Saturday, March 13, 2004

Pregnancy And Delivery

When it comes to pregnancy and delivery, should women be allowed to make medical decisions?

I'm writing a book for women. The topic has nothing to do with pregnancy, deliveries, abortions, or fetal rights. (It's about period management--what women can do to control their periods. Hence the title of my blog, in case you were wondering.)

The basic idea behind the book is that women can and should be able (not to mention, trusted) to make and participate in decisions about their life and health. The final draft absolutely, positively must be ready in 2 weeks. This means I have no business doing anything else but working on my draft. Of course, that didn't stop me from checking out a few blogs, to catch up on the news and make sure there's still a world out there. During my meanderings (bloganderings?) I came across Utah Woman Charged With Murdering Fetus and just had to read it. Big, huge mistake!

Once again, my theory that, when it comes to making decisions about their lives and health, women are treated like incompetent buffoons has been confirmed. And then some!

My first instinct, after reading the article, was to run outside and explain to any passers-by why what I'd just read was so unbelievable. However, I didn't do that because I'm the reserved type. And also because I still remember, from the days when I wasn't glued to my computer, that harassing perfect strangers on the street with ones ruminations is frowned upon. Luckily, doing the exact same thing to virtual perfect strangers is encouraged, so here I go.

The gist of the article:

As Melissa Ann Rowland's unborn twins got closer to birth, doctors repeatedly told her they would likely die if she did not have a Caesarean section. She refused, and one later was stillborn.

Authorities charged 28-year-old Rowland with murder on Thursday, saying she exhibited "depraved indifference to human life," according to court documents.

Also from the article, Kent Morgan (the spokesman for the district attorney):

"We are unable to find any reason other than the cosmetic motivations by the mother" for her decision [no to have a C/S--ed.], Morgan said.

Mr. Morgan and the DA for which he speaks are either incompetent or malevolent.

A Cesarean Section (C/S) is a major surgical procedure. You can die from anesthesia-related or surgery-related complications, and you can suffer significant morbidity.

A C/S significantly increases a woman's risk of pregnancy-related death (35.9 deaths per 100,000 deliveries with a live-birth outcome) compared to a woman who delivers vaginally (9.2 deaths per 100,000).

Granted, in the U.S. maternal death associated with cesarean delivery is rare. A 1980 study reported a series of 10,000 consecutive C/S with no maternal deaths. A 1988 study noted only 7 deaths associated with over 121,000 C/S. Finally, a 1990 study, while documenting a sevenfold relative risk for maternal death associated with cesarean delivery, observed that most deaths were associated with complicated nonelective procedures.

What's not rare is the maternal morbidity. From Williams Obstetrics:

There is no doubt that maternal morbidity is increased dramatically in cesarean compared with vaginal delivery.

Some of the complications associated with having a C/S:

- hysterectomy (surgical removal of the uterus)

- operative injury to near-by organs (bladder, intestines)

- uterine infection (endomyometritis)

- significant, active blood loss (hemorrhage)

- blood clot complications (thromboembolism)

- urinary tract infections

- wound infections

- infection with the "flesh eating" bacteria (necrotizing fasciitis)

So, although I don't know the particulars of the situation described in the article, I can unequivocally tell you that for any woman faced with having to have a C/S, "cosmetic motivations" are never the only consideration. [The risks of a C/S exist independent of the DA's ability to locate them!]

Also, in the article:

The same day, a nurse at Salt Lake Regional Hospital saw Rowland, who allegedly told her she had left LDS Hospital because the doctor wanted to cut her "from breast bone to pubic bone," a procedure that would "ruin her life."


Prosecutors said Rowland didn't want to be scarred, and one nurse told police that Rowland said she would rather "lose one of the babies than be cut like that."

and, finally

Caesarean sections usually involve delivery through a surgical incision in the abdomen and front wall of the uterus. Dr. Christian Morgan, a family practice doctor who regularly performs C-sections at the University of Utah Health Sciences Center, said he had never seen vertical skin incisions performed at LDS Hospital for a first-time C-section.

"Even when you need to get a baby out in minutes, it can still be done in the bikini incision," Christian Morgan said.

Here's the informed translation:

-- Pregnant woman, carrying twins, comes in complaining of decreased fetal movement.

-- History/Physical/Tests are done and the recommendation is for an immediate delivery (that's the nonelective kind of C/S, the one associated with the highest risk of maternal mortality and morbidity).

-- MD explains the procedure, as well as the benefits/risks involved. MD mentions the possibility of a vertical skin incision ("up and down"..."from breast bone to pubic bone").

[The reason you do a vertical incision is because it's the quickest way to reach a distressed fetus. One cut from skin to uterus, one cut on the uterus, fetus is out. You can't do that with a Pfannenstiel ("bikini') incision because you risk injuring the urinary bladder.]

-- Woman tries to express her concerns about the surgery and is made out to sound callous (to put it mildly) by people around her/reporter.

-- Woman elects not to undergo procedure (one fetus dies, one lives). [I can't tell from reading the article, but it's possible that, after hearing about the complications associated with a vertical incision, Ms. Rowland thought that by refusing a C/S she would save herself and her pregnancy.]

-- The DA charges woman with committing murder. [Note to DA: just because you weren't able to find any reason other than the "cosmetic motivations", doesn't mean they don't exist. Pick up a book...or at least google.]

-- Dr. Morgan regales us with a personal anecdote which highlights his powers of observation. [Just so that Dr. Morgan isn't the only one admonished for using anecdotes instead of data, let me join him for a moment. I've done hundreds of C/S. I can do them in my sleep. I've seen the benefits and speedy, uneventful recoveries (most patients) and I've seen the risks (including the patient dying on the table). Had I been Ms. Rowland's physician I, and, without a doubt, any of my colleagues, would've talked/explained/pleaded/sung/drawn pictures/mimed/laughed/scolded/educated/jumped up and down and then some more. I would've done anything in my power to inform her and convince her to have that C/S. However, I would have never, ever forced her to have it.]

My point:

Nowhere in the article does it say this woman is not legally competent. And, yet despite the fact that she's an adult, she's charged with murder for refusing to undergo an operation that could kill her and her pregnancy.

My question:

At a minimum, when faced with life and death options, shouldn't women be allowed to make their own [informed] decisions, instead of being charged with murder?

UPDATE: More on the case, here.

Williams Obstetrics 21st ed. p545

(via Drudge)

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