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OSCE: actor and procedure stations · Core06 / 22

Consent for a labour epiduralActor: a 27-year-old first-time mother, 5 cm dilated, in strong pain with contractions every 3 minutes

Actor: informed consent for a labour epidural under time pressure

From memory: the diagnosis and the notes are hidden. Answer each question aloud, then press Show.

Know this first

  • Accidental dural puncture: 1–1.5% of labour epidurals; 30–60% of these cause headache.
  • Epidural haematoma: about 1 in 251,463 (SCORE).
  • Permanent injury: 0.015–0.09 per 10,000 epidurals.
  • May lengthen the second stage; does not raise the caesarean rate.
  • A pregnant woman with capacity gives her own consent; pain can impair capacity.

The patient

Actor: a 27-year-old first-time mother, 5 cm dilated, in strong pain with contractions every 3 minutes. She has asked for an epidural; her husband is with her. Platelets normal, no anticoagulants. Task: obtain her consent.

The examiner asks

Answer aloud, then press Show.

  1. Open

    How do you open?

    Show the answerHide the answer
    • I'm speaking to a first-time mother in active labour who has asked for an epidural. Patient
    • I'll keep this short and talk between contractions. Stop me whenever you need. Communication
    • Have you heard much about epidurals before today?

  2. Explain

    Explain the benefits, risks and alternatives.

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    • A fine tube in your back gives pain relief that usually lasts until the birth. (Communication)
    • Your legs may feel heavy and your blood pressure may dip; we watch you closely.
    • About 1 in 100 epidurals punctures the fluid sac; a third to over half of those cause a headache.
    • Serious nerve damage or bleeding around the spine is very rare: fewer than 1 in 100,000.
    • It can lengthen the pushing stage, but doesn't raise your chance of a caesarean.
    • Gas and air or a remifentanil pump are options, but the epidural relieves pain better.

  3. Respond

    She asks: 'Will it paralyse me? Will it hurt my baby?'

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    • Permanent paralysis is extremely rare. Any leg heaviness wears off afterwards. (Communication)
    • Your baby's blood supply isn't reduced, as long as we keep your blood pressure up.
    • The midwife will monitor the baby's heart rate closely once it's in.

  4. Respond

    Her husband says: 'Skip all this, just let her sign.'

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    • I understand you want her comfortable quickly. I'm nearly finished. (Communication)
    • She needs to hear the main risks to decide. The decision is hers.
    • Knowing all this, would you like the epidural?

  5. Close

    How do you close?

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    • Any questions? You can change your mind at any point. (Communication)
    • I'll record the risks we discussed and your consent in your notes.
    • Then a drip, blood pressure checks, and we start when you're positioned comfortably.

Fatal mistakes

  • Letting the partner consent for her.
  • Leaving out serious risks.
  • Not offering alternatives.

Checked against: Miller 10e · Barash 9e · Saudi Guidelines for Informed Consent, First Edition 1440H (2019)

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