Vaginal deliveries - is there a need for documented consent?

Vaginal deliveries – is there a need for documented consent? To the Editor: We thank Anthony et al.1 for responding to our article,2 which was not meant to be prescriptive but to prompt thought, initiate discussion and exchange ideas about the issues raised. We feel we have been successful in raising interesting points that need to be considered. We do not intend responding to every point but highlight some essentials that were missed in their commentary. Our central tenet is that vaginal delivery is not without its risks, and these hazards may include concerns about intrapartum care and non-medical risks with potential for medical complications. As we perceive these risks as ‘material’, we argue that they warrant discussion with the patient and that it would be prudent to document the conversation. This view is not inconsistent with the law, the regulator or ethics. Obtaining informed consent for a vaginal delivery does not equate to us favouring caesarean section over vaginal delivery, and we do not recommend that people in training should be taught this. We feel that a weak justification is given as to why our legal arguments do not merit discussion. Medical practice is already regulated by laws that govern the conduct of business either directly or indirectly, The Medical Schemes Act (131 of 1998), Health Professions Act (56 of 1974) which has sections dealing with fees, and The National Health Act (61 of 2003), which also requires a health professional to disclose cost of treatment and management in Section 6 on informed consent. Private practitioners expect that reasonable fees will be paid to them by the patient for appropriate services rendered. This is legal and, where the fees are reasonable, not unethical. Doctors do not lose their professional ethical standards because of charges for services rendered. Public sector professionals are paid a global salary for services rendered. Business ethics exist alongside the doctor’s professional ethics and, should the ethical component of either be lost, it is common knowledge that the Health Professions Council can and does punish that person for unethical and unprofessional conduct. Our paper is not an attack on the public sector nor does it attempt to create an obligation on the State to provide resources for all women to deliver by caesarean section. If anything, the resulting discourse as pertaining to the State should focus on its obligation to provide an environment that allows for safe vaginal deliveries and well-informed patients. We agree with Anthony et al. that, where a choice exists, this does not mean that a choice can be made. However, we do not agree that, based on this argument, women should not be given all material information and neither do we agree that the ‘therapeutic privilege’ should be invoked to justify this approach which, in our opinion, dangerously borders on paternalism.