Informed consent is “both an ethical obligation and a legal requirement spelled out in statutes and case law in all 50 states,” notes the American Medical Association. Along with the diagnosis, physicians are to detail the therapeutic route under consideration and alternatives—what these are, why they are used, the risks and benefits of each option. The risks and benefits of forgoing treatment should also be discussed. Patients then need a chance to ask questions. But how long do patients have to contemplate what they’ve been told, especially in emergent situations? Journal Club members discussed a new study that explored this question.

Researchers Salmeen and Brincat examined the informed consent process among laboring women who had an unscheduled cesarean section. Discussants agreed that this was a timely and important issue in medicine; especially in obstetrics, where obtaining consent is an everyday issue. The main aim of the study was to determine the amount of time that passed between consent to surgery and incision. In addition, the investigators looked at whether certain factors put women at higher risk for particularly short consent times. In explaining their work, they state that “although the practice of obtaining informed consent for cesarean delivery during labor is common, the process has not previously been described in the literature.”

In this retrospective observational cohort investigation, 63% of the women in the study population were white, and the average age was 29 years. Notably, 52% had a body mass index that characterized them as obese; 31% were overweight. Most were nulliparous and on average, the women were carrying a full-term pregnancy. The study site was an academic center with a moderate volume of 4000 deliveries per year. Subjects were drawn from the medical records of all cesarean deliveries performed in 2004. After excluding all scheduled cesarean deliveries, the authors then chose the first 100 cesarean deliveries performed for urgent indications. Nine were then excluded for missing or incomplete medical records. Another patient was excluded because she consented to cesarean delivery during a prenatal admission that took place prior to the start of labor.

To obtain the time data most critical to the study question, the authors preferred to use the time documented on the consent forms. When the time was not provided on the consent form, the authors took the time associated with documentation of consent from nursing or physician labor notes, flow sheets, and operating room records.

The main finding was that, in the authors’ opinion, time for informed consent was suboptimal. Overall, the median time from consent to surgery was 48 minutes. Consent time was significantly shorter for women undergoing cesarean section for fetal indications, which is in line with what we see clinically. Both a fetal heart rate indication for delivery and use of fetal scalp electrodes were significantly associated with increased odds for <30 min of consent time.

Journal club participants felt that the study findings argued for obtaining consent for cesarean delivery during outpatient prenatal visits if possible. They recognized that this may be difficult to achieve 100% of the time. Members lauded the authors for tackling an understudied question. One limitation raised was that this study measured time but not necessarily quality of the consent process. Participants also agreed that further work is needed in this area, including studies focused on assessing the quality of the consent process and women’s post-delivery perceptions of this essential exchange.