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What we can learn from Jehovah’s Witnesses about obstetrical violence and autonomy during pregnancy

imgres-1Many years ago when I was the most junior person on the team I sat on the hemorrhaging wound of a person who was a Jehovah’s Witness. She  was literally bleeding to death. I was medically the least helpful person so I was the human sandbag as the gurney flew down the hallway towards the operating room pushed by a surgeon and a resident. Before the woman lost consciousness she was asked again about the document she had signed on admission saying no blood under any circumstances. This wasn’t hypothetical, she would die. She said, “No blood.” Those were her last words. We never made it into an operating room. I couldn’t understand how someone who could easily have been saved by blood could have turned it down. It was a hard lesson in choice.

This week Caroline Malatesta won a $16 million dollar verdict in a lawsuit about patient choice and obstetrical violence. It is challenging to discuss the medical issues of the case with the limited information presented, but suffice it to say you have to try very hard as an obstetrical unit to mess up a 4th delivery. But whatever may or may not have been medically indicated doesn’t matter, because if a patient doesn’t want the intervention or was coerced into it then the intervention wasn’t merited. If we as obstetricians think a c-section has almost a 100% chance of saving a baby’s life at 38 weeks (for example, anterior placenta previa with a back down transverse fetal lie) if the pregnant woman doesn’t want the c-section she doesn’t get it. This is because women are sentient beings, not baby making vessels.

I want to be clear there are amazing OB/GYNs, and wonderful nurses, and well trained midwives, and incredible hospitals and unfortunately cases like the one presented above tarnish everyone with the same brush. However, there are also issues. 

Some doctors, nurses, and hospitals are steeped in patriarchy and believe patients should just accept what they are offered. This is not limited to the delivery room. I still wonder about my elderly mother’s hip surgery. She wouldn’t hear anything from me about what to ask. Her doctor knew best. It turned out horrifically wrong in almost every iatrogenic way imaginable and so I am left wondering what if I have pressed for more information and options?

Many health care professionals have bad communication skills. There are times I have been referred a patient who turned down a procedure that I felt was indicated and when I explained it she changed her mind.

Some American OB/GYNs don’t have more traditional OB skill sets. When I moved here I was the only one at my medical center doing vaginal breeches, forceps rotations, and vaginal twins that weren’t vertex/vertex. Many residents and nurses had never seen forceps used or a vaginal term breech. If the only tool you have is scalpel that’s what you use. Doing more c-sections affects how much one-to-one nursing care you can provide if you are not staffed accordingly. And of course, more c-sections means more repeat c-sections or more VBACs. In a 2009 survey 26% of OBs said they stopped offering VBACs because of malpractice concerns. VBAC rates began to fall in 1998, so unless the tide is turned at some point once a c-section always a c-section or a rogue home delivery will become the rule.

Some obstetricians and OB nurses are anxious or have questionable training or cave to staffing pressures. They rupture membranes early or get women pushing far to soon. As soon as the labor curve stalls many feel the pressure to do something, especially if the unit is already overflowing with women in the hallway. Some are too aggressive with oxytocin and yet some are not aggressive enough.

It is never medically correct to hold in a crowning head, never mind for six minutes. How did that happen? Hospital policy? Inadequate training? Rogue nurse? A nurse who had been screamed at before by a doctor for letting a multiparous woman deliver before the doctor arrived? The doctor’s policy? This one event requires a root cause analysis before you even get to the issue of consent. A women or her delivering baby will not be harmed if she is on a flat, soft surface and her baby delivers spontaneously. We typically catch babies or guide them out, so if they slide onto the bed unassisted that is okay. Obstetricians sometimes miss deliveries. When that happens we apologize, check if the placenta has delivered, and then do a repair if needed. 

Many labor and deliveries are understaffed. Continuous fetal monitoring has done nothing for saving babies and has raised the c-section rate, yet it’s standard because it takes skilled one-to-one nursing to do intermittent fetal heart rate monitoring correctly. It’s easier to rupture the membranes and put on a scalp clip. (If a patient is obese this may be the only way to monitor the baby, but I’m going to confine the discussion to the things that happen to low risk women). However, if you don’t do electronic monitoring and there is fetal compromise you will be sued for not doing it. How is that for being between a rock and a hard place?

Speaking of lawyers, did you know John Edwards successfully argued that a woman in labor can’t give consent? Basically if you don’t badger and twist a woman’s arm to have the intervention you think she needs you are negligent. Over 90% of OB/GYNs have been sued at least once during their career and the average number of times an OB/GYN is sued is 2.7. One third of obstetrics claims involve a neurologically impaired infant and 49% of these claims are lost (meaning money was paid). Two-thirds of OB/GYNs change their practice in some way because of risk of fear of litigation and I bet none of these changes involve less intervention.

