Nurses role if Dr is not giving all options (VBAC specifically)

[maiday]

Hi!

I am in nursing school and writing a paper on ethical dilemma's in childbearing nursing. We are allowed to choose any topic as long as we can define the ethical dilemma and how it relates to BENEFICENCE, NONMALEFICENCE, JUSTICE and AUTONOMY. I have chosen to write my paper on VBACs. I believe it's an ethical dilemma considering how many hospitals will not even offer this as an option. I will be discussing VBAC in general, but my question is as a nurse, what would you consider your role to be if the Dr. you are working with does not do VBACs and is not giving your pt the full story. The Dr. is pushing the pt to have a repeat cesarean and not giving both sides of the story.

I chose this issue because it's personal to me and the above situation is not hypothetical except for the nurses role. I was pregnant after having my first child cesarean and the hospital my Dr. is affiliated with will not do VBACs. My Dr. did not even offer VBAC or tell me that might be an option, she assumed I would have a repeart c-section. I had to pry my options out of her and tell her flat out I wanted a VBAC. She tried to tell me that is was extremely risky and talk me out of it, but finally consented and said that at 36 wks my care would be transferred to a hospital an hour a way that would do VBACs.

Sorry for length. Also, I am not asking for opinions on VBACs, I've done my research there, but thanks. I'm just asking for what you would consider your role to be if the Dr. was not fully informing their pt.

Thanks!

[creating_wellness]

Hm... I don't see the ethical dilemma here for the nurse, to reference the original post.

There appears to be an ethics violation by the doctor in this case, by not informing the patient that VBAC, in certain cases, *may* be a viable option for the patient. A C-section is major surgery, and has a higher chance of causing harm to the woman than attempting a VBAC.

It is NOT practicing medicine without a license if a nurse informs the patient of her rights and of the existence of alternative choices. Nor is it an ethical dilemma. The nurse can further cover him/herself by saying "It is up to you to inform yourself, to ask questions of your doctor, or to switch doctors if that's what you decide." By making it very clear that the nurse is not recommending a specific course of action, that is not practicing medicine. Rather, that is fulfilling a primary nursing obligation of patient education.

Sometimes, it is enough to simply say "Tell me about your feelings about having a C section." Perhaps this hypothetical patient (except.... not hypothetical in the original poster's case...) only wanted to be understood and listened to, which could have lessened some anxiety. :)

Now a comment aside:

I am a newly licensed RN, and I also work as a birth doula (DONA trained). I walk the line of not practicing as a nurse while I am practicing as a doula, which means: no vital signs, no physical assessments, no speaking for the client. As a doula, however, it is my job to say, "Let's take a minute here and review the risks and benefits of this option, so you can give your informed consent or dissent."

It depends on the situation. Sometimes it is more diplomatic to say, "Do you have any questions about this procedure, before it is performed?" or, "This would be departing from your birth plan. Are you okay with that?"

But really, what it comes down to for a birthing woman is having that constant, loving support. I've been amazed at the times when my clients departed significantly from what they originally wanted, but felt satisfied overall because they felt respected and involved in the decision-making process.

Because I do home visits prenatally, am there for the entire labor and birth, and then do home postpartum visits, I get a chance to really *see* a woman, to understand how things are for her. I'm excited to start practicing as an RN, and at the same time, I wouldn't give up being a doula for anything.

[maiday]

As some other posters pointed out, I'm not sure my original question was phrased properly. However, I feel I've got some great feedback anyway so thank you. I think I did sort of phrase it broadly just to include any type of nurses who may have found themselves in this situation and it seems that at least a few have.

The ethical dilemma from a nurses stand point (in my opinion) is like somebody else pointed out, when the Dr. has maybe not communicated all the pt's options or has even given false information as one poster stated she has heard. Of course I would not expect for a nurse to recommend a VBAC or any other procedure, but at least to make sure she understood her risks and or options fully. If the nurse is signing informed consent, she should know the pt is fully informed.

Or even more specifically, if a nurse hears a pt stating, "I really wish I didn't have to have another c-section or something along those lines." I don't mean when she comes in the day of the c-section, but nurses often see pt's throughout her pregnancy in places such as antepartum testing or I'm sure there are other areas.

So thank you to everybody that has responded.

[shortstuff31117]

I don't think telling somebody about vbac is giving medical advice. I have had pts. come in for NSTs and tell me that their doctor is making them have a c-section. I cannot stand by and let them think this is okay. I encourage them to do some research and look into their options. I would never tell them they should have a vbac though, that's not okay. It is the pts. responsibility to do their research and figure out what is right for them, but it doesn't help that doctors are not always good about laying out options. They don't want to lose income if the pt. transfers care.

I remind all my pts., regardless of situation, that they have the right to ask questions and to say no to anything we're suggesting. Because that's what we're doing....making suggestions. This is an important part of nursing. So many people think they have to come in and just do whatever we tell them to, and that is not okay in my mind.

[rbytsdy]

I think its hard from your question to delineate where exactly the ethical dilemma lies. Hospitals have every right to choose not to perform VBACs. That isnt so much an ethical issue when the patient comes into the facility in labor because one could assume that this information was communicated to her before hand. If a VBAC was wanted, then the request to transfer care elsewhere should have been made.

