Informed Consent

Editor’s note: This article first appeared in Midwifery Today, Issue 89, Spring 2009.
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An analysis of enquiries to the AIMS Helpline reveals that almost without exception women who intend to birth at home are given a long list of the “risks” the staff perceive them to be taking. We have yet to hear from any woman who was also given a list of the risks of a hospital birth, so we have produced our own and suggest that this should be handed out to all women who intend delivering in hospital.

INFORMED CONSENT FOR GIVING BIRTH IN HOSPITAL

PLEASE READ, SIGN and DATE

Name: ________________________________ Hospital: ________________________________

Consultant: ________________________________ Date: ________________________________

Dear Mrs/Ms/Miss:

This Trust supports the view that women have choice and in order properly to exercise that choice they need to be fully informed of the risks in association with childbirth. You will already have had information about the risks of homebirth. The following are the risks of a hospital delivery:

This hospital operates a shift system which means it is unlikely that you will be attended by the same midwife throughout your labour.

Because we are short of staff you are unlikely to have the continuous support of a midwife, as she will probably be trying to attend to at least two other women.

As this hospital has a 25% caesarean operation rate, you have at least a one in four chance of having a caesarean. Please be aware that this is major abdominal surgery that doubles the risks of maternal mortality, increases the risk of damage to other internal organs and blood vessels, carries a risk of infection, which may prolong a hospital stay, interferes with the establishment of breastfeeding and delays postoperative recovery. Research has also shown that this type of surgery produces harmful side effects according to which anaesthetic is used, lowers fertility rates in women, may increase the incidence of postnatal depression, adversely affects the baby because of the anaesthetic used, can accidentally cut the baby as the incision is made, produces babies who are less likely to breastfeed, results in babies with breathing difficulties because they haven’t received the benefits of being squeezed through the vaginal canal, increases the risk of miscarriage in future pregnancies, produces a greater risk of childhood asthma and results in a greater risk of Sudden Infant Death Syndrome.

As the World Health Organisation has stated that there is no improvement to maternal or infant health when the caesarean operation rate exceeds 10%, you should understand that we are trying to reduce our caesarean rate.

This hospital is a medical training centre, so in February and August we have a new intake of junior doctors and the caesarean operation and forceps delivery rates increase at that time. But please be aware that doctors have to be trained and you may be the person especially selected as a training subject.

As a first-time mother you may wish to stay in hospital for a number of days in order to establish breastfeeding. However, as we are short of staff and the postnatal wards are grossly understaffed you are unlikely to receive consistent advice and you will be vigorously encouraged to leave as soon as possible, as we need the bed.

At one time the midwives were required to visit a postnatal woman for at least 10 days. We have introduced a system that allows the midwives to make a judgment about your needs in this respect, so you are unlikely to be visited on more than a couple of occasions.

You should understand that in this hospital, which is a high technology obstetric unit, only one in six women expecting their first baby and only one in three women expecting their subsequent babies will have a normal, straightforward birth.

This hospital applies a time limit on the second stage of labour; this is not applied for your benefit, but is imposed in order to ensure that you deliver as quickly as possible so that we can use your bed for another woman.

At this hospital the midwives will cut the cord as soon as the baby is delivered. This has adverse effects on the baby, but you need not worry as we have resuscitation equipment at hand to help the baby breathe.

At this hospital the majority of women will give birth on their backs, despite the research indicating how this position increases the difficulty in pushing the baby out and causes trauma to both mother and baby.

During your labour you may find that your room is visited by multiple members of staff, many of whom will fail to introduce themselves or justify their reasons for being there.

This hospital prefers women to be quiet when they are in labour, as shouting or screaming may upset others in the ward, especially the doctors. Therefore, in order to maintain a more subdued atmosphere, you will regularly be offered a range of opiate-based drugs either in the form of pethidine or diamorphine (also known as heroin). Please be aware that this can lead to an increased chance of your child becoming a drug addict in later life and if administered at the wrong time during labour, will result in your baby being born in a dangerously stupefied state. Do not worry, as the medical staff will inject the baby with an antidote as soon as it is born.

Visiting hours for husbands and partners are between 11 am–3 pm and 6 pm–9 pm. Although postnatal midwives will be on hand for advice, they are extremely busy and therefore you will be expected to cope on your own with your new baby in between these times and overnight.

It is our policy to encourage women to choose whomever they wish to have with them. We will require you, however, to put a request in writing should you wish to have more than one person with you. All requests will be considered sympathetically but will probably be turned down, as we have to consider the risks of hospital-spread infection, security, our small rooms and our desire to maintain our control.

Wherever possible, this hospital operates a system of continuous electronic foetal monitoring. This has not been shown to improve outcomes for mother or baby, however, it will lead to an increased likelihood of a caesarean operation.

At this hospital, our philosophy is “one size fits all,” therefore, we would prefer it if you did not write a detailed birth plan as this interferes greatly with our ability to make decisions about your care without your knowledge or consent. If you feel a birth plan must be undertaken, a simple “I would like a natural birth with gas and air” will suffice.

A hospital birth involves a much higher risk of serious infection. One in three babies will leave with an MRSA infection. In the event that this happens to you, this hospital will bear no responsibility, however, you are welcome to utilise NHS facilities for your recuperation.

If you would like an epidural or spinal block during your labour, please note that this will interfere with your body’s natural production of oxytocin hormones and therefore will be likely to impair the bonding between you and your baby. In turn, this may lead to a higher chance of postnatal depression and unsuccessful breastfeeding.

If your baby is presenting by the breech, research has shown that more damage is caused when the doctors attempt a vaginal delivery than if they do a caesarean operation, so they will invariably recommend a caesarean operation. Skilled midwives trained in the Cronk/Evans breech birth procedures are able to assist a woman to birth by the breech with excellent outcomes. Unfortunately, the midwives in this hospital have not taken advantage of regaining these lost skills so you will need to do your own research to locate these midwives if you want a vaginal birth. A similar situation arises should you be expecting twins.

DATE: ________________________________ SIGNED: _________________________________________________________

Reprinted with permission from Association for Improvements in Maternity Services (AIMS) Journal 19(4):11–12, 2008.

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