Ceci n’est pas “Informed Consent” 9
One of my previous doula clients recently mailed me a copy of a “patient safety update” that she received from her current OB/GYN practice.*
The topic of this particular patient safety update was vaginal birth after cesarean, or VBAC.** And it was…”interesting.”
In fact, it was so “interesting” that I’ve transcribed the entire document below, for your reading “pleasure.” (And just so I don’t color anyone’s opinion of the safety update before you read it, I’ve left my editorializing for the end.)
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Patient Safety Update: Vaginal Birth After Cesarean (VBAC)
On a monthly basis the staff of **** meets to discuss current practice protocols and to review various patient safety issues raised by our staff. We jointly discuss challenging cases from the preceding month as well as those due to deliver in the near future. Our goal has always been to provide the safest medical care possible to our patients. The topic for our recent meeting was a review of the safety implications of Vaginal Birth After Cesarean Section, more commonly known as VBAC.
Trends:
Fewer women are attempting a Trial of Labor after a Cesarean. There are several potential reasons for this: medical and legal pressure; changes in patient and provider preference; changes in obstetrical practice; and publication of complications related to vaginal delivery and failed trial of labor.
The most serious concerns are increased risks of uterine rupture and perinatal death. A recent study of 33,000 patients showed that the risks of uterine rupture, hysterectomy, thromboembolic disease (blood clots), transfusion, severe infection, and death are 56% greater in women attempting VBAC vs. Repeat Cesarean Section.*** Overall you would need to do 588 elective Cesareans to prevent one poor perinatal outcome.
Summary
588 Cesareans to prevent one poor perinatal outcome is acceptable to some but not to others. Our group is evenly divided. Some of our physicians do participate in VBACs and some do not. As a result the following key points need to be understood by our patients.
If you definitely want to have a trial of labor and attempt a VBAC, you should consider transferring to a practice that supports VBACs completely.
If you want a VBAC and stay with the practice it must be understood that you will not be guaranteed the opportunity to have a VBAC attempt. On certain days there might not be a physician who will participate in a VBAC trial of labor.
A trial of labor is definitely more risky for the baby than an elective Cesarean Section (much in the same way that labor is more risky than an elective cesarean section). You must be willing to accept that risk in order to proceed with a trial of labor.
We regret any inconvenience this may cause to our patients planning to attempt vaginal birth after cesarean section. We urge our patients to stop and contemplate the statistics listed above. We plan to meet individually with the patients affected by this decision and address their individual concerns.
Thank you.
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Oh, where to begin.
How about with this: I think that framing this issue as a “patient safety update” is problematic, to say the least. For if I were to receive a letter from my care provider (OB/GYN or not) alerting me to a patient safety update, I would automatically think that the information contained therein would be primarily concerned with protecting me from harm. With keeping me safe.
Thus, it seems reasonable to assume that many women who received this “patient safety update” have approached this document with the belief that the OB/GYNs at this practice had a safety concern about vaginal birth after cesarean.
And it seems quite obvious that the safety concern here places an extraordinary emphasis on the risks of VBAC (and labor, for that matter) without giving even a mere mention of the risks associated with repeat cesarean section.
It makes no mention of the current research concluding that babies born after VBAC have significantly lower rates of respiratory morbidity and NICU admission than babies born after elective repeat cesarean.
It makes no mention of the recent report concluding that elective repeat cesarean is associated with a threefold increase in maternal mortality when compared with vaginal birth after cesarean.
It doesn’t even mention any of the risks associated with repeat cesarean sections, including abnormal placentation in future pregnancies (which can lead to life-threatening problems), bowel obstruction, and blood clots.
I’m sorry (and I’m angry), but highlighting the risks of VBAC (and LABOR!) in a “patient safety update” on VBAC without even mentioning the risks of elective repeat cesarean does not offer transparent information to the women in this practice. In fact, I’m not even sure that it best keeps patient safety in mind.
How can a woman make a major decision such as this one without knowing the risks (and benefits) of both options?
How can she even go on to rationally weigh those risks and benefits when she has received a letter putting the fear of God into her about VBAC?
It should be stated that I wholeheartedly support a woman’s right to choose a repeat cesarean delivery over a VBAC. Wholeheartedly.
But failing to present a woman with the risks and benefits of VBAC and repeat cesarean in a letter such as this one undermines her ability give informed consent to either option.
So at best–and despite the fact that the practice recommends that women seeking VBAC should switch to a more VBAC-supportive care provider–this letter is disingenuous.
And at worst, it strikes a major blow to women’s ability to give informed consent to what they do with their bodies in order to birth their babies.
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*I want to extend a hearty thanks to my doula client for thinking of me after reading this “safety update.” Quite simply, she rocks!
** I think it is no coincidence that this letter was sent out mere days after the NIH Consensus Panel released their statement on VBAC.
***It’s worth noting that a recent Agency for Healthcare Research and Quality Report determined that “the rates of maternal hysterectomy, hemorrhage, and transfusions did not differ significantly between TOL [trial of labor, or VBAC attempt] and ERCD [elective repeat cesarean delivery].” Even the 2004 Landon study, which this practice may have been referring to when they mentioned that “recent study of 33,000 patients,” concluded that while the rates of endometritis and blood transfusions were higher in women attempting VBAC than in women undergoing repeat cesarean, “the frequency of hysterectomy and of maternal death did not differ significantly between groups.”
