Informed Consent - "accurate, adequate and relevant information must be provided truthfully in a form (using non-scientific terms) and language that the patient can understand."1
Implied Consent - Consent assumed based on circumstances or a person's actions. For example: a care provider automatically assumes they can exam you if you are in a gown on their exam table.
Most care providers set out with ethically decent intentions regarding the care of their patients. I think that problems arise when consent is assumed and not asked. Probably the number one example of this is regarding cervical exams.
Scenario 1) Care Provider walks into the laboring woman's room " How's it going in here, it's about time for a check, go ahead and lay back."
Scenario 2) Care provider walks into the laboring woman's room. Pausing to see if she's having a contraction or not, they wait until she is ready and listening. "Hey, how are the contractions feeling? It seems like we've been doing the same thing for a while now. I'm thinking it might be beneficial to do a cervical exam, if you're ok with that. The risks, like we discussed earlier, are that your water is broken and any exam will increase your risk of infection. The benefit of having an exam would be to see if the baby is malpositioned, and then we could try some different positions to get them into a better place to progress labor. Baby's and your health both look steady, so you also have the option to just keep doing what you're doing. I can step out if you need a minute to discuss your options with your partner and doula. Do you have any questions?"
You don't have to be a doula to see the difference. In the first scenario, the woman is not asked for her consent to be examined. The care provider likely assumes that since she is their patient, and possibly has consented to an exam before, that they have consent for the remainder of the birth. AKA Implied Consent.
In the second scenario, the care provider makes sure the woman is focused on her words. Women in labor often get a little spacy, and unfocused, especially during contractions. The care provider truly informs the patient the risks and benefit of what she is requesting, with the option to still do nothing. She respects the relationships between the laboring women and her support team, the patient's body and her capacity to make her own decisions about her care. AKA Informed Consent.
There is so much more that goes into the ramifications of Implied vs Informed Consent. Mainly a woman's right to her own body, even when she's carrying a fetus.
“The freedom to accept or refuse recommended medical treatment has legal as well as ethical foundations. . . . In the obstetric setting, recognize that a competent pregnant woman is the appropriate decision maker for the fetus that she is carrying” (ACOG Committee on Ethics Committee Opinion No. 390 Ethical Decision Making in Obstetrics and Gynecology; Dec 2007, reaffirmed 2013).
This includes the right to decline interventions, exams, treatment, monitoring, medications, and even surgery. It is illegal to threaten a woman about calling CPS, as sometimes happens, if she does not comply with the care provider's request. It equates very closely with a First Degree Sexual Offense, that the woman must allow something to happen to her body for fear of something happening to her baby.
To advocate for your own Informed Consent always use your
When deciding about your options in childbirth, remember to always use your BRAINS. Have your care provider, nurse, or doula, go over these points with you to make a truly informed decision. B - what are the benefits of the item being proposed, conversely what are the R - risks to myself, to my baby, to the rest of this labor, to future pregnancies. Are there any A - alternatives, such as waiting, position changes, natural augmentation? What does your I - intuition tell you, trust your body knows how to give birth. N - what if you simply wait and do nothing? S - lastly, if you don't agree with the proposed care, ask for someone else's opinion. There is no one right way to manage a labor and birth, it is organic, and changes.
Trauma in childbirth doesn't always come from the act of an exam, an intervention, or a cesarean. There are many women who reflect positively on their very medicalized labor that ended in a cesarean birth. Trauma can occur when a woman feels like she was not heard, like she had no choice, and like she was violated. The easiest way to help mitigate these feelings is to make sure she has truly informed consent. That she is supported in making the decisions regarding the care of her own body and baby; and she is ultimately respected in the decision she makes. Empowered women are more satisfied with their birth experience. Some might still feel sorrow and loss over the detours from their original birth plan, and that is completely normal and ok! Grief is healthy in its own way, trauma is not.
Whether your birth went "perfectly" or detoured tremendously, avoid feeling traumatized by empowering yourself with informed consent.
Trauma Healing Series Introduction
My experience of sexual trauma during pregnancy and childbirth, healing that trauma through reiki and de-armoring techniques, and my continued witness of other's experiencing trauma has prompted me to start a new blog series.
I had to have a cervical exam at 34 weeks due to a preterm labor scare that sent us to the hospital. The hospital doctor dug around trying to find my cervix to see if I was dilated. His fingers scraped my insides as the bones of his hands ground against my pubic bone. All the while he proceeded to tell me that he would never let his wife give birth in a hospital because it isn't really a safe place to have a baby. One of the movements your cervix has to make besides dilating, is moving from a posterior to an anterior orientation aka moving from facing your back to your front/center. A posterior cervix can be difficult for a practitioner to reach, and when some discover the cervix to be that far back, they don't try and reach it. This provider didn't practice that way. Even though I stopped having contractions, and wasn't in labor, I wasn't allowed to go home unless I had a cervical exam. The doula in me now knows I could have refused, but at the time I didn't know I could say no. I shut myself down in attempts to ignore the pain, the invasion, the loss of control over decisions and myself. It took a lot of self healing work to not be triggered by similar sensations and to connect with my partner again.
I see this over and over again with my clients. Not giving consent, and even revoking consent only to have those pleas fall upon deaf ears. Being told to "just hold still", "breathe through it", "it'll be over shortly", "I have to do this, you don't have a choice" are phrases I hear spoken by providers, nurses, and well meaning partners. I've seen women physically crawl away from the hands of their provider, only to have the provider keep at what they are trying. I've seen an anesthetist touch a woman's clitoris after giving her an epidural to see if it took. Let's be clear I'm not talking about any sort of life saving touch or measure, I am talking about something being done to a women simply because another person wants to do it.
There's a controversy about sexual assault during childbirth being a "real thing". Either because some truly believe a woman has no right to her body when she is pregnant (or any other time), or because other's believe care providers always know best, and would never do anything unnecessary.
Maryland law (and other states similarly) defines a first degree sexual offense as "Engaging in a sexual act with another by force, or the threat of force, without the consent of the other and: ... - Threaten or place the victim in fear that the victim, or a 3rd person known to the victim, imminently will be subject to death" The later part of the law I see expressed through coercion regarding the baby's health and survival. How is there doubt that sexual assault exists and matters in childbirth? There are cases where the woman has video evidence, and still nothing is done, or it takes years to even get a lawyer, see a judge, and have the case resolved. Woman are scorned for being upset at their birth experience, especially if they "have a healthy baby".
Trauma in childbirth is real, it is a problem, women need the space and support to heal from it, and the medical system needs to change. This is the start of a blog series that will discuss implied vs explicit consent, healing birth trauma, finding your sexual autonomy again, and more.