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Jose Henrique A, Rodney P, Hall W, Thorne S, Joolaee S. Women's autonomy for managing labour pain in a relational context: An interpretive description study. J Clin Nurs 2023; 32:7390-7401. [PMID: 37272285 DOI: 10.1111/jocn.16780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2022] [Revised: 05/08/2023] [Accepted: 05/22/2023] [Indexed: 06/06/2023]
Abstract
AIM To describe how women perceived relational autonomy for decision-making during childbirth pain and illuminate influencing factors. BACKGROUND Most women report challenging pain during birth. Circumstances can affect their ability to engage in pain management decisions. DESIGN We used an interpretative description approach to conduct this study. METHOD A purposive sample of ten women who reported pain during childbirth participated in semi-structured interviews. The study was conducted between July 2019 and November 2020 and reported according to the COREQ checklist. RESULTS Circumstances during childbirth, such as women's expectations and relationships, influenced their efforts to engage in relational autonomy. Care providers dealt with the unpredictability of childbirth and challenges with pain management using decision-making practices that could disrupt women's expectations, undermine women's trust, demonstrate disrespect for women and rely on inadequate communication. Women who felt dependent on others were less likely to participate in decision-making. When care providers' perceptions about pain differed from women's reports of pain, participants became distressed because care providers did not acknowledge their subjective pain experiences. CONCLUSIONS Women regarded their relationships and communication with care providers as foundational to relational autonomy in decision-making about pain management during childbirth. RELEVANCE TO CLINICAL PRACTICE Study findings can support care providers' considerations of the complexity of childbirth pain and factors affecting women's relational autonomy in decision-making about pain. In particular, the findings highlight the importance of women's expectations and care providers' recognition of women's experiences of pain. PATIENT OR PUBLIC CONTRIBUTION Women who shared their stories of childbirth pain contributed to the data collected. The chief nursing officers in the data collection setting facilitated the recruitment and data collection.
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Affiliation(s)
| | - Patricia Rodney
- University of British Columbia School of Nursing, Vancouver, British Columbia, Canada
| | - Wendy Hall
- University of British Columbia School of Nursing, Vancouver, British Columbia, Canada
- BC Children's Hospital Research Institute, Vancouver, British Columbia, Canada
| | - Sally Thorne
- University of British Columbia School of Nursing, Vancouver, British Columbia, Canada
| | - Soodabeh Joolaee
- Iran University of Medical Sciences, Tehran, Iran
- Research Ethics & Regulatory Specialist, Fraser Health Authority, Vancouver, British Columbia, Canada
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van der Pijl M, Verhoeven C, Hollander M, de Jonge A, Kingma E. The ethics of consent during labour and birth: episiotomies. JOURNAL OF MEDICAL ETHICS 2023; 49:611-617. [PMID: 36717252 PMCID: PMC10511989 DOI: 10.1136/jme-2022-108601] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 12/26/2022] [Indexed: 06/18/2023]
Abstract
Unconsented episiotomies and other procedures during labour are commonly reported by women in several countries, and often highlighted in birth activism. Yet, forced caesarean sections aside, the ethics of consent during labour has received little attention. Focusing on episiotomies, this paper addresses whether and how consent in labour should be obtained. We briefly review the rationale for informed consent, distinguishing its intrinsic and instrumental relevance for respecting autonomy. We also emphasise two non-explicit ways of giving consent: implied and opt-out consent. We then discuss challenges and opportunities for obtaining consent in labour and birth, given its unique position in medicine.We argue that consent for procedures in labour is always necessary, but this consent does not always have to be fully informed or explicit. We recommend an individualised approach where the antenatal period is used to exchange information and explore values and preferences with respect to the relevant procedures. Explicit consent should always be sought at the point of intervening, unless women antenatally insist otherwise. We caution against implied consent. However, if a woman does not give a conclusive response during labour and the stakes are high, care providers can move to clearly communicated opt-out consent. Our discussion is focused on episiotomies, but also provides a useful starting point for addressing the ethics of consent for other procedures during labour, as well as general time-critical medical procedures.
