Defensive Medicine and Internet Message Boards
Wednesday, December 16, 2009 at 7:58AM
Fetal death mentioned
I rarely jump into message boards to which I don’t already belong. When I do, it might be just to remind people that it’s okay to question their care provider if they have any doubts about their recommendations, but every now and then I pull out ACOG’s practice guidelines or articles about inaccuracy of fetal weight prediction. I went in with good intentions on a major baby/parenting site awhile ago. Here’s how it went down:
The original poster was all, “I’m 35 weeks and my doctor says the baby is huge and I might tear a lot” and Dr. Dangerpartum Von Deathtrap was all, “25 percent of babies over 9 pounds experience birth trauma so they should offer you a cesarean so you know your options” and I was like, “That is not true… cite” and meanwhile the person I later found out was the moderator was all “Are you calling him a liar? My money’s on the doctor” (because apparently it’s a competition) and then Dr. Von Deathtrap listed several factoids that didn’t address the 25 percent claim and another poster chimed in and was like, “Why would doctors rely so heavily on ultrasound if it’s so unreliable” and the doctor was all, like:
“It is because you have never had a baby die
with its head out and shoulders stuck…that is
why you don’t understand. Have have seen
docs leave Ob after the trauma of losing a baby.
One dead baby in a docs career is one too many.”
And with that, I felt bad for jumping in, realized the site wasn’t for me and apologized to the OP for what had devolved into an unsupportive thread and bailed. I just now found a follow-up comment from the group owner that asked why I was even there because the group was about being helpful and supportive.
Indeed. Support the pregnant woman in the last few months of her pregnancy by graphically describing dead babies and telling her how doctors rely on ultrasound to make inaccurate estimates of fetal weight after having had one bad outcome that they probably couldn’t have predicted in the first place and for which all future patients will pay by being, what, over-tested and sectioned?
It’s reassuring to believe that all doctors make their decisions based on scientific data. In fact, it seems that some doctors love to pat each other on the back and talk about how they work from facts and patients, or “laypeople” as they’re known in this social hierarchy, merely run around with anecdotal silliness.
This might be true. However, if doctors really have all of this data and accurate information about the risks and benefits of interventions, then why don’t they all share it with the pregnant women who trust them? Typically, the knee-jerk response to that question is “fear of litigation.” How many times have we heard doctors and the general public brush off defensive medicine as just an unpleasant reality of our litigious society? Even ACOG admitted publicly that doctors practice defensive medicine and “ultimately hurt patients.”
Defensive medicine involves lying to patients.
Defensive medicine is about putting a doctor’s or hospital’s interests before those of the patient.
Defensive medicine takes “First, do no harm” and turns it into “First, redefine harm and try to sell your patients on it without them suspecting.”
So if doctors really operate from facts, some of them sure put a lot of energy into trying to scare their pregnant patients into compliance. The problem with so many of them crying wolf is that it’s hard to know who can be trusted. Even creepier is that the anti out-of-hospital birth lobby thinks all women need to just suck it up and deal with it.
Over on another message board, I addressed a question I came across of a woman who had received some big baby warnings because of her possible case of gestational diabetes that had been discovered in her 35th week of pregnancy even though her 30 week screening was negative. I left a really long reply of mostly questions and personal experience, which is excerpted here:
I’m finding myself right now spending an inordinate amount of time trying to decide what to say succinctly (and failing at the succinct part). I blog about this a lot but I usually don’t jump in and chat with women directly, but I just answered a similar concern elsewhere last week which will tell you where I’m coming from.
You are not alone—this scenario is increasingly common. And yes, I think you are correct in saying that they are working really hard to scare the crap out of you. Just wait until they start telling you about procto-rectal episiotomies and the Zavanelli maneuver.
I was in your shoes four years ago to the day (with two exceptions: they scheduled me a c/s and the pointless GDM test, which they did a few days before I gave birth was “normal but on the high end”) and we had a really hard time fighting off a cesarean. I wasn’t planning on any interventions in labor if I could avoid them, nor was I opposed to surgery if there was an actual need for it. I also had the benefit of time, which I used to read medical journals and articles. It was a really stressful and fairly morbid way to spend the last week and a half of pregnancy when all I really wanted to do was nap and compulsively fold and organize baby socks.
I also had a Bizarro World experience when a friend convinced me to go spend a few hours with her home birth midwife. The only person in the last week and a half of my pregnancy that gave me any evidence-based information on shoulder dystocia, ultrasounds, macrosomia and birth in general was a home birth midwife. I looked up everything she told me and everything the doctors told me (which was not based on anything but their personal anecdotes) and it blew my mind. I’ve never really looked at the world the same, honestly.
The similar concern that I had addressed elsewhere that was mentioned above was this Yahoo! Answers question:
Question: I’ve heard so many people say the doctors guessed the baby’s weight by ultrasound and were off by 2 lbs or so. They think my baby weighs 10lb 4oz now. I’m 4 days past my due date and baby has measured at least a week ahead from my first ultrasound. They said it could be off by a pound. How many of you were told your baby would be this big and it was much smaller? And were any told baby was this big and it was bigger?! Women who have delivered 10+ lb babies, did your baby have shoulder dystocia?
