Friday, December 7, 2012

The Illusion of Informed Consent

    I hadn't thought much about the role informed consent would play in my pregnancy and childbirth. I knew I would eventually make up a birth plan, including my preferences in the case of transfer or c-section, and that these plans would play a crucial role in establish what types of procedures I did and did not consent to. After all, I'm fairly informed on those topics. I had heard stories of women being dropped as patients for refusing to consent to certain procedures, or being bully or guilted into signing on the dotted line. But I figured I wouldn't have to worry about all of that. After all, those were some of the main reasons I was choosing to home birth. So in my limited conceptualization, informed consent was simple. You became informed, and then you either consented or you didn't based on that information. The fact that you informed yourself was all that was required by the establishment at hand. 
   Apparently I was wrong. Informed consent appears to mean they inform you, you consent. Period. I learned this today after a particularly nasty conversation with a CNM at the campus health clinic. Let me back up a moment. Contrary to what some may believe, my midwife requires me to get the usual pregnancy blood work done so we can make sure everything looks good and there aren't any complications that might affect my ability to safely birth at home (shockingly, she doesn't just bring over her ouija board and call it a day). She suggested I look into getting the lab work done through campus health because it might be cheaper rather than just going through an independent lab she normally uses. So I called campus health and after speaking with 7 different people finally got across what I needed done, and yes they could do it there. Then I got a call back from the one of the nurses saying that if she got the CNM who saw me for my pregnancy test to order the labs, insurance might cover a larger part than if I had the order from my midwife (because my midwife is out of my network). Ok, cool. I like saving money; go for it. So I get a call from the CNM. She gives me a nice little talk about how she will order these labs, but that if the results are funny she would probably handle things differently than my midwife, so I just need to be aware, mentions something about syphilis, do I understand? Well yes, in the event that something is wrong (I'm Rh-, protein in my urine, etc) I'm sure my midwife and I will both want me to seek further attention (you know, right after we do a rain dance and burn a wicker man as an offering). So I go in, pee in two cups and give 5 (5!) vials of blood. Sweet. 
   Well, this morning the CNM called with my results. She sounds serious. She needs to talk to me. Some of my results that came back need to be discussed. Now I know I don't have syphilis and I know my blood is O+. I have great blood pressure and no edema. So I patiently wait for her to tell what is so terribly wrong. She tells me I have...a urinary tract infection. Oh, ok. I'm not surprised. I have had them before and am usually asymptomatic except for having to pee a lot. And since I'm pregnant, it's not weird for me to pee a lot, so that makes sense. UTI. Sweet. Thanks for your time. But wait! There's more! She also says, in a very worried tone, that my white blood cell count is a little high! Oh the horror! Now, I know what white blood cells are and do. I know what having a lot of them mean. So I asked, isn't that because I have an infection? To which she replied, "Well, yes, it could be. But it could be something else!" Well, ok, on a metaphysical level the possibilities are endless. But since we know I have a UTI, it would seem likely that this is the reason behind the elevated white cells. Or maybe I'm just crazy. And I guess because I was obviously unimpressed with this tidbit, she continued " platelets are low!" Ok, I don't know that much about platelets. But considering the three ring circus she just pulled with the white cell count and the fact that I have no type of blood disorder symptoms (I do know platelets are in the blood), I take this information with a salt-lick. She tells me I must get rechecked within the next week and keep a close eye and inform my midwife immediately. Ok, I can do that. Sounds reasonable. And then she asks, can my midwife write a prescription? How will  I go about getting the required meds for my debilitating asymptomatic UTI? Now, I know darn well she is capable of writing a script, and because she ordered the lab work, it would not be outside her jurisdiction to call in the antibiotics to the campus pharmacy. But she is obviously not offering to do so. Not only that, she is playing coy asking if my midwife will be writing the script. She knows a CPM cannot write prescriptions. She is simultaneously creating a difficult situation and then calling attention to it as if it in some way validates her initial concerns about my choice of care provider. Nice. So she asks, how do I plan on getting the required antibiotics? 
    This ain't my first rodeo. I have had a few UTIs over the past years and have never taken an antibiotic for them. In fact, I can't remember the last time I took an antibiotic period. Normally I went to the campus health in Memphis, they confirmed I had a UTI, and then gave me a bottle of pills which I promptly dumped in a drawer in my bathroom and never touched. It was the path of least resistance. But here I'm not being given that option. She wants to know where I will get the pills that I will never take. So, I think for a moment then decide to go with honesty. I tell her I'm not worried about a script. I don't take antibiotics for UTIs. She. flips.out. I would have explained I have a drawer full of antibiotics that I can "take" if it means that much to her, but I don't get a chance. I'm going to get a kidney infection, my baby will die, I will die, the whole world will end. Plague. Disease. Destruction. And then, because she apparently detected it was my weakest link, she starts harping about the platelets. I honestly believed I had some very rare, very serious condition. For a split second. Then I remembered that this is the person who is audibly angry, on what appears to be a personal level, about a UTI. 