So here we are. A system that does a pretty good job in high risk situations, but an over medicalized, legal complex with pockets of inadequate training for low risk pregnancies.  I don’t think the answer to better medical care for women is more lawsuits, I think we need to learn from Jehovah’s Witnesses.

Doctors are sometimes wrong about patients needing blood. I have seen Jehovah’s Witnesses survive with blood counts we thought incompatible with life. Jehovah’s Witnesses have pushed us to be more careful with blood loss in the operating room, more conservative with transfusions, and even driven technology such as cell savers. After all, blood is expensive and not without risks. However, sometimes you really do need a blood product to live so a few Jehovah’s Witnesses who refuse blood products will die and others will have a more prolonged and difficult recovery. The fact that doctors don’t get sued for following these wishes helps us follow them, but we are trained from the start that an 18 year old of sound mind gets to choose their medical care. 

It took a while for doctors to abandon the patriarchy, listen to patient’s requests, learn some new things, and be brave enough to watch a very few people die who might have lived. Why can we not use this model for competent adult women who are pregnant?

I envision a world were every woman is given a package at the beginning of her pregnancy with a list of the procedures that could happen. Episiotomy, electronic monitoring, scalp clips, c-sections, forceps, antibiotics. The document would be very in depth and include ACOG recommendations and the reasons for and against interventions. Individual OBs could add in what they feel is best practice. The language can be specific, here is one example:

Episiotomy for shoulder dystocia – rarely after the baby’s head delivers the shoulders get stuck and the baby cannot be delivered. This is an obstetrical emergency. There are very specific maneuvers that doctors must do with their hands inside the vagina to dislodge the baby’s shoulders. Sometimes these procedures can be easier with the additional space that an episiotomy provides. Do you consent to an episiotomy in a shoulder dystocia? Yes   No

There are people who will be okay with everything or nothing at all and there will be people who are very specific about what they want just as there is with blood.  It will all be in writing up front with time to think about it and ask questions. If hospitals/doctors/nurses promise to follow them and don’t they should be sued. If hospitals/doctors/nurses follow their patient’s wishes and the outcome is bad they should not be sued. It will not work if the legal system can’t be aligned correctly.

When I practiced obstetrics I was fine with intermittent fetal heart rate monitoring, but hospitals must be upfront about what they can offer and that also means being upfront with their doctors, nurses, midwives, and prospective patients. A doctor can give a patient a package and say they are fine ordering intermittent fetal heart rate monitoring if everything is progressing and is low risk, but what if they get assigned a nurse who wants continuous monitoring or the nurse is covering three patients and isn’ t staffed to do intermittent monitoring, then what? Right now some patients are either forced to have excessive monitoring that they don’t want or labeled as adversarial when then decline. Fixing the system can’t happen unless the hospitals come to the table too. 

Might some women regret their choices? Yes, a few will. Once when I was a resident I heard about a case where a woman had a signed birth plan that said, “Under no circumstances, even if I ask, do I want an epidural.” Several hours into labor she was begging for an epidural and her husband asked if the team could just ignore that part of the birth plan. The anesthesiologist was called, read the document, and declined to place the epidural. He told me that he could easily have been sued if he placed it as she was under duress. I heard that she regretted her decision bitterly throughout her labor and delivery, but the next day she was over it. Would she have been over it the next day if the anesthesiologist had agreed to place the epidural?

What about fetal compromise and fetal demise? A few babies will die or be compromised, but I suspect it will be far fewer than most obstetricians think. I’ve had a dead baby myself and I do not wish that on anyone. I accepted every intervention in my pregnancy. I would have regrets if I had done less. However, I heard of a woman who was badgered into a c-section because of several fetal compromise. It took 15 minutes of hard core press to get her to change her mind. By the time consent was obtained, the anesthetic was given, and the abdomen was opened it was too late. I heard that she was most upset about the consent and feeling violated. I don’t understand that, but that isn’t any different that not understanding a dying person refusing blood on the grounds of religion.

There was a UK review of 15 fetal deaths due to home deliveries. Thirteen were high risk that should never have been delivered at home, yet the women chose to deliver there because they feared interventions. The midwives knew they were high risk and didn’t want to abandon them. Has it come to this that high risk women have to hide out at home and risk fetal death? We don’t ask Jehovah’s Witnesses not to bother to coming to the emergency department if they are hemorrhaging, we ask them to come to the hospital and then we do our best to give them care within the boundaries of their wishes. Why can we not use that model in obstetrics?  Women get choices with their bodies, whether we agree with them or not doesn’t matter. I often don’t agree with my patients’ choices and that’s okay because they are not my choices.

It will take what happened with Jehovah’s Witness to make the change. Patients, doctors, hospitals, nurses, midwives and the government coming together (the government so doctor’s and midwives don’t get sued for following patient wishes). Midwives also should be required to have malpractice insurance, because that is a big source of conflict between OBs and midwives. It’s very easy to not offer interventions when you don’t risk being sued.

