Archives for posts with tag: informed consent

American Heritage Dictionary (my personal favorite) defines treatment in a medical context as

a. The use of an agent, procedure, or regimen, such as a drug, surgery, or exercise, in an attempt to cure or mitigate a disease, condition, or injury.
b. The agent, procedure, or regimen so used.
Notice the terms cure and mitigate.
If we go back to the dictionary, cure is
a. A drug or course of medical treatment used to restore health: discovered a new cure for ulcers.
b. Restoration of health; recovery from disease: the likelihood of cure.
c. Something that corrects or relieves a harmful or disturbing situation:
and mitigate is
a. To make less severe or intense; moderate or alleviate.
Thus, we should expect that any medical treatment should make us better than we would be without it.  Yet reporting on a systematic review in JAMA,  the New York TImes recently ran a piece called “If Patients Only Knew How Often Treatments Could Harm Them.”
Perhaps in these cases, we might want to reconsider using the term “treatment.”
The JAMA review, “Patients’ Expectations of the Benefits and Harms of Treatments, Screening, and Tests,” concludes
The majority of participants overestimated intervention benefit and underestimated harm. Clinicians should discuss accurate and balanced information about intervention benefits and harms with patients, providing the opportunity to develop realistic expectations and make informed decisions.
But where are patients getting this information?  While some may see advertisements for a handful of drugs, for the most part, patients get information on “treatment” from their doctors.  A commentary on the review suggests limiting advertising and changing product labeling to be more transparent (big thumbs up from me on the second one in particular).  It also says that
[A] physician must first understand the risk herself (or himself) and must then communicate it effectively.  It is not clear that physicians do either of these things well.
Addressing OB care, the JAMA article notes that only 9% of women accurately identified the benefits of a trial of labor after cesarean (TOLAC) over an elective repeat cesarean (ERCS), and only 37% accurately identified risks of a TOLAC. Patients also incorrectly identified the benefits of a fetal abnormality scan (90% overestimated the benefits), and 57% could not accurately identify the risks of amniocentesis.
One of the original articles from the review, Trial of Labor After Repeat Cesarean: Are Patients Making an Informed Decision, states
Women in both groups [TOLAC or ERCS] were insufficiently informed about the risks and benefits of TOLAC and ERCS, particularly women in the ERCS group. Specifically, our patients were not familiar with
  • the chances of a successful TOLAC,
  • the effect of indication for previous cesarean section on success,
  • the risk of uterine rupture,
  • the increased length of recovery with ERCS versus TOLAC
  • the increased risk of maternal death, neonatal respiratory compromise, and neonatal intensive care unit admission with ERCS.

In addition, if our patient felt her provider had a preference, she was more likely to choose that mode of delivery, whereas when patients felt their providers were indifferent or if they were unaware of their providers’ preferences, 50% chose one mode and 50% chose the other.

 Note there is no indication that the women who did not feel the provider had a preference were making their own decisions based on accurate information.
Anecdotal evidence indicates that providers rarely provide accurate information–and sometime provide no information, simply saying, “Let’s schedule your cesarean.”  Some examples:
  • Jessica: I was told I need not waste my time trying to attempt a vaginal birth because it would be another long birth that would ultimately end in another section.
  • Jenerra: “I was always told by my doctors that because I had my first c-section that I would have to keep having them, even though my first c-section was the result of an induction gone wrong.”
  • Kiara: I do believe that [my primary cesarean] was the best outcome for everyone, but I knew that I didn’t want that
    experience again. When I discussed this with my OB, she said ‘Oh, we don’t do VBACs in this practice. When you get pregnant again, we’ll just schedule you like a hair appointment. Easy!’
  • Jamie: [My OB said], “You don’t want to VBAC. You don’t need to tear up your little bottom.”
The JAMA article, which is not focused on obstetric care in particular, does not address other common obstetric “treatments.” For instance, many physicians conduct ultrasounds routinely during pregnancy.  A friend of mine said her doctor never measured her fundal height, instead conducting an ultrasound at every appointment, even though there is no indication that having ANY ultrasounds improves pregnancy outcomes.   Other “treatments” for which women may not be adequately informed of benefits and risks include elective inductions,  Pitocin augmentation, and episiotomies, along with any number of other “treatments” offered in prenatal care, labor, and childbirth.
Women often believe they have no say in these procedures at all, as they are often presented as something that is going to occur rather than a choice that the woman can make.  Unfortunately, though ACOG offers excellent guidelines on informed consent, in practice informed consent is rarely more than a women signing a form that she has no time to read, and informed refusal is never on the table at all.  In fact some recent cases have indicated that in some cases doctors override a woman’s informed refusal, as in the case of Rinat Dray’s forced cesarean and Kelly X’s forced episiotomy.
The New York Times report on the JAMA review states:
This study, and others, indicate that patients would opt for less care if they had more information about what they may gain or risk with treatment. Shared decision-making in which there is an open patient-physician dialogue about benefits and harms, often augmented with use of treatment decision aids, like videos, would help patients get that information.
Unfortunately, shared decision making operates as a buzz phrase rather than a practice most of the time.  Perhaps this uninformed approach to “treatment” is why Marinah Valenzuela Farrell, a certified professional midwife, and president of the Midwives Alliance of North America notes in the New York Times series “Is Home Birth Ever a Safe Choice?” that hospitals carry their own risks.
They just don’t inform you about them.
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It is often noted that change takes time, specifically that it takes about 17 years for research findings to be consistently adopted as practice.  We see that issue frequently in obstetrics, where it often takes longer.  For instance, even though high quality research has shown for more than 20 years that routine episiotomies cause the very tears they were initially hypothesized to prevent, in many hospitals, episiotomy rates remain above 30%, with rates at some institutions being much higher (read more on episiotomy here).

