Do pregnant women lose their right to bodily autonomy? (Interesting blog post.)

[Crunchy Frog]

http://navelgazingmidwife.squarespace.com/navelgazing-midwife-blog/2010/3/19/what-i-learned-watching-the-nih-vbac-conference.html#comments

What I learned watching the NIH VBAC Conference

I’ve never sat in on anything as political or crucial to the birth community as last week’s National Institute of Health’s Consensus Development Conference on Vaginal Births After Cesarean. I’ve been to Medical Board meetings, participated in the California Association of Midwives’ board meetings and witnessed the surges of energy (meetings) that eventually turned into the (re-)creation of legalizing midwives in Florida. The opportunity to see the two day conference (spread over three days) is still there by clicking on the NIH link above; I highly encourage birthy folks to take the time to listen through at least some of the presentations. There are too many highlights to pick just one speaker; several shared information so profound as to bring me to tears or to clench my fists – they sure evoked emotion!

~snip~

In the VBAC community, there is documentation of women who, even though they entered the hospital pushing, were forced… yes, physically… into the operating room and, even though they were screaming their objections (not a strong enough word), stating they were not consenting to the surgery, their abdomens and uteri were cut open and their babies pulled out of them. It sounds unreal, doesn’t it? Like this could never happen?

~snip~

Rebecca Spence from RHRealityCheck says, “Panelist Laurence McCullough, the Chair in Medical Ethics and Health Policy at Baylor College of Medicine, spoke for the panel during the public comment session and in a press briefing, taking the position that a physician has an independent obligation to protect a fetus, which, it is claimed, is not dispensed by a laboring woman’s refusal to consent. The panelists’ comments indicated that a conclusion regarding the ethical question was beyond their scope, yet stated to the press and to the audience that the body of law and ethics that protects the right to refuse surgery was not written for, and may not include pregnant patients.” (emphasis mine) It took me asking several women and reading a few blogs before I understood what they were saying: that pregnant women might not/do not have the right to refuse a cesarean… that doctors can still force women, whether through the courts or even strong-arming them, into the operating room.

I'm wondering if other people here besides myself consider the issue of forced surgery and other medical treatment for pregnant women to be a choice issue.

http://consensus.nih.gov/2010/vbac.htm

[BrklynLiberal]

1. Your froglets are adorable....

[Crunchy Frog]

29. Thank you. I think so too.

:)

[BrklynLiberal]

30. They are twins..right? It is so adorable that the one in front is clutching the toes of the one in

back. How old are they?

[Crunchy Frog]

31. You know, I never even noticed that until you pointed it out.

They're 14 months old now. They were around 10 months in that picture. I can't believe how quickly they grow.

[BrklynLiberal]

32. I am sure they are a source of endless joy and total exhaustion :D

[HockeyMom]

2. Right to self preservation

trumps all else. You are not under legal obligation to save someone elses life (including unborn) if it puts your own life in danger.

It is really only the very fringe of society who say a pregnant woman MUST give up her life to save her unborn.

[bain_sidhe]

23. You are not obligated to save someone's live even if your life ISN'T in danger

A person (a real person, I mean, which obviously doesn't include pregnant women) can't even be forced to give blood to save another person's life. Yeah, we might think the person who refuses is a shithead, but they have the legal right to refuse.

[paulsby]

3. i am assuming there is some sort of

viability/time standard?

iow, the physicians claiming duty to protect fetus, does this vary based on whether it's 1st trimester vs. 8th months?

[Crunchy Frog]

6. This is about forcing women to undergo ceasarean sections at term

rather than allowing them to give birth vaginally. A large percentage of hospitals are now "banning" VBAC. In some cases women are going into hospitals in labor, even with birth iminent, and being forced into OR's and cut open despite their vocal refusals.

This is not even about saving the life of the fetus/baby, as these are otherwise normal healthy labors apart from the women having had a c-section in the past.

I know this forum is mostly about abortion rights, but I think a woman's ability to refuse major surgery is also a choice issue.

