The capacity to consent to epidural analgesia in labour

Epidural analgesia and related ethical issues among pregnant women: Literature review

OBJECTIVE

This study aims to review the literature regarding epidural analgesia and related ethical issues among pregnant women.

METHOD

The authors were searched many electronic databases (CHINAL, Ovid Midline, Pub MED and Google Scholar, Science Direct Database, Biomed) under the following keywords (Informed consent, epidural analgesia, pregnant women, and antenatal period). The several quantitative studies published in English were reviewed and analyzed. The authors were analyzed the studies using a literature review matrix subheading to author, years published, type of study, variables, design and methodology, finding, conclusion, limitations for practices and limitations for studies.

RESULTS

The themes that emerged from the literature review were: difference between patient and provider in perceptions of informed consent toward EA during childbirth process; factors affecting the women choice of using EA during childbirth process and awareness regarding using of EA in childbirth among women in antenatal clinics.

CONCLUSION

The process of signing of informed consent for EA in women during childbirth is linked to many ethical responsibilities from women and healthcare providers. The informed consent practice can be enhanced by putting greater emphasis on antenatal information, providing suitable timing of information and developments in recent methods of information release and transfer.

How well do women understand and remember information in labour versus in late pregnancy? A pilot randomised study

Medical informed consent is the process by which a 'competent', non-coerced individual receives sufficient information including risks of a medical procedure and gives permission for it to occur. The capacity to give an informed consent might be impaired during labour. This study aimed to examine women's abilities to understand and remember during labour. Women were prospectively recruited at 36 weeks of gestation and randomised to undertake questionnaires which assessed their ability to understand and remember information. They were randomised to: (1) information given in labour only, written format (2) information in labour, verbal (3) information at 36 weeks plus labour, written (4) information at 36 weeks plus labour, verbal. Immediate comprehension and retention was assessed at 36 weeks, in labour, and 24-72 hours after birth. Forty-nine women completed the questionnaires regarding understanding and retention of information at 36 weeks, six intrapartum, and five postpartum (90% attrition). Women receiving information at 36 weeks and in labour versus in labour had a higher comprehension of pregnancy-related information, its retention, and total score. Women receiving information in late pregnancy and labour may comprehend and retain it better than women only receiving information during labour. Given small sample size, further research is needed to support these preliminary findings. Impact statement What is already known on this subject? The evidence regarding the capacity of labouring women to give informed consent is largely based on women's self-reported experiences or expert opinions and has mixed findings. Existing guidelines recommend that an informed consent should be given antenatally for both clinical practice and research. Studies show that obtaining an informed consent antenatally is neither feasible nor widely implemented. What do the results of this study add? A novel approach to providing empirical evidence regarding women's capacity to comprehend and retain information during labour. Our study confirms the difficulty with antenatal recruitment for intrapartum research. What are the implications of these findings for clinical practice and/further research? This raises ethical concerns regarding the current intrapartum research in which consent is largely sought at the time of the study. Emphasises the need to explore the question 'Do labouring women have the capacity to consent to research?' in order to ensure that women are protected during labour.

Waived Consent in Perinatal/Neonatal Research-When Is It Appropriate?

Informed consent is a process ensuring that subjects enrolled in research are appropriately informed of the risks and benefits. While this process is well-defined when it is possible and practical to obtain consent prior to the research intervention, it can be less clear in cases of deferred or waived consent. Defining minimal risk, such as when research is attempting to determine which of two currently practiced interventions is safest and/or most effective, is critical to moving forward in establishing appropriate care in newborns. For perinatal/neonatal research the challenge lies between the ethical justification for approaching women in labor or under medication vs. the scientific integrity of excluding a number of subjects that may potentially benefit the most from an intervention. Researchers must work with their IRBs as well as families who have participated in trials to determine the most appropriate method for obtaining informed consent from expectant parents. Clinical researchers and IRBs ultimately need to find a middle ground for the appropriate use of deferred or waived consent.

Epidural analgesia during labour - maternal understanding and experience - informed consent

Women obtain information on epidural analgesia from various sources. For epidural for pain relief in labour this is provided by the anaesthetist as part of the consenting process. There is much discussion about the inadequacy of this consenting process; we report on women's knowledge, experience and recall of this process at a regional hospital with a 24-h epidural service. Fifty-four women were interviewed within 72 h of a vaginal birth. 91% of the women had acquired information from friends, relatives and antenatal classes. Lack of recall of benefits of epidural analgesia accounted for 26 (38%) and 25 (26%) of the responses, respectively. Similarly in terms of amount of pain relief they could expect, 13 (21%) could not remember and 13 (21%) thought that it may not work. We suggest use of varying methods of disseminating information and wider utilisation of anaesthetists in the antenatal educational programmes.

Pregnant women's views on informed consent for research in labour

BACKGROUND

Studies of the optimal treatment of accidental dural puncture occurring during epidural insertion in labour are difficult for practical reasons and because of the ethical issues around seeking consent. In a recent study of accidental dural puncture, participants were assigned to one of two treatment groups and only informed about the study and consent sought, after treatment. We sought the views of parturients on the timing of consent for such a study.

METHODS

After ethical approval and written consent, 100 nulliparous women in the third trimester of pregnancy completed a structured, facilitated questionnaire, rating the acceptability of the consent process occurring: (i) in antenatal clinic; (ii) after the epidural was requested in labour; (iii) after the accidental dural puncture had occurred but before treatment; (iv) after the allocated treatment; or (v) without consent (waived consent). Results were analysed with the Friedman and Wilcoxon signed-rank tests.

RESULTS

Antenatal consent was considered the most acceptable option, whilst consent on request for epidural analgesia and after accidental dural puncture were least acceptable. Consent after treatment and waived consent were rated in-between these extremes. There was a statistically significant difference between these three groups (P<0.0001). There was a wide range of opinions on each option presented.

CONCLUSIONS

Antenatal consent was the preferred option but if this is not possible and the need for the research is strong, consent for the use of women's data after intervention, or waived consent, is acceptable to many women. It is important to seek the views of the participants themselves before planning research with difficult ethical aspects.