Thoughts on Informed Consent, Refusal and VBAC

If you’ve been listening to the news lately, you’ve probably heard a lot about vaginal birth after cesarean (VBAC). The NIH held a consensus meeting to decide what was appropriate in VBAC care. The general thought was that the overall VBAC rate should increase and that the rate of primary cesareans should decrease due to the risks of surgery to the baby and mother. The panel had several recommendations that can be boiled down into:

• ACOG and ASA should revise their guidelines on the “immediately available” guidelines.
• The decision to do a VBAC or a repeat c-section should be made between a woman and her practitioner, after an informed discussion.

The problem with the last statement is that true informed consent and discussion is very rare in obstetrical care. The closest that we tend to come is the woman who is choosing a VBAC. She is likely to spend the last several months of her prenatal care being told of the risks of VBAC and the parameters in which it will happen. In contrast, had that same woman chosen to have an elective repeat cesarean, she would simply be handed an appointment card for her scheduled surgery and then sign a sheet of paper that would have to suffice as informed consent, all done a few minutes before her surgery. Neither of these is truly informed consent.

So how can women get informed consent, particularly when it comes to a hot topic like VBAC? My advice is:

• Do independent research.
• Seek out information from neutral sources.
• Talk to other mothers who have had a VBAC.
• Talk to other mothers who have had a repeat c-section (planned and not).
• Prepare for your birth by childbirth class, doula support and emotional support.
• Consider alternatives including midwifery led care.
• Make a decision only after a lengthy discussion with many people, including your practitioner.

Providers have to consider multiple issues when recommending one mode of birth over another: health of mother and baby, liability for complications, availability of self and staff during uncomplicated and complicated births, personal beliefs, medical malpractice insurance (if they choose to carry it), what other practitioners will think of their choices, etc.

Women have their own issues to consider when deciding her mode of birth: health of baby and mother, likelihood of the success of VBAC, physical and emotional pain after the birth, personal beliefs, etc.

The final point is that of informed refusal. ACOG has a policy of informed consent and refusal. This states that they believe that a woman who has all the information, is allowed to make a decision to choose not to receive the recommended procedure or therapy that is being suggested by her doctor.

At the panel yesterday, when asked specifically about the policy of informed refusal as it included forced repeat c-section, either by practice policy or individual recommendation, they basically said that this was unclear. Some advocates took this to mean that the consensus panel was suggesting that women did not have the right to choose a VBAC if that wasn’t the recommendation of her doctor or that if she did, it was acceptable to coerce her with threatened legal action. In other words, a woman is free to make any decision she would like, unless it conflicts with what her practitioner decides.

That leaves us in a sticky spot. What’s a birth activist to do?

Related:

• Maternal Decision Making, Ethics and the Law
• Refusal of Care Based on Religious Beliefs
• Women Need a Chance to Avoid Repeat Surgery

Distortion of Natural Birth

I was so happy to follow up on Ashley’s Midwife Vs. Medwife post because I really feel as though this will be a little piggy back on the subject. Last night I tuned into ABC’s hit series Private Practice, and during the episode I seriously started to wonder why I continue to watch the show that makes my blood boil.

But what really ate at me was they way they portrayed a mother who was working towards a natural birth. Which made me think about the way that the public views the natural birth community, as well as women who simply want a natural birth for themselves.

They treated this woman in the episode like the butt of all the jokes in the episode until the emotionally charged climax of her birth viewed by perfect strangers that would have been a major HIPAA Violation.  The episode shows this woman with a multi-page birth plan, grinding on the door frame of the birth suite trying to squat to help her labor, joking about how she had been in labor for 3+ days, all of which as a mother who has labored naturally, I found offensive.  The character was essentially the comedy of the episode.

It made me think about the perception the American public is going to get from this message, as well as their views on women who do choose to give birth naturally. Do they think we are all just a bunch of hippies that bite on sticks until we drop a baby out in the middle of a meadow while singing show tunes?  Come on!

