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Random Thoughts on (VBAC) Informed Consent

Jill at Unnecesarean opened her blog for random comments regarding Informed Consent. This is what I wrote:

How informed is informed consent? Who gets to decide the informing phase has ended and the deciding phase has begun? Who picks the studies/statistics/anecdotal/experiential information imparted? What if English is the second language or the patient has a 10th grade education or the doctor speaks as if he's talking to a medical student? Who is the moderator that translates or calls a time out for clarifications?

I live these questions -as a provider and as a pro-VBAC woman. The two hats I wear often look the same, but, as with OBs, there can be vast differences based on The Law and how it affects each "side." When variations of the norm, or complications, arise in a pregnancy, it's imperative of me to help the woman become informed about her situation so that, to the best of her knowledge, she can make an autonomous decision. There is rarely a decision that I haven't had my hand or say in, despite the noble desire to remain neutral. I am hired for my knowledge and expertise, the same as an OB, so to not offer thoughts would defeat the purpose of hiring a consultant. If the woman doesn't want my thoughts, she's probably UCing and doesn't give a whit what I think anyway.

Watching the NIH VBAC Conference, I was struck by how often doctors made the decision to incise an abdomen based soley on legalities or insurance worries... that they gambled the life of a woman in order to serve themselves, trying to keep themselves (legally) safe and sound. To hell with the woman and her life; the OBs' okay, so all's right with the world. It was in listening to these stories, over and over, that I had to think, "Do I do that?"

And I have made decisions that would keep me out of legal hot water - transporting a butting surprise breech, for example. Granted, I don't have any experience delivering a breech beyond what I learned as a midwifery student and apprentice, but did I offer the mom informed consent as the whole thing went down? Did I say, "I have never done this before and almost any midwife who gets sued in the United States is sued for a dead breech baby, but would you like me to try my hand at your baby right now?" I did not. Equal in the decision was my inexperience and that line of midwives who've lost their licenses for dead breech babies.

So, sitting and watching the people flicker on my computer those 2.5 days, I developed an, "I'll be damned if I act like that arrogant (s)OB. I'll be damned if I ever let the law sit on my shoulder again, let the law dictate whether a mother has her belly sliced open or not. If I have a mom (I said to myself) who sits in front of me and says, "I know my baby and I can die; I want a VBAC anyway," I will be her champion and help her to the best of my ability. I felt all Power-Full, like I, the mighty midwife, can stand outside hospitals around San Diego, catcher's mitt in hand and say, "Hear, ye VBAC-wanters! Come labor in the parking lot and let's show them!"

Until I think about the Informed Consent crap again. My shoulders slump and I groan an exasperated sigh. How can I possibly get informed consent regarding her understanding that she might have a baby die? Women can know what it's like to not take a test or have an ultrasound, but how do you really get women to understand that a baby can DIE. DIE. Gone forever. Is "The Cause" really that important? Is the issue really bodily integrity and who gets to lay a hand on whom and what for? If the woman really said she wanted to die before she had another cesarean, what if she's in a car accident and unconscious and they take her to the OR and take her baby out? Is she going to be pissed as hell? Or will she be happy they (perhaps) saved the baby?

With every question, there are four more after it. What kind of lawsuits are we building with these very discussions? Why does it have to come down to lawsuits? I hate that we will have to have wrongful cesarean suits to get anything done on this issue. I hate to think of the screaming, howling, end-laboring women that will have masks smothering their faces and gloating, greedy doctors wielding sharp and steely knives above their swollen bellies, carving babies out of their flesh. I hate what that baby will be experiencing, feeling, how s/he will feel growing up knowing s/he was the center of a controversy that said, "My mom didn't want a cesarean so much she didn't care if I died or not."

How do I "inform" a mom of the lifetime of repercussions that come from her scrawling signature on a piece of paper? How do I know, if she says she's informed, how do I know she's taken the scary road to the illogical ending and still wants to go down it?

How, how, how, how, how, how, how, how?

And, why oh why oh why oh why.

