Yesterday, I posted the comment made by the NIH guy about how informed refusal is a foggy area. I felt like his response was such a cop out - but I suspect they never even discussed or thought to discuss it. He said that informed consent/refusal did not take into account the mother-baby relationship.

There is legal precedent, according to Katie Prown's document "Enforcing and Promoting the Rights of Women Seeking VBAC" at http://ican-online.org/vbac/enforcing-and-promoting-rights-women-seeking-vaginal-birth-after-cesarean-vbac-primer . It cites a few cases, including Meador v. Stahler and Gheridian, stating:

...the jury awarded a $1.5 million settlement to a Massachusetts woman and her husband for undergoing a medically unnecessary cesarean that she had made clear she didn’t want.

The plaintiffs successfully claimed that the woman’s obstetricians misrepresented the risks of alternative procedures, i.e. VBAC; ignored her expressed wishes for this alternative treatment; compelled her passive consent to surgery through emotional coercion; and that the failure to obtain proper consent constituted substandard and negligent medical care resulting in the development of post-traumatic stress disorder. Further, the plaintiff argued, and the jury agreed, that the loss of personal decision making power over her body, her health, and the birth of her child was both physically and emotionally disabling and deprived her husband of “consortium,” i.e. sexual companionship. In addition, her husband argued that his loss of consortium was exacerbated by the physicians’ failure to include him in the decision-making process, leaving him to feel powerless, and as a result nearly one-third of the total damages was awarded to him. While this case doesn’t hold the same legal standing as appellate court rulings, it does establish a useful precedent for other women to refer to in pursing malpractice suits alleging negligence related to failure to obtain proper consent.

Another one she sites is the Angela Carder case:

In Re. A.C., involved Angela Carder, a pregnant cancer patient who refused to consent to a cesarean at 25 weeks gestation and stated that she wanted to undergo cancer treatment instead, which her doctors believed would kill her fetus. Officials at George Washington University Hospital intervened and obtained a court order to force her to undergo a cesarean that neither she nor her baby survived. Her estate appealed the decision and won.

The Court of Appeals upheld the right of pregnant women to make all medical decisions on behalf of themselves and their fetuses, arguing that to compel invasive treatment on pregnant women would give fetuses rights superior to those of the mother and diminish the rights of born children whose parents could not, by law, be forced to undergo surgery or donate organs on their behalf. The court further ruled that the viability of the fetus and any potential harm the mother might cause to it by refusing treatment could not override her fundamental right to bodily integrity and informed consent/refusal.

It’s important for VBAC mothers to know that the Carder ruling has had a very chilling effect on the willingness of doctors or hospitals to use the courts to force women to undergo cesareans. Many continue to use the prospect of a court order as a threat to coerce women to consent, but hospitals, doctors, and their attorneys are well aware that, should they proceed and should the mother decide to appeal, they’re looking at a long and expensive legal battle that they will lose in the end.

Prown adds,

...in the aftermath of the Carder ruling—and more recent appellate rulings, such as In Re. Fetus Brown in which the Illinois Supreme Court upheld the right of a pregnant woman to refuse a blood transfusion—the AMA and ACOG issued ethical guidelines mandating that physicians must respect the autonomy of pregnant patients and declaring that using the courts to compel treatment is rarely, if ever, justified. ACOG’s ethical guidelines regarding patient rights and maternal-fetal conflict state (http://www.acog.org/from_home/publications/ethics/): “Occasionally, a woman’s autonomous decision will seem not to promote beneficence-based obligations to the fetus. In this situation, where there is insufficient time to obtain transfer of care, the obstetrician must respect the patient’s autonomy, continue to care for the pregnant woman, and not intervene against the patient’s wishes, regardless of the consequences.”

There is a third case that comes to mind which I thought she had referenced but couldn't find by skimming, but the case was about two brothers - one suing the other so he could get a life-saving transplant from him. Short version: the court upheld that a person could not be forced to undergo a medical procedure to save the life of another; no person's life is more valuable than another's.

So, I'm no lawyer - perhaps Courtroom Mama or someone else can elaborate further about the validity of these cases in terms of informed consent/refusal - I'm kind of interested in that perspective, actually. And between this and EMTALA, a hospital can't turn a laboring mom away, and can't do anything she says no to.

Now, I realize this is actually about informed refusal, but we really can't have one without the other, right?

Just my .02 - if it's worth even that much...

