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Sunday
Nov202011

How I Would Counsel a Woman with a Suspected Large Baby

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Guest post by an anonymous OB-GYN 

 

 

The prompt:

Suppose that tomorrow you were faced with a woman in a similar situation, and an estimated fetal weight of 10 pounds. Would you offer her an elective C-section? Why or why not? How would you counsel her about the risks? Could you do that without mentioning the risk of death? In what way would that be different than playing the “dead baby card?” Please tell me the specific language that you would use as a doctor. Mother has diet controlled gestational diabetes and otherwise uncomplicated pregnancy.

 

My first response is that I want more information. Was this her first pregnancy? If not what were the weights of her previous newborns?  How much did she and her husband weigh at birth? Where did the estimated fetal weight come from?  If, as I suspect, it is simply the result of a term US, then I would be inclined to ignore it entirely.

The estimated fetal weights derived from ultrasound are routinely incorrect by a factor of 10% across the board and those errors are higher in term mothers with excessive weight gain and much higher in mothers with BMI greater than 25.  At forty weeks gestation, that translates to over 2 pounds in an average size fetus and over three pounds in a larger fetus, i.e.: an 8 pound fetus is likely to be estimated as a ten pounder while a 9 pound fetus risks being estimated at 11 1/2 pounds or even twelve pounds. The larger the fetus, the greater the error.

How have the fundal heights been? We religiously collect this data during prenatal visits for a reason. It has better predictive value than a third trimester US. Has the growth curve according to fundal height been steady or has it accelerated in the third trimester?

How was gestational diabetes diagnosed? How well have her blood sugars been controlled? How much weight has she gained?

How was her gestational age (GA) determined?  Did she have regular menses prior to conceiving? What is the length of those cycles? Does she know without question when her last normal menstrual period began? Did she have any bleeding following her LNMP?

Did she have an early US that confirmed her gestational age?  Was that US abdominal or vaginal. Was her GA determined by an US at any point and if so when? Was that US done by an obstetrician, midwife, or US technician with experience in obstetrical ultrasound?

All of this information should be factored in to properly counsel a woman in this situation.

 

 

How would I counsel her without that information?

There is always a possibility that you could have difficulty delivering your baby’s shoulders, which are generally the widest part of the baby to get through your pelvis. That is true with every woman and every baby. We refer to this as a shoulder dystocia.

The risk of a shoulder dystocia is around 1% with babies less than 4000 grams but increases to 5% in babies greater than 4000 grams and higher as weights increase. Most women will not experience a shoulder dystocia even with babies greater than 5000 grams. In women who do experience shoulder dystocias most of those infants are delivered without incidence. Between 5 and 15 % of infants experiencing shoulder dystocia may have a brachial plexus palsy, which is nerve damage that limits mobility of the affected arm.  Ninety percent of those resolve without treatment within 12 months.

The single most common risk factor for shoulder dystocia is the use of vacuum extractors or obstetrical forceps to facilitate delivery.  Other risk factors include: known abnormal pelvic anatomy, poorly controlled gestational diabetes, post-dates pregnancy, previous shoulder dystocia, and short maternal stature.

However, most cases of shoulder dystocia occur in normal weight infants and are unanticipated. Because of this, identifying risk factors has not been shown to have any clinical usefulness.

No evidence exists to support induction in mothers who have gestational diabetes and suspected fetal macrosomia. Induction has been shown to increase rates of cesarean delivery, increase rates of newborn respiratory distress, but has not been shown to decrease rates of shoulder dystocia, or to have any impact on the risk of maternal or neonatal injury.

Elective cesarean delivery likewise is not recommended in cases of suspected fetal macrosomia.  It is estimated that 2,345 cesarean deliveries would be required to prevent one case of permanent brachial plexus injury.  That number may be somewhat smaller in women with both gestational diabetes and suspected fetal macrosomia but there remains no evidence that elective cesarean produces better maternal or neonatal outcomes.

If we were to encounter a shoulder dystocia during your delivery then there are a number of maneuvers that might be employed to complete the delivery. We might ask you top change positions, squat or get on your hands and knees. We might put some pressure above your pubic bone to attempt to dislodge your baby’s shoulder.  We might attempt to rotate the baby’s shoulder manually to dislodge it and to deliver one of the baby’s arms to reduce the thoracic diameter. In severe cases we may intentionally break the baby’s clavicle to reduce the bi-thoracic diameter. This will generally heal without difficulty.  In extremely rare and severe cases we must make more room to get the baby safely through the pelvis. That is best done by injecting local anesthesia into your pubic mons and using a scalpel to cut through the cartilage holding the two halves of the pubic bone together thus allowing the bony pelvis to expand.  This will normally heal without difficulty but may require a temporary brace to facilitate walking until healed.

