O&G Forum

OBSTETRICS & GYNAECOLOGY FORUM 2021 | ISSUE 2 | 9 O&G Forum 2021; 31: 06 - 09 ORIGINAL RESEARCH for the doctor must not be a family member as they can obscure the truth. Informed consent is designed to give patients liberty to decide on their treatment. Also, the patient’s educational background plays a role in the ability of the patient to comprehend the terminology used to counsel the patient. 17 Another factor to be considered is the patient’s religious beliefs, the treatment or intervention may be contradictory to their beliefs, e.g. a Jehovah’s Witness patient will decline blood transfusion due to religious reasons. 17,18 Other patient perceptions and possible misinformation must be considered when obtaining informed consent because such misconceptions may lead to misunderstandings and litigation. 17 Furthermore, some populations in South Africa still live in paternalistic communities where the husband, family or community will dictate the final decision that the patient eventually makes. 16,17 Speculating on possible solutions to the identified problems, educational brochures should be considered. Educational brochures are an important tool for communicating information and can aid the informed consent process. Bester et al. conducted a study on the effectiveness of brochures as teaching aids for patients and they found them to be very effective in communicating information to patients. 19 Our informed consent process for caesarean deliveries could be improved by the use of standardized information and templates included in the maternity case record, that incorporates the four elements essential for informed consent according to RCOG guidelines, namely, name of proposed procedure, intended benefits, significant, unavoidable and frequently occurring risks, and extra procedures which may become necessary during the procedure such as blood transfusions. 20 This may facilitate counselling of patients regarding the possibility of caesarean deliveries already initiated during antenatal visits when the environment is relaxed and avoids the stress associated with labour pains and a busy labour ward. This emphasizes the importance of ante-natal counselling of our patients in terms of their birth plans and the need for a possible cesarean delivery. 15 Audio-visual material containing pertinent information can similarly be used in the obstetric units waiting areas. 19 The strengths of this study included the large sample size that was distributed across three hospitals and the data collected by a single investigator. Limitations of the study included that the questionnaire was only available in English, and the lack of documentation with regards to what was actually discussed with the patient during the informed consent process, as this study used patient recall as reporting tool. Caesarean delivery is a common procedure in obstetrics and with the rise in litigation cases makes it an ideal subject in the study of informed consent. Litigation in obstetrics may be prevented through ensuring adequate communication with and consent of patients during treatment. 21 Informed consent provides evidence that a clear, concise and structured explanation was given prior to a procedure. 18 Obstetric patients are a unique patient population that pose multiple ethical and practical challenges to the healthcare provider. 15,18 The informed consent process epitomizes sharing of information and a partnership between physician and patient. The fact that the physician has made a proper disclosure to the patient and the patient understands the limitations, the less likely the patient will abandon the confidence and trust had in the physician and initiate legal proceedings 22 especially with the current growing rate of litigation due to an inadequate informed consent process. Conclusion Adequate communication is essential to all aspects of medicine. This study reports on the patients’ recall of inadequacy of the informed consent process prior to caesarean deliveries, especially regarding risks and complications. Thus, there is a need for improvement in the informed consent process. The introduction of a standardized informed consent document including all pertinent information in simple language should be considered. This will assist healthcare workers to start the conversation about the possibility of a caesarean delivery already in the antenatal period. References 1. Kumar NK. Informed consent: Past and present. Perspect Clin Res. (2013); 4(1): 21-25. doi:10.4103/2229-3485.106372 2. Main BG, Adair SRL. The changing face of informed consent. British Dental J. (2015); 19(7): 325-327. doi:10.1038/sj.bdj.2015.754\ 3. Beauchamp, Tom L, and James F. Childress. Principles of Biomedical Ethics. 7th ed. New York: Oxford University Press, 2009. 4. Ursin LO. Personal autonomy and informed consent. Med Health Care and Philos. (2009); 12: 17–24. doi: 10.1007/s11019-008-9144-0 5. American College of Obstetricians and Gynaecologists. Informed consent. Committee Opinion number 439. (2009). Obstet Gynaecol. 2009; 114 (2 Pt 1): 401-8: doi:10.1097/AOG.0b013e3181b48f7f. 6. Constitution of the Republic of South Africa [South Africa], 10 December 1996, available at: https://www.refworld.org/ docid/3ae6b5de4.html [accessed 20 March 2021] 7. Rao KH. Informed consent an ethical obligation or legal compulsion? J Cutan Aesthet Surg. (2008); 1(1): 33-35. doi:10.4103/0974-2077.41159 8. Government Gazette. National Health Act. Act No.61;Vol 469: Cape Town: (July 2004) Available from: www.gov.za/documents/national- health-act. April 2018. [Accessed on 29 November 2020] 9. Latika, Nanda S, Duhan N, Malik R. Study of adequacy of informed consent in caesarean section in a tertiary care, teaching and research institute of Northern India. Int J Reprod Contracept Obstet Gynaecol. (2015); 4(3): 780-784. doi:10.18203/2320-1770.ijrcog20150091 10. Ogunbunde O, Oketona O, Bella F. Informed consent for caesarean section at a Nigerian University teaching hospital: Patients’ perspective. Trop J Obstet Gynaecol. (2015); 32(1): 55-63. Corpus ID: 58913523 11. Kirane AG, Gaikwad NB, Bhingare PE, Mule VD. Informed Consent: An Audit of Informed Consent of cesarean section evaluating patient education and awareness. J Obstet Gynaecol India. (2015); 65(6): 382- 385. doi:10.1007/s13224-014-0651-z 12. Bako B, Umar NI, Garba N, Khan N. Informed consent practices and its implication for emergency obstetrics care in Azare, North-Eastern Nigeria. Ann Med Health Sci Res. (2011); 1(2): 149-157. PMID: 23209969; PMCID: PMC3507103. 13. Tripathy S, Shubhashree T, Kumari SR, Mohapatra S. Informed consent process before caesarean section: A study of patient’s perspective regarding adequacy of consent process. Indian J Obstet and Gynae Research. (2020); 7(2): 239-242. doi:10.18231/j.ijogr.2020.049 14. Glaser J, Nouri S, Fernandez A, et al. Interventions to improve patient comprehension in informed consent for medical and surgical procedures: An updated systematic review. Medical Decision Making. (2019); 40(2): 119-143. doi: 10.1177/027989X19896348 15. Treharne A, Beattie B. Consent in clinical practice. The Obstetrician & Gynaecologist. (2015); 17(4): 215-5. doi:10.1111/tog.12219 16. Neil O. Symposium on consent and con dentiality: Some limits of informed consent. J Med Ethics. (2003); 29(1): 4-7. doi:10.1136/jme.29.1.4 17. Nijhawan LP, Janodia MD, Musmade PB. Informed consent: Issues and challenges. Journal of advanced pharmaceutical technology and research. (2013); 4(3): 134-140. doi: 104103/2231-4040.116779 18. Barit A. Exploring the Adequacy of Obtaining Informed Consent for Caesarean Deliveries - A Patient Perspective. (Thesis). 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