The problem is shows like this.
The problem is the myths about who has natural births.
The problem is typical stereotypes.

Where do we start?
How do we start to re-educate and properly educate the public so they don’t think all moms who want to have a natural birth aren’t ding bats like this character was?

I really hope that shows like this, and Grey’s Anatomy, and other medical drama’s take the time to fix the American stereotype of birthing naturally. Women from all walks of life do it!

Just on a side note, the character who was attending this woman’s birth “Dell” a “student midwife” came off as a Student OB/GYN if anything. He had no type of midwife qualities in him what so ever and I think that is another huge slap to the natural birth community. He at best was a “medwife” if that!

The Duggar Family

I would like to extend my well wishes and thoughts to the Duggar Family though this difficult period of their lives after welcoming their 19th baby, Josie Brooklyn Duggar yesterday, December 11th 2009 via emergency cesarean section for Pre-E after a hospital stay due to gallstones. Baby Josie was born at 25 weeks gestation at 1 pound 6 ounces.

Over the past 24 hours I have seen some of this most disgusting comments via the internet on news articles, and just message boards. Whether Michelle was on her 3rd or 30th child, Pre-E can happen to anyone at any age and during any pregnancy. This family may live differently than the vast majority of Americans, but seriously, if you want to say something negative, say it when mother and baby are far out of the woods, not when a micro preemie is fighting to live.

Some people never cease to amaze me.

Michelle has been such an amazing asset to the VBAC community in having 12 VBAC’s herself.
I can only hope in future years she will continue to work with and praise ICAN like she has in the past.

The first Duggar grandchild is born at HOME.

Anna Duggar, famous for being the wife of Josh, son of Jim Bob and Michelle Duggar, had her first baby last night. While there were some cameras and video, like at many normal births, this baby was also welcomed lovingly into her parents arms at home in the presence of family, midwife and doula. Her baby weighed in at 8 lbs. Nothing seems too wild or out there, unless of course you think home birth is wild or out there. The funny thing is that the Today Show, infamous for their discussions of the horrors of home birth, laid low and said nothing. Why is that? Perhaps it was that Mackynzie Renee Duggar’s birth provided no drama.

If you’d like to share your thoughts with the Today Show, you can email them at Today@NBCUNI.com or send snail mail to:

NBC News
30 Rockefeller Plaza
New York, N.Y. 10112

Reducing Infant Mortality

Please watch this video and then spread the word about how to reduce infant mortality. Click here to visit the website and get help with writing to your legislator, or sending them this video.

Reducing Infant Mortality from Debby Takikawas on Vimeo.

Birth Videos on YouTube: Sick or Slick?

I was reading a debate between some people, women and men, about individuals who post their birth videos online. The basics of the debate were that women posted birth videos online at sites like YouTube, unlike written birth stories, these were graphic and contained (*gasp*) nudity. Some people felt that this was horrible and awful and should be stopped. They felt that some of these women were attention seeking, others felt it was just tacky. The other side of the debate believed that the births were helpful from a real world perspective, that it wasn’t heavily edited (usually) like real birth on television shows or infused with intense music and dramatic interviews with care providers.

Which side of the fence do you fall on? Do you think births on YouTube are slick or sick?

(And just to fuel the fire, here’s a birth video for you…)

Salma Hayek Breastfeeds Another Woman’s Baby

There has recently been much talk about Salma Hayek breastfeeding an African baby whose mother had stopped producing milk.? Here is an article in Time Magazine about the incident (scroll down to see the video).

I have heard that some are critizing her choice to breastfeed this child.? However, from what I have seen, the press has been quite positive about what she did.? On the daytime show The View, this was discussed during their “hot topics” segment.? The women of the View were mostly positive, saying that Salma Hayek did the natural thing.? Whoopi Goldberg surprised me by being the most liberal in her views.? Her attitude is generally not very nurturing when the topic of children comes up. ? First she was appalled that the producers of her show blurred out the portion of the video that showed part of Salma Hayek’s breast as she nursed the baby.? Whoopi said that this was not a sexual picture, it was a picture of breastfeeding and should not be blurred out.? She went on to say that women in our own country should help each other out in this way.? She said whoever has the milk should share it when needed.? Her co-hosts drew the line at cross nursing in our own country, but agreed that what Salma Hayek did was a wonderful thing, and that any of them would have done the same.

