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The most important thing to remember as you walk into your pregnancy and birth journey is that EVERYTHING is a choice, once you understand that one key concept you will suddenly have your eyes opened to the variation of language used in maternity care, and that it is actually your responsibility to protect and advocate for this right.
Pregnant women do not have less of a right to informed consent than a non-pregnant women.
Maternity services are bound by the same laws as everyone else in terms of informed consent.
Consent and the Law
Quite simply it is against the law to treat you without your consent, once your baby is born it is also against the law to treat them without your consent as you will have parental responsibility.
Consent means saying yes to the treatment. In the law, consent must be genuine, meaning you must understand your treatment well enough to make a decision, and undue pressure must not have been put on you to make a particular decision.
If someone 'treats' you without your consent they are breaking the law.
Treatment covers a wide variety of things,
In pregnancy this may be: Carrying out a physical examination, taking a blood test, weighing you, giving you medication, giving you an ultrasound scan, measuring your bump, listening to babies heart beat, giving you a sweep.
During birth this may be: Cervical checks, listening to babies heartbeat with a doppler, putting you on the CTG, breaking your waters, administering any drugs like pain relief, doing an episiotomy, assisting your birth with instruments or performing a C-section.
After you give birth this could be: Giving you an injection to manage the third stage, cutting the cord, weighing your baby, stitching you up, performing a vaginal and rectal exam, performing fundal massage.
Thinking back in your pregnancy so far, how many of these things have been done without asking expressed consent?
Does consent have to be verbal?
This is where it gets tricky, consent does not have to be verbal, for example you could give consent for a blood pressure examination or blood test by holding out your arm in the response to the question 'Is it ok if I take your blood pressure?' or 'Please can I take your blood to test for x / y?'.
You could consent to a vaginal exam by getting on the bed and opening your legs.
But this works both ways, you can withdraw consent by pulling back your arm, or moving up the bed away from the person, this withdrawal of consent is often not respected.
When should I be asked for consent?
Consent should ALWAYS be asked before something is done.
It is not acceptable confirm consent after a procedure has been carried out, the most common example of this is performing a sweep during a cervical check.
'I gave you a quick sweep whilst I was up there to help things along ok?' is not informed consent, and is actually an intimate assault.
or
'I have started some oxytocin to get things going ok?'
What information should I be given so that I can make an informed choice in pregnancy and birth.
The answer to this is complicated.
You should be given the information that you feel is necessary to allow you to make an informed choice.
This may include:
Knowing the reasons behind why the particular test or treatment is being offered (the benefits).
Knowing the risks of that particular procedure.
Discussing the alternatives to the suggested test / treatment and the risks/ benefits of these so that you can weigh them up against each other.
The benefits and risks of not doing the test / treatment (doing nothing).
What the evidence says about the suggested test / treatment, its alternatives and the option of doing nothing.
If your Dr doesn't have the answers to your questions they should tell you this, and help you to find the information.
It isn't your responsibility to google to answers or find research articles to help you make the decision, but unfortunately this the the route many women have to take in order to make a truly informed choice.
This information should be personalised (personalised care) to you, for example if you wish to have a large family it may be important to you what impact the test / treatment may have to future pregnancies and births, but if this is your last pregnancy you do not need to know this information.
This is why handing you a leaflet is not acceptable in place of an informed discussion.
Shared Decision Making
Shared decision making does not mean that your Dr gets a say in what your decision is.
What it means is that they have a responsibility in helping you to come to that decision.
The RCOG patient leaflets have a box on shared decision making on them, and it makes it clear that it is actually about helping you come to a decision and getting the information you need to do that.
The questions come from a study in 2011
Three questions that patients can ask to improve the quality of information physicians give about treatment options: a cross-over trial.
The study concluded that by asking these three questions, the information given by the Dr;s increased patient involvement.
They stated that these questions can drive evidence-based practice, strengthen patient-physician communication, and improve safety and quality.
So what are these three questions?
What are my options?
What are the pros and cons of each option for me?
How do I get support to help me make a decision that is right for me?
Your instinct is important when making an informed choice.
When we delve into the world of medical tests, procedures and treatments, we are often looking outwards for answers.
It is also important to look inward, your body and your baby are in constant communication, only you can feel how your body is responding to the pregnancy, if you feel well, or if you feel like something may be wrong.
After hearing all the 'facts' you may not feel like making what appears to others as the logical choice, listening to your instinct is often as important as all the other information.
Using your BRAIN to make informed choices
It can be difficult to remember all the things you should be asking about to make an informed decision, especially if you are in a high pressure situation.
Many hypnobirthing courses use the BRAINS tool as a prompt to help you remember the questions to ask, this pulls together everything we are talking about above like this:
B - What are the Benefits
R- What are the Risks
A -What are the alternatives (and the benefits / risks of these)
I- What is your instinct saying?
N- What happens if you do nothing (and the benefits / risks of this)
S - What does the science say?
I have put together a free worksheet that you can use to remember this tool and print out to write out all of these things to help you make an informed choice, you can find it here.
Saying no, and undue pressure or influence.
In the UK we are protected by law to say no to any test or treatment.
You can say no to treatment even if your Dr's or midwives think this is the wrong decision.
You can say no even if this puts you and / or your baby at risk of death or serious harm.
You do not have to explain your reasons for saying no.
You do not have to base your decision on something that is logical or makes sense to others (remember instinct!).
As your right to autonomy is protected by law, your health care professionals should not put any undue influence or pressure on you, or threaten to withhold care to persuade you to make a certain decision.
