21. Communication and Consent in Birth
I debrief from most of my births in therapy, even the straightforward ones. There’s something about retelling the experience to someone who’s trained to listen and help me interrogate my thoughts, feelings, and actions that helps me organize the birth in my head. I like to think about what went well, what was challenging, what I want to hold onto, and what I want to learn more about. I’m always deepening my understanding of birth and what it means to support it well, and every client has something new to teach me. I’ve also noticed that without this debrief, the births can start to weigh on me. Witnessing someone bring a new soul into the world is heavy, even if it’s mostly wonderful.
One thing that comes up over and over in these sessions is communication skills. Everything in birth can be so heightened, and sometimes decisions need to be made quickly, even in situations that aren’t really emergent. And a lot of times, unfortunately, these decisions are made by a provider or nurse, and the only way we know they’re happening is by hearing the provider or nurse communicate them to another team member.
Here’s what that usually sounds like:
Nurse to another nurse: “get me the internal.”
Provider to nurse: “get the vacuum ready.”
There’s nothing wrong with getting something ready, especially in an urgent situation, but the problem is what happens after: nothing. There’s usually not a discussion with the birther. The nurse or provider is ready to move forward, and then it falls to me to turn to the client and say, “They are wanting to do X. Are you okay with that?”
I know not every provider operates in this way, but it happens enough that I think every birther should be ready for a situation like this. My therapist has certainly heard me talk about it many times. Her take on it is that this missing communication skill is an interpersonal skill, not something taught in their clinical education.
So let’s dive in to the different forms of consent and how consent might be handled in different situations in labor.
First, this article examines why consent in birth can be such a complicated subject. Here are a few reasons:
Birth is normal and not (usually) a medical procedure. When I say normal, I just mean that it’s “naturally occurring.” Unlike coming into the hospital for a surgery, birth is a bodily process that’s going to happen regardless of setting. Can medical interventions occur in birth? Totally. Can medications or devices be used to start labor? Yes. Can birth end up being a planned (or not) medical procedure in the form of surgery? Also, yes. But you’re not going to go into spontaneous back surgery at home, unlike with labor.
Because birth is a process, how to intervene (or not) is more complicated. Birth is an unfolding function, not a singular event, and so there are many opportunities to make decisions about whether or not to do something, and if the decision is to do something, then what to do.
Birthers can sometimes be more difficult to communicate with in labor because they are in labor. The sensations are intense, and they’re often in an altered state of consciousness because of the hormones of labor, so they may not respond to a question in the same way that a non-laboring person would.
Birth is hugely important. Birth has personal significance in a way that another surgery never will. A person is meeting their baby for the first time, and no matter what that looks like, it’s transformative and raw and has such deep meaning.
Sometimes decisions in labor need to be made quickly. If you’re having back surgery, you’ve probably talked to the surgeon about what the process will be like, and because you are going under general anesthesia and it is a medical event, you have to trust them to make decisions should any complications arise. With birth, the process can unfold in any number of ways, so it’s not always possible to know ahead of time what decisions you will be faced with. It’s also pretty rare that you’d have general anesthesia, so even in a surgical situation, you’re usually conscious.
Birth involves a person’s vagina, cervix, uterus, pelvic floor, rectum, etc. While touching anyone without their consent is wrong, touching someone’s cervix or perineum without consent (ex. a cervical check or perineal massage being done without consent) is sexual assault.
All of these things make consent even more important in birth than in other areas.
The above article goes into four different types of consent and the situations in which they are appropriate:
explicit: This is what we typically mean when we say “informed consent.” This is the full conversation where there’s time to talk about the pros and cons, explore other options, and make a decision that the client communicates with a “yes” or “no.”
Honestly, I rarely see this happen voluntarily during labor in the hospital. Sometimes I see a shortened version of it when the client is proactive in asking a bunch of questions. This should be the gold standard, but the reality is that this is most likely to happen in prenatal appointments where the stakes are low and there’s not an urgency issue. I highly encourage clients to talk to their providers about monitoring, augmentation, induction, and pain management options in the prenatal appointment setting, so that when/if these things come up in labor, they can reference back to those longer conversations and have a shorter one in the moment with the provider because they’re already gotten the background information.
implied: This is when the client gives consent with their actions rather than a clear “yes” or “no.” The article gives the example of rolling up a sleeve for a blood draw as implied consent for that.
The tricky part about this type of consent is that for it to “count” as consent, “patients must know (roughly) what is going to happen and must be sufficiently informed and aware of their rights to know they have (other) options.” You can probably see how holding out your arm for a blood pressure check makes sense as implied consent, but that moving onto your back when a provider comes in and demands you do so falls short of true consent if you don’t feel like you have other options.
opt-out: This is when the provider assumes consent and requires that the client revoke consent if they don’t want something to happen. This must be clearly stated out loud by the provider.
According to the article, “there are strict requirements for not-opting-out to constitute consent: patients need to be informed that they are consenting by not opting-out; what they are consenting to by not opting-out; and what they need to do to opt-out. Moreover, the opportunity to opt-out needs to be realistic and feasible.” The article goes on to give an example of what this could look like with an episiotomy: “There is a limited, circumscribed place for opt-out consent. Only if consent has explicitly been asked but the woman has not given a response, and there is a very clear conviction by the care provider that the episiotomy is necessary and congruent to the woman’s likely wishes, would it be ok to move to opt-out consent. Of course, the conditions for valid opt-out consent need to be met: it needs to be communicated clearly what is going to happen; that a woman can opt-out; and how she can opt-out. The woman must also have adequate time to opt-out. For example, ‘I really think an episiotomy is necessary, but I am not getting a clear response from you. So, unless you tell me you object, I will do the episiotomy on the next contraction. If you DO NOT want me to do an episiotomy, please say no, or give some other sign’.”
presumed: If the client is unconscious, their partner or other representative is not present or is also unconscious, there’s an emergency, and the provider believes the client would genuinely have consented, then the provider can move forward with treatment because they have presumed consent.
In my mind then, here are the circumstances where each form of consent should be obtained:
low stakes, common procedures with minimal risk like taking blood pressure or temperature: implied consent
literally everything else: explicit consent
in conscious emergencies: explicit consent followed by clear opt-out consent if client does not respond to explicit consent in a way that means “yes” or “no”
in unconscious emergencies: presumed consent
I reached out to an OB to ask her how she handled consent in emergency situations. I loved her response. She said that ideally, she would’ve had many of these discussions with clients prenatally, so that if a situation came up in labor, she could say, “Hey remember when we talked about X and your preferences in that situation. That’s happening now and I definitely recommend X. Is that still okay with you?” Of course, this relies on continuity of care (a whole other component and blog post), but it highlights the importance of having these conversations with your provider in advance.