In a multiparous woman with six prior cesarean sections who desires a seventh cesarean and is advised to have tubal ligation, whose consent is required?

Consent for Tubal Ligation During Cesarean Section

The patient alone must provide consent for tubal ligation—no spousal or representative consent is required, and she should be informed that she may discuss this with her husband if she wishes, but his agreement is not legally or ethically necessary. The correct answer is C: Take consent from her and tell her to inform her husband.

Legal and Ethical Foundation

A pregnant woman with decision-making capacity has the sole legal and ethical authority to consent to any medical procedure performed on her body, including sterilization, regardless of her husband's wishes. 1

• In law, a pregnant woman with capacity can refuse or accept any treatment for any reason, and this autonomy extends to accepting procedures like tubal ligation 2, 1
• The pregnant woman is the patient, and only she can provide consent for maternal interventions 1
• No spousal consent is required for medical procedures performed on a competent adult woman 1
• The husband has no legal veto power over the woman's medical decisions 1

The Consent Process

Valid informed consent requires that the patient be competent, understand the procedure and its risks/benefits, and make a voluntary uncoerced decision. 3, 4

Essential Elements to Document:

• The patient's capacity to make medical decisions 1
• Her understanding of the permanent nature of tubal ligation 3, 4
• The risks of future pregnancy with six prior cesarean sections (including uterine rupture, placenta accreta, maternal mortality) 1
• Alternative contraceptive methods 3
• That this is an elective procedure that can be declined 4
• Her voluntary decision without coercion from medical staff or family 3, 4

Role of the Husband

While the husband may be included in counseling to provide support and facilitate shared understanding, the final decision rests solely with the woman. 1

• Counseling may include the partner, but this is for support purposes only 1
• The woman should be encouraged to discuss the decision with her husband as part of her decision-making process 1
• However, his agreement is not a legal or ethical requirement to proceed 1

Critical Pitfalls to Avoid

Do not delay the procedure waiting for spousal consent or require the husband's signature on consent forms. 1

• A representative is only needed when the patient is incompetent to make decisions 1
• Requiring spousal consent violates the patient's autonomy and may constitute coercion 3, 5
• Drugs, fatigue, pain, or anxiety during labor may compromise capacity but do not necessarily lead to incapacity unless severe 2
• The presumption of capacity remains unless there is clear evidence of severe impairment 2

Practical Implementation

Obtain informed consent from the patient alone, ideally discussed during prenatal care rather than during active labor. 2

• Information about sterilization should be provided early in pregnancy, not immediately before the procedure 2
• Sufficient time must be allowed for the patient to make a considered decision 2
• Document the discussion, her understanding, and her voluntary decision 2, 3
• Note that she was advised she may discuss this with her husband, but clarify his consent is not required 1
• If she requests time to discuss with her husband before deciding, this should be accommodated 2