Tort reform chaps my ass in a world where NIH panel members say things like gravid women have no right to informed consent.

And I do not agree with linking the VBAC issue to abortion. That comparison is a red herring IMO. The ONLY issue to focus on is that VBAC for a normal-risk mother is *still* less risky to mother and child than repeat cesarean. Emotionally and erroneously pitting a mother's interest against her baby's is not serving either at all.

Amy, KK and Jill

I think that because this is an open discussion format on the issue of VBAC and informed consent that it is completely appropriate to present this issue from the other side. Amy has provided an example of a case in which informed consent was given to the patient. Yes, we can do VBAC, yes, there are risks...and despite this informed consent, there was a lawsuit. It is terrible that this individual suffered fetal loss...horrible....but the doctor provided the patient with information about the risks involved, was willing to perform the VBAC and then suffered the consequence of not only fetal loss in their patient but also a lawsuit.

I would venture to guess that this physician no longer does VBAC deliveries because they are unwilling to assume the small (but higher) risk of maternal/fetal death when despite informed consent, a lawsuit was the outcome.

And regarding the Angela Carder case...this was a terrible miscarriage of medicine that occurred in the 1980's...

I recently survived a pregnancy with cancer and underwent 6 rounds of chemotherapy during the pregnancy. I was informed of all of the risks...and had to have a c-section because of complications from the chemotherapy drugs. There were complications post c-section for me and the baby spent 5 long weeks (for me) in the NICU. Though several options were presented to me, I was permitted to make the treatment choices. I also chose to listen to my health care providers and not insist on options that were unrealistic or carried even greater risks.

These issues are all very layered.

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';; 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.

At some point, I think "do you really KNOW your baby could die" is a moot question. We all knew it the day we got pregnant. Most women have miscarriages. Many women willingly abort. Yes, they know, deep down inside, because it's their worst fear. Trying to state that women don't know that reality is just...unfathomable...in my world. Not willing to accept, maybe, ignorant..never. Not unless they are mentally impaired.

So what I tell people is this: VBAC moms aren't different nor special. They don't have especial risks even if some risks seem slightly higher clinically. The difference for VBAC moms is that they KNOW the risks and are reminded of the risks in a way that most moms don't EVER have brought to their attention so when those risks turn into reality,

So what is informed consent. When I signed the papers for the c/section...no one told me that 20 years later I would be doing constant battle with yeast in the scar. Adhesions were mentioned, but no one told me that with age, adhesions can become more serious causing bowel obstructions and resulting in sepsis...which is often fatal. Is our medical system prepared to deal with the numbers of women who now have abdominal adhesions (thanks to protecting the malpractice insurance of the OBS).

Based on the conference earlier this week...I would have failed the Screening Predictor for VBAC success...on many points...I would have been seriously cautioned for a repeat c/section, perhaps even having doctors who would refused to care for me.
If I don't have the right to refuse their recommendation of a repeat c/section...I'm sectioned again. Only thing is...I've had two vbacs.

The Emporers are wearing no clothes. And the more women figure out that they aren't birthing with an OB, but with an entire Obstetric dynasty that only prioritizes its interests as it sees fit (through a wide angle lens of medical legal financial and litigation issues) they will take their consumption of maternity care elsewhere. And the CDC says it is already happening.

NM: the short answer is..yes. If a woman (and how many women as a percentage, truly, are we talking about, who want to take extreme risks in birth?) wants to take the extreme risk, she has a right to. However misguided. And she may end up grieving a dead baby, or be dead herself. But that will be her risk to have taken. You have to treat her like an adult capable of this decision.

I mean, put it in a different context; what if she doesn't want her cancer treated, when you know she could survive? Or has to decide whether to let her spouse get taken off life support when you think he could make it? We trust her to be competent to make that decision, because we have to. This is no different.

Now, in the breech case you cited, it wasn't just about the lawsuits, it was about *your inexperience* no? You did not feel confident you could deliver that baby breech. I do think a midwife or OB has a right to say "I need assistance with this" as well, as hard as that may be. Breech does have increased risk, although better training of OBs and midwives could certainly reduce that risk and the c/section rate as well. But you personally were caught in a judgement call, and you made the best one you could.

I agree with much of what has been said. I also think that a trial of labor is fair in most situations post-c-section. The only point that I'm trying to make is that because litigation is a real risk, that many doctors are simply deciding against offering VBAC. As a patient, we are free to choose to exercise our choice and find someone else.

