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The timely feature article by van der Pijl et al 1 highlights not only the widespread frequency with which unconsented episiotomies and other procedures during labour are reported by women but also that there is hardly any discussion in the literature on the ethics of consent for procedures in labour. Those national and international bodies with responsibility for midwifery and obstetric practice need not only to recognise but also act to remedy this unacceptable situation.
The studies quoted used the recollection of women in reporting consent or lack of it and, although this is an entirely appropriate measure, it gives no insight into what, if any, informed decision-making the care providers carried out. Such information would be useful to determine how better practice might be achieved. A study into the practice of episiotomies by Dutch midwives and obstetricians is referred to and is not reassuring.2 They frequently expressed surprise that consent should be necessary and women were minimally involved in the decision for performing episiotomy. This and other examples quoted of lack of valid consent have a corrosive effect on the fundamental but fragile trust and necessary trustworthiness of the relationship between the person being cared for and the carer.1
The authors1 emphasise that consent for any procedure in labour and birth is always necessary and this is consistent with guidance from the all the relevant statutory and regulatory bodies in the UK. For example, the Royal College of Midwives states, ‘Do not provide any care without first receiving consent3 and the General Medical Council4 requires that practitioners must be satisfied that they have consent or other valid authority before carrying out any examination, investigation or treatment. This position is reinforced in law in the UK as elucidated by Cook5 in her discussion of midwifery perspectives on the consent process.
It is axiomatic that recognition of their autonomy means that patients must be treated with respect, be properly informed, be listened to, give their consent voluntarily and without coercion, and have their confidentiality fully respected. Properly understood in ethical terms choice/consent is typically a process rather than a single act. The terms ‘informed choice’ or ‘informed decision-making’ are often to be preferred over ‘informed consent’. ‘Consent’ suggests ‘we want to do something to you’ whereas ‘choice’ implies offering options from which women can indicate their preference and ‘decision-making’ affirms their autonomy.
Given that informed choice is mandated by law and all the professional bodies to which caregivers belong why do so many women report unconsented episiotomies and other procedures during labour? The feature article1 recognises and discusses the complexities of informed decision-making in labour and during birth and makes ‘a constructive proposal’ of an individualised approach (starting antenatally) which midwives, obstetricians and others responsible for the care of pregnant women would do well to take note of. The Royal College of Midwives3 has produced a useful guide on how midwives can support women’s informed decision-making. In their Clinical Governance Advice, the Royal College of Obstetricians & Gynaecologists6 suggests that ‘Where possible, women should be informed during the antenatal period about predictable problems that may occur in labour’. Does this include the possible need for common procedures such as episiotomy? The advice continues, ‘When consent has to be obtained from a woman during painful labour, such as to perform a vaginal examination, episiotomy, operative delivery or to site an epidural, information should be given between contractions. If appropriate, on admission in labour or for induction of labour, consideration should be given to the provision of summarised information concerning possible procedures and interventions. Women should be encouraged to express their views on such procedures so that their carers are aware of the choices made by the women and act accordingly.’6
In the particularly dynamic situation of labour and delivery, there will always be tension between definite statements about what should happen and ‘real life’ practice but accommodation to the latter should not allow substandard practice to go unchallenged. More research is also required to achieve better consensus on indications for episiotomy.1
If knowledge of ethical principles and practice is to be improved among healthcare professionals, it must begin while they are still students. Thus, there is an absolute need for structured learning on informed decision-making and capacity within, in this context, the training and assessment of student midwives and doctors. This must be carried forward in their developing careers and become discipline specific. Box 1 outlines the key ethical and legal aspects of informed decision-making proposed by the Institute of Medical Ethics.7
Informed decision-making and capacity7
Students should be able to:
Demonstrate the application of the key principles of the consent process.
Demonstrate an understanding of how the concept of capacity relates to everyday decision-making.
Analyse the legal and ethical implications of the rights of a patient with capacity.
Discuss the scope of the patient’s right to request specific treatment and the issues surrounding respect for patient autonomy.
Discuss the scope of the patient’s right to information about their diagnosis and treatment options, and when withholding information can be justified.
Discuss how to approach situations where patients have capacity but are otherwise vulnerable.
Evaluate the best interests of patients who lack capacity, including the appropriate weight to be given to the views of their relatives/carers.
Analyse the ethical and legal aspects of restrictions on liberty, the rights of patients who lack capacity, and the use of restraint in patients who lack capacity.
This feature article1 deserves close study by all responsible for the care of women in labour and during delivery. The fruits of that analysis should then be translated into action through ongoing dialogue with women themselves and those organisations that represent them.
Patient consent for publication
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.