My answer:
Hi! You got some good comments. I was in your shoes a few years ago. I was told the baby was 10#2 at 37 weeks. She was born with no problem at 39.5 weeks and weighed 10#3, which would have put her about 9-ish lbs at the time of the u/s. Big babies run in the family and I later had an 11#5 baby, again with no problem. In the absence of gestational diabetes, babies over 10 lbs. are rare.
The hospital (midwives, docs) went nuts trying to push me into a c-section based on the u/s estimate. I declined because they gave me no evidence— only anecdotes of their personal experience that they had seen shoulder dystocia and “it’s really bad.”
It can be really bad. However, the problem with their claim was that 1) there is no truly accurate predictor of fetal weight and 2) shoulder dystocia occurs unpredictably and 50% of the time it occurs in babies that are not considered macrosomic (big). So if they couldn’t tell with scientific accuracy the actual weight of the baby, then as far as anyone knew, I wasn’t actually at an increased risk of shoulder dystocia.
Most cases of SD are resolved with no injury. It would take 3,700 of scheduled cesareans on suspected macrosomic babies to prevent ONE case of permanent brachial plexus injury.
Sorry… long answer. Anyway, sorry you’re having to focus on morbid stuff at this point in your pregnancy. Another thing to keep in mind is that there is a recent study suggests that inducing a macrosomic baby with Pitocin makes shoulder dystocia 23 times more likely.
I had to fight to give birth normally, unfortunately. I’m not sure if they’re giving you the c/s push or not, but ask what you can sign in advance to let them know you understand their concerns if you are fine with labor taking its course. Good luck! –Jill
The best part was finding her reply in my inbox:
Great info, this is why I was worried about inducing and ending up with a c-section. Fortunately I ended up going into labor the night I asked this question and he was born after a 4 hour total labor at 10lbs 8.7oz. He had no problems at all. Thanks!
That’s about it for 2009. I don’t give a lot of advice, but I will share my experience and try to point people in the direction of asking questions of multiple sources so they can make their own decisions and hopefully feel good about them. This blog and its Facebook fan page have shown me that there’s really no need to poke around the internet to find women who have felt the discriminatory sting of defensive medicine or who are suffering the consequences of trying to give birth vaginally in a system that is slowly snuffing out a woman’s right to do so. They’ll search for you.
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Reader Comments (222)
Ugh, I know what you are talking about. At least the forum I moderate is all about doing it yourself LOL
I usually send people private messages if I need to go against the grain, and just say take it for what it is worth. I get more positive reactions from doing that. I don't even post publicly on mainstream forums anymore. Am just there to get a idea as to where most women are when it comes to pregnancy, birth and maternity care. It is rather appalling and tragic.
I have been banned from a few message boards just by simply saying what you were saying. I started a few riots. *eye roll*
I try to help when I can... but it's sad when you have to watch out what you say and how you say it because someone won't like it. God forbid you think for yourself. God forbid you question anything.
That's awesome that woman ended up having her baby vaginally with no problems--10 lbs and all! Woo-hoo!!
Doctors don't like it when their idea of "facts" and "science" is exposed. I never went to medical school but you don't need an MD to smell bullshit.
And yes, what is it with "support" apparently meaning "encourage subject to take the route that is most dangerous, non-evidence based, and not what she wants at all"?
"Defensive medicine involves lying to patients.
Defensive medicine is about putting a doctor’s or hospital’s interests before those of the patient.
Defensive medicine takes “First, do no harm” and turns it into “First, redefine harm and try to sell your patients on it without them suspecting.”
Are you serious? You think the only person who is harmed by a dead baby is the doctor?
Defensive medicine is about doing everything possible to prevent preventable deaths. We could have a meaningful ethical discussion about whether we can ethically justify doing "everything possible" in light of the fact that "doing everything" has risks of its own. However, you've effectively short circuited any possibility of a meaningful discussion by flinging absurd charges.
Ah, Amy, you are back. And again, you have totally misinterpreted the comments. Nowhere did Jill say that a dead baby only affects doctors. What she said was that the weight of evidence does not support the interventions suggested. She also pointed out that many doctors act on anecdotal rather than scientific evidence, and in my experience this can be true of ALL HCP's. All HCP's are capable of doing things because they have "seen" a given outcome. The simple fact is that when a doctor or other HCP who is practicing based on anecdotal experience acts against the weight of evidence, said HCP has a responsibility to provide the woman with the scientific evidence as well. For example, within my practice, I sometimes suggest women consider visiting a cranial osteopath. I councel them on the fact that I cannot give them any scientific data to support this evidence, as there isn't any. I point out that while many women report improvement in settling babies following this intervention, no studies have been done to prove that it actually works. I then leave it in their hands to make a decision. Some go, some don't. Some are happy to accept anecdotal evidence others are not. In the case of a recommended C section for macrosomia, there IS scientific evidence, and that evidene does not support the intervention. But, you can recommend it anyway, as long as you present BOTH the scientific evidence against AND the anedotal evidene for.
I HATE the dead baby card. It can be used in any situation. It is emotive, non scientific and completely inappropriate. The problem with pulling out the dead baby card is two fold: One, it is used in situations where women could be given balanced fats to make an informed decision, but are instead threatened and bullied. two: the use of the dead baby card in the aforementioned way results in women mistrusting their care providers, so that when I recently had a client at 5 cms who's baby was suffering a bradycardia to 70bpm and was told we needed to urgently deliver the baby, she felt the need to question for a full five minutes. All that time, the babies hear rate stayed low, and when it was eventually born by CS it was in a very bad way. But all the earlier inappropriate usage of dead baby threats had left her unable to trust that this was not one of those situations. Terrifying.
