# Doctor refusing to take cerclage out until labor



## Aslanswake (Mar 23, 2010)

Ok I will do my best to summerize the situation.

First a quick breakdown...I am currently pregnant with my fourth child. I have uterine didelphus, which means i have to complete uteruses.This causes me to have an incompetant cervix in which a cerclage is needed at some point in the pregnancy. I carried 2 girls in my right uterus, vaginal deliveries, and my son in my left, emergency c-section.

So this is my fourth pregnancy, a boy who is in my right uterus ( the non c-sectioned side) I am planning a homebirth in Iowa with a midwife and a doula soon. I am 32 weeks along.
No since its illigel in Nebraska to have a homebirth this is not something I could discuss with the high-risk perinatologist I was assigned too after my OB decided she could no longer follow me. he is not homebirth supportive, nor Vbac supportive as I found out the other day.
I went in for my weekly trans-vaginal to measure cervical leangth, which is steadily holding at a 3! I then asked the doctor when they were planning on taking out my cerclage...he said oh, well not until you go into labor!!! I said what? I have had all previous cerclages removed by 37 weeks, and delivered within a week or so after. I told him no, I wanted it out at 37 which is pretty standard everywhere else. He wasnt very willing to talk to me about it. He also stated I would need an epidural to have it removed, I have NEVER had an epi with other cerclage removals. I told him no that was not neccesary I wanted to stay away from any other drugs like that. He stated well it will just be easier for you to come in in labor get an epidural to get teh cerclage out and proceed with a c-section! I was in shock, I said Im not planning a c-section, I am planning a vbac, even though I am not a true vbac because my csection was in my left uterus.
Ive been going back and forth since with the RN manager about the situation and they are refusing to take out my cerclage at 37 weeks...

I am extremely upset as I feel I am not requesting something unreasonable. I have also looked into switching doctors but noone will take me. I am looking for direction, advice etc on this issue. I refuse to just let a doctor tell me what can and cannot be removed from my body! I feel this is a reasonable time for it to be removed and in fact have read there are risks involved with going into labor with a cerclage still in...

I know this was long but hopefully you are able to gather my frustration...

HELP!


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## Valerieg (May 13, 2007)

I don't have any direction, suggestions, or advice but I do want to let you know that I'm behind you 100% and you deserve to get the birth you want. I hope that someone here can suggest something!

*HUGS* and hang in there!


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## Aslanswake (Mar 23, 2010)

Thank you Valerie! I have my midwife and Doulas support as well as many friends....I can only hope this issue is worked out sooner than later as I dont want to have to deal with this stress at this point in the pregnancy!


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## MegBoz (Jul 8, 2008)

Yikes, that's really a tough one.









Well, this is a bit of a reversal of the normal HCP-mama conflict we read about here. Normally we're trying to fight with our HCPs _not_ to do something (induce, AROM, etc.) but in this case you need the OB _to do_ something.

Well, legally we all always have the right to refuse any procedure or treatment. Do you legally have the right to insist upon a procedure? Tough one. If it's not within the realm of 'normal/safe' (like requesting an appendectomy when you don't have appendicitis), then NO, you have no grounds for the request. But in this case, you're request is perfectly 'normal' & within the "standard of practice".

Tough.

Any chance you could print out research from reputable sources on how it's dangerous to labor with a cerclage in & take them to the OB? & be very, very firm - you're mind is made up on this, it worked well for your previous births, so this is the path you've selected unless he comes up with good reason otherwise.

If worse comes to worse, you can probably see if a lawyer will take your case & literally march in there & demand the OB remove the cerclage. I do think you have a legal right to make that demand. Obviously though that would be a last-resort & I hope it doesn't have to come to that. Perhaps if you use key phrases like, "MY RIGHTS AS A PATIENT" when you have above conversation, the OB will catch your drift (your 'drift' being that you will use legal 'force' if necessary.)

Best of luck to you!!


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## treeoflife3 (Nov 14, 2008)

Would it be possible to ask former doctors or whomever who took it out at the 37 week mark and without an epidural to offer information for you to share with this OB as to why it is a perfectly acceptable option for you? Perhaps if they hear it from another doctor, they'll take it more seriously. I myself have had issues with doctors not taking me seriously purely because I'm not a doctor myself so maybe this OB is that kind of doctor.

I would definitely though look for qualified sources who can back you up as to why it should come out sooner rather than during labor even if you can't use former doctors as your source.


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## mgg (Jul 26, 2010)

I'm going to share a couple thoughts. First, having a fourth child born to a mother with uterine didelphys is very impressive. The potential for complications that would make you unable to have further pregnancies is high enough with didelphys that you certainly have a lot to be thankful for









I respect the desire for a natural home birth. As a pediatrician, I certainly see the benefits that a hospital birth can offer, but I do also appreciate that this was done at home, with no medical professionals, for centuries. And as such, if people so choose to do it that way, it is reasonable.

Here's my problem, while we as a society tend to embrace the ideals that often times have been marginalized in the name of "progress" (i.e. home births, etc...), we also tend to dismiss what gains that progress has also delivered to us. Case in point, you've had three children and you have didelphys! When you stop and think about it, if that had happened 200 years ago, it is very likely neither you, or the first child would have survived.

