Informed decision making and consent in maternity care

All medical professionals should obtain their patient’s informed consent i.e. agreement or permission, to undergo any type of medical intervention, including investigations, treatments or procedures. In maternity care, this means that pregnant women have the autonomy to make informed decisions about all aspects of their care during pregnancy, labour, delivery and postnatally. This guide will explore:

• What is informed consent in maternity care
• What information should be provided
• Who is responsible for providing this information and how they should do it
• What to do if a woman wishes to make an unwise decision or deny medical intervention

Whilst the outcome of some decisions will confirm the woman’s preferred course of action, such as place and mode of delivery, other decisions will require the woman’s informed consent to be obtained. For example, where medical intervention is proposed such as routine or diagnostic testing and investigations, vaginal examinations, induction of labour, surgical procedures and termination of pregnancy. 

Unfortunately, many independent maternity reports have found that this is not always the reality for many pregnant women, and inadequate informed consent remains a consistent issue across many maternity services within the UK. 

What is informed consent in maternity care?  

Informed consent in maternity care means that you should be fully and clearly informed about your pregnancy, labour and birth options before any decisions are made. Your healthcare professionals should explain what is being recommended, why it is being suggested, any risks to you or your baby, and any reasonable alternatives available to you, including the option of saying no. This information should be tailored to your individual circumstances, allowing you the time and support you need to understand it and make decisions that are right for you. 

What information should be provided in maternity care? 

The general rule is that a medical professional must give a patient, all of the information which they want or need, in order to make an informed decision. However, any discussions regarding medical care or intervention should be tailored to the individual patient, as well as the nature of the decision or intervention which is being proposed.  

For pregnant women, personalised care and decision making is a fundamental principle of maternity care, and various information will be provided throughout her pregnancy and during the post-natal period.  

However, some examples include information regarding: 

• Antenatal testing and investigations, such as blood and urine tests, ultrasound scans or screening and diagnostic tests 

• Antenatal diagnoses and any subsequent management or treatment, such as pre-eclampsia or fetal abnormalities 

• Labour and delivery preferences, such as place and mode of birth, induction of labour, the level of medical intervention and administration of pain relief, including the benefits and risks of each option 

• Termination of pregnancy, such as legal time limits and the available methods, including the benefits and risks of each method 

• Postnatal care preferences, such as method of feeding, as well as the type, frequency and duration of any postnatal input 

If a pregnant woman asks specific questions about her maternity care, the medical professionals involved in her care, must ensure they provide the woman with full, honest and objective answers.  

The law also states that a pregnant woman’s consent must be sought for all medical care provided during labour, which includes consent for medical students to be present during a birth. This means that any person who is providing maternity care should explain their role, and whether they are a student. Therefore, allowing the pregnant woman to decide whether she is happy to receive care from them or to have them present. 

How should information be provided in maternity care?

In any event, the information, which is provided to the pregnant woman should be clear, accurate and up to date, and provided in a way in which the individual woman is able to understand and retain it. It should be communicated in simplified non-technical language, wherever possible. Usually, the information will be provided verbally and then followed up in writing, such as in a letter sent following the appointment.  

Leaflets and online material may be used as a helpful starting point; however, maternity staff should not rely on these in lieu of a verbal discussion with the pregnant woman. Moreover, maternity staff must ensure that a woman has the necessary time and support they require in order to understand and consider the information which has been provided, including to make any notes or ask further questions.   

Additional care must be taken when providing information and obtaining consent from women who are in labour, particularly where their capacity may be temporarily affected. 

Throughout the consent process, women should be reminded that they have the right to seek a second opinion in regard to any recommendations or proposed medical intervention, and that they are permitted to change their decisions at any time. 

Who is responsible for providing the information? 

Responsibility for providing information to women during pregnancy, labour, delivery and postnatally will depend on the women’s individual circumstances, the nature of the decision or proposed intervention and the specific clinical situation. It may be appropriate for information to be provided by a range of medical professionals, including a woman’s GP, midwives, sonographers, obstetricians, gynaecologists, neonatologists, fetal medicine specialists and health visitors.  

However, a pregnant woman should have a named midwife, who will be responsible for coordinating her maternity care and ensuring her needs are met throughout pregnancy and the post-natal period. This includes seeking guidance and support from specialist midwifery services such as fetal medicine or other members of the maternity team, if information falls outside the midwife’s expertise.  

How can a pregnant woman give her informed consent? 

