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.