Definitions

Informed Consent-

Permission granted in the knowledge of the possible consequences, typically that which is given by a patient to a doctor for treatment with full knowledge of the possible risks and benefits. (Webster)

Informed consent includes freedom from external coercion, manipulation, or infringement of bodily integrity. It is freedom from being acted on by others when they have not taken account of and respected the individual’s own preference and choice. (ACOG)

 

Examples of Breached Consent, or a Failure to provide Informed Consent-

  • Failing to inform of drug tests being completed upon intake
  • Performing a vaginal or cervical exam without informing and/or obtaining consent
  • Administering a medication without informing and/or obtaining consent
  • Breaking your water without informing and/or obtaining consent
  • Conducting a membrane sweep without informing and/or obtaining consent
  • Manually removing placenta, especially within 30 minutes after birth, without informing and/or obtaining consent.  This may also be referred to as an “assisted delivery” of the placenta, or a “managed third stage.”
  • Forced Cesareans- see below link for definitions and for a form asking doctors to sign that they are forcing a cesarean without consent: http://www.birthinginstincts.com/blog/consent-for-a-forced-cesarean-section
  • Forced Episiotomies without informing and/or obtaining consent
  • Labor inductions without informing patient of potential risks and complications
  • Unconsenting medical procedures such as vacuum assisted or forceps delivery
  • “Husband stitch”: “some doctors perform an unnecessary extra stitch–referred to as a “husband stitch”–on the assumption that doing so will tighten the woman’s vagina and create more sexual pleasure for her male partner.” (KUKURA, E. (2018). Obstetric Violence. Georgetown Law Journal, 106(3), 721-801.)

 

Coercion-  “Forced compliance—the alternative to respecting a patient’s refusal of treatment—raises profoundly important issues about patient rights, respect for autonomy, violations of bodily integrity, power differentials, and gender equality.”

The use of coercion is not only ethically impermissible but also medically inadvisable because of the realities of prognostic uncertainty and the limitations of medical knowledge. As such, it is never acceptable for obstetrician–gynecologists to attempt to influence patients toward a clinical decision using coercion. Obstetrician–gynecologists are discouraged in the strongest possible terms from the use of duress, manipulation, coercion, physical force, or threats, including threats to involve the courts or child protective services, to motivate women toward a specific clinical decision.

https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Ethics/Refusal-of-Medically-Recommended-Treatment-During-Pregnancy

Examples of Coercion:

  • (a) seeking judicial intervention; (b) instituting blanket policies restricting access to particular forms of care; (c) threatening involvement of child welfare authorities; or (d) withholding treatment, manipulating information, or applying emotional pressure. (KUKURA, E. (2018). Obstetric Violence. Georgetown Law Journal, 106(3), 721-801.)
  • Coercion by VBAC Restrictions. Restrictions on access to VBAC are perhaps the most widespread form of coercion in the American maternity care system. (KUKURA, E. (2018). Obstetric Violence. Georgetown Law Journal, 106(3), 721-801.)
  • Coercion by Withholding Treatment, Manipulating Information, or Applying Emotional Pressure. A final category of coercive conduct used to secure a woman’s consent involves controlling the situation by withholding treatment, manipulating information, or applying emotional pressure. Some women report consenting to treatment under duress, such as being threatened with lack of treatment, abandonment by the doctor, or the choice between two unwanted treatments. (KUKURA, E. (2018). Obstetric Violence. Georgetown Law Journal, 106(3), 721-801.)

Obstetric Violence- “…[obstetric violence is] the appropriation of the body and reproductive processes of women by health personnel, which is expressed as dehumanized treatment, an abuse of medication, and to convert the natural processes into pathological ones, bringing with it loss of autonomy and the ability to decide freely about their bodies and sexuality, negatively impacting the quality of life of women.” (https://journals.lww.com/jbisrir/Fulltext/2017/03000/Experiences_and_impact_of_mistreatment_and.6.aspx)

 

Birth Trauma & PTSD-

Trauma can be defined as: a psychological, emotional response to an event or an experience that is deeply distressing or disturbing. (American Psychological Association)

Some of the factors that cause an event to be internalized as a trauma is when a person feels alone or isolated, powerless, exceptionally vulnerable, or without hope. For each person this is very different, and therefore we cannot look at or hear one woman’s experience and label it as a trauma for her.  She must identify it as traumatic for herself.

“Forced procedures are often described as birth rape or with equally strong language. Even without physical or economic consequences, when a woman is denied her choice of childbirth procedure––either because the physician did not properly inform her, did not give her any choice, or had a court bypass her refusal––she is denied agency to make a decision. The trauma of being denied this choice generates psychological trauma, and even posttraumatic stress disorder (PTSD). (BORGES, M. R. (2018). A VIOLENT BIRTH: REFRAMING COERCED PROCEDURES DURING CHILDBIRTH AS OBSTETRIC VIOLENCE. Duke Law Journal, 67(4), 827-862.)

  1. 2% women had symptoms of PTSD following childbirth based on the PTSD Symptom Scale. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3745743/  

 

Abuse: “The most extreme forms of mistreatment women experience while giving birth rise to the level of abuse by medical staff. Abuse in this context includes: (a) forced surgery; (b) unconsented medical procedures; (c) sexual violation; (d) physical restraint; and (e) other forms of abuse.” (KUKURA, E. (2018). Obstetric Violence. Georgetown Law Journal, 106(3), 721-801.)

  • Unconsented Medical Procedures. In addition to forced surgery, medical abuse during childbirth may take the form of other unconsented medical procedures, including labor induction, membrane stripping or breaking, vacuum-assisted or forceps-assisted delivery, or manual removal of the placenta.(KUKURA, E. (2018). Obstetric Violence. Georgetown Law Journal, 106(3), 721-801.)
  • Sexual Violation. Some women experience unwanted touching during childbirth that amounts to sexual violation. Although regular vaginal exams are not necessary during childbirth, women may be subjected to frequent vaginal penetration during labor, sometimes without their consent or knowledge, by nurses or doctors when checking the dilation, effacement, and position of the cervix. Some women describe their birth experiences and the emotional aftermath as rape. (KUKURA, E. (2018). Obstetric Violence. Georgetown Law Journal, 106(3), 721-801.)
  • Physical Restraint. When permitted to move around freely, women may deliver their babies in a number of different positions, including squatting or lying on their sides, which often feels more comfortable based on their pelvis and the baby’s position. However, some women report being forced onto their backs in the final stages of pushing and being forcibly restrained in a supine position. (KUKURA, E. (2018). Obstetric Violence. Georgetown Law Journal, 106(3), 721-801.)
  • Other Abusive Conduct. Several other types of conduct by health care providers may constitute abuse of a woman in childbirth, including the denial of pain relief and verbal attacks. Some women find themselves punished by a hostile care provider who delays the administration of pain medication or foregoes pain relief altogether. This may occur during a forceps-assisted birth or during the repair of an episiotomy or natural perineal tearing. Other women are subjected to verbal abuse by their physicians or nurses if they decline an induction or cesarean, or question why a particular intervention is necessary. For example, a Texas woman who declined induction in favor of spontaneous onset of labor found her doctor began “yelling at the top of his lungs about what a horribly selfish and dangerous parent [she] was.” Women are subjected to degrading put-downs about their qualities as mothers or their ability to withstand pain, and are made to feel like animals, like failures, or like they are worthless. (KUKURA, E. (2018). Obstetric Violence. Georgetown Law Journal, 106(3), 721-801.)