There is a large body of data that suggests the mother and baby have a higher risk of post natal complications from a cesarean including maternal hemorrhage, hysterectomy, post operative and nosocomial infection, increased difficulties with bonding, post partum depression, and breastfeeding - all of which carry there own sets of future complications,  increased risks of maternal death both with the index pregnancy and more so with future pregnancies, bowel obstruction, placenta previa, placental accreta, vasa previa, and uterine rupture with subsequent pregnancies.

Babies have a higher risk of respiratory difficulties not only in the immediate post operative period but well into adulthood. They have increased rates of asthma, and recently recognized: increased rates of bronchiolitis (birth to 24 months for elective C/S) and pneumonia (12 to 24 months “emergent C/S”), and a huge array of cesarean complications that have been widely reported.

There is no evidence that offering someone a trial of labor produces worse outcomes.

 

 

And in answer to the additional question:

 

“What do you all think about the fact that the woman involved wasn’t counseled about the possibility of a large baby having a possibly difficult delivery and the option of a C-section?”

Every woman who has ever gone into labor since the beginning of time has “the possibility of a large baby (sic) having a possibly difficult delivery…”  Every woman who delivers in the United States has the option of a C-section – but there is not one shred of evidence that that C-section improves her outcome or her baby’s outcome. For the 10,000th time – first do no harm. If you can’t demonstrate with a reasonable degree of significance that doing an intervention actually improves outcomes then you should not be doing it.

 

 

 

 

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  • Response
    In this retrospective study, there were 27 hysterectomies in 46,766 cesarean deliveries, and 376 hysterectomies in 2,292,420 vaginal deliveries. That is the same as 0.6 per thousand cesareans, and 0.2 per thousand vaginal deliveries. The adjusted odds ratio of any hysterectomy is 3.2 higher odds for cesarean than vaginal delivery. So, ...

Reader Comments (57)

Thanks MomTFH, I did read those quoted percentages. But later in the post, the obgyn mentions that most cases of dystocia occur in normal weight infants. So maybe I should reframe my questions: how can we better predict dystocia in all women, regardless of fetus weight (predicted or otherwise)? What is the proportion of dystocia cases that are due to macrosomia? (PS. I know that second question is virtually impossible to answer).

Dr Amy, I'm not familiar with your prompt/quote or the $144 million dollar lawsuit. Out of curiosity, was there mention of the baby's predicted or actual weight?

November 20, 2011 | Unregistered CommenterRomy

“If, as I suspect, it is simply the result of a term US, then I would be inclined to ignore it entirely.” That is just plain foolish.
“The estimated fetal weights derived from ultrasound are routinely incorrect by a factor of 10% across the board... “ …In EITHER direction, as addressed in an earlier reply.
“How have the fundal heights been? We religiously collect this data during prenatal visits for a reason.” This is misleading as to the predictive value of fundal height. We religiously collect this information to predict a need for ULTRASOUND.
“How much weight has she gained?” I’m not sure maternal weight gain has any predictive value in the realm of diabetes and/or shoulder dystocia…
“How was her gestational age (GA) determined?”… What bearing does accurate dating have on the estimated fetal weight beyond term? I’m confused at the utility of this information…
“Induction has been shown to increase rates of cesarean delivery…” Please stop perpetuating this inaccurate information. Induction in the setting of a favorable cervix DOES NOT increase the need for cesarean section.

November 20, 2011 | Unregistered CommenterANON

Good grief. I was going to stay out of this until that last line. ANON - horse s**t. All inductions regardless of cevical status are associated with an increase incidence of cesarean delivery irrespective of means of induction. Have you never heard of hyperstim? Even happens with nipple stim contractions. Hyperstim in natural onset labor is essentially unheard of. And no I am not going to get this response bogged down in all the other cesarean risks with elective induction, but if you want a challenge with a practicing MD on this I am game for the rabbit hole. Dr. Tuteur your points are well taken but you must agree that in excess of 2000 cesareans to prevent one permanent palsy seems extreme. The problem with this award bantered about is that we have no insight to the breakdown of the payout or for that matter of the legal argument put forth. I have seen these huge sums based on a 80 year lifespan in a severe brain damaged infant that lived 10. The problem with hinging your argument on a jury award is that we have no jury of our peers. I do not know if this award was punitive but if my environment is any indication it certainly exceeded any medical cost so I am guessing yes. If people want less defensive medicine then there needs to be in place a system that would be real in terms of mandated informed consent points and appropriate pay-outs of culpable negligence. If the govenment wanted real health care reform it would have put these in place instead of mandating insurance purchase. Protected patients, compensated malpractice, defined standards, defined malpractice, better outcomes. How novel.