[paulsby]

7. oh wow

that's gnarly. i didn't realize THAT was what this was about.

let me stop being a moran and read the whole article. :)

[Jax]

41. "let me stop being a moran"

great since you have stated on these forums you are not liberal or progressive.

Read this ones views on abortion people.

[uppityperson]

43. I think most of us are aware. Thanks though. Fun quote

[hlthe2b]

10. I believe a woman should have the right to refuse under certain

circumstances...Clearly if neither the infant nor the mother's life are at risk, her decision holds.

But, I do believe that the physician and the hospital with whom and at which the woman plans to deliver should inform her as part of prenatal care that an emergent decision of c-section would be left to attending staff. That way the woman knows ahead a time that if her life and/or the baby's life are at risk that the decision of the attending physician will hold.

But yes, under non-emergency situation, the woman's choice should hold "supreme."

[GreenPartyVoter]

12. +1

[Crunchy Frog]

13. It's just that "emergency situation" is now defined so broadly

as to be virtually meaningless. There are a number of cases on record now where a court order for a c-section was obtained due to an "emergency" where the fetus would supposedly not survive a vaginal birth, where the woman somehow escaped and had the baby elsewhere, sometimes on her own, and the baby was born healthy. Doctors are simply too fallible and too subject to other influences (such as liability concerns) to be allowed that kind of supreme power over other people's bodies.

When I had my babies I was told that a c-section was necessary (though I'm not actually convinced that it was) but I was also told that they couldn't force me, and that ultimately it was my choice.

Some women are actually being scared completely away from hospitals and having their babies completely without assistance, often due to the fear engendered by these types of practices. I would be willing to bet that the potential loss of life from women doing that is far greater than that from women being free to refuse c-sections under all circumstances.

[hlthe2b]

14. The woman has every right to clarify prior to delivery...

what would constitute a "life or death emergent situation." If she wasn't satisfied with the procedures in place, the decision to prearrange a new delivery setting would be hers. However, the time to have an argument about whether or not to do a c-section is NOT when facing a life or death decision, where every second might count. That is why the ultimate decision HAS to be the treating physician. Is it perfect? No. But at some point one has to put trust in the knowledge and training of others. If the woman were an OB/GYN herself, I might argue differently.

Bottom line, clarify BEFORE delivery. But, I must say I can not imagine any competent physician agreeing to withold their own judgement for that of the mother's if they see an imminent life threatening situation developing. Yes, in that situation they SHOULD be worried about their own liability as well. I know that I would refuse to enter into a physician relationship with a patient that would substitute their own judgment for mine in a life threatening situation. There are ethical concerns that are very valid. But, I think there is room for discussion ahead of time where the issues are more "gray."

[Crunchy Frog]

16. I see where you're coming from.

I don't agree with you, as I am staunchly pro-choice when it comes to adults making decisions about their own bodies, but I do know that your view is a very common one in this society.

[hlthe2b]

19. Put yourself, for just a moment , in the shoes of the physician

Would you accept as a patient one who refuses to accept your judgement in a life or death situation? How would you feel about being asked to allow a preventable death to occur in such a situation? They aren't just covering their ass with liability issues. There are very valid ethical issues as well. As a female, I see both sides. But, I do think good communication can win out and reassure. That is the nature of a REAL physician-patient relationship.

By the way, this is what allows ERs to treat you, even if unconscious, without consent in an emergency situation, which extends to unaccompanied minor children. Courts hold that life and death decisions on treatment in these instances (in the absence of a DNR or other legal measure) are held by the treating physicians.

I am staunchly pro-choice as well and there are plenty of areas where I would be arguing for the woman's autonomy (as in the recent case of the woman hospitalized against her will to ensure she got bed rest in a pregnancy becoming higher risk, which I found to be abhorrent).

[Crunchy Frog]

22. If her mental fuctions were intact, I would have her sign a release form.

There are just too many incidents on record where a woman safely delivered vaginally when she'd been told that the baby would certainly die for me to trust medical judgement in these matters. I believe that ultimately the final decision must belong to the woman. There are just too many cases of that power being abused.

