Wednesday, September 24, 2008

Have patient's rights undermined obstetrics?

Several recent posts have touched on the issues of informed consent, patients' rights, and the importance of respecting maternal autonomy in decision making. I came across an article yesterday that left me dumbfounded: How I (and my OB colleagues) swindle patients into thinking that their decisions make any sense. It's a short blog post written by an anesthesiologist, plus a repost of another anesthesiologist's piece of writing, "How Obstetricians Ruined Their Lives (And Mine)."

Let me repost the two excerpts here, and then add some commentary:
Dr. Diastolic wrote: Call me old fashioned, but I am not alone. I often believe that patients don't have the capabilities to make proper decisions about their clinical options. When the issue is childbirth, excuse me, patients are often nuts. Just witness the epidemic of home childbirths!

Dr. S.W. McFee of Parkville, MO wrote to the American Society of Anesthesiologists Newsletter: "How Obstetricians Ruined Their Lives (And Mine)."

If the tone of this epistle is less cordial than you’re used to, well then so be it. I’m feeling a bit surly.

It is 0230 again. We could have done this case nine hours ago. The sun was still up, and she’d been stuck at 6 cm longer than the life cycle of some butterflies. We should have done this case nine hours ago, but the patient “really wanted” to delivery vaginally. Apparently becoming a mother just wasn’t enough, and the actual avenue of the child’s arrival had some bearing that I, as a sleep-deprived and callous male, just couldn’t grasp.

She had been told that the baby was too big and that a primary C-section was indicated, not what she wanted to hear. She doctor-shopped until she found one who agreed with her diagnosis. It doesn’t always happen this way, but this time we got a meconium-stained, cone-headed, floppy baby that required resuscitation. I guess that balances with the patient’s need to labor and attempt an ill-advised vaginal delivery. Or not.

No other specialty has allowed itself to deteriorate to the state of patient control that obstetrics has. We are all concerned about patient rights. We have to be. But come on. Let’s say you have a kidney stone and you present at the urologist’s office wincing with pain but holding in your hand a seven-page stone-retrieval plan and a list of dates that are satisfactory to your social calendar (and as a bonus would make the stone a Libra) – the urologist would and should inform you that his afternoon was booked but that his esteemed colleague from across town would (he’s sure) be happy to see you.

Patients don’t always know best. I’m not suggesting that doctors always know best. I am suggesting, however, that we can make an expensively educated guess and be right enough of the time to eclipse the records of Jean Dixon, Nostradamus or the average meteorologist.

Good medicine should not infringe on the patient’s rights. I’m afraid our brethren in OB have let patient’s rights infringe upon their medicine.
First off--the title of the blog post is confusing. I get that the doctors don't think their patients' reasoning makes sense, but I am not sure how they are swindling women into thinking their decisions do make sense.

Epidemic of home births? Not sure that something that affects 1-2% of the population, and that has been relatively stable since the 1970s, could be considered an epidemic.

The second post accuses the woman of doctor shopping, while in fact her decision to find a physician who was on board with a vaginal birth was an entirely reasonable one. Even the ACOG's practice guidelines note that induction or elective cesarean for a suspected large baby (fetal macrosomia) are controversial and do not seem to yield clear benefits. Some excerpts from the practice guidelines:
Randomized clinical trial results have not shown the clinical effectiveness of prophylactic cesarean delivery when any specific estimated fetal weight is unknown. Results from large cohort and case-control studies reveal that it is safe to allow a trial of labor for estimated fetal weight of more than 4,000 g. Nonetheless, the results of these reports, along with published cost-effectiveness data, do not support prophylactic cesarean delivery for suspected fetal macrosomia with estimated weights of less than 5,000 g (11 lb), although some authors agree that cesarean delivery in these situations should be considered....

In cases of term patients with suspected fetal macrosomia, current evidence does not support early induction of labor. Results from recent reports indicate that induction of labor at least doubles the risk of cesarean delivery without reducing the risk of shoulder dystocia or newborn morbidity, although the results are affected by small sample size and bias caused by the retrospective nature of the reports.
It's not as if the woman had a complete placenta previa at term and went doctor shopping for someone who would agree to a vaginal birth (which would be a bad idea, hands down).

It's also not clear what the eventual outcome of the birth was, although it sounds like it was a vaginal birth. And the existence of molding in the baby's head is certainly not a pathological sign--it's what babies heads are meant to do during a vaginal birth!

And the really bad analogy of childbirth to kidney stones...totally different situations. Add that to the other bad analogies I've seen used in comparison with childbirth: dental surgery, brain surgery (I've seen one article compare home birth to do-it-yourself brain surgery), and broken bones, to name a few.