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Affiliation(s)
- Marit van der Pijl
- Amsterdam UMC location Vrije Universiteit Amsterdam, Midwifery Science, Amsterdam, The Netherlands
- Midwifery Academy Amsterdam Groningen, InHolland, Amsterdam, Netherlands, Amsterdam, The Netherlands
- Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands
- University of Groningen, University Medical Center Groningen, Department of General Practice & Elderly Care Medicine, Groningen, The Netherlands
| | - Corine Verhoeven
- Amsterdam UMC location Vrije Universiteit Amsterdam, Midwifery Science, Amsterdam, The Netherlands
- Midwifery Academy Amsterdam Groningen, InHolland, Amsterdam, Netherlands, Amsterdam, The Netherlands
- Amsterdam Public Health, Quality of Care, Amsterdam, The Netherlands
- University of Groningen, University Medical Center Groningen, Department of General Practice & Elderly Care Medicine, Groningen, The Netherlands
- Department of Obstetrics and Gynaecology, Maxima Medical Centre, Veldhoven, The Netherlands
- Division of Midwifery, School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Martine Hollander
- Amalia Children's Hospital, Department of Obstetrics, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Ank de Jonge
- Amsterdam UMC location Vrije Universiteit Amsterdam, Midwifery Science, Amsterdam, The Netherlands
- Midwifery Academy Amsterdam Groningen, InHolland, Amsterdam, Netherlands, Amsterdam, The Netherlands
- University of Groningen, University Medical Center Groningen, Department of General Practice & Elderly Care Medicine, Groningen, The Netherlands
- Amsterdam Reproduction & Development research institute, Amsterdam, The Netherlands
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Dias RA, de Faria Cardoso C, Ghimouz R, Nono DA, Silva JA, Acuna J, Baltatu OC, Campos LA. Quantitative cardiac autonomic outcomes of hydrotherapy in women during the first stage of labor. Front Med (Lausanne) 2023; 9:987636. [PMID: 36660001 PMCID: PMC9844258 DOI: 10.3389/fmed.2022.987636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/05/2022] [Indexed: 01/04/2023] Open
Abstract
Introduction Most hydrotherapy studies during childbirth report findings related to pain using a widespread set of subjective measures. In this study, ECG biomarkers as quantitative cardiac autonomic outcomes were used to assess the effects of warm shower hydrotherapy on laboring women during the first stage of labor. Methods This was a prospective single-blind cohort study on stage I delivering women. Their cardiac autonomic function was assessed using heart rate variability (HRV) measures during a deep breathing test using point-of-care testing comprised of an HRV scanner system with wireless ECG enabling real-time data analysis and visualization. Labor pain and anxiety were assessed using the Visual Analog Scale for Pain (VASP) and the Beck Anxiety Inventory (BAI). A total of 105 pregnant women in the first stage of labor who received warm shower hydrotherapy, intravenous analgesia (scopolamine + sodium dipyrone), or spinal anesthetic (bupivacaine + morphine) were enrolled. Results In women during the first stage of labor, parasympathetic modulation reflected through RMSSD (root mean square of successive RR interval differences) was significantly reduced by hydrotherapy and intravenous analgesia (before vs. after mean rank diff. 35.73 and 65.93, respectively, p < 0.05). Overall HRV (SDNN, standard deviation of RR intervals) was significantly decreased only by intravenous analgesia (before vs. after mean rank diff. 65.43, p < 0.001). Mean heart rate was significantly increased by intravenous analgesia, while spinal anesthesia reduced it, and hydrotherapy did not alter it (before vs. after mean rank diff. -49.35*, 70.38*, -24.20 NS , respectively, *p < 0.05, NS not significant). Conclusion This study demonstrates that warm shower therapy may impact the sympathovagal balance via parasympathetic withdrawal in women during the initial stage of labor. The findings of this study provide quantitative support for using warm shower hydrotherapy during labor via point-of-care testing. The dependability of hydrotherapy as a non-pharmacological treatment is linked to the completion of more clinical research demonstrating quantitative evidence via outcome biomarkers to support indications on stress and birth progress.
