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!