Informed Consent And Birth Plan: A Case Study

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The patient selected in the case scenario is Sandra who had been a primigravida woman attending a 40-week appointment with the midwife assigned to her at the antenatal clinic. In the clinic, we had performed her routine antenatal checks, after which, we had shifted her to the labour ward to discuss the induction of labour (IOL) with her. It was discovered that the risk of stillbirth was exceptionally high for the patient as she was 40 years old.  However, the patient had not been very keen on the topic of induction of labour and had wanted her delivery process to be as natural as possible. However, in the discussion that had been led by the out of guidelines midwife, the head midwife explained to Sandra and her husband with evidence the need for out-patient IOL for her and her risks given her condition and her age. Post the discussion of the benefits of the IOL and her possible risks, Sandra and her husband agreed to an out-patient IOL to be carried out for her as her whole pregnancy term had been low risk and no risks had been identified for her from the maternal age. Post this stage the patient went on to have a discussion regarding her birth plan where she discussed her preferences and aversions.

I would like to mention in this context that being a midwifery student, taking a part in the IOL discussion had been an excellent opportunity for me. The patient in the case study named Sandra had been a primigravida woman, who had been going through her first pregnancy. Hence, she had very limited knowledge regarding the aspects of labour and giving birth which was apparent from the discussion experience that we have had with her. Although, according to my personal thoughts and feelings, as the discussion progressed, the evidence-based knowledge and patient education that was given by the head midwife was very effective which helped Sandra and her husband understand the impact of the risk of stillbirth and opt for the IOL instead.

According to the standards of practice for the midwives, informed consent is one of the greatest requirements of midwifery practice which has eased the process of evidence-based practice and patient centered care in the care scenario effectively (Nice.org.uk 2018). Elaborating more, according to the NICE guidelines as well, the midwives are expected to practice informed consent under all circumstances to inform the women of the choices that are available to her regarding her delivery and postnatal care. This is the step where the midwifery care team will explain to the patient about all the risks that are associated with the pregnancy and the benefits that each of the delivery choices presented to the patient so that the patient can make a completely informed decision about her delivery and postnatal care (Rcm.org.uk 2018).  In this case, the discussion experience that I have had with Sandra and the head midwife, the patient was informed of her choice to go for IOL in order to avoid the risk of stillbirth taking an evidence-based patient education approach (Hadar et al. 2012). Hence, it can be mentioned that the course of action followed in the event had been in accordance with the recent guidelines of NICE and RCM.

Evaluation

However, it has to be mentioned in this context that the patient, in this case, has also had a birth plan discussion with the team which is one of the most vital recommendations of maternity care guidelines of both NICE and RCOG. Elaborating more, it also needs to be mentioned that birth plans are considered to be a potent tool to articulate the concerns that the women have before delivery and provide a significant opportunity for the pregnant women to have the opportunity to express their preferences with the entire process (Aragon et al. 2013). In this case, Sandra expressed that she did not want to have an epidural or the hormone syntocinon to augment her labour unless it was absolutely necessary for her or the baby’s safety. She also did not want to have active management of her 3^rd stage of labour either which was accurately documented in her birth plan with respect to her outpatient IOL.

According to the statistical data of 2016, the rate of stillbirth in the UK is 4.4 per 1000 total births (Rcm.org.uk 2018). Researchers are of the opinion that obesity and age are very important factors associated with stillbirth. For instance, the data suggest that women with BMI that is more than 30, have a higher risk of stillbirth. Along with that, as per the guidelines of the RCOG, the women that are over the age of 40 are at considerably higher risk of experiencing stillbirth as well. It has to be mentioned that even though for first pregnancies with low-risk maternal term, the risk of stillbirth is fractionally lesser, most of the medical practitioners recommend taking precautionary measures beforehand to avoid the chances of the patient going through a stillbirth. The induction of labour is one of the most common procedures opted for late labours in women, especially in their late thirties and early forties (Zizzo et al. 2017). According to NICE, induction of labour has a significantly better impact on the health of the new mothers and the child when compared to instrumental births or emergency cesarean sections. As Sandra was 40 years old and she had not been spontaneously laboring even at 40 weeks gestational period, the risk of stillbirth and other such complication was high. Hence, the discussion and birth planning with IOL was extremely important for Sandra. However, it is very common for primigravida women to be skeptical of anything other than the normal delivery due to their limited knowledge and understanding of the concepts. According to Walker et al. (2017), extensive patient education and consultation with the aid of valid, relevant and authentic evidence has a significant impact on the understanding and response of such patients. Along with that, making an informed choice was also excellently aided by the use of literature evidence by the head midwife leading the discussion which helped Sandra understand the need for IOL and consent to it eventually (Middleton, Shepherd and Crowther 2018). The entire process of informed consenting and birth plan also encouraged her to express her disregard towards the use of an epidural or the hormone syntocinon and helped in outlining a patient centred plan for her as well.

Conclusion:

On a concluding note, it has to be mentioned that this had been an excellent opportunity for me to understand the importance of informed consent and birth plans in outlining delivery plan and postnatal care plans for women along with ensuring optimal patient-centeredness of the same. In this case, we had been successful in successfully explaining the patient the need for IOL and the risk of stillbirth. I hope that this experience will help me in my professional growth and wi0ll help me in providing similarly effective and safe care as per the guidelines of my scope of practice.

Reference:

Afshar, Y., Mei, J.Y., Gregory, K.D., Kilpatrick, S.J. and Esakoff, T.F., 2018. Birth plans—Impact on mode of delivery, obstetrical interventions, and birth experience satisfaction: A prospective cohort study. Birth, 45(1), pp.43-49.

Aragon, M., Chhoa, E., Dayan, R., Kluftinger, A., Lohn, Z. and Buhler, K., 2013. Perspectives of expectant women and health care providers on birth plans. Journal of Obstetrics and Gynaecology Canada, 35(11), pp.979-985.

Hadar, E., Raban, O., Gal, B., Yogev, Y. and Melamed, N., 2012. Obstetrical outcome in women with self-prepared birth plan. The Journal of Maternal-Fetal & Neonatal Medicine, 25(10), pp.2055-2057.

Middleton, P., Shepherd, E. and Crowther, C.A., 2018. Induction of labour for improving birth outcomes for women at or beyond term. The Cochrane database of systematic reviews, 5, pp.CD004945-CD004945.

Nice.org.uk. 2018. Antenatal care for uncomplicated pregnancies | Guidance and guidelines | NICE. [online] Available at: https://www.nice.org.uk/guidance/cg62 [Accessed 11 Jul. 2018].

Rcm.org.uk. 2018. Informed consent: ethical issues for midwife research | RCM. [online] Available at: https://www.rcm.org.uk/learning-and-career/learning-and-research/ebm-articles/informed-consent-ethical-issues-for-midwife [Accessed 11 Jul. 2018].

Walker, K.F., Dritsaki, M., Bugg, G., Macpherson, M., McCormick, C., Grace, N., Wildsmith, C., Bradshaw, L., Smith, G.C.S. and Thornton, J.G., 2017. Labour induction near term for women aged 35 or over: an economic evaluation. BJOG: An International Journal of Obstetrics & Gynaecology, 124(6), pp.929-934.

Zizzo, A.R., Kirkegaard, I., Pinborg, A. and Ulbjerg, N., 2017. Decline in stillbirths and perinatal mortality after implementation of a more aggressive induction policy in post?date pregnancies: a nationwide register study. Acta obstetricia et gynecologica Scandinavica, 96(7), pp.862-867.