It is a shame, because both physicians AND patients feel victimized. That is KEY in this issue. Both parties feel victimized.

A close friend of mine is a family practitioner. During her residency, she attended a birth where the baby died as a result of a uterine rupture during a VBAC. She was absolutely devastated by this as was the patient and the patient's family. There was a lawsuit...but beyond that was the horrible grief experienced by the mothertas well as my good friend. From that point forward, she determined to never practice OB again...ever...and she hasn't.

Something worth thinking about is that we know that the risks are low..and yet...if a physician or midwife experiences this particular horrific thing in their practice...well...it seems more common than the statistics would imply. Doctors and mid-wives are humans and they are also incredibly moved by these losses and experiences.

I'm sure to you, for example, the idea of developing cancer during pregnancy seems like ... well...so rare it would never happen. Having experienced it myself, and being a volunteer for an organization that provides care to women undergoing this issue, I suddenly feel that every pregnancy carries this risk. Of course, it does not....but I am affected by this experience.

Physicians are motivated in part by their fear of litigation too...which can not only ruin their careers, but can have devastating financial impacts. The risks imposed by most c-sections are also fairly low, but again...as a woman who has successfully delivered by VBAC and experienced a rupture with VBAC I still preferred my VBAC to recovery from a c-section.

All I'm trying to say is that these issues are very layered. It is not the evil establishment of medicine against women...in most cases...at least most cases that I know of...though my experience is anecdotal at best.

What I'm asking for is that you consider that there are many reasons that VBAC is done this way now and that perhaps instead of vilifying physicians, we look more at the root cause...and try to address that.

As to the comment about risks of c-section years later, like yeast infections....risks of vaginal birth include urinary incontinence (please, PLEASE don't make me laugh) as well as other unmentionables.

We look to medicine as a perfect science...a cure-all.... Many years ago, women and children regularly died during childbirth. Things have improved but maybe the pendulum has swung too far to the other side. Do we also need to look at ourselves and our role in that? How can we make trials of labor post-section the norm without alienating the medical profession? What factors influence physician choice to reject VBAC (besides our own personal bias as to what those reasons might be?).

Again...I feel this issue is quite layered...but I commend this website for bringing the issue of VBAC to the forefront. I remember how absolutely desperate I felt to experience childbirth after my initial c-section and how hard I searched to find a nurse midwife willing to accommodate my wishes. Had I not experienced rupture, I might wholeheartedly embrace VBAC without question.

I have chosen to read only for most of the discussions hoping to learn more talk less if you know what I mean.
Kris your words crystallize things more for me than all the pontificating and punditing I have been voraciously reading for days- I only hope people will read your words and understand that lofty ideals on choice, informed consent, .8- 1% risk, tort malpractice reform have heart and flesh you are not a variable or percentage point- I am so grateful to hear your story.

I find it interesting that informed consent is emphasized with a VBAC, but not with a RCS other than the canned anethesia/surgery consent form. I know that it was never, ever discussed with me when my second child was born by C-section. All I was told was that I could not have a vaginal breech delivery because my baby would get stuck and die, so I must have a C-section. There was no mention of any other risks and no questions about my planned family size.

I have a good friend who had 4 C-sections, the first one after a failed labor induction and the following three as elective repeats. Upon switching OB/Gyns during the 4th pregnancy, she was informed that it was a huge risk for her to have that many C-sections and that she might develop placenta accreta/percreta, putting her baby and potentially herself at risk. No one had discussed the risks of multiple C-sections with her prior to that point, and now she had to live in fear for the remainder of her pregnancy, which luckily ended in an uneventful 4th C-section.

Another mother on a Cesarean Support board recently posted that she is 22 weeks pregnant with her 4th child after three C-sections and has severe placenta percreta incorporating multiple abdominal argans, which is definitely putting her own life and her baby's life in danger in a real way. She is under close monitoring and her medical team is trying to keep anything devastating from occurring before her fetus becomes viable for early Cesarean delivery. I would consider that condition to be just as serious as a uterine rupture risk in VBAC, but where is the informed consent in this situation? Couldn't patients like this also theoretically sue that they were not accurately informed of the risks of opting for elective repeat C-sections? Why do we single out uterine rupture in VBAC as THE major legal obstable, but not uterine rupture in pregnancy following C-sections or any of the serious consequences of C-section, which are rarely verbalized to the pregnant woman?