I guess my hang-up is this: You aren't typical. Because of the didelphys, and the associated incompetent cervix, if left completely to nature, you would have never succesfully carried to term. A previous poster said "you deserve to get the birth you want". And while that is a very nice sentiment, and I'm sure you do deserve it, sometimes we don't get what we deserve. The medical advancements that have allowed you to have three (and now hopefully four) healthy children are wonderful, but unfortunately they do come at a price. To me, that price is that you might need to give in a little to ensure what's best for your baby. I know you like the idea of a home birth, and I respect that you would prefer the cerclage come out at 37 weeks, allowing you to do so. But is it really going to be a disaster to let go of that, place your confidence in the hands of the doctor that has gotten you this far, leave the cerclage in, and have a healthy baby in the hospital?

As yourself this: what are you most looking forward to: the home birth or the baby?

I'm sorry if this seems harsh, but there's an old saying: It's okay to think about what we WANT to do, until it's time to do what we HAVE to do.

Good luck!


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## billikengirl (Sep 12, 2008)

It sounds like the doc is trying to force the issue about a repeat section and you may have to find another provider to take over your care if you want a vaginal birth.

What does your midwife suggest?


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## MsBlack (Apr 10, 2007)

mgg--

Did you miss the part about this baby being in the same uterus as her 2 other babies with whom she's already had normal births? Did it seem to you that the OP was ever avoidant of the medical care and technology that could help her have live, healthy births-- or that she is presently unmindful of what help is now possible for her and her babies, IF she needs it? Did you miss the part about having a professional attendant at her upcoming homebirth, one who can help her monitor her health and baby's health throughout pregnancy and birth--and help her know when (IF) medical care may become necessary for safety?

Because I didn't read that in her post at all.

To me, this is simply about matters of Informed Consent, of 'who is in charge of decisions about her birth', of hiring a competent (in her own mind) care provider to provide ONLY the services she herself desires--because she herself is making assessments of safety, based upon being well-informed and also confident in herself to make care decisions for herself and baby. Something she has clearly proven (3 times) she is capable of doing well.

To me, choosing some forms of med maternity care should NOT have to mean 'submitting to all and whatever forms of care' an OB wishes to provide, regardless of the universal evidence against many of those forms of care, and regardless of the facts (along with the considered wishes) presented by individual women (that is, NOT just her 'risk group', but her actual individual state of health, her birth history, etc). To me, the expectation by the med system that women will indeed submit to 'all or nothing' of OB care, is at the heart of both the growing body of women and babies who suffer birth trauma along with breastfeeding and attachment difficulties, AND at the heart of the present litigation crisis in obstetrics. Women/families handing over all power to obstetrics and hospital policy has just not worked out so well for anyone, from the growing body of evidence we have about this.

Just My Opinion, of course









Aslanswake--

Your MFM seems to be laboring under some misconceptions here, and I think perhaps if you take a calm, assertive and evidence based approach you may be able to persuade him to undo your cerclage as you wish. Rather than letting him cast this as a question of 'who's in charge here', gently help him see that valuing him and his services does not mean he gets to make all the decisions. Politely, cheerfully and firmly insist that before he makes any judgement calls, he read your records carefully and perhaps have a conversation with your other OB about removing cerclage and trial of labor to see if you and baby are capable of giving birth normally. You might even prepare an informed consent/personal responsibility/waiver type of document with wording such as this:

"We, Aslanswake and partner, hereby affirm that we have studied the following issues in depth, and have come to our own independent decision about preferred care: we want A's cerclage removed at 37wks without epidural, and to allow labor to start naturally in it's own time, undertaking only the usual procedures for checking on motherbaby well-being throughout labor to determine whether or not normal vaginal birth continues to be safely indicated. We affirm that we are wholly willing to follow all signs indicating that motherbaby health is compromised, and to allow surgical delivery or other medical care, if signs point to that. We further affirm that we are fully aware that Dr OB believes that instead, mother and baby will be safest if the cerclage is removed only under epidural, and that immediate cesarian section is accomplished. In view of this difference of opinion, we assume full responsibility for all of our decisions made with respect to A's pregnancy and birth, and agree to hold Dr OB harmless should he follow our wishes in this and any harm comes to mother or baby as a result."

Hope this helps! You go, woman...don't let him cast the terms of this HIS way, you really don't have to let him do that. Breathe deep, and gather your power and calm to work this through.


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## PoppyMama (Jul 1, 2004)

mgg- Why does she have to keep the cerclage in when the doc wants to leave it there so it can be taken out with an epidural and proceed straight to c-section. She has given birth to 3 children having had the cerclage removed at 37 weeks and 2 of those were vaginal birth from the uterus now in question. This doc has not given her any compelling medical reason to leave the cerclage in or have a c-section. I worked in a medical setting with doctors most of my adult life, before ending up at home, and the idea that they always have the patients best interests at heart is bogus. Even the nice ones often have much of the decision making influenced by their own best interests and convenience. This is human and understandable but when they translate their own interests to the patient as this is the only safe way to do it...well that is a large part of why docs have lost so much respect and obedience. I think more people would chose to birth in a hospital if hospital birth wasn't so much in the docs/hospitals interest and not ours. Birthing on your back isn't better for anyone but the medical personnel, yet we are continually told it is, inductions carry hefty risks, even though we're told they don't. Continuous monitoring is proven to be problematic, but we're told it's mandatory. If docs want us to listen to them more they need to revisit ethics and come to fully respect that patients own their own bodies and informed consent is not just an idea or something that happens in other specialties.


