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Editorials, Ethics, Medicolegal

Forced c-sections. Unethical outliers or a disturbing trend?

RH Reality Check is reporting that Jennifer Goodall, a woman in her late 3rd trimester with 3 previous c-sections who wants to attempt a vaginal birth has been notified by the chief financial officer of the hospital where she planned to deliver (Bayfront Health Port Charlotte) that her “prenatal care providers intended to report her to the Department of Children and Family Services, seek a court order to perform surgery, and perform cesarean surgery on her “with or without [her] consent” if she came to the hospital.”

I don’t have many more facts other than Ms. Goodall had 3 c-sections and now wants to consider a vaginal birth after c-section (VBAC), but I really don’t need any because no competent adult should be forced to have any medical procedure. Ever.  And the implied threat of reporting someone to the Department of Children and Family Services counts as force.

What are the medical risks of attempting a VBAC after 3 c-sections? I have done a few in highly motivated low-risk patients. There aren’t a lot of prospective studies, but a retrospective review of over 25,000 women with at least 1 previous c-section indicates that the chance of a successful VBAC after 3 previous c-sections is about the same as after 1 and the risk of complications for mother and baby are about the same in both groups. In fact, 79% of women with 3 previous c-sections had a successful VBAC.

There is infinitely more data for a trial of labor after 1 or 2 previous c-sections, pb115asummarized here in this document from the American Congress of Obstetrician and Gynecologists. The risk of uterine rupture is higher after 2 c-sections (uterine rupture is the big complication).  In the study I just quoted there were no uterine ruptures, however only 89 women had a VBAC and so there were just not enough women to know. Another study also reported a 79% success rate (Miller et al) also retrospective, so not the highest quality of evidence). The Miller study had over 200 women and reported a 1.2% risk of uterine rupture (on par with the 2 previous c-section data).

There is not a lot of good data on labor after 3 previous c-sections because the number of women who do so is quite small. However, the literature, such as it is, does not at all indicate that a low-risk woman with 3 previous c-sections is endangering herself or her fetus if she enters labor spontaneously in a facility equipped for an emergency c-section. Repeat c-sections, as you can see from the chart, are not without risks and so  the desire to VBAC is not some kind of fool’s errand or crunchy-granola-new-age-mumbo-jumbo.

The ACOG opinion on more than one previous c-section is as follows:

…the chance of achieving VBAC appears to be similar for women with one or more than one cesarean delivery. Given the overall data, it is reasonable to consider women with two previous low transverse cesarean deliveries to be candidates for TOLAC, and to counsel them based on the combination of other factors that affect their probability of achieving a successful VBAC. Data regarding the risk for women undergoing TOLAC with more than two previous cesarean deliveries are limited.

  (TOLAC= trial of labor after c-section)

Are there situations where attempting a VBAC is contraindicated? Yes, some examples might be a vertical scar in the uterus (up and down, this is weaker and is more likely to rupture), if it looks like the placenta is invading the c-section scar (placenta accreta), or if the placenta is covering the cervix (placenta previa). However, even with placenta previa or accreta, situations where a catastrophic outcome is almost certainly guaranteed without a c-section a woman still has the right to turn down medical care.

This is not the first time a hospital and court in Florida have attempted to force a woman to have a c-section against her will and a woman also reports she was forced to have a c-section against her will at Staten Island University Hospital. What I don’t understand is if these threatened/forced c-sections are born from the OB/GYN and/or hospital’s fear of lawsuits (a significant percentage of OB/GYNs don’t offer VBACs because of fear of lawsuits), the insurance carrier refusing to cover VBACs (either the doctor and/or the hospital’s carrier), a complete lack of knowledge of the literature on VBACs, or some highly misguided pro-fetus-anti-woman agenda. Remember, a repeat c-section (especially a 4th one, or what we call a four-peat) is not without maternal risks.

The “best case scenario” I can come up with (I use that term lightly) is that the hospital’s insurance carrier (or the perinatal group’s) won’t cover a VBAC after 3 previous c-sections and so they are trying to scare her away. Alternative scenarios involving life of mother over life of fetus are even more frightening; if the courts consider that a valid argument then really the sky’s the limit because it means a pregnant woman would essentially give up her rights for 9 months in deference to her uterus.

