Vaginal deliveries - is there a need for documented consent?

Abstract

A pregnant woman nearing delivery, with an uncomplicated pregnancy and no immediate indication for caesarean section (CS), can either deliver vaginally or by CS. Historically CS has been viewed as more dangerous than vaginal delivery. However, CSs are far safer today and the complications of unmonitored labour are increasing, especially in the public sector.Delivery should be discussed during the antenatal period. The decision to have a CS is usually followed by signing an authorisation form -incorrectly referred to as the consent form. Women who decide to deliver vaginally are not asked to sign a similar form, possibly because consent is procedure specific and a vaginal delivery is not seen as a procedure. However, natural birth, a normal physiological process, and modern medical vaginal childbirth are not synonymous and each intervention in the latter requires consent, albeit often tacit.The merits of antenatal care and monitored childbirth are obvious. However, it is not clear to most people that when a woman seeks medical attention and is admitted into an antenatal programme for her pregnancy and subsequent childbirth (including a 'normal' vaginal delivery), there is a transition to medicalised care. Hence the ethical and legal tenets must apply to management in this context. Therefore, does the modern medical vaginal birth process itself require an authorisation form? This is because the process includes medical interventions and unique risks, and there is a clear alternative. When well informed the woman has probably passed the threshold for consent from an ethical point of view, but is there an additional legal threshold that must be crossed, given the increasing tendency to litigation?While presenting current scientific opinions on the risks and benefits associated with vaginal and abdominal delivery, we do not argue for either mode of delivery. We recognise women's right to choice in respect of mode of delivery. We argue that even when a normal vaginal delivery is anticipated, the practitioner is obliged to discuss the alternative of CS with the woman. We argue that the context and environment of the delivery ward are important components of the communication. These are informed by the doctrine of informed consent, which we examine from the legal perspective. We aim to stimulate discussion and debate on the current and future status of vaginal deliveries. Vaginal delivery or caesarean sectionthe factsDespite being more costly and associated with maternal and neonatal complications, morbidity and mortality more often than vaginal delivery, 1-4 CS is an increasingly common procedure in the public and private sectors in South Africa. 5 South Africa's CS rate is much higher than the ideal rate of 10 -15% in low-risk obstetric populations recommended by the World Health Organization in 1985. 6 According to the Health Systems Trust the public sector rate was about 17% in 2005, and rates of about 30% were reported by regional and tertiary public hospitals in Durban. 5High CS rates have been reported in the pri...

Physiotherapy management strategies for woman post-ceasarean section delivery in public hospitals in KwaZulu-Natal, South Africa

“…An audit done by Naidoo and Moodley (2009) on a spe cialist private practice within KwaZulu Natal found that maternal requests, breech delivery, HIV and previous CSD contributed to the high CSD rates in that particular practice. Literature has further cited that fear of vaginal deli very, the need for control in the birthing process (Lavender et al, 2012;Dhai et al, 2011), convenience, and the preserva tion of the pelvic floor (Dhai et al, 2011) are some of the reasons why women opt for a CSD. Although CSD are consi dered relatively safe (Dhai et al, 2011), there are still a number of complications associated with this procedure.…”

“…Literature has further cited that fear of vaginal deli very, the need for control in the birthing process (Lavender et al, 2012;Dhai et al, 2011), convenience, and the preserva tion of the pelvic floor (Dhai et al, 2011) are some of the reasons why women opt for a CSD. Although CSD are consi dered relatively safe (Dhai et al, 2011), there are still a number of complications associated with this procedure.…”

Editor's Choice

“…Anthony and colleagues 12 challenge the suggestion by Dhai et al 13 that that there are strong ethical and legal imperatives for a practitioner to obtain authorisation for modern 'medicalised' vaginal delivery. Unchallenged, these views carry serious implications for overburdened public sector facilities.…”

The 'boom' in medical malpractice claims – patients could be the losers

“…Doctors will tend to 'focus on a hypothetical court case, which in turn may affect the quality of the care that is delivered' . [3] There are signs that this may be occurring already: this country has an abnormally high caesarean section rate, ranging from 20% to 30% in the public sector to nearly 60% in the private sector, [10] and there is a documented increase in pathology costs due to increased utilisation. [11] The editorial in this issue [2] advises doctors in this 'increasingly hostile, pressurised and uncertain' practice climate to ensure that they have insurance or indemnity (see box, p. 460) and that their provider has experience of managing claims in SA.…”