November 20, 2011 | Unregistered CommenterOb

Why is the obstetrician anonymous? Why can't he or she publicly stand by his or her writing? If it is the correct way to counsel patients, there should be no problem.Or should we infer that it is his or her personal preference and in violation of legal and ethical requirements and he or she does not want the insurance provider and hospital to know?

November 20, 2011 | Unregistered CommenterAmy Tuteur, MD

My HBAC baby was a 10 lber. My father was a 10 lber back before they made that into a big thing to be terrified of. Nebraska farmwives had 10 lb sons all the time then, and it wasn't noteworthy except to say he was "healthy". My 10 lb son, the first I had ever birthed vaginally, was healthily genetically large, not large due to some pathology. Being at home with a skilled homebirth midwife who had been in practice since before the whole movement to stamp out VBAC began, made a huge difference, but I didn't start out that way. It took hearing the supposed 'only pro-VBAC OB in town' telling me that she induced on VBAC "all the time" to motivate me out of obstetrics altogether and walk away from that at 30 weeks, into the office of the homebirth midwife. Happily, in my state, I had that option. Some women do not, or have to cross state lines to get it. I would counsel another woman who had been forecast to have a big baby, that first of all, the forecasts are trusted far more than they deserve to be, and secondly, there is nothing terrible about having a 10 lb baby, unless you end up being made to do it in the worst position possible (on your back or sitting on your tailbone, for OB convenience) and/or under drugs and being stressed out and harangued while in labor. People give more respect to a golfer about to swing, than they do to a woman birthing.

Despite what they told me that first time around, induced labor is not like natural labor. It hurts much, much more, and is more risky to both mother and baby. I learned that pushing out a 10 lb baby, all natural, at home, hurt less than only getting to 4 cm on a Pitocin induction, before ending up with an epidural and cesarean. And I learned that the undrugged baby, sees, and is aware, at birth. And I learned that the unhindered birth, the nonseparation of mother from newborn, made an enormous difference in how we bonded. The seeming precocious alertness and muscle tone that my nondrugged baby had, compared to my hospital-drugged, 38 week induced, surgically "delivered" baby, was astounding, but instead of seeing the HBAC baby as somehow more able than a newborn ought to be, I see that newborns are not actually supposed to be born groggy, disoriented, and unable to focus. That's just what we have come to accept as a norm in a society that drugs almost every baby, as it is being born, and turns 1 in 3 births into surgeries with all the risks that entails.

The belief system that birth is somehow more dangerous than surgery in general, coupled with a system in which hospitals and doctors stand to make the least money on healthy natural births, creates a self-perpetuating cycle. Every woman alive is the living descendant of women who birthed successfully. The argument that childbirth is uncontrolled, while surgery is a controlled event, is fatuous. Surgery is controlled only so well as human beings can control it, and entails a certain known risk of embolism, infection, and morbidity, that physiologic birth does not. That is not to say surgery is never justified. When it is, it is a miracle. But 1 in 3 women are not unable to birth, suddenly. To say that birth is an uncontrolled event is a partial truth. It is not under the direct control and management of the human beings who barely understand it, and certainly did not have a hand in its creation. It is therefore, in general, less prone to human misconception and error, than unnecessary surgery, which makes it safer overall, to anyone sensible of the periodic revelations of human hubris and arrogance over natural systems.

Necessary surgery is by definition safer. Unnecessary surgery is by definition more risky. The big question is, does a pregnant woman retain, or relinquish, her civil rights upon pregnancy?

November 20, 2011 | Unregistered Commentermaggie

Here are replies to the prompt, which appeared in the comments on this post:


Jill’s reply:
Amy wrote: Suppose that tomorrow you were faced with a woman in a similar situation, and an estimated fetal weight of 10 pounds. Would you offer her an elective C-section? Why or why not? How would you counsel her about the risks? Could you do that without mentioning the risk of death? In what way would that be different than playing the "dead baby card?" Please tell me the specific language that you would use.

