• Informed Consent
• Obstetrics

Van der Pijl et al outline data suggesting an alarmingly high incidence of violation of the bodily integrity of patients in labour, including episiotomies performed without patients’ consent, or over their explicit objection.1 Similar data have been reported from the USA and Canada.2 The authors appropriately conclude that explicit consent is required at the time of all invasive obstetrical procedures, including episiotomy. Commonsense adjustments to the duration and detail of consent under conditions of clinical urgency are appropriate and should be familiar to any clinician involved in perinatal care, as well as non-obstetric proceduralists caring for acutely ill patients. However, complete omission of consent for any of these procedures is both disrespectful to patients’ autonomy and strongly associated with morbidity from birth-related psychosocial trauma.3–5

The true incidence of obstetrical procedures performed without patients’ consent is difficult to determine for multiple reasons, including sample selection, recall bias and patients’ reluctance to reengage with traumatic experiences; however, available data suggest an unacceptably high incidence of reported trauma: 7%–42% in developed countries cited by van der Pijl et al, and potentially higher for patients in under-resourced or otherwise vulnerable settings.6 7

In the USA, investigative reporting starting in 2016 by the Atlanta Journal-Constitution8 and the recent high-profile prosecution of six gynaecologists for sexual misconduct highlighted the need for reinforcement of protections for patients during clinical encounters.9 In 2020, the American College of Obstetricians and Gynecologists Committee on Ethics stated unequivocally that unconsented touching of sensitive areas by clinicians, whether part of an examination or a procedure, constitutes sexual misconduct and must be eliminated from healthcare. Requirements for consent, therefore, apply to many common obstetrical procedures, including amniotomy, operative vaginal delivery, placement of fetal scalp electrodes or intrauterine pressure catheters, and cervical examination.10 From an ethical and regulatory perspective, sexual misconduct should be considered a ‘never event.’ Such events are associated with potentially devastating physiological or psychological consequences—in this case the iatrogenic morbidity of traumatic birth experiences—and merit significant investment in prevention. Accordingly, the US Agency for Healthcare Research and Quality cites the elimination of sexual misconduct as a critical indicator of quality care, on par with wrong-site and wrong-patient surgery.11

Clearly, education of obstetrical clinicians and trainees about consent should be an ongoing effort; the data make it clear that some clinicians either do not think consent is necessary or are not facile at obtaining consent. However, institutional measures are also needed as a safeguard against sexual misconduct. Clinical practices can promote patient-focused care through policies requiring a chaperone for sensitive examinations, and explicit consent—whether written or verbal—for obstetrical procedures. Patients and clinicians should be made aware of these policies, and mechanisms for reporting concerns. All personnel attending a birth should be empowered to ensure that procedural consent has been obtained, and that deviations from policy are reported for review. The combination of clinician education and robust systems processes will go far in promoting trust in obstetric healthcare.

There are, of course, uncommon clinical scenarios that require significant adjustment to the procedural consent process. Patients without decisional capacity or true emergency situations can be managed by existing ethical frameworks and clinical protocols that both support autonomy and patient safety. Antepartum discussion of potential procedures can also support patients’ autonomy in anticipation of emergencies; however, consent should be confirmed at the time of the procedure, as clinical details and patient preferences may have changed from prior discussions. When a rare patient objects to the consent process or a chaperone, clinicians and institutions should have clear guidelines on how and when to proceed with safe care.9 12

Finally, although van der Pijl et al focus their discussion on high-resource settings, the ethical requirement for procedural consent is a fundamental expression of patients’ rights to bodily integrity. These rights do not depend on healthcare resources present during labour: all patients deserve this ethical standard of care. However, particular attention is warranted to ensure safeguards for labouring patients who are at higher risk for harm, including those who are underserved or under-resourced.

Obstetrical clinicians and their institutions have a duty to ensure that ethical standards for consent are upheld, and that sexual misconduct during labour never occurs. Implementation of safeguards requires a multipronged approach, including reinforcement with clinicians of relevant ethical concerns, promulgation of policies requiring consent and integration of systems processes to report, address, and prevent deviations from ethical best practices. Patients in labour deserve nothing less.