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Affiliation(s)
- Raquel Aparecida Dias
- Center of Innovation, Technology and Education (CITE) at Anhembi Morumbi University—Anima Institute, São José dos Campos Technology Park, São José dos Campos, Brazil
| | - Cláudia de Faria Cardoso
- Center of Innovation, Technology and Education (CITE) at Anhembi Morumbi University—Anima Institute, São José dos Campos Technology Park, São José dos Campos, Brazil
| | - Rym Ghimouz
- Fatima College of Health Sciences, Abu Dhabi, United Arab Emirates
| | - Daniel Alessander Nono
- Center for Special Technologies, National Institute for Space Research (INPE), São José dos Campos, Brazil
| | | | - Juan Acuna
- Department of Public Health and Epidemiology, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates
| | - Ovidiu Constantin Baltatu
- Center of Innovation, Technology and Education (CITE) at Anhembi Morumbi University—Anima Institute, São José dos Campos Technology Park, São José dos Campos, Brazil,Department of Public Health and Epidemiology, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates,*Correspondence: Ovidiu Constantin Baltatu,
| | - Luciana Aparecida Campos
- Center of Innovation, Technology and Education (CITE) at Anhembi Morumbi University—Anima Institute, São José dos Campos Technology Park, São José dos Campos, Brazil,Department of Public Health and Epidemiology, College of Medicine and Health Sciences, Khalifa University, Abu Dhabi, United Arab Emirates,Luciana Aparecida Campos,
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Deherder E, Delbaere I, Macedo A, Nieuwenhuijze MJ, Van Laere S, Beeckman K. Women's view on shared decision making and autonomy in childbirth: cohort study of Belgian women. BMC Pregnancy Childbirth 2022; 22:551. [PMID: 35804308 PMCID: PMC9264300 DOI: 10.1186/s12884-022-04890-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 06/29/2022] [Indexed: 11/10/2022] Open
Abstract
Background Health care providers have an important role to share evidence based information and empower patients to make informed choices. Previous studies indicate that shared decision making in pregnancy and childbirth may have an important impact on a woman’s birth experience. In Flemish social media, a large number of women expressed their concern about their birth experience, where they felt loss of control and limited possibilities to make their own choices. The aim of this study is to explore autonomy and shared decision making in the Flemish population. Methods This is a cross-sectional, non-interventional study to explore the birth experience of Flemish women. A self-assembled questionnaire was used to collect data, including the Pregnancy and Childbirth Questionnaire (PCQ), the Labor Agentry Scale (LAS), the Mothers Autonomy Decision Making Scale (MADM), the 9-item Shared Decision Making Questionnaire (SDM–Q9) and four questions on preparation for childbirth. Women who gave birth two to 12 months ago were recruited by means of social media in the Flemish area (Northern part of Belgium). Linear mixed-effect modelling with backwards variable selection was applied to examine relations with autonomy in decision making. Results In total, 1029 mothers participated in this study of which 617 filled out the survey completely. In general, mothers experienced moderate autonomy in decision-making, both with an obstetrician and with a midwife with an average on the MADM score of respectively 18.5 (± 7.2) and 29.4 (±10.4) out of 42. The linear mixed-effects model showed a relationship between autonomy in decision-making (MADM) for the type of healthcare provider (p < 0.001), the level of self-control during labour and birth (LAS) (p = 0.003), the level of perceived quality of care (PCQ) (p < 0.001), having epidural analgesia during childbirth (p = 0.026) and feeling to have received sufficient information about the normal course of childbirth (p < 0.001). Conclusions Childbearing women in Flanders experience moderate levels of autonomy in decision- making with their health care providers, where lower autonomy was observed for obstetricians compared to midwives. Future research should focus more on why differences occur between obstetrics and midwives in terms of autonomy and shared decision-making as perceived by the mother.
