What is the best course of action regarding consent for a tubal ligation in a multiparous patient with a history of six C-sections, now pregnant with her seventh baby?

Consent for Tubal Ligation During Cesarean Section

The patient herself must provide informed consent for tubal ligation—spousal or family consent is neither required nor appropriate, making Option C (take consent from her and tell her to inform her relative) the correct answer. 1

Legal and Ethical Framework

Patient autonomy is paramount for permanent sterilization procedures. The woman alone must provide informed consent for tubal ligation, as this procedure permanently affects her reproductive capacity. 1 Requiring spousal or family consent violates patient autonomy and may be illegal in many jurisdictions. 1

Essential Elements of Informed Consent

The informed consent discussion must include: 1

• Permanent nature of sterilization and its irreversibility
• Procedural risks specific to tubal ligation at cesarean section
• Alternative contraceptive options (levonorgestrel IUD, copper IUD, progestin implants)
• Serious maternal risks of future pregnancies given her obstetric history

Clinical Context: Why This Patient Needs Counseling

Extreme Risk Profile with Six Prior Cesarean Sections

This patient faces catastrophic risks with future pregnancies: 1

• Uterine rupture with potentially fatal hemorrhage
• Abnormal placentation (placenta accreta, increta, percreta) requiring emergency hysterectomy
• Severe hemorrhage necessitating massive transfusion
• Maternal mortality risk substantially elevated

Postpartum tubal ligation at the time of cesarean section is appropriate and can be safely performed. 2, 1

Timing and Technical Considerations

Preoperative Requirements

• No oral intake of solid foods within 6-8 hours before surgery, depending on fat content 2, 1
• Consider aspiration prophylaxis given delayed gastric emptying, especially if opioids were used during labor 2

Anesthetic Approach

Both neuraxial and general anesthesia are acceptable, with the choice individualized based on patient preferences, anesthetic risk factors, and obstetric factors (e.g., blood loss). 2, 1 However, neuraxial techniques are generally preferred for most postpartum tubal ligations. 2

Critical Pitfalls to Avoid

Consent Process Errors

• Never require spousal consent—this is ethically inappropriate and potentially illegal 1
• Conduct consent discussions well before the scheduled cesarean section, not in the immediate perioperative period 1
• Ethics consultation is not needed for standard informed consent in a competent adult patient 1

Documentation Requirements

Detailed documentation is essential, including: 1

• Risks, benefits, and alternatives discussed
• Patient's understanding verified
• Voluntary agreement confirmed
• Discussion of serious risks of future pregnancy in her specific case

Why Other Options Are Incorrect

• Option A (consent from patient and relative): Requiring family consent violates patient autonomy 1
• Option B (consent from relative only): Completely inappropriate—the patient herself must consent 1
• Option D (consult ethics): Unnecessary for routine informed consent in a competent adult 1

Option C is correct because it respects patient autonomy while acknowledging that she may choose to inform her family—but this is her choice, not a requirement.