I also saw this discussed recently on the Oprah Winfrey show.? On this show she had a panel of four people.? There was Oprah, her friend Gayle King, George Stephanopoulos’ wife Ali Wentworth, and Kelly Ripa’s husband Mark Consuelos.? They were all sitting at a table discussing recent news events.? When this topic came up, the three people on the panel besides Oprah all rushed in to say that what Salma did was a wonderful and natural thing.? Gayle King stated that when one is breastfeeding the breasts get hard and full of milk, and Mark Consuelos added that when a baby cries the milk lets down.? It was implied that it was only natural to feed the baby.? Ali Wentworth stated that there has been wet nurses throughout the ages, and that this was nothing weird or strange or abnormal.? She said that breasts are for nurishing children, not for sexual pleasure.? Mark Consuelos quickly jumped in at this point and said he believed that they were “multi-functional”.? It was a great exchange and all three of them were very supportive of what Salma Hayek did.? Oprah stayed silent on the matter, claiming she wasn’t knowledgeable enough on the topic to speak on it.

I was very happy to see these two very popular daytime shows jumping to Salma Hayek’s defense for breastfeeding this child.? I noticed how many of the people, both on Oprah and on The View spoke of the biological process of breastfeeding and implied that one is compelled to feed a crying and starving child when they have milk readily available.? Though I am aware that not all sentiments about the incident were this positive, I am very happy to have seen a mostly positive response myself in all the media I have consumed since this happened.? Perhaps this will help change the way people view breastfeeding, and the “multi-functional” purpose of the breast.

What have your seen in the media about Salma Hayek breastfeeding this child?? What are your opinions on breastfeeding another mother’s child?? Click on “leave a comment” on the left to voice your opinion.

New Study On Scheduled Cesareans

There is a new comprehensive study about the safety of cesareans before 39 weeks gestation.? From the article, Early Repeat C-sections Increase Risks, Study Finds, published in the Washington Post, there is this quote about the study:

The study of more than 24,000 full-term infants found that those delivered at 37 weeks to mothers who had elective repeat C-sections were about twice as likely as newborns delivered at the recommended 39 weeks to experience breathing problems, bloodstream infections and other complications. Babies born at 38 weeks were 50 percent more likely to have problems; the risk was about 20 percent higher just a few days early.

The article states that the rate of cesareans is now over 30%, and that there is a great deal of debate as to why this is.? However, they then go on to say:

Although a pregnancy is considered full term after 37 weeks, the American College of Obstetricians and Gynecologists recommends that elective repeat C-sections occur no earlier than 39 weeks to make sure the baby has fully developed. But some women opt to deliver a little earlier for a variety of reasons, including being eager to see their baby, being tired of pregnancy or for convenience.

The article here suggests, with no data or studies to back it up, that the women themselves are convincing their OB’s to disregard their instructions from ACOG, go against evidence based care, and put the babies at risk in order to give in to the mothers whims.? I find it very curious that women hold so much power in this regard, when most other choices they make in childbirth in a typical hospital would be disregarded.? If doctors are so concerned for mothers choices, even when it means breaking their own rules and putting babies in harms way, then why aren’t the choices that women make for their labors and births that do not infringe on any rules or cause harm to their babies respected?? I doubt very much that doctors are truly allowing women to make an informed choice on this.? Perhaps women who are getting a repeat elective cesarean are showing an interest in an earlier delivery, but, are they then given the risks, benefits, or alternatives to delivering early?? Did they make a truly informed choice?? Or are they making a decision based on the belief that their baby is “full term” and is ready to be born?? In the absence of any cited study on the subject, it is my feeling that the article is making quite the presumption.