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Reader Comments (5)

But, Barb.... the risk that the Mom, or the baby, might die, is kind of there, ALL THE TIME. In hospital birth, home birth, water birth, synto birth, Induced birth, caesarean birth, every birth.... there is a risk that something will go worng, and mom and or baby will die. We cannot take away that risk. How many women are informed of the risk of uterine rupture from prostin or misoprostil induction against the risk of waiting? How many women are informed of the true risks of primary sections for breech, against the risk of breech birth? How many women are warned of the risks of cord prolapse after ARM? How many women are warned that even with no interventions, no problems, no labour, they can just wake up one day with a dead baby? And never ever have any reason for that? Birth and death go hand in hand. I come from a place where VBAC is well, the norm. I have only had three clients choose to have repeat CS for previous CS. The rest have VBAC'd, and only one of the fourteen women that I have supported to VBAC had a repeat section. I know the sample is small. I haven't been working that long, and have only had so many clients: but I am not alone, there are lot's of midwives and OB's supporting women to VBAC in NZ. And in the UK. And in lots of other places. The situation in the US is such as it is, mainly because of this crazy expectation the US has that doctors can, should and will fix everything, or by god, they shall pay. Here in NZ, we don't get to sue for damages, or mental anguish or emotional trauma. We have a no blame system. Which allows people to recieve appropriate compensation, and doctors and midwives and nurses to follow evidence based guidelines without fear of losing our livelihood. And you know what? it works. Maybe you all in the US need to lose your God complex. I think women are capable of understanding you/your baby could die. They are also capable of making a decision about how they feel about that. Women here are not given the infomration in such an emotive way though. They are told the numerical risk of rupture, and of catastrophic rupture and of outcomes. then the numerical risks of repeat CS. and then, they choose. THEY. the women, the ones taking the risk. YOU are not the one taking the risk here. THEY are. The god complex and fear of litigation in US obstetrics is terrifying. Stop BEING responsible for eveything. And just do your jobs. Might make it a wee bit easier.

March 11, 2010 | Unregistered CommenterAnna

As an L&D RN I have seen hundreds of successful VBACs. VBACs where the baby weighed ounces or pounds more than his older sibling.
I have also seen a TOLAC uterine rupture with a dead baby.

Would I (theoretically) TOLAC? Absolutely. Do I do everything in my power to prevent primary C/S? Even more absolutely.

March 11, 2010 | Unregistered CommenterDenise

This really ties in to some of your recent posts too. The person receiving the consent is going to be biased, and after giving the info, they're going to expect women to come to the same conclusion they did. Do you just keep giving MORE info that you think will help them reach that decision?

Definitely must be a difficult place to be on your end. Thanks for the thought provoking post!

March 11, 2010 | Unregistered CommenterStassja

Informed consent is pretty empty, when I was going to have my c-section it was we can do this or you can try for a while longer, the long term implications were not explored or explained. With the VBAC it was similar, that there another c-section is safer then a VBAC, that was about it, they didn't get into the ramifications of what could happen or the long term consequences. As long as I knew that a VBAC was not as safe for the fetus (never mind what was safer for me, and I am sorry but mom's long term health decides the long term health of her family, not the loss of one child, I'm kind of rough that way) they were okay with letting me have a "trial of labor", and we were all satisfied in the end.

It's kind of like Catholic hospital's priority of saving the fetus over the mother's life if they have to choose, in my opinion in the long run it compromises the lives of her living children and spouse and poses a greater harm. As for VBACs, in the long term if she is going to have more then 2 kids, the less harm to her and thus her family, thus a VBAC is preferable over further c-sections. Sure if we narrow our focus to this pregnancy, this delivery, it's safer not to deliver vaginally for this mother, but I just dread the long term consequences of serial c-sections on health and well being for her and her family because of her health.

March 12, 2010 | Unregistered CommenterEthel

I think that you know by now that I'm HUGE on informed consent (I bemoan it all the time on facebook).

I think that for me, informed consent is about having questions answered rather than being told about all the possibilities without having asked.

In the situation of the breech baby, I would ask what the options are.

I think that if a provider told me "It IS possible to deliver your baby this way, but I have no experience in it and a bad outcome is very likely if the person delivering the baby isn't experienced with this complication. This is not a risk that I am willing to take. If you want, I can try to help you find an OBGyn at the hospital that has experience with this sort of breech situation and that is willing to try to deliver your baby this way, but most providers feel the way I do. That the risks are substantial to both baby and mom", I'd trust that provider 100%.

When a provider puts it in terms of what they and others have experience with, and how those experiences can change the possibility of a positive outcome.. It makes me trust them. When they say "If you try to deliver a baby breech, your baby will very likely die." it.. doesn't make me trust them.

It's not always about "Here are your million and ten options, most of which I do not support or have experience with". Sometimes it's about "If mom asks for another option or for more information about something that she thought was an option, give it to her."

Too often, care providers refuse to discuss other options. Refuse to say that there ARE other options. Refuse to give mothers the opportunity to seek out care from another practitioner (when this is possible- such as during prenatal care).. That's the lack of informed consent.

March 12, 2010 | Unregistered CommenterSara

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