Written consent should not be obtained at the time of emergency caesarean section: AGAINST: Written consent should be obtained.

Abstract

Documented consent of a pregnant patient or her surrogate to emergency caesarean delivery should always be obtained, to document the patient's authorisation of recommended clinical management. The patient's medical record should document the informed consent process and state that the patient has authorised recommended clinical management. In medical emergencies documentation may be postponed until after the procedure. The professional responsibility model of obstetrics and gynaecology guides the informed consent process (Chervenak et al. Am J Obstet Gynecol 2011;205:315.e1–5; Chervenak et al. The Professional Responsibility Model of Perinatal Ethics. Walter de Gruyter 2014). There is a beneficence-based ethical obligation to make evidence-based recommendations about clinical management of the patient's condition. There is an autonomy-based ethical obligation to provide information to the pregnant woman that any patient in her clinical circumstances needs, in order to make an informed decision. The information needed is simple: a description of why caesarean delivery has become the only safe form of delivery; the clinical benefits and risks to maternal, fetal, and neonatal patients of caesarean delivery; and the plan for anaesthesia. Her questions should be expeditiously addressed. Preparation of the patient for caesarean delivery should commence immediately after she signs the consent form. Preparation of the operating room should have been ordered by her obstetrician as soon as caesarean delivery was indicated. The informed consent process for emergency caesarean delivery, given its simplicity, can be completed without delaying the procedure. The phrase ‘medical emergency’ has a precise meaning: the patient's life or health is in imminent danger and clinical management must therefore be implemented immediately, to prevent this danger from running its natural course. In a medical emergency, there is no time for the informed consent process. The use of ‘emergency’ in ‘obstetric emergency’ differs and means that preparation of the operating room and assembling the operative team should commence as soon as the obstetric emergency is declared. As explained above, expeditiously completing the informed consent process does not interfere with achieving these goals. The phrase ‘obstetric emergency’ is therefore potentially misleading for the unwary obstetrician who may, mistakenly, assume that there is no time for the informed consent process for emergency caesarean delivery. Caesarean delivery is a possibility in all pregnancies. Pregnant patients should be prepared for this possibility well in advance of the intrapartum period, by her obstetrician deploying the clinical strategy of preventive ethics (Chervenak et al. Am J Obstet Gynecol 2013;209:166–7): the informed consent process described above. She should be asked to authorise caesarean delivery in advance should the obstetrician deem it the only safe form of delivery at the time. The patient should also be informed that the obstetrician will be making a recommendation that caesarean delivery be initiated and reminding the patient that she has previously agreed to accept these recommendations. This preventive ethics discussion should be documented in the patient's medical record. In some obstetric emergencies, the patient may lose her capacity to engage in the informed consent process. Informed consent should be obtained from the legally designated surrogate decision maker. If this person is not available, hospital policy should authorise performance of caesarean based on the obstetrician's evidence-based recommendation. None declared. Completed disclosure of interests form available to view online as supporting information. Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.