In considering VBAC, however, we can see that change can occur almost instantaneously–in one direction.  The American College of Obstetricians and Gynecologists (ACOG) began recommending restricted use of episiotomy in 2006–more than a decade after research showed the risks of routine use–and many practitioners still aren’t on board.  But when ACOG changed its recommendations regarding vaginal birth after cesarean (VBAC), the practice came to a screeching halt.

ACOG has offered a series of recomendations on VBACs, beginning with Committee Opinions in 1988 and 1994, with Practice Bulletins following in 1995 (#1), 1998 (#2), 1999 (#5), 2004 (#54), and 2010 (#115).  Dr. Hilary Gerber put together an excellent slide show explaining the changes in each set of recommendations, which you can view here.

For most of the twentieth century, when lifesaving cesareans became a real option in hospital births, the common wisdom was “once a cesarean, always a cesarean,” a statement made professionally in 1916 at the New York Association of Obstetricians & Gynecologists.  However, for the next 60 years, cesareans were so rare to begin with that the number of women undergoing repeat procedures was small.  The overall cesarean rate in 1965 was under 5%.  As primary cesareans became more common in the late 1970s and through the 80s, more and more women also underwent repeat cesareans, and by 1990 the overall c-section rate was almost 23%.  At the same time, surgical techniques advanced to make VBACs safer, and in 1990 about 20% of women who had a prior cesarean had a VBAC.

In 1994, ACOG issued a Committee Opinion that said that in the absence of contraindications (primarily classical incision in prior cesarean), women should be encouraged to undergo trial of labor after cesarean (TOLAC) rather than automatically being scheduled for a repeat cesarean.  We know now that most women, especially those with only one prior cesarean, are good candidates for VBAC, and it is estimated that 70% of women undergoing TOLAC can have successful VBACs, but the next year, the VBAC rate was only 27%.  While this was definitely an increase, it hardly indicated that all of the most appropriate candidates for TOLAC were actually going into labor.  The VBAC rate peaked in 1996 at 28.3% and then began to decrease, driven by an article by Michael McMahon et al that linked TOLAC to an increase in maternal complications.

In 1999, ACOG released new, more restrictive recommendations, in part as a response to the McMahon article.  Chief among the changes was what became known as the “immediately available standard”:

VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.

This recommendation was Level C evidence, meaning it was based on clinical opinion, not research trials.  Level A evidence, the level with the highest quality research to back it, still stated in the same bulletin that most women with prior cesareans were good candidates for TOLAC.

The problem with the immediately available standard is that most smaller hospitals can’t meet it.  They may not have an anesthesiologist in house 24/7 or enough OBs that there is necessarily one standing by on the ward, ready to perform surgery.  Even large hospitals may not meet this standard if they cannot guarantee that the available doctors will not be busy with other patients.  The standard was not specifically defined, and rather than be concerned that they weren’t meeting it, many hospitals simply stopped offering TOLACs, requiring patients who had previous cesareans to schedule a repeat surgery.

Here’s what happened:

cesarean VBAC graph

The line that ends at the top is the overall cesarean rate.  The line that ends in the middle is the primary cesarean rate, and the line that ends at the bottom is the VBAC rate.  In the mid 1990s, the VBAC rate was higher than the overall cesarean rate, but within a year of the 1999 guidelines, VBAC rates were down to what they had been in 1993, the year before less restrictive guidelines were initially recommended.  But it didn’t stop there.  The rate just kept decreasing.

in 2010, ACOG again issued less restrictive guidelines for VBAC.  Dr. Richard Waldman, ACOG’s president at the time, said,

Given the onerous medical liability climate for ob-gyns, interpretation of ACOG’s earlier guidelines led many hospitals to discontinue VBACs altogether. Our primary goal is to promote the safest environment for labor and delivery, not to restrict women’s access to VBAC.

The new guidelines stated not only that most women with a prior cesarean were good candidates for VBAC, but that many women with two prior cesareans were as well.

Here’s what happened:

primarycesvbactbl

The rates rose a tiny amount, and remain about half of what they were in 1990.

In 2014, AGOC issued a consensus statement about preventing primary cesareans.  This publication pointed out some of the risks of cesarean over vaginal birth, including a tripling of risk of maternal death.  While some hospitals and doctors have gradually become more receptive to VBAC and have lifted out-and-out bans, some hospitals have instituted new bans since the 2010 and 2014 guidelines were released.

Many providers do not support VBAC and do not present benefits and risks in a way that allows women to make informed decisions.  The website My OB Said What? is full of quotes from doctors misrepresenting VBAC risks:

Attempting a VBAC is comparable in risk to standing your older child out in the middle of a busy highway and hoping she doesn’t get hit by a semi. Maybe the odds of her being hit are low, but you wouldn’t take that risk with your other child, so I don’t understand why you’re willing to risk your unborn baby’s life.

I don’t know where you got the *delusion* that you could VBAC, there was a law that was passed against VBAC’ing after more than one cesarean.

A VBAC is like *jumping off a bridge* in which mortality is close to 90% with a uterine rupture!

When citing risk of “uterine rupture,” many physicians include scar separation in the totals.  Just to clarify, there is a difference between genuine uterine rupture, which is a genuine emergency, and a cesarean scar opening, which is not:

In contrast to frank uterine rupture, uterine scar dehiscence involves the disruption and separation of a preexisting uterine scar. Uterine scar dehiscence is a more common event than uterine rupture and seldom results in major maternal or fetal complications.

So let’s review:

  • When VBACs were recommended as safe in 1994, the rate slowly crept up, reaching over 28% in 1996.
  • The rate began to go down in 1997 in response to a single article, even before recommendations were issued by ACOG.
  • When the “immediately available” standard was introduced in 1999, the rate plunged to its pre-1994 level within a year.
  • 10 years after the “immediately available” standard (level C) was introduced, the rate was 8.4%, even though the Level A recommendations still said that most women were good candidates for TOLAC.
  • Two years after less restrictive standards were introduced in 2010, the VBAC rate had inched up less than 2 percentage points, to 10.2%.  Many hospitals have continued their de facto VBAC bans, some hospitals have introduced new bans, and many physicians still refuse to perform VBACs.