I was disturbed by the antagonism and hostility directed toward the laboring woman, especially because it kept the anesthesiologist from getting a good nights' sleep. As if it was her personal fault that he was tired, that she had a slow labor. Now birth attendants should be allowed to be human, which means getting tired and grumpy at times. But to take it out on the woman, blaming his suffering on her silly desire for a vaginal birth, is not fair at all.

I fail to see how this story illustrates that patient control has hijacked the practice of obstetrics. I have yet to come across a woman who felt that her physician or hospital staff gave her too much control! I would argue that it's the other way around: coercion, lack of true informed consent, denying women the ability to refuse certain medical procedures (such as mandatory cesareans instead of allowing women to choose a VBAC or vaginal breech birth), failure to follow evidence-based guidelines such as intermittent monitoring rather than EFM, and manipulation to get women to adhere to hospital policies seem to still be common in our current birth culture. What obstetrics needs is more respect for patient autonomy, not less.

Note the doctor's view of long labor (in this case, over 24 hours) as inherently problematic.

A final thought, based on the comment that "We could have done this case nine hours ago." I had an aha moment when reading this, although it's probably not that profound and certainly nothing that original. For many physicians working in the field of childbirth, birth is the end to a pregnancy. From that perspective, it's better to finish things sooner rather than later, because after all it will have to end one way or another. And it is just one day in a woman's life; what's the big deal about waiting it out and causing yourself needless suffering, when we can just end it now, quickly and easily? A woman has her baby and leaves a few hours or a few days later, and for the hospital staff it is the end of the experience.

But for many women, birth is the beginning of a lifelong relationship. It's not about something ending, but something beginning, and from that perspective it is very important to guard the woman's experience, to ensure that she is able to make her own decisions about what is happening to her.

I do have one positive comment, though: I loved the waterbirth picture!


  1. What? No comments yet? I'm surprised. This is a really great post. My jaw actually dropped when I read it. My husband's did, too.

    I must say that it's interesting to hear things from the doctor's point of view, but he sure sounds a bit selfish and full of himself instead of looking at it from the woman's point of view. Sure, a c-section 9 hours earlier would have let him get a full night's sleep, but is it worth it for her? Is major abdominal surgery and all the inherent recovery factors really worth 9 more hours of sleep on one night? Come on, Doc! Be a little less self-centered and look at it from the woman's side of things. She's the one recovering from the surgery, Buster, not you!

    Wow, I didn't expect to get so worked up.

  2. The mysogony embedded in the discourse here is breath-taking. Lip service is made for belief in informed consent and the cavalier attitude toward birthing is not surprising. Its a totally medical paradigm. Nice post

  3. Ouch. Was he TRYING to be a soulless word-that-rhymes-with-click? Jeebus. No wonder there's a homebirth "epidemic"...women are tired of having their babies delivered by assholes like HIM.

  4. The kind of ignorance displayed by that article is truly breathtaking. I didn't comment because I don't even know what to say to that. Appalling, really.

  5. Did you read the comments attached to the article?
    People are crazy. This doc is crazy. His mind will not be changed so I hope people realize and stop giving him attention.
    as always, Rixa, love your blog. How's the baby?

  6. Just from my experience on the L&D floor during my OB rotation... "Doing a case..." from an anesthesiologist generally means performing a c-section.

    "We could have done this case 9 hours ago..." I read to mean that they should have sectioned the mother 9 hours ago when she was stuck at 6cm, but the mother insisted that they wait and thus the baby was cone-headed, mec-stained and limp... but that's just my interpretation.

    Thanks for the wonderful post!

  7. This is sad, but comes as no surprise. This is one of these things that makes me want to tell people to run screaming from the hospital- MY hospital, where I work! The paradigm is so ingrained. Good example of why midwives should be managing births- and independently thinking midwives, not ones who are just slaves to a**holes like this guy and his OB colleague. Thanks for digging up that ACOG guideline.

  8. I hate it when birth is compared to other medical procedures. Women are not so obtuse as to treat a kidney stone like birthing.

    And, I really like your statement about birth being seen as the beginning for a mother and child, and not just the end of pregnancy.

  9. Goodness, Rixa, you are brilliant. I've read your blog for some time now and have been overwhelmingly impressed at your general reach into all things birth and your rational, calm reasoning. Today, I am breathless with your conclusions about pregnancy being the beginning and medicalized practitioners viewing it as an end. You are seems so "duh" but somehow it doesn't feel that way to me as I read it. It seems like a new perspective - fresh - and one that could make a difference if presented in the right circumstances. Thank you.

