Obstetric patients often have unrealistic expectations of the birth experience - a healthy baby, a healthy mother, a natural birth without intervention, complete control and active participation are the anticipated outcomes. Anything less than this may be perceived as a failure by them or the providers of their obstetric care. The patients' knowledge of the analgesic techniques available to them as obtained by ante-natal education varies greatly and may be influenced by educator bias, the womens' media and the patients' own cultural and personal characteristics.
A recent (1) study of patients receiving epidurals during labour showed that patients who attended antenatal epidural information classes had statistically significantly better recall of epidural risk information than those who did not attend, although overall recall of information was poor. The risks of the epidural had been outlined in a short, but detailed, discussion prior to insertion of the block. The authors recommended that:
1. women attend antenatal epidural information classes,
2. informed consent for epidural analgesia be obtained antenatally whenever possible, and
3. details of the informed consent explanation be recorded in the patients notes.
The legal requirements for informed consent vary greatly between and within countries. It would generally be agreed, however, that the notion of informed consent implies that it is a doctor's duty of care to disclose the material risks inherent in a procedure.
In Australian law (Rogers v Whitaker) a risk is defined as a material risk if
1. in the circumstances of the particular case, a reasonable person in the patient's position, if warned of the risk, is likely to attach significance to it, or
2. the medical practitioner is aware that the particular patient, if warned of the risk, is likely to attach significance to it.
It should be noted that the patient's signature on a consent form is not proof that the duty of disclosure has been fulfilled.
Information regarding epidurals can be provided in a number of ways during the antenatal period:
1. leaflets (2) in antenatal clinics and obstetricians' offices,
2. lectures at ante-natal classes, and
3. video presentations showing the practical aspects of the procedure.
The information should be available in a number of languages if required.
Staff who are capable of answering the pregnant woman's questions appropriately and discussing the side-effects and risks of regional techniques should become actively involved in this education process.
At the time of insertion of the block, the minimum information that should be recorded on the epidural record is:
1. the nature of any antenatal epidural information received - brochure / video / class;
2. whether specific risks were mentioned or discussed;
3. clear documentation of the procedure and any difficulties or complications.
(A tick-box system can facilitate this)
Ideally, a post-delivery visit should be made by a departmental member prior to the patient being discharged from hospital.
Suggestions for the content of a fact-sheet for epidural analgesia are outlined in Chapter 56.
References:
2. Pamphlet Planning Your Childbirth (Anesthesia & You series) American Society of Anesthesiologists