Nursing Component Task
Nursing procedures & clinical learning

Midwifery (RM)

Explanation of a Procedure to a Patient/Client

Explaining a procedure is the process of describing an action or task before it is carried out. Clear, honest explanation supports informed consent, cooperation, reduced fear, and the woman’s right to participate or refuse.

Purpose

  • Explain purpose, benefits, risks, alternatives, and expected sensations
  • Support informed consent and cooperation
  • Reduce fear and enable questions and shared decisions

Indications

  • Before an examination, treatment, investigation, or maternity procedure
  • When the procedure, plan, or risk changes
  • When a woman or family asks for clarification

Equipment

  • Current order and care plan
  • Private space
  • Approved teaching materials or interpreter
  • Consent documentation
  • Hand-hygiene supplies

Preparation

  • Know the procedure and local policy well enough to answer within scope.
  • Arrange a qualified clinician for questions about diagnosis, prognosis, or treatment alternatives outside the midwife’s scope.

Procedure steps

  • Confirm the procedure, indication, scope, and authorized order.
  • Identify the woman using two identifiers and assess language, hearing, cognition, distress, and preferred support person.
  • Explain what will happen, why it is needed, expected sensations, benefits, possible risks, alternatives, and the option to stop.
  • Use plain language, diagrams or an interpreter where appropriate; avoid coercion and jargon.
  • Provide privacy and ask permission before touching or exposing the woman.
  • Allow time for questions and use teach-back to confirm understanding.
  • Obtain and document informed consent according to policy; respect refusal and clarify consequences without pressure.
  • Prepare the woman and equipment, maintaining dignity and infection prevention.
  • Pause if the woman becomes distressed or withdraws consent and reassess.
  • Document the explanation, questions, consent or refusal, procedure, response, and any escalation.

Precautions

  • Explanation is not a substitute for informed consent.
  • Do not proceed if identity, order, capacity, or consent is unclear.
  • Use an authorized interpreter where communication is limited.
  • Respect the right to change one’s mind before or during a procedure.

Aftercare

  • Check understanding and provide written or verbal instructions about recovery and warning signs.
  • Tell the woman how to obtain help or request review.

Nursing considerations

  • Support autonomy, privacy, dignity, health literacy, and culturally safe care.
  • Never use fear, pressure, or misleading reassurance to obtain cooperation.

Patient education

  • Use teach-back and explain what the woman should expect before, during, and after care.
  • Explain warning signs and when to contact the maternity team.

Documentation

  • Record information given, participants, consent or refusal, questions, interpreter use, and agreed plan.
  • Record any delay, referral, or escalation.

References and further reading

Educational resource only. Follow current Nursing and Midwifery Council guidance, local institutional protocols, scope of practice, and clinical supervision.

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