I find the Flagg case interesting in a vaguely horrifying way. As a physician, you want to provide full informed consent, but on the other hand there is some issue of protecting a preceding patient's privacy - I don't know that the physician was trying to deliberately mislead the patient, or perhaps she was? Perhaps she practices in a small enough community as I do that disclosing that there had been a death would immediately identify the previous patient (my community is small enough that a patient would be likely to know who I was talking about if I mentioned a death, becoming a thorny privacy issue as well as an informed consent issue.) I tried searching for the ultimate outcome in this case, and couldn't find anything definitive, but I did find a judicial newsletter that seems to indicate that this appellate decision was overturned by the state Supreme Court, with the finding being that physicians had a duty to disclose their level experience and what a "reasonable patient" could expect to need to make a decision, but that the fact that this physician had a previous death did not change the risks/benefits for the current patient so she was not required to disclose that.
Regardless, I suspect that cases where the physician did everything right and the patient pushed for a VBAC and then there was later a lawsuit are rare. Most successful litigation I've read (at least in my state) involved malpractice, not merely a bad outcome (for example failure to respond to nurse's concern over fetal well being for hours, failure to recognize a uterine rupture in a timely fashion,etc.) Even the fear of litigation, regardless of liklehood of success is of course a big deterent to physicians.
I don't know what the ultimate answer is. I feel like honest dialogue is required, though. As a physician at a hospital that had a de facto VBAC ban, I tried hard to counsel my own clients that this "ban" had to do with liability concerns, and that there were other hospitals where they could have a VBAC if they wanted. Other docs in my community told their patients things like "it's against the law now" I kid you not. Even with what I felt like was balanced counseling, knowing that a hospital has banned VBACs is a pretty big deterrent to most clients - they figure it must be too risky if the hospital has banned it. I didn't have a single client choose to go elsewhere for care, and only 3 that pressed the issue and had VBACs despite the de facto ban. (At our hospital, a patient presenting in labor who refused a cesarean had their requests honored, with actually a minimum of fuss, my OB back up just wrote "counseled on repeat cesarean and patient refused" and then we labored away.)

@Shannon - "Most" women do not have miscarriages. 1 in 4 pregnancies ends in a miscarriage, but some/many of those are in the same woman.

And, I will absolutely disagree that women get what it means to have a baby die. I've heard too many women who, during their pregnancy, said they knew the risk of the baby dying (whether they were choosing to UC or not take insulin for GDM or...) and then, when their babies *did* die, they, distraughtingly cried saying how ignorant they were. One midwife (Kneelingwoman) speaks about her own 2 cesareans to save two of her babies, both of whom died, and how the reality was infinitely worse than the imagining of it.

The concrete is always more intense than the imagination.

How this relates to VBAC, what annoys me is that the focus continues being on the risk of VBAC and not the risk of a repeat cesarean, which, if we look in the other direction, is the very real risk of the mother dying. I can imagine a partner saying, "We'll take the risk," and then be horrifyingly sad if it happened. "I never thought it would happen to her!"

It's all a jumble. I see bolg after blog, comment after comment, trying to sort it all out. "It's the doctor's issue," "It's a tort reform issue," "It's an informed consent issue," "It's a malpractice insurance issue," "It's a women's right issue," and on and on.

It's all of these and more.

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."

I'm a VBAC mom and that does not describe me at all...and I doubt it describes any or most VBAC moms. My first cesarean could have and should have been avoided. I sure as heck didn't want another unnecesarean and it wasn't because I didn't care if my baby lived or died. I had to weigh out the pros and cons of a VBAC vs a repeat cesarean. VBAC was a better option for both my baby and I. I did know of the uterine rupture risk as well as the long long list of potential complications of a repeat c/s. I had never known anyone who had a uterine rupture, but did know TWO women whose incision got infected after their repeat sections.

I agree that the issue is layered and pretty much a tangled mess, however I don't think any of it is an excuse. Why should someone else's fear of litigation force me to have unwanted and unneccessary surgery? And the whole malpractice insurance thing has never made sense to me. Why they would skyrocket the rates for pro-VBAC docs is ridiculous....if their going to do that at all, why not make the rates higher for docs with an unreasonably high cesarean rate and induction rate?

