Informed Consent Isn’t Signing Paperwork

Using the “Big Baby” Conversation as an Example

There’s something that happens in pregnancy care all the time. Someone is told their baby might be “too big,” and suddenly the conversation shifts. Instead of beginning with options, the conversation begins with a recommendation. Induction. Cesarean. A timeline gets attached to the birth before labor has even started, and families are reassured that risks were explained, questions were answered, and consent forms were signed.

But explaining a procedure is not the same thing as explaining a decision.

“If only one option is presented, that isn’t informed consent.”

Informed consent means understanding all reasonable options, not just the recommended one. It means hearing the risks and benefits of each path forward, including the option of waiting. If only one option is presented, that isn’t informed consent. It’s agreement to a recommendation, and those two things are not the same. Suspected “big baby” is one of the clearest places this confusion shows up in modern maternity care.

Legally and ethically, informed consent requires more than describing what a provider plans to do. It requires explaining the alternatives, the risks of doing nothing, and the uncertainty involved in prediction-based decisions. When those pieces are missing, what patients are being offered is guidance, not informed consent.

Most parents first hear about a “large baby” after a late-pregnancy ultrasound estimate. That estimate can feel very concrete. A number gets attached to the baby, and that number quietly begins shaping decisions weeks before labor even starts. But estimated fetal weight late in pregnancy is not precise. Research summarized by Evidence Based Birth shows that ultrasound estimates predicting larger babies are frequently inaccurate, with error rates often falling between 50 and 70 percent depending on the weight category being used.

“Prediction is not the same thing as diagnosis.”

That doesn’t make ultrasound useless. It means it’s a tool with limits. When recommendations like induction or cesarean are based primarily on predicted weight, families deserve to understand how uncertain those estimates can be. Prediction is not the same thing as diagnosis, especially when decisions are being made weeks before labor begins rather than during labor itself.

One of the biggest concerns behind suspected macrosomia is shoulder dystocia. It’s a real complication and it deserves careful attention. But what families are often not told clearly is that shoulder dystocia is difficult to predict in advance, even when babies are larger than average. Guidance from American College of Obstetricians and Gynecologists acknowledges that estimating fetal weight near term has significant limitations, and that suspected size alone is not a reliable predictor of whether shoulder dystocia will occur.

Risk deserves explanation, not assumption.

Research does show that induction for suspected large babies can slightly reduce the rate of shoulder dystocia, but summaries reviewed by Evidence Based Birth show that it has not clearly been shown to reduce serious injury, and it introduces its own tradeoffs that deserve discussion. A true informed consent conversation about suspected macrosomia should include how accurate fetal weight estimates are, what shoulder dystocia actually is, how often serious injury occurs, what induction changes about labor, what cesarean changes about recovery, and what happens if families choose to wait.

Most families never hear that full picture.

Instead, they are often told what the safest option is assumed to be.

I once had a conversation with a provider about this exact issue. She explained that she always reviews the risks of cesarean before asking patients to consent and makes sure they have time to ask questions. But when I asked whether she also walks patients through the risks and benefits of the other available options first, she said “not always”, because in situations like suspected big baby she believes those other options are not the safest choices.

That response is incredibly common, and it usually comes from a place of genuine concern. Providers want good outcomes. They want to reduce risk. They want to recommend what they believe will protect both mother and baby.

But that still isn’t informed consent.

If alternatives were never discussed because they were considered less safe, that isn’t informed consent. That’s directive counseling.

True informed consent does not require providers to present every option as equally good. It does require them to explain what the reasonable alternatives are and why they believe one option is safer than the others. Families cannot weigh risks they were never told existed.

Suspected macrosomia is a perfect example of why this matters. When recommendations are based on prediction rather than diagnosis, families deserve to understand not only the recommended intervention but also the realistic alternatives, the uncertainty behind the estimate, and what choosing to wait might look like.

Long before fetal weight prediction existed, birth attendants expected babies to come in different sizes. They relied on movement, positioning, patience, and observation during labor rather than prediction weeks in advance. Organizations like Spinning Babies and Breech Without Borders continue teaching positioning strategies rooted in the long-standing understanding that labor itself provides information prediction cannot.

Observation matters.
Movement matters.
Time matters.

I once supported a client who was told she needed a cesarean at 38 weeks because her baby was expected to reach 11 pounds by 39 weeks. Her baby was born weighing just over 7. That experience isn’t the statistical average, but it isn’t rare enough to ignore either. It’s exactly the kind of situation where informed consent matters most, because recommendations were being made primarily on prediction rather than certainty.

Uncertainty should never be hidden inside confident recommendations.    

Research consistently shows that one of the strongest predictors of whether someone experiences birth as positive or traumatic is not the type of birth they have, but whether they felt informed and involved in decision-making along the way. Findings from the Listening to Mothers Survey show that more than half of women report feeling pressured into at least one intervention during childbirth, and international research from the World Health Organization has found that up to 70 percent of women in some settings report at least one experience of mistreatment, coercion, or loss of autonomy during maternity care.

“Informed consent isn’t about agreeing to a recommendation. It’s about understanding your choices before the recommendation is ever made.”

Communication shapes birth experiences more than most people realize. Informed consent isn’t about agreeing to a recommendation. It’s about understanding your choices before the recommendation is ever made. When families understand what is urgent, what is uncertain, and what is preference-sensitive, they are able to participate in decisions with confidence instead of fear.

This conversation isn’t about rejecting medical care. Modern obstetrics saves lives. Emergency cesareans save lives. Monitoring saves lives. Skilled intervention saves lives.

But informed consent protects trust.

Sometimes the safest birth includes modern tools. Sometimes the safest birth includes fewer tools. The important question isn’t which system is better. The important question is whether families are given the information they need to choose confidently within the system they’re in.

Families deserve to hear when something is urgent. They deserve to hear when something is uncertain. They deserve to hear when something is preference-sensitive.

Because informed consent isn’t about refusing care.

It’s about understanding care well enough to choose it with confidence.