It’s not just civil litigation that doctors and midwives should fear. They and their patients must also keep an eye on the criminal system. A woman was charged criminally in 2004 for not having a timely c-section and 38 states have fetal homicide laws. Midwives have been charged criminally for home deliveries that resulted in neonatal death even when the mothers said the home deliveries were what they wanted. An unlicensed midwife is a different story. If you are not appropriately trained I don’t think you can give informed consent. However, if a woman is appropriately informed of her risk and accepts that risk could she or her obstetrical team face criminal charges if a declined intervention leads to a fetal death? We know the intent of these laws (typically murder of a pregnant woman) does not stop them from being abused by zealous prosecutors.

I am convinced we can learn from the Jehovah’s Witness experience with blood products and that medicine and the legal system can work together to honor patient choices. Maybe this case will push us in that direction.

The rule in medicine is first do no harm and in obstetrics that rule applies first to the mother. We shouldn’t need lawsuits to remind  us of that. 

Discussion

35 thoughts on “What we can learn from Jehovah’s Witnesses about obstetrical violence and autonomy during pregnancy

  1. Read every word, Jen. As a former L&D RN I agree with much of your post. There are so many variables when you enter the hospital about to give birth–the staffing that day; complications other patients might have; the presence of ancillary staff members. I told my patient to push when the resident told me to tell her to pant. She was a Gravida 3 Para 2 or something and the resident didn’t what to get in trouble because the physician hadn’t arrived. She pushed and delivered. I got a personal letter from the doctor, thanking me. Interventions can be convenient for staff, but truly make the process awful for the patient. We had midwives on staff and I loved working with them. Wish I could have worked with you and LOVE the idea of the booklet with explanations previous to entrance to the hospital. Education can often push the lawyers away.

    Posted by bethhavey | August 10, 2016, 11:21 am
  2. I have somewhat similar misgivings about my mother’s ultimately final choice. A little over five years ago, she had a prophylactic BSO. She had multifocal serous tubal intraepithelial carcinoma, and her washings were positive. This caused a major stir at the major academic cancer center where she was being treated because they had apparently not seen this situation before. They ultimately decided that they did not want to treat her.

    I packed the case up and sent it up to Brigham & Women’s, and I was told that I should bring her up there, and their guys would treat her.

    She decided that she did not want to spend the necessary time living in Boston and elected not to go up there. At the time, I discussed it with her, but I did not feel comfortable having a major battle with her since I was not entirely certain myself about the prognosis, not having seen a situation like that before.

    She died of her disease at the end of May. She was never treated because by the time it became clear that she needed treatment, she was no longer capable of giving informed consent. I will always wonder whether chemotherapy would have made a significant difference. At the time, she was 76 years old, and I also recognize that giving her platinum-based chemotherapy could have caused an even more rapid demise. I sort of feel ambivalent about whether I did the right thing. It could have gone either way.

    As for the lawsuit, the description of events suggests that there was a cord prolapse (I am assuming that she had proper prenatal care, and there was no placenta previa). I suppose the outcome of the lawsuit would depend upon exactly what she signed. There are not enough details in the article to make an independent judgement.

    Posted by Michael Finfer | August 10, 2016, 11:28 am
  3. Very interesting article. I didn’t realize anybody considered forceps deliveries for decades. I was a forceps baby (1947) and oldest child.

    Posted by CoalCracker | August 10, 2016, 11:34 am
  4. Reblogged this on things I've read or intend to.

    Posted by donesoverydone | August 10, 2016, 12:00 pm
  5. Thoughtful article. One issue I have with the idea of advanced consent is the reality that people do change their minds when they are in an emergency situation. The woman who in advance says no I do NOT want an episiotomy for shoulder dystocia might feel differently when she’s mid delivery and the baby is stuck. Maybe in that moment she is “under duress” and cannot properly consent, or maybe the emergency situation crystallizes her priorities and she realizes that in fact she does want that intervention if its the last hope. I think that part of informed consent is the ability to change your mind, and we need to make sure that patients are given this opportunity, the system can account for this reality, and practitioners are sensitive to changing patient wishes and protected when they act in accordance with changing instructions.

    Posted by Brooke | August 10, 2016, 12:09 pm
  6. What a fantastic post. I think your idea of a document with questions about care given to patients in advance is a fantastic idea — though you make a good point vis a vis the woman with the epidural.

    My only (wildly minor) quibble is with the repeated use of the term “the patriarchy.” We respect people we think are experts — especially doctors. Maybe something to think about — use of this term — because it might stop people who blanch at the term from reading a terrific and thoughtful post.

    Posted by Amy Alkon | August 10, 2016, 12:28 pm
  7. Interesting.

