Informed Consent for Epidural Analgesia at the Time of Labor Pain, Seems Too Late!

Letter to Editor

Pain in the process of childbirth is the phenomenon mostly feared by every woman in her pregnancy, and is a major cause of dissatisfaction and embarrassing memories of labor. Usage of lumbar epidural analgesia as a very effective pain management option has solved this problem to a great extent, and its utilization has turned to common practice in most of the women hospitals worldwide. The use of lumbar epidural analgesia in labor is widespread due to its benefits in terms of effective pain relief in comparison with other labor pain treatment options [1].

Vaginal delivery is an extremely painful process accompanied with great emotional disturbance, which may not be possible for the laboring mother to focus and concentrate to understand the anesthetist explanations at that moment and sign the epidural analgesia informed consent properly. On one hand, the laboring mother expresses doubts because of uncertainty on her decision and on the other hand she desperately wants to get rid of the excruciating labor pain by any means possible. Therefore, the decision to have a neuraxial analgesia (epidural, combined spinal epidural) sounds obligatory on this condition. Each of these analgesic methods beside desirable effectiveness in pain management may have some side effects and it is obvious that each complication takes lots of time and patiently concentration for the mother to be precisely understood and the decision making is even beyond of it. Decision making process cannot get precisely completed just in labor time, so free of any upcoming complication, informed consent may not be ethically verified on labor time.

Decision making capacity is a complex mental process involving both cognitive and emotional components. Sometimes this complex action is reduced to “understanding” alone. There are uncertainties about decision-making capacity (mental competence) of women in labor in relation to giving informed consent to neuraxial analgesia. Considering these parameters, sufficient information about pain management methods (advantages, side effects, the way each procedure is conducted) should be provided as part of prenatal education and the consent process must be carefully conducted to enhance mothers’ autonomy [2]. To utilize effective methods for presenting the mothers with (like multimedia modules, recorded video of the sample procedure and so on) in late pregnancy should be considered to achieve better understanding and right decision.

Patient decision aids are beneficial in clinical anesthesia and studies have shown that patients feel better informed, have better knowledge, and have less anxiety, depression and decisional conflicts after using this method [3]. It has been demonstrated that using decision aids prior to the procedure can significantly reduce the decision conflict, and improve both autonomy and outcome as a united benefit in favor of laboring mothers [4].

It seems that pain-relieving methods (neuraxial and other treatment options) should be described in details at the second and third trimester of pregnancy by a team consist of midwife, anesthesia provider and obstetrician. The more time is spent on this process; the better informed consent is achieved finally. Also high quality decision aids can increase women’s familiarity with medical terminology, options for care, and an insight into personal values, thereby decreasing decisional conflicts and increase knowledge [5]. Factors like parity, pain threshold, and estimated length of labor should be considered together in the decision process to individualize the best pain treatment option for mother [6].

Keywords: Childbirth; Epidural analgesia; Labor pain; Informed consent.

References

1. Supriyatiningshi Permana I, Budi Y, Esha p. Lumbar epidural analgesia: shortening time of active phase at first and second stage of labor. Advances in Health Sciences Research. 2021; 33.
2. Wada K, Charland LC, Bellingham G. Can women in labor give informed consent to epidural analgesia? Bioethics. 2019; 33: 475-486.
3. Southerland Warren A, Beight Leah J, Shapiro Fred E, et al. Decision aids in anesthesia: do they help? Current opinion in Anesthesiology. 2020; 33: 185-191.
4. Shishido E, Osaka W, Henna A, Motomura Y, Horiuchi S. Effect of a decision aid on the choice of pregnant women whether to have epidural anesthesia or not during labor. Plos One. 2020; 15: 1-13.
5. Kennedy K, Adelson P, Fleet J, Steen M, Mckellar L, Eckert M, et al. Shared decision aids in pregnancy: A scoping review. 2020; 81.
6. Borrelli S, Evans K, Pallotti P, Evans C, Eldridge J, Spiby H. Mixed-methods Systematic review: Childbearing women’s views, experiences, and decision making related to epidural analgesia in labor. 2020.