Pregnant Woman Denied Care Over VBAC
By Rachel Walden — August 17, 2007
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.
WOW about this story and grr on this. Good for that woman for sure and just wish that every other women was like her for sure.
An obstetrician who may be amenable to VBAC in this particular situation might not be amenable to VBAC without adequate monitoring. You cite “much research” about EFM in the “low-risk” setting which doesn’t apply to this particular woman.
There is mutual autonomy at stake here: doctors shouldn’t let patients violate their own professional ethics, and patients shouldn’t let doctors override their expressed wishes. If these are not mutually compatible, you need to terminate the relationship.
The poor physician in this situation has the terrible choice between discharging the patient and waiting in fear of something that they knew could have been prevented.
Hi folks — As you may have noticed, these comments were re-posted after I accidentally deleted them. But we’re missing one that would have gone here from “Megan.” Mea culpa!
Megan, if you read this and want to resubmit your comment, I’ll post it in this space. Thanks!
Thank you all for your comments. Hildy, yes, I did try to point out that the woman is not the traditional “low-risk” birth on which more of the studies seem to have been conducted. I think if her doctor had let her know early in the pregnancy that he wouldn’t continue to care for her, and if he had done a better job of the transfer, it would have been less of a problem, although it’s still a concern as to whether the doctor respected both the medical evidence and patient autonomy in general.
Megan-Thanks for that info, I’ll be interested in reading the full study.
As the activist who arranged for Lara’s media story, I just wanted to clarify that Lara never refused electronic fetal monitoring entirely.
Rather, she challenged having to have CONTINUOUS monitoring that would prevent her from laboring normally (walking, changing positions, using the bathroom, etc.) Many times birth does not happen when women are confined to beds strapped to continuous fetal heart monitors.
Also, the OB only agreed to provide 7 days on ongoing care – not much per patient abandonment standards considering she could start labor at any minute.
As the previous poster indicated, the most recent study of VBAC after multiple cesareans showed no statistically different risk for VBAC after multiple vs. VBAC after one cesarean. In fact, had the study bothered to separate out the induced / augmented labors (a known risk factor for uterine rupture) from the non-induced / augmented ones, the .7% and .9% rates reported would have probably even been
The New England Journal of Medicine reported a study in 12/04 that DID separate out the types of labors and those that were left alone only had a .4% rupture rate. Since not all ruptures are catastrophic, the study summarized you have to do 588 elective, repeat cesareans in order to prevent “one poor perinatal outcome.”
Since the risks of cesareans increase for each additional one a woman has, the OB was definitely not practicing evidence based medicine when she stated, “I’d rather do SEVEN cesareans on ONE woman than ONE VBA2C!”
Surely Lara was acting reasonably to assert her rights to choose a VBAC. Fortunately, the Maryland Attorney General’s Office agrees.
What seems sad to me is the fact that doctors in general are always harping on patient safety, yet this doc just basically set this woman free at 38 weeks. I have heard stories of women moving to my state at 38 weeks of pregnancy and not being able to find a care provider because of how far along she is. How is that safe? Midwives could definitely close the health care gap!
Thank you very much for providing that additional detail, and for your role in exposing this issue to wider scrutiny via helping Lara’s story get out. Good work.
Hildy, continuous fetal monitoring is associated with worse outcomes in some cases, including higher rates of cesarean section without cause.
Here is a good review:
This is its synopsis:
4 randomized controlled trials were done that studied high-risk pregnancies and 4 were done that studied low-risk pregnancies. The studies compared electronic fetal monitoring with active clinical monitoring by nursing and medical staff. Most had small samples of patients. For the 4 studies of high-risk pregnancies, 3 increased the rate of cesarean sections, 2 increased other obstetrical deliveries, and 1 increased blood gas levels and neurological signs in the infants; no other significant differences were found. For the low-risk pregnancies 2 studies found an increase in cesarean section deliveries and 2 found an increase in other operative deliveries.
The Cochrane Database of Systematic Reviews had 4 reviews of electronic fetal monitoring and they showed no benefits of electronic fetal monitoring for Apgar scores, admission to the special care nursery, or perinatal death. Electronic fetal monitoring showed decreased rates of neonatal seizures but increased rates of cesarean section and maternal infection.
* There is poor evidence to include or exclude electronic fetal monitoring in the PHE of high-risk pregnant women [C, I].
* There is fair evidence to exclude electronic fetal monitoring from routine intrapartum care [D, I].
This should apply to all pregnancy and labor, regardless of prior cesarean section. Yes, a trial on VBACs would be more informative, but I think the record is pretty clear that this is not evidence based care.
Barbara (who posted a previous comment) updated the ICAN leader’s list that this mom indeed had her successful VBA2C a couple of days ago! Way to go Lara!
Elaine, thanks for the update!
My obgyn sent me a letter in the 5th month terminating me as a patient because I refused to take a medicine called glyburide twice a day. I only took it once a day because it drops blood sugar extremely low. The phone conversation was on a friday and I got the letter Monday with no warning and no 30 day notice. No referrel to other doctors and no emergency care. It took over a month to find a new doctor because he put in my medical records that i was non compliant patient. Does anyone think this is patient abandonment? I certainly feel that it is.
I think that is absolutely horrible. Your doctor should treat you like an adult and talk to you about the meds and your decision.
Hi all and thanks for all the information here. I am also trying to refuse continuous electronic fetal monitoring but I would like to show my hospital research papers and other scientific data to back me up. If anyone has some links to these data, it would be highly appreciated.
Claudia, try the Agency for Healthcare Research Quality: