Thoughts on Informed Consent, Refusal and VBAC

If you’ve been listening to the news lately, you’ve probably heard a lot about vaginal birth after cesarean (VBAC). The NIH held a consensus meeting to decide what was appropriate in VBAC care. The general thought was that the overall VBAC rate should increase and that the rate of primary cesareans should decrease due to the risks of surgery to the baby and mother. The panel had several recommendations that can be boiled down into:

• ACOG and ASA should revise their guidelines on the “immediately available” guidelines.
• The decision to do a VBAC or a repeat c-section should be made between a woman and her practitioner, after an informed discussion.

The problem with the last statement is that true informed consent and discussion is very rare in obstetrical care. The closest that we tend to come is the woman who is choosing a VBAC. She is likely to spend the last several months of her prenatal care being told of the risks of VBAC and the parameters in which it will happen. In contrast, had that same woman chosen to have an elective repeat cesarean, she would simply be handed an appointment card for her scheduled surgery and then sign a sheet of paper that would have to suffice as informed consent, all done a few minutes before her surgery. Neither of these is truly informed consent.

So how can women get informed consent, particularly when it comes to a hot topic like VBAC? My advice is:

• Do independent research.
• Seek out information from neutral sources.
• Talk to other mothers who have had a VBAC.
• Talk to other mothers who have had a repeat c-section (planned and not).
• Prepare for your birth by childbirth class, doula support and emotional support.
• Consider alternatives including midwifery led care.
• Make a decision only after a lengthy discussion with many people, including your practitioner.

Providers have to consider multiple issues when recommending one mode of birth over another: health of mother and baby, liability for complications, availability of self and staff during uncomplicated and complicated births, personal beliefs, medical malpractice insurance (if they choose to carry it), what other practitioners will think of their choices, etc.

Women have their own issues to consider when deciding her mode of birth: health of baby and mother, likelihood of the success of VBAC, physical and emotional pain after the birth, personal beliefs, etc.

The final point is that of informed refusal. ACOG has a policy of informed consent and refusal. This states that they believe that a woman who has all the information, is allowed to make a decision to choose not to receive the recommended procedure or therapy that is being suggested by her doctor.

At the panel yesterday, when asked specifically about the policy of informed refusal as it included forced repeat c-section, either by practice policy or individual recommendation, they basically said that this was unclear. Some advocates took this to mean that the consensus panel was suggesting that women did not have the right to choose a VBAC if that wasn’t the recommendation of her doctor or that if she did, it was acceptable to coerce her with threatened legal action. In other words, a woman is free to make any decision she would like, unless it conflicts with what her practitioner decides.

That leaves us in a sticky spot. What’s a birth activist to do?

Related:

• Maternal Decision Making, Ethics and the Law
• Refusal of Care Based on Religious Beliefs
• Women Need a Chance to Avoid Repeat Surgery

Avoid Interventions That Are Not Medically Necessary

This is the health birth practice that gets me strange looks - why would anyone want to avoid medical interventions?? I truly think that people 1) aren’t stopping to hear the medically unnecessary part and 2) simply don’t trust birth to be uncomplicated and go off without a hitch.? Seriously, machines are not designed to give birth but women are!

The use of medical technology in the rare instance of a complicated birth is a blessing, but the flip side is that overuse of the exact same technology is a curse.? The use of fetal monitoring has done nothing but increase the cesarean rate.? Don’t believe me?? Ask ACOG.? We routinely give women IVs, fetal monitoring and the cesarean surgery rate has gone up 46% in 10 years.? Something is wrong.? That is the misuse of medical technology in a typically uncomplicated process.? When cooking, do you skip the blender because you know how to chew your food?? Or do you process all your food into liquid in case you might choke on a piece of it?

Here are some ways to avoid unnecessary interventions in birth:

• Consider where you are giving birth. Giving birth at home or in a birth center will help ensure that you are well supported in an uncomplicated pregnancy.? Unnecessary technology is not available because it is not needed.? Emergency equipment is saved for emergencies.

• Consider with whom you are giving birth. Giving birth with a midwife at home, a birth center or even a hospital could have beneficial effects on your labor by the lack of unneeded technology.? There are certainly OBs and family practitioners who provide quality, low risk care without overusing medical technology, but they are not trained in the specialty of low risk women.

• Frequent conversations about your needs. Talk to your practitioner about what you need both in terms of support and (in)action from them.? Ask them when they would resort to medical technology and open up that conversation.? Remember, the point is not that intervention is bad but that unnecessary intervention is harmful to labor, baby and mom.

• Don’t hesitate to change. So many women get into their pregnancies and realize that either they’ve changed their goals or that their practitioner is not supportive.? Some choose to have home births, some choose to go to a different facility or different provider.? That is an acceptable thing, do not be concerned about hurting your practitioner’s feelings.? If your plumber provided services that were not what you needed would you hesitate to find a new one? Or live with a broken faucet?

Trying to tell if a medical intervention is necessary?? Talk to your practitioner.? Over the course of your prenatal care, your relationship has grown and you need to trust this person in practice and philosophy.? Get informed consent.? Do you have time to think about it and discuss it or is this an emergency? Do you know why a test or procedure is being proposed? What is it supposed to so?? When will you know if it worked?? Are there other procedures, tests or possibilities?? What are the benefits?? What are the trade offs? What happens if you decide to do nothing or not go forward with what they are proposing?? If you determine, with the help of your medical team, that an intervention is necessary and not “just because we do it to everyone,” then you are still keeping with the spirit of this healthy birth practice.

Lamaze Healthy Birth Practice | Mothers Advocate Video | Mothers Advocate Handout

Informed Consent & Refusal in Maternity Care

Register today for this FREE Webinar!

It?s time to put women back in the driver?s seat when it comes to their maternity care decisions. CIMS? experts have examined how current laws and professional practice guidelines affect patient decision-making in maternity care, and demonstrate in this FREE Webinar how patient access to evidence-based research is particularly important during a time when perinatal mortality and morbidity rates, interventions, and disparities are on the rise in the U.S. Need a continuing education certificate? Processing fees apply.

? Friday, June 19, 2009

? 1:00 pm ? 2:30 pm (Eastern) / 10:00 am ? 11:30 am (Pacific)

? Register online at: www.motherfriendly.org

Participants will learn:

? The legal and ethical responsibilities that health care professionals have to provide informed consent and refusal

? The components of informed consent and refusal and how to implement them fully during their interactions with patients

? The benefits of informed patient decision making and ways to utilize this knowledge to affect policy change within their institutions

Earn 1.33 Nursing Contact Hours! Here?s How:

Continuing education processing fees: $20 CIMS Members / $25 Non-Members. Payments processed through the CIMS Continuing Education Payment Center at: www.motherfriendly.org/webinar.php.

This continuing nursing education activity was approved by the Texas Nurses Association, an accredited approver by the American Nurses Credentialing Center?s Commission on Accreditation.

Provider approved by the California Board of Registered Nursing, Provider Number 15290, for 1.33 contact hours.