I did manage to find the Duffy v. Flagg decision from 2006, in which the defendant (the OB/Gyn Flagg) won the case at the State Supreme Court level:

www.jud.ct.gov/external/supapp/Cases/AROcr/CR279/279CR132.pdf

‘‘[I]nformed consent involves four specific factors: (1) the nature of the procedure; (2) the risks and hazards of the procedure; (3) the alternatives to the procedure; and (4) the anticipated benefits of the procedure.’’

The court made a point that informed consent should include an objective disclosure that a reasonable physician and patient in the state would find material, not all information that a particular patient might find relevant (like Duffy's assertion that had she known Flagg had overseen a uterine rupture with fetal death, she would not have pursued the VBAC; they felt Flagg was not required to reveal that). They concluded that Duffy had been adequately counseled about VBAC risks.

It seems like there is a happy medium between a woman totally signing away her right to sue vs. it being a given that a woman suing over a VBAC gone bad wins the case, which leads to VBAC bans. If I have a uterine rupture and fetal death during my VBAC attempt, wouldn't I only have a malpractice claim if the OB/Gyn failed to respond to clear signs of fetal distress? Otherwise, it's just my bad luck, and it would be like a fetal death from any sudden, unforeseeable labor catastrophe.

@KK - That's my view, as well. There seems to be a lot of concern that patients will sue despite good informed consent and good medical care. Hearing about cases like Flagg reinforce that idea - but knowing that it was ultimately unsuccessful is at least a little reassuring.
I think Jill (blog owner Jill) is right that we are allowing the perceived (legal) risk to the doctor to outweigh the perceivied (medical) risk to the patient, and that just isn't right.

Dr. Jen, you are right about Duffy v Flagg.
The appellate court decision referenced above was indeed reversed by the Connecticut Supreme Court, the final decision can be found at

http://www.jud.state.ct.us/external/supapp/Cases/AROcr/CR279/279CR132.pdf

“The judgment of the Appellate Court is reversed and
the case is remanded to that court with direction to
affirm the trial court’s judgment.”

This means that there was no new trial and the court affirmed that the defendant (doctor) had provided the information considered adequate for a “reasonable person” to give informed consent.
In fact the CT Supreme Court gave significant import to the idea of an objective standard for informed consent: :

"Our standard of disclosure for informed consent in
this state is an objective standard that does not vary
from patient to patient based on what the patient asks
or what the patient would do with the information if it
were disclosed. As this court stated in Logan, the lay
standard of informed consent requires a physician ‘‘to
provide the patient with that information which a reasonable
patient would have found material for making
a decision whether to embark upon a contemplated
course of therapy.’’

"Our conclusion and reasoning are supported by the
decisions of courts in several other states.

"We agree with the reasoning of
these courts, and reaffirm the objective standard of
informed consent that is well established in our case
law."

So in fact this case does not at all support the contention that:
"Decisions like these have made it clear that no consent process for VBAC, no matter how detailed is acceptable to patients or the court. Patients can claim that they didn’t “understand” and courts will side with them."
Quite the contrary.

So Kathy, even though you're "...not a lawyer and just a regular person" your thinking is in fact in in line with the established legal precedent (at least in Connecticut). The appellate court was wrong.

Sorry KK I was apparently composing my response at the same time as you.....

Perhaps it is also relevant that the original poster at the top of this thread also brought up the case of Duffy v Flagg in a VBAC discussion on another blog back In December. In fact her quote above is mostly a cut and paste from that exact comment thread.
http://academicobgyn.com/2009/12/17/ten-thoughts-on-vbac/#comment-397
and that the reversal by the supreme court was also noted two comments later in that same thread.

So it remains for the reader to speculate:
Is Dr Tuteur not aware of the fact that this case was reversed?
or
Was Dr Tuteur being intentionally misleading to cite this case repeatedly and imply that it was a final disposition?
or
Does Dr Tuteur honestly believe that an overturned court case should be used as a guideline for legally prudent medical practice?

Thank you Saanenmother. I have also learned a lot from reading the discussions here as well.

As to the topic of informed consent vs. repeat c-section: I don't have an answer...just more thoughts...