    I’m in the US and it’s a fight to get the care needed or refuse care once in the hospital. My birth stories; same hospital, different teams, and different outcomes, are polar opposites. First was emergency c-section at 25 weeks with my baby in breach position. Four days earlier was admitted for broken waters and in labor. Mag drip and both steroid shots received. Mag drip tapered off and labor stablised until I got food of some kind in my stomach. I’m still glad it was only soup! Yes, they starved me and I was begging for at least a Slim-fast.

    At least my lil one managed to turn even if it was breach as I was facing a classical c-section to pull her out if she hadn’t descended. And not a single doctor there had delivered a breach presenting preemie. The only decision I disagreed with was over feeding me, a minor issue at best.

    The second, full term VBAC, high risk due to former c-section and increasing blood pressure, induced at a quarter the typical pitocin drip. I still wonder if the pitocin increased my blood pressure.

    And it was a fight the entire time with the medical team. The amount of pressure to just sign papers and get wheeled into surgery was insane. Nobody deserves that amount of badgering. Six hours of: consider an epidural, consider a c-section, of let’s just get it over with it, just sign this just in case b.s. My waters were not even broke.

    I had to fight the medical team to have the labor I wanted. No complications occurred and the second-degree tear was genuine because it only took three pushes. I still remember my heart stopping watching them fumble and catch her. My only satisfaction was having the student doctors watching loose a sure bet. I delivered three-minutes to midnight, a little over seven hours after getting admitted, less than two hours after having my waters punctured.

    I wish they had a simple form I could have signed that said yes I refused all these options. I would have signed it so fast! The amount of stress of having to say no repeatedly, of having to explain and argue why I was a good candidate for VBAC to everybody, to explain why you’re not going to stick a needle in my spine, to be strong in front of these people who see you as just another difficult patient who doesn’t know squat, is ridiculous.

    One simple form could have prevented all of that stress for them and me.
    Changing the laws to accept the outcome of those decisions would be a huge step in the right direction.

    I knew the risks of what I was doing. I also knew I did everything to minimize those risks, yet the risk remains. I was willing to take that risk for me and my child. So much is really up to chance. Why can’t the law recognize and accept that and decriminalize it?

    Posted by Isabella LeCour | August 10, 2016, 1:05 pm
    • Perhaps you were that one person that completely understood everything. It’s funny I’ve read all about flying have a great 737 simulator on my computer but not once have I tried to suggest to my pilot how to land the plane. My 13 years of post secondary education and 25 years experience pal in comparison to people who have done their research.
      With that said there are far too many high handed physicians and if you want the best safest obstetrical care all low risk women should be managed by certified midwives with OB’s available to assist only when asked.

      Posted by Doug Hepburn | August 10, 2016, 5:20 pm
      • I don’t know if the patronising tone is what you meant or not. I assure you that attitude is exactly the one I was up against. It’s odd the comparison you draw. How can any doctor’s expertise compare to the person who’s body they are dealing with? I assure you every pilot listens to what their plane is telling them and reacts accordingly, mostly appropriately. It is the rare doctor in my experience that actually listens and discusses care with a patient. The funny part about a doctors years of education, the only part that counts most is experience and the care they have in practicing the art of medicine. And it’s high time the entire medical profession get a grip that it’s an art and not yet a science. There is too much still unknown that matters. Until the day there is no longer any mystery, no sudden miracles unexplained, medicine will still be an art and the best source of information for who they are practicing this art on, is the patient. I’d rather work with my doctor on MY care than deal with the high and mighty approach of some undereducated in me doctor.

        Posted by Isabella LeCour | August 10, 2016, 6:59 pm
      • WOW. A woman’s body is not your plane.

        Posted by Claire | August 15, 2016, 1:50 pm
  8. Very interesting post. I’m in the UK where we are always a bit behind the US.

    Many, many years ago I had the pastor of the local Jehovah’s Witnesses as a patient. He had a mass in the pelvis arising from a sigmoid carcinoma. I told him that it might not be possible for me to remove this without the need for a blood transfusion. He was quite content with the situation, saying I should try; but he absolutely refused a transfusion, even if it would have made the excision possible. In the event, the mass was stuck to the pelvic side wall, and my attempts to remove it were met with considerable bleeding; I abandoned the resection, doing only a colostomy. Afterwards, my patient remained fully content with the situation, attached no blame or responsibility in any way to me. He died a few months later.

    As for vaginal breeches; herself is an ob/gyn elsewhere in Europe. She is the only local doc who does these, and tells me that she puts patients into a sort of ‘knee-elbow’ position (if I’m understanding correctly) and this makes things much easier. Thoughts?

