Five Coffin Nails to Informed Consent: An Autoethnography of Suffering Complications in Breastfeeding

This autoethnography describes an illness episode caused by breastfeeding complications. It focuses on informed consent processes accompanying this illness episode. Informed consent is a cornerstone of ethical medical practice and has to be obtained before a medical intervention can legally be implemented. It is therefore not trivial that in practice, informed consent processes often fail to achieve what they are set out to. With this autoethnography, I want to provide a review of how informed consent processes can fail in the context of breastfeeding, but also draw attention to what these situations can mean and feel like for those affected. I provide in-depth descriptions of five scenes from my illness episode each representing a different barrier to informed consent. The scenes were developed based on emotional recall and written to grant access to the emotional dimensions of my experience in the tradition of evocative autoethnography. As part of my story, I engage with various issues like practices of prescribing, communicative requirements in vulnerable situations to ensure understanding, the dual purpose of informed consent in the moral and legal realm, and the moralized breastfeeding discourse. Possible routes for change to abolish or reduce described barriers to informed consent are discussed.

Quality of Informed Consent Practices around the Time of Childbirth: A Cross-Sectional Study in Italy

Background: Few studies have explored consent request practices during childbirth. Objective: We explored consent request practices during childbirth in a referral hospital and research centre in Italy, capturing both women and health workers’ perspectives. Methods: Data were collected using self-administrated questionnaires between December 2016 and September 2018. Nine key maternal and newborn procedures were analysed. Associations between consent requests and women characteristics were explored by multiple logistic regression. Results: Among 1244 women, the rate of consent requests varied widely, with caesarean section (CS) showing the highest rate (89.1%) and neonatal conjunctivitis prophylaxis presenting the lowest rate (11.4%). Information provided on “risks/benefits” and “reasons” for procedures by health staff was most often not comprehensive for procedures of interest (range 18.6–87.4%). The lack of informed consent is not specifically linked to any pattern of women characteristics. According to 105 health workers, adequate protocols and standard forms for consent requests were available in 67.6% and 78.1% of cases, respectively, while less than one third (31.4%) reported having received adequate training and supportive supervision on how to deliver informed consent. Conclusions: Study findings align with previous evidence showing that consent request practices during childbirth need to be largely improved. More research is needed to investigate effective strategies for improvement.

Risk of obstetric anal sphincter injuries at the time of admission for delivery: A clinical prediction model

OBJECTIVE

To develop and validate a model to predict obstetric anal sphincter injuries (OASIS) using only information available at the time of admission for labour.

DESIGN

A clinical predictive model using a retrospective cohort.

SETTING

A US health system containing one community and one tertiary hospital.

SAMPLE

A total of 22 873 pregnancy episodes with in-hospital delivery at or beyond 21 weeks of gestation.

METHODS

Thirty antepartum risk factors were identified as candidate variables, and a prediction model was built using logistic regression predicting OASIS versus no OASIS. Models were fit using the overall study population and separately using hospital-specific cohorts. Bootstrapping was used for internal validation and external cross-validation was performed between the two hospital cohorts.

MAIN OUTCOME MEASURES

Model performance was estimated using the bias-corrected concordance index (c-index), calibration plots and decision curves.

RESULTS

Fifteen risk factors were retained in the final model. Decreasing parity, previous caesarean birth and cardiovascular disease increased risk of OASIS, whereas tobacco use and black race decreased risk. The final model from the total study population had good discrimination (c-index 0.77, 95% confidence interval [CI] 0.75-0.78) and was able to accurately predict risks between 0 and 35%, where average risk for OASIS was 3%. The site-specific model fit using patients only from the tertiary hospital had c-stat 0.74 (95% CI 0.72-0.77) on community hospital patients, and the community hospital model was 0.77 (95%CI 0.76-0.80) on the tertiary hospital patients.

CONCLUSIONS

OASIS can be accurately predicted based on variables known at the time of admission for labour. These predictions could be useful for selectively implementing OASIS prevention strategies.

Informed consent and birth preparedness/complication readiness: A qualitative study at two tertiary maternity units

BACKGROUND

Informed consent in obstetrics should involve full disclosure of risks, benefits and alternative interventions. However, we have found no evidence of a formal informed consent process before an attempt at vaginal delivery in published policy or practice. The idea of informed consent in vaginal birth has attracted controversy and has been the subject of some debate.

AIM

To explore the perspectives and experiences of informed consent and birth preparedness/complication readiness for birthing women in a high resource setting.

MATERIALS AND METHODS

Qualitative study using semi-structured interviews to examine experiences and perspectives of women following birth.

RESULTS

Forty telephone interviews were concluded. Eight statement categories were identified: (i) no issues of consent, (ii) absent/inadequate informed consent, (iii) adequate birth preparedness/complication readiness, (iv) inadequate birth preparedness/complication readiness, (v) desire to forfeit decision making to a trusted and accountable health professional, (vi) belief that informed consent is not realistic in birth under some circumstances, (vii) negative feelings related to birth and (viii) poor postnatal follow-up.

CONCLUSIONS

When complications arose during birth, 20% of participants felt that informed consent was absent/inadequate, 25% of participants suggested policy change in favour of a formal informed consent process and 55% of participants suggested policy change in favour of increased birth preparedness/complication readiness. Our study suggests that informed consent for vaginal birth and formal birth preparedness/complication readiness should form part of routine antenatal care. Women's preferences for decision-making and informed consent should be established before birth.

