Reply turned post, “reasonable” commenters style

Jill has had a great series of posts on The Unnecesarean about a large malpractice payment based on jury findings of a lack of appropriate informed consent prior to a shoulder dystocia that resulted in a permanently affected child, and a follow up post on how to properly counsel a patient with a baby with a large estimated fetal weight.

As you may have expected, both of these posts had lively comments sections. I only got involved in the second post. Yes, I haven’t just been MIA here, I have been MIA in the interwebs in general. However, I tend to jump in when I actually get a chance to read something, and then see someone creating straw men arguments or grossly misinflating aspects of the conversation in order to make a point, which happened a few times in the second comment thread.

My first comment was in regards to informed consent. A few commenters acted as if there is an exact formula for informed consent, and it includes presenting every worst case scenario, even if the risks of that scenario are diminishingly rare. Also, some commenters were treating the one verdict and award in this very specific case as the totality of case law on informed consent.

ACOG has a Committee Opinion on Informed Consent which discusses the complicated and amorphous subject of malpractice case law and informed consent. This opinion, which I recommend that you read, like I recommend you read all of the links I am including (yeah, I know, you haven’t got all day, but still), states that first of all, informed consent is more of an ethical issue than merely a legal issue. Secondly, the adequacy of disclosure, which is the issue that the huge malpractice payout in the original Unnecesarean post hinged on, has been judged by different criteria in different cases. In recent history, “common practice of the profession” was the most common trend for judgments. That could be troublesome, because standard of care in different areas can be quite variable, and not necessarily evidence based or best for the patient. Now, the trend seems to be moving towards the “reasonable person” criterion, which can also be troublesome. Especially if the all the commenters on these threads are “reasonable people.” Ahem.

Physicians are notoriously poor at presenting risk (pdf) in a way a reasonable person can understand. Many practitioners will very selectively and erratically present risk, sometimes exaggerating, downplaying or completely omitting risks or benefits in order to lead the patient in a certain direction. Ignoring that, statistics are still highly complicated even with the best of intentions. This article recommends using “natural frequencies”, such as saying three to five people out of ten taking Prozac will report some sexual dysfunction, as opposed to saying there is a 30 to 50% probability of sexual dysfunction. Many people will assume the latter will mean that every time they have a sexual encounter, there will be a 30 to 50% chance of there being a problem. Percentages or other comparative methods (__ times more likely) can be tricky.

For example, in Liu et al’s Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term, one of the outcomes measured was any hysterectomy. I picked this specific outcome because it is a good example of how to discuss the numbers, but also because one of the commenters grossly misrepresented this particular risk, stating it was ONLY a risk of vaginal birth, and not at all associated with cesarean section.

In this retrospective study, there were 27 hysterectomies in 46,766 cesarean deliveries, and 376 hysterectomies in 2,292,420 vaginal deliveries. That is the same as 0.6 per thousand cesareans, and 0.2 per thousand vaginal deliveries. The adjusted odds ratio of any hysterectomy is 3.2 higher odds for cesarean than vaginal delivery. So, three times higher, or 320% higher. Sounds huge, right? But, the absolute risk difference is 0.4 per 1,000. Or, four hysterectomies per 10,000 cesareans. Does increased risk of hysterectomy need to be part of the informed consent for cesarean section? Does it need to be part of the informed consent for vaginal delivery? How frequent does an adverse event need to be for it to deserve a mention? Does an adverse outcome such as nerve injury resulting in foot drop, usually due to epidural or spinal anesthesia, which only appears in isolated case reports, not even in large studies such as this, need to be mentioned?

I still haven’t touched on the topic of how to counsel a patient who is near term and has high estimated fetal weight. This is a complicated topic, and I don’t think I am going to cover it in this post. Based on the evidence, including the ACOG position statements on the topic and UpToDate’s review of the literature, shoulder dystocia is unpredictable and unpreventable. Prophylactic cesarean section does not prevent nerve injuries or neonatal death. Induction of labor (which is disappointingly common in these cases) actually increases neonatal poor outcomes. Instrumental vaginal delivery (use of vacuum extraction or forceps) increases the risk of shoulder dystocia. Estimated fetal weight is a tool with poor accuracy, given a rating of I for insufficient evidence to support its use by the United States Preventative Services Task Force. This list does not even take into account the maternal history and characteristics.

I think informed consent for any pregnant person should include the chance of a shoulder dystocia. I think as the risk factors increase (estimated fetal weight greater than 4500 g, gestational diabetes, prior macrosomic baby, prior shoulder dystocia, male fetal gender, small maternal pelvic size), that increased risk should be presented. If a practitioner is acting out of fear of a lawsuit in the extremely rare case that there is a very poor outcome, the practitioner should mention this fear.