    Posted by korhomme | August 10, 2016, 2:33 pm
  9. Preconceived notions of how you want things to go are not informed consent and to simply say 3 months ago you didn’t want an episiotomy to save your baby and now that you realize your baby might die and ask for it and you say nope too late! Shame on you!

    If you read most birth plans they are the way people want things to happen not reasonable thought out plans of action that covers complications. Dissatisfaction with OB because things didn’t follow plan are commonplace. I don’t know a sane OB that doesn’t crave for a normal vaginal delivery without interventions with a baby that falls out with no tears. If a person is making an irrational decision I will do everything in my power to stop it. Be it a drunk who thinks he is ok to drive or a mom who has done their research.

    To abdicate ones responsibility to patient over all else is what defines clinicians who believe they are merely serving clients. Yes madam that hat is perfect for you

    Posted by Doug Hepburn | August 10, 2016, 5:09 pm
    • There are women getting interventions they do not want. That is not up for discussion.

      I know nurses who won’t do intermittent monitoring, hospitals that refuse VBACs and doctors who rupture membranes at 2 cm.

      As I said at there are many OBs who want normal vaginal deliveries but as c-sections rates are > 25% it is far from all. My residency had a c-section rate of < 20% and was a tertiary care facility. But it's not just what the OB wants, which I also pointed out.

      No one is saying it's as simple as saying nope, no episiotomy to save your baby now (that scenario could only happen with a shoulder dystopia), but women are badgered into procedures regularly – many of which are not necessary. ACOG just wrote an ethics committee opinion on this very subject. So shame on you for being uninformed.

      Posted by Dr. Jen Gunter | August 10, 2016, 6:39 pm
      • Not American so really not concerned I don’t know guidelines in America. Actually it was your example of shoulder dystocia being yes no 4 months before delivery. I know you will call me patronizing but if baby dying and epis would save I would do epis. ( yes I am pro choice totally different situation). By the way poor choice of example because I have fixed 100’s of shoulder dystopia without ever using epis. Respecting JW right to die withholding lifesaving transfusion means you will never talk to the living JW with three small children that is grateful they won’t grow up without a mother. You won’t be thanked by the mother of a healthy baby who had bradycardia with cord prolapse that would certainly die who refused c/s because she was convinced she goes to die during operation. Polar opposite of your article and I understand you will despise my actions but I would not be able to live with myself if I had not acted.

        FYI I totally agree with most of what you say too many interventions too many all knowing doctors deciding for women or presenting things in a way that make them choose what they think is best. In my career I have always presented all options clearly and will always respect the patient’s choice except when I know that choice will have tragic outcome fortunately this has only happened twice (amniotic fluid embolism DIC plts 10 INR > 110 hgb 37 )

        I also believe low risk women would be better served by certified midwives and only see OB when problems

        Posted by Doug | August 11, 2016, 2:20 pm
      • Dr. Jen, it seems like your premise is that many interventions are poor care period, not just against the wishes of the patient. Why not focus on improving obsetetric care, instead of trying to completely reverse the normal premises of medical care and turn the patient into the medical expert? Isn’t that too much a burden to put on a woman? I’m just wondering if we’d ever turn this kind of burden over to a male patient. No, I think that if there were bad practices in, say, prostate surgery, we’d focus on improving those practices, rather than shifting the burden onto the man.

        What you seem to be saying is that we should facilitate “empowering” women. But that power is illusory; no woman can become an OB just by virtue of being pregnant.

        Posted by lawyer jane | August 15, 2016, 9:53 am
      • Lawyer Jane, you’re conflating obstetric expertise with basic patient rights. You don’t have to be an obstetrician to make decisions about your own body, just like you don’t have to be any other kind of doctor to make an informed decision about how you want to treat your cancer or lower your blood pressure. It’s not about “becoming an OB.” It’s about retaining ownership over your own body… It’s about not having your civil rights removed simply because you are pregnant. Remember, too, that most pregnancies are low risk, and the lawsuits we are seeing (like the Malatestas’) don’t involve complicated obstetrical issues. They are about moms wanting to be mobile in labor, not having routine episiotomies, not consenting to a non-emergent C-section simply because a doctor or hospital has a liability-based blanket policy on how women give birth.

        One other conflation: it’s not that “interventions are bad”; it’s that right now, in the U.S., what women are dealing with in reality is often over-intervention that puts them at risk. Every intervention incurs some risk, so in this context, yes, too many interventions are associated with actual risk. In some other places in the world, they have the opposite problem: a lack of access to needed interventions, or a refusal to provide them because of religious or cultural beliefs. That’s not what we are dealing with here.

        Top-down improvements in care are absolutely necessary. But they take a very long time to effect–decades, even. In the meantime, women can better protect themselves against outdated and unsafe care if we have the power to enforce our most basic rights in healthcare: Informed Consent & Refusal.