  10. I've been reading your blog lately (trying to learn AS MUCH AS POSSIBLE about home birth) and this post was too good not to respond to. I also LOVE Jill's comment!

  11. Further evidence that some doctors are just morons...
    What I don't get though is his thing about being tired and being able to do it 9 hours earlier. Most anesthesiologists (OK, all that I've heard of) do shift work, so this shouldn't matter to him. He does what he's required to do til his time is up and then the next doc comes in, so why the attitude of being inconvenienced?

  12. I tried to leave a comment on his post, but it didn't show up. The misogynistic attitudes! And when women respond with evidence that contradicts what he says, he claims he's "being attacked" by a "herd of women" who are "emotional" and "calling him names".

    Ugh. It's beyond me why anyone would *choose* an OB/GYN as a primary carer for an uncomplicated pregnancy. Their attitude...

  13. He's not only a jerk, but a wimp. Oooh, he had to wait several hours for the baby past his bedtime. Somebody call the WAAAHmbulance.

    Pfft. Midwives do this every day, and they don't whine like little babies about it (although that's probably unfair to babies). And mom's doing all the work, not him!!What a useless whining waste of a medical degree.

    "I was disturbed by the antagonism and hostility directed toward the laboring woman," rixa wrote. Me too, but I wish I could say I was surprised.

  14. I always enjoy your posts, but I think that the last two paragraphs of this one are ridiculously brilliant. It is such a subtle, yet profound, difference in the way birth is viewed. Nicely put.

  15. I always enjoy your posts, but I think that the last two paragraphs of this one are ridiculously brilliant. It is such a subtle, yet profound, difference in the way birth is viewed. Nicely put.

  16. Just wanted to remind you guys to try to keep things civil. Remember that no matter how upset you might be, try to critique the arguments, rather than attack the person himself. As much fun as it might be to vent about this (fill in the blank) of an anesthesiologist, let's try to keep the personal/character attacks at bay. Thanks!

  17. This is one reason why, when the anesthesiologists come around asking about potential c-sections, I try not to suggest that a woman is "circling the drain" or otherwise looking like a potential c-section patient unless I think it is very likely. (As many of the nurses on my unit tend to do).

    If I do, this is the type of crap that they are going to say later on if it actually materializes into a section later in the night at an "inconvenient" time.

    Now to defend our anesthesia people a little bit, they do work very, very long hours at times... but, sorry, you picked the line of work and you can always quit and get another job if you don't like it, just like the rest of us! Feel free to quit and be a nurse like me. See how ya like dem apples!

    It's the same with the OB's, if they ask if she is going to do it (vaginally) I tend to say, "yeah she'll do it slowly but surely, she can do it" (if I think she can - of course there are situations when I really don't think it is going to happen). Most of the others would be sighing "WHEN are you going to cut her?"
    Sometimes it is a private joke just to let off steam from a frustratingly slow or difficult labor, but many times they mean it and I think it makes a difference. I would love to see the section rates BY NURSE on my unit. I think it would be interesting to see the correlation.

    They don't remember all the ones that we say those comments about who go on to delivery just FINE vaginally even though we worried over whether they would it all day. So it's just better not to say it.

    He also doesn't mention what the baby ended up weighing... which, if like many of our "macrosomic" babies, was probably 7.5 pounds.

  18. Ahh yes one slighlty less sleepless evening for ole'd doctor and hmmm what for Mom? What for Baby? What for Dad? What for her children, her family, her body, her soul?

    I am FOURTEEN weeks postpartum on my c-section, and hell yes it was only the beginning. When they sent me on my way after my lil' "procedure", it was buh-bye as far as they were concerned...Live mother, live Infant. Next?

    But yes Rixa ir sure is a beginning. And the importance of some selfish overpaid mysogynistic ignorant, ignorant doctor's perfect little night shift is infantesimally miniscule. Drink a freaking coffee, enjoy your millions, you wanted to "deliver" babies...didnt they tell ya in med school that it aint alwasy a speedy thang?

    "scuse my typos, Im nursing my baby and yeah my scar hurts too, alot. Will for a long time after mister doctor has forgotten about me, long after he got that oh so important nights sleep, i, a person, a mother, a wife, a sister, a daughter, a friend, will suffer the pain of cesarean birth.

    I really dont know how I dont go on a rampage sometimes.

  19. Great post. I love your "aha" moment of realizing that doctors consider birth an end, so just get it over with ASAP. Too true. You make excellent points here - thanks.

