More on Medical Malpractice
Charlie Thronson adds more to the medical malpractice debate. He writes:
This is the story of Vaginal Births After Cesarian Section:
1. In the old days, C-sections were performed with a long, vertical incision, cutting through the uterine muscle (where the muscle fibers are arranged horizontally) and creating a scar that was very susceptible to rupture. This led to the phrase "once a C-section, always a C-section."
2. A new technique came along, called the Pfannenstiel incision, which was a low, transverse "bikini" incision, far less disruptive of the uterine muscle. It became the delivery method of choice for those undergoing C-sections.
3. In the 1980's, faced with a rising C-section rate, rising health care costs and seeking to reduce medical expenditures and maximize profits, health insurance companies and hospitals began to push VBACs as an alternative to routine repeat C-sections. In addition, physicians began to utilize Pitocin (oxytocin) to stimulate uterine contractions and speed labor in VBACs, even though the manufacturer of Pitocin warned that the use of the drug in the face of "prior uterine trauma" (i.e., C-section) was contraindicated.
4. Predictably, the rate of uterine rupture went up, resulting in catastrophic injuries or death to both the fetus and the mother (from uncontrolled bleeding). It is my understanding that the rate of uterine rupture in a VBAC is somewhere between 3 to 7 %. The studies have shown that the child must be delivered within 18 minutes or less after the time of the uterine rupture to avoid permanent brain damage or death. The problem is that the first signs of uterine rupture are often not picked up by the nursing staff, and the physician generally cannot stay around the bedside all day, waiting to see if the uterus is going to hold up. So VBACs have sort of fallen out of favor because of safety and convenience reasons. Mothers who have carried the child for 9 months and taken meticulous care of themselves and their unborn child often don't want to risk their lives or the lives of their newborn to save a few hundred dollars (and not face a care requirement in the millions of dollars if things go wrong). The issue often comes down to adequate informed consent, and the physicians who do VBACs use what is called the "Phalen Consent" (named after it's originator, Jeffery Phalen, an early proponent of VBACs) which sets forth in very clear detail what can go wrong if the uterus ruptures. It is a good document, not "happy medicine" and give the patient the information she needs to make an informed decision.
So this really is not an issue of "defensive medicine." It is an issue of choice, full informed consent and "risk versus benefit." This happens every day in medicine (and in every other facet of life--smoke detectors, life insurance, hang gliding, wearing seat belts, buying a trampoline, quiting a job and starting a business, etc.) I am sure there are physicians who will not do VBACs, knowing what they know now about what can go wrong, and how often--I wouldn't do one, or have one done. I also wouldn't stay on an airplane if the pilot came over the intercom and told the passengers that the plane had a 7% chance of crashing that day. The decision to do VBACs is the physicians' choice too. Many of them think it is just too risky for their patients.
Since we were originally talking about Medicaid, the question remains whether is is cheaper for Medicaid to pay for repeat C-sections, or take care of catastrophically-injured babies. I don't know the financial answer to that one, but I do know the humane answer.
Thank you, Charlie. I'll respond in the comments below.
This is the story of Vaginal Births After Cesarian Section:
1. In the old days, C-sections were performed with a long, vertical incision, cutting through the uterine muscle (where the muscle fibers are arranged horizontally) and creating a scar that was very susceptible to rupture. This led to the phrase "once a C-section, always a C-section."
2. A new technique came along, called the Pfannenstiel incision, which was a low, transverse "bikini" incision, far less disruptive of the uterine muscle. It became the delivery method of choice for those undergoing C-sections.
3. In the 1980's, faced with a rising C-section rate, rising health care costs and seeking to reduce medical expenditures and maximize profits, health insurance companies and hospitals began to push VBACs as an alternative to routine repeat C-sections. In addition, physicians began to utilize Pitocin (oxytocin) to stimulate uterine contractions and speed labor in VBACs, even though the manufacturer of Pitocin warned that the use of the drug in the face of "prior uterine trauma" (i.e., C-section) was contraindicated.
4. Predictably, the rate of uterine rupture went up, resulting in catastrophic injuries or death to both the fetus and the mother (from uncontrolled bleeding). It is my understanding that the rate of uterine rupture in a VBAC is somewhere between 3 to 7 %. The studies have shown that the child must be delivered within 18 minutes or less after the time of the uterine rupture to avoid permanent brain damage or death. The problem is that the first signs of uterine rupture are often not picked up by the nursing staff, and the physician generally cannot stay around the bedside all day, waiting to see if the uterus is going to hold up. So VBACs have sort of fallen out of favor because of safety and convenience reasons. Mothers who have carried the child for 9 months and taken meticulous care of themselves and their unborn child often don't want to risk their lives or the lives of their newborn to save a few hundred dollars (and not face a care requirement in the millions of dollars if things go wrong). The issue often comes down to adequate informed consent, and the physicians who do VBACs use what is called the "Phalen Consent" (named after it's originator, Jeffery Phalen, an early proponent of VBACs) which sets forth in very clear detail what can go wrong if the uterus ruptures. It is a good document, not "happy medicine" and give the patient the information she needs to make an informed decision.
So this really is not an issue of "defensive medicine." It is an issue of choice, full informed consent and "risk versus benefit." This happens every day in medicine (and in every other facet of life--smoke detectors, life insurance, hang gliding, wearing seat belts, buying a trampoline, quiting a job and starting a business, etc.) I am sure there are physicians who will not do VBACs, knowing what they know now about what can go wrong, and how often--I wouldn't do one, or have one done. I also wouldn't stay on an airplane if the pilot came over the intercom and told the passengers that the plane had a 7% chance of crashing that day. The decision to do VBACs is the physicians' choice too. Many of them think it is just too risky for their patients.
Since we were originally talking about Medicaid, the question remains whether is is cheaper for Medicaid to pay for repeat C-sections, or take care of catastrophically-injured babies. I don't know the financial answer to that one, but I do know the humane answer.
Thank you, Charlie. I'll respond in the comments below.
posted by steve u. at 7/10/2006
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1 Comments:
No doubt, VBACs can be scary, for the reasons you raise. That gives mothers and doctors reason to opt out. However, I wasn't addressing those issues.
I was addressing effects of VBACs on the babies. Even where mothers and doctors would like to have a VBAC, after weighing the risks, they often can't because of concerns about the VBAC and the baby. Those concerns, however, appear to relate much more to litigation than health.
Big litigation awards over the health of the child (that VBAC difficulties cause cerebral palsy) have greatly reduced the number of hospitals willing to perform VBACs and, thus, greatly increased the number of c-sections. Unless the litigation awards are based on junk science (at least to some degree), we should see a drop off in the incident rates of cerebral palsy. Less VBACs, less consequences of VBACs (e.g., less cerebral palsy). But we aren't seeing a drop off.
Thus, as a result of the litigation, instead of increased health benefits, we're only seeing a reduction in women's ability to give birth naturally.
VBAC/cerebral palsy cases, by the way, are how former VP-candidate John Edward made bank.
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