MAKING BIRTHING WISHES PART OF THE DELIVERY PLAN

Honoring a mother’s wishes in a delivery plan is an expected component of modern medicine. With these discussions, however, comes the responsibility of the physician to counsel the patient on the risks and benefits of the various options available for delivery.

As with any informed consent issue, the more thorough – and early — the discussion of the birth plan, the more likely the patient will understand the medical implications. Once a physician accedes to a birth plan, he or she will be accountable to treat any situation that develops.

A 41-year-old patient made 14 prenatal visits with all three physicians working at an OBGYN office. Her course was unremarkable save for a positive Rubella test early in the pregnancy and Group B strep later on. AFP and chromosome analyses showed no abnormality. At an office visit at 40 3/7 weeks, Dr. OB1 noted that the patient did not want induction.

Six days later, the patient – now nine days post-date — visited with Dr. OB2. The estimated fetal weight was 7 1/2 pounds and positive fetal movement was noted on an ultrasound. Dr. OB2 discussed induction with the patient. Despite a favorable cervix, the patient refused induction on that Tuesday even after discussing the risks of meconium, placental insufficiency, and a large baby. The patient did agree she would undergo induction by that upcoming Friday if labor did not commence.

On Thursday, however, the patient called Dr. OB2 stating that she wanted to wait until 42 weeks before induction. Dr. OB2 explained that because the 42-week point fell on a Sunday, Friday remained the last day for induction.

When the patient did present on Friday, Dr. OB1 started Pitocin and ruptured the membranes because of variations on the monitor. The rupture at 7:30 a.m. revealed minimal fluid. When meconium was discovered early that evening, Dr. OB1 ordered an amnioinfusion.

The patient progressed to complete dilation at 11 p.m. but because of non-reassuring decelerations at 11:33, Dr. OB1 attempted, unsuccessfully, to deliver with a vacuum. Because Dr. OB1 then believed that the patient’s strip had improved, she allowed the patient to resume pushing. At 1:24 the next morning, the patient spontaneously delivered a boy with a tight nuchal cord and thick meconium. Further examination of the newborn revealed cerebral edema and a small petechial hemorrhage. (The child developed cerebral palsy, developmental delays, and seizure disorder.)

In a lawsuit against Dr. OB1, the plaintiff contended that the physician failed to properly treat and advise the mother during the pregnancy and failed to properly manage the labor and delivery. The plaintiff specifically accused Dr. OB1 of failing to recognize the need for delivery by cesarean section. The case was resolved informally prior to arbitration.

Whether the mother’s initial refusal to allow induction had any effect on the outcome is conjecture. What the case does illustrate is that even when a particular birth plan presents a more difficult situation for the physician, the decisions that he or she makes in the situation that develops will still be evaluated in isolation.

If a patient’s birth plan could present a dire situation, it is time for a frank discussion and detailed documentation of any decision the patient makes against medical advice. By holding that discussion early on, the patient and the physician have more choices available to them – including a physician’s decision to terminate the relationship.

Gordon Ownby is general counsel at CAP-MPT.Comments on Case of the Month should be directed to gownby@cap-mpt.com