  20. On the flip - I do have a woman who I worked with who is the wife of an anesthesiologist. He routinely asks women multiple times if they are sure. If he is called 'late' into a birth, he will often ask if they have a birthplan and if he can read it. If it says they are trying for natural, he will often ask if they are surely sure 'because you are so close and I don't want you to regret it later'...

    His wife was an NCBer and he is not too popular in his field.

  21. See, when I entered the field of medicine, they didn't give me a crystal ball, or any other method of forseeing the future. In many areas of medical practice, there are a lot of black/white type situations. Birth is rarely that way. I've been surprised so many times now, that I consider it part of the package! Sometimes you are sure the baby will never come down, and suddenly mama is pushing. Sometimes things go beautifully and then there is a crisis at the end. This article is talking about "failure to progress" as near as I can tell - one of the diagnoses in obstetrics that has the most controversy. Many docs want to call FTP at 2 hours with no progress, but there is great evidence that just waiting 4 hours instead hugely reduces the number of FTP labors. I always say as long as baby is fine and mom is willing, we can continue - sometimes, we wait and things move along again, and the birth happens vaginally; sometimes, we wait and wait, and there is no further progress, and we eventually decide to intervene. Sometimes, I'm good with the intuition and I'm right, and sometimes, I'm wrong. I don't think "patient rights" have undermined anything in medicine, except perhaps the egos of physicians.
    I'm typing this in a bleary eyed state. I labored all day and all night with one of my first time mama clients - and then she birthed her baby by cesarean at 5:15 am today, after being "stuck" at 4 cms for 9 hours. Baby was 9 lbs 13 oz, but more importantly, straight posterior and wouldn't turn. We tried every non-medical trick, and then some medical tricks (including the last 4 hours with an epidural, hoping it would somehow relax her pelvis and help the baby descend), but he would neither turn nor descend. Yeah, we could have "done the case" 6 hours earlier. In fact, mama and I were agreeing that if we knew for sure that was how it would turn out, we would have chosen to do it earlier! But this morning she could say to me "I know we really tried everything we could think of" and though she was sad at how things turned out, she was content that we'd both done our best. Six hours earlier she may have wondered the rest of her life if there wasn't something else we could have tried.
    Peace of mind with your decisions in labor is worth 6 hours. (Even if I would have loved that 6 hours in my bed!)

  22. It's clear the rantings are from a man seeing his income decline as more and more women realize childbirth is not a medical emergency and very VERY VERY few women need anyone there to help at all... for shame on him to write this, goes to show that piece of paper doesn't give anyone class.

  23. I can understand a doctor's frustration with a woman's unwillingness to go with a course of action that is believed to be clinically best. If its true.

    I've been reading many of these birthing blogs and it seems to me there are two primary problems:

    1. Clinical indications and standards of care are not an exact science. One hospital requires one thing, while another does the opposite. One doctor believes one thing, another doctor doesn't. In many cases, there simply are no absolutes.

    The idea of having an iv when I'm physically having to work that hard, really makes me uncomfortable. Who wants an iv when they're jogging or lifting weights? It sounds like most of the time its done as a standard practice for "just in case", but I digress.

    2. Clinicians are people. They have the same personalities, issues, problems, intelligence, and arrogance as any other statistical sample in the community. It would be nice if you alway knew they were making a call based on what was best for you and your baby. Many times, though, it seems like a choice is made based on convenience- when to do a c-section (to get home early), labor the woman on her back (for the clinician's convenience), etc.

    Some things sound like they ought to be easy fixes- darkened, quiet room; few exams; allowed to walk and labor where you want; etc, but again we are dealing with SOC, and preferences.

    It would be nice if we lived in a country of absolutes. This is "always" the best standard of practice. This doctor or midwife always has the "best of intentions". But we don't.

    Change can happen. It will. It has to. Hospitals and doctors have to change to accommodate patient wishes, or they lose business- and patients. Eventually the old doctors, old nurses and old administrators with outdated beliefs will be replaced by the new who will never know how it used to be.

    Keep demanding what you want. If your wishes are deliberately countermanded, when there was no clinical need, make sure you tell management (immediately if possible)- the nursing supervisor, the Director of OB, the hospital administrator. Its these people who can change policy. They will only do so if you make a big enough issue of it.

    Just pick your battles.

    Just my thoughts on a very sticky subject.

  24. Fordo--great comments. Thanks.

  25. That was breath of fresh air. Thank you.

    1. You're welcome! It's been a long time since I got a comment on this one :)


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