Guest blogger Rachel Walden of Women’s Health News is posting here this week, while Christine is on vacation.
According to this report, a Maryland woman was dropped by her obstetrician via letter at 8 months pregnant because she wanted to attempt a vaginal birth after cesarean and refused electronic fetal monitoring. The patient, Lara Ecker, said, “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.”
Ecker had planned to deliver at Frederick Memorial Hospital, which responded, “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.”
Ecker was able to find a different hospital at which to deliver, although the story doesn’t report whether the new place is more willing to comply with her requests.
Attempting VBAC and a refusal of electronic fetal monitoring aren’t necessarily “unreasonable demands” for an individual patient, however, and the issue affects more than this one woman as doctors continue to make choices intended to limit liability rather than improve care.
Much research indicates that, for low-risk deliveries, continuous fetal monitoring is no better than periodic checking with a stethoscope at improving fetal outcomes, and continuous monitoring is associated with an increased rate of cesarean sections.
Although a VBAC guideline issued by the American College of Obstetricians and Gynecologists states that “for women with 2 prior cesarean deliveries [such as Ecker], only those with a prior vaginal delivery should be considered candidates for a spontaneous trial of labor” due to a risk of uterine rupture “nearly 5 times greater” for women with two previous c-sections instead of one, “5 times greater” apparently means the risk ranges from 1%- 3.7%, and the guideline acknowledges that there are few studies on this topic.
ACOG also asserts that “There is no completely reliable way to predict whether a trial of labor will be successful in an individual patient.”
Although Ecker is not the traditional “low-risk” birth for which outcomes studies are usually conducted, protecting the autonomy of all patients, as the ACOG guidelines prescribe, is never “unreasonable.”
Likewise, the late “firing” of this patient should be of concern to all women who seek continuous care from a trusted provider throughout their pregnancies. The International Cesarean Awareness Network informs us that:
Many people are under the mistaken impression that in instances where they disagree with their physician about a course of treatment, their doctor has the right to discontinue care. However, professional ethical guidelines stipulate that a physician may only terminate care after reasonable notice and after providing for necessary interim or emergency care. Physicians who fail to meet these guidelines may be charged with patient abandonment, which is grounds for malpractice and constitutes a violation of ethical conduct that could result in loss of licensure. As a general rule, physicians who wish to discontinue care in a non-emergency situation must notify patients in writing, give 30 days notice and offer a general referral to other physicians in the area. However, if ongoing care is required at the time the physician wishes to terminate care (certainly the case with pregnancy), then the physician must ensure that the patient is transferred to a specific provider.
According to Ecker, “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.”
While her doctor may have just squeaked by on the 30-days notice, this unfortunately indicates that women need to be well-informed of their rights and the medical evidence during pregnancy and childbirth in order to receive proper care that respects their choices and bodies.