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Hello!
In recent weeks, we have been discussing instrumental delivery. Later, we talked about who is allowed to use a vacuum extractor (suction cup). Can a midwife do it on their own initiative?
This week, I've been pondering what happens when the person we're treating, the patient, says no! I don't want to! Or when we don't have enough time to provide proper information so the patient understands. Perhaps something even worse is when the doctor or midwife says no. What do we do then?
Event
I have an event that sticks in my memory even though it happened many years ago. A multiparous woman came to me at the specialist maternity care unit. She had been for an ultrasound to check her baby's growth. She was at around 32/33 weeks of pregnancy. The ultrasound revealed that the baby had severe intrauterine growth restriction. The baby had not grown at all since the last measurement a few weeks ago. In fact, it had shrunk in size/weight. The blood flow in the umbilical cord was extremely poor. The baby was simply dying.
When we find growth restriction, we always do a CTG (cardiotocography) to assess how the baby is doing at that moment and to determine further management. That was why she urgently came to me. We performed the CTG, and the tracing was severely abnormal. I explained to the woman the situation and that we needed to admit her urgently for an emergency cesarean section. I also explained that the baby was large enough to have a good chance of survival but would require care in the neonatal unit for a significant period.
At that point, the woman said, "Thank you, but no, I don't want to."
She then disconnected herself from the CTG and left the clinic. She mentioned before leaving that she was religious and that she would go to her church to talk to her priest. I explained then that the baby most likely wouldn't survive much longer if we didn't take action.
However, she still said, "No, thank you."
A few hours later, she returned. We hooked her up to a new CTG, and this tracing was even worse than the previous one if that's possible. I asked her again if we could have the opportunity to help her, but the same thing happened.
She said, "No, thank you," disconnected herself and left.
A few days later, she returned with a stillborn baby, an intrauterine fetal demise (IUFD). The baby had probably passed away the same evening or the morning after. The woman cried and was devastated by what had happened.
This case has stayed with me over the years. What was right, and what was wrong? How should I have handled the situation? Could I have done something differently? Should we have compelled her to receive medical care for the sake of the baby? The answer is no. All medical care is voluntary.
We can never force a woman to receive medical care, even if we really want to and believe she is making the wrong decision.
This event was horrifying. Some of my colleagues cried, and everyone was distressed. Most of us involved carry this with us forever. I met the woman at a later time, and she said she hadn't really understood and hadn't fully believed us at the time.
Afterward, she realized the seriousness of the situation.
What does the Patient Act say?
I have now read a bit about what the law says. In Sweden, we have a law called the Patient Act (2014:821). The law includes provisions for:
Accessibility
Information
Consent
Participation
Individual planning
Choice of treatment options
The opportunity for a new medical assessment
Choice of healthcare provider
The law specifies the obligations that healthcare providers and healthcare professionals have toward patients.
It is important to respect the patient's autonomy and integrity. Normally, healthcare should only be provided after the patient has been informed and has given consent. The patient can give consent in writing, orally, or by other means.
The patient can withdraw their consent at any time. If a patient declines certain healthcare or treatment, they should be informed about the potential consequences. If the patient decides to decline certain healthcare or treatment, it should be documented in the medical record.
This is what happened in the case you described. She received all the information, and we noted in her medical record that she declined.
How is a patient's autonomy regulated?
1 § The patient's autonomy and integrity should be respected. 2 § Healthcare should not be provided without the patient's consent unless otherwise specified in this or any other law. Before obtaining consent, the patient should receive information as per Chapter 3.
Healthcare is voluntary, and treatment should occur with the patient's consent. This means that a person can refuse medication and treatment, as the woman in my case did. Very clearly.
Now, this case I described was extreme. However, those of us working in healthcare encounter these situations all the time. Due to the crisis in maternity care, I believe this has become more pronounced in recent years.
Many women are afraid, afraid that they won't be heard or that there won't be care available when they need it.
I have a feeling that in the past, women trusted us and our knowledge more. Today, they question things in a completely different way. Is this good or bad? Sometimes decisions are made without the woman having the knowledge required to make a wise decision, and sometimes the woman's refusal may be justified.
Another more common group is women who don't want to give birth with a vacuum extractor or be stimulated with oxytocin. It happens relatively often that I meet them at the clinic, and they want it clearly documented in their medical records that they don't want it.
What happens if you violate the Patient Act?
Those who, in certain treatments like cancer or diabetes, intentionally or negligently cause significant harm or risk significant harm (Chapter 10, §6) may be subject to fines or imprisonment for up to one year.
How should this be interpreted?
I don't want to give birth with a vacuum extractor. I'm scared!
If I have a woman in labor who has clearly stated in her medical record that she doesn't want to give birth with a vacuum extractor, and if something happens toward the end of her labor where it becomes urgent for the baby to be born immediately to prevent serious harm or death, what do we do then?
Sometimes it is a matter of just a few minutes. Should I follow the patient's wishes? Instead of using a vacuum extractor, should I opt for an emergency cesarean section? This involves hitting the button, moving the patient to the operating room, possibly administering anesthesia, and performing an extremely urgent cesarean section with significantly increased risks for both the woman and the baby.