The problem is (as others have also pointed out), why are hospitals not ready to perform an emergency cesarean?  Isn’t that the whole reason to birth in a hospital–that they are prepared for emergencies?  Uterine rupture is not unique to VBAC–it can happen as a result of  any number of complications, including labor inductions.  A hospital that is not equipped to support a TOLAC is not set up to support birth emergencies.

VBACfacts.com has a list of VBAC myths and corresponding correct information.  here is my favorite:

Myth:  If your hospital doesn’t offer VBAC, you have to have a repeat cesarean.

As Howard Minkoff MD said at the 2010 NIH VBAC Conference, “Autonomy is an unrestricted negative right which means a woman, a person, anybody, has a right to refuse any surgery at any time.” ACOG affirms that “restrictive VBAC policies should not be used to force women to undergo a repeat cesarean delivery against their will.”

If your hospital does not support VBAC, ask them why they are not properly equipped and staffed to perform emergency cesareans.  Then go elsewhere.

 

There has been renewed interest in cesareans in the news (and on this blog) since the release of the ACOG/SMFM consensus statement on preventing primary cesareans in March.  When all health care providers are following best practices, rates of procedures should be relatively similar in patients with similar risk profiles.  This is not so for cesareans, where rates of the procedure in low risk births (singleton, cephalic fetus at term; woman with no health complications) can range from less than 5% to nearly 60% depending on the hospital.

Recently the Contra Costa Times ran a story about the issue in which they quoted Dr. Kirsten Salmeen (whose research interests indicate that she is interested in shared decision making models).  Here is the section of the story in which she comments on practice variation:

Why such profound variations? Should our standards of medical practice be so flexible?

The answer is “complicated” replies Dr. Kirsten Salmeen of the Maternal Fetal Medicine Division at UC San Francisco. She thinks variations in cesarean rates across the country are “likely due to a combination of factors.” That includes differences in patient populations and preferences, provider availability and coverage, hospital and provider culture, access to anesthesia and surgical obstetric services, and the prevailing medico-legal climate.

For example, Salmeen proposed that a difference in rate might depend upon the scope of available obstetrical services. In a hospital staffed with 24/7 obstetric coverage and resourced to provide a C-section when needed, a woman might be allowed more time for labor with a vaginal delivery. In contrast, that may not be as feasible with a solo or small-group provider who’d have to cancel scheduled clinic appointments with many patients in order to wait upon one patient’s labor.

While resource allocation can affect cesareans, in many countries, scant resources mean that women cannot get cesareans that they do need, which is one reason infant and maternal mortality rates are so high in developing nations where hospitals are not universally accessible by birthing women.  It seems preposterous that a lack of resources would lead to more cesareans–it’s how those resources are allocated.

The more important question in terms of shared decision making and informed consent is what women are told when a doctor performs a cesarean.  Are they given the real reasons as outlined by Dr. Salmeen:

  • Does an obstetrician in solo practice say, “Your labor is normal and you and the baby are doing fine but it looks like your birth is going to take several more hours, and I have patients waiting at the office, so is it okay if I just do a cesarean?”
  • Or perhaps in a state with high malpractice claims, the obstetrician says, “Your labor is normal and you and the baby are doing fine, but you had a brief indeterminate fetal heart rate tracing, and if your baby isn’t perfect, you could use that to sue me, so is it okay if I just do a cesarean?”
  • Or perhaps the obstetrician says, “Our culture here at this hospital is to do cesareans on women who don’t really need them, so let’s schedule yours now.”

Somehow, I think not.  Here is a video, intended to be humorous, in which the “OB” convinces a woman to have a cesarean, which “will be way easier” for him:

 

Unfortunately, the kinds of things the actor says are often not that far from things some obstetricians say in real life.

As Dr. Elliott Main (a generally great guy) points out, a doctor can convince pretty much any woman to have a cesarean.  Few women will refuse when a doctor tells them their baby is in danger.

That’s a much easier sell than needing to get back to the office.

 

Rinat Dray was forced to have a cesarean in 2011 at Staten Island University Hospital.  Dray had two previous cesareans and chose a doctor who said he supported her desire for a VBAC and a hospital with (by American standards) a low cesarean rate and a good VBAC rate.  But once she arrived at the hospital in labor, according to Dray (as reported by the New York Times),

The doctor told her the baby would be in peril and her uterus would rupture if she did not [have a cesarean]; he told her that she would be committing the equivalent of child abuse and that her baby would be taken away from her.

She still refused the cesarean, and she was supported in her refusal by her husband and her mother.  The hospital strapped her down and wheeled her into surgery as she begged them to stop.  A note in her medical record by Dr. James Ducey says, “I have decided to override her refusal to have a C-section.”  During the surgery, the doctor punctured her bladder.  You can hear a podcast on RH Reality Check in which Dray discusses her case along with professionals in obstetrics, law, and ethics.

Dray is a Hasidic Jew, which likely means that she wants a large family.  While there are risks to vaginal birth after cesarean, in most cases there are even greater risks to having many cesareans.

In the podcast, Dr. Katharine Morrison, MD, FACOG (Director of Buffalo WomenServices, which I wrote about here) says that she reviewed the record and it did not appear that there was an emergency situation or that a cesarean was needed at all.  But even if a cesarean has appeared necessary to preserve the life or health of Dray or her baby, as Dr. Howard Minkoff, chairman of obstetrics at Maimonides Medical Center in Brooklyn, said in the NYT article, “I don’t have a right to put a knife in your belly ever.”

One would think that a case in which a psychologically stable woman refused surgery and was then strapped down, sliced open, and had her bladder perforated would be apparent to anyone as a horrendous breach of human rights.  (And actually, she was asking them to wait a little longer, not saying she would not agree if she felt a cesarean was truly necessary).

