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Risk-Averse

Chavi Karkowsky, MD, Ob/Gyn & Women's Health, 10:27PM Jan 12, 2011

I am becoming more so, but not in the usual way. Instead, I've become less comfortable, when counselling patients, with the litany of catastrophic possibilities that used to roll off my tongue. 

So, for example: When consenting a patient for a primary cesearean section for breech - a scheduled, routine, low-risk occurrence - do you include the risks of: 


a) Cesearean hysterectomy?


b) Damage to fetus/infant?


c) Maternal death?

 

I used to mention both (a) and (b), routinely. Risk of bleeding, infection, damage to organs, and small risk of cesarean hysterectomy; remote risk of damage to the fetus. Well, these things happen, they do, right? We've all been there, or at least known someone who has been there for the completely unexpected c-hyst in the young primip, or the wildly unimaginable scalpel laceration or broken femur during delivery of the infant. 

But is it really reasonable to bring the spectre of the tremendously unlikely to bear? Is it fair, especially when what you're offering is standard of care, and there is no really clinically reasonable other way out? Is it even, really, truthful? 

I used to mention (a) and (b). And then one of my partners, a venerable pillar of our practice, twiddled his mustache one day on the labor floor and said to me: Well, why don't you mention (c) then? Maternal deaths happen, you know. They do. 

And I stammered and said: Well, that is, thankfully, an extremely remote possibility. Really unlikely. Tremendously anxiety provoking. Not fair to bring up. 

Ah, he said. And left me to my thoughts. 

And it is true that entire fields of academic research are devoted to this, research that borders both on the linguistic and the philosophical. How do you express risk? How do we talk about this? What is the reality we aim to express? 

But we are clinicians, and we do this every day, without the benefit of hours of analysis or navel-gazing. And so I am wondering what you all are doing: (a)? (b)? (c)? None or all of the above?

What seems fair? What seems truthful? 

About This Blog

It's the best job in the world, except on the days when it's the worst. Here's a blog from the front lines of obstetrics.

Disclosure: Chavi Eve Karkowsky, MD, has disclosed no relevant financial relationships.

Poll: If the primiparous patient with a breech fetus at 24+4 weeks continues to labor and progress, you will: 1) Provide her with a cesarean section. It's the only reasonable thing to do once she's viable. |2) Offer her a vaginal breech delivery. The data on any advantage offered by section for breech in the peri-viable period is not impressive, and I think she should have the option before I give her a likely classical cesearean hysterotomy, which will seriously impact her future reproductive life. |

  • Chavi Karkowsky

    After a few years as an OB/GYN generalist, Chavi Karkowsky returned to training as an MFM Fellow. She recently completed her fellowship at Albert Einstein College of Medicine/Montefiore Medical Center in New York City, where she has stayed on as faculty.

 
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