Conflicts Between Physicians and Patients in Non-Elective Cesarean Delivery: Incidence and the Adequacy of Informed Consent

Abstract

A study was undertaken in 372 consecutive patients undergoing non-elective cesarean delivery to explore the incidence and nature of conflicts between physician and patient surrounding the decision to undergo non-elective cesarean delivery; to examine the adequacy of informed consent at the time of non-elective cesarean delivery; and to describe the importance of a preventive ethics approach to non-elective cesarean delivery. During a 6-month interval, all patients who underwent non-elective cesarean delivery and their physicians were asked to take part in a survey in the early postpartum period concerning their response to recommendations for cesarean delivery. The survey included demographics as well as questions pertaining to informed consent and the presence and nature of patient-physician conflict. Of the 326 patients who were interviewed, 319 (98%) agreed to the recommendation for non-elective cesarean delivery and 7 patients (2%) initially disagreed. Reasons for disagreeing included: feared surgery (4 of 7), needed husband's approval (1 of 7), and questioned the medical necessity of surgery (2 of 7). In all 7 cases of initial disagreement, cesarean delivery was eventually performed with the patient's consent. The mean age of patients who initially disagreed was younger (24.7 +/- 6) than that of those who agreed (31.0 +/- 4 [p < 0.05]). Conflicts were present in 7 of 113 clinic patients and 0 of 213 private patients (p < 0.05). Of those surveyed, 26 (8.7%) indicated that they did not have adequate input in the decision for non-elective cesarean delivery. Patients with inadequate input expressed significantly more concerns with regard to the effect of surgery on their own health (p < 0.05) as well as its effect on the baby (p < 0.05). Our findings suggest that even though the incidence of physician-patient conflict about non-elective cesarean delivery was quite low, a significant number of patients (1 in 12) may have reservations concerning the informed consent process at the time of non-elective cesarean delivery. Patients with reservations are more likely to have greater concerns with regard to maternal and fetal risks, suggesting that a more detailed risk disclosure prior to the procedure is warranted for all pregnant patients. Perhaps by incorporating the preventive strategies discussed, the adequacy of informed consent and therefore the patient's autonomy could be enhanced, thus diminishing patient reservations and preventing physician-patient conflict in the intrapartum period.

Involvement of Women with the Decision of Caesarean Section and their Degree of Satisfaction for Post-operative Care and Pain Management

“…A number of studies have identified poor communication as a significant negative predictor of maternal satisfaction, [24,25] but none of them assessed to what extent it influenced satisfaction. Poor communication resulted in patientdoctor conflict in 8.3% of cases in one study, resulting in failure to give informed consent for delivery [26].…”

Non-pregnant patients? preference for delivery route

“…The issue of informed consent for cesarean section has been addressed by several authors [7,38,44,45,46]. Most women interviewed after a non-emergency cesarean were satisfied with their surgery, felt that adequate prenatal and preoperative information was given, and understood the indication for their cesarean section [11,14,17,44].…”

“…Most women interviewed after a non-emergency cesarean were satisfied with their surgery, felt that adequate prenatal and preoperative information was given, and understood the indication for their cesarean section [11,14,17,44]. Patients were less likely to report informed consent when an emergency cesarean was necessary [14].…”

Fetal therapy: practical ethical considerations

“…To our knowledge there is not any law passed to force a pregnant woman to undergo invasive fetal treatment outside mainly historical legal orders of performing cesarean section for fetal distress (Lescale et al, 1996). Furthermore, as previously mentioned, embarking on fetal invasive therapy or surgery is a long-term commitment encompassing perinatal care, postnatal treatment and long-term follow-up, including medical and societal aspects, which cannot be successful without the full and active cooperation of the pregnant woman to begin with.…”