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## mgg (Jul 26, 2010)

A cerclage is a pretty significant thing. And a cerclage on a now gravida 4 para 3, para vaginal 2 is a lot different than the first or second cerclage.

It's impossible to assess to relative competency of the cervix until the cerclage is removed, and doing so on a para (vaginal) 2 runs a much higher possibility of immediate labor.

So first, I would not be keen on risking immediate labor at 37 weeks. If she really wanted to take it out, I would consider a compromise- 38 weeks, and she remain hospitalized for 24 hours afterwards.

I respect the right to own one's body, and I do respect informed consent. But I think the patient also needs to respect the position in which the physician is being put. I do not know any MFMs that would endorse the idea of a G4P3 VBAC didelphys home birth. And you can agree or disagree with that. But it is really putting the MFM in a very bad position to push for them to do something they are very much uncomfortable with.

Maybe a compromise can be worked out.


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## MsBlack (Apr 10, 2007)

Is it really a vbac when the uterus in question is NOT SCARRED? I really don't know; I can imagine that being so close by, the scarred uterus may have some minutely raised risk in association with labor on the intact uterus--but do you have any evidence to offer on this, mgg? That would be more helpful to me, anyway, than just hearing your opinion on it.

As for removing cerclage at 37wks, well if it were me I'd likely want to know my baby was big enough, via measures I respect (not u/s at that late stage, but palpation by someone experienced with palpation and good at weight estimation via palpation). On the face of it, 38 wks does 'sound better'--but this mama has already had 2 normal deliveries at 37wks so it may be safe to assume that she knows how to grow babies plenty well by that time. I've had clients consistently grow healthy 9lb babies in 38wks, after all--even though ordinarily I see smaller babies, 6-to-7+lbs at that stage.

As for a 24 hr hospital stay following cerclage, I see no reason for that even if labor commences within minutes of undoing the cerclage. At least, no reason if Aslanswake doesn't usually go from 'undoing cerclage all the way to birth' in less than an hour or so. Hard to imagine that she would try to rush home, if the baby started crowning before she managed to get dressed and out to her car







I don't hear any 'crazy fanaticism' in her--only a well-investigated, well-founded plan for care.

Again, respectfully I ask what the evidence is that you are going on. I can respect that you, a medical practitioner, believe in medical care--that choice is your right and I expect you to give that opinion to us. However, I think for me (and this group) to give your opinion much weight, you'll just have to present more evidence to show how your suggestions are safer than what the OP has researched, and *already experienced* is safe for herself and babes.


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## mgg (Jul 26, 2010)

Fair point about the VBAC if it's the other uterus. The problem is that there is not going to be good evidence (if there is any) one way or the other. I mean, realistically, how many VBAC opposite uterine didelphys deliveries have there even been to study?

So, when I can't rely on hard evidence, I have to consider physiology. How much stress does the other uterus undergo during labor of a didelphys? Well, I pretty sure that's never been quantified either. But making an educated guess, I would speculate that it certainly doesn't undergo the strain and pressure of the actual laboring uterus. But I would also imagine that there will at least be some contracting going on. After all, that uterus has the same hormone receptors as the laboring uterus. Additionally, mom stated that the previous section was emergent. This likely means a transverse incision rather than the longitudinal incision. These do run a higher risk of rupture with VBAC's. As such, I would prefer to have that patient in the hospital, where I feel this can be more quickly addressed if there is an issue. But I do respect your point.

As for the 37 vs. 38 weeks. While her previous history of healthy 37 weekers is compelling. We hold dear to 38 weeks, not because of size, but lung maturity. Additionally, the first two pregnancies were girls. Females have earlier lung maturation than boys. In fact females always seem to do a little better than males (whimpy white boy as it is affectionately referred to in the NICU's!). So that would raise a concern.

It's a tricky area to ask a medically inclined professional, the MFM to take a major role in the patients care (ongoing obstetric management, cerclage), but then ask them to disregard their long standing standards of practice.

When a practitioner goes against their typically embraced and practiced standards, they open themselves up to liability. I'm not talking about litigation or lawsuits, but professional ramifications. The MFM does this, and there is a problem, he or she is going to have to answer for it. And saying "mom wanted me to" is not going to satisfy any review board.

As for the 24 hour stay, the OP has already said she is planning a home birth, but hasn't discussed it with the MFM. So, the MFM is ASSUMING she is going to come back to the hospital for delivery. If he or she is hesitant to remove the cerclage because of the potential it might induce a precipitous delivery, he or she is going to want to make sure mom is in and ready to go.

Thoughts?


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## MegBoz (Jul 8, 2008)

Quote:


Originally Posted by *mgg* 
It's a tricky area to ask a medically inclined professional, the MFM to take a major role in the patients care (ongoing obstetric management, cerclage), but then ask them to disregard their long standing standards of practice.