Informed consent can be given: 

• In writing e.g. by signing a consent form for induction of labour or a caesarean section 
• Verbally e.g. by saying they’re happy to have a vaginal examination 
• Non-verbally e.g. by holding out their arm for a blood test 

Again, the appropriate method for giving informed consent, will depend on the nature of the proposed decision or intervention, and the women’s individual circumstances. 

It does not always need to be a formal, time-consuming process and for most quick, minimally invasive interventions such as a blood tests, verbal or non-verbal consent may be appropriate, providing the woman understands what procedure or treatment is about to take place. Whereas for more complex decisions or interventions such as a caesarean section, only written consent may be appropriate. 

However, where consent is given verbally or non-verbally, this should also be recorded in the women’s medical records.  

What if a woman wishes to make an unwise decision or decline intervention?

Providing a pregnant woman has the necessary capacity to make a voluntary and informed decision, their decision must be respected, even if their decision would result in death or serious harm to woman, or her unborn baby. 

Common examples of decisions which may be considered ‘unwise’ or would fall outside of recommended national guidance include where a pregnant woman:  

• Declines certain aspects of maternity care at home, or in a maternity unit 
• Requests a place to give birth or aspects of maternity care at any time that is considered outside of Trust or board clinical guidelines  
• Declines a recommendation for care, procedure, intervention or pathway, such as antenatal screenings, increased monitoring or ultrasound scans, consultant-led care, induction/augmentation of labour, antibiotics for infection prevention e.g. aspirin  
• Declines emergency life saving medical intervention, such as a Jehovah’s witness refusing to undergo an emergency blood transfusion during a caesarean section due to her religious beliefs.  

What might amount to a lack of informed consent in maternity care? 

Informed consent can only exist where all four elements (voluntary, adequate information, understanding and capacity) were met, at the time that the pregnant woman’s consent was required. Therefore, if any of these elements were missing, the woman’s consent will not be valid or informed. 

Common situations whereby informed consent has not been provided, may include where the woman: 

• Has not been given all of the necessary information which was needed to make an informed decision. For example, where they have not been told about certain material risks, or alternative modes of delivery.  
• Has been coerced or placed under undue pressure by a medical professional, or a relative to consent to a particular procedure or treatment option. For example, where a woman’s partner has pressured her into terminating a pregnancy.  
• Lacks the required mental capacity and understanding to make an informed decision about their treatment. For example, where the pregnant woman was suffering from a severe mental health condition at the time her consent was obtained. 

Providing a pregnant woman with misleading information regarding their maternity care and any proposed interventions, may also mean that her consent was not valid and informed. 

It is important to note that where a pregnant woman has provided her consent, by signing a consent form for example, this does not necessarily prevent them from making a claim, providing she can demonstrate that her consent was not valid and informed.  

Common consent issue in maternity care

Pre-natal screening and diagnostic tests 

All eligible pregnant women should be offered pre-natal screening for Down’s syndrome, Edward’s syndrome, Patau’s syndrome and 11 physical conditions, as part of their standard antenatal care.  

Pregnant women who are considering pre-natal screening should receive detailed, accurate counselling by suitably trained maternity staff, including explanation of: 

• The condition(s) being screened for 

• Who is invited to the screening test/scan and what is involved  

• The benefits and risks of screening, such as the additional risk of miscarriage and the risk of false positive or negative results 

• Possible further tests/scans, and the importance of women attending any follow-up testing or treatment 

Women should also be reminded that they can change their decision at any time, prior to the last appropriate date for screening.  

Following any pre-natal screening, maternity staff must ensure that pregnant women are provided with accurate information regarding any confirmed diagnosis of a serious or fatal foetal abnormality and the possible implications of the same. the option of termination. Where an abnormality is suspected, but not yet confirmed, women should be provided with the same information, however, it should be made clear that the diagnosis is not yet certain. 

When providing information, maternity staff should not disclose their personal views or beliefs, nor should they allow this to influence the nature of the information which they provide.   

Wherever possible, a pregnant woman should be allowed sufficient time to understand and consider any information provided, particularly in regard to the nature and severity of any foetal abnormality before deciding whether or not to proceed with the pregnancy. This also means that any information regarding screening and/or foetal abnormality, should be provided well in advance of the legal cut off date for termination (see below). 

