Birthrights and GMC – what does informed consent mean in maternity care?

Informed Consent

Human rights law requires every individual to be treated with dignity and respect and for their autonomy to be upheld. These principles are at the heart of guidance given to doctors by their regulator the General Medical Council (‘GMC’).

We’ve worked with the GMC to explore what women and birthing people can expect from their obstetricians and other doctors they may encounter during their maternity care.

We specifically talk about doctors in this blog. Although, nurses and midwives have to follow similar principles that are set out in their own professional standards.

We reached out to you for positive birth stories about decision making and consent so that we could share examples of good practice.

What women and birthing people should expect of their doctors

During your pregnancy you may have to have conversations with doctors about your care, so you can make decisions on behalf of yourself and your baby. Your doctor should support you during this process, and the GMC sets how doctors should have conversations with women and birthing people in its Decision making and consent guidance. It says that doctors should:

• find out what’s important to you and explore how you feel about the different options available.
• talk to you in a way that you can easily understand, using plain English terms and explaining any medical terms.
• clearly explain all the treatment options available and what each would involve. This should be done well in advance where possible.
• go through the benefits and risks of each treatment option and how they may be affected by your specific circumstances. The option to do nothing must always be included in the discussion.
• start from the assumption that you have the mental capacity to make these decisions for yourself.
• treat you with dignity and respect.

How does this apply to maternity care?

Pregnancy is a nine-month journey which allows plenty of time to find out information, have meaningful discussions and come to decisions.

It could also be said that pregnancy is exceptional because it involves two people – the person carrying the baby and the unborn baby itself. However, in the eyes of the law, this doesn’t make any difference. An unborn baby has no legal rights until it is born.

Even when your baby is born, you have the final decision about what is best for you and your baby, which only a court can overrule. Your decisions cannot be overruled because a doctor is concerned that your decision might harm your baby – it is always your decision. The only exception is if you are not able to make these decisions for yourself (you lack mental capacity) which is very rare.

What you can expect from antenatal care

The GMC set out high level principles in its Decision making and consent guidance which they expect your doctor to follow.

“Decision making is an ongoing process focused on meaningful dialogue: the exchange of relevant information specific to the individual patient.” (Principle 2, Decision Making and Consent) “All patients have the right to be listened to, and to be given the information they need to make a decision and the time and support they need to understand it.” (Principle 3, Decision Making and Consent) “Doctors must try to find out what matters to patients so they can share relevant information about the benefits and harms of proposed options and reasonable alternatives, including the option to take no action.” (Principle 4, Decision Making and Consent)

It’s important that doctors have a meaningful conversation with you when you’re making decisions about your care. Your doctor should ensure that you are in a position to have a two-way conversation with them. This might mean, for example, providing an interpreter if English is not your first language. They should give you a choice of formats for information where this is possible, and this information should be accessible in advance of you being asked for a decision. You can also ask your doctor if you can record the conversation so that you can recall the information later, and your doctor should agree to this.

Your doctor should be open minded and non-judgemental. They should not make assumptions about you and should treat you as an individual.

Your doctor must listen to you, and try to find out what is important to you. They should give you the opportunity to ask questions and respond honestly when you do.

Doctors should never rush you into making a decision and should encourage you to think about the options available to you. They should also give you time to talk about your options with family, friends or someone you trust.  

Remember that decision-making is a fluid process; things change and you are allowed to change your mind. You might have started your pregnancy wanting a planned caesarean and then realised you want a home birth or vice versa. You may be keen to have an agreed personalised care and support plan early on in your pregnancy or you may prefer not to make any decisions until much closer to your due date. It is up to you.

When you speak to your doctor during pregnancy…

If you have an antenatal appointment with a doctor to discuss options relating to your maternity care or birth you might find it helpful to write down in advance, the main things you want to say about what is important to you, and any questions you may have. The GMC have created a page for all patients that you may find helpful.

If your doctor gives you treatment options, you can use the BRAN method (from Choosing Wisely UK) to ask them:

What are the Benefits of each option?

What are the Risks of each option?

What are the Alternatives?

What if I do Nothing?

Doctors should put any benefits and risks in context. For example, a doctor should say that the likelihood of a rupture in your uterus is around 1 in 200 if you are having a vaginal birth after a caesarean, rather than simply saying you have an “increased risk” of a rupture compared to a woman who hasn’t had a caesarean.

During labour…

Labour/childbirth is unpredictable. It is worth thinking about what might happen in labour and what decisions you might be asked to make, even if this is not what you want or are planning for. For example, even if you are planning a vaginal birth it is worth finding out about instrumental and caesarean births, and the risks and benefits of each, well before you go into labour so that you can make an informed decision if your baby needs some assistance to be born. Feel free to ask your doctor or midwife any questions you have at any point during your antenatal care.

Labour can be a more challenging time to make decisions and you may need more support to be able to do this.  For example, doctors should wait until after contractions to ask questions if at all possible, and should respond promptly to requests for pain relief, before having conversations about next steps. The GMC guidance recommends that doctors should check that previously made decisions, such as those in your personalised care and support plan, are still what you want and that nothing has changed before they go ahead with any intervention, but this should not feel coercive.

Doctors will only ask for written consent for major interventions such as surgery. However even if a doctor is only taking your blood pressure or feeling (sometimes called palpating) your baby bump, they must still:

• explain what they are doing and why,
• make clear that you can say no and stop immediately if you do,
• be alert to any signs that you may be unhappy or confused about what they are doing.

Even if you’ve said yes to an examination or intervention previously, doctors must check with you again every time they carry it out. You can withdraw your consent at any time, including in the middle of an examination and the doctor must stop immediately.

You can say no to any intervention, for example, vaginal examinations, even if it is a routine part of maternity care, and your decision should always be respected.

When you speak to your doctor during labour…

The questions about the Benefits, Risks, and Alternatives including the option of doing Nothing can be useful during labour too. You also can ask how much time you have to make the decision – not all decisions during labour are urgent.

You can ask a healthcare professional to wait until after a contraction before they try and have a discussion with you. You can also ask your partner or chosen supporter who knows your wishes to lead the conversation with your healthcare professional so you can conserve energy, although ultimately the decision is yours.

Emergencies

The GMC guidance for doctors makes it clear that in an emergency, decisions may have to be made more quickly but the same principles apply. Unless you are unconscious, doctors must assume that you have capacity to make decisions and must check that they have your consent before providing treatment or care.

Complaints

If you want to make a complaint about a doctor, there are a number of organisations that support you. The NHS trust or Health Board that employ the doctor may be able to handle the complaint, or you can approach the GMC directly.

Birthrights’ factsheet about making complaints contains further information. The GMC also has webpages that can help you if you’re looking to raise a concern. They outline the type of concerns that the GMC investigates, how to raise a concern, and who can help you if the GMC isn’t the right organisation to speak to.

A huge thank you to all those who provided the positive stories quotes in this piece.