   Now this struck me as odd. I had expected the normal, "Well, I have to recommend antibiotics and can't recommend any other type of treatment. If you want to try something else, please check back next week and if your not better, you should seriously consider...blah blah blah." In Memphis, I went to a regular OBGYN for my well-woman stuff. Nothing crunchy or alternative about her or her practice. Because of a type of birth control I was on, I was getting recurrent yeast infections. I had read echinacea was a good treament. I tried it; it seemed to work, so I brought it up at my next check-up. I asked by doctor, was that okay if I just did the echinacea? "Hey, if it works, it works!" was her reply. In fact, she also said she had heard eating yogurt regularly could help balance everything out. Maybe I could try that too. And if they infections became a problem, just call the office nurse and she would call me in a fluconazole script. Everything was fine and dandy and she wasn't personally offended, I never needed the prescription. I was healthy, she was happy. 
   Not this CNM. She laid the guilt on thick. This was going to affect me and my baby. It was going to be terrible. And then, she told me while I had a right to refuse what I wanted to, she couldn't continue to see me if I wasn't going to get the treatment she recommended. Yep, she dropped me as her patient over a UTI. I was informed, I did not consent, and as a result, I was dropped. Her way or the highway. Which is fine, I'd rather not receive care from a provider like that anyway. And I realize it was completely in her rights to do so. No hard feelings there. I just couldn't believe that something so simple was such a big issue. So I got to thinking about it and I have come to a couple conclusions. 
1) The whole incident bothered me, because I don't like to feel as if people are mad at me or upset with me. That's how she made me feel. Like it was personal. Like I was being stupid and irresponsible. There was no respect or desire for understanding. She didn't even ask what kind of treatment I use instead. But as sucky as it was to feel like I "got in trouble", I have more important things to worry about. Namely my baby and my own health. 
2)She was making a lot of assumptions. She kept asking about my midwife, as if she was somehow the reason I didn't want antibiotics. Nope. Just me. A choice I have made for myself many times and will continue to make. She also assumed I was simply being pig-headed. If she would have calmed down for two seconds, I could have explained that I would happily consider antibiotics as a last resort. I always do. I've just never needed them. Why destroy my natural flora balance and contribute to resistant strains of bacteria if I don't need to? Seems silly to me. She was also acting like she was the only person who cared about me or my baby. Like those things weren't important to me or my midwife also. She couldn't pause and think that maybe my concern for my baby and I was WHY I am reluctant to use antibiotics unnecessarily. 
3)She was a bully. She lied and used scare tactics to try and get her way. I knew it when she tried to pull it with the white blood cell count. So when I got home and looked at my results, I did some research on the whole platelet thing and UTIs in general. UTIs are only dangerous in pregnant women if they develop into rampant kidney infections complete with high fever (which is never good). Obviously I'm not going to let it get anywhere near that point. As far as the platelets, my count was 133 and the normal range was 150-450. That is only 17 units too low on a 300 unit scale. Barely abnormal. So I did some research. Everything I found said as long as you were above 50 units, there wasn't too much need for concern and only 10 and below were truly dangerous. And you know what a common cause of thrombocytopenia is? Pregnancy. Well that explained a lot. So I looked into gestational thrombocytopenia. It's perfectly normal. Happens in quite a few pregnancies. Entirely asymptomatic and clears up right after birth. Nothing dangerous about it. No risks or effects for mother or baby as long as the count doesn't get too low. No treatment required. No. big. deal. 
   So this CNM was either unaware of this and incompetent, or she deliberately lied and tried to scare me into doing things her way. Lame. So I called my midwife, explained the happenings to her, and ask what she recommended as far as my UTI goes. She asked what I usually do. So I told her, I have a regimen of cranberry supplements, echinacea, and colloidal silver. Great, that is exactly what she would recommend. I can also try laying off sugar for a few days and soaking in a bath with baking soda. Super. I asked was she worried about the white blood cells and platelets? Not at all, perfectly normal. Well that was refreshing!
   Here's the thing. It took a lot for me to stick up for myself. If it hadn't been for the fact that I am pregnant and not about to start making health compromises to please other people, I might have just given in. I might have let her scare me. How many other patients has she bullied this way? And why? Probably because of liability. Because everyone in this medical system is freakin' scared of getting sued. Or maybe she is just used to working with irresponsible college students. But come on lady, have a little faith in me. She was impressed the first time I saw her because I had correctly self-diagnosed a corpus luteum cyst. I told her all about my doula stuff and how I was a birth junkie and my PhD program. She knew I was informed and cognizant. She could have given me the benefit of the doubt. But she pulled the patriarchy card. She has the coat, she has the degree, she apparently thinks she has control over my body. Sorry, it doesn't work that way. Not with my body, and not with my baby. 


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