Thursday, December 20, 2012

Hindsight is 20/20

Somewhere between my doctors and the hospital and health authority involved in my daughter's birth, we slipped through the cracks.  I have looked back on what happened countless times, and have come to the conclusion the it should not have been that way, that it was not my fault that it was that way, and that it should not happen again.

I get that maternal request cesarean is controversial and that while there are many doctors who will accede to a woman's request, there are many that won't.  I also get that some hospital policies are more accommodative than others.  I get that health care resources are limited. However, there is an obligation to respect bodily autonomy and ensure that access to medical care is available in timely fashion.

I believe women who wish to plan a cesarean delivery (or an epidural assisted vaginal delivery for that matter) after being informed of the risks and benefits of cesareans AND the risks and benefits of vaginal delivery should be able to do so.  These women should be able to make their plans without fear that their birth plan will be frustrated and that they will be subjected to a vaginal delivery (or an unmedicated delivery) against their clear wishes and without medical cause.  Just as women who desire a unmedicated vaginal delivery need to be able to plan and to know the limitations and conditions of their plan, women who desire cesareans or epidurals need to be able to plan and know the conditions and limitations of their plan.

So, with the benefit of hindsight, what do I think should have or could have been done differently to prevent what happened to me?

1. I think my maternity doctor should have ordered an ultrasound at the earliest possible date to establish a more certain EDD.  I estimated my due date to be July 13 - I had been keeping track of my cycles and was using an ovulation prediction kit.  Yet my care provider decided it was prudent to use a due date based on a 28 day cycle and set it to July 17 - which while consistent with later ultrasounds that I had, it should be noted that when it comes to ultrasound they become less accurate at dating as a pregnancy progresses.  I believe a EDD of July 13 would have also been consistent with those later ultrasounds and should have been used.

2. I think an earlier referral to an OBGYN would have been prudent.  Waiting to refer until I was late in my pregnancy meant that despite my clearly stated desire to deliver by way of cesarean, that there was a risk that the OBGYN would decline to perform the procedure and that insufficient time would remain to make alternate plans.  Further, anxiety about being able to access my desired delivery mode caused undue anxiety during the pregnancy.  Shared care is not necessarily a bad model, but for women who are planning cesarean delivery, knowing that a GP or midwife cannot perform a cesarean, arrangements for the delivery are best made early on.

3. A fixed OR date and time.  The OB involved in my care has claimed that there was a hospital policy in place that did not allow for maternal request cesareans to be scheduled and that as a result my case was added to the add board.  At the time I really did not appreciate how much risk this introduced to my birth plan - I assumed that I would know the day of delivery, but not necessarily the time and when asked what I would like should I happen to go into labour prior to surgery - I indicated that I would still prefer a cesarean.  In fact, I did not worry much when my surgery got bumped the first day, or even the second, as at the time I believed that if I did happen to go into labour that my case would then be considered urgent and would be completed without undue delay (ie. within 2 hours).  I also believed that should I go into labour that an epidural would have been available to manage labour pain prior to delivery.  I should have been warned that if I did go into labour that there was a chance that cesarean delivery would have an undue delay (in excess of two hours) and that an epidural may not be available. I believe if this policy was in place, the effect of the policy led to an inability to access timely medical care and resulted in a contravention of my charter rights.

4. Assessment for the risk of going into labour.  From the time I was admitted to hospital until the time I went into labour I was not physically assessed.  My case was bumped and bumped again without any physical assessments as to the likelihood that I would spontaneously go into labour.  If an assessment had been done, it might have been found that labour was imminent and my case could have been managed accordingly.

5. Upon presenting to the nursing station with signs and symptoms of labour - my OBGYN should have been called immediately.  According to the records - I presented at the nursing station at around 11:45.  This was shortly after I noticed a second contraction after a first contraction 15 minutes prior and wiped bloody mucous when I went to the washroom.   According to the statement of defense submitted my OBGYN was not called until 130 - nearly 2 hours after I first presented to the nursing station.

6. I was told an OR and an anaesthesiologist was not available.  I laboured under the belief that should things go sideways, and the knowledge that if things did go sideways, that my child or myself could suffer serious adverse consequences.  I was not told that there was a back-up on-call anaesthesiologist in the event of life or limb emergencies - and that he/she would be available within 15-30 minutes if needed.  I was terrified. 

7.  Staff and doctors should be trained to respect and support all pregnant mothers.  Pregnant mothers have a diverse array of values and beliefs with respect to birth and not all pregnant mothers desire a vaginal birth without epidural pain relief.  I was told by nursing staff  "my body was made to do this", and that "if I wanted a maternal request cesarean, I should have gone to Brazil", and to "direct my screams into pushing".  From an on-call OB I saw regarding complications after the birth that he "was happy the c-section did not occur" - although he immediately apologized when I responded that I was not happy the c-section did not occur, the words still hurt.  Women choosing cesarean or epidural pain relief are not well supported - the deserve (and should be entitled to) timely access to these desired medical resources - especially when they have indicated well in advance of their deliveries that they would like access to these things.

The sad thing is that maternal request cesarean was available in British Columbia - it was even available on the island at the time I had my daughter.  There are doctors and hospitals that will accommodate women who choose to deliver by way of cesarean - who will schedule a date and time for delivery.  The sad thing is, that what happened to me did not need to happen.  I would have been both willing and able to travel to access care if that was what was needed.  I clearly communicated my preferences early in my pregnancy and throughout my pregnancy.  I did my part.

Somewhere, somehow, the system and my doctors failed us - and for that, there must be some accountability and retribution for the wrong that was done. Further, measures need to be taken to ensure the same wrong is not done again, and again, and again. Access to timely medical care during labour and delivery should not be uncertain - and that includes access to cesarean delivery and epidural anesthesia on maternal request. 

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