But if the "their long standing standards of practice" are something the patient objects to, then they will *have to* disregard them. A few things that come to mind:

Not allowing women to eat & drink in labor
cEFM
Those are "long standing standards of practice" for many OBs & hospitals. So Is it wrong for women to have a HCP (What is MFM, by the way?) take a major role in our care, but ask them to disregard their standards?

What I'm really driving at here is:
What you wrote, it really sounds as though you're saying, "*If you're going to have an HCP care for you, you need to be obedient to all of their 'standards of practice.'"*
i.e. *You need to do what your doctor says.*

Perhaps I'm stretching your words, but I really don't think so. I think that's exactly what you wrote.

Quote:


Originally Posted by *mgg* 
When a practitioner goes against their typically embraced and practiced standards, they open themselves up to liability. I'm not talking about litigation or lawsuits, but professional ramifications. The MFM does this, and there is a problem, he or she is going to have to answer for it. And saying "mom wanted me to" is not going to satisfy any review board.










Well, "mom wanted me to" is going to have to satisfy any review board.

Because, conversely, if mom says, "I _don't_ want you to do XYZ" IT IS A CRIME for a doc to do something without consent ("Medical battery"). So, again, as to the issue of what will "satisfy his review board" OBs can put that







where the







don't







shine.

Cuz the fact of the matter is that *patient autonomy trumps "satisfying the review board" or "long standing standards of practice."*

Again, patient autonomy is paramount. It is superior to all other objectives. The only time autonomy is sacrificed is when the patient is unconscious due to trauma & therefore in mortal peril.


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## mgg (Jul 26, 2010)

Quote:


Originally Posted by *MegBoz* 
What is MFM, by the way?

MFM- Maternal Fetal Medicine. In many places it's the term used for the high risk OB service.

Quote:


Originally Posted by *MegBoz* 
it really sounds as though you're saying, "*If you're going to have an HCP care for you, you need to be obedient to all of their 'standards of practice.'"*
i.e. *You need to do what your doctor says.*

No, that's absolutely not what I am trying to say. I don't like being painted in that light either. I think it's very important to honor the patients wishes. But there has to be some mutual common ground. Ideally, this is why these conversations should take place earlier on.

Quote:


Originally Posted by *MegBoz* 
Well, "mom wanted me to" is going to have to satisfy any review board.

This has to be a two way street. While the system failed by giving too much authority to the physician, and marginalizing the preferences of the patient. The opposite end of the spectrum is really not a lot better.

Just as the physician needs to have good reason to pursue a certain course of action, the obligation should exist for the patient as well. Otherwise, where do you draw the line? It's okay to remove the cerclage at 37 weeks because mom wanted to. Fine. What about 35 weeks? What about 33 weeks? What about other decisions? How do you differentiate? You are assuming that the mother will always take her and the fetus' well being into consideration. But not all moms do. Otherwise, nobody would smoke during pregnany, nobody would drink, no babies would be born addicted to heroin. Where do you draw the line?

Quote:


Originally Posted by *MegBoz* 
if mom says, "I _don't_ want you to do XYZ" IT IS A CRIME for a doc to do something without consent ("Medical battery").

Cuz the fact of the matter is that *patient autonomy trumps "satisfying the review board" or "long standing standards of practice."
*
*
*
*
What if the physician feels equally as strongly. What if the physician is amenable to no to X or Y, but believes that it is unconscionable to forego Z? At what point does the obligation to provide care become so burdened under the pressure of patient autonomy, that the physicians clinical ability and conscience is crushed? While you are correct that the physician cannot do something to which the patient doesn't consent, if this is presented in advance, then the physician too has the right to decline altogether. But it's a very tricky situation when the physician is forced into the situation.

Quote:


Originally Posted by MegBoz 
Again, patient autonomy is paramount. It is superior to all other objectives. The only time autonomy is sacrificed is when the patient is unconscious due to trauma & therefore in mortal peril.

Again, an ethical slippery slope, especially with a fetus involved. If patient autonomy leads to an action that knowingly harms the fetus, then we have a problem.*


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## Aslanswake (Mar 23, 2010)

Thank you all for all the thoughts and points here...
Let me just clarify a couple things...

I don't want my baby here quicker simply to get out of being pregnant longer...If I could carry full-term I would!! But my history is as follows, first child born roughly 38 weeks, cerclage, right uterus, vaginal delivery no labor complications. Second daughter born 37 weeks cerclage placed, removed at 35 weeks ( not by request) vaginal delivery, no labor complications. Third child, my son...cerclage placed, left uterus, cerclage removed at 35 weeks ( not by request) went into labor at 36 weeks, c-section due to breech position. Born healthy, but small, no extra stay in the hospital.

There is a question as to how far along I really am as well...my doctor is putting me at 31 weeks as of right now, my midwife says Im further along at nearly 33 weeks. If I am further along ( which I suspected from the beginning) waiting till I was 37 weeks to remove the cerclage would actually put mt at 39 weeks according to my midwife...and I guaruntee you I will not carry that long.

From everything I have read, researched, and spoken to midwives about puts the general time a cerclage is removed at 36-37 weeks. There are risks involved with going into labor with a cerclage still in, including, ripping and tearing holes in the cervix which would then have to be repaired. I don't want to go through that period! I have enough problems as it is!

Though my pregnancy is a higher risk case, my delivery is not.Which I why I feel homebirth is perfectly safe for me and my baby. And also the fact that I am not a true vbac. ( they need to come up with a new term for me!!)

