Several studies of the patient’s perspective of informed consent during labor show that the pain of labor does not appear to interfere with the patient’s ability to hear and comprehend the information relevant to consent.⁴ Furthermore, a woman’s ability to understand epidural risks does not correlate with level of labor pain, anxiety, duration of pain, opioid medication, previous epidural experience or the desire for an epidural.⁵ In fact, the ability to recall the risks has been found to be similar in both laboring and nonlaboring, nonobstetric patients.⁶ Ideally, written or visual information about labor analgesia should be provided or at least available during prenatal visits to the obstetrician’s office in the antenatal period or during early labor allowing time for consideration of the available options and any questions.

Is Sarah’s consent impeded by the fentanyl she has received? In general the answer is poorly addressed in the literature. There are no US legal precedents regarding this issue and most institutions have inconsistent policies. Anesthesiologists can and do routinely make judgments about a patient’s capacity for informed consent based on the elements described above. There is normally no need to contact a psychiatrist or obtain legal advice. Sarah must have the mental capacity to comprehend and participate in the consent process and analgesia may allow her to do this. Withholding appropriate analgesia, particularly if there is a delay in the anesthesiologist obtaining consent, may in itself put the anesthesiologist in an unsupportable ethical position.

However, autonomous decision-making brings with it the privilege for a woman to change her mind, especially if she has never experienced the pain of childbirth before. One might argue that Sarah’s directive be considered invalid because it was made at a time when the she was not fully informed. Antenatally, she may have been determined not to have an epidural. However, she may not have received appropriate information regarding the risks and benefits of epidurals, nor had she experienced labor pain previously. Information and valid experience are critical prerequisites for autonomous decision-making. While Scott considers it unethical “to withhold pain relief from a greatly distressed woman … solely because of a statement written in her birth plan..”, Thornton and Moore have argued that this “… does not respect her long-term preferences”, and hence her autonomy.”⁷ Other authors have even postulated that the duty of beneficence (in this case to relieve pain) may allow an intervention to proceed in the absence of informed consent until evidence of patient refusal is forthcoming.⁸ In this instance there is no unequivocal ethical ground upon which to stand and it has been suggested that the anesthesiologist be guided by the circumstances.⁹

Sarah is a primiparous woman at 4 cm cervical dilatation and is likely to be in labor for many more hours. Placing an epidural for analgesia is certainly an ethically defensible decision in this case. Interestingly, frequently it is the legal ramifications rather than the ethical debate that cause anesthesiologists the most concern. As a woman with capacity, Sarah can legally overrule her birth plan at any point. However, there is a risk after delivery, when the pain is long gone, that Sarah might feel she somehow “failed” during the birthing process by agreeing to have an epidural and see the anesthesiologist as an accomplice in this failure. This could result in an accusation of assault, or unconsented touching of the patient.

The anesthesiologist should be encouraged to see the patient and her family postpartum. At that time the anesthesiologist can discuss the events and reassure the patient that her decision was the correct one for the circumstances in which she found herself. It may help to inform the patient that relief of pain and stress during labor has benefits for the fetus and the course of labor. It is also wise to document the decision-making process that occurred. An example chart note might read:

After an appropriate consent process, the patient has decided to withdraw her previous refusal of epidural analgesia for labor. I will proceed based on her currently stated request for epidural analgesia.