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Affiliation(s)
- Elke Deherder
- VIVES University of Applied Sciences, Doorniksesteenweg 145, 8500, Kortrijk, Belgium.
| | - Ilse Delbaere
- VIVES University of Applied Sciences, Doorniksesteenweg 145, 8500, Kortrijk, Belgium
| | - Adriana Macedo
- Student master management and policy of health care, department of Public Health and Nursing and Midwifery Unit, Vrije Universiteit Brussel, UZ Brussel, Brussels, Belgium
| | - Marianne J Nieuwenhuijze
- Research Centre for Midwifery Science Maastricht, Zuyd University / CAPHRI, Maastricht University, Universiteitssingel 60, 6229 ER, Maastricht, the Netherlands
| | - Sven Van Laere
- Vrije Universiteit Brussel, Interfaculty Center Data processing & Statistics, Laarbeeklaan, 103, Brussels, Belgium
| | - Katrien Beeckman
- Vrije Universiteit Brussel, Universitair ziekenhuis Brussel (UZ Brussel), Faculty of Medicine and Pharmacy, Public Health, Nursing and Midwifery Research Unit, Laarbeeklaan 101, 1090, Brussels, Belgium.,Verpleeg- en vroedkunde, Centre for Research and Innovation in Care, Midwifery Research Education and Policymaking (MIDREP), Universiteit Antwerpen, Antwerpen, Belgium
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Clinician-reported childbirth outcomes, patient-reported childbirth trauma, and risk for postpartum depression. Arch Womens Ment Health 2022; 25:985-993. [PMID: 36030417 PMCID: PMC9420181 DOI: 10.1007/s00737-022-01263-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 08/23/2022] [Indexed: 11/02/2022]
Abstract
Childbirth trauma is common and increases risk for postpartum depression (PPD). However, we lack brief measures to reliably identify individuals who experience childbirth trauma and who may be at greater prospective risk for PPD. To address this gap, we used data from a racially diverse prospective cohort (n=1082). We collected survey data during pregnancy and at 12 weeks postpartum, as well as clinician-reported data from medical records. A new three-item measure of patient-reported childbirth trauma was a robust and independent risk factor for PPD, above and beyond other known risk factors for PPD, including prenatal anxiety and depression. Cesarean birth, greater blood loss, and preterm birth were each associated with greater patient-reported childbirth trauma. Finally, there were prospective indirect pathways whereby cesarean birth and higher blood loss were related to higher patient-reported childbirth trauma, in turn predicting greater risk for PPD. Early universal postpartum screening for childbirth trauma, targeted attention to individuals with childbirth complications, and continued screening for depression and anxiety can identify individuals at risk for PPD. Such efforts can inform targeted interventions to improve maternal mental health, which plays a vital role in infant development.
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Ely S, Langer S, Dietz HP. Informed consent and birth preparedness/complication readiness: A qualitative study at two tertiary maternity units. Aust N Z J Obstet Gynaecol 2021; 62:47-54. [PMID: 34455584 DOI: 10.1111/ajo.13417] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/09/2021] [Accepted: 07/24/2021] [Indexed: 01/13/2023]
Abstract
BACKGROUND Informed consent in obstetrics should involve full disclosure of risks, benefits and alternative interventions. However, we have found no evidence of a formal informed consent process before an attempt at vaginal delivery in published policy or practice. The idea of informed consent in vaginal birth has attracted controversy and has been the subject of some debate. AIM To explore the perspectives and experiences of informed consent and birth preparedness/complication readiness for birthing women in a high resource setting. MATERIALS AND METHODS Qualitative study using semi-structured interviews to examine experiences and perspectives of women following birth. RESULTS Forty telephone interviews were concluded. Eight statement categories were identified: (i) no issues of consent, (ii) absent/inadequate informed consent, (iii) adequate birth preparedness/complication readiness, (iv) inadequate birth preparedness/complication readiness, (v) desire to forfeit decision making to a trusted and accountable health professional, (vi) belief that informed consent is not realistic in birth under some circumstances, (vii) negative feelings related to birth and (viii) poor postnatal follow-up. CONCLUSIONS When complications arose during birth, 20% of participants felt that informed consent was absent/inadequate, 25% of participants suggested policy change in favour of a formal informed consent process and 55% of participants suggested policy change in favour of increased birth preparedness/complication readiness. Our study suggests that informed consent for vaginal birth and formal birth preparedness/complication readiness should form part of routine antenatal care. Women's preferences for decision-making and informed consent should be established before birth.