        Posted by Cristen Pascucci | August 31, 2016, 7:52 pm
  10. I have enjoyed every one of your passionate, informed and humane posts. As a birthworker, ( several certifications and 16 years educating and supporting birthing and breastfeeding women and teens)I love this one too. Just one thing…episiotomy for shoulder dystocia? I work at a Planned Parenthood prenatal clinic, and when I teach about avoiding routine interventions, I inform clients about this little bit of info along with lots of other stuff, as you can imagine…here it is…whaddya think?

    From Reuters Health Information
    Episiotomy for Shoulder Dystocia Does Not Reduce Nerve Injury Rates
    Information from Industry
    NEW YORK (Reuters Health) Apr 27 – Despite long-time use of episiotomy to avoid brachial plexus injury from shoulder dystocia, a review of data indicates that the strategy has little if any neonatal benefit.
    Episiotomy rates have fallen drastically since the late 1990s, but rates of brachial plexus injury have remained unchanged, according Dr. Amy Paris at Brigham and Women’s Hospital in Boston and colleagues.
    This pattern suggests that episiotomy does not prevent brachial plexus injury in deliveries with shoulder dystocia, the authors say in an April 15th online paper in the American Journal of Obstetrics and Gynecology.
    Indeed, given that shoulder dystocia is caused by bony impingement rather than soft tissue obstruction, the rationale for episiotomy is not rock-solid, according to their article. But some doctors go so far as to do prophylactic procto-episiotomies in this setting, and quality assurance reviewers often cite episiotomy as a criterion for performance improvement in managing shoulder dystocia, the research team says.
    To look into this issue, the investigators reviewed all 94,842 births at Brigham and Women’s Hospital between 1998 and 2009. They identified 953 cases of shoulder dystocia and 102 brachial plexus injuries.
    During that period, the rate of shoulder dystocia remained constant, ranging from 1.1% to 1.9% of all vaginal deliveries, but the rate of episiotomy with shoulder dystocia dropped from 40% to 4%. Despite this change, the rate of brachial plexus injuries held steady, ranging from 0.53 to 2.68 per 1000 vaginal deliveries (p for trend = 0.531).
    “We therefore recommend limiting this intervention to carefully selected cases where, in the judgment of the clinician, performance of maneuvers to effect delivery cannot be reasonably achieved without episiotomy,” Dr. Paris and colleagues conclude.
    “Furthermore,” they add, “quality assurance standards which penalize lack of performance of episiotomy during shoulder dystocia delivery should be eliminated.”
    SOURCE: http://bit.ly/kE3Gvq
    Am J Obstet Gynecol 2011.

    Posted by Jacqueline Levine | August 10, 2016, 6:37 pm
    • I don’t think shoulder dystopia is directly helped by episiotomy at all as the literature suggests and as you have pointed out it is a bony issue. However, what if the soft tissue is so tight you can’t get your hand in to dislodge the anterior shoulder? I have had that situation. I’m not suggesting at that routine episiotomy can help shoulder dystocia in anyway, but I was trying to come up with a scenario that might require some degree of flexibility based on individual situations. That’s why I said may. It was really just an example of how something might be worded.

      Posted by Dr. Jen Gunter | August 10, 2016, 6:47 pm
      • Ah yes…I thought that might be the reason, an example of a scenario for the list. I’m sure you know about the Gaskin Maneuver…The tragedy is that some doctors don’t know / understand the legal construct of a patient’s autonomy in maternity care. Clients ask why docs don’t behave with their own written and promulgated ethical precepts as their guide, and I’ve a bit of research addressing that question… here’s a look at something hair raising in its idiocy from the AMA: This is the headline in bold at the top of the article.

        September 2013, Volume 15, Number 9: 786-790.The Difference between Science and Technology in Birth: Obstetrics seems to be particularly resistant to making evidence-based changes to common practice, perhaps because of the emotional climate surrounding pregnant women and babies. Aron C. Sousa, MD, and Alice Dreger, PhD

        Here’s another tidbit I scrounged up:
        Why Do OBs and Policymakers of Maternity Care Resist Changing Their Protocols to Reflect Best-Evidence Scientific Practices for Childbearing Women?
        Abstract
        In 1998, a questionnaire mailed to family physicians and obstetricians found that only 40% felt that evidence-based medicine was “very applicable to obstetric practice”. Concerning comments from this survey included “obstetrics requires manual dexterity more than science”, “evidence-based medicine ignores clinical experience”, and that following guidelines could result in “erosion of physician autonomy”. These views were described as obstacles to the adoption of evidence-based practices, and the authors recommended emphasis of critical analysis of the literature as part of medical education.
        Olatunbosun OA, Eduoard L, Pierson RA. Physicians’ attitudes toward evidence based obstetric practice: a questionnaire survey. Br. Med. J. 316, 365–366 (1998).