I know that when my cancer didn't go into remission after chemotherapy (followed by a pre-term delivery) that I was told that I would need radiation. The *risks* of the procedure were briefly discussed, but there were few options really...more chemo that would likely not do anything but cause more damage (because the drugs damage healthy cells too), no chemo and accept the consequences, or radiation therapy (carrying several risks). Was I properly informed of every single solitary risk during my pregnancy and treatment? No. Did the physicians pull out all of the literature, sit with me and explain every single thing that could possibly go wrong from chemotherapy during pregnancy to radiation therapy? No. The big issues were mentioned. Would it have made a difference in my choices? Not really. Ultimately, every treatment option or decision that we make comes with risks and it is up to our health care providers and US as adults to inform ourselves of the options and risks.

As an adult woman, I listened to the opinions and options, asked the questions that I had and researched on my own as well. When I chose to begin treatment, it was my choice and I knew that many things could (and actually did) go wrong. I accepted that these things were as much the fault of the physicians caring for me as they were my own fault....not at all....we were just working together to have the best possible outcome.

My daughter is about to turn 4 years old now and ... the health issues that I have now that relate back to my treatment were unexpected and were not ever explained to me as potential problems...and yet I accept that this is not anyone's fault. There is no one to reach back and blame.

I do not know the medical circumstances surrounding some of the repeat c-section stories posted here...neither does the owner of this blog. We are left to hear the stories of women who feel strongly that they have been robbed of a birth experience important to them, that they have been injured emotionally and physically by a system intent on controlling their choices. There are though, some high risk situations where it is understandable that a physician might not want to allow a VBAC. Someone here mentioned a breech delivery. Though it sounds like the attending physician handled the explanations poorly, a vaginal breech delivery is risky and even scary for health care providers. In a breech delivery, the head (the largest part of the baby) is delivered last. There are risks of cord prolapse as well as the babies head becoming stuck in the birthing canal. This is a situation that could spell disaster. When things go wrong during a delivery, they go wrong very fast and by the time they could get your baby delivered by an emergency c-section it could have suffered brain injury from oxygen deprivation or death....

One could make the argument that it would be your choice. You know the risks and are willing to accept the consequences. Should the physician be forced to follow your wishes when their experience and education has taught them that the risk is too high? What is the role then of the doctor in the physician/patient relationship? I'm certainly not a fan of those doctors who approach medicine with a paternalistic mentality...but at the same time, I also recognize that my doctors have had many years of medical school, residency and fellowship training and have a better understanding of some of the risks than I do relying on my google search and the blogs that I read.

I can definitely understand the disappointment of wanting a VBAC and being told no. And yet at the same time, that disappointment is nothing in comparison to the preventable loss or severe disability caused during delivery.

These risks must be weighed, and what I hear people saying here is that they do not have faith in their physicians. They do not have the trust that these people are making choices that are in the best interests of their babies and themselves. I would argue that then, perhaps, it is time to find a health provider that you can trust and talk with openly about these issues. Vote with your feet. If enough women leave the hospitals that won't allow VBAC for more VBAC friendly institutions then things may change.

Are too many repeat c-sections performed? Probably. Though the risks of maternal and fetal death are still low with a VBAC, it is unquestionable that if you or I were to become that statistic that we would suddenly not understand...not feel as informed...want to turn back the hands of time...

FWIW, I wasn't totally in disagreement with my own OB/Gyn when he said a vaginal breech delivery was not advisable, even though he gave me a patently false percentage of babies that die during that kind of delivery. My other delivery was vaginal, so I only have one C-section experience in my past, and in that experience, zero consequences of C-section were presented at any time. All I got was the anesthesia consent form, which mentions paralysis and anesthetic death. Four years later, I'm in my second trimester and planning a VBAC, so I am very sensitive to how those risks are presented to me in comparison to what I was told before either of my past deliveries.

"It seems like there is a happy medium between a woman totally signing away her right to sue vs. it being a given that a woman suing over a VBAC gone bad wins the case, which leads to VBAC bans. If I have a uterine rupture and fetal death during my VBAC attempt, wouldn't I only have a malpractice claim if the OB/Gyn failed to respond to clear signs of fetal distress? Otherwise, it's just my bad luck, and it would be like a fetal death from any sudden, unforeseeable labor catastrophe."

And herein lies the itch:

Wouldn't you only have a malpractice claim if the ob/gyn failed to respond to clear signs of fetal distress?

Maybe...but how would you define failed to respond? And how would you define fetal distress?

