Interesting thoughts on autonomy

[Elvish, BSN, DNP, RN, NP]

I came across this blog and think it points out some interesting things regarding autonomy and maternity care.

Thoughts/comments, etc.?

My earlier question asking if autonomy is just for the natural birth crowd got sidetracked into arguments about the safety of home birth. Yawn. (Is anyone else ready to move on from these worn-out debates?)

Anyway, let's talk about what autonomy is and what it means in a healthcare context. From Wikipedia (emphasis mine):

Autonomy (Ancient Greek: αὐτονομία autonomia from αὐτόνομος autonomos from αὐτο- auto- "self" + νόμος nomos, "law" "one who gives oneself their own law") is a concept found in moral, political, and bioethical philosophy. Within these contexts, it refers to the capacity of a rational individual to make an informed, un-coerced decision.

.....

In maternity care, the right to refuse and inability to demand are not always consistently applied. Women are often not allowed to refuse certain treatments, such as repeat cesarean section or IV therapy. On the other hand, many women are able to demand medically unnecessary treatments, such as elective primary cesarean or elective induction. This inconsistent application of autonomy and patients' rights has emerged from cultural beliefs in the inherent risk of labor and inherent safety of medical intervention and from concerns about litigation and liability.

http://rixarixa.blogspot.com/2011/06/what-is-autonomy.html

PS - I read this blog but don't comment on it nor do I know the blogger, so I have no vested interest in anyone agreeing nor disagreeing. Please feel free to share your honest comments. :)

[Frozen08]

No one is forced to have have procedures done or withheld. Providers simply can refuse to take part or treat conditions which they feel uncomfortable or untrained to perform.

You don't want a repeat c section? Go to a different provider who will accommodate you or deliver in the backseat of your car.

Also at time of delivery the fetus/baby now has ethical consideration and limited legal protections in these things since they can now technically survive outside the womb. These issues can conflict with the mother/fathers autonomy wishes.

[EowynRN]

Yeah, I agree. I had to argue tooth and nail to have my pit stopped with baby #2 once I was in active labor, and they still refused. I finally gave up as it got so painful. I'm just going back (to only 6 months ago) and still wondering where my right to deny my medication went. It definitely was not needed at that point. ugh. My other favorite was having to be on the monitor 24/7 during cervadil when nothing was happening. Having my babies at the hospital always leaves me feeling like a prisoner. Granted I have to since I'm high risk, but still - my babies come out just fine, it's the pregnancy that's a problem.

[CEG]

I attended an interesting lecture on this recently at the ACNM annual meeting. The speaker (Dr Andrew Kotaska) concludes that in maternity care we often provide coercion rather than consent.

"Your baby is breech, you must have a c-section" is what women hear. It's all well and good to say it is the patient's responsibility to find the provider to give her what she wants but

1) she hasn't been told that c-section is not necessarily the best option-- no INFORMED consent, just consent

2) providers who have the skills to do lady partsl breech are very limited

3) she may be restricted by insurance or geography about who she can see

4) there's the possibility that she will go into labor and show up pushing her breech baby and no one will have the skills to deliver her safely

My only hang up is that because no one I work with does breech delivery, I cannot get good experience and therefore have no skills so I can't fairly offer it to patients since it isn't safe. But then I feel I have a responsibility to be able to safely deliver that patient who comes into the ER at 3 am with a butt on it's way out. But how can I get the skill... I guess I will have to move to Canada or England:)

OT: but eowynmn, I wanted to let you know that continuous monitoring on cervidil is a good idea as it can cause uterine hyperstimulation and fetal distress throughout the entire time it is in. some babes react poorly to it even with no contractions registering or being felt.

[Frozen08]

I attended an interesting lecture on this recently at the ACNM annual meeting. The speaker (Dr Andrew Kotaska) concludes that in maternity care we often provide coercion rather than consent.

"Your baby is breech, you must have a c-section" is what women hear. It's all well and good to say it is the patient's responsibility to find the provider to give her what she wants but

1) she hasn't been told that c-section is not necessarily the best option-- no INFORMED consent, just consent

2) providers who have the skills to do lady partsl breech are very limited

3) she may be restricted by insurance or geography about who she can see

4) there's the possibility that she will go into labor and show up pushing her breech baby and no one will have the skills to deliver her safely

My only hang up is that because no one I work with does breech delivery, I cannot get good experience and therefore have no skills so I can't fairly offer it to patients since it isn't safe. But then I feel I have a responsibility to be able to safely deliver that patient who comes into the ER at 3 am with a butt on it's way out. But how can I get the skill... I guess I will have to move to Canada or England:)

OT: but eowynmn, I wanted to let you know that continuous monitoring on cervidil is a good idea as it can cause uterine hyperstimulation and fetal distress throughout the entire time it is in. some babes react poorly to it even with no contractions registering or being felt.

This is the problem. Few OB/Midwives are trained and feel competent delivering higher risk lady partsl delivery. I would argue about point 1 though...If no other options are available C-section is the best/safe option.

Ultimately you will have to change the US legal system to increase providers willing to do high risk lady partsl delivery. The payout limits and the statute of limitations are both huge, making any deviation from SOP in the local area a huge liability. Not my hospital, but one near us in the state just had a 16 mil payout for a cerebral palsy case.