October 13, 2008 at 3:30 pm #3195AIMSIrelandMember
IMPROVEMENTS IN THE
Informed Decision Making
Informed decision making is essential in order for women to be a part of the decision process in her maternity care. AIMSI have created this factsheet to discussed informed consent, informed refusal and basic tools women may use to help them with the decision making process.
Making informed decisions means that you have been presented with all the information available at that time to assist you in making a decision. You should be given the benefits, risks, implications and future consequences of the action. You are to be made aware of all the possible information available before consenting or refusing the action. All information should be presented to you impartially; without bias or persuasion. Informed decisions are an essential part of every woman’s maternity care and you should be given the opportunity to make informed decisions before any test, treatment or procedure. Informed decision making consists of 2 main areas: Informed Consent and Informed Refusal.
Informed Consent is when a woman accepts a test, treatment, or procedure based on her own knowledge and after being presented with all the necessary information (benefits and risks, implications and future consequences) by her care providers in an unbiased way. Any test, treatment, or procedure in your maternity care requires informed consent. It is essential to ask questions if you feel you need more information.
Example of Informed Consent:
Susan is 6 days overdue on her first baby. She is feeling heavy and tired and her consultant offers her a sweep to get things going. Susan isn’t sure what a sweep is or how it is performed and asks her consultant for more information. Susan’s consultant explains that a sweep is performed internally and that he would use his fingers to sweep along the cervix in the hope that it might stimulate the start of labour for Susan. Susan’s consultant explained that it generally works for 1 in 8 women who are close to starting labour themselves and that it may just be what Susan needs to get things going. He also explains that after the sweep, many women experience a show and have lots of cramping which may or may not be the start of labour. He also tells Susan that there is no guarantee that the sweep will start labour. Susan asks her consultant if a sweep will hurt and he tells her that the less favourable a woman is (if her cervix is still hard and posterior) the more likely a sweep is to be uncomfortable. Susan consents to a sweep but asks her consultant to only perform the sweep if her cervix is soft and favourable for labour.
Informed Refusal is when a woman refuses a test, treatment, or procedure based on her own knowledge and after being presented with all the necessary information (benefits and risks, implications and future consequences) by her care providers in an unbiased way. Any test, treatment, or procedure in your maternity care carries the option of informed refusal. It is essential to ask questions if you feel you need more information.
Example of Informed Refusal:
Mary has just given birth to her third baby. Throughout her pregnancy she has read information about managing the third stage of labour by injection. Mary has requested in her birth plan that she deliver the placenta naturally and for the cord to finish pulsating. Mary’s midwife has mentioned that the routine practice in the unit is for the third stage to be managed. Mary asks the midwife what the risks of having a natural 3rd stage would be and discusses the benefits she had read about during her pregnancy. After discussing the benefits and risks and possible consequences with the midwife, Mary refuses a managed 3rd stage of labour and delivers the placenta naturally some time later.
Coercion/Disregard of Consent
Unfortunately, sometimes women are not all the information when they ask questions or sometimes the information is presented in a biased way; women feel pressured to consent. Coercion is when consent was sought but women were given no choice or information to refuse andsometimes felt pressurized to give consent. Coercion is often used when a medical professional sites ‘hospital policy’ or accuses the mother of putting her baby at risk when asking about her choices or information on refusing a procedure. Disregard of Consent, where there was a complete disregard to the fact that consent needs to be sought and obtained. The women were given no information or choice in the decision process and procedures were carried out specifically against mother’s wishes or without even informing the women of what was happening.
Examples of Coercion/Disregard for Consent:
Aoife has presented herself to the labour ward at 3cm dilated. She is having good regular contractions and has been admitted. On admittance to the labour ward, the midwife tells Aoife that they are going to break her waters. Aoife does not understand why her waters are to be broken as things are progressing well and she is scared that she may not cope as well once the waters are gone. Aoife’s midwife tells her that it is hospital policy and that they need to break the waters to make sure her baby is OK. Aoife consents as she does not want to be seen as a trouble maker and wants to make sure her baby is OK.
Tara has been pushing for half an hour. She is has had an epidural and she and her baby are both doing fine. On the next push Tara’s doctor says “I am just going to make a little cut” and performs an episiotomy. Tara’s baby is born shortly after but Tara wishes that the episiotomy had been discussed with her before it was performed.
Tools to use in Decision Making
Many women express a deep concern with how to initiate informed decision making with their care providers. Informed decision making is a continuous process. Throughout your pregnancy, you should be considering your birth preferences and what is important to you for your labour and birth.
Initiate discussion with your care providers; birth plans are a wonderful tool for initiating discussion. It may help to write a list of questions you have for your care provider to ask at routine ante-natal appointments and ante-natal classes. You may also find information from pregnancy books, private ante-natal classes, and evidence based information from organisations like AIMSI and Cuidiu.
The more informed you are, the more likely that you will be involved in the decision process.
A helpful tool to use in your decision making, before consent or informed refusal is to assess the situation by using BRAIN
Ask yourself and your care providers:
B – what are the benefits involved
R – what are the risks involved
A- what are the alternatives
I – what does my intuition tell me
N – what would happen if we do nothing
Another quick way to assess the situation or to buy a bit of time is by simply asking
Is my baby OK?
Am I OK?
What other suggestions do you have?
Tina has been in labour for 5 hours and the midwives are not happy with her progress. It is suggested that her labour be accelerated. Tina asks the midwife, is my baby OK? Am I Ok? And she is told that they are all doing well but that labour does not appear to progressing as quickly as it should be. Tina asks the midwives if there is anything she can suggest which may get things moving on their own. The midwife suggest that sometimes getting up and moving about may help. Tina suggests to the midwife that she go for a walk for a half an hour/hour and then they can reassess the situation then. Midwife feels this is a good idea.
Discussion and good communication are vital ingredients for informed decision making.
Please discuss any concerns and questions you may have with your care providers. Your care providers should present you with unbiased information on the risks, benefits, possible implications, and any future consequences before you consent or refuse a test, treatment or procedure. Remember, if you feel you are not getting the information you need from your care provider you can request a new carer at any time. Finally, never feel that you are trapped into a decision – you can change your mind at any stage!
For further information contact AIMSI at: firstname.lastname@example.org
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