A change in the babies heartrate (ie a nonreassuring fetal heartrate), for example, might be due to the normal stress of labor...or...it might be an indication of something more sinister. Your own pain might be a function of normal delivery or a sign of an imminent rupture. In a perfect world, these issues would be very clear and easy to define. In the labor and delivery suite, they aren't always as clear cut. When the risks are increasd by previous c-section or breech delivery, the lines become even less clear. Has your doctor handled these issues appropriately if they give you more fluids, have you lie on your side and continue to monitor ... or is c-section the next step?

What is adequate?

But beyond legal issues, because lets just put those aside. Physicians aren't motivated only by legal issues.

Yes, it would be just your bad luck if you God forbid were to experience something as awful as a fetal death. But what about the physician. Is it just their bad luck to be forced to be a part of it? Part of the job? Hey, suck it up...you were concerned that it wasn't in the patient's best interest, you asked them to consider a c-section, they refused, you delivered a dead baby and nearly had a mom die...but....what's for lunch in the cafeteria today?

Does a physician have the right to sue a patient for emotional damages? ;) Just playing devil's advocate.

No, doctors don't have the right to sue for emotional damage. It's one of things you have to learn to live with, if you are going to be a doctor. Bad things happen sometimes. These bad things happen even when you do absolutely everything right. It's not that we don't have feelings, because, believe me, I can still cry thinking about my first full term demise as an attending physician 7 years ago, but I have to have "broad shoulders" as one mentor taught me, and in the moment with the patient I have to be professional and compassionate and be their support, not the other way around. Also, as a doctor, or midwife, or any health care provider, you have to face up to the fact that you will make mistakes. Some will be not your fault - hindsight being 20/20, sometimes you don't have the information you need. Some might be someone else's fault - you make a decision based on a test, or another provider's opinion, or what have you. Some might even be the patient's fault - I took care of a woman in residency who missed 2 prenatal appts and 2 scheduled NSTs and then showed up to labor and delivery with a fetal demise due to her out of control Type 1 diabetes. And some are likely to be your own fault, because we are human and fallible. if you can't do those things, you shouldn't practice medicine, or midwifery, or anything other caring profession.

Yes, there are always situations where it's not clear what the best course of action is. What I argue, is that the choice and the burden of responsibiltiy need to fall on the woman who truly has the consequences from her decision. It's fine to talk about these out-lier situations where some woman refuses what is truly a medically necessary procedure, but in reality every day women are not even being allowed the chance to hear the true risks/benefits or maybe even to know there is a decision to be made. I've defintely seen some great discussions of risks/benefits by many docs, but I have also seen downright false statements and coercive behavior.

Sure, people can vote with their feet. At least, that is, people who have the privilege of having multiple providers to choose from, and multiple hospitals. In my little community, when we quit doing VBACs, the options were to 1. Have a repeat cesarean 2. Drive 1 1/4 hours to the nearest teaching hospital to attempt a VBAC, which also involved being cared for by whatever resident was on call, and meant traveling all that way for every appt as well 3. Birth unassisted 4. Go against the hospital de facto ban - which although in my hospital this wasn't as hard as it is in some, is still very scary for most women, and definitely the type of support you'd get depended on who was working and who was on call.

"No, doctors don't have the right to sue for emotional damage"
Doctor Jen beat me to the punch, but expressed herself much more eloquently than I can. Doctors and nurses face emotionally charged situations often. It is the nature of the medical field. Suing a patient because of a bad outcome that caused a medical professional emotional damage indicates to me that this person should not be in the medical field. My guess is the "emotion" the plaintiff would be feeling is anger at a perceived loss of control and authority.

Well, like I said, I was playing devil's advocate regarding lawsuit issues.

I agree with doctorjenn for the most part.

I really appreciate doctorjen's contributions here. I've seen so many discussions where doctors just go on and on about tort reform. Doctorjen's last comment is exactly what I'd want my doctor to believe.

I have been astonished at the degree to which some doctors seem to WANT to make life altering decisions for their patients when it is the patients that have to live with the consequences. I am a criminal defense lawyer. I would never want to make a decision for my client whether to plead guilty or go to trial. Because it's their life, not mine, and they are the ones that have to live with the consequences. Many clients try to get me to tell them what to do, but I won't. It's my job to lay out their options, and their job to choose. Now, when I think there is an obviously better course of action I will say so, but if a client understands the risks and potential benefits and makes a different choice that is his/her right. It lets me sleep at night that ultimately it's their decision, not mine.