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6 Comments

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6 responses to “Reply turned post, “reasonable” commenters style

  1. Susan Peterson

    Why male gender, independent of size? Do they have bigger shoulders even in the womb? Or isn’t the reason known?

  2. MomTFH

    Shoulder dystocia is related to actual fetal weight, not estimated fetal weight. Boys are more likely to be large than girls. So, a male fetus is more likely to accurately be estimated to be large than a female fetus. In other words, not independent of size at all.

  3. Dreamy

    I always appreciate your comments and posts! I don’t mean to take this too far afield, but I have to say that, re-reading the comments (which are now closed), I am frustrated that my point was completely missed… and then that the comments were closed. I am sure it’s largely due to my intended point’s tangential and somewhat abstruse nature, but…

    My point was not really to argue all of the relative risks of vaginal vs. C-birth in general, nor even in such a case as presented. All I was really doing was breaking down the logic (or lack thereof) of choosing one option over another simply because the latter has a tiny risk of a particular scary outcome. That was what the previous commenter was doing IMO– not particularly using outside information, but using words that implied “It’s very likely to be a sunny day tomorrow” to conclude she should immediately start boarding up her windows and doors in preparation for a hurricane.

    Of course I didn’t present every single significant risk of vaginal birth. Nor did I present every single significant risk of C/S. All I was REALLY focused on was the risk of symphisiotomy vs. the risk of C/S for a woman like the theoretical patient.

    Why?

    Because that was what the previous commenter was focused on, and I was trying to demonstrate that it was a false dilemma. To me, it made no sense to choose C/S JUST from what was written– and yet, it seems people draw similar such conclusions all the time. My statistics were completely fabricated– I never once claimed they were “accurate” to any real degree– they were just illustrations drawn from the original doctor’s words. Words like “usually,” “rarely,” etc. You know– if someone says “usually” that is supposed to mean “more than 50%.” I wasn’t saying that the actual number was 51+%– I never claimed to know if it were 51%, 99% or even that the original speaker was full of it, and the real number were 5%. I was just saying that “more than 50%” is pretty much what “usually” means, and going from there.

    Ergh, this is as clear as mud, isn’t it?

    What bugged me was this idea that “I would choose a C/S over a symphisiotomy” actually represented any sort of realistic choice. I mean, who wouldn’t choose a C/S over a symphisiotomy? Vanishingly few people.

    But that wasn’t the choice. The choice was between a definite C/S and a very, very small possibility of a symphisiotomy.

    Heck, I’d rather have my pinkie surgically removed than lose a whole hand, but if my choice is between a 100% chance of losing a pinkie and something like a fraction of 1% of losing the hand, then I’m taking my chances with the latter option. Of COURSE that’s an oversimplification, but choosing the “pinkie” option only makes sense if you believe that even vaginal birth NOT resulting in a symphisiotomy is as risky or nearly as risky as a C/S in a pregnancy where the sole “bad sign” is a late U/S that seems to indicate a large baby.

    What I saw was someone concluding– based on the OP at The Unnecesarean alone– that a vaginal birth is the riskier choice. That really defies all logic. And not just logic, because sure, symphisiotomy is scary, and we’re allowed to have feelings, too! But such a response IMO reflects the general bias that C/S is “no big deal” (or almost never a “big deal”) and vaginal birth is just as risky or perhaps riskier than C/S. Or at least nearly as risky as C/S, such that the mere presence of a single, highly unreliable “bad sign”– which only rarely leads to scary outcomes even WHEN accurate– easily makes vaginal birth riskier.

    Does any of that make sense?

    It keeps me up a little at night, trying to think of good analogies (LOL), when people present straw men and false dilemmas, as they so often do when it comes to ideas that challenge oppressive societal structures.

  4. Angela

    Ugh. My only mal case against me a result of a crack using patient w NIDDM who only showed up for 3 or 4 prenatal visits, disappeared entirely while she was in jail, had 4 prev deliveries of large babies 10lbs. 5 min dystocia = worst fear of my life. Baby had Erbs so I knew suit would follow. One of the ” damning factors”. I didn’t put an efw in my h and p despite the “inaccuracy of any method of estimating efw at term”. all I can say is at least poor kid isn’t brain damaged or dead.

  5. Pingback: Us vs. them (or a blog retrospective) | Mom’s Tinfoil Hat

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