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Table 5 Cross-cutting narrative – genuine dialogue

From: Consent in pregnancy - an observational study of ante-natal care in the context of Montgomery: all about risk?

  Field note from ante-natal clinic for elective Cesarean Section
N is a woman in her second pregnancy having suffered a traumatic first delivery which included a third-degree tear (obstetric anal sphincter injury). She is not sure whether to try for another vaginal delivery or have an elective Cesarean section. She has her first child in pushchair with her.
HCP tells her to come in sit down – standing shuffling papers – little eye contact.
N seems distrustful. Sitting forward supporting chin with hand. Starts to tell HCP about her first delivery - lots of symptoms – major problem with tear - bowel interference bleeding from bowel – magnesium tablets ‘it’s been really, really awful’ - seems to want to tell him about her previous experience (he doesn’t seem aware) He doesn’t seem interested but this clinic is packed – heaving waiting room
HCP a bit distracted – struggling with computer … little eye contact. Limited rapport
you didn’t want a sweep – sounds a bit accusatory
N ‘no’
HCP ‘this is a consent form – basically we tell you the possible rare risks ….and then you sign this for us’.oLooking at form goes through risks - any op has risks, bleeding/transfusion, infection/antibiotics, bladder ‘very rare’ ‘no big deal’, blood clots TED stockings, no other procedures planned but repair any damage – if can’t at time then later. Very, very fast
N doesn’t say anything or acknowledge – defensive arms folded – looks unhappy
distracted by fractious toddler gives him a drink (researcher tries to distract toddler – N smiles at researcher)
Knock on door – colleague enters – asks advice
HCP leaves room says he’ll be back
N to researcher says he’s not listening to what she’s saying – gives toddler drink – researcher encourages her to ask HCP questions
HCP returns – where were we? ‘Oh yes’. explains about bikini line incision HCP – passes N form says this is my signature you sign here
N hesitates, looks at form appears to be reading – seems very unhappy? sullen
HCP seems oblivious – busy with computer screen
Long pause HCP – tries to take form from N
N hangs on to form – ‘tussle over table’ – she hasn’t signed it – she doesn’t let go of the form
HCP ’anything you don’t understand’
N queries section on other procedures which might be needed
HCP no extras planned so doesn’t apply
N reads form further – several minutes pass
HCP asks if anything else – impatient
N asks him what he advises – have Cesarean section or try natural birth says ‘I’m not sure’
HCP ‘I thought you were sure’ – kindly tone but seems impatient? confused by her apparent wavering (? not sure why they haven’t discussed alternative in detail?)**
Explains first delivery big achievement – second should be easier – induction + smaller baby. Risk from every direction – given that she had lots of problems after delivery CS is the best option for her.
N looks unconvinced - HCP doesn’t notice
HCP books date – looks at form and says ‘good you’ve signed it’ Tells N to bring form with her to Labour Ward – (NB no mention N can change her mind)
N still hasn’t let go of consent form – picks up & leaves. No parting words – goodbye, thanks
Impression Distinct feeling that she doesn’t feel heard? wonder if she will go through with Cesarean – whole consultation has felt rushed and a bit chaotic – don’t get any sense of her making a choice. N subsequently confirms to researcher that she’s not sure what to do which was why she was determined not to relinquish the consent form – very unhappy – doesn’t really know how risky a vaginal delivery would be.
** researcher asked HCP later re alternative of vaginal delivery who explained that although she could take her chance with a vaginal delivery it was not really a sensible thing to do in her circumstances