Termination of pregnancy  

All pregnant women who are considering terminating a pregnancy, should receive detailed, accurate counselling by suitably trained maternity staff, including explanation of: 

• All appropriate available methods of termination, including any benefits, risks, possible side effects 

• Relevant time limits for each available method, such as when a medication induced termination (by taking tablets) will no longer be appropriate i.e. after 10 weeks 

• Possible complications associated with a termination 

• Where a foetal abnormality has been confirmed child being born seriously handicapped (physical or mental abnormalities) 

However, of particular importance, is the accuracy of the information given in regard to the relevant time limits for termination in England, Scotland and Wales, namely that termination is legally permitted up to 23 weeks and 6 days.  

Termination after 24 weeks is not generally permitted, unless it would reduce the risk to the pregnant woman’s life, the physical or mental health of the pregnant woman and/or her existing children, or if the unborn baby is at substantial risk of being serious mentally or physically handicapped. In which case, there is no final cut off point for termination, though the risk of complications increases, the longer the pregnancy continues. 

Wherever possible, a pregnant woman should be given a choice as to the method of termination and allowed sufficient time to understand and consider any information provided.  

Women should also be reminded that they can change their decision(s) at any time, prior to the termination taking place and that the unborn baby’s biological father has no legal right to demand or refuse a termination, nor is his consent required. Subsequently, additional care should be taken to identify potential issues regarding vulnerabilities or coercion, from the biological father or the partner, before obtaining the woman’s consent. 

Unlike some other decisions during pregnancy, consent to a termination, must be given in writing by signing a detailed consent form. In addition, consent must also be obtained in order to share information regarding the termination with third parties, including the pregnant woman’s GP, her partner/the biological father, a parent (if under 16 and competent). Therefore, if the woman does not consent, any information must remain confidential, unless in exceptional circumstances. 

Place of birth and mode of delivery 

It is vital that pregnant women are provided with detailed information in regard to all appropriate modes of delivery which are available to them, by suitably trained maternity staff, including explanation of: 

• All appropriate modes of delivery i.e. vaginal birth, caesarean section, assisted vaginal delivery and vaginal birth after caesarean 

• Any benefits and associated risks, with information tailored to the individual woman where appropriate. 

• For example, possible risks associated with a vaginal birth include vaginal or perineal tears, future urinary incontinence, the need for induction of labour, assisted delivery, or emergency c-section.  

• Whereas, possible risks associated with a caesarean section include wound discomfort or infection, development of internal scar tissue, heavy bleeding and subsequent need for a hysterectomy. 

• What each mode of delivery involves and any implications for the mother and baby, both prior to, during and following birth, including any relevant statistical figures. For example, such as the number of women who require an assisted vaginal delivery or emergency caesarean section, despite planning a vaginal birth.  

• Any individual circumstances or risk factors which mean a particular mode of delivery may be recommended 

• Implications for future pregnancies associated with each mode of delivery 

Discussions as to mode of delivery should begin early in the pregnancy and continue throughout. Women should be reminded that they are permitted to change any decisions which they have made in regard to their birth plan, place of birth, mode of delivery etc.  

Again, maternity staff should not share their own personal views or beliefs and any information provided should be balanced, unless the woman’s individual circumstances and risk factors mean that one method may be more appropriate, for example. 

Usually, a caesarean section will not be recommended, over a vaginal birth, unless there are specific issues complicating the pregnancy, for example, if the pregnant woman has pre-eclampsia, certain infections or a low-lying placenta. However, if, having considered the benefits and risks of the different options for birth, a woman decides upon having a planned caesarean, or if she decides against having a caesarean section as recommended, her maternity team should respect this decision.  

If a woman’s maternity team are not able to offer her a planned caesarean birth as requested, she should be referred to another maternity team who can offer this.  

For surgical interventions, such as a caesarean section, written consent will be required and this should be obtained either shortly before the procedure, or during the woman’s admission to the maternity unit. The exception to this, however, is if an emergency procedure is required, verbal consent may be appropriate instead. 

Can I make a medical negligence claim?

If you have any concerns about your maternity care, the information which you did or did not receive, or if you believe you did not provide your valid informed consent before undergoing a medical investigations, treatments or procedures during your pregnancy, labour, delivery or postnatally, please contact our specialist team today. 

At Fletchers Solicitors our dedicated team of solicitors have extensive experience and expertise in all types of medical negligence claims involving issues of informed consent, including during pregnancy, labour, delivery and the postnatal period. We can offer you a confidential, no-obligation conversation to discuss any concerns that you have and advise you as to your options. 

*In this guide, the word ‘claimant’ refers to the injured person i.e. the pregnant woman or their baby*.