* New! Download the “Professional Guidelines: Informed Consent & Pregnancy” handout
Lecture 2: References and Resources
American College of Obstetricians and Gynecologists Committee Opinion (2007). “Ethical decision making in obstetrics and gynecology.” Obstet Gynecol 110(390):1479–87. (https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Ethics/Ethical-Decision-Making-in-Obstetrics-and-Gynecology)
American College of Obstetricians and Gynecologists Committee Opinion (2005). “Maternal Decision Making, Ethics, and the Law.” Obstet Gynecol #231. (no longer available online)
American Medical Association Council on Ethical and Judicial Affairs. (2012). “Opinion 8.08 – Informed Consent.” AMA Journal of Ethics. Virtual Mentor. 14(7):555-556. (https://journalofethics.ama-assn.org/article/ama-code-medical-ethics-opinions-informing-patients/2012-07)
Diaz-Tello, Farah. (2016). “Invisible Wounds: Obstetric Violence in the United States.” Reproductive Health Matters. 24(47): 56-64. (https://www.tandfonline.com/doi/full/10.1016/j.rhm.2016.04.004)
Pascucci, Cristen and Hermine Hayes-Klein. (2018). “Ep. 14 The Problem with Implied Consent.” Birth Allowed Radio. (http://birthmonopoly.com/ep-14/)
Pascucci, Cristen. (2016). “Obstetrician Ethics: Awesome Guidelines from the National OBs Group.” Birth Monopoly blog post. (http://birthmonopoly.com/acogethics/)
Pascucci, Cristen. (2016). “ACOG to Docs: Women’s Right to Say ‘No” Comes First.” Birth Monopoly blog post. (http://birthmonopoly.com/no/)
Pascucci, Cristen. (2017). “Being Admitted to the Hospital or Signing Consent Forms is Not ‘Implied Consent’.” Birth Monopoly blog post. (http://birthmonopoly.com/impliedconsent/)
The discussion has come up before where hospitals and nurses have a different policy of using the consent form. I’ve heard nurses do not have patients sign it until dr is there. I’ve heard that or can sign consent for bc provider has already discussed “hospital expectations” with pt in office. Our consent form read “delivery with possible episiotomy.
And possible intrathecal narcotic and possible epidural. The. We have a new paper consent form for epidurals that patients sign when they are arrive too.” So how do hospital get away with this practice? So thankful I’m taking this course!
I have personally had hospitals tell me I consented when I signed the “universal consent” upon admission.
In my work as a doula I have also seen providers and medical personnel violate my client’s rights by telling them what will happen or what is going to happen vs explaining what they would prefer to do and why, the benefits, risks and alternatives, and asking for permission. Things like “I’m going to start your IV” or “I’m going to check your cervix” are common phrases. I typically say to my client, “So and so said they would like to (insert procedure/exam), your birth plan says (insert phrase if addressed in birth plan or prenatal conversations), do you have any questions or concerns? or Do you consent? My clients have all told me they feel very safe, supported, and advocated for with me because when I say these things to them, they feel they are able to voice concern, ask questions, and deny consent if desired.
It’s so common, isn’t it? That’s awesome your clients feel safe with you there! It is such a huge shift in the room to have someone pointing out and making space for the question and answer that should have happened in the first place
Far too often I am hearing birthing people say “well they told me that’s what they do so I didn’t think to ask any questions.” I also had to pause and take a moment when you said, “In the U.S. obstetric violence is a term, not a crime.” My heart breaks. Thank you for this course.
As a doula, I struggle with my role when I step in to an announcement of what a care provider is going to do. I will ask my client if they fully understand and help them ask their provider what the risks and benefits are. Often the care provider will say “there really are no risks” which then puts me in the place of delineating exactly what those risks are. I feel this is not my role, but my clients won’t get informed consent unless they know the full picture. What would you do if the provider refuses to fully disclose?
Was there ever a reply or further discussion about this? This was also my thought while listening to this section. I often see clients trying to get their care providers to talk to them about risks and benefits and then see the care provider either rush through and/or down play the risks or skip over them all together by saying “there aren’t really any.”
M.E. and rgreenan, here are some resources for you with information I think you’ll find really helpful!
