Tag Archives: Cesarean Section

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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Catching Babies Blog Series: Refusal, Rights and Balance

This is an entry in the Catching Babies Blog Series, a conversation with medical economist and author J.D. Kleinke about his new novel, which focuses on ob/gyn residents at the end of residency and the beginning of private practice.

Hilary: Hi J.D.,

I am a medical student who is currently on her obstetrics and gynecology (ob/gyn) rotation. I hope to be an ob/gyn resident in just over a year, and after that, a private practitioner, hopefully in an academic practice.

When I first heard about your book, I thought it would be more like Peggy Vincent’s Baby Catcher: Chronicles of a Modern Midwife than Grey’s Anatomy. But, as I read it, I was reminded of life in the call room, listening to the residents at my core rotation site talking about their engagements, their breakups, their exercise routines and their more difficult patients, in that order.

I was enthralled and moved by the dramatic medical and ethical issues in the beginning of the book: a resident so tired he is hallucinating, a vaginal birth after cesarean (VBAC ) patient with a ruptured uterus bleeding out in a snowstorm, and a twin to twin transfusion vaginal delivery with head entrapment. At first I thought, well, these are all extremes. But, the easy births don’t make good literature. And, the easy births don’t form residents’ practice patterns for years to come.

When I was doing my research on labor and delivery interventions, I asked an obstetrician in his late 60’s about VBAC. He said he saw a traumatic uterine rupture during his residency, and he would never let that happen to one of his patients. This same physician said he thought breech deliveries were fine, as long as they met certain conditions. He had never had a case of head entrapment, obviously, so his attitude and practice patterns reflected this.

How do you feel, as a medical economist and as a patient, about physicians practicing based on clinical experience and attitude as opposed to evidence? As much as I try to base my attitudes toward my future clinical decision making on evidence, I have a constant barrage from everyone around me, telling me I will only have one license and thousands of births, that obstetricians have to be “right” all of the time, that I need to protect my lifestyle as much as I need to advocate for my patients, and evidence is flawed, anyway.

This doesn’t even take into consideration the emotional and physical strain the particular practitioner is experiencing on that particular day. If a physician is practicing late on a Friday night, after not eating since breakfast, has already had two gynecological procedures go badly that day, hasn’t seen his family and has a chance to make it home just before bedtime, and will have to pay his weekend coverage physician for any births that he leaves behind, how does that factor into his decision making toward the women he has admitted in labor, if at all? We do hold physicians to much higher standards. We are not supposed to make any mistakes, ever, at all, and we are not supposed to let hunger, sadness, exhaustion, or pain affect our skills and our judgment. But they do. How can we balance this?

I am happy that there are new work hour rules in effect as of July of this year. (Link to new rules) Residents can still work 24 hours straight, and can still work up to 80 hours in one week. But, there are more limits on unsupervised practice and excessive work loads on first year residents. Catching Babies focused on graduating residents, who are presumably ready to practice on their own. Some people, mostly older physicians who walked uphill both ways during their residencies, criticize limits on resident work hours as limiting continuity of care and preventing residents from being trained adequately for private practice. As someone who once worked more than 100 hours in a so-called “Hell Week” at my midwifery training, I can tell you that you don’t learn very well once you are hallucinating, and your patients don’t have good continuity of care at that point, either.

I would also like to touch on the part of the book that dealt with anti-abortion protestors. I am glad you chose a religious resident who was struggling with his perspective on abortion as the victim of this violence. The real abortion debate is not black and white. It is very, very gray. As a co-president of our local Medical Students for Choice chapter, I found that most medical students who had qualms about performing abortions due to their religion were not in support of making all abortion illegal, and did not think all future practitioners should not be trained on how to do an abortion. I had many good discussions with them on what it means to be pro-choice, and how practitioners can separate their own values and choices from what they recommend or even force on their patients.

We had a Maternal Fetal Medicine specialist talk to our chapter of the obstetrics and gynecology interest group once. She was Catholic and self identified as “pro-life”. She said she was put in the position of having a mom almost die on her as an attending physician because she had refused to be trained on how to treat a ruptured ectopic pregnancy, which inevitably involves removing the embryo. She told us that she will never be in that position again, and neither should we.

It was very important in Catching Babies for Dan, despite his religious beliefs, to be well trained in second trimester abortion. He paid for it dearly. It’s easy for a fervent protestor to be behind a sign or a brick, and easy for me to walk past their bullhorns and pictures of gruesome products of conception blown up to billboard size with a glare when I attend the American College of Obstetrician and Gynecology Annual Clinical Meeting, but I am not sure how I will feel when I am on my Family Planning rotation when I, like Dan, have to face those very real, very tiny body parts in the stainless steel bowl. Or how I will feel if a brick comes through my window or my family is threatened when I am an abortion provider. I do know that I will never face a teenager who has been date raped, like I was in high school, and tell her that there is nothing I can do. And I will never let a woman die from an ectopic pregnancy because of a philosophical argument.