I should also clear up the fact that it is not illegal to have a homebirth in Nebraska, but a CNM cannot legally attend, a DM can. But I am in Iowa so it's really a non-issue.

PLease keep this discussion going as it greatly helps me process and decide on what my next step should be!


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## MegBoz (Jul 8, 2008)

Quote:


Originally Posted by *mgg* 
No, that's absolutely not what I am trying to say. I don't like being painted in that light either. I think it's very important to honor the patients wishes. But there has to be some mutual common ground. Ideally, this is why these conversations should take place earlier on.

Absolutely - "mutual common ground" is _the ideal_. No question. But - differences of opinion will occur. No 2 humans will ever agree 100% of the time. So even IF there is a LOT of mutual common ground, there still may be a time when the doc & the pt disagree. And then what?

Quote:


Originally Posted by *mgg* 
Just as the physician needs to have good reason to pursue a certain course of action, the obligation should exist for the patient as well. Otherwise, where do you draw the line? It's okay to remove the cerclage at 37 weeks because mom wanted to. Fine. What about 35 weeks?

I don't see the lines as all that difficult to draw. When it comes to having something _done to the pt_ (procedure, medication), pt always has the right to refuse. Period. (again, unless unconscious due to accident, then consent to resuscitate is assumed.)

When it comes to asking the doc to _perform something_ (or administer a drug), the pt only has the right to 'demand' something that IS within the scope of "standards of practice" _*for their profession*_ (not just within their own personal standard of practice! Because then docs could make up their own rules as they go along! Example: VBAC (in ideal circumstances, of course) is considered safe, but some docs "don't do it." In this case, _industry standards_ should trump personal physician preferences. I don't consider it ethical for an OB to deny VBAC.)

So with regards to your specific question, it would be reasonable for the MFM to refuse to remove the cerclage at 33W. However - if you Google "cervical ceclage" the first link that comes up states:

Quote:

How long is the cerclage stitch left in?
Generally the thread is removed at the 37th week of pregnancy, but it can be removed before if a woman's water breaks or contractions start. Most stitches are removed in the doctor's office without any problems. The procedure is similar to having a pap smear and may cause some light bleeding.
(this also confirms that epidural isn't necessary for removal.)

Plus the OPs previous 2 OBs removed it at 37W as well. In this case I think it's very clear: Removal of the cerclage at 37W, as opposed to awaiting the onset of labor, falls well within the "standards of practice" for MFM. (although you raise a good point that a VBA1C didelphus is so unique that there's no "evidence-based practice" to fall back on in her case.)

Quote:


Originally Posted by *mgg* 
You are assuming that the mother will always take her and the fetus' well being into consideration. But not all moms do. Otherwise, nobody would smoke during pregnany, nobody would drink, no babies would be born addicted to heroin. Where do you draw the line?

Actually, I'm not making that assumption. (Although from my, admittedly, limited knowledge, the OP in this particular case is making reasonable choices.)

But the fact of the matter is that patient autonomy trumps all, even if the mama is being a total moron.

Even ACOG recommends against using the courts to compel women into treatment.

Docs DON'T have the right to override patient autonomy in order to protect those fetuses. Sad but true - women have the right to abuse their fetuses.

Quote:


Originally Posted by *mgg* 
At what point does the obligation to provide care become so burdened under the pressure of patient autonomy, that the physicians clinical ability and conscience is crushed? While you are correct that the physician cannot do something to which the patient doesn't consent, if this is presented in advance, then the physician too has the right to decline altogether. But it's a very tricky situation when the physician is forced into the situation.

Well, I agree that ideally the pt's demands & preferences should be made clear in advance - so the doc has the opportunity to decline to take on the pt. I also agree that it's not "fair" per se, for a physician to be forced to treat a pt that constantly disagrees with the doc's recommendations. And docs can and DO have the right to dismiss pts from care. Of course, my understanding of EMTALA is that a woman in active labor can't be dismissed until "stable' (completion of 3rd stage.) and dismissing a PG pt from care is classified as 'patient abandonment' & grounds for disciplinary action unless that pt has 30 days notice & is able to find other care. So in this case, I guess this MFM might just be stuck continuing to treat this woman despite massive differences of opinion. I will acknowledge that that's a bit unfortunate for the doc. But oh well. Pt autonomy trumps all.

Quote:


Originally Posted by *mgg* 
Again, an ethical slippery slope, especially with a fetus involved. If patient autonomy leads to an action that knowingly harms the fetus, then we have a problem.









That last sentence of yours kinda frightens me. No, it DOES frighten me. I don't see a slippery slope at all. PATIENT AUTONOMY COMES FIRST. As I wrote earlier, women have the right to abuse their fetuses. Not that I advocate it, or anything. If courts want to prosecute for child endangerment or child abuse, then I suppose that is their right (although I think legal precedent is to NOT grant fetuses rights in that regard and NOT treat them as citizens with rights the same way as children.)

Just like docs don't have the right to treat children against a parents wishes. How many docs would LOVE to vaccinate children even when the parents decline? LOTS! And lots of pedis dismiss kids from their care for parents continued refusal to vax. *But do you think the doc has the right to do it anyway because it's in the best interest of the child?* I don't. THAT is what is the slippery slope - the removal of personal freedoms - a slippery & horrifying slope, in my opinion.

