OB-GYN-L Messages for May, 2006: Re: cesarean art

Re: cesarean art

From: Anna Meenan, MD

annam@uic.edu

Sun May 7 10:05:46 2006

-- Anna Meenan, MD

At Sun, 7 May 2006, Charlie Chambers wrote: > >I do offer the option of VBAC to my patients but they cannot have it >locally. The nearest facility is one hour away in Portland. I >encourage esp. candidates that would have a high chance of success >(prior breech, twins, failed induction) to consider the option and I >would be glad to establish the referral. If they ask why the local >hospital does not participate, I inform them that current >recommendations require the ability to have personnel on hand to >perform an immediate cesarean and our facility cannot conform to >those recommendations. I let them know that the likelihood of a >complication is quite low but should it occur it could be rather >catastrophic for mom and/or baby unless the appropriate personnel are >available. I never mention liability issues. Our hospital has stopped >doing VBAC's for about 4 years, and I've been amazed by how few >people have selected to go to Portland for a trial of labor. And >further, how accepting people have been of the policy. Of course, >they may already have self selected out since they know the local >policy but looking at our clinic numbers this must be happening >uncommonly. > >On May 7, 2006, at 6:33 AM, Jamie wrote: > >> I don't think I'm naive. I've seen families who would not be >> disabused >> of their unreasonable expectations. I've also seen families with >> not so >> great outcomes, when in hindsight a different choice might have >> changed >> the outcome, but the families didn't try to place blame. I didn't >> suggest that better communication would prevent every lawsuit, but I >> believe, based on my interaction with patients and physicians, that it >> would reduce the number. >> >> I'm not talking about uncaring care providers here, ftmp, and >> certainly >> not about incompetent ones. I'm talking about caring physicians and >> nurses (and midwives, I'm sure) who either forget how little the >> average >> nonmedical person knows about medicine (thus assuming knowledge that >> isn't there) or who operate from an assumption that the knowledge gap >> can't be bridged, so give out incomplete information. My friend's >> doctor was neither incompetent nor uncaring. He just didn't think she >> and her husband could make a good decision based on the facts, so he >> chose which facts to give her, to make sure she made the right >> decision. >> >> I also agree that medmal reform as well as doing something about the >> excessive control insurance providers have over medicine are essential >> steps. I just think there are some things that care providers can >> do as >> well. >> >> A question for listmembers: if you are unable to attend VBACs, what do >> you tell women who are seeking one? Do you tell them that you are >> unable >> to provide the service d/t liability concerns? Or do you emphasize the >> risks to mother and baby so that they will decide it's a bad idea? >> >> At Sat, 6 May 2006, Charlie Chambers wrote: >>> >>> Jamie >>> >>> I think that you are being rather naive. I can cite a number of cases >>> where communication and trust were excellent. And through no fault of >>> their own the provider was successfully sued. Some of these stories >>> include midwives who had wonderful relationships with the patient and >>> the family. Who throughout the process involved the patient in each >>> and every decision. Yet when the time came, the patient/family >>> disavowed any and all informed consent or involvement in decision >>> making. The point being that the bulk of litigation is just do to bad >>> stinking luck. A provider finds themselves with the wrong patient in >>> the wrong situation at the wrong time. Sure, there are the occasional >>> incidents of the uncaring provider who provides obvious faulty care >>> but these are the minority. On the other hand, I've seen a number of >>> cases where an uncaring provider gave substandard care and no >>> litigation occurred. Like I said, it's mostly dumb luck. >>> >>> On May 6, 2006, at 7:28 PM, Jamie wrote: >>> >>>> I won't argue that there are a lot of people who refuse to accept >>>> that >>>> sometimes bad things just happen. I think improved communication, >>>> though, would go a long way toward changing things. Women are >>>> often not >>>> told that a VBAC is not offered d/t liability concerns; instead >>>> they are >>>> told that if they attempt a VBAC, they or their babies may die. >>>> When >>>> they find out the real statistics, they feel lied to. I also think >>>> honest communication about risks and limitations of modern medicine >>>> would reduce lawsuits. Too many people believe that modern >>>> medicine can >>>> do anything (I've been told by an individual with no health care >>>> choices >>>> other than the county hospital that Parkland is a bad place to go >>>> for >>>> trauma b/c they couldn't save the President Kennedy). >>>> Unfortunately, I >>>> have seen quite a few physicians cultivate rather than dispel this >>>> myth, >>>> so when bad things do happen, it must of course mean that someone >>>> screwed up. >>>> >>>> An acquaintance of mine had her first child by c/s after an >>>> induction, >>>> which stalled out when the epidural was administered. Baby was >>>> fairly >>>> large and posterior. She was told that "we really need to do a >>>> cesarean >>>> before the baby gets into distress". She agreed to the c/s, with a >>>> perfect strip and only about 12 hours into the induction, b/c she >>>> feared >>>> for her child's life. Had she been told that waiting a little >>>> longer >>>> for labor to reestablish was a safe option, she would have done >>>> so. She >>>> still believes that c/s was unnecessary. Her second OB told her >>>> that >>>> she was a good VBAC candidate until her 32 week appointment, when he >>>> informed her husband that she and the baby would likely die if she >>>> attempted VBAC (her LTCS was 3 years prior). Turns out, he just >>>> didn't >>>> do VBAC. I don't believe either physician was intentionally >>>> dishonest, >>>> but the facts were presented each time with the intention of >>>> influencing >>>> her decision. Had she been trusted to make the decision with the >>>> bare >>>> facts, she might still have required both c/s, but it would have >>>> been >>>> much easier for her to accept them as necessary. Some of you >>>> will no >>>> doubt laugh at the touchy-feely aspects of this story, but emotions >>>> play >>>> a large role in litigation. No, she did not sue, but she did change >>>> providers after feeling that the first one deceived and pressured >>>> her >>>> into an unwanted surgery. >>>> >>>> At Sat, 6 May 2006, D. Ashley Hill wrote: >>>>> >>>>> I wonder how many ladies on the ICAN list have called and written >>>>> their >>>>> elected representatives to demand professional liability reforms, >>>>> or to >>>>> support legislation that protects physicians and hospitals that >>>>> want to >>>>> offer VBAC services, but cannot. Most ob/gyn physicians I know >>>>> rationalize that if they get hit by a big suit by offering VBACs, >>>>> they >>>>> can't help the thousands of other patients who depend on them, nor >>>>> can >>>>> they provide for their families, pay their staff, and pay off >>>>> medical >>>>> school loans if they lose insurer and hospital privileges because >>>>> of one >>>>> or more VBAC lawsuits. Further, women undergoing VBACs have >>>>> caused a >>>>> lot of this mess because they have sued doctors and hospitals when >>>>> their >>>>> VBAC attempt has a poor outcome, which statistically can happen in >>>>> about >>>>> 1 in 200 cases. If these patients would say "well, I tried a VBAC >>>>> and >>>>> knew the risks but it didn't turn out ok, buto nobody is to blame" >>>>> then >>>>> there would be a lot fewer ob/gyn physicians and hospitals >>>>> reluctant to >>>>> offer this service. Instead there invariably is a multi-million >>>>> dollar >>>>> lawsuit because the patient loses her uterus, or her baby has a >>>>> neurologic injury, so physicians and hospitals have decided not to >>>>> offer >>>>> this service as a business decision. Best wishes, >>>>> >>>>> Ashley >>>>> >>>>> At Sat, 6 May 2006, GA12L@aol.com wrote: >>>>>> >>>>>> In a message dated 06/05/2006 04:47:03 GMT Daylight Time, >>>>>> annam@uic.edu >>>>>> writes: >>>>>> >>>>>> or hospitals that would, but can't because the >>>>>> anesthesiologists are not willing to come in and sit for hours >>>>>> when they >>>>>> could be home. >>>>>> >>>>>> Ah, I see. So you don't have 24 hour anaesthetist cover? Where >>>>>> I work >>>>>> there are always 3 on-call anaesthetists in the hospital at night >>>>>> but they don't >>>>>> only cover the labour ward they also cover the high dependency >>>>>> and intensive >>>>>> care wards. >>>>>> >>>>>> It's a shame because judging from the ICAN list there is a lot >>>>>> of resentment >>>>>> pointed at the OB's when the truth is they would probably support >>>>>> a woman in >>>>>> a VBAC but can't because of the constraints placed upon them by >>>>>> the >>>>>> hospitals. >>>>>> >>>>>> Thanks Anna, >>>>>> >>>>>> Gail >>>>> >>>>> -- >>>>> D. Ashley Hill, MD >>>>> Orlando, FL >>>>> >>>> -- >>>> JFields, RN, BSN >>> >>> ********************************************************************* >>> *** >>> *********************************************************************

>>> * >>> >>> -- >>> ********************************************************************* >>> *** >>> *********************************************************************

>>> Charlie Chambers >>> Hood River, OR >>> cchamber@alumni.rice.edu >>> >>> "No matter where you go... >>> there you are." >>> Dr. Buckaroo Banzai >>> ********************************************************************* >>> *** >>> *********************************************************************

>>> >>> ********************************************************************* >>> *** >>> *********************************************************************

>>> >> -- >> JFields, RN, BSN > >************************************************************************ >**** >

>-- >************************************************************************ >Charlie Chambers >Hood River, OR

>cchamber@alumni.rice.edu > >"Almost anything you do will seem insignificant but it is very important >that you do it....You must be the change you wish to see in the world" > -- Mahatma Ghandi. >************************************************************************ >******* >************************************************************************

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