Obtaining consent for c-section during labor may be suboptimal

Image: Salim Fadhley

1. Among women undergoing urgent or emergent cesarean deliveries (CD), informed consent was frequently obtained only after the decision for CD had been made. 

2. Short consent times were more common in women undergoing cesarean delivery for fetal heart rate indications. 

Evidence Rating Level: 2 (Good) 

Study Rundown: This study found that short consent times were more common among women undergoing urgent or emergent cesarean deliveries (CD) such that informed consent was frequently obtained only after the decision for CD has been made by the clinical team. While median time from consent to incision for all women was 48 minutes, the median time in women undergoing CD for fetal heart rate (FHR) indications was much more likely to be under 30 minutes. This short duration of time, combined with the stress of labor and a woman’s concern for fetal well being, may result in suboptimal conditions for informed consent.

Strengths of this study include data abstraction from multiple sources, use of a representative study sample at a hospital with cesarean rates comparable to national rates, and comparison of consent procedures for scheduled CDs. Limitations include that of a retrospective analysis and the lack of assessment of quality of informed consent provided. Future studies might include a prospective design, standardization of procedure to obtain informed consent and evaluation of whether complications are associated with consent time.

Click to read the study in the American Journal of Obstetrics and Gynecology

Relevant Reading: Understanding and recollection of the risks associated with cesarean delivery during the consent

Study Author, Dr. Kirsten Salmeen, M.D., talks to 2 Minute Medicine: University of California San Francisco, Department of Obstetrics, Gynecology & Reproductive Sciences. 

“When informed consent for cesarean delivery is obtained at the time the decision for cesarean delivery is made, women may be asked to consent quickly. This has particular importance to physicians who care for pregnant women and may speak to a need to discuss the risks, benefits and alternatives to cesarean delivery during routine prenatal care, before the onset of labor. This study suggests a need to explore strategies for the informed consent process of labor and delivery, which is unpredictable and has considerable emotional ramifications for the patient and her family. Future studies should focus on identifying strategies that allow patients the opportunity to fully understand delivery modes including cesarean section without engendering fear of the process of labor.”

In-Depth [retrospective chart review]: This study evaluated the length of consent time, defined as the time between obtained consent and incision, and risk factors for short consent times in cases of cesarean delivery (CD) when informed consent was obtained during labor. Data was drawn from a representative sample of 90 cases of unscheduled CD at an academic hospital in 2004. Consent time was defined as dichotomously as <15 and ≥15 minutes or as <30 and ≥30 minutes. Maternal demographics, labor characteristics, indication for CD and timing of events were abstracted from patient medical records.

Median time to consent was 48 minutes. Overall, consent time increased with time from admission to incision (p=0.002) and use of oxytocin (p=0.01) whereas the use of a fetal scalp electrode (FSE) and a fetal heart rate (FHR) indication for CD were associated with decreased consent time (p=0.03 and p<0.001, respectively). Women with FHR indications were more likely to have a consent time less than 30 min (OR 4.7, CI 1.4-15.2) when compared to peers undergoing CD for non-FHR reasons. 10% of women in the study had a consent time <15 minutes; all of these were women had fetal heart rate (FHR) indications for CD.

By Denise Pong and Leah Hawkins

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