Advertisement
JOGC

Consent in Obstetrics

      Consent is a fundamental requirement to the practice of obstetrics. However, consent becomes complicated when there is shared care or transfer of care or where past or present circumstances have created barriers to developing a relationship of trust. Particularly troubling are the stories we've been told by Aboriginal women in Canada who felt coerced to undergo sterilization. These experiences challenge us to, among other things, reflect on the dynamics of the physician–patient relationship from the point of view of racialized or vulnerable women and on the complicated nature of consent in obstetrics.
      Our members are increasingly being asked to obtain consent for an intervention during a woman's labour where there has been a transfer of care, sometimes in situations when the member's presence may be unwelcome. At times, we may be unprepared for the strong negative emotions that confront us. This is, therefore, a good time for us to re-examine how we think about consent.
      Consent is far from a signature on a line; it is a process founded on a trusting therapeutic relationship. The Canadian Medical Protective Association (CMPA) provides general advice for physicians in its handbook Consent: A guide for Canadian physicians.

      The Canadian Medical Protective Association. Consent: A guide for Canadian physicians. Available from:cmpa-acpm.ca/en/advice-publications/handbooks/consent-a-guide-for-canadian-physicians. Accessed: January 10, 2020.

      We are all familiar with the three basic conditions for valid and legal consent: the patient has the capacity to give consent, the patient is adequately informed about the procedure, including advice on alternative treatments, and it has been given voluntarily. Current best practices in consent involve giving the patient a copy of any documentation relevant to the consent discussion for her to review and retain. As complex as consent can be in any area of practice, it is particularly so in obstetrics.
      Medical consent usually assumes that there is a relationship of trust in place even before the conditions of capable, informed, and voluntary consent can be met. Trust is typically developed within a relationship over time. Obstetrical care providers often have the opportunity to develop that relationship over the course of prenatal care or with patients who have been part of our practice for a long period of time. In an emergency situation, however, providers often do not have that luxury. In such circumstances, the starting point in the relationship may be characterized by fear and apprehension, or even a profound mistrust. These reactions may have little to do with us as individuals but are shaped by the patient's expectations, which can often be based on their past experiences or beliefs or formed by things they have read online. Our patients' past negative health care experiences and the (often generational) repercussions of institutionalized racism are beyond our control, but they are present in the room with us. As such, it is important we do not assume a relationship of trust—we will need to earn it.
      The CMPA stresses that consent must be, among other things, voluntary. We must be conscious of the fact that circumstances outside the case room can lead a patient to believe she has no choice. For example, women who are incarcerated, women with children in protective care, or women in abusive relationships may believe they have little or no autonomy. Similarly, women who have been transported far from home to an unfamiliar setting under stressful circumstances may not feel empowered to speak up for themselves. The care provider and the patient may have just met and the provider may be unaware of the patient's unique circumstances, but these issues may well affect care. Your patient may not feel able to answer a direct question or to speak her true mind, but it is worth asking, “Do you feel safe and free to give your consent to… .?”
      Legally, a patient either has the capacity to consent or they don't, but in obstetrics, there seem to be a lot of grey areas in between those two states. In labour and delivery, there is no doubt that capacity can be impaired by pain or exhaustion, by medications, by fear, or by mistrust–or a combination of factors. The mother's autonomy must remain paramount when we seek consent under adverse circumstances. We must remember too that it is important to have some record of discussions prior to labour or prior to any situation in which the patient's capacity to consent may become compromised.
      Obtaining valid informed consent can also be challenging in the context of language or educational barriers or cultural differences. The CMPA consent handbook notes that the expectation is higher for the consent process when the intervention is “non-therapeutic,” specifically tubal ligation. In the 1986 ‘Eve decision,’

      The Supreme Court of Canada. E. (Mrs.) v. Eve (October 23, 1986). Available from:decisions.scc-csc.ca/scc-csc/scc-csc/en/item/170/index.do?q=Eve. Accessed: January 10, 2020.

