I started writing about one thing - personal responsibility and contraception and a bit of compassion fatigue - but ended up writing about something else entirely.
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I covered a clinic session for one of my co-fellows last week. One of the patients I saw for her is 25 years old. She is having her fifth baby. Babies one through four were born by c-section. I had to schedule her fifth delivery. By c-section.
The fifth c-section makes obstetricians get a little nervous. Our eyebrows start to twitch. It's not good.
I don't want to get into the whole VBAC* issue (I will another time. I know I keep saying that, but I really will) but the the thing about ceseareans is that they are surgery. And like any other surgery, they get scarier and scarier with each repeated entry into the abdomen (and if you think about it, there's no other surgery that you have multiple times. Once your appendix is gone, it doesn't come back. But babies are different; you regenerate them! Or something similar. Anyhoo.).
Regardless, cesearean number 2 is usually (but not always) ok, and number three can be a bit hairy (or not. Everyone heals differently. Genetics. Complication rate. Surgical technique. All of the above play a role here.) However, broadly speaking, once we start to get to numbers greater than or equal to 4, anything can be scarred to anywhere, and it's a little bit terrifying. Hence the twitchy eyebrows.
This patient's risk of an abnormally adherent placenta is quite high. Her risk of needing a hysterectomy, large volume blood transfusion, ICU stay and sundry other interventions is high as well.
(All this leads to the fact that yes, I am a HUGE VBAC fan, and I wish I had been there at her second delivery. But more on that in another post.)
It doesn't help that she weighs more than 300 lb, has diabetes, chronic hypertension, and no family support.
Anyway, she of course wants her tubes tied. Which makes sense; she will hopefully have five healthy kids, she has minimal social support, she feels that she is already at her limit. Despite her relatively young age, I am ok with this.
But here's the really, really sad thing: In all of the states I've worked in as a physician, including Large Urban Area, there is a special paper that you need to sign if you are on public insurance (i.e. Medicaid, Medicare) before getting your tubes tied. This paper states that you were in no way coerced, and that you understand that this is an irreversible sterilization procedure, and that you had time to think about it.
And the killer part of this paperwork (because this gets us every time): it needs to be signed more than 30 days before the surgery in order for us to legally do the surgery. It's a bit like that waiting period in gun control laws, but for some reason, far more strict.
And I get it, I get the fact that the government does not want to pay for sterilization procedures and then get accused of forcing people to tie their tubes and somehow seem like it has some draconian China-style anti-constitutional control over the reproductive rights of women who get public care. I get that. But I also gotta wonder if there's a better way, because I can't even tell you how many women (like this one) do not manage to get their papers signed more than 30 days from their delivery, or who lose their papers before the surgery, or who just in general are obstructed from the choice they want to make.
Now, it's true that some of these very same women make this choice altogether too young; they have two kids by age 22, then decide they're done, without realizing that by age 35, they might have a whole different life with totally different resources and, often, a whole different partner with whom they might want a child. So clearly, the counselling about the risks of this surgery - not just the usual (bleeding, infection, risk of damage to organs) but also the risk of regret (which can be a relatively high number of women, and often so tragic) needs to be extensive.
But in the meantime, this woman is coming to have her cesearean. Her risk of regret, based on her age and other factors, is low. It would take me exactly 5 minutes during the surgery that we are already going to do to tie her tubes. She is already taking on all the surgical risks for the day, and it would be so nice make sure she doesn't have to do it again.
But I can't.
*Vaginal birth after cesearean. Sometimes called TOLAC (trial of labor after cesearean)
That just sucks.
ReplyDeleteI think in general, we make laws without thinking through the implementation and the consequences thereof.
This is exactly what frustrated me most during my medical school clerkship. I was also frustrated that it would cost $50 for a patient to get her tubes tied post c-section and $350 post SVD. Therefore, patients that could TOLAC, would rather op for a c-sections just to get a more afordable tubal ligation.
ReplyDeleteThere's a history behind these requirements. Years ago there was a court case in which two sisters in Alabama who were allegedly sterilized mostly because their mother wanted it done(and the mom probably had the right idea under the circustances, but an attorney got hold of her after the fact). There was great hue and cry and the regulations you describe were the result. The idea was to protect people from being asked to sign sterilization papers while in labor (a lot of people would do that in labor even if they wanted more kids!). A lot of the time the ones who need it the most don't attend prenatal clinic regularly and are the most likely to deliver prematurely, resulting in the catch-22 you describe. Once they leave the hospital they are lost to followup, at least until they come back next year pregnant again. Alas, the gods of unintended consequences were hard at work here.
ReplyDeleteAnonymous #1: That price difference makes a tiny bit of sense, if only because a TL can be done DURING a cesarean, but you need a whole additional surgery after an SVD.
ReplyDeleteAnonymous #2: I thought it was som3thing like that. Thanks for some historical context.
PS. Had to look up the details, couldn't remember them, exactly. This took place in Alabama in the 1970's. The case, Relf vs. Weinberger, was decided in 1973. I was a resident in Alabama in the late 1970's. The intent of the litigation and subsequent HEW regulations was to protect people from (alleged)involuntary sterilization, but unfortunately "protects" them from voluntary, desired steriliztion as well--as in the case you've described.
ReplyDelete