The ethics of consent during labour and birth: episiotomies

Abstract

Unconsented episiotomies and other procedures during labour are commonly reported by women in several countries, and often highlighted in birth activism. Yet, forced caesarean sections aside, the ethics of consent during labour has received little attention. Focusing on episiotomies, this paper addresses whether and how consent in labour should be obtained. We briefly review the rationale for informed consent, distinguishing its intrinsic and instrumental relevance for respecting autonomy. We also emphasise two non-explicit ways of giving consent: implied and opt-out consent. We then discuss challenges and opportunities for obtaining consent in labour and birth, given its unique position in medicine.We argue that consent for procedures in labour is always necessary, but this consent does not always have to be fully informed or explicit. We recommend an individualised approach where the antenatal period is used to exchange information and explore values and preferences with respect to the relevant procedures. Explicit consent should always be sought at the point of intervening, unless women antenatally insist otherwise. We caution against implied consent. However, if a woman does not give a conclusive response during labour and the stakes are high, care providers can move to clearly communicated opt-out consent. Our discussion is focused on episiotomies, but also provides a useful starting point for addressing the ethics of consent for other procedures during labour, as well as general time-critical medical procedures.

Consent and refusal of procedures during labour and birth: a survey among 11 418 women in the Netherlands

“…Sometimes, women may want to make a decision about some procedures antenatally. The woman’s preference is guiding here, and antenatal decisions are always reversible 27…”

“…Care providers also cite women’s competence, their vulnerability and emergency situations as barriers for meeting consent requirements during childbirth. Although these are challenges that should be acknowledged, this does not take away women’s explicit right to consent to or refuse any procedure 27 44. At minimum, even a short or simple interaction could establish (at least some form of) consent and could make a big difference in a woman’s experience and hence the quality of her care.…”

“…The woman's preference is guiding here, and antenatal decisions are always reversible. 27 Women do not often refuse procedures, ranging from 0.7% for external CTG and vaginal examination to 8.7% for IOL and CS during labour. However, if women decline a procedure, the frequency of them being over-ruled is high, in some cases even more than 50%.…”

Shame, health literacy and consent

“…Asking for permission before infringing on another's body meets not just legal and regulatory requirements, but is also regarded as morally transformative in the sense that consent vests the control over bodily integrity in the patient, thus respecting their autonomy. 10 The importance of the second of these elements, communication and information-giving, was affirmed by the UK Supreme Court in Montgomery v Lanarkshire Health Board. 11 The basic information that needs to be disclosed to the patient for consent to be valid relates to the benefits of the proposed intervention and the risks attached, as well as any reasonable alternative options.…”

“…Asking for permission before infringing on another's body meets not just legal and regulatory requirements, but is also regarded as morally transformative in the sense that consent vests the control over bodily integrity in the patient, thus respecting their autonomy. 10…”