To my mind, when a woman is carrying a potentially macrosomic infant, it is important to tell her the risks and benefits of interventions, and also to offer her all the options available to her, including CS. But, relative risk s an important discussion to have. even infants of diabetic mothers have more risks from CS than from vaginal birth, even including SD. Amy, if you want to discuss defensive medicine and the varying ethics of "doing everything possible" please do. Nothing that has been said on this thread is preventing that. But, bring your references with you, love.
Wikipedia has a neat and tidy little definition:
Defensive medicine is the practice of diagnostic or therapeutic measures conducted primarily not to ensure the health of the patient, but as a safeguard against possible malpractice liability. Fear of litigation has been cited [1] as the driving force behind defensive medicine. Defensive medicine is especially common in the United States of America, with rates as high as 79% [2] to 93% [3], particularly in emergency medicine, obstetrics, and other high-risk specialties.
Defensive medicine takes two main forms: assurance behavior and avoidance behavior. Assurance behavior involves the charging of additional, unnecessary services in order to a) reduce adverse outcomes, b) deter patients from filing medical malpractice claims, or c) provide documented evidence that the practitioner is practicing according to the standard of care, so that if, in the future, legal action is initiated, liability can be pre-empted. Avoidance behavior occurs when providers refuse to participate in high risk procedures or circumstances [3].
Theoretical arguments based on utilitarianism conclude that defensive medicine is, on average, harmful to patients.[4]
From a September 11, 2009 ACOG press release:
ACOG Releases 2009 Medical Liability Survey
Results Paint Dismal Reality for Ob-Gyns and Their Patients
Washington, DC -- As the negative state of the medical liability environment continues, ob-gyns across the US are forced to make changes to their practice that ultimately hurt patients, according to The American College of Obstetricians and Gynecologists' (ACOG) 2009 Survey on Professional Liability. More than 63% of ob-gyns report making changes to their practice due to the risk or fear of liability claims or litigation; 60% have made changes to their practice because liability insurance is either unavailable or unaffordable.
Medicinenet.com’s definition:
Defensive medicine: Medical practices designed to avert the future possibility of malpractice suits. In defensive medicine, responses are undertaken primarily to avoid liability rather than to benefit the patient. Doctors may order tests, procedures, or visits, or avoid high-risk patients or procedures primarily (but not necessarily solely) to reduce their exposure to malpractice liability. Defensive medicine is one of the least desirable effects of the rise in medical litigation. Defensive medicine increases the cost of health care and may expose patients to unnecessary risks.
Merriam-Webster online:
Main Entry: defensive medicine
Function: noun
Date: 1973
: the practice of ordering medical tests, procedures, or consultations of doubtful clinical value in order to protect the prescribing physician from malpractice suits
Amy Tuteur’s definition of defensive medicine:
“Defensive medicine is about doing everything possible to prevent preventable deaths.”
Sounds closer to the definition of preventative medicine. There’s a huge difference.
I find it ironic, Jill, that you feel it necessary to practice defensive medicine while condemning others for doing so. Why is that disclaimer at the bottom of this page if not because you fear being sued?
Sorry, is Jill a doctor now? Or any type of HCP? Amy, come now, you can do much better. That is a standard dislaimer for any and all websites which discuss medical information. It is defensive, possibly, but it is certainly not medicine!
Ever since you suggested a google alert along the lines of "big baby c-section ultrasound", I have had one set up. Hoo-boy, it does kick up a lot! I have tried to keep my fingers out of it (have sometimes just considered posting a link to your website!) and look on it more as an educational experience than an opportunity to tell someone they're Wrong on the Internet (see the xkcd comic Rixa posted) in part for not wanting to get drawn into the situation you experience with your first posting. But I'm glad you are jumping in sometimes and giving the info! It's a nice counterbalance to 'if ur dr says u need it then u prolly do".
Jill, I think I have a girl-crush on you. Excellent post and follow-up. Thanks!
My point is the chance of being sued after a bad outcome is so high, and the net is cast so wide that even a writer in the far corner of the blogosphere feels compelled to take action. Jill trivializes doctors' fear while at the same time attempting to protect herself from the same thing.
I see that herpes, I mean... Dr. Amy is back...
Wow, I guess it is obvious what Amy does when she is set straight... Jill, it has been said before, but it is a huge accomplishment that Amy is here :-)
I like reading what people respond in these discussions, because it is so informative. It helps me to educate myself about the mainstream rhetoric and to look at the numbers better and better. I think that this is really Amy's plan.
Dr. Amy said:
"Defensive medicine involves lying to patients.
Defensive medicine is about putting a doctor’s or hospital’s interests before those of the patient.
Defensive medicine takes “First, do no harm” and turns it into “First, redefine harm and try to sell your patients on it without them suspecting.”
Are you serious? You think the only person who is harmed by a dead baby is the doctor?
Defensive medicine is about doing everything possible to prevent preventable deaths..."
Really? Is that what you think defensive medicine is and is not? Back in 2006, you didn't seem to feel the same way. What changed your mind? :
Amy Tuteur, MD:
"The C-section rate is rapidly approaching 30%. That’s at least twice what it ought to be, and last I heard babies have not doubled in size and fetal distress has not doubled in incidence. If that’s not defensive medicine, I don’t know what is."