Anyway, I guess I am commenting on the amorphous line where the private life of the practitioner ends and the needs and rights of the patient begins. I think work hour rules, oversight, some sort of protection against frivolous lawsuits and consideration of the physician as a human being is important. But I also think the autonomy and informed consent of the patient, along with the practice of evidence based medicine, is just as important. I am wondering how you think this interplay can be balanced.

J.D. Kleinke: Thanks for your comments, Hilary.

These are great observations and important questions. If I am teasing out your questions properly, I’ll respond as follows.

The recent movement across all medical residency programs toward reduced work hours is decades overdue. There is no clinical rationale for the brutality, on providers or patients, of any OB/GYN shift lasting longer than 12, let alone 16, 18 or 20 hours. 24 hours is a reform? You want someone cutting past YOUR uterine artery in hour 23? Into a uterus holding your baby? Around your bladder or clitoris? I wouldn’t want them cutting my bagel at that point, for fear of what they could do to themselves with the knife, let alone me. The OB/GYN residency, like most residency programs, is hazing, plain and simple, more frat house than boot camp – because boot camp is actually a workplace-relevant culling – and it is incredibly dangerous. It is also an incomprehensibly stupid way to compensate for the dysfunctional economics of federal residency funding, academic medicine generally, and our operation of a major part of the safety net we have woven over the years to care for the poor and uninsured and lost. As a gruesome physical, psychological and emotional endurance race, OB/GYN residency selects for and rewards physicians based less on sheer clinical skill and commitment, but on irrelevant criteria like stamina and the ability to think without sleep. It probably weeds out, before match or during residency, God knows how many gifted physicians who do not have these characteristics, or do not want to endure their mobilization. Not only does this bizarre gauntlet-based acculturation process NOT yield for society the best of all possible OB/GYN workforce – it probably yields a subset of people with a special capacity for detachment, indifference, masochism, self-denial, and/or dissociation. Is this who we want to deliver our babies? Is this who we want making emotionally gut-wrenching decisions about medically indicated termination, oopherectomy, hysterectomy? People chronically overstimulated from adrenaline, exhaustion and stress? When they themselves are so compromised, they have lost all sense of wonder, joy, and pathos? Let’s speak plainly: sleep deprivation is a method of torture. And it’s a great one for a secretive regime, because it leaves no visible marks. But prolonged sleep deprivation is how you break people, get them to compromise their most deeply held beliefs, sell out their own friends and families. Is this really how we want to acculturate those attending our childbirths?

Medical evidence and clinical experience are equally valid and equally important. This is not an either/or question, though the loudest voices on both sides of this debate make it sound like it is. All medical fields need more and better data, data-driven protocols, richer informatics at the point of care, and real feedback loops. But we also need human beings at the helm. And we need human beings – both OBs and midwives – who are willing to answer AND follow through on the toughest, most frequent, most important question that patients ask: if this were you, or if this were your wife, what would YOU do? As with that VBAC-averse veteran OB, when one provider’s negative experience with a difficult case diverges with the best known evidence on that case, they have a profound ethical responsibility to turf the case to somebody, anybody. Because no human being can be expected to repress their own terror about a clinical pathway that, even though they know the numbers and the evidence in support of that pathway, they can no longer go down it for their patient. That’s their right as a provider, and as a patient, I’d much rather be warned about it and turfed. And if that weren’t possible, and the potential divergence in outcomes were not that great, I might also prefer the less evidence-backed approach, if my provider were completely comfortable with that pathway and terrified of the evidence-backed pathway. This is the damnable reality of evidence – it works for the study group, but study groups are made up of thousands of little clinical realities, each of which are multi-factorial and, at rock bottom, ultimately human, not machine. Medical evidence is like snow, and every patient is a snowflake.

Much of the clinical practice of abortion is indeed gray, despite deeply held beliefs in this country that abortion is a black-and-white issue. This is why the book takes the abortion problem head-on, as it rears it hydra-headed self in residency, no matter what the protesters out in front of the clinic want to believe. The clinical case I chose in Catching Babies runs right down the middle of the line, for both the devoutly Catholic OB and the desperately ill teenager he is trying to help. All OB/GYNs, no matter how deeply held their views against abortion, run up against these ugly, clinically ambiguous realities in their training, and they have to decide, often with heartbreaking angst, how they are going to navigate them. Ectopic pregnancies do rupture, women do miscarry and need D&Cs, fetuses do develop fatal in utero anomalies in the middle of the pregnancy that will erupt and kill the woman if they are not terminated. These are the gruesome facts of nature, no matter how many laws we pass, providers we harrass, or patients we terrorize outside clinics. All OB/GYNs need to be trained adequately to deal with these clinical situations. And with equal force, I’ll say that all OB/GYNs need to have complete freedom to decide for themselves what they are willing to do, and under what circumstances. Most importantly, they need to be honest with themselves and their patients. Finally, all women and their families need to understand that their OB/GYNs are also human beings, people with hopes, dreams, frustrations, beliefs, fears and political agendas, who are bringing their own souls into every exam room, labor deck, and OR. This is probably the key impulse for my writing the book. I wanted people to understand how the culture of the OB/GYN is formed, informed, mal-formed, and where it can and should be re-formed.

