One of the basic principles underlying all medical care is a patient’s right to make informed decisions about their medical treatment. Health care providers have an obligation to discuss with you the risks and benefits of any treatment being proposed. They must also let you know about viable alternatives to that treatment, and the risks and benefits of those alternatives. Once you understand the treatment options, it is your right to make a choice about what treatment option is right for you. Consent to medical treatment must be ‘informed consent.’ That means that this full discussion about risks, benefits and alternatives must be completed before you give consent.
Informed Consent for Childbirth
One of the areas of medicine where this process of informed consent has historically been lacking is in obstetrics. In the past, women have often been told that they are not allowed to choose caesarean section unless it was, in the doctor’s opinion, medically necessary. This practice, however, is slowly changing. In July 2018, the Society of Gynecologists and Obstetricians of Canada (SOGC), the professional body that sets guidelines for practicing obstetricians, published a Committee Opinion making it clear that informed consent must be obtained for childbirth as well.
The first step required of the medical team (doctors, nurses, midwives) is to have a clear understanding of the risks and benefits of both planned caesarean section (for non-medical reasons) and of attempted vaginal delivery. The discussion of risks should include both common risks (like pain after delivery) and rarer, long term consequences (brain damage, death, complications in future pregnancies, etc.).
There are currently no studies comparing the safety to mother and baby of these two methods of delivery. Studies have been done on the safety of caesarean section versus vaginal delivery but this data includes the risks associated with all caesarean sections, including those done on an emergency basis for medical crises. Some of the information from existing studies can aid in the risk/benefit discussion, but the inclusion of emergency caesarean sections in the studies likely results in higher numbers of poor outcomes from caesarean sections. What is needed is studies that only include caesarean sections that were done at the mother’s choice, without medical reasons to choose caesarean section over vaginal delivery.
A Risk/Benefit Discussion
The SOGC is clear that the discussion about elective caesarean section should be focused on the individual patient. Medical professionals should not assume that all people place the same value on the mode of delivery. They have an obligation to provide up-to-date, evidence-based information and the risk/benefit discussion needs to take into account your values, beliefs and individual needs. The medical professional should explore your reasons for the request, fears and concerns, and should be culturally appropriate.
Medical professionals should offer their medical recommendation for the appropriate mode of delivery for each individual. Your autonomy, however, must be respected. The mode of delivery must be a mutual decision and must be made without bias or coercion. Physicians also have a right to autonomy in deciding whether to perform a caesarean section, but this does not erase your rights. If you opt for caesarean section, the physician must either perform a caesarean section, refer you for a second opinion or transfer your care to another physician. They may not simply refuse to perform a caesarean section and force you to have a vaginal delivery.