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Affiliation(s)
- Sally Ely
- Sydney Medical School Nepean, The University of Sydney, Penrith, New South Wales, Australia
| | - Susanne Langer
- Sydney Medical School Nepean, The University of Sydney, Penrith, New South Wales, Australia
| | - Hans Peter Dietz
- Sydney Medical School Nepean, The University of Sydney, Penrith, New South Wales, Australia
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Bakker W, Zethof S, Nansongole F, Kilowe K, van Roosmalen J, van den Akker T. Health workers' perspectives on informed consent for caesarean section in Southern Malawi. BMC Med Ethics 2021; 22:33. [PMID: 33781273 PMCID: PMC8008515 DOI: 10.1186/s12910-021-00584-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 02/14/2021] [Indexed: 11/24/2022] Open
Abstract
Objective Informed consent is a prerequisite for caesarean section, the commonest surgical procedure in low- and middle-income settings, but not always acquired to an appropriate extent. Exploring perceptions of health care workers may aid in improving clinical practice around informed consent. We aim to explore health workers’ beliefs and experiences related to principles and practice of informed consent. Methods Qualitative study conducted between January and June 2018 in a rural 150-bed mission hospital in Southern Malawi. Clinical observations, semi-structured interviews and a focus group discussion were used to collect data. Participants were 22 clincal officers, nurse-midwives and midwifery students involved in maternity care. Data were analysed to identify themes and construct an analytical framework. Results Definition and purpose of informed consent revolved around providing information, respecting women’s autonomy and achieving legal protection. Due to fear of blame and litigation, health workers preferred written consent. Written consent requires active participation by the consenting individual and was perceived to transfer liability to that person. A woman’s refusal to provide written informed consent may pose a dilemma for the health worker between doing good and respecting autonomy. To prevent such refusal, health workers said to only partially disclose surgical risks in order to minimize women's anxiety. Commonly perceived barriers to obtain a fully informed consent were labour pains, language barriers, women’s lack of education and their dependency on others to make decisions. Conclusions Health workers are familiar with the principles around informed consent and aware of its advantages, but fear of blame and litigation, partial disclosure of risks and barriers to communication hamper the process of obtaining informed consent. Findings can be used to develop interventions to improve the informed consent process. Supplementary Information The online version contains supplementary material available at 10.1186/s12910-021-00584-9.
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Affiliation(s)
- Wouter Bakker
- St. Luke's Hospital, Malosa, Malawi. .,Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands. .,Faculty of Science, Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands.
| | - Siem Zethof
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands
| | | | | | - Jos van Roosmalen
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands.,Faculty of Science, Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands
| | - Thomas van den Akker
- Department of Obstetrics and Gynaecology, Leiden University Medical Centre, Leiden, The Netherlands.,Faculty of Science, Athena Institute, VU University Amsterdam, Amsterdam, The Netherlands
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Wilson EH, Burkle CM. The Meaning of Consent and Its Implications for Anesthesiologists. Adv Anesth 2020; 38:1-22. [PMID: 34106829 DOI: 10.1016/j.aan.2020.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Elizabeth H Wilson
- Department of Anesthesiology, University of Wisconsin School of Medicine and Public Health, B6/319 CSC, 600 Highland Avenue, Madison, WI 53792-3272, USA
| | - Christopher M Burkle
- Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, 200 First Street Southwest, Rochester, MN 55905, USA.
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Abstract
An extensive review of new resources to support the provision of evidence-based care for women and infants. The current column includes a discussion of a new National Academy of Medicine report on planned place of birth and implications during the SARS-CoV-2 pandemic and commentaries on reviews focused on anorectal sexually transmitted infections and feeding methods following cleft lip repair in infants.
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