Here is the link to the post and comment:
http://www.kevinmd.com/blog/2006/03/kate-steadman-thinks-defensive.html
Kudos for getting Dr. Amy here! Definitely means your post is awesome and true, which needs to be 'rebuttled' by such a defensive ex-doctor.
I have been banned from SOOOOOO many forums for saying exactly what you are saying. I have also been banned from blogs and other places for comments that say the truth.
It amazes me that people follow like sheep to slaughter when it comes to birth. I'm glad at least one person listened to you tho!
Great post, and you truly are helping women, even if it doesn't seem like it at first.
Lalalalala, not feeding the troll. Besides, Jill already said what needed saying.
Anyhoo, Jill, I hear you on the offering advice thing; it's hard to know when to step back and when to say something. I have also had the experience that messaging someone directly with links, cites, what have you, and offering to talk if they want to is far more helpful. It takes off the heat of the spotlight, for one; a woman who posts on a given board a lot may be afraid to disagree with other posters she likes, or take sides in a dispute.
But one on one, she can have time to think and consider, and then it's on her whether to get back to you or not, without feeling pressured or defensive.
I do try to take the stance that I and my little stack of citations am just one of many sources of information a pregnant woman receives, and to expect her to trust me, Random Internet Person, over everyone else, is impractical. So all I can do is say "here are what some Really Smart People have said that contradicts what you have been told; read them and see what you think."
Ah, the dead baby card. How we love it. It's the ultimate conversation stopper; the "don't argue with me, I'm the mother of a dead baby and I'm ALWAYS right!" never-failing tool. It's a variable "get out of jail free" card for anyone involved in a debate who has been backed into a corner by a logical argument. It's the ace up your sleeve: whip it out and immediately everyone involved in the debate will stop dead (ha!), shower the poster with unending praise and remorse, and then take everything she says next as absolute gospel because... well, we don't want to admit that dead babies (much like [bull]shit) happens, do we?
You just don't argue with the dead baby card.
It slices, it dices, it even slims your thighs!
Played by doctors it's worth at least double, I hear. Not just an ace; it's a royal flush! It automatically makes their argument factually correct and effectively stonewalls any opposition. How DARE you argue with the guy who brought out the dead baby card... I mean, they "know". They must</I> know: they've seen a ... *whisper* dead baby. </I>
It's especially good if they throw in a little "personal story" about how the devastated and bereaved mother, possibly near suicide (<I>always</I> a juicy detail) "wanders the halls of the hospital", or the nursery, crying for her lost little one like she was some sort of schizophrenic poltergeist. Oh, if only she'd consented to that one extra prenatal test! If only she'd not been so 'selfish' and insisted on a natural birth! Oh, if only those crazy birthers didn't convince her poor, weak, female mind to be at home! She's just a helpless victim... now with a DEAD BABY! Damn you crazy birth junkies... damn you! Thank god we have the voices of those clever doctors to avoid such a plight.
*cough cough* Sorry, got a little carried away, there.
Oh, how I hate it.
... you know, AS THE MOTHER OF A DEAD BABY.
michele:
"Back in 2006, you didn't seem to feel the same way."
What are you talking about? My current comment is in no way opposed to my previous comment.
Let's assume for the moment that at least some of you want to have a serious discussion on the topic. I'm presuming that at least Jill does.
First we need to stipulate certain facts:
1. Most parents of a baby who dies will contemplate suing the doctor.
2. Many parents will consult a lawyer.
3. The ONLY way to prevent a lawyer from filing a lawsuit is to convince him that he can't win.
4. The ONLY way to convince a lawyer that he can't win is to demonstrate that everything possible has been done.
Can we agree on those points before getting into the discussion.
My point is the chance of being sued after a bad outcome is so high, and the net is cast so wide that even a writer in the far corner of the blogosphere feels compelled to take action. Jill trivializes doctors' fear while at the same time attempting to protect herself from the same thing.
I don't think it's so much trivializing doctors' fear as it is protesting that women are being lied to, and then being subjected to interventions with higher risks, so that doctors are protected from liability. Or at least, they perceive that it is safer. I understand, as a doctor, you feel a certain kinship with fellow doctors. I also can sympathize with doctors who spend 6-8 years (perhaps more) getting their degree, running up $200,000 in student loan bills, and then operating under pressure and high malpractice rates, knowing that one or more lawsuits could put them out of business, or make it more difficult for them to practice. But can you not also sympathize with women who are being sliced and diced? -- who are bearing the personal burden of the doctors' attempt at becoming insulated from liability? Women and their children, who are being subjected to more and more interventions, in a futile attempt at stopping lawsuits? Women who are being lied to? Women who are being given only part of the information they need in order to give proper informed consent? Everything, including doing nothing and doing everything, has *some* element of risk -- electively deliver every mother at 37 weeks, and you're going to have a lot more NICU admissions and neonatal deaths, along with some iatrogenically premature babies, although the risk of stillbirth at 38+ weeks disappears (because no woman is pregnant at 38+ weeks). But in addition to the increase in perinatal/neonatal morbidity and mortality that undoubtedly will come, there will also be an increase in maternal morbidity and mortality, as more and more women are subjected to inductions and C-sections, which carry their own risks.