Yes, I would offer her an elective cesarean. One thing I would take into account is whether or not the other folks that might be covering for me will actually honor the patient’s wishes for a vaginal delivery if that is her preference; otherwise, I would be setting her up to be met with hostility if I am not there and had already promised her she could try to deliver vaginally. If she tested positive for GDM, she is at greater risk of SD because of head/abdomen ratio concerns, which would answer “why”. Counseling about risk would depend largely on what my malpractice carrier allows me to include in my consent forms. I would hope that I would be free to discuss the documented inaccuracy of third trimester estimates of fetal weight. I would tell her about the increased risk of shoulder dystocia in patients with GDM as well as description of BPI, asphyxia and death in addition to whatever I regularly provide for informed consent for both vaginal birth and cesarean. I might go over what we do specifically to resolve shoulder dystocia when it occurs.

The difference between this scenario in which I mention death and what is know as the “dead baby card” is that I am clear that I am neutral as to her decision. I am not trying to provoke an emotional response through anecdote or an exaggeration of risk (or discussing relative risk without actually sharing the absolute risk) to make her consent to a certain treatment; rather, I am providing her with accurate information with which to make a decision and leaving it up to her. In this ideal world, she would have an understanding of percentages, rates, ratios and levels of risk. She would also make her decision with full agency and take responsibility for her decision, rather than delegating the decision-making process to me.

I have privileges at Never Never Land Medical Center and Idealville Memorial, where all patients like shared-decision making. "Ob", will you hire me?


Reply to prompt by “anonymous so lawyers can't use this against me l8r”

This isn't theoretical for me. It's part of my job.

We would suspect macrosomia if the patient suspected it, if we were concerned on physical examination, or if an ultrasound estimation of fetal weight came in >4500g (about 10 lb.) The precision of all these is about the same, that is, +/- 15%. So the patient and I would talk about how we could be wrong by a pound either way.

But presumed macrosomia doesn't exclude a vaginal delivery. And shoulder dystocia, which is a feared complication--I have seen some fatal ones--isn't easily predictable. Half of shoulder dystocias occur in babies LESS than 4000 g. There's a case on record of a five-plus pounder. I know of a Canadian study on outcomes with birthweight >5000 g (11 lb) , in which 80% of babies did not sustain SD. (Alsunnari et al, JOGC 2005; 27: 323. I recall a Scandinavian study of babies >6000 g at birth (13 lb) in which the SD rate was roughly 50%. In both of these, the variable here is birth weight. That is, the actual baby was put on a scale and weighed. But fetal weight is different, since you can't weigh the fetus. All you can do is gestalt the estimate either clinically or based on the mother's impression, or measure a couple of circumferences on ultrasound, and plug those into a regression equation which has never been validated at high "weights."

So then we'd talk about her obstetrical history, and the experience of other women in her family, and her hopes & fears for the birth. I would touch on the possibility of shoulder dystocia, and I'd be more concerned if she were diabetic (because the head-to-body ratio is different, these kids are blocky,) and we would talk about how SD is managed if it occurs, including that there are some very difficult to extract and some that result in trauma or injury. Most of the time people don't ask me to describe the Zavanelli maneuver---I think somebody alluded to that here. But WTF, if she wanted details I'm OK with that.

And we'd discuss the usual risks of CS.

And if she wanted a trial of labor, I'd take the option of instrumental delivery (vacuum or forceps) off the table, so it's either SVD or CS in labor. And we'd be prepared at the time of delivery, and I'd rehearse my team just in case. And the patient and I would have an ongoing discussion as labor progresses.

And after the fact I'd notify my risk management officer that we're gonna get sued if anything other than an easy spontaneous vaginal birth eventuated.


Reply by Gustavo San Roman, M.D.

All this talk about macrosomia without any reference to the mother’s physical characteristics illustrates that we have forgotten that child birth is a process where BOTH the physical characteristics of the baby AND the mother will affect outcome. ACOG gives us a fetal weight at which one should consider a cesarean birth but ignores the size of the mother. Is the outcome of a ten pound baby the same for a woman who is five foot tall having her first baby as it is for a woman who is five foot seven inches tall having her fourth baby? My database of over 285,470 deliveries provides the answer.

To provide informed consent an obstetrician needs to use data to communicate the risks and the benefits. The obstetrician also needs to listen to the concerns of the individual patient. This has been nicely described in the post by ASLCUTAML. Unfortunately, the data that obstetricians seem to be using these days comes from our legal system and not our medical system. For example, if the risk of disaster is 1 in 100, then 99% of the patients will have a good outcome and blog about how they ignored their obstetrician’s advice and still had a good outcome. However, for the obstetrician, the 1% could end their career (unless they have $144 million to spare). Until we are insured by the people for whom we provide medical care and malpractice is determined by a jury of obstetricians, there will continue to be concerns over the motivation for providing informed consent.