All one has to do to see where a woman falls in the human rights spectrum of many is to read the comments on the New York Times piece.

The comments fall into a number of categories, including some that unequivocally support Dray.

Many, however, unequivocally support the the doctors or the profession of obstetrics.  Here is Northstar5:

If this woman had 2 prior C-sections then the doctors are absolutely right that vaginal delivery was exceedingly risky. I almost laughed when I read that the woman is charging the doctors and hospital for “improperly substituting their judgment for that of the mother.” What?? That’s what they are supposed to do. They are doctors, she is not.

Some defend the doctors doing whatever they like to avoid risks of malpractice:

Attempting a vaginal birth after two c-sections is extremely dangerous and reckless. The physicians involved would likely have been sued regardless of the method of delivery, so I applaud them for at least saving a life in this case.

I’m not sure where the commenters get their medical information, but the doctor agreed in advance to attend Dray at a vaginal birth.  You can read the entire American College of Obstetricans and Gynecologists’ practice statement “Vaginal Birth After Previous Cesarean Delivery,” which specifically says, “women with two previous low transverse cesarean deliveries may be candidates for TOLAC [trial of labor after cesarean].”  I highly recommend that you visit Jennifer Kamel’s website VBACFacts.com and read “13 Myths about VBAC.”  Repeat cesarean and VBAC both have risks.  The newest ACOG obstetric care consensus statement on cesarean points out the risks of cesarean over vaginal birth.  Cesarean nearly quadruples the risk of maternal death, and risks of maternal morbidity and mortality go up with every cesarean.  This would be a particular concern for a woman who wanted a very large family, as many Hasidic women do.  Here is a consent form that clearly lays out the risks and benefits of repeat cesarean and VBAC.

Some commenters are completely on the side of the fetus–if the mother’s status is reduced to that of a container, so be it.  Here’s NYC Commuter:

In this case, the hospital and doctors have not one patient, but two. One is an adult who appears competent to make medical decisions. The other is a fetus, at term, who has no voice. The courts have repeatedly affirmed that the state has a duty to protect citizens that cannot protect themselves. If a fetus is believed to be “alive,” then an argument can be made that it must be protected as well. Pregnant women have been forced to receive imprisoned to prevent them from harming their fetuses (e.g. drug abusers), take medication (e.g. for treatable diseases), and even receive c-sections if the baby’s life is judged to be in direct jeopardy.

I have written about the ethics of privileging the well-being of a fetus over an adult woman many times, including here, here, and here.  ACOG also agrees that a woman should have the right to make her own decisions, even if it may negatively impact the fetus.  One recommendation from ACOG’s Committee Opinion, “Maternal Decision Making, Ethics, and the Law” says,

Pregnant women’s autonomous decisions should be respected. Concerns about the impact of maternal decisions on fetal well-being should be discussed in the context of medical evidence and understood within the context of each woman’s broad social network, cultural beliefs, and values. In the absence of extraordinary circumstances, circumstances that, in fact, the Committee on Ethics cannot currently imagine, judicial authority should not be used to implement treatment regimens aimed at protecting the fetus, for such actions violate the pregnant woman’s autonomy.

In addition to wanting to protect the rights of physicians and fetuses over those of pregnant women, many commenters simply condemn Dray as selfish, selfish, selfish.  Here’s Beth Green:

What an incredibly selfish woman putting her unborn child in harms way. She got her several hours of trial-labor and no baby, so according to the standard of care she got a C-section and a healthy baby.

Some also posit that Dray is not only selfish but also psychologically compromised.  Here’s Dave:

This case is not about the “debate over C-sections.” This case is mostly about psychopathology, but there is a larger point. Rinat Dray’s actions harm us all. In her narcissism, she was willing to sacrifice her child to maintain her sense of control. This bears repeating – we are dealing with someone who would rather her child suffer than allow a section. So I’m sure she cannot put herself in the place of others, and she will not understand this, but she makes it all the more difficult to deliver babies in the US. Once all the OB/GYNs suffer these indignities and these lawsuits from those with personality disorders, who will deliver babies safely?

And here’s Reader:

A mother in labor who focuses more on her joy of delivery rather than trying to ensure that she delivers a healthy child who could be stuck with birth defects for up to an average of 7-8 decades thereafter is not rational, is selfish and needs to have her head examined.

What we get above all else if the “all that matters is a healthy baby” trope.  Here is NMY:

I have absolutely no sympathy for this woman at all. Her sense of entitlement is simply galling. She’s having a baby. The most important thing here is to ensure the delivery of a healthy baby, not to satisfy some preconceived notion that she should have a vaginal delivery.

Here’s Jen:

The OBGYNs can’t win. Now they are going to get sued for performing c-sections. It used to be they got sued for not doing the section soon enough. This lawsuit is absolutely ridiculous and I hope the physicians win. Do you want a c-section and a healthy baby or a VBAC and a dead baby? How can any mother refuse a c-section when the physician is telling you the health of your baby is at risk?

Here’s Stephen:

Sorry, but the health of the fetus should trump the intellectual desires of the mother….There are too many C-sections performed to be sure, but isn’t the point of labor and birth to deliver a healthy baby?

Here’s Lynn in DC:

She had this child in 2011 and all of her children are healthy so what’s the big harm here?

Aside from the fallacy of believing that Ms. Dray could not have both a respectful vaginal birth AND a healthy baby, a healthy baby is not all that matters.  A healthy mother matters too.  As in Ms. Dray’s case, having a perforated bladder and the trauma of being strapped down for a surgery that she actively refused did not result in a healthy mother.  Not being dead is not good enough.