& considering what so many OBs think about birth, how many could say, to paraphrase your last sentence, "patient autonomy has lead to an action that knowingly harmed this fetus, so we have a problem." in the following cases:

choosing to attempt VBAC
eating & drinking in labor
choosing intermittent vs. cEFM
choosing to not get ABTs for GBS+
refusal to induce for (name your pick - being 41W, 42W, low AFI, high AFI, etc.)
refusing CS for reasons like FTP, big baby, etc.
Those are absolutely, positively cases where, as we say here on MDC, the OB may "played the dead baby card" & tell a mama her choice could lead to a "dead baby" but most of us agree that such choices* are very wise & are evidence-based.
*well, in most circumstances. I.e. intermittent EFM is good for low-risk birth.

So, again, those are cases where an OB can say, "patient autonomy has lead to an action that knowingly harmed this fetus" but I still support a mamas choice to make those decisions. I *guess it reminds me of the famous Voltaire quote, "I may not agree with what you say but I will defend to the death your right to say it?"*
So I may not agree with every action every pt may take, but I will defend to the death their right to pt autonomy - even when a fetus is at stake.


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## Evergreen (Nov 6, 2002)

If I was in your shoes I would probably talk to the doctor about removing the cerclage at 38 weeks and having a vaginal birth in the hospital once you go into labor.

Since I am not you and you are planning a home birth (I planned two myself but only got one) I would talk to your midwife about what she feels comfortable doing. From what I gather about your situation it's illegal to have a homebirth in your state (nebraska) but you plan to go to Iowa to deliver so technically what you are doing is not illegal for you or your midwife, right? Does your midwife use any back up doctors who could just remove your cerclage?


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## Aslanswake (Mar 23, 2010)

I am in the process of trying to switch providers...but since I ma a high-risk case with a cerclage in alot of other docs wont take me on! I have considered calling the doc I had previously with my other pregnancies.
And I actually reside in Iowa all my care is in Nebraska. Its just not something I even care to bring up to the high risk Ob because I know it will cause me undue stress as Ive been told he is totally non-supportive.

My Midwife has mentioned taking the cerclage out herself or another midwife in the area, that is a possible option.

What gets me so riled up is my OB refusing to take it out at a reasonable time. That I feel is a violation of my rights as a patient!


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## MsBlack (Apr 10, 2007)

Quote:


Originally Posted by *Aslanswake* 
.

My Midwife has mentioned taking the cerclage out herself or another midwife in the area, that is a possible option.

What gets me so riled up is my OB refusing to take it out at a reasonable time. That I feel is a violation of my rights as a patient!


I'm glad your mw, or possibly another mw, is considering removing the cerclage herself--I was wondering if this might be a possibility.

And I totally agree, despite mgg's arguments: for the OB to have ALREADY made up his mind and simply deliver a plan to you, without discussing it first, taking your wishes or your history into consideration, is clearly a violation of your rights to informed consent under the law. I don't care WHO he answers to, or WHAT 'standard care' would be in your case (and since you inhabit a very small group indeed, I wonder just how 'standards' could even be formed), Informed Consent is REQUIRED by law. That means, you must be told in plain language about any proposed treatment, and any alternatives to the treatment including the alternative of doing nothing, and all risks/benefits of all possible alternatives, and allowed to make your own decision about it, without duress.

Yeah, all he should have to say to any board is "the client insisted, and took responsibility even though I tried to make her know the risks and do it our way". And they should all know that that is your right by law.


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## Evergreen (Nov 6, 2002)

Oh. I see. My kids came at around or after 42 weeks so in my world I guess 37 just sounds super early even though I know it's full term.


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## nia82 (May 6, 2008)

My mom has had cerclages in three of her five pregnancies. They were all removed at 37 weeks but the first, which the doctor forgot and it wasn't removed until she was in labor. Luckily her cervix wasn't hurt by it. Can you midwife remove it or is there any chance you can find a doctor to remove the cerclage at 37 weeks?
My son was born at 37 weeks and neither the obgyn nor the pediatrician were concerned about it. In fact, the obgyn refused any Terbutaline after 35 weeks as he said the risks outweigh the benefit at this point, apparently, so we see how medical professionals don't even see eye to eye on these topics. I personally would feel very comfortable doing a homebirth at 37 weeks and I will have a birthing center (freestanding, absolutely no MDs) birth with this one if I make it to 37 weeks. It is absolutely your right ot have this cerclage removed and not being forced into a c-section. Just because this situation isn't according to textbook we do not need to panic and schedule a c-section. Going into labor will show if it works out - if you stall, or whatever, need to transfer one still can have a c-section. It's rather crazy to just want to schedule it, I would run from such a obgyn in no time. It just shows again how wrong this system is, gosh I wish a more European approach would change the American health system (as: midwives always attend births and the obgyn if wished only shows up at the end, homebirths are a normal choice, vaccination choice is not a bully matter to peds, they just let parents choose, and so on).