You and I both agree and understand that there is no 100% safe course of action. If the woman is not given any choice in the matter (being threatened with a court order, or calling CPS, being physically forced to accept an intervention, or otherwise subjected to high-pressure tactics), then she has no rights, and therefore no responsibility in the outcome, and the doctor bears it all. The doctor's best course of action is to follow informed consent, and tell her the risks and benefits of everything (including the slight risk of fetal demise or any other negative outcome with or without the intervention), and let her choose, rather than lying to her about the size of her baby, and about the risk of vaginal birth, or the risk of shoulder dystocia, etc. Because when she finds out the truth, and that her doctor lied to her, she's going to be pissed off -- and very likely going to disbelieve her doctor and/or other medical professionals from that point on, and that'll just be one more woman to plan a home birth next time, which is the opposite of what you want.
I just had a really, really frustrating experience at a labor and delivery these past four days. (Yes. Four days.) I can't really go into much detail, but both my doula client and her first labor nurse (who was 38 weeks) were getting induced as low risk primips so their babies wouldn't get "too big". When the induction dragged on into its 3rd day and she still wouldn't be admitted off the street as being in active labor, when the doctor tried to explain her reasoning, it was a cyclical statement like this,
"Well, I could do an ultrasound (her last one was at 36 weeks and wasn't outside the range of normal predicted EFM) but they're 20% off in either direction, and it would probably just worry us. So, we just want to get this baby out before it gets too big, because shoulder dystocia blah blah blah..."
She didn't have gestational diabetes, she wasn't obese, and she didn't have any other risk factors for a large baby.
He ended up being 8 lb 11 oz, and there was no problems delivering the shoulders. The doctor repeatedly told her about shoulder dystocia during the labor, to the point that the woman, who was well informed, snapped at her to stop it already, she got it. The physician said she was just CYA, legally. I am not sure how, considering we had talked about it at least twice during the long labor.
The doctor and the nurse were calling him "large" and I actually got in a short, polite argument with the nurse about whether that weight was "within normal range". I told her ACOG's definition of macrosomia was much higher than that (4500 g), but she said the hospital defines it at nine pounds.
"I don't think it's so much trivializing doctors' fear as it is protesting that women are being lied to"
What evidence do you have that women are being lied to? Impressing upon them the risks of various treatment options is not lying, it's telling the truth.
Furthermore, there are quite a few legal cases out there that are based on a woman's claim that she was told about a specific risk of childbirth, but that she didn't understand it. Many of the cases involving VBAC raise the issue of informed consent. The mother doesn't claim that she wasn't told about the increased risk, but, rather, she didn't "understand" the increased risk because the doctor did not emphasize it enough.
Remember, doctors are responding to the demands and actions of the vast number of women. If most women who lose a baby sue and the only way to defend such a lawsuit is to show that you did everything, what are doctors supposed to do?
MomTFH:
"He ended up being 8 lb 11 oz, and there was no problems delivering the shoulders."
So what? Do you think that's a defense suitable for court: "the last woman with a big baby didn't have a shoulder dystocia"?
What would you do if you were RESPONSIBLE in the event that a baby died because you didn't do everything you could to prevent it? Would you shrug it off? Would you tell the mother, "Too bad things didn't work out, but it's more important that fewer women have C-sections than that you have a live baby?" How well do you think that would go over?
Oh wow, MomTFH, you know I feel you on the doula-for-four-days piece where it's 3 days before they're even really in "labor"...my sympathies! I think there's a lot of post facto justification in those situations,, especially trying to call the baby big when it's really, you know, not. I had a mom told by the doctor she had a big baby that she could "never have pushed out" at around 8.5 lbs. This was not a small woman and furthermore, she was never even able to try to push because it was a stalled induction at 5 cms. - so how in the world would the doctor know? Is it trying to make her feel "better" about not having a vaginal birth, CYA, or a mix of the two? I guess it's easier when every hospital can set its own definition of macrosomia! (And how did this nurse get away applying it to a baby who was still under her made-up cut-off?)
I will simplify:
Dr. Amy says:
"Defensive medicine is about doing everything possible to prevent preventable deaths..."
Unnecessary cesareans, that you stated were twice as high as they should be, are not "doing everything possible to prevent preventable deaths"--they're especially not in the best interest of the patient. You scoffed at Jill's statements such as "defensive medicine is lying to the patient". It is.
Giving someone a (unnecessary) cesarean when you know damn well babies, as well as the incidence of fetal distress, did not "double in size" isn't helping women.
Defensive medicine IS lying to patients.
It IS about putting a doctor’s or hospital’s interests before those of the patient.
It IS taking “First, do no harm” and turning it into “First, redefine harm and try to sell your patients on it without them suspecting.”
I wonder if it's Dr. Amy's office that has that sign by the reception desk from your previous post...hmmmm
http://www.theunnecesarean.com/blog/2009/11/4/photoshop-contest-the-anti-doula-sign-in-the-utah-obstetrici.html
"Giving someone a (unnecessary) cesarean when you know damn well "
If it is so easy to figure out IN ADVANCE which C-sections are unnecessary, why don't you explain how to do it?
Amy, you said it yourself--if the cesarean section rate is double what it ought to be, then you tell me.
"What would you do if you were RESPONSIBLE in the event that a baby died because you didn't do everything you could to prevent it?"
