It may or may not surprise you to know that much of my interest in birth evolved out of an interest in reproductive justice. In that area of my life, we talked a lot about consent, using phrases like the ones found in this post on the Free Figure Revolution Consent Rally. There are more images in their photo gallery, but the ones that appear in the tumblr post include phrases like:
- If you have to convince or coerce them, it's not consent.
- Consent is never implied, assumed, or expected.
- If they're incapacitated, drunk, or high, they cannot consent.
- Consent to one act is not consent to all acts.
- Hesitation or doubt does not equal consent.
- Consent = voluntary, continuous, sober, informed, mandatory, mutual agreement.
- Silence does not equal consent.
Those are, of course, all referring to consent to sex. But what if we shift our focus and apply them to medical consent?
What you should know before we get started:
The laws about consent for things done to your body are much the same in the medical community as they are elsewhere, with some exceptions for urgent emergencies or some circumstances where consent may be given by a proxy (usually your next of kin, someone with power of attorney for you, or, in some cases, the state).
The laws about consent for procedures performed on newborns after delivery vary due to some ethical questions. These are different than consent for pregnant women up until the moment of birth.
In almost all cases (in the US and Canada at least), until a baby is born, its mother's bodily autonomy and right to consent/refusal supersede the baby's well-being, if the two are at odds. That is, if the mother refuses a procedure or treatment, it cannot legally be forced on her even if the life of the unborn baby is at risk.
Some of these laws are in flux, and you should research them in your own area if you are concerned about the details.
Today, we're going to talk about consent for things done to you while you're in labor. This article is not intended to sway your decision about any particular procedure, only to make sure you know your rights when it comes time to make choices.
What is medical consent?
First of all, when we talk about medical consent, the term informed consent usually comes up. What this means is that you've been given all the information necessary to make an informed decision, and you're allowed to make that decision for yourself. It also means that informed refusal is an option. Agreement without room for disagreement is not true consent, and even if danger to you or your baby means that you are very, very unlikely to refuse, there should still be space for refusal. This sometimes gets tricky in birth, because when urgency and your child's safety are on the table, you may be easily convinced by phrases like "risk to the baby," whether or not the risk is real, severe, or urgent. You always have the right to demand full explanations and complete information from doctors, nurses, and midwives.
Why does this matter?
If you're happy with your doctor and trust them completely to take the best care of you, you're lucky and it's very likely that they'll seek your complete consent anyway. Unfortunately, due to aspects of medical training and philosophies about care and legal risk within the medical community, many people in the medical professions are taught, implicitly and explicitly, to use certain tools to get your consent that can be highly coercive. Things like telling you what's going to happen (which you can still refuse, but might feel like you can't) instead of asking, or getting you to sign a generalized consent form that covers any possible procedure in advance without discussing it with you, are ways that this happens. Certainly, not all doctors and nurses do this, and some who do may still be doing an excellent job of caring for most of their patients, but in some areas and practices, it's part of the philosophy and the way things work. They probably truly believe they are doing their jobs the best way they know how and are usually not trying to hurt you, but depending on your personal history and circumstances, these approaches may be very damaging. The knowledge the medical professionals have and the fact that they know when a procedure is appropriate (if not 100% necessary) is paramount. And certainly good doctors and nurses work even in those areas and practices, and will seek fully-informed consent for everything. But some don't. It's important that you know.
How can I make sure I get to consent appropriately?
Your best bet is to talk about everything with your doctor in advance. Make lists of topics to bring with you to your prenatal appointments, and start early to make sure you can cover everything you need to over the course of your pregnancy. If your birth location requires a general consent form, refuse to sign it until you've had someone sit down and go over each procedure with you. They should tell you what it does, when it's used and why, what the side effects are for both you and baby, and what recovery will be like. That way, if there is an emergency situation where it's not possible to sit down and have that long conversation, you've at least had it once and are truly informed in your decision. Choices made in a rush, when you're worried and in labor-brain, are difficult to think through completely.
What about routine procedures?
Many hospitals as well as individual providers have procedures they consider "routine," or that are part of their specific standard of care. These might include IVs or heplocks for every patient at intake, constant fetal monitoring for every patient, an intake period of monitoring for every patient, guidelines about when to come in to the hospital in labor, guidelines about post-dates and inductions, rules about how long they are comfortable having a patient labor before they suggest cesarean (which may or may not be stricter if your water has broken), a schedule for vaginal exams, preferences about laboring or pushing positions, preferences about episiotomy, and others. Know that although there are some procedures for newborns that are mandatory in certain areas, when it comes to procedures done to you, hospital procedure or routine is not law, and you do have the right to refuse even routine procedures. You may be asked to sign a waiver stating that you have refused, but they cannot force anything on you just because it's their routine or policy. Just like anything else, the nurses and doctors have a responsibility to explain to you what a procedure is, why it's being done, and the risks if you do or don't choose to use it. This conversation should be complete and should always be consent-seeking rather than demanding.
This is another conversation that is good to have with your doctor in advance, and if you're planning a home birth with a midwife, in addition to talking about her routines and policies (yes, midwives have them, too!), it's also a good idea to talk about the expectations you'll face if you require a hospital transfer, especially if she will no longer be with you. Knowing what the hospital policies and routines are will better prepare you to accept or refuse them according to your wishes when the time comes.
An earlier version of this article also appears on my blog.