became a standard obstetrical procedure before studies could show if the benefits outweighed the risks, and without clear-cut guidelines on how doctors should interpret the findings. (Brody, 2009)
Evidence shows intermittent auscultation is the best way to monitor baby during labor.  Were you told this or of the risks of cEFM, including increased vacuum extraction, increased incidence of cesarean section without a reduced risk in perinatal mortality?  I have seen all too often women whose doctors told them they'd have the freedom to move during labor only to find once in the situation they were restricted far more than they would have liked and had been led to believe by the monitors.  In the examples above and below, restriction to the bed could be the cause of the 'problem.'

Perhaps your labor seems to not be progressing.  Before you sign the consent for a cesarean , consider dilation is not the sole purpose for contractions.  Labor is a delicate dance, according to an article in Midwifery Today,
What a contraction is doing is always ahead of what a cervix is telling.
There is purpose for pauses in labor, yet some medical professionals tend to jump the gun and assume labor has stalled, opt for a c-section and jot down "failure to progress" on your medical record. Easy, safe, fast fix.  Though it's not always safe.  Let me remind you, to be informed you must be aware of the risks and benefits of accepting the intervention as well as declining it.  Informed consent should not be fear based, yet the laboring woman is told you're not progressing, something is wrong.  This creates fear & anxiety, which are not conducive to labor and birth, and also puts the pressure on the laboring mother to "hurry up and dilate" -a bodily process she cannot directly control. 
Labour in a clinical environment may undermine women's feelings of competence, perceptions of labour, confidence in adapting to parenthood and initiation of successful breastfeeding. (Hofmeyr, Nikodem et al. 1991) 
This referenced study exhibits some of the risks of laboring at a hospital.  A hospital 'requires' at least one cervical exam and the risks explored here include unnecessary surgery, postpartum depression and more.  Were you informed of this?  Were you informed of the risks and benefits of cervical examines?  Did you know you have the option to say no.  Remember, it's your body, your birth experience.  Keep calm and birth on!

A person must be "in a reasonable state of mind" in order to give informed consent.  A woman in a non-medicated labor is in a primal state- this is not of reasonable mind.  When in this state, being coerced with fear does not equal informed choice.  It is essential to educate yourself on labor and birth, create a birth plan, get to know your care provider and hire a doula- this person can advocate for you and help you remember your options and assist you in making informed choices when emergencies arise.  Labor and birth are unique to each woman and each birth yet too frequently women are treated on the same basic template.  When something arises that an intervention is suggested, a woman in labor is not necessarily of a "reasonable state of mind" and her partner may become intimidated, stressed and concerned for her well being and that of the baby.  A doula comes equipped with a clear mind in the time of need and knowledge of the physiology of labor and birth, of various medical interventions and of hospital protocols.  Using a doula facilitates informed consent.  She is not there to make choices for you but to inform you of your choices.

Evidence shows that using a doula decreases the request for epidurals.  When a woman asks her doctor about pain relief it isn't very often they recommend a doula, most frequently they'll mention narcotics and epidurals.  Ask about the risks and benefits! And don't accept the answer that there aren't any risks- it's simply not true. 

Empower yourself on this Journey of Life with education to understand all of your options for labor and birth.  Be informed when you consent!

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Jennifer Valencia | Labor & Postpartum Doula | 928.300.1337


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