I have learned that to some of my patients, I am always wrong. If I recommend a C-section, they will prove me wrong by having a vaginal delivery. If I said their baby is at risk of complications, including death, I will be accused of fear mongering and applying the dead baby card. On the other hand, I can and will be accused of forcing my decisions on to these same patients, without proper “informed consent”. I put it in brackets, because I am not sure that they understand what my job is, and what true informed consent is.
Lets use a healthy primiparous lady I once cared for. She had a completely uneventful pregnancy until it was discovered at term that her baby was in a breech presentation. When I met her for consultation, I dutifully reviewed her history, her pregnancy and even the images of the most recent scan. I informed her that in my opinion the safest mode for delivery was a C-section, that I would be happy to attempt an ECV, but did not think that it would be successful because the amniotic fluid was low and that I would not recommend waiting until after 40 weeks because in addition to the oligohydramnios, the baby was small for gestational age. I reviewed the three options of vaginal breech delivery, ECV (including the remote possibility of spontaneous version) and C-section. I explained the risks and benefits of each, and mentioned the results of the Term Breech study with a risk of approximately 1 in 800 for intrapartum death related to a vaginal breech delivery. She started to cry and accused me of pressuring her into a C-section, threatening that her baby would die without the C-section. She even went as far as quoting Gloria Lemay to me as reasons why my ultrasound wasn’t accurate, and that I wasn’t providing informed consent because I didn’t mention any risk of death with a C-section, for her or for baby.
It got me thinking, what the heck do they think informed consent is? For some patients, I don’t think they actually listen to what I say, they only listen for what they want to hear. They have likely made up their mind before the have met me, they have already decided that they will have a normal vaginal delivery (just because they want it) and that I must somehow want to get my hands on every pregnant patient and intervene in anyway I can. They accuse me of not being evidence based, but then completely ignore any evidence I do present.
Back to the breech. I am not opposed to a trial of vaginal delivery for a term baby presenting in a frank or complete breech presentation, provided that the baby is average sized, with normal fluid and a mother is in agreement, in advance, that should complications arise, the plan will change to C-section. I don’t support a vaginal breech for a patient who thinks that an ECV carries too much risk, because the delivery is definitely more risky. I won’t support a women who is going to fight me if the situation changes and I think the baby needs a C-section. I explain that prior to the term breech study, there was already a degree of anxiety in most care provides about the vaginal delivery of a breech baby. If you practice long enough, you will see the complications that you know could have been prevented by a C-section. Although the Term Breech Trial (TBT) was not perfect, it did teach us and provide us with some good evidence about the management of a vaginal breech delivery. The safest delivery is a planned C-section before labour. It could likely be argued on a population basis, just focusing on the current pregnancy without thought of risks to subsequent pregnancies that this is true for vertex presentations too. The TBT showed that it is safest to have a vaginal delivery with an average sized baby, bigger that 2500g but not greater than 4000g. A larger percent of the stillbirths were in IUGR babies. The fetal heart rate should be monitored continuously, especially in the second stage. Some of the stillbirths and compromised babies were related mismanaged labour and not responding to abnormal fetal heart rates, not necessarily unique to breech deliveries, but definitely, the rate of abnormal heart rates is greater in the breech presentation, mostly due to cord compression. Hand off a breech is a great plan, but make sure you have a back up plan. There was more than one intrapartum death related to obstetricians taking the hands off rule to literally, and have the baby die while it was halfway out, when simple maneuvers may have freed the baby. Have a qualified paediatric attendant at the delivery, as these babies have a greater need for resuscitation. Finally, even in the elective C-section groups, several women delivered vaginally, because they presented in precipitous labour. The TBT study showed that a pre-labour C-section was because, but there will come a time in an advanced, progressive labour that it becomes safer for mom and baby (and the uterus and potentially future pregnancies) to just go ahead a have a vaginal breech delivery. Finally, they study only looked at the current pregnancy. The risks of C-section on future pregnancies must be taken into account, especially if the mother is likely to have a lot of children. In most cases, the mother is not planning 8 more pregnancies, but I suspect the risk of one vaginal delivery is less than the cumulative risk of 8 VBACs or repeat C-sections.
Common sense is required for informed consent. And a real discussion about the risks involved. I am not a sadist, I don’t like to talk about dead babies, but the reality is, a vaginal breech delivery, in qualified hands, in hospital, with monitoring and the availability to intervene still carries a risk of death for the baby. It is not a “Dead Baby Card”, it is the result of a randomized control study, the highest level of evidence we have to work with. Just because you don’t want to hear it, doesn’t mean you should dislike me for saying it.
Back to my patient. She decided that low fluid was only subjective, but the amniotic fluid index was
She left without a plan for coming back to hospital. Did I adequately provide her with informed consent? I hope I did, I spent three hours talking to her. She disappeared for the next two weeks, not even her midwives knew where she went. However, there is a happy ending to this story. After having green discharge for two days, she returned to hospital for assessment. The membranes had ruptured, but because the fluid was so low, all we could see was the meconium. The baby had a flat fetal tachycardia, and when she finally had a contraction, a prolonged deceleration. Finally she agreed to the C-section. Baby weighed 2100g at 41 weeks, spent a week in NICU on antibiotic and mom did well post-operatively. She told me that I was wrong, she didn’t need the C-section for breech, for oligohydramnios or the IUGR. The baby needed the C-section for chorioamnionitis. How silly of me. However, she now struggles with breastfeeding, but I figure that is somehow my fault too. Hey, at least she has a baby to breastfeed.