When I started training, the kindly but authoritarian clinician ruled; however, the growth of patient autonomy was demonstrated in the UK in 2015 by the ruling from the Supreme Court in the case of Nadine Montgomery (summarised by Bolton BJOG 2015;122:1273) that women were entitled to choose caesarean section. The American College of Obstetricians and Gynecologists has published specific guidance regarding women who request a surgical option that is not ‘traditionally’ recommended (e.g. caesarean section at maternal request; ACOG committee opinion 578, November 2013). The situation is even more complicated when a woman declines a surgical procedure that the obstetrician thinks is medically appropriate, e.g. choosing vaginal birth after caesarean (VBAC). A mentally competent woman's right to refuse caesarean section, even at the risk of her own or her baby's life, is well established [e.g. in the case of St George's Healthcare NHS Trust v S; R v Collins and others, ex parte S (1998) 3 All ER 673, the judgement stated specifically that ‘A competent pregnant woman can refuse treatment even if that refusal may result in harm to her or her unborn child’]. This is true even when a woman's refusal might seem particularly risky, for example if she has had a previous classical caesarean section, multiple previous sections, or a uterine caesarean section scar rupture in a previous pregnancy. In such cases, counselling must be especially thorough, because in cases of adverse outcome, the temptation (and financial pressure) for the woman and her family to claim compensation is very high, even if the outcome is related to her refusal to accept medical advice. Proving that the woman was fully aware of the risks of her choice of VBAC is essential if the practitioner is to avoid being held responsible. I suggest that such proof should include not only full documentation of detailed discussions with the woman, but also evidence that written advice was given for the woman to study at leisure, preferably with her partner/family. I advise including witnesses in such discussions, preferably including the partner/family (if the woman agrees, which she is entitled not to), but importantly also another experienced obstetrician (a condition that cannot be refused). The identity and involvement of the witnesses should be recorded in detail, ideally by recording the discussions verbatim using audiovisual technology (one such device, the ‘virtual chaperone’, has been developed and patented by Lord Ara Darzi of Imperial College London: http://www.digitalhealth.net/news/20974/virtual-chaperone-keeps-watch-on-clinicians). A plan of care must be fully documented with the woman and communicated to all potential care givers: the fact that her decision was against medical advice is no defence if any adverse outcomes can be attributed to a substandard response to an emergency. A documented discussion of the plan with the multidisciplinary team (involving obstetricians, midwives, neonatologists, and other relevant professionals, e.g. social workers) is also advisable (Obstetric standards for the provision of perinatal care, http://www.bapm.org/publications/). 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.