Musings of a Dinosaur

A Family Doctor in solo private practice; I may be going the way of the dinosaur, but I'm not dead yet.

Monday, August 20, 2007

This Sucks

Assuming all the facts are as they are presented, this sucks big time:
A Smithsburg woman is speaking out after she says she was dropped by her obstetrician when she was more than eight months pregnant, all because she refused to have a caesarean section.

"It is major surgery and you do have risks, not only during the birth, but down the road,” says expectant mother Lara Ecker.

Ecker says she knows how risky a c-section can be, after having her first two kids that way. So when she became pregnant with her third child, she told her doctor she wanted to do it naturally, or VBAC (Vaginal Birth After Caesarean).

“I was getting so close to my due date, I thought "certainly they'll help me try to do this',” she says.

But she says she was shocked when at eight months pregnant, her doctor's office, Simmonds and Simmonds in Frederick, gave her a letter telling her they were letting her go. They said it was because she challenged the use of a fetal heart monitor during labor and insisted on having a VBAC, a somewhat controversial procedure that some doctors say carries a higher risk of uterine rupture.

"The tactic I felt she was using was a fear tactic; it was like I was choosing between the life and death of my child, not the type of birth I was choosing,” says Ecker.

Simmonds and Simmonds did not return NBC25’s call for an interview, but officials with Frederick Memorial Hospital, where Ecker planned to have the baby, say the decision to perform a VBAC depends on the situation.

"If the patient comes to the physician with unreasonable demands, and will not allow him to deliver them in a safe manner, then the physician has the right to discharge the patient from his practice,” says Dr. Chet Wyman, vice president of medical affairs at FMH.

According to an opinion issued in July by the Maryland Attorney General's Office, a doctor cannot force a woman to have a c-section against her will unless the baby's health is in jeopardy, and ultimately the decision lies in the hands of the patient. It’s a notion shared by many women who have been down the same road before.

"Even though at that point, she could go into labor at any minute, her doctor only agreed to provide on-going care for the next seven days, we feel that constitutes patient abandonment,” says Barbara Stratton, Baltimore chapter leader of ICAN (International Caesarean Awareness Network).

Ecker says in the letter, her doctor gave her a list of three alternative options for other doctors, one which her insurance did not accept and two others who would not take her in at 38 weeks.
I began with the caveat "if these facts are correct":
  • Did the patient wait until the third trimester to bring up her concerns about delivery? If so, shame on her.
  • Did the physicians (or the allied practitioners) rush her through the regular office visits without allowing her time to discuss her delivery concerns, perhaps telling her, "We can discuss that later." If so, shame on them.
  • Did the docs spend each and every visit patiently trying to explain to her why they felt the hazards of VBAC outweighed the risk of another c-section, failed to convince her and gently warned her that they could not in good conscience abide by her wishes and would have to discharge her as a patient? If so, shame on her for misrepresenting the situation.
That said, assuming the facts are as stated, waiting until 38 weeks and then dismissing a pregnant patient without warning is outrageous. This kind of discussion should begin at the first prenatal visit, and if by the beginning of the third trimester doctor and patient remain at an impasse, the transfer should occur then. Certainly patients deserve the opportunity to discuss things like fetal monitoring and other labor interventions ahead of time. I've known people to change OBs, albeit earlier in the pregnancy, when they felt their wishes weren't going to be respected.

I agree completely that, in effect, by waiting to this point in a pregnancy, this constitutes patient abandonment. The OBs involved knew or certainly should have known that at 38 weeks, the patient would not have any other realistic options for delivery.

I'd love to hear the opinions of my OBG colleague/readers on this issue, but in my humble opinion, this sucks.


At Sun Aug 19, 11:05:00 PM, Anonymous Anonymous said...

OK. so the patient "questioned" the use of a fetal heart monitor. wtf? I can understand that after TWO - 2- TWO! c sections, she wanted a vaginal delivery. ... ok. so what's the big deal about keeping an eye on the fetal heart monitor? There's so many risks involved. At least give the doctors a chance to know when there's a problem - so changes can be made! I suppose you'd be on the phone to your lawyer if anyting went wrong.. Why should the dr's take this kind of risk? They can't stay in business because of liability insurance, and idiots like this only make it worse! you've got to give your doctors the tools they need! I delivered two healthy children vaginally, both with fetal monitors. If at any time those monitors indicated a problem, I would have DEMANDED that they take me in to surgery for a c-section to save their lives. Go ahead..try for vaginal --but wouldn't you want to know if there's a problem so you can save the life of your child.. or will you be a stupid and selfish and risk the life of your child?? I'd rather submit to the expertise of those who have gone to med school and delivered many healthy children than think I - with no med degree - know better. !!! this idiotic attitude makes me crazy! arghh...
Love you dr. dino!

At Mon Aug 20, 06:23:00 AM, Blogger #1 Dinosaur said...

