Informed Consent?

"informed consent  -
–noun
a patient's consent to a medical or surgical procedure or to participation in a clinical study after being properly advised of the relevant medical facts and the risks involved"

I hear it often, how we are to have informed consent; especially when relating to our health care choices. You sign off on everything under the sun from dental x-rays to lab work stating that you have been given informed consent and understand the risks and facts. But, I have been reminded yet again that an 18 year old who is getting breast augmentation has more informed consent about her procedure then a college educated 28 year old mother of 2 who is pregnant and under the care of an OB/GYN.

Earlier this week I walked into my routine pregnancy appointment with an OB/GYN. My blood pressure is taken (134/84 compared to my normal 120/70), and I wait for the OB to come in. She asked how I was feeling and I told her I've been better. I then explained that I had been into a urologist after more kidney pain and they had ran another screening and culture and u/s. Now normally I'm a minimally invasive gal. But after discussing with my home birth midwives (who I am receiving dual care from) all the symptoms and seeing that homeopathically nothing was kicking the problem, we all agreed to get me into the urologist since Sutter Davis' OB/GYN's were not very proactive about my previous kidney infection.

I told the OB that they had found high amounts of blood in my urine and that the culture had bacteria and it was resistant to amox and macrobid. The u/s found a few small stones and the urologist gave me orders to tweak my diet, lighten my exercise and to start augmentin. The OB was not concerned and said she couldn't treat it if she didn't diagnose it and my last culture on the 7th had shown nothing. I explained to her i was letting her know what treatment I was undergoing. She moved on to ask me why i had missed my last appointment, and I explained that it was at the same time as the last infection popped up and that I had been too sick to come in, but i had made an appointment as soon as possible to get in, which was that day. I also explained that I would be transferring care to a closer physician/hospital as driving 50 minutes each way was too much. She told me I could not miss appointments this late in the pregnancy and I needed routine lab work done since i was almost 28 weeks. I proceeded to ask her what routine lab work and she said I needed to be tested for anemia (which I had been the previous month) and for gestational diabetes. To which I politely explained we were going to waive the GD test.

The immediate response I got was that you cannot waive the gestational diabetes test. It is not something that you can choose not to take, you have to take it since it was their recommendation. I explained that i was incredibly familiar with my rights to sign a waiver 'Against Medical Advice' and if she would please grab one, I'd gladly sign it. To which I was responded with, "If you have undiagnosed gestational diabetes the baby will die, you are being foolish". I calmly explained to her that I did not have to take the test, would not be taking it and felt it was a foolish test since we are the only country that routinely runs it on pregnant women. She told me that we have the best health care system in the world, to which i quietly asked, "Then why is our maternal death rate the 3rd highest in the world?"

Now let's switch back to informed consent. Informed consent is in no way, shape or form able to be translated as 'scare tactics' or 'false information'. And for a care provider who cares for many women in her practice I was appalled that she said something false and untrue. I know that insulin does not cross the placenta, the glucose does and can result in macrosomia which can cause shoulder injury during birth, low blood glucose levels at birth, jaundice, and an increased chance at having breathing troubles after birth. Please see http://www.diabetes.org/gestational-diabetes.jsp for these facts, notice it does not mention fetal death or neonatal death anywhere. I had to search about 15 different sites on GD to finally find one that mentions "Rarely, untreated gestational diabetes results in a baby's death either before or shortly after birth." This OB didn't mention ANY Of the risks except death. This really angered me because this is not providing her patients with informed consent. Saying a baby WILL die of GD if left untreated is false and screams of manipulation. I was very upset because 1- I was not given informed consent, facts, data or any real information and 2 - I am an educated and smart individual. Do not try to scare me of a death and then if i do not follow medical advice imply that I am risking a child's life and care nothing of it. I am a gestational surrogate, the very nature of which entails that every day for the last 9 months I have done nothing but care for another family's dreams and hopes, and I insure that the best outcome possible for baby and myself are what happens. I do not take things lightly with this role.

I also knew I have none of the risk factors, except being 3 years over the 25 year old cut off age. I am not overweight, I have never had a history of GD or large babies, none of my family members have diabetes or GD. And the effectiveness of the GD test is still up in the air with many practitioners. I explained to the OB that I was able to regularly test my blood levels because my diabetic mother in law lives with us and I use her meter to monitor. I also ( though unable to tell her due to liability laws of Sutter Davis) do a one hour type test with my home birth midwives with a meter. And at the end of the day, my issue was not with the test itself. I always pass it with flying colors and know that i do not have GD. But what I hold issue with was the false information, the scare tactic and the treatment I received immediately following the OB realizing I was not going to have my mind changed on this.

After asking about why our maternal death rate was 3rd highest in the world, I received no response. She turned to me and told me that she needed to keep me and I needed a cervical check. I asked her why and she told me that my blood pressure was elevated and she needed to screen me for preeclampsia. I declined the cervical check, which only frustrated her more. But went and did the pee test and waited 20 minutes for another check on my blood pressure. I asked the nurse what my protein levels were and she told me only a trace. But my BP was a bit higher (which is no surprise to me considering I'd just been told that I was risking the baby's life and treated pretty badly). The OB came in and said my BP was too high, we needed to have me go into L & D for monitoring because that combined with the protein in my urine were clear signs of Pre-E. I asked her to please pull up my lab work from the 7th and was my protein the same then or lower? She got agitated and said she had no time for that but I refused to move and she finally pulled it up and admitted that on the 7th my protein had actually been at 1+, higher then it was today. I explained that had they routinely done urine dips they would see that blood and trace amounts of protein in my urine are normal. That I have the strips at home and monitor it myself. But Sutter Davis would never have known what is normal for me because they've only ever run one urine test on me. I had no headaches, no blurred vision, no swelling. . . basically no other symptoms of Pre-E. My blood pressure was not the required 140/90 nor had it jumped 15 diastolic or 30 points systolic which are the guidelines for evaluating a pregnant woman at risk for Pre-E.

I explained that my kidneys were working overtime and the urologist had warned me that it could effect my blood pressure and to watch for swelling, pitting and headaches. But he felt once the infection and stones were passed, my BP would resume to normal. I told the OB that this is why I had mentioned my treatment with my urologist to her at the beginning of the appointment. Finally, she took another reading of my BP which by this point was down to 120/80 and said she was letting me go home (as if she were able to force me to stay) but i was to be back in 2 weeks or she'd report me (to who? the intended mother who received a phone call updating her on the appointment from me?). I went to the front desk, made my appointment for 2 weeks and drove home upset, crying and frustrated with the health care system which makes women fight for proper care and have to put up with badgering and scare tactics.

Thankfully we are switching OB/GYNs and I was able to call them once I got home. I grow amazed at the difference in care, I grow tired of fighting for my rights and that of this child. I believe there IS a better way. That you can educate your patients, that you can have good care. . . but to constantly have to fight for it and to be your own advocate is something one must be well prepared for when re-entering the medical model of care for pregnancy after having been in the home birth model of care for the past 3 years. I am use to having my care providers be my advocates and educators, instead I am faced with the opposite from the very people who take an oath to protect, educate and provide me with informed consent. Clearly, something is backwards in our health care system. . .