Response to the RCOG Consent Advice Guideline Draft – Planned Caesarean Birth

The draft document can be found here

General comments:

The comments form is online only and cannot be downloaded. This makes it very difficult for considered responses to be put together as it can only be completed in one go.

What is this? Who is it for?
We question the actual purpose of this form which gives the impression of another tick-boxing exercise for the health professional to go through, to cover their back if something does not go according to plan rather than a tool to support informed decision making?

We are concerned that because this form provides some information it will be seen as THE provision of information to support informed decision making. The sections on intended benefits and risks should therefore be removed and replaced by a checklist of the topics which should have been covered in the discussion, and a note of information sources provided e.g. the RCOG patient information leaflet.

How will this information be provided in the antenatal period as it is commonly known midwives only have 10 minutes per antenatal visit? Is this a separate antenatal appointment to discuss the guidelines and how much time will be allocated? This should be clarified when and by whom.

There is no mention of the fact that a caesarean birth is major abdominal surgery.

There is no mention of making this a positive birthing experience, which it can be for many. We suggest adding a section to record the woman’s preferences for personalised care.

This is a great opportunity to take into account personal preferences, eg gentle caesarean, immediate/early skin-to-skin, optimal cord-clamping, breastfeeding, so they can be signed off beforehand.

The form fails to capture the reason that a caesarean is being offered or requested; or that there will be additional risks and benefits relating to that situation.

Section: How to use this guidance:

We suggest that Health Professionals are encouraged to use the IDECIDE Framework.

Section:How to provide information:

This section should include the following (or maybe there needs to be a section on “What to include in the discussion”):

“Explain why you are recommending a caesarean and the evidence on which your recommendation is based. Provide whatever information the woman wishes about the benefits and risks of caesarean and vaginal birth in her particular case.”

“In discussing risks, give information about the absolute risk in a form which is easy for the woman to understand. This might include giving the actual number e.g. 1 in 1,000, or a pictogram.”

“Encourage the woman to ask whatever questions she wishes about the procedure, its risks and benefits, and the alternatives, allowing sufficient time during the discussion for her to do this.”

“Include information about the benefits and risks of the options for anaesthesia (general or regional) during the procedure, to enable the woman to make an informed decision about which of these she wants to have. Also include the types of pain relief which can be offered to cope with post-operative pain.”

“Healthcare professionals must also explain the likely impact that a caesarean will have on postnatal recovery, compared to a vaginal birth, including potential post-operative complications. ”

Section: Taking written consent

This section contains an implicit assumption that the woman will consent, and that she will be ready to decide immediately after the discussion. It would be better to say

“At the end of the explanation and discussion about the procedure, women should be given time to consider their options before being asked whether they wish to consent to the procedure. If a woman is not ready to make the decision at that time, or wishes to discuss it with her partner or others first, provide an opportunity for her to contact you with any further questions or concerns that occur to her following the initial discussion.”

Section: Consent Form for Planned Caesarean Birth

Name of proposed procedure: Planned caesarean birth (PCB)
This should make it clear that this is major abdominal surgery. For example:

“This is a major abdominal surgery which involves making a cut through your abdomen (tummy) and uterus (womb) to allow your baby/babies to be born through the opening. You will need a period of recovery and reduced activity as for any post surgical patient.”

The “Statement of Health Professional” needs to cover more than this. It should say something along the lines of:

I have given the woman information and enabled her to ask questions about the following:

• The reason why a caesarean birth is being offered or requested and the evidence on which any recommendation is based

• What the procedure involves and the implications for her recovery after the birth, including length of hospital stay

• The risks to her and her baby of a caesarean versus a vaginal birth, making clear that the figures are estimates only based on limited available data, and including any specific risks relevant to her individual circumstances

• Procedures that may become necessary during the caesarean including

  • Blood transfusion

  • Repair of any damage to bowel, bladder or blood vessels

  • Emergency hysterectomy (when necessary, as a life-saving procedure)

• The benefits and risks of the different options for anesthesia during the procedure, and for pain relief afterwards

We recommend that the wording “(including vaginal birth: unassisted or assisted, emergency caesarean birth)” is changed to read “(including vaginal birth: spontaneous or assisted, emergency caesarean birth), to avoid confusion with freebirth which is often referred to as ‘unassisted’.

Intended benefits

We were concerned to see the list of risks that may be lower with a caesarean compared to a vaginal birth framed as “Intended benefits” since we would not expect a healthcare professional to be recommending a caesarean on these grounds alone. As noted in the general comments, we feel it would be better to remove these sections on intended benefits and risks altogether.

The statement “Safer way for your baby to be born when caesarean birth is medically indicated compared with vaginal birth” is misleading and will not apply in all cases. It might be safer for the baby if there is reason to expect complications in a vaginal birth, or concerns over how a particular baby will cope with labour, but not if it is being recommended e.g. because of concerns over the mother’s well-being.

We feel that rather than the healthcare professional stating “I confirm the woman has been given time and opportunity to seek clarification on the information provided on planned caesarean birth”, it is essential that the woman is asked to confirm “I have been given time and opportunity to seek clarification on the information provided on planned caesarean birth”.