I don't disagree with you, Anon, but there's not really enough information given (about the fetal monitoring issue) for you to make those kinds of projections. The whole conversation about monitoring pros/cons still should have happened much earlier in the pregnancy, rather than cut her off without warning and with no other viable options at 38 weeks.

At Mon Aug 20, 08:03:00 AM, Blogger CrankyProf said...

I had pre-term labor and PIH with my first child -- a daughter. Two years later, when I got pregnant with my son, the same OB practice turfed me at 32 weeks because I was "too high risk."

I asked 'em specifically if they could handle it, and if things would go south again. The answer I got was, "No problemo!"

Although they had no problems collecting my co-pays and managing my prenatal care up to that point.

So, new doc/practice delivered my son, and the new sprog.

At Mon Aug 20, 09:28:00 AM, Blogger Greg P said...

I think I would give the docs the benefit of the doubt mainly in that it can't possibly be so simple as getting to 38 weeks and firing the patient.

Considering the pressure on OBs these days, for them to allow the patient to make the call on a vaginal birth would be lunacy. There is no release the patient could sign that would be worth anything after a delivery disaster.

Presumably at 38 weeks they were talking about planning the C-section, and that's when this all came about.

At Mon Aug 20, 12:31:00 PM, Anonymous Anonymous said...

" I know what I said, but I don't know what you heard" -

I gather from the facts that this women has had a 3+ year relationship with the Drs. S.; implying some degree of satisfaction with the Dr's service.

Is it possible this issue arose when the discussion of the C-Section being scheduled came up? Emphasis on the word scheduled, vs. letting labor start.

?What were the resons for the earlier sections? key missing fact

Assuming a transverse, lower segment incision with the two previous sections, the literature states a risk of rupture rate of 0.05%-minimal, but still a risk.

Patient objects to FHM, well why is that? Doesn't understand the +/-, or??

To many questions to take a side here.

At Mon Aug 20, 01:15:00 PM, Blogger GeorgeH said...

What's the alternative?
Force a doctor to perform a delivery he believes is wrong or excessively dangerous?

At Mon Aug 20, 02:02:00 PM, Anonymous Anonymous said...

Only in America!

While I accept and understand a person's right to decide what happens with her body, medicine is not an a-la-carte restaurant, where you order whatever you want. Especially in today's malpractice-obsessed world.

That woman should have thought about not wanting another cesarian BEFORE becoming pregnant, or at least at the beginning of the pregnancy. I think her vaginal delivery would be high risk, and no normal OB-GYN would expose herself to the high risk of a malpractice suit. When stupid patients take bad decisions and pressure their doctors to follow them, the jury tends to find in favor of the patient, because the doctor "should have known better".

These doctors knew better, kudos to them! It's not nice what they did, but it IS ethical and also practical.

At Mon Aug 20, 02:05:00 PM, Anonymous Anonymous said...

crankyprof, your copays are worth nothing. Let's see how many lawyers would even say "Hello!" to you for the amount your insurance pays, not talking about your copay.

At Mon Aug 20, 09:05:00 PM, Blogger ER's Mom said...

As an OB, I can't believe that it wasn't discussed earlier. We don't do VBACs in my practice, but that is stated in the prenatal interview and we then offer referral to those who do (about an hour drive away - I'm in rural midwest).

Sounds like there was some communication breakdown somewhere along the line.

At Tue Aug 21, 12:41:00 PM, Blogger dr. whoo? said...

Hi Dr. Dino...I've read for a while but never commented before. I, like ER's mom, find it difficult to believe that mode of delivery was not discussed prior to 38 weeks. It seems a great failing of communication, as the story is reported.

I'm not certain, but "8 months" may be 36 weeks, not 38? If that is the case, technically, the practice has a month (30 days) to dismiss the patient, recommend alternate providers, and provide emergent care in the interim. I don't think physicians should be browbeaten into procedures with which they are not comfortable providing. I agree that it is a pretty thin line to walk, though.

Personally, I will do VBACs with appropriate candidates. At the initial visit it is discussed, and an informed VBAC consent is given to the patient to consider and sign if in agreement. I also discuss internal uterine monitoring at this time, as I feel that an IUPC should be used...especially if the patient gets pitocin. The patient then has the freedom to decide if they are comfortable with the way I manage VBAC. If not, I provide a referral. I do not negotiate my professional practice standards with patients.

Enough rambling...but you did ask! Love your blog!

At Wed Aug 22, 01:21:00 PM, Anonymous Anonymous said...

I think OB/GYN medicine is a victim of its own success. Americans misperceive pregnancy and labor as "safe" events. They are not. A great deal can go wrong during a pregnancy and most Americans do not realize this.

We, as a society, need to do a better job of educating people about the realities of reproduction.



At Wed Aug 22, 05:16:00 PM, Anonymous Anonymous said...