 

 

 

Image The cesarean rate is Brazil has been high for a long time, and it is getting higher.  In private hospitals, almost all women deliver by cesarean; in public hospitals it’s about half.  According to Ricki Lake, who went to Brazil in the process of filming The Business of Being Born, “There was actually a joke circulating that the only way to have a natural birth in Rio was if your doctor got stuck in traffic.”  Brazil’s childbirth practices have come to attention recently because of Adelir Carmen Lemos de Góes, who on April 1, 2014, was taken by police to have a forced cesarean under court order.  Here’s an account of what happened from The Guardian:

…Brazilian mother Adelir Carmen Lemos de Góes was preparing for her third birth. Despite living in a country with one of the highest caesarean rates in the world (82% for those with private insurance and 50% for those without), she was looking forward to giving birth vaginally after previously having caesareans she felt were unnecessary.  However, in the midst of her labour, six armed police banged on her front door. Despite there being no question of reduced mental capacity, doctors had obtained a court order allowing them to perform a caesarean…Adelir was taken from her home, forcibly anaesthetised and operated on without consent.

Attorney Jill Filopovic writes,

A Brazilian court granted a prosecutor’s request for the appointment of a special guardian. And just in case it was unclear whose life gets prioritized when a woman has a c-section against her will, the judge specified that when there is a ‘conflict of interests of the mother with the child’s life … the interests of the child predominate over hers.’

Filopovic quotes Dr. Simone Diniz, associate professor in the department of maternal and child health at the University of São Paulo: 

In our culture, childbirth is something that is primitive, ugly, nasty, inconvenient….It’s part of Catholic culture that this experience of childbirth should come with humiliation.

The Atlantic subsequently ran a longer piece by Olga Khazan, “Why Most Brazilian Women Get C-Sections,” which, also points to a confluence of attitudes, practices, policies, and norms that lead to a trend toward universal cesarean.  Humiliation isn’t hard to come by in Brazilian obstetrics.  Khazan reports,

Many physicians’ attitudes toward childbirth weave together Brazil’s macho culture with traditional sexual mores….When women are in labor, some doctors say, ‘When you were doing it, you didn’t complain, but now that you’re here, you cry.’

Mariana Bahia, who participated in protests against forced cesarean, noted:

There’s no horizontality between patients and doctors.  Doctors are always above us.

And Paula Viana, head of a women’s rights organization, said,

We have a really serious problem in Brazil that the doctors over-cite evidence [of fetal distress].  They think they can interfere as they would like.

But much of what these various articles says about childbirth in Brazil is eerily similar to what happens in the United States.  Khazan quotes Maria do Carmo Leal, a researcher at the National Public Health School at the Oswaldo Cruz Foundation about birth practices in Brazil:

Here, when a woman is going to give birth, even natural birth, the first thing many hospitals do is tie her to the bed by putting an IV in her arm, so she can’t walk, can’t take a bath, can’t hug her husband. The use of drugs to accelerate contractions is very common, as are episiotomies.  What you get is a lot of pain, and a horror of childbirth. This makes a cesarean a dream for many women.

In the United States, Pitocin induction and augmentation are ubiquitous , and episiotomies, though less common than in Brazil, are still greatly overused.  Almost all U.S. hospitals use IV hydration as a matter of policy (rather than allowing women to eat and drink as they please, which is the evidence based recommendation).  And in the U.S., taking a bath in labor may be impossible, as many hospitals do not provide bathtubs out of a misguided fear of women attempting waterbirths. The website My OB Said What documents a seemingly endless stream of U.S. health professionals’ humiliating comments, such as referring to a pregnant women as a “little girls,” criticizing their weight, or belittling their pain.

Court ordered cesareans occur in the United States as well, as Erin Davenport documents in “Court Ordered Cesarean Sections: Why Courts Should Not Be Allowed to Use a Balancing Test.”  Davenport notes that forced cesareans are generally ordered because of concerns for fetal welfare–as in Brazil, U.S. courts often privilege the rights of the fetus over those of the pregnant woman.

Alissa Scheller created infographics on Huffington Post showing how states’ policies are used to persecute and prosecute pregnant in the name of fetal welfare.

Image

National Advocates for Pregnant Women, whose research supplied much of the information for the above graphic, documents the legal control of pregnant women that occurs in the name of fetal rights, such as prosecuting a woman for murder after a suicide attempt while pregnant (in this case, the baby–born by cesarean–was alive, but died a few days later).

While the cesarean rate in the United States is much lower than in Brazil, a third of U.S. births are by cesarean, more than double the “threshold not to be exceeded” identified by the World Health Organization.  Khazan notes the parallels between Brazil’s medical system and the the system in the U.S.–both incentivize cesareans:

With the higher price of the private system [in Brazil] comes better amenities and shorter wait times, but also all of the trappings of fee-for-service medical care. C-sections can be easily scheduled and quickly executed, so doctors schedule and bill as many as eight procedures a day rather than wait around for one or two natural births to wrap up.

As in Brazil, though some cesareans performed in the U.S. are certainly in the interest of maternal and/or fetal well-being, many are in the interest of the obstetrician’s well-being.  There is still a convenience factor; in addition, OB-GYN Dr. Peter Doelger said doctors and hospitals are protecting themselves by following protocols based a fear of litigation:

So you’re stuck with this situation where we’re doing things, not based on science.  [The increase in C-sections is] really based on protecting the institution and ourselves. And, you can’t blame them. Getting sued is a horrible thing for the physician, a horrible thing for the nurse, and a horrible thing for the institution.

And the woman?  Well as long as the baby is healthy, does she matter?

Medical practice has many issues around informed consent, with many procedures being routinely performed with no shared decision making process, no informed consent, or no permission at all.  Rebecca Dekker of Evidence Based Birth wrote than in her training as a nurse,

I was taught to say, ‘I am going to listen to your lung sounds now.’ My instructors told me that the patient would be less likely to refuse if I simply stated what I was doing, instead of asking permission. I practiced that way– and even taught nursing students that way– for several years. (emphasis mine)

This seems relatively innocuous when it involves listening to lung sounds, but has more onerous implications for pregnancy and childbirth.  Training to make statements is training for practitioners to say, “I am going to cut an episiotomy now” or “I need to do a cesarean.”  It may be true that the procedure is a good idea, but it is not acceptable to tell a woman that you are going to do something to her body.  A woman needs to have to opportunity not only to consent to a procedure, but also to refuse it.