      the Supreme Court of Canada ruled that reproduction is a basic human right and that it cannot be taken away by someone else—only the individual can consent to the loss of their reproductive capacity.
      Decisions during childbirth on permanent contraception are particularly problematic because circumstances in active labour, during patient transport, or following transfer of care to another care provider may not allow for the discussions needed for a patient to be able to give voluntary informed consent, or she may no longer have the capacity to do so. As a result, many hospitals simply do not allow these procedures unless a prior consent discussion has taken place and it has been properly documented.
      Early and thoughtful discussions with a patient about the different scenarios that would require consent for an intervention in labour are the best way to meet the requirements for obtaining valid consent. These consent discussions, spread over time when possible, allow maternity providers to gain perspective on a woman's circumstances and values and to appreciate the various factors that may be at play in her decision making. They also give the patient the opportunity to ask questions when and where she chooses to help her understand the rationale for interventions and the material (to her) risks and benefits. But this approach works only when prenatal and intrapartum care are managed by the same care provider.
      Obstetrical care today is increasingly delivered by teams where all members share responsibility for patient care. The dialogue that leads to consent will be based on the sum of the all information and care the patient receives over the course of her pregnancy. Where there is conflicting information or understanding, consent becomes even more difficult.
      The CMPA recently discussed a team-based approach to disclosure in cases involving members of the health care team that normally don't have patient contact.
      The Canadian Medical Protective Association
      Disclosing harm associated with pathological analysis or diagnostic imaging: A team-based approach.
      I would argue that it is time for us also to consider a shared team responsibility for preparing the women in our care for eventualities that may lie ahead during labour. In some cases that team could include social workers, probation officers, or other individuals in a position of authority in a woman's life, which adds another layer of complexity. Within our interprofessional teams, we need to be able to establish relationships of trust, particularly in situations that could involve emergency transfer of care—whether within our institution or to another facility. If we do not have respect and trust among ourselves, and our various professions, how is our patient to be able to form trust at the time of transfer?
      There are steps being taken to ensure that consent is properly obtained and documented, particularly in the context of interprofessional teams and in cases of transfer of care. Programs like moreOB and ALARM help care providers develop and strengthen the skills needed for effective teamwork and handover of care. The use of surgical safety checklists is not only an important advance for surgical safety but also an effective tool for teams to ensure they have obtained valid informed consent for a procedure.
      For those circumstances where a women's ability to speak in her own best interest is impaired or where we know there is a legacy of racism or systemic bias, we need a systemic solution. And there are some questions we need to ask in order to get there. Is there a role for a cultural navigator or an ombudsperson in the consent process? Do we need new processes or additional resources to ensure we are indeed following the wishes of our patient? How do we incorporate culturally informed consent as an integral part of the clinically informed consent discussion? We don't have all the answers yet, but I believe further consultation is needed with women, ethicists, professional bodies, Indigenous provider groups, and other stakeholders. Health care providers can and should seek out training in cultural safety and cultural humility in the context of health care delivery.
      We need to deepen our understanding of the issues that can impair consent in obstetrics. We need to be aware of how the discourse on social media can influence the relationships we have with our patients. We need solutions that will protect all women's right to voluntary informed consent and will give providers the confidence that the consent we obtain is freely given. Within health care institutions, antiracist frameworks for organizational systems and practices can help foster new perspectives.
      Above all, we need to view consent from a position of humility. It is a hard reality to face, that we may have (unintentionally) contributed to a situation where a woman did not feel her voice had been heard. Let us work together to help foster new perspectives and continue to do the best we can to ensure we obtain consent that meets the conditions for it to be valid and legal, while remaining mindful of the complexities and, as always, properly documenting these best efforts.

      Acknowledgements

      The author thanks Drs. Dorothy Shaw, B. Anthony Armson, and Douglas Bell for their input on the content this editorial. The views presented here are the opinions of Dr. Blake, with the input of the Executive Committee of the Board of Directors of the Society of Obstetricians and Gynaecologists of Canada, SOGC, (Drs. Anthony Armson, Linda Stirk, Elio Dario Garcia, Margaret Morris, and R. Douglas Wilson). These comments do not necessarily reflect the views of the SOGC.

      REFERENCES

      1. The Canadian Medical Protective Association. Consent: A guide for Canadian physicians. Available from:cmpa-acpm.ca/en/advice-publications/handbooks/consent-a-guide-for-canadian-physicians. Accessed: January 10, 2020.

      2. The Supreme Court of Canada. E. (Mrs.) v. Eve (October 23, 1986). Available from:decisions.scc-csc.ca/scc-csc/scc-csc/en/item/170/index.do?q=Eve. Accessed: January 10, 2020.

        • The Canadian Medical Protective Association
        Disclosing harm associated with pathological analysis or diagnostic imaging: A team-based approach.
        The CMPA Perspective. Dec 2019: 17-18

      Linked Article

      • Le consentement en obstétrique
        Journal of Obstetrics and Gynaecology Canada Vol. 42Issue 4
        • Preview
          Le consentement est une exigence fondamentale de la pratique de l'obstétrique. Toutefois, le consentement devient complexe en situation de soins partagés ou de transfert de soins ou en présence de circonstances passées ou actuelles nuisant à l'établissement d'une relation de confiance. Les histoires que nous ont racontées des femmes autochtones du Canada, qui se sont senties contraintes de subir une stérilisation, sont particulièrement troublantes. Ces expériences nous incitent, entre autres, à réfléchir sur la dynamique de la relation médecin-patiente du point de vue des femmes racialisées ou vulnérables et sur la nature complexe du consentement en obstétrique.
        • Full-Text
        • PDF