2025/07/21 by Anna Impiumi, R. Kearsley · 1 voice · 1 citation
Business, Management and Accounting · Social Sciences · #Corporate Law and Human Rights #International Labor and Employment Law #Labor Movements and Unions
paper · pdf · doi:10.1111/anae.16697
openalex publication_date 2025/07/21 · openalex created_date 2025/10/10 · openalex updated_date 2026/07/15
We read with interest the article by Nitzani et al. [1] exploring women's perceptions of the consent process for epidural analgesia during labour induction. We found the quotes from women particularly interesting as well as the thematic analysis capturing a critical challenge in modern obstetric care: the significant discrepancy between the legal and ethical requirements for informed consent and the practical realities of the labour ward. The themes of compromised understanding due to time constraints, the overwhelming impact of pain and fatigue and the lack of robust checks for patient comprehension are extremely important and challenging for obstetric anaesthetists. While the study concentrates mainly on the legal aspects of consent, we believe it is equally important to consider the ethical aspects. The implications of these findings raise questions about consent across the spectrum of intrapartum interventions as well as how best we can achieve this. Healthcare professionals have an ethical and legal duty to inform patients about procedures beforehand, so that they can exercise their right to autonomy, which is the primary basis for both healthcare ethics and law. Often on a busy labour ward, in the context of epidural analgesia, clinicians are caught between two competing needs: the ethical and legal duty to ensure a patient understands and consents voluntarily; and the clinical urgency to provide safe and effective care. To be able to exercise their authority and consent voluntarily, patients need to have capacity, which is the ability to understand, at the time that a decision is to be made, the nature and consequences of the decision to be made by them in the context of the available choices at that time and retain the information given [2]. There is no consensus on whether women in labour have capacity [3]. This aspect may compromise the legal aspect of consent at the time. However, the clinical urgency to provide safe and effective care can challenge our ethical and moral responsibility to relieve pain and do no harm. Clinicians aim to act in the patient's best interest. Providing pain relief or intervening to ensure a safe delivery is a clear manifestation of beneficence, with evidence showing the benefit of labour epidurals in reducing severe maternal morbidity [4]. However, if achieving this benefit compromises the patient's autonomous decision-making, it may be perceived negatively by the patient. The study also highlights how the physiological and psychological demands of labour can undermine a woman's ability to engage with the consent process for an epidural. This situation may also arise when consent is required for more urgent and invasive procedures. If a woman's capacity to process information about an epidural is diminished, her ability to provide robust informed consent for an instrumental delivery or an emergency caesarean section must be questioned. These procedures involve significantly higher risks and more serious long-term consequences than epidural placement, including major haemorrhage; infection; organ damage; and future obstetric complications. The consent process for these interventions often occurs under heightened stress. It may also be exacerbated by potential fetal distress, escalating pain and extreme time pressure. This highlights a critical vulnerability in safeguarding patient autonomy precisely when it is most crucial. Similar studies are required to explore women's perception of the consent process for these procedures. The General Medical Council guidance on decision-making and consent [2] states that information that might be relevant to the decision-making of a patient should be shared with them at a time when they are most likely to understand and retain the information, which in the case of information about analgesia in labour is probably not when spontaneous labour or induction of labour has already commenced. This study should serve as a catalyst for change, compelling us to move beyond simply acknowledging the problem. The solution potentially lies in fundamentally redesigning the timing and delivery of information. However, the optimal timing for consent for labour epidurals has yet to be determined. Is it feasible to see all women antenatally and consent them for a procedure they may or may not require? Should they have antenatal consent for emergency caesarean sections and discussions around general anaesthesia? Guidelines from the Association of Anaesthetists regarding consent in obstetrics state “every obstetric unit must provide, in early pregnancy, advice about pain relief and anaesthesia during labour and delivery” but do not specify obtaining consent antenatally [5]. We believe the core tenets of consent – namely risks, benefits and alternatives –should ideally be comprehensively discussed antenatally, well before the onset of labour. How best to do this in practice remains to be seen. Perhaps the answer is a combination of antenatal anaesthesia-led clinics, interactive decision aids, and standardised information leaflets provided early in the third trimester.