Lithotomy-Now-300x230

Sometimes practitioners do not even say what they are going to do–they just do it.  Sometimes they tell the woman after it has been done, as in this case from My OB Said What?:

‘I gave you an episiotomy.’ – OB to mother after birth. Nothing was mentioned about an episiotomy being needed during the birth, and when the mother screamed in pain when the OB touched her, both the OB and the L&D nurse insisted the OB was just ‘stretching’ her.

Or this one

‘We will go ahead and schedule your cesarean section now.’ —OB to mother with two prior cesareans, at the mother’s 10 week prenatal appointment, after the mother indicated that she wanted to have a VBAC.

Sometimes the practitioner doesn’t tell tell woman anything, and she finds out what happened by reading her chart or talking about her case with a different practitioner, as in this report from Cookieparty at Community Baby Center:

I remember my OB saying he was stitching me and I was like oh I must have torn. He didn’t even tell me he did [an episiotomy], I found out later that day or the next day I think, when one of the nurses was tending to it. [It] pissed me off!

Instruction on “Patient Rights” from The Birth Place of UCLA Medical Center make it sound that their belief is that women do not have the right to refuse what health practitioners want to do in any case.  Their responsibility is to follow the rules and cooperate (emphasis mine):

Patient Responsibilities
As a patient, you have the responsibility to:

  • Treat those who are treating you with respect and courtesy.
  • Be considerate of the rights of other patients and hospital personnel.
  • Observe the medical center’s rules and regulations, including the Visitor and No Smoking policies.
  • Be as accurate and complete as possible when providing information about your medical history and present condition, including your level of pain.
  • Cooperate fully with the instructions given to you by those providing your care.
  • Fulfill the financial obligations of your health care, know your insurance benefits and eligibility requirements, and inform the hospital of changes in your benefits.
  • Provide a copy of your Advance Directive (Durable Power of Attorney for Healthcare) if you have one.

In their Committee Opinion “Elective Surgery and Patient Choice,” the American College of Obstetricians and Gynecologists (ACOG) says that OBGYNs may perform unnecessary surgeries upon a woman’s request, including cesareans, as long as the woman is adequately informed of the risks and alternatives and the OBGYN believes the surgery is not an undue health threat:

Performing cesarean delivery on maternal request should be limited to cases in which the physician judges that it is sufficiently safe, given the specifics of the woman’s pregnancy and setting, and has had the opportunity for thorough and thoughtful conversation with the patient.

In their Committee Opinion “Maternal Decision Making, Ethics, and the Law,” ACOG points out

  • Appellate courts have held…that a pregnant woman’s decisions regarding medical treatment should take precedence regardless of the presumed fetal consequences of those decisions.
  • [M]ost ethicists also agree that a pregnant woman’s informed refusal of medical intervention ought to prevail as long as she has the ability to make medical decisions
  • [I]n the vast majority of cases, the interests of the pregnant woman and fetus actually converge.
  • Because an intervention on a fetus must be performed through the body of a pregnant woman, an assertion of fetal rights must be reconciled with the ethical and legal obligations toward pregnant women as women, persons in their own right….Regardless of what is believed about fetal personhood, claims about fetal rights require an assessment of the rights of pregnant women, whose personhood within the legal and moral community is indisputable.

Two of the main conclusions of this committee opinion are

  • Coercive and punitive legal approaches to pregnant women who refuse medical advice fail to recognize that all competent adults are entitled to informed consent and bodily integrity.
  • Court-ordered interventions in cases of informed refusal, as well as punishment of pregnant women for their behavior that may put a fetus at risk, neglect the fact that medical knowledge and predictions of outcomes in obstetrics have limitations.

However, the obstetric community continues to bully women into acquiescing to procedures that the obstetric team wishes to perform, and women are still persecuted for refusing procedures both legally and socially, even when these procedures are not evidence based.

Even when medical professionals do explain risks and benefits to a procedure, they often expect a woman to draw the same conclusion that they do regarding what should be done.  The flip side of informed consent, however, is informed refusal.  Women not only have the right to know what their options are, they have the right to choose the option they believe is right, regardless of what their health practitioner believes.

What is an Episiotomy?

To attempt objectivity in definition, let’s start with the dictionary: episiotomy is “an incision into the perineum and vagina to allow sufficient clearance for birth.”  This means the vagina is cut open to make it bigger, ostensibly to make it easier for the baby to come out.  The cut goes in the direction of the anus.

There are two types of episiotomy: midline, in which the cut is made in a straight line toward the anus, and mediolateral, in which the cut is made at an angle toward one side of the anus.

episiotomy

In a review of the procedure, Cleary-Goldman and Robinson note that technically episiotomy refers to the cutting of the external genitalia, and perineotomy more accurately describes what is called episiotomy in American obstetrical practice.  If you are not squeamish, you can do a search on Google Images for episiotomy and see what they look like in photos rather than drawings.  I mean it about the not squeamish part.

A Short History

There is documentation of episiotomy being performed in the 1700s in particularly difficult and prolonged births.  There is also documentation in this era of using support and lubricants (such as hog lard) to prevent tearing of the perineum during birth.  Accounts in the preceding links differ, but episiotomies appear to have been introduced in the United States in the mid 1800s.  The combination of anesthesia, hospital birth, and routine use of forceps served to popularize episiotomies in the late 19th and early 20th centuries.

In 1918, advocating for episiotomy in a journal article, obstetrician Ralph Pomeroy wrote, “Why should we consider it other than reckless to allow the child’s head to be used as a battering ram?”  Obstetrician Joseph B. DeLee published a subsequent article on episiotomy in 1920 and claimed that episiotomy “preserves the integrity of the pelvic floor, forestalls uterine prolapse, rupture of the vaginal-vesico septum, and the long train of sequalae.”  Doctors also preferred the ease of sewing the straight incision of an episiotomy rather than a tear.

