Informed Consent OSCE - Caesarean Section Consent

Case Overview

• Age/Sex: 31-year-old female
• Occupation: Office administrator
• Setting: Antenatal clinic, 24 weeks gestation (second trimester)
• Chief complaint: "I was told I need to sign consent for a caesarean — I want to talk about it."

Patient Script

Who I Am

I'm 31, pregnant for the second time, working full time in an office and I have one previous baby delivered by caesarean three years ago.

What Brings Me In

At my 20-week scan they said my placenta might be low and last week the doctor told me they want to plan for a caesarean and get my consent — I came to talk it through and ask questions.

My Story

I found out on my detailed scan last week (I’m 24 weeks now) that my placenta is described as low-lying / covering part of the cervix. I had a caesarean section for my first baby 3 years ago (they said it was because the baby wasn't coming down). I haven’t had any heavy bleeding since this pregnancy started — I had a tiny bit of spotting about two weeks ago that stopped on its own, and I haven’t had any bleeding since then. I feel the baby move normally. My pregnancy has otherwise been quite straightforward — mild heartburn and tiredness. I was given a leaflet and told to come in to discuss the plan and sign consent for a planned caesarean if it’s still needed later.

My Medical Background

• Past medical history: previous emergency caesarean (3 years ago), childhood asthma (no regular inhalers), appendicectomy at age 16
• Current medications: pregnancy multivitamin, folic acid
• Allergies: none known
• Social: lives with partner, stopped alcohol when I found out I was pregnant, was a light smoker before pregnancy but quit when I became pregnant
• Family: mother alive, no major illnesses noted (one aunt once had a very bad reaction after a surgery — I’m worried about that)

What I Think & Worry About

• I want my baby to be safe — that’s the most important thing to me.
• I don’t really want another big operation if it can be avoided; I was worried about recovery last time.
• I worry about being awake or having something go wrong with the anaesthetic.
• I’m anxious about the possibility of blood transfusion, and also about future pregnancies if they say anything about my uterus.

If You Ask Me About Other Symptoms...

• Vaginal bleeding: "No active bleeding now — only that tiny spotting about two weeks ago."
• Pain/contractions: "No contractions, just normal pregnancy twinges and a bit of lower back ache sometimes."
• Fetal movements: "I feel the baby moving regularly, nothing worrying."
• Fever/illness: "I had a sore throat last week but it went away; someone treated a wee urine infection a week ago with antibiotics and that was fine."
• Previous anaesthetic: "I had anaesthetic for my last caesarean and remember feeling groggy afterwards — my aunt apparently had a very bad reaction to anaesthetic years ago."
• Desire for future children: "Yes, I hope to have more children someday, so I’m worried about anything that could affect that."
• Recovery concerns: "I’d like to know how long I’d be in hospital and when I can go back to work."

---

Clinical Summary

Examination

• General: well, comfortable, no distress
• Vitals: BP 118/72 mmHg, HR 82 bpm, RR 14/min, Temp 36.8 °C, O2 sat 98% on air
• Abdominal: fundal height consistent with 24 weeks, palpable fetal parts, cephalic/position not reliably assessed at this gestation
• Fetal heart rate (doppler): 150 bpm, reactive
• Abdominal scar: Pfannenstiel scar visible from previous caesarean
• Vaginal exam: not performed (no active bleeding, cervix closed on recent assessment)

Investigations

• Transabdominal ultrasound (24+3 weeks): anterior placenta low-lying, partially covering the internal cervical os (interpretation: placenta previa / low-lying placenta identified)
• Haemoglobin: 11.2 g/dL (mild anaemia)
• Platelets: 240 x10^9/L (normal)
• Coagulation (INR/APTT): within normal limits (no coagulopathy)
• Blood group & antibody screen: O positive, antibody screen negative (group & save completed)
• Urinalysis: leukocyte esterase + (recently treated UTI) (clinical correlation; treated)
• COVID PCR: negative (screening)

Diagnosis

Primary: Antenatal counselling and informed consent discussion for planned Caesarean section due to low-lying / placenta previa at 24 weeks in a patient with a previous caesarean section.

• Evidence: ultrasound demonstrating placenta partially over internal os; prior uterine scar increases risk of abnormal placentation and of antepartum haemorrhage; patient preference and obstetric risk profile support planning for surgical delivery if placenta persists.

Differential considerations:

• Low-lying placenta that may migrate: some cases resolve as the uterus grows, so expectant management with repeat imaging is a reasonable alternative — requires counseling and follow-up.
• Placenta accreta spectrum (abnormally adherent placenta): higher risk given anterior placenta over a prior scar — must be considered; further imaging (e.g., specialist ultrasound or MRI) and senior review if suspicion.
• Trial of labour / VBAC: generally not recommended if placenta previa persists and covering the os — risk of catastrophic haemorrhage.

Management

• Explain clearly to the patient the current finding, why a caesarean is being considered (risk of major bleeding if placenta covers the cervix), and that the placenta position can change; discuss the plan for repeat imaging (usually reassess at ~32–34 weeks) to confirm placental location.
• Obtain informed consent if the plan is to schedule an elective caesarean should the placenta remain previa: confirm capacity, ensure voluntary decision, discuss indication, benefits, risks, and alternatives (including expectant management and timing of delivery).
• Discuss specific risks to cover: significant haemorrhage, need for blood transfusion, possible hysterectomy (if placenta accreta), anaesthetic complications, infection, thromboembolism, wound complications, and neonatal risks related to prematurity if early delivery required.
• Discuss anaesthesia options: regional anaesthesia (spinal/epidural) is usual for planned caesarean; outline advantages and discuss possibility of conversion to general anaesthesia if needed (address her concerns about being awake and family history of anaesthetic reaction — arrange anaesthetic pre-op review).
• Arrange practical pre-op planning: crossmatch and reserve blood (group & save done), iron optimisation for mild anaemia if time allows, senior obstetric and anaesthetic involvement if placenta remains previa, neonatal team present at delivery.
• Plan timing: if placenta remains previa, schedule delivery at appropriate gestation (commonly around 37 weeks for placenta previa if stable); urgent/emergency delivery if antepartum haemorrhage occurs.
• Document the consent conversation comprehensively: patient questions, understanding, decisions, and any refusal of elements (if applicable).
• Provide written information and offer opportunity to discuss with partner and return with further questions; arrange follow-up ultrasound and antenatal clinic review.

Key Learning Points

• Informed consent in obstetrics requires clear explanation of indication, benefits, risks (including blood loss and potential hysterectomy in placenta previa), alternatives, and confirmation of capacity and voluntariness, with documentation.
• A low-lying placenta detected in the second trimester may migrate; management includes repeat imaging later in pregnancy, but placentas over a prior cesarean scar raise concern for abnormal placentation and warrant senior input and planning for possible significant haemorrhage.
• Preoperative planning for a planned caesarean in placenta previa should include anaesthetic review, blood availability (group & save/crossmatch), involvement of senior obstetric and neonatal teams, and counselling about postpartum recovery and future fertility implications.