No they don't. Hospitals have no right to force surgery on a woman (or anyone). They can have any policies they want but when it comes down to it, they cannot force surgery or any procedure on a woman. I once asked a hospital about VBAC and they said the anesthesiologists wouldn't allow it. I asked what they do if a woman has a cord prolapse or has a placental abruption. The only answer they could give me was, "well, it's the known risk vs the unknown risk." So, in other words, anesthesiologists are okay running in a playing hero when there is no reason to "expect" an emergency (other than an OB who broke a woman's water at 2cm increasing her risk of a cord prolapse or decided to induce her at 38 weeks because he's going on vacation, etc).

Hopefully the information on VBAC has been communicated to a woman ahead of time regarding the hospital's "policies" on VBAC. The fact is that VBACs are low risk and a uterine rupture is about as likely as a cord prolapse so the hospital's claims that VBACs are dangerous is fundamentally flawed. As pointed out, they shouldn't be doing ANY deliveries if they can't handle emergencies. I'm all for informed consent though. A woman wanting a VBAC must understand that there is the risk of uterine rupture. While most ruptures happen slowly and are not catastrophic, there is always the chance that things will go very wrong. I don't think it's fair for a woman to sue over a VBAC when she should be aware of the risks. A woman who is coerced into a c-section that she doesn't want has no recourse if things go bad because you really can't sue over a c-section.

The real dilemma is when a woman presents in labor and refuses a c-section. Many OBs will try to talk a woman into a c-section or claim it's not allowed. What is the nurses role then? Should she stand by as an OB feeds a woman lies about a 10% mortality rate, etc? Should she aid the OB in talking a woman into a c-section? Or should she be objective and try to explain the risks and benefits of repeat c-section and VBAC? While this doesn't happen often because most woman will try to find VBAC friendly hospitals, it does happen. Nurses are supposed to advocate for their patient's wishes but they still have to work with these doctors long after this patient leaves. It's a sticky situation. What about a patient who presents at a hospital where they do VBACs but her doctor changes his mind and wants to coerce her into a c-section that she doesn't want? What about when a doctor just wants to get a delivery over with an section a mom who is slowly progressing but otherwise fine? These are the real ethical dilemmas.

[jennylouwho]

This has been worked out between the patient and her provider before she gets to the hospital and by then she is resigned to what will happen. I wouldn't ask a patient if she considered VBAC. The only way I'd get involved would be if the patient said something like, "I really don't want to do this, do I have to have a C/S?" Then I'd tell her that we can't do anything to her that she doesn't agree to. I'd tell the doc what she said and get him/her in to talk more with the patient. Even in that situation, I'm not sure I'd be the one to bring up VBAC. I'm not sure I wouldn't either, it would depend a lot on the circumstances.

My hospital doesn't offer VBACs because we don't have enough deliveries to offer 24/7 in house, dedicated OB anesthesia or OR staff and cannot guarantee getting a section going in 30min in case of emergency. We have done VBACs though. One doc has told some of his patients that if they stay home until they're in very active labor, they'll probably deliver before we can get a section set up. I don't know this to swear to in court, but I know in my heart that's what he sometimes does.

We have also had patients come in and refuse a repeat section. We then try to get them to fly out to a hospital that does do VBACs. If they still refuse, we have them sign an AMA form refusing a C/S and a transfer and be sure they know the risks of attempting a VBAC in our facility. The doc, anesthesia, and the OR crew then have to come in and stay in house until the patient delivers. If the patient doesn't use anesthesia or the OR, I don't think we can get reimbursed for that extra expense to the hospital.

I was billed for anesthesia for my VBAC w/out an epidural for merely the fact that they were in house. When I called and told them I didn't have anesthesia they explained that for the privilege of having a VBAC, I had to pay for them to be there.

[melmarie23, MSN, RN]

I never once said anything about a hospital forcing a woman to have a VBAC.

[rbytsdy]

Okay, well if they have "every right not to perform VBACs" then where does that leave a woman other than forcing her into surgery? A VBAC is not a procedure. It is a normal physiological process where a woman expels a baby through a natural orifice in her body. Hospitals have a right not to perform invasive procedures/surgeries etc but they don't have a right to prevent a woman's body from doing something it is naturally able to do.

[melmarie23, MSN, RN]

a hospital is well within their rights, as a business, to dictate certain policies and procedures they are comfortable with performing within their boundaries. Additionally, doctors reserve the same right, especially if they are concerned with risks associated with certain procedures. Just as nurses have the right to decline participation in treatments and procedures they are uncomfortable with assisting in.

[rbytsdy]

They can put whatever policies in place they want. But when it comes down to it, policies against VBAC are doing nothing more than forcing (or trying to force) women into surgery. What I'm always confused about is implying that VBAC is a "procedure to perform." Hospitals don't need to perform anything for a VBAC. The mother does all the performing by allowing a baby to pass through her lady parts. A c-section, on the other hand, is a procedure to be performed.

[klone, MSN, RN]

They can put whatever policies in place they want. But when it comes down to it, policies against VBAC are doing nothing more than forcing (or trying to force) women into surgery. What I'm always confused about is implying that VBAC is a "procedure to perform." Hospitals don't need to perform anything for a VBAC. The mother does all the performing by allowing a baby to pass through her lady parts. A c-section, on the other hand, is a procedure to be performed.

I guess, then, that she has the option of HBAC (homebirth).

[CEG]

I guess, then, that she has the option of HBAC (homebirth).

Except that the AMA, ACOG, the AHA, state hospital associations, individuals and lawmakers are doing all they can to keep that option from women. Women are forced to do that illegally, pay out of pocket, and increase the risk to themselves and their baby in the process.