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Rapid Responses: Rapid Responses published:
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patient autonomy
- Jeremy L Menage (8 July 2007)
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Not offering unsafe treatment options does not violate right to refuse treatment
- Paul T-Y Ayuk (9 July 2007)
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Re: Vaginal birth after a caesarean is not always beneficial
- Tarek S Arab (10 July 2007)
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Vaginal birth after a caesarean is not always beneficial
- Paul T-Y Ayuk (11 July 2007)
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Jeremy L Menage, GP Nuneaton CV10 0PB
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I was astonished to read that "women with a breech presentation are no longer offered a choice between vaginal delivery and caesarian section"1. Perhaps Paul T-Y Ayuk is not aware of the General Medical Council guidance2 which states: "you must...Work in partnership with patients..Listen to patients and respond to their concerns and preferences..Respect patients' rights to to reach decisions with you about their treatment and care". The National Institute for Clinical Excellence(NICE) guideline on caesarian section3 states in paragraph 1.1.2.2 "A competent pregnant woman is entitled to refuse the offer of a treatment such as CS, even when the treatment would clearly benefit her or her baby's health. Refusal of treatment needs to be one of the patient's options." I suggest he inform his Trust Board that, contrary to their declaration to the Healthcare Commission4, the Trust is not, in fact, compliant with NICE interventional proceedures guidance. References 1. Paul T-Y Ayuk, Vaginal birth after a caesarian is not always beneficial BMJ 2007:335,7 (7 July) 2. Good Medical Practice (2006), General Medical Council 3. Caesarian section, Clinical guidline 13, April 2004 National Institute for Clinical Excellence 4.Declaration of compliance with core standards,Oxford Radcliffe Hospitals NHS Trust 2006 http://annualhealthcheckratings.healthcarecommission.org.uk/_db/_documents/RTH_Declaration_200506.pdf Competing interests: None declared |
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Paul T-Y Ayuk, Obstetrician and Gynaecologist John Radcliffe hospital, OX3 9DU
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It is not clear how the issue of a patient’s right to REFUSE treatment became part of a discussion on which treatment options doctors should OFFER patients, including options that are known to be ineffective, unsafe or dangerous. The primary responsibility of a doctor is the patient’s safety (not choice) and this is not served by presenting patients with options that are dangerous. Doctors should not offer patients treatment options they are not prepared to implement. So you will not give an 18 year old with focal migraine the option of COCP as contraceptive. If you did, and after reading all the risks she chose this option, you will not prescribe it, making it a sham. Presumably, you will not consider that you had dispatched your responsibilities as a doctor by presenting the options and explaining the risks and she has exercised her right to chose therefore justify your use of COCP in this situation! Not presenting patients with dangerous or unsafe treatment options in no way violates their right to choose or refuse treatment and is good medicine. Once a patient has refused the safe / effective options presented to them, doctors have to explore other options, including those that would have been considered as unsafe. However, this is a totally different debate. Competing interests: None declared |
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Tarek S Arab, Resident, Obstetrics and Gynaecology University of Ottawa, Ottawa, Ontario, Canada
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C-section as opposed to vaginal birth after C-section does not per se save lives. Most women undergoing a trial of scar will not experience a dehiscence or rupture of the scar, the pre-requisite for neonatal/maternal mortality (the risk of rupture according to the Feb 2007 RCOG Green top guideline on Vaginal Birth after C-section (VBAC) is of order 0.7%). If this means that 99.3% will not experience a scar rupture/dehiscence why should the majority be discouraged from a trial of labour? The success rate of a well selected patient for VBAC can reach almost 80% ( Landon et al 2001 ) and even 90% if there is a history of a previous successful VBAC. The benefits of this are shorter hospitalization, lower rates of RDS of the baby, the emotional satisfaction of the mother that she was able to deliver vaginally, healthcare savings but more importantly the avoidance of a repeat C-section with the attendant risks both short term ( infection, bleeding, adhesion formation, damage to organs) and long-term ( increased risk of placenta accreta). Surely this justifies VBAC? The same guideline states: “There was no statistically significant difference between planned VBAC and ERCS groups in relation to hysterectomy), thromboembolic disease or maternal death. The vast majority of cases of maternal death in women with prior caesarean section arise due to medical disorders (such as thromboembolism, amniotic fluid embolism, pre-eclampsia and surgical complications). Maternal death from uterine rupture in planned VBAC occurs in less than 1/100,000 cases in the developed world”. This figure is comparable to the risk of a healthy woman dying from anaesthetic complications during an elective low risk procedure. There is undoubtedly a 2–3/10000 additional risk of birth-related perinatal death compared with planned caesarean section, but according to the RCOG this is the same risk as is faced by a woman delivering her first baby vaginally. Noone would suggest based on this that vaginal birth is dangerous or should be discouraged. Thus far the best evidence we have on the safety of VBAC is that published by Landon et al ( N Engl J Med 2004;351:2581–9. )regarding the safety of VBAC in well selected patients. Apart from another prospective series with a larger sample size, I cannot see how an RCT will be possible given that impossibility of blinding either patients or their care providers to the intervention chosen. As for vaginal breech delivery; since the publication of the Term breech trial, there has been a shift to delivery of all singleton term breeches by C-section. Long term follow-up however has shown no difference in neurodevelopment or mortality of breech babies born by C-section compared to vaginal route. The most recent analysis of the data from the Term Breech Trial by Glazermann in the January 2006 American Journal of Obstetrics and Gynecology called into question the conclusions of the trial by illustrating serious methodological flaws that were not highlighted in the original trial publication or initial discussion. The RCOG updated their position on the delivery of the singleton term breech in December 2006:” Women should be informed that planned caesarean section carries a reduced perinatal mortality and early neonatal morbidity for babies with a breech presentation at term compared with planned vaginal birth…..there is no evidence that the long term health of babies with a breech presentation delivered at term is influenced by how the baby is born…………..In units where planned vaginal delivery is a common practice and when strict criteria are met before and during labour, planned vaginal delivery of singleton fetuses in breech presentation at term remains a safe option that can be offered to women”. The American College of Obstetrics and Gynaecology in July 2006 issued a Committee Opinion which found: “The decision regarding the mode of delivery should depend on the experience of the health care provider. Cesarean delivery will be the preferred mode of delivery for most physicians because of the diminishing expertise in vaginal breech delivery”. Hence women still have a choice in the matter, and in my mind it would be a dereliction of care if the option of vaginal breech delivery were not discussed, provided of course no contraindications existed. The two issues of VBAC and Breech delivery are still areas of significant contention despite the attempts to bury them by many. I applaud Montgomery et al and Mr. Ayuk for raising them once again for discussion. Competing interests: None declared |
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Paul T-Y Ayuk, Obstetrician and Gynaecologist John Radcliffe hospital, OX3 9DU
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It is important to highlight the key issue in the RCOG guidelines with respect to vaginal breech delivery: “In units where planned vaginal delivery is a common practice…” It is maintained that this equates to NO unit in the UK and therefore NO unit is in a position to offer women vaginal breech delivery as a safe option Competing interests: None declared |
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