“At 41 weeks, the midwife on call for my appointment told me that I would be induced the next day. I asked what the risks of inducing or not inducing would be, at this point, in my case. (The ultrasound had showed everything fine with the baby, fluid, and placenta.) She responded by saying, “Look, you are about to become a mother. It’s time to stop thinking about yourself, and start thinking about your baby.” That was the end of the discussion. I was induced the next day.”
“With my first, they hooked me up to Pitocin after delivery without mentioning it. With my third, I arrived fully effaced and 10cm dilated. The nurse was about to give me a shot of Pitocin until my doula told me that she was prepping the shot, and I told her no. She said that the doctor had called it in as an order, and it wasn’t negotiable.”
“The OB stripped my membranes at my 38-week appointment, without warning, explanation, or consent. I was in huge pain during and after. When I asked why that vaginal exam hurt so much, he told me what he had done. I asked him why he hadn’t told me first or asked if it was ok? He said, ‘Most women want me to do that, and I assumed you would too.’”
“The doctor cut an episiotomy, without notice, after I EXPRESSLY forbade it. I have not trusted doctors since that day. Traumatizing. I felt assaulted.”
“After the birth of my son, my doctor manually removed the placenta without first telling me what he was about to do or asking my permission.It was a brutal and horribly painful procedure and I felt overwhelming shock and horror. He told me that I should just be happy to have a healthy son. I am pregnant again and terrified to give birth again after my experience.”
“As a registered nurse, informed consent was one of the biggest things I was taught during nursing school. And then I graduated and started working in maternity and all of a sudden informed consent was important to no one. I can say from experience that while patients have to sign an informed consent, their signatures don’t follow a real discussion of both risks and benefits. So they might think they are informed; sadly, they are not.”
“When the ultrasound showed twins, I was referred to a high-risk practice. The only discussion of “options” was the date when my cesarean would be scheduled. When I tried to ask about how the risks of twins birth applied in my personal case, I received frowns but no answers. I explained that I wanted to attempt a physiological birth unless there was evidence that intervention was needed in my case. I was told that this kind of birth would not be allowed at any hospital in the area. When I said that I was looking for a midwife who could support a physiological twins birth, the OB said that she would have no choice but to call Child Protective Services.”
What Should Informed Consent Look Like?
If I am asked by doctors or midwives what informed consent should mean in birth care, I tell them that it could be said to consist of three parts:
1) Inform. Tell the woman about what you observe to be going on at this moment in the pregnancy or birth. Tell her about all of the healthcare alternatives that are available to her. Not just the one you think she should do. Tell her as much as you know about the risks and benefits of each alternative, and what kind of evidence exists for this information. This part of the discussion should be a transfer of objective facts, and you should leave your opinion out of it.
2) Advise. Tell the woman what you think she should do. Tell her why. This is a good moment to express the limits of your own skills and knowledge. Are you advising a cesarean for breech because you haven’t been trained in breech births? This is a time to mention that. This part of the discussion can be an expression of your subjective opinion about what you would counsel the woman to do.
3) Support. Support the woman in the exercise of a decision between the alternatives. This includes the decision not to follow your advice. It isn’t informed consent unless the patient has the ability to choose an alternative other than the one that the provider recommends.
With a cesarean rate of over 32%, all women have an interest in ensuring that they have the right to make an informed decision about the risks of cesarean for their own births, that every intervention offered—up to and including surgery—may be freely accepted or freely declined. Many patients freely choose to say, “Doctor, tell me what to do.” But that, too, is an autonomous choice to follow a practitioner’s advice, and must be recognized as such. A “yes” is not meaningful unless you also have the right to say “no.”
Birth matters. Women matter. Women are competent and capable of making good decisions for themselves and the babies they birth, and they have the legal right to be supported in that process.