Birth Monopoly’s resource page on Doulas and Advocacy, with various articles and podcasts and a video titled “Obstetric Violence and What to Do About It”: http://www.birthmonopoly.com/doulas
Traci Weafer’s Keeping Your Power course also addresses this question/these dynamics and I think is invaluable.
Keeping Your Power: https://www.maternalinstinctsdoula.net/keepingyourpower-for-doulas.html
I think challenges to informed consent is the biggest threat to bodily autonomy in the maternity space. The number 1 culprit is coercion.
At a recent birth, we had a nurse who was lovely and overwhelmingly supportive of my client’s wishes to birth without medication and use a variety of comfort measures that kept her out of the bed. It surprised me to hear what she said when my client shared she desired to not deliver on her back. The nurse stated that they really prefer clients to deliver on the back because it’s the “most comfortable position for the doctor”. She took this a step further and said “I know if I’m having surgery, I want my doctor to be the most comfortable so he can perform his job the best”. This nurse had no bad intentions. I truly believe she wanted my client to have the birth she most desired. I think the words that came out of her mouth were completely institutionalized in her brain, and she didn’t even realize she was challenging my client’s right to informed consent.
At this same birth, a lab technician appeared to draw blood for a “state mandated test”. When my client asked if she had to take the test, the lab tech stated “it’s the law”. I did not know this, but luckily the skilled CNM who had been the primary provider during my client’s homebirth stated very calmly that it wasn’t law, however it was a recommendation by the department of health and likely hospital policy. This was a blatant misrepresentation of facts by the lab tech, and again may not have been a knowing one on their part. They may have just been repeating what their supervisor told them, and so on.
Liz, those are great examples. These things often go unexamined and are passed along as true–often unknowingly, as you said. In both cases, the patient’s wishes and rights were considered subordinate to someone else’s authority. It’s so simple to see the skewing of the human rights when we look at it as not respecting the birthing person as the decision-maker and legal authority.
In my own birth, I remember having to struggle to refuse consent to a vaginal exam during a contraction. It still makes me so sad remembering it, thankfully, I was able to speak up for myself and not be violated, but really, I shouldn’t have had to(I was laboring unmedicated so the effort to speak during the contraction was intense). It makes me more sad than angry because, as one of the lovely commentators above said, so much of the hospital staff have been “institutionalized” and don’t recognize the part they are playing in coercing consent or flat out ignoring it. So thankful for this course and everyone here working to reveal and stop this from happening.
I remember being told by a nurse that patients give consent when they sign the form in regards to giving vaginal exams without the choice being presented to them first. At the time, I knew better but didn’t quite have the language to counteract that statement.
Yeah, that’s disappointing, but pretty common, unfortunately.
The main driver of me taking this course was a traumatic birth that I experienced as a doula Jan 2020. My client was having a twin birth at a hospital (she was epiduralized and was told she had to birth babies in the OR). It was around 3 am and the attending doctor was in such a rush. Mom literally birthed both babies within 20 minutes (both posterior positioned!) Afterwards, doctor thought it was a good idea to reach her hands into my client’s vagina and proceed to pull out her placentas. I was stunned, as I’d never witnessed anything like that or knew doctors did that in a non-emergency situation. My client was in so much pain, even with the epidural and I was frozen. The only thing I could tell her to do in the moment was to breathe. Afterwards, I had time to process and felt like I had failed her. I’m sad that experience is what it took for me to wise up and know how to handle those kinds of situations in the future. I can’t understand for the life of me why they don’t teach these kinds of pervasive examples in certain doula training certifications (I certified with CAPPA), let alone give us the proper tools on how to communicate and advocate for our clients!
Oh and I left out the part about how the doctor completely manipulated and coerced in her rushing mom to push babies down (mom wanted to do birth breathing, as she still felt the expulsive reflex with epidural). 1st baby came out in 10 mins and immediately staff began with the coached pushing prompts again…this time I witnessed the doctor look around and proceed to tell my client that her baby’s heartrate was dropping and she needed to push baby out NOW or she’d have to do a c section…so traumatic and unnecessary!
Ebony UGH. That sounds so traumatic for all of you. I think it’s really common though for doulas to feel unprepared for situations like that–after all, it shouldn’t have to be part of doula training “how to manage a medical professional who is assaulting your client.” I recommend Traci Weafer’s advocacy course: https://www.maternalinstinctsdoula.net/keepingyourpower-for-doulas.html