You and I just have fundamentally different philosophical viewpoints on this issue.

[hlthe2b]

25. I am thinking of situations I've seen where massive hemorrhage

in a woman initiating a vaginal birth rendered her semi-unconscious or drifting in and out of consciousness. These are the kind of situations where every second counts. That is but one example... I think that you are considering situations that really are NOT emergent and where a clear discussion with the doctor before hand could have resolved. Or, the woman could have negotiated for two concurring physician opinions before a c-section is to be done as another possible solution.

And, yes, I agree there have been decades of unnecessary c-sections which the current guidelines are meant to reverse. But, that is not what I am referring to here as I have already adamantly concurred that a non-emergent situation should be the choice of the woman.

[Crunchy Frog]

34. Oh, and there was a case like that recently.

The woman had to travel to a different state, several hundred miles away, and be away from her husband during the birth, just in order to give birth vaginally. The hospital even threatened to get a court order to force the c-section if she refused.

http://www.cnn.com/2009/HEALTH/10/15/hospitals.ban.vbacs/index.html

I think this case fits your definition of "clarifying before the delivery" but still left the woman with few real choices, and most women in that situation would not have had the option of travelling hundreds of miles to get the birth they wanted.

Of course, for the doctors in the first hospital, it did constitute a "life threatening emergency". Where do you draw the line? I'm not in favor of putting that kind of power into anyone, even a physician's, hands, all due respect. And I don't think that a woman should be forced to choose between being cut open against her will, travelling hundreds of miles away to give birth, or staying home and winging it on her own without medical assistance.

[hlthe2b]

35. Substituting "lay" judgement for that of highly trained professionals

is surely a risky solution. I think the issue is the definition of "emergency" which is not as subjective as you suggest for most well trained, ethical physicians. Again, good communication (and a second opinion where necessary) could make the difference. Even asking a trusted nurse midwife or someone similar to mediate the decision making process could make the difference and reassure all involved.

[Name removed]

42. Deleted message

Message removed by moderator. Click here to review the message board rules.

[RKP5637]

4. To me, the RW'ers and others feel a woman's body is their personal property and hence

they will make all of her decisions for her with respect to her womb. The height of a power, control and domination trip.

[stray cat]

5. Should we pay for medical treatment for a fetus in utero since its not a child?

it would save alot of money as alot of medical expense goes to saving premies

[Crunchy Frog]

9. I think that's considered to be part of prenatal care, which is usually covered.

If you're talking fetal surgery, I'm not sure. It's not really within the scope of the article though, unless you were talking about forcing women to undergo fetal surgery. I'm not aware that that's been happening, but with all the other attacks on pregnant women's rights, I wouldn't be surprised if it came up at some point.

[LiberalFighter]

8. They are totally confused. It is suppose to be a doctor patient relationship.

And the pregnant woman is the patient. The primary concern should be the pregnant woma.

[GreenPartyVoter]

11. I was told that it had to do with the ability of a uterus that had been cut into dealing with

natural childbirth after healing. (But it still alarms me that I could have been forced into an unwanted C-Section.)

[Crunchy Frog]

15. I have researched this issue somewhat.

the risk is something called uterine rupture, but it is an extremely rare occurrence, something on the order of 1 in every 200 births or less in women with a single c-section scar whose labors are not induced or artificially augmented. And not all ruptures are catastrophic resulting in fetal death. Overall, we're talking about a risk of maybe one or two babies in a thousand VBACs dying from this type of complication.

On the other hand, c-sections are major surgery and carry their own risk of severe complications including death for the mother. Every subsequent c-section carries a higher risk. There is also a higher risk of near term or full term fetal death for women with past c-sections (greater the more she's had), so it's really six of one half a dozen of the other from the standpoint of risk to fetuses.

The maternal mortality rate has actually been increasing in this country for about the past 15 years, and there is strong suspicion that it is partly linked to the number of repeat c-sections going on.

These VBAC bans are not about safety for mothers and fetuses, but about liability concerns and convenience for doctors and hospitals.