For now, pregnant women and their obstetrical care providers can get outcome data (cesarean birth rate, vacuum and forceps rate) for women with similar physical characteristics at www.Birthrisk.com. I can’t predict shoulder dystocia, but if 80% of women with similar physical characteristics had a cesarean birth after they attempted to labor, it stands to reason that many of the other 20% didn’t have an “easy” birth.

November 20, 2011 | Registered CommenterJill

Conspicuously missing: Amy Tuteur, MD's exact wording used to counsel a patient on suspected macrosomia. Go for it, Amy. You're up.

November 20, 2011 | Registered CommenterJill

Amy, can you please give everyone the correct answer to your prompt?

I also want to know why you didn't answer the question why you think the cesarean rate should be 15 percent in the U.S.

November 21, 2011 | Unregistered CommenterJennifer

Jill has taken the prompt out of context.

She asked me if she could reprint a post of mine about a recent obstetric malpractice case. In my post I pointed out that Jill's writing about macrosomia directly violated the principles ennuciated in the court decision. Specifically, Jill haa written disparagingly of the "dead baby card" but the court specifically said that informed consent REQUIRES telling a woman that her macrosomic baby might die.

I asked Jill if she could reconcile her personal views of macrosomia and her disparaging comments about the "dead baby card" with the result of a recent court case that awarded $144 million to a disabled teenager because her mother had not been informed that a big baby was at greater risk of dying of shoulder dystocia and that the mother should have been offered an elective C-section to avoid that possibility.

Jill can't do it and neither can the anonymous obstetrician who can't even bear to have his or her name publicly associated with the specific counseling. Asking me what I would say is just an attempt to dodge the issue. I have absolutely no problem accurately counseling women about the inherent dangers of childbirth including the risk of permanent injury and death.

Moreover, the blather about whether prophylactic C-section reduces mortality in large populations ignores the fact that court cases are decided on an individual basis without regard to large populations. While a policy of routine C-section for macrosomia may not improve overall outcomes, there is simply no question that an elective C-section in this specific case would have resulted in a healthy baby.

Homebirth and natural childbirth advocates who disparage the "dead baby card" demostrate a profound ignorance of the medico-legal requirements of informed consent. What they think is the appropriate way to counsel a woman violates the law and that's why no one pays any attention to the whining about the "dead baby card."

Unless and until NCB and homebirth advocates learn more about the real world, no one will ever take them seriously.

November 21, 2011 | Unregistered CommenterAmy Tuteur, MD

Unless and until NCB and homebirth advocates learn more about the real world, no one will ever take them seriously.

Mmmm... Replace "NCB and homebirth advocates" with "Doctors and hospitals" and "learn more about the real world" with "stop threatening and misinforming patients" and I fully agree.

I really haven't figured you out, Dr. I mean, what could cause a person to appear to so spectacularly miss the point? Over and over and over again, no matter how it is explained? Simple trolling? A more subtle advocacy for the devil (though one which never clearly reveals its motivation)? Stupidity? Singleminded hyperfocus? Superiority complex? Learning disorder? The mystery remains...

The "dead baby card," as I understand it, consists essentially of at least a couple of the following:

-Gross overstatement of risks presented in vastly oversimplified language.

-The statement or very strong implication that the fetus/baby will die or is very likely to die.

-Refusal to consider or even discuss alternatives to the HCP's preferred course of action in a realistic and/or dispassionate manner.

-Outright, direct threats or threatening language and nonverbal cues (though generally not only nonverbal cues).

Now, others may have other definitions, and this is admittedly off the top of my head. And as with anything, it can theoretically be overapplied and bastardized*. But I have rarely seen such.

A good example of "playing the dead baby card:"

"If you attempt a VBAC, your uterus will explode and your baby will die. I won't let you do that and no other doctor I know will."

This contains the statement that "your baby will die." It includes a gross overstatement of risk-- "will," not might, and "explode," not rupture. Not to mention the causal relationship with fetal death. The vastly oversimplified (and inaccurate) language should be similarly self-evident. There is no consideration given to alternatives-- they are simply not allowed. There is a strong implied threat of patient dismissal, forced surgery without consent and/or the patient being left to fend for herself in birth.