Here is all the study really had to say about the matter:

Of 24,077 women who gave birth through a repeat C-section between 1999 and 2002, 13,258 were clearly elective — meaning the researchers could find no evidence that the baby or mother was in distress or any other medical reason the woman could not attempt to deliver through labor. Of those, nearly 36 percent of the deliveries occurred before 39 weeks.

It is unclear from the study why there were so many “elective” cesareans performed.? It is not clear to me whether the researchers considered a repeat cesarean to be elective or not.? If the researchers didn’t consider a previous cesarean as a medical reason as to why the mother should have another one, then that would explain the large number of scheduled “elective” cesareans.? It doesn’t seem that any data was provided as to whether the mothers or the doctors were selecting the time in which these cesareans would be scheduled.

The articles goes on to talk about the findings in the study about the true risks of a scheduled cesarean before 39 weeks:

More than 15 percent of the babies delivered at 37 weeks suffered a complication, such as problems breathing, low blood sugar, infections or conditions that required intensive care, compared with about 8 percent of those delivered at 39 weeks. About 11 percent of those delivered at 38 weeks experienced complications. Babies born at 37 weeks were four times as likely as those delivered at 39 weeks to have breathing problems.

It seems very clear cut, but then another angle is presented:

While other experts agreed that the study provides important information to help women and their doctors make decisions about timing C-sections, some said the risks of complications are relatively low and need to be weighed against the small but not insignificant chance that waiting a week or two would result in more stillbirths.

The article does end with a voice of reason though:

But Spong said the magnitude of the risk of stillbirth from waiting is unclear, and the new study shows the risks of complications from early delivery is significant.

“It’s hard to advocate doing a Caesarean at 37 weeks to try to prevent a stillbirth when we don’t really know the true risk,” she said.

Overall, I feel this is a very good study that has been done.? Many babies and new parents will be saved the possible traumatic experience of the NICU.? Many doctors, who already had some research and guidance from ACOG to tell them not to schedule repeat cesareans before 39 weeks, will now have this additional comprehensive study that clearly shows the impact of doing so.? This also may bring to women’s and doctor’s consciousness that cesareans themselves are not perfectly safe for all involved no mater what.? They need to be carefully planned and managed and only performed in cases of true emergency, or they could possibly do more harm then good.

Midwives Deliver

There was a recent article in the Los Angeles Times called Midwives Deliver written by Jennifer Block, author of “Pushed: The Painful Truth About Childbirth and Modern Maternity Care”.? She talks about what is currently wrong with maternity care in this country, and then puts forth her idea of how it should be fixed.? She proposes that midwives should take on the majority of care for low risk pregnant women and explains the benefits of doing so.? It is a very well written and well researched article.

A Cause Worth Latching Onto

Finally embracing the social networking sphere, I noticed that there is a circulating petition on Facebook. People’s photos with a child in the act of breastfeeding has been labeled “obscene” by the powers that be at Facebook.

This speaks to a larger social issue. Mainstream media has a difficult time embracing breasts as anything but sexual, despite the fact that they have played a crucial role in our species’ survival.

Fortunately, there are groups advocating for the revealing of breastfeeding in mainstream media. ProMoM has joined the Facebook causes, and thanks to our very own Robin, they are gaining in numbers.

There are advocacy groups that have lobbied for breastfeeding for many years. La Leche League has a list of advocacy organizations, from state to international. I encourage you to see if there is an organization you can join. Additionally, National Alliance for Breastfeeding Advocacy has a good description of what an activist/lobbyist can do. ProMoM’s website is undergoing some construction, but they have a 3-minute advocate link, which is enough time to fill out an on-line form or to make a phone call voicing your support for breastfeeding.

If you’re looking for another approach to being a “lactivist,” there are always products you can buy to display your view. Or you can get crafty and make some breastfeeding-friendly washcloths. There are options for everyone, and every mother advocates for breastfeeding each time she helps her child latch on.