Thursday, February 14, 2013

Are the common practices with respect to Maternal Request Cesarean negligent?

I have been wondering if the common practices that are applied by many physicians in Canada and in many Canadian hospitals with respect to maternal request cesarean are negligent and unreasonably frustrate the rights of women to make medical decisions for themselves.

In my own case with respect to the birth of my daughter (and I do not believe this is uncommon), my maternity doctor did not refer me until I was 32 weeks pregnant. This might be common practice with respect to elective cesareans in general, but I would argue that it is negligent when it comes to maternal request cesareans. This is because under most circumstances an elective cesarean has an underlying medical need and as a result there is little doubt that the doctor who is receiving the patient will agree to undertake the procedure. In contrast - many doctors will not agree to perform a maternal request cesarean - just as many doctors will not agree to perform an abortion - and that is their prerogative (frankly, having a doctor who disagrees with treatment is probably not a good thing anyways). This may lead to the need to see more than one doctor to request the cesarean. Further, many mothers who are requesting cesareans are doing so because of anxiety over the prospect of a vaginal birth - and often that anxiety is not resolved until there is some certainty that the desired mode of birth will be realized. As such, the doctor who is referring the patient needs to be reasonably confident that the doctor that the patient is being referred to will agree to the request or at the very least it would appear prudent for the physician to refer as soon as the request is made and facilitate shared care of the maternal request cesarean patient with an OBGyn. To do otherwise seems to have a high risk of frustrating the patient's ability to direct her own medical care.

Also with respect to my birth of my daughter, it has been alleged that Vancouver Island Health Authority had no OR booking schedule for elective cesarean deliveries and as a result my case was necessarily added to the OR Slate. Failing to provide a fixed time and date leaves elective cesarean patients particularly vulnerable as they are competing with other emergent cases on the open slate. As a result, it is fairly predictable that an elective cesarean patient (unless she's in labour) is likely to be bumped by more urgent cases. This unreasonably frustrates the woman's right to choose a pre-labour cesarean - particularly in large hospitals with a high volume of emergent cases that arise. I would argue that it is negligent and discriminatory to provide for other elective surgeries on the regular slate but not elective cesarean deliveries. It is plain and obvious that a woman at 39 weeks' gestation is at high risk of going into labour, and that subjecting her to uncertain access to an OR puts her at risk of having her medical decision frustrated. Why should patients who choose tubal ligations, adult circumcisions, bladder suspensions, or any number of other elective surgeries be allowed a spot on the regular OR slate, but women in need of elective cesareans be denied space on the regular OR slate? This is particularly true when a delay in access to OR resources may result in that woman being deprived of exercising her right to make a medical decision for herself with regards to how her child is to be delivered. It is obvious that patients in need of elective cesarean deliveries deserve to have more certain access to OR resources as their conditions are arguably more time sensitive than many other elective surgeries. Again, I do not think that it is uncommon practice for hospitals to deny space on a regular OR slate to elective cesarean patients - even though it is plainly obvious that the practice of doing so poses unnecessary risks.

Women who choose cesarean section deserve to have their medical wishes respected and practices that unreasonably frustrate their ability to exercise their autonomy with respect to the delivery of their child should end. If the woman is going to need an OBGyn eventually - what purpose does delayed referral serve? If the woman is going to need OR resources for the delivery of her child - again what purpose does denying space on the regular OR slate serve? The only logical purpose these practices serve is to prevent women from obtaining the medical care they desire in a timely way - and there's something that's wrong with that.

1 comment:

  1. Well said. I personally, have never worked in a hospital that didn't have Caesarean sections on the elective slate, even in community hospitals. At teaching centres, there are usually at least two elective c sections per day. It sounds preposterous that a woman would be unable to access caesarean. It blows my mind. Please keep up the hard work...