Consent Stations

Legal Framework

Montgomery v Lanarkshire (2015)

• Material risk standard: disclose risks a reasonable person in the patient's position would consider significant
• Doctor must also disclose risks this particular patient would find significant (based on individual circumstances)
• Includes alternatives to the proposed treatment
• Replaces Bolam test for consent

Structured Consent Discussion

1. Indication: why the procedure is recommended
2. Description: what the procedure involves (in lay terms)
3. Benefits: expected outcomes and improvements
4. Risks: common AND serious risks (use numbers/percentages where possible)
5. Alternatives: other treatment options including doing nothing
6. Questions: invite questions, check understanding
7. Decision: confirm patient's decision, document, sign consent form

Common Consent Scenarios

Caesarean Section

Risks to discuss: - Haemorrhage (may need transfusion) - Infection (wound, endometritis — 5-10%) - Thromboembolism (VTE prophylaxis given) - Injury to bladder, bowel, ureter (<1%) - Need for further surgery - Fetal laceration (~2%) - Longer recovery than vaginal delivery - Future pregnancy implications: scar on uterus, VBAC vs repeat CS, increased risk of placenta praevia and accreta with each subsequent CS - Anaesthetic risks (spinal headache, nerve damage, GA risks if conversion needed)

Total Abdominal Hysterectomy

Risks: - Haemorrhage / transfusion - Infection (wound, pelvic, UTI) - VTE - Ureteric injury (~1%) - Bladder injury - Bowel injury - Vaginal vault prolapse (long-term) - Loss of fertility (permanent) - Psychological impact - If BSO included: surgical menopause, need for HRT discussion - Conversion from laparoscopic to open if applicable

Diagnostic Laparoscopy

Risks: - Port-site complications (bruising, infection, hernia) - Visceral injury: bowel, bladder, vascular injury (1-2 per 1000) - Gas embolism (very rare) - Shoulder-tip pain (diaphragmatic irritation from CO2) - Conversion to laparotomy - Failed entry / inability to complete procedure - Subcutaneous emphysema

Hysteroscopy

Risks: - Uterine perforation (1-2%) - Cervical trauma - Fluid overload (glycine in monopolar systems — hyponatraemia) - Infection - Bleeding - Failure to complete / false passage - Gas embolism (if gas distension medium)

Assessing Capacity (MCA 2005)

The patient must be able to:

1. Understand the information relevant to the decision
2. Retain that information long enough to make a decision
3. Weigh (use and balance) the information to make a decision
4. Communicate their decision (by any means)

Key principles:

• Assume capacity unless proven otherwise
• An unwise decision does NOT mean lack of capacity
• Support the patient to make their own decision before concluding they lack capacity
• If patient lacks capacity: act in their best interests (consider past wishes, beliefs, values)

Gillick Competence and Fraser Guidelines

• Gillick competence: child under 16 can consent if they have sufficient understanding and intelligence
• Fraser guidelines: specifically for contraception — the young person understands advice, cannot be persuaded to tell parents, is likely to have sex regardless, their health would suffer without treatment, treatment is in their best interests
• 16-17 year olds: can consent to treatment (Family Law Reform Act 1969)

Key Points Examiners Mark

• Clear explanation of the procedure in lay terms
• Discusses indication (why it's needed)
• Lists common and serious risks with approximate frequencies
• Mentions alternatives including conservative management
• Assesses understanding ("What do you understand about what we've discussed?")
• Allows questions
• Does not coerce — respects autonomy
• Documents the discussion
• Arranges time for patient to consider before signing (if not urgent)

Common Pitfalls

• Listing risks without explaining what they mean in practice
• Failing to mention alternatives (including doing nothing)
• Not checking understanding — assuming patient has understood
• Using medical terminology without explanation
• Rushing through the discussion (examiners want to see genuine dialogue)
• Forgetting future pregnancy implications for caesarean consent
• Not mentioning Montgomery v Lanarkshire when discussing material risks

Clinically reviewed by NHS obstetricians and gynaecologists

MRCOG AI is an independent educational tool. It is not affiliated with, endorsed by, or connected to the Royal College of Obstetricians and Gynaecologists (RCOG).