Some excerpts from his presentation, via Birth Sense:
Dr. Kotaska posed the question, how does a physician or midwife stay with a patient when she declines your recommendations? ...Read the rest here.
Dr. Kotaska argues that we need to promote the policies that systems like those Britain and Ontario, Canada have adopted. The Royal College of Midwives' policy is "If a woman rejects your advice, you must continue to give the best care you possibly can, seeking support from other members of the health care team as necessary." Midwives in these areas do not have to remove themselves from their patients’ care (effectively abandoning them), but are expected to continue to support and care for the woman even if she refuses to follow the midwife’s advice.
Dr. Kotaska urges providers to "explicitly state your commitment to her [the woman's] autonomy over your idea of beneficence." He emphasizes that each provider should embrace these three points:
What is the result of a provider maintaining this type of attitude with their patient? Dr. Kotaska asserts that women trust these providers because they have not threatened the therapeutic alliance. He also stated that "informed consent" is not truly an informed consent if the woman will not be supported in her choices. For example, giving a woman informed consent about the risks and benefits of a trial of labor after cesarean, while telling her that your hospital does not allow VBACs, is not truly giving her an informed consent because she has only one option.
- Your job, as a provider, is to inform your patient
- She is free to decline your recommendations
- She will not lose your support if she declines your recommendation
When asked how a woman should respond when she is refused a trial of labor, Dr. Kotaska replied that a woman should create her own "informed consent" form that she asks the provider to sign. It should state that:
With this proposal, Dr. Kotaska received a standing ovation from the midwives attending his presentation. What was clear to me is that midwives and mothers are fed up with the status quo in modern obstetric care today, and if change will only happen through women creating an informed consent form they ask their provider to sign, so be it. It’s time for a birth revolution, and it has to start with midwives, mothers, and a few progressive physicians who are not afraid to challenge the status quo.
- she does not want a repeat cesarean section
- she is aware of the potential risks of a repeat c-section, including placenta accreta, hemorrhage, increased risk of stillbirth, infection, increased risk of maternal death, and four-fold increases in neonatal respiratory distress
- she is not being offered a choice of how she will give birth
- if she experiences any complications as a result of being forced to have a c-section, she will be pursuing legal action against the provider who would not support her in a trial of labor.