They can explain the risks, and offer an opinion on which choice they feel is best, but language is important.
There is a big difference between saying 'do you want your baby to live' and saying 'if you choose to do nothing the risk of stillbirth increases from 1 in 1000 to 2 in 1000.
In fact the RCOG has published tables to help guide Dr's on how to appropriately discuss risk.
Term | Number ratio | Colloquial language |
Very common | 1/1 to 1/10 | A person in a family |
Common | 1/10 to 1/100 | A person on a street |
Uncommon | 1/100 to 1/1000 | A person in a village |
Rare | 1/1000 to 1/10000 | A person in a small town |
Very rare | Less than 1 in 10000 | A person in a large town |
If you have made a decision but this decision is challenged repeatedly by different members of staff and no new information has been given / the situation has not changed this is 'un due influence'.
Coping with undue pressure
You can repeat the phrase 'I have made an informed decision and any further discussion will feel like coercion and undue pressure'.
You can email the head midwife through PALS and make it clear what your decision is and what you are happy to discuss at further appointment, if anyone tries to have these discussions with you, hand them a copy of the email.
If coercive or threatening language is used, ask them to write that in your notes (it is unlikely they will want to and will probably back track).
Or ask for evidence to back up their claims (a print out of trust policy or guidelines isn't sufficient).
You can request a new Dr or midwife at any time.
You can leave any appointment at any time.
Can I give consent in advance?
Yes and No.
The RCOG guidelines state 'Where possible, women should be informed during the antenatal period about predictable problems that may occur in labour'.
This is because informed decision making can be tricky in labour.
Even if you have previously given consent to something, it is important that your continued consent is checked before the procedure is carried out, and you have the right to change your mind at any point, for example:
In your midwife appointment they explain episiotomy and why it may be done, the benefits and risks, you indicate that you would be willing to have one if necessary.
During labour you still need to be asked your continuing consent before it is done, and you can change your mind.
Informed consent in labour
Can informed consent be obtained whilst you are giving birth?
The RCOG guidelines state:
'When consent has to be obtained from a woman during painful labour, such as to perform a vaginal examination, episiotomy, operative delivery or to site an epidural, information should be given between contractions.'
Prior to emergency procedures there is scope to allow verbal consent to be obtained when it is considered to be in the interest of the woman or baby. However, if time allows written consent should be obtained for all such operations under general or regional anaesthesia. In the emergency situation, verbal consent should be obtained which should be witnessed by another care professional. Obstetricians and the witness to verbal consent must record the decision and the reasons for proceeding to any emergency delivery without written consent. If a woman who is deemed to have capacity to consent refuses assisted delivery or caesarean section, even after full consultation and explanation of the consequences for her and for the fetus, her wishes must be respected.
Therefore a healthcare professional has a responsibility to ensure they have appropriately gathered (not during contractions) informed consent either verbally or on paper before anything is carried out.
Being in labour does not mean informed consent is not important or possible.
The difficulties and limitations of obtaining informed consent during labour is what makes birth preparation in antenatal classes important, so that you have a basic understanding of the things that may be offered to you head of time.
Consent in an emergency
If you are unconscious your healthcare professionals may do what is necessary to prevent your condition getting any worse. Where possible your treatment should be discussed with your next of kin.
Unless you are deemed to lack the mental capacity to give consent (and this is a lengthy leal process), you should be asked for consent.
One of the recommendations in the UK Birth Trauma includes a dangerous legal error whish removes this right:
'Except in an emergency, no procedure should be carried out on a woman without her consent.'
This is in direct conflict to current Uk law.
This is important as 'Emergency' is subjective.
Birth Plans
Your birth plan has no legal status.
However a birth plan is an important tool for you, to decide between your partner and yourself, what your wishes would be in certain situations. This can be useful when making informed choices during labour, as you have already done the prep work.
You can ask your care team to read your birth plan, this will inform them what is important to you.
A birth plan can be used in a court of law as evidence of your wishes.
Adjustments
If you need reasonable adjustments under the Equality Act 2010, the Trust has to provide these.
If English isn't your first language you can request an interpreter to help you give informed consent, this is protected under the GMC code of conduct.
Why Informed Choice is important.
Informed choice in pregnancy is the difference between feeling like your birth is something that has been done to you, or something that you participated in.
Maintaining a sense of control can effect how you feel about your birth, and if you view the experience as positive.
Feeling positive about your birth can help protect your mental health postpartum, and leave you feeling empowered rather than traumatised.
Birth does not always got to plan, if we can cope with these changes to your original plan and participate in decision making it is a way to help you feel as though you are in control.
How a Virtual Doula can help with informed decision making.
Whilst a midwife or a Dr offer you opinions about what they think you should do, a doula does not do this.
As a virtual doula I work with you to find the information important to you to allow you to make the best decision.
I can find research papers, policies, guidelines, evidence based podcasts and blogs with reliable information to help you make those choices.
I can remind you of your right to say no, and offer tools to help you advocate for those choices.
Summary
Know your rights
Know how to make informed decisions
Understand how to advocate for your decisions
Use a Birth Plan as a tool to make decisions and inform your team of your wishes
Who am I?
I am Charlotte, a Virtual Doula, providing bespoke evidence-based pregnancy support to families who want an empowering birth.
With 10 years + of clinical research experience, a biomedical science degree, and two hospital births under my belt, I use my knowledge to provide pregnancy support to help you make informed decisions about your pregnancy, birth, and postpartum.
I provide pregnancy support for all types of births, including hospital births, helping you to navigate NHS guidelines and have an empowering positive birth.
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