The maternal pelvic floor and labor outcome

Vaginal birth is the major cause of pelvic floor damage. The development of transperineal ultrasound has improved our understanding of the relationship between vaginal birth and pelvic floor dysfunction. The female pelvic floor dimensions and function can be assessed reliably in pregnant women. Maternal pushing associated with pelvic floor muscle relaxation is the central requirement of vaginal birth. Many studies have evaluated the role of the pelvic floor on labor outcomes. Smaller levator hiatal dimensions and incomplete or absent levator ani muscle relaxation seem to be associated with a longer duration of the second stage of labor and a higher risk of cesarean and operative deliveries. Here, we presented an overview of the current knowledge of the correlation between female pelvic floor dimension and function, as assessed by transperineal ultrasound, and labor outcome.

Should we inform women about the recognised risks of childbirth?

BACKGROUND

At present in Australia women are not routinely, systematically informed of the risks of childbirth.

AIMS

It is hoped this presentation of the perspective of some women who suffer unexpected obstetric complications will encourage change.

MATERIALS AND METHODS

The experience of women involved in obstetric medicolegal reports prepared by a colorectal surgeon over ten years is analysed.

RESULTS

Twenty women were identified. Sixteen had vaginal deliveries. All 16 suffered third or fourth-degree tears, six developed rectovaginal fistulae, six required stomas and 11 developed faecal incontinence. Of the four women who delivered by caesarean section, there were two post-operative caecal perforations, one unrecognised small bowel enterotomy, and one patient developed sepsis due to an infected haematoma. Seventeen of the 20 women were noted to suffer psychological sequalae. None of the women recollected being warned of the complication they suffered, and there was no record of such warnings in their medical records.

CONCLUSION

Informed written 'consent' for natural vaginal delivery is, understandably, a contentious topic. Although learning from medicolegal cases may go against the grain, as medical professionals it is very difficult to ethically justify the status quo, where women are not routinely simply informed of the risks of childbirth. This is not fair. Even if informing women does not decrease the incidence of complications, the women who subsequently suffer these complications may well handle them much better, recognising they could occur.

Rotational forceps: a retrospective study evaluating anatomical and functional consequences for the pelvic floor

INTRODUCTION AND HYPOTHESIS

The use of Kielland's rotational forceps is considered to involve greater technical difficulty and may be associated with a higher rate of pelvic floor trauma. Our main objective was to evaluate the association between avulsion of the levator muscle and rotational and non-rotational forceps.

METHODS

This was an observational study carried out at a tertiary hospital that recruited singleton cephalic vaginally primiparous women with previous Kielland's forceps delivery between March 2012 and May 2017. Patients were retrieved from a local database, contacted consecutively and blinded to all clinical data. Power calculations determined a sample of n = 160 patients. All women underwent a urogynecological interview, clinical examination and 4D translabial ultrasound (TLUS). The 4D TLUS volumes were stored and analyzed offline by an experienced ultrasound examiner who was blinded to all clinical data.

RESULTS

A total of 165 patients were available for analysis. Rotational forceps accounted for 27.3% (45 out of 165) of the study sample. Avulsion was present in 41.8% (69 out of 165) of all forceps deliveries. On multivariate analysis, rotational forceps was associated with avulsion, with an adjusted odds ratio (OR) of 2.57 (CI 95% 1.20-5.62, p = 0.016). Body mass index at the beginning of gestation was found to be a protective factor, with an adjusted OR of 0.918 (CI 95% 0.847-0.986, p = 0.025).

CONCLUSION

Rotational forceps is associated with a higher avulsion rate than non-rotational forceps, with an adjusted OR of over 2.5. Obstetricians need to consider the potential long-term consequences of performing a rotational forceps for mothers.

A survey of obstetricians' attitudes to induction of labour at 39 weeks gestation with the intention of reducing caesarean section rates

BACKGROUND

Induction of labour (IOL) and caesarean section (CS) rates continue to increase in Australia, New Zealand and globally. There is evidence that CS rates are decreased in the context of medically indicated and elective IOL; therefore, the emerging concept of using IOL as means of preventing CS warrants investigation.

AIMS

To assess obstetricians' opinions of elective IOL at 39 weeks gestation, its feasibility, generalisability and utility as a means of preventing CS in Australia and New Zealand.

MATERIALS AND METHODS

A de-identified cross-sectional survey was distributed electronically to all Fellows and trainees of The Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG). The survey was voluntary and distributed with the approval of the RANZCOG Continuing Education Committee. The survey addressed opinions relating to rates of and indications for IOL, the perceived validity of those indications and explored the acceptability of using a screening tool to predict women at increased risk of intra-partum CS and tailoring obstetric management to include the option of IOL at 39 weeks gestation.

RESULTS

The overall response rate was 34% (492/1423) (including trainees) and the response rate was 53% (394/750) for currently practising obstetricians. The majority (90%) of responders agreed on medical and clinical indications for IOL. There was no consensus on the validity of IOL if a woman were at apparent high risk of intra-partum CS; however, 81% (360/443) of clinicians would be interested in a tool that could predict those women at risk.

CONCLUSIONS

There is heterogeneity of obstetrician's beliefs on using IOL at 39 weeks as a mechanism to reduce the CS rate.

'Normal birth': Time to change our tune?

Recent research indicates that atraumatic 'normal vaginal birth' only occurs in 33-40% of women who intend to achieve a vaginal delivery, depending on how the term 'normal birth' is defined. In contrast, the NSW birth policy continues to promote 'normal birth', suggesting that the majority of women will achieve 'normal birth' and that 'normal birth' produces optimal maternal outcomes. Our continued use of the term 'normal birth' may be outdated. This article will consider the term 'normal birth' with regard to history, politics, policy and obstetric practice, and recommend a reconsideration of terminology.