The speculations of  Pomeroy and DeLee were absorbed as truth, and episiotomy became routine procedure for physician-attended births, even though there was no actual evidence to support episiotomy’s effectiveness in preserving women’s pelvic function.  The procedure was not widely questioned or tested by anyone in mainstream obstetrics until the 1990s.

What Happens after Episiotomy?

Episiotomy has sometimes been referred to dismissively as a “little snip,” but like mackerel and pudding, the words vagina and snip should exist far, far away from one another.  Episiotomy can have serious health consequences, including

  • Bleeding
  • Tearing past the incision into the rectal tissues and anal sphincter
  • Perineal pain [short and long term]
  • Infection
  • Perineal hematoma (collection of blood in the perineal tissues)
  • Pain during sexual intercourse [short and long term]

Some women recover quickly from episiotomy and do not report lasting problems.  Some women even request an episiotomy to shorten second stage labor–after hours of pushing, anything to hasten the birth may seem a relief.

For many women, however, episiotomy (which, after all, is a deep cut into the genitals) is traumatic and has long-term effects.  In nearly all cases, an episiotomy is not necessary, meaning that these women suffer while accruing no medical benefit.

Evidence

(See here for a brief explanation of a randomized control trial.)

In 1992, a group of Canadian physicians published the results of a randomized control trial in Current Clinical Trials showing that there was “no evidence that liberal or routine use of episiotomy prevents perineal trauma or pelvic floor relaxation.”  In addition, they found that almost all severe perineal trauma occurred among women who had median (midline) episiotomies, and that among women who had already had at least one vaginal birth, those who had episiotomies were much more likely to tear and needed more stitches on average than women who did not have episiotomies.

In 1993, a group of Argentine physicians published the results of a randomized control trial in the Lancet.  Their randomized control trial of 2606 women showed that routine episiotomy (rather than “selective” episiotomy) increased risk of severe perineal trauma.  Those in the routine group also showed higher rates of ” posterior perineal surgical repair, perineal pain, healing complications, and dehiscence.”  The study concluded that “[r]outine episiotomy should be abandoned.”

A 1995 study published in the Canadian  Medical Association Journal found that “Physicians with favo[rable] views of episiotomy were more likely to use techniques to expedite labour, and their patients were more likely to have perineal trauma and to be less satisfied with the birth experience.”  This study also found that the doctors who liked episiotomy had difficulty following study protocols about when to perform the procedure and were more likely to diagnose fetal distress and perform cesareans than their counterparts who did not have favorable views of episiotomy.

Some physicians still try to justify performing episiotomy to prevent tears, but tearing was shown to be preferable to episiotomy in a 2004 Scandinavian randomized control trial: “Avoiding episiotomy at tears presumed to be imminent increases the rate of intact perinea and the rate of only minor perineal trauma, reduces postpartum perineal pain and does not have any adverse effects on maternal or fetal morbidity.”

A 2012 Cochrane Review did not find significant differences between midline and mediolateral episiotomy–both were generally worse than avoiding an episiotomy altogether: “Women [who did not have episiotomies] experienced less severe perineal trauma, less posterior perineal trauma, less suturing and fewer healing complications at seven days (reducing the risks by from 12% to 31%); with no difference in occurrence of pain, urinary incontinence, painful sex or severe vaginal/perineal trauma after birth.”

Current American College of Obstetricians and Gynecologists (ACOG) guidelines note that “routine episiotomy does not prevent pelvic floor damage leading to incontinence” and recommend against routine use of episiotomy.  The guidelines note that median (midline) episiotomy is associated with anal sphincter injuries but that mediolateral episiotomy is “associated with difficulty of repair, greater blood loss, and, possibly, more early postpartum discomfort.”

The Royal College of Midwives (RCM, in the United Kingdom) offers the following evidence based reasons for episiotomy:

  • Aid the delivery of the presenting part when the perineum is tight and causing poor progress in the second stage of labour
  • Allow more space for operative or manipulative deliveries, such as forceps, shoulder dystocia or breech delivery (NICE, 2007; RCOG, 2005)
  • Prevent damage of the fetus during a face or breech presentation, or during instrumental delivery
  • Shorten the second stage of labour for fetal distress (Sleep, 1995) or maternal medical condition
  • Accommodate issues associated with female genital mutilation to the benefit of both mother and baby (Hakim, 2001).
  • Episiotomy is contraindicated when there is a high head. In these circumstances, descent will not be assisted.

Note that in the case of shoulder dystocia, the episiotomy is justified only to give the practitioner more room to perform necessary maneuvers.  Episiotomy does not, in itself, help with shoulder dystocia.  As the obstetrical nurse and midwife who blogs at Birth Sense explains:

Many physicians will openly admit that episiotomy does nothing to help facilitate the delivery of a baby with shoulder dystocia, because it is not a tissue problem, but a bone problem. The shoulder is stuck behind bone, and cutting the woman’s perineal tissue does not resolve the problem. Then why do it? Most physicians I’ve spoken with admit it is simply a matter of protecting themselves legally: by cutting a large episiotomy, they can show they’ve done everything they could possibly do to try to deliver the baby.

A recent study by Paris et al concluded episiotomy does not appear to reduce brachial plexus injuries (a rare paralysis associated with shoulder dsytocia):

There were a total of 94,842 births, 953 shoulder dystocias, and 102 brachial plexus injuries. The rate of episiotomy with shoulder dystocia dropped from 40% in 1999 to 4% in 2009 (P = .005) with no change in the rate of brachial plexus injuries per 1000 vaginal births.

Despite the evidence, shoulder dystocia is still commonly cited on popular consumer websites as a reason for episiotomy.