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Other posts in the Catching Babies Blog Series:

Consider the Source: A new voice for maternity care reform
Tolerating Risk in the U.S. Maternity Care System
Catching Babies Blog Series: Fear, Faith and Perverse Incentives

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Catching Babies Blog Series

I am participating in a blog series on Catching Babies, a novel about obstetrics and gynecology training by health economist J.D. Kleinke. As a medical student on her obstetrics and gynecology rotation who is (hopefully!) staring down an obstetrics and gynecology residency soon, it really resonated with me.

Amy Romano kicked it off with an interview with the author on Science and Sensibility, and Kristen Oganowski followed up with a great back and forth with him on Birthing Beautiful Ideas.

Stay tuned for more great posts!

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VBAC Summit

As long promised, here is my wrap up of the VBAC Summit, hosted by the illustrious Birthgirlz, aka Miriam Pearson-Martinez and Michelle Fonte. I was one of many speakers at this year’s summit. I was part of an impressive line up including Miriam Pearson-Martinez, Laureen Hudson, R. Zachary Pearson-Martinez, Jill Arnold from The Unnecesarean, Tamara Taitt, Dr Christ-Ann Magloire, and Nancy Wainer.

I had a fantastic time at the summit. Here are a few pictures from the summit, including a not very flattering one of me starting off my presentation with a grin. Jill Arnold and I spent the weekend together and caused all sorts of trouble and were very silly. All of the speakers were wonderful.

Here is a link to my presentation, “ACOG, VBAC and other four letter words,” a history of ACOG’s position on VBAC.

I was promised audio of my presentation, so I am hoping that shows up in my email inbox sometime soon. In the meantime, I am wrapping up my Geriatrics rotation and really looking forward to finally starting ob/gyn next month!

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Shenanigans

I still owe a VBAC Summit post, but in the meantime I want to link to some photographic evidence of the total goofiness that happened in and around the conference.

VBACitivist of the Year and Birth Activism Diva Jill Arnold stayed with me for the conference, and within about, oh, two minutes of meeting in person we figured out that we were two peas in a very, very twisted pod. In between talking like Foghorn Leghorn and giggling, she had some time to take some pictures. Some of them involve me, some are very silly, and some have made it onto her blog.

February Travel with Pictures

From Supine to Lupine

Proof that we feminist activist aren’t humorless.

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Defensive medicine series

Please hop on over to The Unnecesarean for an outstanding series on Defending Ourselves Against Defensive Medicine. I am sorry to say I was invited to contribute and didn’t manage to get a piece ready. I am very impressed with what has been released so far.

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So, I’m still here

Again I find myself apologizing for the blog silence. There are a few reasons I have been quiet.

First of all, my ex has been reading my posts and complaining to players in our divorce about what I write on here. So, I am not writing more about our divorce on here.

Secondly, I have been pretty busy. I have been doing the holiday thing with the kids, family and friends. I did get a few days off work. I am actually pretty happy to get back. I am enjoying pulmonology, and may look into doing a 4th year elective with the same attending physician. I am getting pretty good at ABGs.

I am not so good at EKGs. I did a module on EKGs using this ECG Wave-Maven, and I am really confused by a 5:4 AV Wenkebach. I could spot the MI’s, which is a relief, I guess.

So, there is more stuff I wish I had the energy to talk about. Mtv had an episode of “16 and Pregnant” called No Easy Decision in which one of the teen moms gets pregnant again, and decides to terminate the pregnancy. I have not seen it, but I think there are actually three young women who discuss choosing abortion. From what I have heard, it is a well put together show. Exhale has put together a site called 16 and loved that supports her coming forward with her story.

California Watch published a report entitled “As early elective births increase so do health risks for mother, child”. Thanks to Jill at The Unnecesarean for covering this.

CNN had an article on CNN.com called “Mom defies doctor, has baby her way” about a woman who had a home birth VBA3C (vaginal delivery after 3 cesareans). She was alternately painted as reckless and also as having no other option. How is a woman supposed to have a VBAC in a facility “with staff immediately available to provide emergency care” if practitioners who deliver in these facilities refuse to attend VBACs?

Anyway, I’m back, at least for the time being. I hope my son’s guardian doesn’t tell me he got an earful about my blog again. I am not airing all of our dirty laundry on here. Believe it or not, this is reticence.

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