Many 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.