I think the risks of CS are often underestimated. Here in the Netherlands, VBAC is more or less the norm (you have to deliver in the hospital though, not at home). Only if there is a specific indication for CS it will be done. In practice, after CS, of the following deliveries about 50% will be vaginal and 50% CS.

At Thu Aug 23, 10:27:00 AM, Anonymous Anonymous said...

As the activist who arranged for Lara's media coverage I can clarify a few points.

Lara was 38 weeks pregnant when she was fired by her OB practice. The reporter mistakingly called this "8 months."

Lara never refused continuous fetal heart monitoring but rather challenged the need for continuous monitoring that would keep her confined to the hospital bed and not able to walk, change positions, use the bathroom, etc. Birth involves the need for a baby to navigate the pelvic bones. Birth can be very difficult to achieve lying down throughout labor plus pain is much worse when women are not allowed to move around. Since Lara wants to avoid the risks associated with an epidural, this is of particular importance.

Lara's two cesareans were for unnecessary and botched inductions.

The latest study on VBAC after multiple cesareans (Landon) concluded that there was no statistically significant increase in risk vs. a VBAC after one cesarean.

Lara was not with this practice since the beginning. Her first practice kept talking about inducing her (inductions are a known risk factor for uterine rupture) to "increase her chances of success." So, she went looking for a new caregiver although her insurance has severe restrictions so shopping was very limited. An additional obstacle was that the hospital in her county only "allows" women to VBAC from 7 a.m. to 3 p.m.

Before making her first appointment with the new practice, she made sure that they did not have a policy against VBA2C. She was then clear from her very first appointment of her plan to VBA2C. The OB who did the firing, was not familiar with Landon's study and was not receptive to even looking at it when Lara presented it to her. Considering that the risks of cesareans increase with each additional one a woman has, plus increasing the risks of placental problems in future pregnancies, the doctor was not practicing evidence based medicine when she stated, "I'd do SEVEN cesareans on ONE woman before doing ONE VBA2C!"

To the first poster who had two vaginal births - none of the women I have been involved with in the work I do want anything less than a good outcome for their babies. However, its hard for you to judge why a mother would not want a cesarean if you are not aware of the risks that they carry including death. NJ just had 2 post-cesarean deaths 10 days apart at the same hospital. MI had one in Feb. and Maryland had one this past spring. Also, if you have not gone through the experience of having major abdominal surgery while trying to care for two other young children without the money to hire nannies, housekeepers, lawn cutters, personal chefs, etc. then you may not be able to relate. Most women are lucky if they have their husbands home for even a week post-surgery and then they are on their own and having to lug laundry baskets up flights of stairs, carry bags of groceries, etc. etc. Although some women recover fairly soon without complications, many do not and are left to deal with hernias, wound infections, long term pain, plus risks to future fertility and births.

For Dr. Whoo, I'm curious as to how you would feel yourself if you hired a doctor for your own medical care and were treated in such a fashion? Have you ever said "no" to an invasive test being offered or a medication that carried more risks than benefits? Do you do your own research on your medical condition or just assume that the one doctor you are seeking care from is an expert on the condition and offers good care 100% of the time? If you were dealing with a medical issue (such as pregnancy)that needed ongoing care, how would you feel if your physician dropped you at a critical point in your care for challenging the suggested test, medication, or whatever?

-Barbara Stratton

At Thu Aug 23, 01:54:00 PM, Blogger #1 Dinosaur said...

Barbara Stratton: So I assume you agree with the title of the post?

At Thu Aug 23, 03:18:00 PM, Anonymous Anonymous said...

I have been following this issue with great interest-and based upon what I have seen posted, the original title was appropriate!

On the issue of using Evidenced Based Medicine as support for one's practice patterns,it appears to me that the OB involved in this case does not wish to have patients who believe in EBM!!

Keep up the good work and how are you coming on your plan to move towards a semi-concierge practice?

At Thu Aug 23, 11:30:00 PM, Anonymous Anonymous said...

Quote: Barbara Stratton: So I assume you agree with the title of the post? End quote.

Yes, fully agree. And, if you want to see how I got into this activism, see today's article on ways to reduce your chances of an unwanted cesarean.

-Barbara Stratton

At Mon Sep 03, 10:18:00 PM, Anonymous Anonymous said...

I am happy to announce that Lara Ecker had her VBAC. She and her husband have a new 8 lb 10 oz baby girl.

-Barbara Stratton

At Thu Sep 20, 01:14:00 AM, Anonymous Anonymous said...

Congratulations to Lara, and good on her for being sensible enough to think for herself and stand up to all the bullying and insults.

Three out of ten deliveries ending in caesarean section is completely unacceptable. What an appalling statistic! Who knew that American women were so hopeless at having babies by themselves? The fact that other countries do it so much better demonstrates a considerable lack of competence amongst American practitioners and an attitude that sucks.

Guess what? That many c-sections isn't normal - it's abuse. Any half-decent midwife could manage better.

So glad that my kids were not born in the USA.

- Aussie mum of six


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