Moving a woman takes time, even if the team is well-prepared. In these situations, time feels endless, I promise. At the same time, I know that I could use a vacuum extractor, maybe make two pulls, and get the baby out much faster. But the woman has said she doesn't want it.
What is right? What is wrong? Did she have enough knowledge to make this decision? Will she regret it if things go wrong?
Since I have been through this a few times in my career, I usually ask the woman during her clinic visit if, in certain situations, it would be okay to use a vacuum extractor. If it's a matter of the baby being on the way out, and there's an urgent need, if there's a risk to the baby, most women would say yes in that case.
Is there a risk that we might exploit this, even if the woman is afraid and doesn't want it? As you can understand, this is not an easy nut to crack. It's also not as if, in an emergency, there's always time to explain and obtain informed consent. Enough for the woman to feel well-informed. There may not be enough time. What do you do then?
My suggestion is to explain afterward, to really take the time to sit down and tell the patient what we did and why we did it.
Many of these cases often come up when we talk about complaints from couples and stories of obstetric violence. OBSTETRIC VIOLENCE?
For me, this is a completely new term that didn't exist when I was a young doctor.
What is obstetric violence? Really? Of course, there are situations where doctors or midwives misuse their power. There are foolish people everywhere. We all know that.
But most of those working in maternity care, would we use unnecessary violence against our patients? It's a strange question, I think. I can only state that I always do what I believe is best for the mother and the baby, with my knowledge and extensive experience in mind.
Using violence just for the sake of it is something that, for me and most people around me, is highly unlikely.
If the doctor says no
Can I, as a doctor, midwife, or other healthcare professional, say no if it goes against my beliefs? Can I refuse to perform a procedure, for example, because of my personal beliefs?
We probably all remember the midwife who was talked about a lot a few years ago. The one who didn't want to deal with women who had had an abortion. Is that right? Because of a personal belief?
I can share another anecdote. I conducted studies in Dar Es Salaam about ten years ago.
In Tanzania, abortion is illegal. This leads to situations where women sometimes buy Cytotec online and perform abortions at home, more or less illegally. During my stay in the city, something terrible happened that scared me then and still does.
This involved a woman who had performed an abortion at home using Cytotec. She had started bleeding heavily vaginally. It's easy to imagine that she was further along in her pregnancy than she had thought. Her husband then drove her to the hospital.
She was examined there by a doctor. The woman had inserted Cytotec tablets vaginally to induce an abortion. When the examining doctor saw the remnants of the tablets, he refused to help her. It went against the rules and his belief to perform an abortion.
The husband then carried his wife to the car and drove to the next hospital. The same thing happened there. Eventually, the woman bled to death because no one wanted to assist her. This is a matter of the doctor's belief and the rules.
It's somewhat similar to the women who say, "Thank you, but no thanks!" People act based on their beliefs. Do I have the right to say no as a doctor? It's not as simple as when women say no.
The answer to this question should be no; a doctor cannot refuse to provide care. However, it's not always so in practice, I'm afraid.
Doctor's Oath
The Hippocratic Oath exists in various versions and adaptations. In some respects, the oath is modern and perhaps even timeless, such as the emphasis on confidentiality or patient secrecy.
In other respects, the oath is not relevant. Physicians within the Hippocratic school were "medical practitioners," so physicians should not engage in surgical procedures. Similarly, the profession should be taught for free to other physicians' sons (but apparently not to their daughters).
Abortion was also not something physicians should practice. Swearing in with higher beings as witnesses to become a member of a professional community must be considered very outdated today and is no longer applied in Sweden.
Different versions and modernizations of the Hippocratic Oath are still used internationally in the context of medical graduation.
The Hippocratic Oath:
I swear by Apollo, the physician, by Aesculapius, Hygeia, and Panacea, and I take to witness all the gods and goddesses, making them my witnesses, that I will fulfill, according to my ability and judgment, this oath and this covenant. I will respect the person of my teacher and share my medical knowledge with him and carry out his instructions. I will consider his sons as my brothers and teach them this art, if they want to learn it, without fee or contract.
I will give no deadly medicine to anyone if asked, nor suggest any such counsel, and in like manner, I will not give a woman a pessary to cause an abortion.
With purity and with holiness, I will pass my life and practice my Art. I will not cut, even upon a stone, but I will leave that to those who are trained in this craft. In every house where I come, I will enter only for the good of my patients, keeping myself far from all intentional ill-doing, especially from sexual relations with both female and male persons, be they free or slaves.
What I may see or hear in the course of the treatment or even outside of the treatment in regard to the life of men, which on no account one must spread abroad, I will keep to myself, holding such things shameful to be spoken about.
If I faithfully fulfill this oath, may it be granted to me to enjoy life and art, being honored with fame among all men for all time to come; but if I transgress it and swear falsely, may the opposite be my fate.
Well, what can one say? Some of what is stated in the oath is worth pondering. Some parts are quite outdated. In Sweden, physicians do not swear any oath. However, it can be good to read it from time to time to remind us that this is definitely not an easy path.
/Doctor Eva
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