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## cathicog (May 7, 2005)

Evergreen, for the record, it is not illegal anywhere in the 50 states of America to have a homebirth. What is challenged in some states is the attendance of a midwife. And if Aslanawake steps foot in a hospital if she doesn't need to, it sounds like they are ready to cut a hole in the OTHER uterus, thereby removing the likelihood of finding an attendant for future homebirths... I would stay farrrrr farrrr away from any med professionals in her area, if that's the case.
Aslansawake, I applaude you for going to so much work researching your options and deciding what is best for you and the baby!







I hope a mw can clip the cerclage at 37 weeks, and you have a happy homebirth! You and your baby deserve it!







FWIW, I do personally know two ladies who both had didelphis uteri, and both birthed vaginally in a hospital- one was early 80's, the other was 5 years ago...both carried to 37-38 weeks, without a cerclage...happy home birthing!


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## Aslanswake (Mar 23, 2010)

Thank you cathicog! Even though this is stressful to have to deal with, I feel I am doing the right thing by standing up for my rights, and for what I believe is reasonable. My midwife is thankfully telling me if there is no other option she or another midwife WILL take out the cerclage. EVen though the doctor made me feel it was a difficult and very painful procedure, to which i replied Ive had 2 removed before with no epidural or meds and it took less than ten minutes? Tell me how this is complicated???


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## *MamaJen* (Apr 24, 2007)

Hi, I know this isn't remotely helpful, but I just wanted to say that I am really fascinated by your multiple uteruses and there is actually a woman right now with Uterus didelphys and she is pregnant in both wombs, due four days apart.
http://pagingdrgupta.blogs.cnn.com/2...-baby-in-each/
I am glad you are sticking up for your medical rights, and I hope this situation resolves itself well.


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## SNemelka (Aug 25, 2007)

Honestly, I would contact a lawyer. That doctor is possibly trying to force you into obtaining care from him, and maliciously prevent you from having a homebirth, which is your choice.


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## Aslanswake (Mar 23, 2010)

I am seriously considering contacting a lawyer at this point!


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## sparkysgirl (Feb 29, 2008)

wow....Seems like this ob is trying to get you to have a cesarean. I realize that it is tempting to stand up for yourself (and possibly the other women in his care that he is possibly manipulating as well) but you know, the stress of it is no good for you right now. I was thinking that a cerclage was just a few stitches in the cervix, can't imagine why it would be a big deal for a midwife to take it out for you (maybe a little research on the procedure might reasure you) I say go with the least stressful route at this point. Enjoy your pregnancy! What if this is your last one?


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## Aslanswake (Mar 23, 2010)

The stress is the one thing keeping me from persuing anything legally...I am calling a doc tomorrow, I will keep an update going here....


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## MsBlack (Apr 10, 2007)

Hmmm, it may be premature to contact a lawyer anyway. At least if it were me, I'd talk to the doc first and see what happens from there. Ask/insist that he give you some time to discuss your care and history; maybe he can be persuaded to try something different (especially if you make it clear that you are taking full responsibility for the outcome of your own decisions). And if he is persistent/stubborn about his plan, well, THEN might be the time to mention that you don't believe he is behaving in accordance with your right under the law to make informed decisions, and you will be speaking to a lawyer to investigate that. (or, just say, 'fine', and nothing more, and go to a lawyer without giving him a warning).

Just my opinion, of course. But one informed by my experience with the law, which makes me loathe to actually go to court if it can be avoided...however, I have learned that it can be very persuasive, making people aware that you know your rights and intend to pursue them! Even if it is essentially a bluff, I have seen it work on various occasions to shift people/events sufficiently in the direction I desire.


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## GOPLawyer (Mar 21, 2005)

Quote:


Originally Posted by *MsBlack* 
Hmmm, it may be premature to contact a lawyer anyway. At least if it were me, I'd talk to the doc first and see what happens from there. Ask/insist that he give you some time to discuss your care and history; maybe he can be persuaded to try something different (especially if you make it clear that you are taking full responsibility for the outcome of your own decisions). And if he is persistent/stubborn about his plan, well, THEN might be the time to mention that you don't believe he is behaving in accordance with your right under the law to make informed decisions, and you will be speaking to a lawyer to investigate that. (or, just say, 'fine', and nothing more, and go to a lawyer without giving him a warning).

Just my opinion, of course. But one informed by my experience with the law, which makes me loathe to actually go to court if it can be avoided...however, I have learned that it can be very persuasive, making people aware that you know your rights and intend to pursue them! Even if it is essentially a bluff, I have seen it work on various occasions to shift people/events sufficiently in the direction I desire.

Excellent advice!!







A threat can be just the perfect amount of fire under their feet.

(hugs) I'm so sorry you are dealing w/ this extra stress.


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## MsBlack (Apr 10, 2007)

thanks, GOPLawyer.

Are you actually a lawyer? I mean, duh, right? Given your screen name...then again, people choose all kinds of screen names. My own comes from the name of the best dog who ever lived--but my name actually isn't Black, and I'm not a dog (well, maybe I am, but only in the *best* sense of that creature







)

anyway, thanks, some other lawyers I know might just scold me for 'practicing without a license', hehehe







.


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## mrsberman (May 7, 2010)

Is it possible to convince the dr that you'll go in to get it removed, refuse the epidural, then leave when it's out because you're not in labor? They might be pissed if he booked a room for a c/s, but it's a tricky way around the situation.