Contrast that with a statement that, in and of itself, is false, misleading and/or inaccurate-- even coercive-- but which does not constitute (IMO), the "dead baby card":

"VBACs are too dangerous. You should have a C-Section."

Nothing in there about a dead baby. Oversimplification and inaccuracy, yes-- but there's less a statement of risk in there than a vague, relative conclusion and recommendation. It's not clear that the discussion is "over" and although it's dismissive, we don't have a threat.

Then there's...

"VBACs carry an X% chance of uterine rupture, which carries a Y% chance that the baby will die. You should have a C-Section."

Okay, we have a dead baby, but it's a chance (I'm assuming X and Y are accurate)-- and not a certainty. The actual risk is given. I don't see any oversimplified language, and while the conclusion implies a disconnect between risk and recommendation, the risk has been accurately, not over-, stated. At least the part of the picture that *has* been painted is accurate. Refusal to discuss alternatives and any threats are as the previous example-- i.e., not within these words, though they could come at some point.

I suppose some of the mythical homogenous tribe of singleminded stereotypical "birth advocates" might twist the last example into "playing the dead baby card," and it might even be (arguably) so with more information about the woman's specific risk, or with the addition of other quotes from the HCP. But by anything like my definition, it might be problematic, misleading, etc.-- but not "playing the dead baby card."

Let us say I take you, Dr. Tuteur, at face value-- if I assume you are an intelligent woman and not trolling/playing devil's advocate with no loftier goal than to prove personal superiority or some such-- then perhaps I can actually clear up the disconnect here. If it really exists and you are willing to have it "cleared up," of course...

The only things I *think* I can glean are...

A) That you believe that HCPs MUST give the risk of death, no matter how great or small, when discussing every possible procedure or medical recommendation. This is a part of what constitutes informed consent in your mind, or perhaps in law, precedent, etc.

B) That you believe that "birth advocates" think that mentioning the risk of death is "playing the dead baby card."

Pretending/assuming that you are actually trying to understand anything I say, I can assure you that B is almost never the case. Of course, that much would be obvious if you regularly read blogs such as this one, which I'm sure you do (?) In fact, if that were true on the whole, we wouldn't advocate for HCPs giving women more information about the risks of death from the use of various interventions in various circumstances. But even if we were only speaking of things we "disagree with"-- such as disallowing VBAC when the mother has no complicating risk factors-- I can say that I have seen very, very little of folks claiming that an accurate assessment of the risk of death is "playing the dead baby card." And especially not the simple statement of risk in and of itself. Honestly, even if ONLY the (actual) risk of death associated with VBAC were given-- and the risk of death with RCS were omitted, implying that only VBAC is associated with any risk of death-- I would not call that "playing the dead baby card." Inaccurate, misleading-- absolutely. But without a gross overstatement of the actual risk of death-- that your baby will die or is most likely or "very" likely to die-- then no-- not the "dead baby card."

As for A, above... Do you believe that the only way to achieve informed consent is to include the risk of death in every discussion of every course of action, procedure, medication, etc.? If not, why not? I ask because I would not be averse to this requirement, I just haven't seen it applied too often in practice. And I include treatments with a statistically significant (if certainly not likely) risk of death-- not just a rare or tiny one. Certainly sometimes risk of death it is given by HCPs-- at least in some written form (sign here and here), but very often a woman is given no information about the risk of death associated with-- to give an example-- AROM. It's not (absolutely) high, but it's there. What is the risk of death from hospital-acquired infections? Is that something that informed consent is obtained for? Why or why not? What constitutes a procedure, treatment, etc., that requires discussion of the risk of death? And I mean not only in obstetrics, but generally, when it comes to the practice of medicine as a whole?

Does it have to have more than an X% chance of death?

Does it have to have an X% GREATER chance of death than the most common alternative?

Does it have to be a certain kind of procedure?

Is it an "I know it when I see it" thing?

Is it not so much a requirement as a CYA? In other words, is it not legally required for every possible procedure, med, etc., BUT you "should" do it for the ones most likely to end in a lawsuit? Of course, if this is the case, then it's not legally required, is it?

Just giving an honest effort to bridge the gap here.


*I'm trying to be well-considered, but my rhetorical strategy of admitting gray areas is probably a poor one in this sort of black or white "discussion." I could pretend to be absolutely certain of everything I say, but I'd be afraid to lose credibility. Then again, maybe that's just me.

November 21, 2011 | Unregistered CommenterDreamy
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