If your first c-section involved a vertical incision, then there really was a substantial risk of rupture and the subsequent c-section was justified. If it was a horizontal incision then not so much.

[uppityperson]

18. crunchy, I was writing below as you were posting this.

Very much in agreement with you. Control vs need.

[GreenPartyVoter]

24. Yes, I had heard it made a difference in which kind of c-section one had. I was not a

VBAC candidate but rather a possible CAVB. MY first son gave me a 4th degree tear so major I was ripped from stem to stern and essentially lost my vagina and rectum in the process. Took an hour and a half and 130 stitches to put me back together, and the doc suggested I may wind up with c-sections in the future to prevent being unzipped again.

However I not only was able to have a completely natural childbirth with my second, but I pushed that little man out in less than 20 minutes, which I think is not bad considering the damage I had taken before. Bruised his wee face in fact, because I pushed too hard!

But what you say about the increased mortality rate is worrying. Perhaps once it occurs to the hospital lawyers that too many C-sections are also a liability problem, perhaps they will change the plan? (Sad that it is the legal department and not the medical staff even making decisions about care.)

[Iris]

40. yes, they'll change the plan

and then some women will get caught in the bad position of needing a cesaeran and not getting one until after they've suffered through hours and hours of a difficult labor.

What needs to be made clear here is why these decisions are made. Blaming a woman for wanting to make decisions about her body and her child because people blindly believe doctors are making decisions based on medical facts or in the best interests of their patients rather than just on the fear of lawsuits is just plain criminal.

[uppityperson]

17. Malpractice issues and previous c-sect issues

(Ed to correct my backwards thinking re vert/horizontal)

I believe that a lot of this is due to malpractice issues, an insurance co not wanting to "risk" vag childbirth but preferring to go with the more (theoretically) "controlled" c-sect. Also, they can charge more for a c-sect, which oddly works against the insurance company, so not sure why they want that.

As far as safety with VBAC, used to be that you were cut vertically during a c-sect, leaving the uterine wall scarred along the muscle and leading to the possibility of rupturing your uterus when under stress later, rather like unzipping a zipper. I believe that changed to horizontal incision long enough ago that most anyone able to bear again would have a horizontal incision. These types heal across the muscle fibers, leading to no additional weakening of the uterus. The uterus is scarred across, but doesn't unzip.

When I was in labor, I fought with the OB nurse who wanted to rupture my membranes (after being in labor only a few hours) to screw a uterine/fetal monitor into my baby's head. "but you are a nurse, why don't you want this?" Yes, I am a nurse and my membranes will rupture when they are ready, and having that damn thing in me will drastically increase my chances of having to have a c-sect since they are new enough and difficult enough to correctly interpret. Get your f'ing hand out of me!

I see it a choice issue indeed. I also see it a time issue, that many docs are pushed so far now that it is really difficult to find enough time to practice good medicine/health care.

[Crunchy Frog]

20. You actually have that in reverse.

It's the vertical incisions that leave you at a high risk of uterine rupture while the horizontal ones make VBAC relatively safe.

I understand that about docs being under alot of pressure, but do not see how that could ever justify cutting someone open with a knife against their will. I don't understand why these docs can't be prosecuted for assault and battery.

Good for you in standing up for yourself while in labor! I'm glad your choices were respected because that's not always the case.

[uppityperson]

21. You are right, I am backwards. Vertical ones can strip apart, horiz hold better

Will go correct myself.

I don't know why they can't be prosecuted either. Pisses me off.

[demigoddess]

26. let's just face it, women are second class citizens, not much better off than in the

victorian age. Those days a woman became a non-person the moment she married, not entitled to her own property or her own children, even as a widow. Today we have the right to jobs, money, and custody of children but not of our own bodies. Remember something, abortion was legal and somewhat practiced until the 1920s or something like that. I guess we can either vote or control our bodies but not both.

Also a man who murders his wife will get a much lighter sentence than a man who murders a stranger. And a lot less than if he murders a cop with a gun and back up.