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## khaoskat (May 11, 2006)

Just wanted to chime in that MGG -- an emergent c/s does not equate to having a uterine scar that is not the normal.

I had an emergent c/s in 2007, and I had a normal incision on the outside and inside..and just had an almost at home VBAC (last minute transfer) in May 2010 of an 11 lbs 1 oz baby...


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## mrsberman (May 7, 2010)

khaoskat said:


> Just wanted to chime in that MGG -- an emergent c/s does not equate to having a uterine scar that is not the normal.
> QUOTE]
> 
> I'm not sure if I follow this. I thought a c/s meant cutting into your uterus, therefore you would have a scar.


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## rhiOrion (Feb 17, 2009)

mrsberman said:


> Quote:
> 
> 
> Originally Posted by *khaoskat*
> ...


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## Aslanswake (Mar 23, 2010)

Just a quick update on the situation!

I am now nearly 38 weeks pregnant, I still have the cerclage in BECAUSE the Doctor I found that was willing to remove it could not remove it because the original Doctor put the stitch up so high in the cervix he cannot get to it without causing too much pain. Therefore he said he will not be able to remove it until I go into labor....but will then send me home afterwards(he is a homebirth supportive family practitioner) While I am thankful I am very stressed that he couldnt get it out....ugh! Ill keep the thread updated and thank you everyone for all the responses!


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## harli (Mar 17, 2010)

I'm so sorry you are going through this but glad you found a supportive doc. Are you still seeing the doctor that did this to you? What a jerk.


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## Climbergirl (Nov 12, 2007)

Hum, that might explain why the original doc said you needed an epidural. Maybe the way he puts in the cerclage, you actually DO need one! Oh, I would be so mad....

I am glad you found someone more supportive to try and take it out. There is no other way for pain relief to get this one out before labor?

I hope things go well for you. And you send the original doctor a letter describing in detail how well things went by not going his route.


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## Kidzaplenty (Jun 17, 2006)

Just wanted to say that I hope you get the birth you want. And I hope the doc can easily get the cerclage out when labor begins.

I wonder if the first doc knew he put it in too high, if it was on purpose, if it was "wrong" and he just did not want to admit it. Or, if he just assumed you were going to do a section, therefore did one that he would normally do for a section patient.


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## Mrs.Music (Jun 15, 2010)

kidzaplenty- I just went in for my cerclage yesterday, and while talking to the doctor about how it's removed, I was told that there are actually several ways to place a cerclage. It was probably just a different style than she is used to... Though he may have used that kind assuming she'd be getting the cesarean because he thought she should. Mine is placed with a little tab that they'll snip and then just pull it out at 37 weeks. No anesthesia or anything necessary. I think this is the most common kind.


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## MsBlack (Apr 10, 2007)

Aslanswake--

Wow, I'm glad to hear you're still pregnant and all is well in most ways.









Sorry to hear of this little complication with the cerclage...though I hope you are seeing it as a 'little complication'. It's definitely great that you found someone to help you!

But I wonder--won't the removal hurt in any event, and perhaps more in labor? I wonder if your hb-friendly fp could be convinced to remove it in any sooner, now that you are so far along. Are there reasons he feels doing it in labor is best...maybe believing that your cervix will likely be positioned lower at that time and make access to cervix easier? I can see that--though it's also true that sometimes in early labor, a woman's cervix starts out somewhat posterior, and does not come forward until later, more active labor.

In any event, all the best to you--and it's inspiring to know that you have continued to work to find what you need to give yourself/baby the best chance of the birth you most desire


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## Aslanswake (Mar 23, 2010)

Another update....cerclage removed here at home by my midwife...it hurt but the sucker is out!!! There were at LEAST 30 knots on each end, its a crazy looking thing...I am now nearly 39 weeks which is unbelievable!
I was refused by the "family Doctor" who tried to remove it once and could not, when i called him to get more information about how this would work when I went into labor I got the run around for a week...I was then told that he was not covered under there insurance to do the procedure therefore I was out of luck!
This angered me and my midwife who I think was just as stressed out as I was last week!
She decided to get the damn thing out herself, otherwise I'd end up at the hospital with a c-section.... thankfully she persisted for an hour, and I struggled through it for an hour and we got it!
Hopefully I will be giving birth soon and all this stress will just melt away!


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## weliveintheforest (Sep 3, 2005)

I'm so happy to read you are still pregnant and the cerclage is out!


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## Kidzaplenty (Jun 17, 2006)

Wonderful! I hope everything goes smoothly from here on out.


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## Toolip (Mar 7, 2008)

thank goodness!


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## jljeppson (Jul 18, 2004)

Glad to hear!


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## MsBlack (Apr 10, 2007)

Oh my, that is so AWESOME! Way to hang in there, mama!


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## honeybee (Mar 12, 2004)

Oh, good for you and your midwife! I'm sorry you had to go through all this drama just to get it out!


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## Banana731 (Aug 4, 2006)

outstanding! Happy Birthing!


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## MegBoz (Jul 8, 2008)

Yeaa! Good for you & your MW!


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## GOPLawyer (Mar 21, 2005)

*Fabulous* news!


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## elanorh (Feb 1, 2006)

Just checking in - hoping for an update!


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## weliveintheforest (Sep 3, 2005)

I would also love an update


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