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Informed Consent

and Induction of Labour

It is freely acknowledged that the rate of intervention in childbirth is on the rise. The so-called 'intervention cascade' commences once a woman consents to the induction or augmentation of her labour but is it always informed consent? In Queensland, in 2010, only 27.1% of women who were induced reported having made an informed decision.1

While induction is appropriate in some cases it is very often resorted to in order to overcome time constraints, staffing limitations overnight and for social reasons. Induction usually involves the use of Dinoprostone to soften the cervix, artificial rupture of the membranes (amniotomy) and an oxytocic infusion to stimulate contractions. These are serious interventions and should never be assented to without a sound understanding of the possible consequences for mother and baby.

Information regarding induction must be offered in such a way as not to exploit the woman’s vulnerability or take advantage of the power imbalance represented in the health care provider/client relationship. It must never be assumed that consent will be given but when given it must be given voluntarily and founded on evidence based information, presented thoroughly and empathetically.

Opportunity must always be given for questions to be asked and where appropriate, other options must be offered. Time should be allowed for decision-making but once made, the woman’s decision should be supported by the entire medical team. Plans must be put in place for management should the induction fail. It is unreasonable to expect a woman to give informed consent to a surgical procedure once she is in strong labour.

Disadvantages:
Information concerning induction must be tailored to each woman’s needs. It must be culturally appropriate, objective and address both the benefits and the disadvantages of the intervention. It is not sufficient to say 'this will speed your labour' without also mentioning other effects:

  • There will be a need for intravenous infusion and continuous monitoring

  • The ability to mobilise freely will be lost

  • There will be little amniotic fluid to buffer the baby during contractions

  • Labour will usually be more painful than spontaneous labour

  • An epidural may be required

  • If an epidural is required a urinary catheter will be inserted

  • Due to the epidural, assisted delivery will be more likely (vacuum or forceps)

  • Surgical delivery will be more probable

  • Breastfeeding initiation may be impaired


Indications for induction:

  • Pregnancy at 41 completed weeks

  • Diabetes

  • Hypertension

  • Intra Uterine Growth Restriction

  • Maternal or fetal ill health

  • Cholestasis of pregnancy

  • Premature rupture of membranes after 34 weeks

  • Rupture of membranes at term (>37 weeks) and after 24 hours

  • Maternal request at or after 40 weeks (NICE guidelines)


Assessment:
Prior to offering induction it is essential to confirm dates. An irregular cycle (other than 28 days) may distort the calculation of the due date.  All available data should be reassessed. A vaginal examination should be performed and a Bishop’s Score calculated as a guide to determine the success or otherwise of an induction. A score over eight suggests that spontaneous labour is probable while a score under five indicates that the cervix is unfavourable. Induction should not be performed unless the score is seven or higher.

Surgical Intervention:
As indicated above, induction of labour is more likely to lead to assisted or surgical delivery than spontaneous labour. Should the labour fail to progress a Lower Uterine Segment Caesarean Section would usually be performed. Adverse effects associated with operative delivery include:

  • Infection of the wound, pelvis, infusion site or urinary tract

  • Uncontrolled bleeding at the surgical site requiring return to theatre

  • Deep vein thrombosis

  • Excessive vaginal bleeding

  • Adhesions requiring later surgery

  • Heart and lung complications

  • Confined to bed following surgery

  • Poor breast feeding initiation

  • Need for opioid and other analgesia

  • Longer stay in hospital

  • Delayed return to normal role


Spinal Anaesthetic:

A spinal anaesthetic is usually administered prior to surgery. The more common side effects of this form of anaesthetic include:

  • Nausea, vomiting, itching and shivering

  • Hypotension

  • Post spinal headache

  • Pain and/or bruising at the injection site

  • Ineffective spinal anaesthetic requiring a general anaesthetic

  • Dysuria


Further information on consent is available on the Queensland Health web site:
http://www.health.qld.gov.au/consent/documents/obst_gyna_04.pdf
http://www.health.qld.gov.au/consent/documents/anaesthetic_04.pdf

1. http://www.health.qld.gov.au/qcg/documents/g_iol5-1.pdf