Overall, there are sometimes good reasons to perform episiotomy for the safety of the woman, the fetus, or both.  However, as Kim Gibbon of the RCM notes,

Consent is required for episiotomy, as it woud be for any surgical procedure. Women must be given a full explanation of the nature of the procedure and the situations under which its use will be proposed (Carroli and Belizan, 1999). Ideally, this should occur in the antenatal period so that the woman’s consent can be sought and documented at this stage. Further explanation should be given to the woman when a decision to use episiotomy is made to provide reassurance and confirm consent.

Current Practice

The Leapfrog Group has begun reporting episiotomy rates as one of its maternity care measures.  Unfortunately, reporting is voluntary at the hospital level, so there is only data for a limited number of hospitals (information on how to find the information on the Leapfrog site is at the bottom of the  page *).  Just looking at the data that is available shows enormous variations in practice.  For instance, among the four campuses in the Baptist Memorial Hospital system in Mississippi, rates range from a low of 1.5% at the De Soto campus to a high of 38.8% at the Golden Triangle campus.  Cesarean rates at all four campuses are similar (32% to 35%), so it appears that women who are not good candidates for vaginal birth (as well as a good number who are) have already been eliminated at all campuses.  Skin elasticity is unlikely to vary much by region, so why the variation in episiotomy rates?

A report on the evidence for episiotomy by the Agency for Healthcare Research and Quality (AHRQ) states,

Wide practice variations suggest that episiotomy use is heavily driven by local professional norms, experiences in training, and individual provider preference rather than variation in the physiology of vaginal birth.

Evidence indicates that many doctors have been slow to change practice regarding episiotomy, and that doctors who have not already changed may be increasingly reluctant to do so.  Like recommendations for bed rest, tradition or a “feel good” factor for the doctor may trump actual health outcomes.

Consistent with the findings of the Canadian study of physicians and their views on episiotomy (cited in the previous section), some hospitals with high rates of episiotomy are less likely to adhere to evidence-based maternity practice overall.  For instance, South Miami Hospital (of the Baptist Health South Florida network) has an episiotomy rate of 33.1%.  They also have the highest cesarean rate in the state (62%) and have not reached Leapfrog goals for early elective deliveries (induction or cesarean before 39 weeks for no medical reason).

The AHRQ report appears to give the most accurate reason for continued use of episiotomy at high rates: provider preference. One obstetrician quoted in the New York Times said that during her residency, “Fifty percent of the episiotomies I’ve done were because my supervising staff wanted to go back to bed.” According to this Times story, the quoted doctor has a colleague, who “‘loves epis’ and cuts them during almost every vaginal birth.”

Mothers’ reports from My Ob Said What? indicate that time is indeed  more important to some doctors than the integrity of women and their vaginas.  One mother reports questioning why her OB performed an episiotomy and was told, ““Why did I just do an episiotomy? I did an episiotomy because you would have been pushing for another 20 minutes!”  A friend of mine had an OB who told her, “Which do you think is easier for ME to sew up–a straight cut or a jagged tear?” (my friend switched practitioners).  A study by Webb and Culhane found that obstetrical procedures such as episiotomies increased at peak times in Philadelphia hospitals, to the detriment of women:

The fact that incidences of 3rd or 4th degree lacerations are high at roughly the same times that procedure use is high is consistent with what is known about the risks associated with episiotomy and vacuum/forceps use, and suggests that efforts to influence the timing of births through more liberal use of obstetric interventions may increase the morbidity associated with vaginal delivery.

Although rates of episiotomy have decreased drastically overall, some doctors do still perform them routinely, as this doctor indicated to a first-time mom who requested not to have one: “Well, we’ll see. I find that pretty much all of my first time mothers require an episiotomy.”

In addition, like the woman above, many women do not consent to episiotomies, but are cut anyway.  After one woman told her OB she did not want an episiotomy and preferred to tear (which is evidence based according to the Scandinavian study cited above), her OB told her, “I’m just giving you an episiotomy anyway.”  Another woman commented at the Chicago Tribune,

When I was pushing out my third child, my doula nudged my husband and told him that the OB was preparing to cut an episiotomy. The OB had not asked me if it was ok, and hadn’t even mentioned it. My husband piped up and said, “My wife doesn’t want an episiotomy.” He said that twice. The OB ignored him and injected me with the lidocaine. I finally clued in and shouted “I do not consent to an episiotomy” two times before the OB put her scissors down. Two times!! The kicker is that I didn’t tear. Not one bit. The episiotomy would have been completely unnecessary.

A 2005 comprehensive review in the Journal of the American Medical Association (JAMA) concurs with the above comment (emphasis mine):

The goals for quality of care must remain focused on both optimizing safety for the infant and minimizing harm to the mother. Given that focus, clinicians have the opportunity to forestall approximately 1 million episiotomies each year that are not improving outcomes for mothers.

While women sometimes successfully sue for episiotomies that are botched, as with cesarean (see this December 23, 2013 post), it is difficult to win a suit for an episiotomy performed without consent.  Generally, a doctor argues that the procedure was in the best interest of the fetus, and the woman’s rights cease to matter.

But women do matter.  Their pain matters.  Their sexual pleasure matters.  And most of all, their informed consent to what is done to their own bodies matters.  Practitioners may want to believe that they know better than their patients and can therefore slice and dice as they please.  They may believe that it is acceptable to sacrifice women’s bodily integrity to their own convenience.  Such a stance turns a woman into an object, a vessel who can be treated in any fashion as long as her body yields a healthy baby.  Women and those who love them must stand for a woman’s right to be human in childbirth — and always.

*To do a comparison of episiotomy rates at hospitals, click the Leapfrog Group link.  On the Leapfrog page, select “state” in the search by menu, select your state, and accept the terms of use.  On the next page, click the “Maternity Care” tab.  If there are any green bars in the “rate of episiotomy” column, click the blue question mark, and the rate will come up in a new window.

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