Someone needs to figure out the motivation behind these cases. If it’s pure medicolegal then serious tort reform is needed around VBACs. If there’s more to this, well, there is a lot more work to do because the implications are terrifying.

 

 

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Discussion

11 thoughts on “Forced c-sections. Unethical outliers or a disturbing trend?

  1. I think you nailed it with them trying to scare her away. They don’t want to do it but legally they can’t refuse so they are doing the only thing they can to avoid the situation.

    Posted by Loren Pechtel | July 28, 2014, 5:26 pm
    • How many patients with previous 3 CDs have you delivered vaginally ? I am a practicing Obs Gyn Splst from India and i too would discourage her from a VBAC / TOLAC . It is also n line with ACOG Guidelines on the subject. I would think. Please correct me if I am wrong.

      Posted by ripplesnreflectiontimes | July 28, 2014, 6:31 pm
      • Possibly 3 or 4 and they were all in Canada which is a different medicolegal climate than the US.

        I’m not sure I agree with AGCOG, after all it was their original guidelines that contributed to the medicolegal issue here. However, that’s all really moot because discouraging someone from having a VBAC and threatening legal action and reporting someone for child abuse is another matter altogether, especially given the fact that the success rates in the literature hardly count as child abuse.

        Some are concerned that these kinds of threats/decisions are a direct assault on a woman’s right to make her own health care decisions in pregnancy which is very scary. No doctor should be forced to do anything, however, what if this patient were to labor at home and hen have a problem, wouldn’t she be better off in a hospital with an operating room, an OB/GYN, and an anesthesiologist? Why can’t our legal system protect doctors so patients can make the decisions they want? People refuse blood transfusions and can still get surgery and in my mind this is really no different.

        Posted by Dr. Jen Gunter | July 28, 2014, 8:52 pm
  2. I guess the medicolegal climate is totally different in the USA… for “many” OB/GYNs to refuse VBACs… wow. As a Family Doc with OB as part of my practice, our group here in Ontario delivers VBACs, as do midwives, if the patient is otherwise low risk; although generally we would get an OB consult if induction or augmentation was required. Althiugh for a patient like this with three prior c/s I would want OB to see them…

    It is an interesting question though, as patients can certainly refuse medical interventions, physicians generally don’t have an obligation to offer or perform an intervention they consider inappropriate… but refusing care altogether and or threatening a lawsuit / CAS… that’s enethical.

    I guess I shouldn’t be so quick to judge… I have had the misfortune of being involved in similar tactics re neonatal eye prophylaxis. That is a clear legal requirement here in Ontario, as dubious ethically as it might be, snd not some nebulous medicolegal concern or even a guideline… but a law that actually says damn consent every baby must get prophylaxis…

    Posted by DancingSamurai (@DancingSamurai) | July 28, 2014, 7:27 pm
    • A 2009 survey indicated 26% of US OBs do not do VBACs.

      The now disgraced John Edwards made his millions suing OBs. He successfully argued that a woman in labor can’t given consent to the process of labor (basically she can’t consent to the discussion you had that the fetal hear rate tracing was reassuring). Then add in the ACOG 30 minute guideline, which is ridiculous. If there a uterine rupture 30 minutes is 29 minutes too long. So, what happened was a TOL, non progression and then a c-setion that happened 32 minutes (or whenever). No one rushed because the c-section was called for failure to progress. The baby ends up with CP, a tragedy but one that was not caused by the labor. However, all a jury sees is a compromised baby and deep pockets and now that doctor and hospital will not do VBACs again.

      Want more VBACs in the US hospitals, well, we need tort reform. However, this reporting to child protection services smacks of something more. Either an ominous “Stay away from out hospital: or worse, “YOu have no rights when you are pregnant.” A 79% success rate can not in anyway be construed as negligence.

      Posted by Dr. Jen Gunter | July 28, 2014, 9:06 pm
      • Whats the serious morbidity risk of a uterine rupture in an otherwise healthy women?

        Side comment about induction of labor and caesarian sections, my gut says that with a vaginal birth the attending doctor feels far less in control of the situation than when he’s wielding the scalpel. That’s a source of cognitive bias.