        I am so happy to read your blog and hear your sane, humorous and compassionate voice in this erstwhile wilderness. I’ve had post partum clients tell me that their docs did the “husband stitch” without permish, all the while describing its benefits as they proceeded, and it’s sort of too late then, no?

        Thanks and keep on.

        Posted by Jacqueline Levine | August 11, 2016, 5:24 am
  11. Thank you for writing an honest article . As one of Jehovah’s Witnesses and a mother who had had several home births, your perspective hones in on a lot of truths. In the end we are all entitled to choose our own medical care. It is sad that many women in the US have hombirths simply to avoid the hospital’s intervention. Many of us have our own horror stories of how we were treated in the hospital. It is a shame that a woman cannot have a child naturally with a midwife in a hospital just in the event she does need intervention. The options are all or nothing here.

    Posted by Melisha | August 10, 2016, 8:56 pm
  12. I am not a doctor. It is very hard for me to give informed consent or refusal for any intervention, and I rely on the doctor to choose the right procedure for me. After labouring for 28 hours, and transitioning for 2, when my cervix was not yet fully dilated, my ob requested me to sign a consent for C-Section. I did, because the pain was unbearable and I just needed it to be done with. Yet, later I was told that they made me sign the document because it was 10.30 pm on December 31st and most of the staff wanted to be elsewhere for new year. I don’t know if that is conspiracy theory, or it was a genuine need for C-S. I merely trust the doctor that she would not have done anything that was not good for me.

    So, although the article is very detailed and lucid, as a lay person, I am not sure how much the “informed consent” would be “informed” at all. I think there is a basic ethical conundrum involved here.

    Posted by LG | August 10, 2016, 9:57 pm
    • “It is very hard for me to give informed consent or refusal for any intervention”

      You’re either mentally competent to represent yourself or you’re not.

      If you didn’t know enough to decide, then that’s an indictment of the medical professionals who were supposed to inform you of your options.

      If you think the staff didn’t want to be elsewhere, then you’re incurably naive. Did their decision hurt you? Maybe not. Was it in your best interest? Was it the best for you baby? Probably not.

      Blind trust is not a virtue.

      Posted by Lurky McLurkerface | August 18, 2016, 4:47 am
  13. It can be hard to watch one’s parent making misinformed health choices, but as you say yourself, patient autonomy trumps what other people may think is the right choice. If a doctor had badgered your mother to have an operation, you would be rightfully incensed. So why think that you should have badgered her yourself?

    BTW, I’m not talking theoretically. I’ve been there. My mother died of not taking a treatment that was indicated. It was extremely sad, but at least she lived her last years according to her own rules, her own values. I can regret her, but I don’t regret not getting on her case. Not that it would have worked, anyway.

    Posted by Irène | August 11, 2016, 7:04 am
  14. Love this post, Jen! I’m a certified nurse-midwife in the US, and just wanted to point out that we also carry malpractice insurance, just like physicians do. It is paid for by the hospital practice and is a requirement for us to have privileges. It is a common misconception that CNMs don’t carry malpractice insurance, which many use as an argument for physicians not to back us up, because they (mistakenly) believe it would place them at risk for being sued for our management and decisions. In the state I practice in (WA) we also have many highly trained certified professional midwives, or home birth midwives who also are required to carry malpractice insurance. I’m sure this varies state by state, but just wanted to throw that tidbit in there!

    Posted by michelleefarber | August 11, 2016, 10:29 am
  15. This is SPOT. ON. Thank you so much for writing this! I can’t even decided which portion of your post to highlight when I share it…!

    Posted by Lindsay | August 12, 2016, 12:29 am
  16. I think this is a difficult comparison, because Jehovah’s Witnesses are an established, well-known group with reasonably uniform requests. As far as I know, they are not known for suing practitioners for not explaining the potential outcome of their decisions; they are very much aware that refusing blood products might lead to death. There also isn’t a pervasive online presence advocating rejecting blood products as being more natural or helping with bonding or some such.

    Women in childbirth are not a monolithic group, and so the degree to which they do and don’t want interventions (the threshold for changing the birth plan) is extremely variable, and what is badgering for one woman may be received as educational and necessary for another. I really don’t believe that most pregnant women in the US truly believe that they or their baby could die in childbirth. A few, perhaps, really get that this is the reality, but definitely not the majority. So you can explain possible procedures that might be needed in the calm office setting, but once labor starts, women really have to trust that their providers are acting in their best interest, and that’s not even getting into the routine gaslighting I see on birth boards. I can’t count the number of times I’ve seen some online stranger say that another woman’s CS was “unnecessary” without any knowledge whatsoever of the woman’s medical records.

    Posted by Eleanor | August 12, 2016, 7:42 am
    • yeah, the issue with the natural childbirth movement is that they ascribe better health outcomes to refusing care, which is not the case with the JWs. it muddles informed consent when misinformation is brought into it.

