childbirth and personal responsibility.......
So there's this lady who's come in to see me the past several years (professionally that is) and she's due to have her fourth child later this month. She's a nice woman, but non-english speaking and not terribly sophisticated. (Not that one has to be an English speaker to be sophisticated mind you, but in my best estimate, this gentlewoman is neither.)
This lady has had two previous C-sections, both done abroad and I have records for neither. When she was pregnant several years ago, I told here that I was not willing to do a vaginal delivery with her, given her previous history, without a clear operative report of her old c-section uterine scars, a vaginal delivery was too big a risk to offer her. If her uterus were to rupture while she was in labor, she could both lose her baby and perhaps her life. Her response was to simply stay at home when she went into labor 6 weeks early. She arrive at the hospital completely dilated and promptly delivered a healthy infant, albeit a bit small and a bit early. Both she and the baby did fine. I needed clean underwear, but they were fine. I was highly annoyed at her accepting that risk. If it were only her life, so be it, but she put her child's life on the line AND to boot she has two other young children at home to take care of. She dies, these two kids are motherless.
Well, let's fast forward to the present. She's now once again with child, due the end of this month. She started care early and we've had several conversations about not trying a vaginal delivery. First of all the hospital where she's due to deliver doesn't allow vaginal deliveries after C-sections. Two years ago, ACOG (Amer. Congress of Obstetrics and Gynecology) issued strict guidelines about offering Vaginal deliveries after sections, foremost of which is the provisor that a child has to be OUT within 15 minutes of the first sign of serious trouble. Note that's out in 15 minutes, as in delivered, not first starting that c-section. That means anyone needed for the surgery is present in the hospital for the entirety of that lady's labor, not just the OB, but full nursing staff, anethstesia, and pediatrics as well. If a hospital can't meet this criterior, they're not to offer VBAC's (Vaginal Births After C-sect.). The hospital I prefer to practice in, decided they could not meet this edict and to avoid the liability involved, no VBAC's. Well, the other hospital in town does allow them, but only by OB-GYN's (not, an FP like me) and so a couple of weeks ago I get a note from one of the OB groups in town thanking me for my referal of this lady to them for a VBAC! I didn't send her to these folks. She apparently heard through the grapevine that they will do VBACs. However, that's people with just ONE c-sect rather than two, and WITH an operative report that indicates what the uterine wound was. Kerr incision is OK to try a VBAC and anything else is not. I called my colleagues and spoke to one of them about the situation and she told me my patient was due to see one of their midwives who was both 'level-headed' and spoke her language. In otherwords not likely to make any rash recommendations, so I shouldn't worry. Well this week I get simmultaniously a note from the mid-wife that this lady IS in her estimation a good candidate for a VBAC and they'll accept the transfer of care, AND a note from the hospital (the one that allows VBACs) delineating their new guidelines governing VBAC. Their guidelines specifically state this lady IS NOT a candidate for a VBAC. No Operative reports.
So it would appear that both hospitals don't think I'm crazy. My question is what the hell gives with this midwife? She's accepted this lady for a service she can't provide. This is not sounding too ethical to me, but then, what do I know? I'm just an FP......
So what do I owe others here? Do I try again to get through to this lady again? She needs to assume some personal responsibility here, but while she's an adult, in my estimation, she's not terribly bright. I've tried at least 4 times to make her risks clear to her, in a language that she speaks. Oh, and none of the OB's that back up this midwife speak this lady's language. Just ducky.
Off to bed for now. I hope the morning brings me the clarity I need to deal with this one....
This lady has had two previous C-sections, both done abroad and I have records for neither. When she was pregnant several years ago, I told here that I was not willing to do a vaginal delivery with her, given her previous history, without a clear operative report of her old c-section uterine scars, a vaginal delivery was too big a risk to offer her. If her uterus were to rupture while she was in labor, she could both lose her baby and perhaps her life. Her response was to simply stay at home when she went into labor 6 weeks early. She arrive at the hospital completely dilated and promptly delivered a healthy infant, albeit a bit small and a bit early. Both she and the baby did fine. I needed clean underwear, but they were fine. I was highly annoyed at her accepting that risk. If it were only her life, so be it, but she put her child's life on the line AND to boot she has two other young children at home to take care of. She dies, these two kids are motherless.
Well, let's fast forward to the present. She's now once again with child, due the end of this month. She started care early and we've had several conversations about not trying a vaginal delivery. First of all the hospital where she's due to deliver doesn't allow vaginal deliveries after C-sections. Two years ago, ACOG (Amer. Congress of Obstetrics and Gynecology) issued strict guidelines about offering Vaginal deliveries after sections, foremost of which is the provisor that a child has to be OUT within 15 minutes of the first sign of serious trouble. Note that's out in 15 minutes, as in delivered, not first starting that c-section. That means anyone needed for the surgery is present in the hospital for the entirety of that lady's labor, not just the OB, but full nursing staff, anethstesia, and pediatrics as well. If a hospital can't meet this criterior, they're not to offer VBAC's (Vaginal Births After C-sect.). The hospital I prefer to practice in, decided they could not meet this edict and to avoid the liability involved, no VBAC's. Well, the other hospital in town does allow them, but only by OB-GYN's (not, an FP like me) and so a couple of weeks ago I get a note from one of the OB groups in town thanking me for my referal of this lady to them for a VBAC! I didn't send her to these folks. She apparently heard through the grapevine that they will do VBACs. However, that's people with just ONE c-sect rather than two, and WITH an operative report that indicates what the uterine wound was. Kerr incision is OK to try a VBAC and anything else is not. I called my colleagues and spoke to one of them about the situation and she told me my patient was due to see one of their midwives who was both 'level-headed' and spoke her language. In otherwords not likely to make any rash recommendations, so I shouldn't worry. Well this week I get simmultaniously a note from the mid-wife that this lady IS in her estimation a good candidate for a VBAC and they'll accept the transfer of care, AND a note from the hospital (the one that allows VBACs) delineating their new guidelines governing VBAC. Their guidelines specifically state this lady IS NOT a candidate for a VBAC. No Operative reports.
So it would appear that both hospitals don't think I'm crazy. My question is what the hell gives with this midwife? She's accepted this lady for a service she can't provide. This is not sounding too ethical to me, but then, what do I know? I'm just an FP......
So what do I owe others here? Do I try again to get through to this lady again? She needs to assume some personal responsibility here, but while she's an adult, in my estimation, she's not terribly bright. I've tried at least 4 times to make her risks clear to her, in a language that she speaks. Oh, and none of the OB's that back up this midwife speak this lady's language. Just ducky.
Off to bed for now. I hope the morning brings me the clarity I need to deal with this one....