Thursday, March 18, 2010

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Thursday, March 4, 2010

Informed Consent - The Myths Vs. Reality

When discussing maternity health care practices there is one phrase that will inevitably be mentioned and that is informed consent. The belief is that women should have informed consent before any procedure, intervention, or alternative action is taken by the provider before, during, or after labor and birth. This supposedly ensures that she is given the optimal chance at being involved in making choices regarding her health care, but does it really?

The Surgery Encyclopedia defines informed consent as: a legal document in all 50 states. It is an agreement for a proposed medical treatment or non-treatment, or for a proposed (emphasis mines) invasive procedure. It requires physicians to disclose the benefits, risks, and alternatives to the proposed treatment, non-treatment, or procedure. It is the method by which fully informed, rational persons may be involved in choices about their health care.

Let's examine the language and implications of that definition. On paper and at first glace, informed consent seems like the gold standard in allowing for participatory practice in maternity health care, but upon closer examination there are some limitations. Because informed consent begins with the caregiver proposing a certain course of action, it suggest that the caregiver has already decided that action is best. Yes, the practitioner may disclose information on not taking that particular action, or other alternatives, but is this enough to be considered participatory care? Let's look at an example of how informed consent may be given:

A first time mother arrives at the hospital, membranes still intact, having regular contractions at about 6-7minutes apart. She has already labored at home for more than 8 hours. During her cervical check, it is discovered that she is only about 3cm dilated. Her contractions are manageable to her, but she can't help but express disappointment that she isn't further along. She doesn't have a written birth plan, but wants to labor without pitocin or other forms of drug augmentation because of fear of what it might do to her labor. After an hour of laboring in bed on monitors, her labor begins to slow. Her contractions are spacing and getting weaker in strength. Although her baby is fine, and she is doing well, her doctor suggests (trying to honor her wishes to avoid pitocin) that her membranes are artificially ruptured. He goes on to tell her that because they rupture her membranes, they may have to monitor the baby more closely as labor is better tolerated by baby with membranes intact, and that there is a slight risk of infection and fever if she labors too long with her membranes ruptured. He tells her the benefit is that it may put her in a better labor pattern and make the contractions longer, closer together, and generally more efficient. He also tells her that her that she could wait a few hours and see what happens considering the baby is looking good, but that in his experience, once a labor stalls, it usually requires some action to get labor going again. He reminds her that, although he knows she doesn't want pitocin, it is still a viable option that usually yields the fastest results. After hearing all of this, the mother decides to have her water broken, and in 7 more hours goes on to delivery her baby vaginally. She did, however, require an epidural (which she was also trying to avoid), not only because of the intensity of the contractions after her water was broken, but because she wasn't allowed to labor outside of the bed. The lack of freedom of movement increased her perception of pain.

In that scenario many would argue that she was given informed consent and in the truest definition of the word, she was. The doctor proposed a course of action, told her the risks and benefits of that action and also discussed the option of not taking that action. He also presented another option (although the patient was already aware of the option and had already declined it) However, when we consider that scenario closely, it's then we can see the true limitations of informed consent. Did the doctor prescribe that particular course of action without bias? Since that action was the only alternative mentioned besides one the patient clearly did not want, I would be inclined to believe no, he did not. The bigger question is why weren't more alternative augmentations discussed? There are a host of different options that could have been presented but were not.

Having said all that, it has been clear to me for a long time that we need more than informed consent to really be participants in our maternity care. We need informed choices. As I learned from both my Doula studies and experiences, the act of informed choice is a process. It suggests that a dialogue is opened between the practitioner and patient. The communication is such that in certain situations the patient may face, multiple options are presented to the patient, with risks and benefits of each, in addition to the option (if possible) of doing nothing. The patient can then carefully weigh the pros and cons of all viable options, without pressure or bias from the practitioner, and then can give her informed consent. Informed choice invites the patient to truly become a participant in her care, and should always be the first step before obtaining informed consent. In this scenario the caregiver has engaged the patient and in doing so builds a positive atmosphere in the birthing room. No longer is the caregiver inviting the patient to "sign off" on a procedure or course of action the he deems necessary, but is "engaging in a dialogue to help the client take responsibility for her own choices."

In closing this post, I want to add that it is important for expectant mothers to know that there can be situations that are true emergencies. In these situations it goes without saying that discussions will have to be limited, if there is time for any at all. This is another reason why informed choices are so valuable, because the act of discussing choices and options should happen not just during labor, but throughout pregnancy at prenatal visits. The open dialogue and subsequent trust the practitioner fosters as result is invaluable in those instants of true emergencies. Not only does the doctor get to understand his patients wishes more deeply, but the patient in turn is able to trust the doctors expertise and opinions if an emergency should arise.