        Posted by Gibbon1 | July 29, 2014, 12:41 pm
      • I’m puzzled by the risk numbers in the blog post… there seem to be a lot of studies showing that VBA2C and VBA3C are much riskier than a VBAC after just one c-section (see discussion and footnotes at this link: http://reference.medscape.com/article/275854-overview#aw2aab6b5). Most studies hover around 0.5% (i.e. 1 in 200 women) risk of uterine rupture for VBA1C, but 1%-3% (1/100 to 1/33) for a VBA2C and 6% for higher-level VBAC. 6% is 1 in 17!

        That link also talks, at the “Overview” tab, about the risks of serious morbidity. From what I can tell at least as far as morbidity/mortality of the child is concerned, it doesn’t matter whether the mother is “otherwise healthy.” When the uterus ruptures and delivers the baby and/or the placenta into the abdominal cavity, that baby is at high risk of death or severe brain damage due to hypoxia regardless of how healthy the mom is.

        Posted by Daleth | July 31, 2014, 12:49 pm
  3. Since the original statement is quoted as coming from the financial officer, it seems plausible that this is an attempt to scare away her business and dodge a customer based on the financial officer’s (or the hospital’s insurer’s) estimate of unacceptable financial risk.

    But, seen in the light of such cases as the one in which a mother refused to consent to a c-section, delivered the child vaginally and without complications, and was then told that the hospital had asked family services to take her child away on the grounds that her refusal to consent to c-section constituted child endangerment …

    I think we have a problem here. Even pregnant mothers have the right to bodily integrity. What exactly is the meaning of ‘informed consent’ if ‘consent’ can be coerced? What does it mean if ‘consent’ is required?

    Posted by maggiebea | July 29, 2014, 12:18 pm
  4. What happened here was that Ms. Goodall got a letter from the hospital stating that if she insisted on continuing to be their patient, they would, “if medically indicated” (quote from the letter, which is included in Goodall’s court filing and thus available to the public), get a court order for a c-section, report her to CPS, etc. However, it also said that if she transferred to another provider they would help her do that, sending over all her records ASAP so there would be no interruption in care. The letter also noted that in addition to her 3 c-sections, Ms. Goodall had a “thin uterine wall” that further increased her risk.

    In other words, the letter could be summed up as, “if you insist on coming here we will do everything we can to try and get the right to do a c-section, because in our judgment a VBAC in your case is too high risk for us to be able to handle it. But if you don’t want a c-section, just go to another hospital and we’ll help you do that by transferring your records ASAP.”

    Instead of transferring to another provider, Goodall filed a federal lawsuit seeking to have a judge order the hospital to do what she wanted (i.e., attend her VBA3C) and also asking the judge to order the hospital not to file an action in state court seeking an order to do a c-section against her will. The court ruled that patients do not have the right to force doctors to provide medical care that is, in the doctors’ “best medical judgment,” substandard or negligent. The court also pointed out that there is a federal law making it generally illegal for federal courts to order anyone, in any type of case, not to file an action in state court (the law is 28 USC s. 2283). That is on the second to last page of the court’s opinion, which is here: http://law.justia.com/cases/federal/district-courts/florida/flmdce/2:2014cv00399/299997/12

    After losing in court, Goodall transferred to a bigger hospital 20 miles away that was equipped, staffed, and willing to attend her VBA3C. She ended up needing a c-section during labor anyway, and she consented to it.

    I am in complete agreement with the federal judge that nobody has the right to force a doctor to provide care that the doctor thinks is substandard or negligent. That would make about as much sense as having the “right” to force your caterer to prepare food for your event in a way that the caterer reasonably believes is likely to cause food poisoning. And it’s a mystery to me why Goodall tried to force things in federal court instead of just transferring to the nearby hospital that was able and willing to do what she wanted.

    Posted by Daleth | July 31, 2014, 12:06 pm
  5. Awesome piece, Jen. Really good perspective and such an excellent read. Thanks for sharing.
    Kate (New Zealand Midwife) x

    Posted by Kate | August 15, 2014, 10:09 pm

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