Autonomy via post on MCDG
A few comments:
- No-one is suggesting “agreeing to support a woman in the provision of an unsafe practice” or “agreeing to a “demand/request” (that) puts the practitioner at risk of an adverse outcome or merely being seen as crazy or unable to “manage” his/her clients/patients.” A firm recommendation against a course of action is not “agreeing” to it. All primary care clinicians and all specialist obstetricians need to realize this. The fact that in some jurisdictions specialists do not understand the difference means they need to be educated, not that women need to be coerced into accepting an intervention they do not want just so the midwife or FP can avoid hot water later. As Kathy points out, communication about these issues ahead of the situation, with involvement of an ethics committee if necessary, will prevent later backlash.
- It is extremely important to separate non-maleficence from autonomy. Although a woman has the autonomous right to refuse any intervention, yet still be cared for, she does not have the right to demand an intervention or procedure that her care provider deems unsafe. Attending a woman birthing at home despite a recommendation against it is not an “intervention or procedure,” nor is it endorsing or agreeing to a course of action. It is duty of care and harm reduction.
- Comparatively, physicians have it easy: our responsibility for ‘difficult’ patients ends if and when they walk out the door. Pity the poor homebirth midwives with their birth kits in the back of the car who have to decide whether to attend the woman laboring at home with a breech who calls them… You think the obstetrician without much skill with breech birth feels out on a limb? In both situations, however, if despite all recommendations against it, the woman is truly determined to have a trial of labour, getting into a pissing match will not help matters. She knows that many breeches deliver normally, so advising her that the sky will fall if she labours only erodes credibility. On the other hand, if the midwife/obstetrician maintains a therapeutic alliance, the woman will likely accept the (even) stronger recommendation for C/S because of increased risk if the FHR tanks or progress is slow. And you better believe that her refusal will motivate that junior obstetrician without much breech experience to make every effort to find a colleague with more skills to back him or her up – on the phone if necessary.
- Despite all of the lip-service about “woman-centred –care,” it is a tragedy that in so many centres with obstetricians who have breech skills, that women have to play Russian Roulette. If Drs. Smith or Fitzgerald are on call, I get to labour. If Drs. Jones or Abraham are on, I get a C/S. If I am laboring when shift hand-over occurs, I might get a C/S after 6 hours of labour. Really??!! In 2013?
At Grey Nun’s in Edmonton, the OB group has gradually supported one another and come in when not on call to attend breech births. They have glossed over the billing issues and they have made themselves generally available (when not on call as long as they are in town and haven’t been drinking) in order to give women choice. They now have a staff that for the most part feels comfortable attending a breech in labour without needing to call in back-up. Grey Nun’s is a medium-sized community hospital. On the other hand, Mount Sinai is an ivory tower in Toronto with over 6000 deliveries annually, two or three specialists on call at any one time, and far more obstetricians with breech skills than the Grey Nun’s. Yet at Mt. Sinai, women with a breech are still forced to play Russian Roulette.
I know life is busy, back-up call is a pain, and admitting that some specialists have extra skills might hurt someone’s feelings, but for the sake of avoiding major surgery in women who want the choice, suck it up. Between six OBs with breech skill, it might mean four extra calls each a year – for a maximum of 90 minutes each given the guidelines on the length of the second stage.
Regards.
