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Sunday
Feb212010

ACOG on Fallibility of Obstetric Judgment and Mode of Delivery

 

The following excerpt from the American Congress of Obstetricians and Gynecologists’ Committee Opinion Number 321 about how fallibility in obstetric judgment is sufficiently high as to warrant wariness in legally coercing women to consent to intervention.

 

Consider, first, the limitations of medical judgment in predicting birth outcomes based on mode of childbirth. A study of court-ordered obstetric interventions suggested that in almost one third of cases in which court orders were sought, the medical judgment was incorrect in retrospect (27). One clear example of the challenges of predicting outcome is in the management of risk associated with shoulder dystocia in the setting of fetal macrosomia—which is, and should be of great concern for all practitioners. When making recommendations to patients, however, practitioners have the ethical obligation to recognize and communicate that accurate diagnosis of macrosomia is imprecise (20). Furthermore, although macrosomia increases the risk of shoulder dystocia, it is certainly not absolutely predictive; in fact, most cases of shoulder dystocia occur unpredictably among infants of normal birthweight. Given this uncertainty, ACOG makes recommendations about when cesarean delivery may be considered, not about when it is absolutely indicated. Because of the inability to determines with certainty when a situation is harmful to the fetus or pregnant woman and the inability to guarantee that the pregnant woman will not be harmed by the medical intervention, great care should be exercised to present a balanced evaluation of expected outcomes for both parties (20). The decision about weighing risks and benefits in the setting of uncertainty should remain the pregnant woman’s to make in the setting of supportive, informative medical care.

 

Maternal Decision Making, Ethics, and the Law (Obstet Gynecol 2005;106:1127–37). November 2005.

 

Related posts:

Can My Doctor Really Predict Shoulder Dystocia?

I Had Shoulder Dystocia Once. Will It Happen Again?

 

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Reader Comments (7)

I think it warrants more than "wariness"; I think it warrants not doing it at all (coercing women into medical treatment) by virtue of the fact that women are people. A doctor's fear of being sued does not warrant removing my right to decide my own medical care.

February 21, 2010 | Unregistered Commenteremjaybee

What the F else do they need...an engraved invitation? I wish they would listen to just a fraction of the reasonable reccomendations that are made within their organization...we would all appreciate it.

February 21, 2010 | Unregistered Commenteranonymous

Because it must be said before I move on: "uh, duh?"

Also, this quote [When making recommendations to patients, however, practitioners have the ethical obligation to recognize and communicate that accurate diagnosis of macrosomia is imprecise. Furthermore, although macrosomia increases the risk of shoulder dystocia, it is certainly not absolutely predictive; in fact, most cases of shoulder dystocia occur unpredictably among infants of normal birthweight.] made me want to dance...until I saw that it was published in 2005 and realized that providers now are still giving the same information; heck, I've received it in this pregnancy.

Also, when ACOG stops referring to its mandates as standard of care and allowing them to be quoted as such, then I'll take them seriously re: consideration v. indication.

February 21, 2010 | Unregistered CommenterANaturalAdvocate

Wait, since when does ACOG simply "recommend" when cesarean may be considered, "not about when it is absolutely indicated?"

Funny, but I thought the 2004 VBAC guidelines are pretty clear about cesareans being "absolutely indicated" when there are more than one prior cesarean with no prior vaginal births.

February 21, 2010 | Unregistered CommenterKnitted in the Womb

"I think it warrants more than "wariness"; I think it warrants not doing it at all (coercing women into medical treatment) by virtue of the fact that women are people. A doctor's fear of being sued does not warrant removing my right to decide my own medical care."

Emjaybee--perfect!

February 21, 2010 | Unregistered CommenterAugusta

This sentiment is also echoed in ACOG Committee Opinion No. 395: Surgery and patient choice.

Here is some of the abstract:

"Decision making in obstetrics and gynecology should be guided by the ethical principles of respect for patient autonomy, beneficence, nonmaleficence, justice and veracity. Each physician should exercise judgement when determining whether information presented to the patient is adequate. When working with a patient to make decisions about surgery, it is important for obstetricians and gynecologists to take broad view of the consequences of surgical treatment and to acknowledge the lack of firm evidence for the benefit of one approach over another when evidence is limited."

Notice the similarity in the language. In the body of the opinion, ACOG strongly warns against a paternalistic attitude towards interventions, including elective cesarean.

February 23, 2010 | Unregistered CommenterMomTFH

In a perfect world, yes, all this stuff would happen. But after my own experiences, and reading some of the stuff that comes up on "My OB said what?!" as well as in talking to other women in person, on internet forums, etc. I know this is NOT the case. Guidelines are one thing, and it's all well and good to say physicians "should" be doing these things. But if they aren't and don't, and furthermore, don't *intend* to, what is ACOG going to do about it?

*crickets*

Yeah, I thought so.

It seems that by and large when it comes to ACOG or WHO guidelines, if they follow what the patient wants, then the physician usually disregards it as meaningless pap. But, if the guidelines contradict what the patient wants and are in line with what the physician wants to do, then suddenly they are the Gold Standard of care.

February 23, 2010 | Unregistered CommenterThe Deranged Housewife
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