I'd like to point out that in most cases of SD, the doctor isn't actually responsible for the bad outcome. And I think, as a formerly practicing OB, you know that. You know that 50% of cases of SD are in babies who are nott large for gestational age and so could not even begin to be predicted. If there is a suspicion that baby is "large" there is still no guarantee that baby will become stuck, and then if baby DOES become stuck there is still a good chance it will be resolved with no issue or that the damage will be less than death (since we're talking about THE DEAD BABY here). So how many women are going to undergo unnecessary c-sections? And is that ethical? Is it ethical to push hard for surgery when the obstetrician should darn well know that the chances of death are very small and the risks of c-section very real?
I agree with Jill. Changing the mode of birth only chances the types of risks involved, it doesn't just eliminate the risks completely. Wouldn't that be great? Have your baby by c-section and there is NO RISK to either of you!!!! Uh, life just does not work that way. I absolutely think that doctors and midwifes should practice in a way that is prudent and I absolutely believe that litigation has gotten out of control. But I do not think that it's OK to present the "facts" in a way that is weighted toward the way you'd rather. Amy, how would you feel if a home birth midwife strongly encouraged a woman to refuse to seek OB help in a case that presented as requiring further intervention based on her personal beliefs? Instead shouldn't she properly inform her client of the risks vs benefits of seeking or holding off on further treatment? Should hospital based staff be held to different standards? Should they not be clearly informing patients of both the possible benefits of a course of treatment (inducing early for suspected macrosomia to possibly prevent shoulder dystocia that may or may not happen) vs the benefits (early induction on an unfavorable cervix for suspected large baby is not recommended by ACOG and it greatly increases the risks of needing surgery which poses increased risks to both mother and baby) and then allow THE PATIENT to make the ultimate decision on what happens to her body and her baby?
And if I may, shall we also discuss OTHER ways of preventing shoulder dystocia? Namely encouraging good positioning of the baby prior to labor as well as encouraging an unblocked delivery so that Mother can assume physiologically normal birthing positions and be helped to move IF baby does get stuck. I've seen blocked women with shoulder dystocias in hospitals (I was one of those myself) and seen them unblocked at home and in hospital and it was a WHOLE lot easier to resolve in women who could assume several different types of positions to help baby out.
"I'd like to point out that in most cases of SD, the doctor isn't actually responsible for the bad outcome."
Really? And do you think a jury is going to believe that? Do you think that the fact the literature shows that SD is not the obstetrician's fault will keep the lawyer from suing?
"then you tell me"
No, you're the one is so SURE that doctors are lying to patients, not me. So please explain how they can acquire perfect knowledge in advance that a C-section is unnecessary. They can't, can they?
No, no one can tell with certainty before-hand if a cesarean is going to be an unnecessary cesarean.
That being said, a 30+% c-section rate is not justified. 30% of women didn't suddenly need c-sections. Yes, I know doctors are lying. My doctor lied to me, and many women who I speak with have been lied to, coerced, been purposely not given full informed consent. etc etc etc.
Gee whiz, Dr. Amy sure has a hot girlcrush on you, Jill! You know what they say....open hostility is one of the best signs that you are making progress. Want to piss people off, try to change something! ;)
"That being said, a 30+% c-section rate is not justified."
That's like saying "peace is better than war." Suppose we agree? It doesn't give us any tools for addressing the problem.
If you want to solve the problem, instead of merely complain about the problem, you need to consider practical suggestions. The power to change things rests in the hands of women. I assure you that if women did not routinely sue when a baby dies or is injured, the C-section rate would be far lower. And I can also assure you that if the legal system did not make "doing everything including a C-section" the only acceptable defense, the C-section rate would be far lower.
Defensive medicine exists because doctors have something to defend themselves against. They don't make people sue. And they are certainly not responsible for the way the legal system handles those suits. So why do you think the solution lies with them?
One particular way to tell in advance if the c/s is unnecessary is if the fetal heart rate is reassuring and reactive, and the c/s is done for failure to wait. Or for suspected CPD. Or because it's a change of shift and the doctor wants to be able to charge for procedure. Or because the c/s is done on the risk reduction ratio of at least a 25% c/s rate per physician. How many DEAD MOMMIES will it take before defensive medicine (AKA premeditated assault and battery) is another bad memory?
"One particular way to tell in advance if the c/s is unnecessary is if the fetal heart rate is reassuring and reactive, and the c/s is done for failure to wait."
Really? And how often does that happen? Any scientific evidence to show us, or just your personal opinion? Remember, your personal opinion is not going to carry any weight in court and it certainly is not going to console a woman whose baby died and might have lived with a timely C-section.
And as for synthetic oxytocin:
18 common allegations in oxytocin-related litigation
1. Unnecessary induction due to lack of medical indication
2. Failure to establish fetal well-being prior to initiating oxytocin
3. Failure to adequately monitor fetal heart rate during oxytocin infusion
4. Failure to adequately monitor uterine contractions
5. Failure to place a spiral electrode and/or intrauterine pressure catheter
6. Failure to discontinue oxytocin in light of nonreassuring fetal heart rate
7. Failure to identify and respond to fetal distress
8. Delay in identifying and responding to nonreassuring fetal heart rate
9. Failure to notify provider of nonreassuring fetal heart rate
10. Failure to identify and respond to uterine hyperstimulation and/or elevated resting tone
11. Inappropriate titration of oxytocin not based on accepted protocols
12. Administration of oxytocin without a physician’s order
13. Failure to follow physician’s order
14. Failure to order a cesarean section when fetal heart rate became nonreassuring
15. Delay in cesarean section after being ordered by the physician
16. Failure to follow hospital policies and procedures
17. Inadequate policies and procedures governing oxytocin administration
18. Failure to initiate chain of command
"And as for synthetic oxytocin:"
Is it really that difficult to stick to the subject? We were talking about defensive medicine, weren't we? So why are you suddenly talking about pit? Is it to deflect attention from the fact that you have no practical suggestions for reducing the C-section rate?