      Posted by Kerlyssa | August 12, 2016, 5:05 pm
      • There should be no quarrel that all birthing women should be educated about what is happening to them when their bodies go into labor. Is there opprobrium in your words about “natural” birth? It’s not that the “natural childbirth movement ascribes better health to REFUSING care”, it’s more likely that when women know about best-evidence care, meaning no routine interventions in the normal physiological process without compelling medical necessity, there are” better health outcomes”. Studies show it takes a minimum of 17 years for recommended changes to practice to take hold. When ACOG itself recommends that a more evidence-based “physiological” approach to labor progress be adopted in its new directives, those directives are often ignored simply because it’s difficult to change one’s work habits of many years. (Here are citations for recommended changes in practice:*ACOG Committee on Practice (2003). ACOG Practice Bulletin Number 49, December 2003: Dystocia and augmentation of labor. Obstet Gynecol 102(6): 1445-1454.
        **Spong et al (2012). Preventing the first cesarean delivery: summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, and American College of Obstetricians and Gynecologists Workshop.” Obstet Gynecol 120(5): 1181-1193.
        ***ACOG Committee on Practice (2009). ACOG Practice Bulletin No. 107: Induction of labor. Obstet Gynecol 114(2 Pt 1): 38

        The Milbank Report is a hugely worthwhile read. Find it online.

        The state of maternity care in this country is concerning: the maternal mortality rate in this country has been rising since the late ‘70s, early ‘80s, and while the rest of the world’s developed countries have falling maternal mortality rates, the US among only eight others has a consistently rising rate.
        The cesarean section rate is uniformly high around the country. The World Health Organization, numerous studies in respected medical journals and the obstetric profession itself acknowledges that the too-high section rate, by definition, means millions of unnecessary surgeries with concomitant extra morbidities/mortalities for mothers and babies both. Informed consent really means that patients be informed of even rare consequences of tests and procedures, and care be taken to assure that the information is understood. It may take a few precious minutes, but ACOG’s own protocols promulgate that necessity. Should they be ignored? We get only one day, one chance to have each baby. It’s our precious body and our precious baby and we deserve, legally, financially and ethically, only best-evidence care, and nothing less.

        Posted by Jacqueline Levine | August 13, 2016, 6:25 am
  17. Loved your article, I am an community Midwife in France and spend many hour with Parents to be working on their birth plan , most ask for privacy, respect on all levels as well as respect to their choice of the birthing process, being part of the decision making when normal is no longer normal. I also am part of a growing international organisation …http://www.humanrightsinchildbirth.org/
    Few have issues when the situation changes and the life of their baby is at risk…..sometimes I wonder how at risk was the baby but more the personnel been out of their experience zone and more in their routine zone. In NZ they use risk management as their model , parents are part of the decision making understanding true risk.
    Thank you again for your article

    Posted by Diana | August 15, 2016, 8:13 am
  18. I think what you’re missing here is that women who are choosing “natural childbirth” are generally not doing so out of religious conviction, like Jehovah’s Witnesses. Many times, they are doing it out of misinformation or ideology that could be changed if they understood more about the reasons for “interventions.” There may be a very few natural childbirth adherents whose beliefs rise to the level of an organized religion. But I think there’s MUCH more fear and disinformation out there.

    Another factor is that childbirth is very complex. Your proposal is essentially that a woman’s birth plan would become a sort of contract, and nothing could change during labor except with some difficulty. This is assuming that the woman actually does understand the clinical implications of her preferences, which of course she cannot … because she is not a doctor.

    There has to be a middle ground between respecting women’s bodily integrity, and making sure that they get the medical care they deserve.

    Posted by lawyer jane | August 15, 2016, 9:43 am
    • This is quite a comment🙂 I’d love to see some research on the statement that many women are choosing natural childbirth “out of misinformation or ideology that could be changed if they understood more about the reasons for “interventions.” Do we ascribe ignorance and irrationality to, for example, the World Health Organization, which is one of many strong proponents of physiologic birth?

      There is a breathtaking level of misogyny in your words that you may not even be aware of. For one, the premise seems to be that physiological birth is unreasonably dangerous (i.e., women’s bodies are broken) and actively managed birth should be the default (p.s. it already is, and we already know there are some big problems with this model), and then, that women who choose a natural childbirth are doing so out of ignorance or irrationality–not because it’s quite literally a scientifically safer and/or less traumatic option for certain women.

      I strongly believe women should give birth however they choose–“natural,” medicated, surgical, whatever. But please, let’s speak factually about the options, even if they are options you would not choose yourself, and not demean each other with baseless judgments about who chooses what and why.

      Posted by Cristen Pascucci | August 31, 2016, 8:07 pm

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