[Warpy]

27. It will stop only when the first woman sues that OB-Gyn for battery and wins

While some women are hustled into surgery against their wishes, it's supposed to be because there is a massive complication, like the kid presenting one foot first. If she gave birth vaginally, the kid would likely die or be severely brain damaged.

Likewise a woman who's been diagnosed with placenta previa or abruptio needs that C-section fast. There is often no time for niceties like formal consent.

However, if the C-section has not been performed for the direst of reasons, any woman who has been rushed into one needs to sue. At least get the facts of the case decided, find out if it was necessary or battery.

C-sections are done far too often and at physician convenience. One of the ways to reduce maternal morbidity and mortality in this country is to cut those rates. All C-sections should be justified before a hospital board, at the least. Doctors who are quick to cut should be dismissed.

[Crunchy Frog]

28. I remember reading about one doc who was actually fired from her job

because she wasn't performing enough c-sections. They gave her an ultimatum to either raise her section rate or lose her job. She chose to quit rather than compromise her patients. They were going strictly on numbers, not on outcomes.

The problems with healthcare in this country go way beyond simply lack of access.

[benEzra]

33. I agree with you. A woman should have the right to choose.

Arguing about consent in the extreme cases is mostly a red herring; it seems to me that the vast majority of these are elective by the physicians, and the primary rationale appears to be tort driven rather than medically necessary.

[joeglow3]

36. A woman should have the right to choose, but a Doctor should have a right to refuse

My wife works for our friends, who are husband and wife OB/GYN's. They routinely refuse to perform VBAC's. Despite what all is out there, in their experience, there are many times it is NOT worth the risk. Sadly, an OB/GYN gets sued for almost anything all the time (the stories of what they have been sued for are ridiculous). In many cases, they simply will NOT VBAC because of this.

Thus, the patient should have a right to choose, but a Doctor should also have the right to refuse.

[Crunchy Frog]

37. So what do they do if a patient shows up in labor and refuses to consent

to the c-section. Do they refuse to attend her? Get another doctor for her? Or do they drag her to the OR without her consent and cut her open?

[joeglow3]

38. They resolve it beforehand

There have been instances where they have told their patients before delivery was imminent they would not VBAC. I don't think any patients have transferred care and, as far as I know, none have agreed but went back on their word. Usually, it would not be an issue of urgency, as the C-sections are scheduled. As to if they patient shows up in labor and refuses a C-Section, I don't know what they would do. The hospital where the do most of their deliveries is a teaching hospital, so there are interns there around the clock. I guess one of them could deliver.

However, knowing them, I would think they would ultimately do the delivery, but it would certainly be a risk they definately do not want to take. And, frankly, it is kind of crappy of the patient to force a Doctor to do a procedure they do not feel comfortable doing. I would think, at a minimum, you would want to document your communications of the risks to the patient, with a witness, to prevent unnecessary potential lawsuits.

[Crunchy Frog]

39. I ask because there are areas of the country

where it is literally impossible to find either a practitioner or a hospital that will "allow" a VBAC. Some women in these areas will resort to subterfuge to avoid a major surgery that they do not wish. They may simply not show up to a scheduled c-section, or they may labor in the parking lot until birth is too imminent for a section to be performed. Or sometimes they just utilize the doctor for prenatal care and end up having the baby on their own.

I guess your friends are lucky in that there are sufficient options in the area for women who want to VBAC that they haven't had to encounter that type of situation.

I kind of question the degree to which a vaginal birth including a VBAC, when it occurs normally, can be considered a "procedure" rather than a physiological process. After all it is a "procedure" that in some cases may have to be "performed" by a husband, a friend, a police officer or taxi driver or paramedic. In some cases by the woman herself or by one of her own young children (those stories always make the news). Is allowing a natural physiological process to take place the same thing as "performing a procedure"? Is a doctor who is being prevented from performing a surgical procedure being therefore "forced" to perform a procedure by simply catching a baby as it is pushed out of it's mother's body? (Nurses sometimes end up catching babies too. Are they being "forced" to perform a "procedure" against their will if a baby comes and they're the only one present?)

I understand the concerns about liability and agree that all communications every refusal of medical procedures should be well documented.