According to the United States Public Health Service failure to progress and/or dystocia is the second most common reason for a c-section and represents about 30 percent of all cases.
http://www.healthline.com/galecontent/cesarean-section
The second most common reason that a c-section is performed (in 30% of all cases) is difficult childbirth due to nonprogressive labor (dystocia).
http://www.answers.com/topic/caesarean-section
Well, I was able to prove in court that my coerced (almost court ordered) section was unnecessary and they knew it before they they did it.
What about that? My labor problem was failure to obey...how many other woman end up having surgery for that same reason?
What about defensive medicine against getting sued for cutting woman up?
"What evidence do you have that women are being lied to? Impressing upon them the risks of various treatment options is not lying, it's telling the truth."
By not telling all the risks, omitting important information, down playing the risks, those are lies when you know better, which a doctor should. Why augment a labor with pitocin without trying nipple stimulation, and say that it is *completely* safe and does not make your contractions hurt more? Those are lies. Amy, don't tell us what we see in the trenches. It is one thing to uphold the correct evidence based obstetrical practice, and quite another to see it done in real life and it lacking. Go work as a doula, Amy and maybe you will better understand where we are coming from.
I agree though, in that it is not solely the fault of the doctors when action are being taken because of litigation fear. I have no answers for that. I do know that looking at birth as a pure scientific event is not the answer either though. We would have the best numbers in the world if it did, and we don't. There is only so much science and research can show. The fruits show what is real.
As if synthetic oxytocin has nothing to do with defensive medicine, opportunistic medicine, fetal distress, and the cesarean rate. Puleez.
We do agree on this: both the fault and solution doesn't lie solely on the doctors.
Wow, I guess that's what happens when I comment without reading the other comments.
Dr. Amy - She had NO risk factors or indications for a macrosomic baby and the baby did not have macrosomia. Are you proposing if, in 3 years when I am a practicing obstetrician, I do not section all similar patients, I am risking killing their babies?
Here is a quote from Up to Date:
Fetal macrosomia — Studies have consistently shown that macrosomia is a major risk factor for shoulder dystocia [2,3]. Fetal macrosomia is best defined as an estimated fetal weight (EFW) of greater than or equal to 4500 grams, as morbidity and mortality increase above this level [4,5]. The overall prevalence of birth weight over 4000 grams in the general obstetric population of the United States is 10 percent [6], but falls to 1.5 percent for birth weight over 4500 grams [4].
Her baby was more than 500 g below this threshold, and did not have an EFW above that threshold.
What do you think of the idea of doing an induction on her at 39 weeks with a Bishop's score of 2 on this low risk patient? Based on ACOG Practice Bulletins and other online materials on quality care, my interpretation of the risks and treatment decision tree is pretty spot on. How much more do you think the baby would have grown if her physician waited for her due date at least, and how much would that increase her risk of shoulder dystocia?
I am not going to argue any of your other point since you are showing your typical arguing style. Ask others for citations but use none yourself. Create straw woman arguments and knock them down bravely. Ignore all good arguments and bring up new bad ones.
Have you read this article yet? The Obstetrics and Gynecology Risk Research Group still thinks obstetricians are misrepresenting risk to patients, to the detriment of women and their babies. You do it also, repeatedly. You have this citation from the thread from more than a week ago. You proceeded to cite a study from the same group the very next day, so you must think it is a good source.
Amy said:
Defensive medicine is about doing everything possible to prevent preventable deaths.
AND
I find it ironic, Jill, that you feel it necessary to practice defensive medicine while condemning others for doing so. Why is that disclaimer at the bottom of this page if not because you fear being sued?
So, defensive medicine is about doing everything possible to prevent preventable deaths. I have a standard disclaimer at the bottom of my site stating that this blog is informational. Amy says that I am practicing defensive medicine on my informational blog. Therefore, I am doing everything possible to prevent preventable deaths.
Say what?
Defensive medicine has everything to do with trying to manipulate patient “care” in order to forge the appearance that everything possible was done in advance to prevent an often unpredictable outcome. You confirm this upthread.
Methinks Dr. Amy doesn't know the difference between defensive medicine and preventative medicine. Or an informational blog and medicine.
Oh, and "Dr. Dangerpartum Von Deathtrap"? Bwah hah hah hah hah hah!
Amy said: First we need to stipulate certain facts:
1. Most parents of a baby who dies will contemplate suing the doctor.
2. Many parents will consult a lawyer.
3. The ONLY way to prevent a lawyer from filing a lawsuit is to convince him that he can't win.
4. The ONLY way to convince a lawyer that he can't win is to demonstrate that everything possible has been done.
Can we agree on those points before getting into the discussion.
I'd like to ask you to back this up, and not just to be a turd. The OB-GYNs with whom I’ve spoken about this over the last year are eager to perpetuate this argument repeatedly, yet no one I’ve spoken to have been able to back it up with anything but anecdotes and emotion. While I am always interested in hearing people convey aspects of their cultural mythology to me, I have been hard-pressed to find anyone who can break down an OB’s actual risk of being sued.
My point, Jill, is that you have a disclaimer because you are afraid of being sued. The disclaimer is an acknowledgement that in the event of a bad outcome, even a blogger can be sued for the information she provides. So you make it clear that you are not providing medical advice.
But what about the people who are providing medical advice? Aren't they entitled to take steps from preventing themselves from being sued?
Let's go back to the facts that I set out.
1. Most parents of a baby who dies will contemplate suing the doctor.
2. Many parents will consult a lawyer.
3. The ONLY way to prevent a lawyer from filing a lawsuit is to convince him that he can't win.
4. The ONLY way to convince a lawyer that he can't win is to demonstrate that everything possible has been done.
Do you agree?
According to James M. Shwayder, MD, JD, Liability in High-Risk Obstetrics, in the Obstetrics and Gynecology Clinics of North America:
Litigation centers on errors of omission or commission. Thus prime areas for obstetrical litigation comprise the following:
1. Errors or omission in antenatal screening and diagnosis
2. Errors in ultrasound diagnosis
3. The neurologically impaired infant
4. Neonatal encephalopathy
5. Stillborn or neonatal death
6. Shoulder dystocia, with either brachial plexus injury or hypoxic injury
7. Vaginal birth after cesarean section
8. Operative vaginal delivery
9. Training programs (Resident supervision markedly impacts litigation exposure. Increased used of nurse midwives and nurse practitioners may increase ones liability exposure.)
Three factors jump out at the reader:
1. Of the 9 most common reasons for obstetric malpractice suits, 6 allege failure to perform a C-section or failure to perform a C-section sooner.
2. Fully 8 out of 9 of the most common reasons allege failure to use more technology or to properly interpret the technology that was used.
3. Supervision and backup of other providers is a significant source of obstetric malpractice claims.
Not surprisingly, therefore, the recommendations for avoiding obstetric lawsuits include:
Antenatal screening and diagnosis
ACOG now recommends offering antenatal screening for chromosomal abnormalities to all pregnancy patients regardless of age. In addition, the broader availability of nuchal translucency screening establishes a standard of care in which most patients should be offered the opportunity for first trimester screening. A physician failing to offer patients such diagnostic testing is at risk for suit...
Antepartum fetal assessment
High-risk pregnancies require antepartum fetal surveillance. Fetal heart rate monitoring, ultrasound surveillance, amniotic fluid volumes, Doppler studies, and cordocentesis are appropriate in pregnancies complicated by conditions such as intrauterine growth restriction, twins, diabetes, hypertension, severe preeclampsia, and sensitization, among others. Guidelines for appropriate use establish an accepted standard of care. Deviating from these guidelines requires substantiated decision making; otherwise, physicians are at risk of a malpractice suit in the event of an adverse outcome.
Intrapartum liability
Obvious liability lies with an adverse fetal or neonatal outcome. Intrapartum management undergoes close scrutiny. The most devastating outcomes,and thus costly awards, center on neurologically impaired infants and babies with permanent neurologic deficits after shoulder dystocia.
Neurologically impaired infants
It is clear that careful attention to labor progress and fetal status, including adequate documentation, enhances defensibility. Intrapartum fetal heart rate changes must be recognized and responded to appropriately. Prompt intervention and operative delivery, if indicated, minimize allegations of negligence.
Shoulder dystocia
Shoulder dystocia is an infrequent, and often unpredictable, nightmare for the obstetrician. However, the law evaluates whether the complication was foreseeable and, if not, whether appropriate maneuvers performed. Recognized risk factors include a prior pregnancy complicated by shoulder dystocia and resultant Erb’s palsy, macrosomia, and a midpelvic operative delivery in fetuses with an estimated weight over 4000 grams. An estimated fetal weight over 5000 grams in nondiabetic pregnancies and over 4500 grams in diabetic pregnancies has been offered as justification for a primary cesarean section. Thus, a physician who overlooks the prior obstetrical history, does not estimate the fetal weight in labor, or who pursues a midpelvic operative delivery in larger infants subjects him or herself to a claim of negligence.
Vaginal birth after Cesarean section
Vaginal birth after cesarean section has come under great scrutiny. It is a safe alternative in well-selected patients delivering in hospitals with appropriate resources. However, recognized risks and the dire consequences have prompted some states to impose practice guidelines for VBAC. Physicians should document discussions of the risks and benefits of VBAC and the hospital's capabilities, with signed patient consent. Immediate physician availability and operative capabilities are required. If this cannot be offered, then the patient should be transferred to a facility with these capabilities.
Supervision of midwives
Certified nurse midwives often have independent practice authority. However, collaborative agreements may be required to independently prescribe medications. Written protocols, including scope of practice and referral guidelines should be in place and carefully followed. Hospital protocols and guidelines often dictate the level of supervision and consultation required. A physician employing a midwife is liable for any acts under the doctrine of respondeat superior. Vicarious liability occurs as it would for an employer liable for the wrong of an employee if it was committed within the scope of employment. Thus, guidelines and protocols must be followed to maintain defensibility of a case.
I have highlighted some of the legal requirements of obstetric practice. The justice system does not consider these tests, techniques and procedures to be discretionary. Any doctor who ignores them or does not use them can easily be charged with negligence.