It's not your fault, except when it is.
So, departing from the world of my gut for a (hopefully long) while....(Although if anybody has any suggestions on getting rid of erythema nodosum, let me know. They're not a big deal, but they're kind of annoying).
I was on call last night. And like most nights, we had a woman on labor and delivery who was loosing or who had lost her baby. And it seems to me that it almost doesn't matter if the loss is at 22 weeks (prior to viability) or 40 weeks, if it occurs after quickening (the time when the mom first feels fetal movements), the grief is always severe.
When women (and their families) are caught up in this terrible grief for this terrible loss, their first assumption is that the baby's death is somehow their fault. In ~90% of circumstances, this is not true. And those women, I always tell, every time I see them, "Remember that this is not your fault. This is a terrible thing, but you did not deserve this." I'm not sure that they believe me, but I think that telling them that is part of doing no harm, as it were. The loss of a child is such a terrible thing for most women, and sometimes heralds the onset of another disease (some women, for example, are diagnosed with lupus only after having a lupus related stillbirth), families have so much potential for self doubt and guilt, that if I can limit the amount that they torture themselves with guilt, then maybe even though I can't save their baby, I've still helped them.
But what about that 10%? The 10% of stillbirths that are preventable. The 10% of stillbirths that are due to uncontrolled diabetics, or patients who did not comply with our recommendation for fetal monitoring once or twice a week? What do I tell those patients?
I think that the diabetics make the best example. Diabetes is the reason Maternal-Fetal medicine came into existence. Way back in the dark ages (pre-insulin), diabetes used to be a death sentence for pregnant women and their fetuses. Then, insulin arrived, and not long after insulin (just a couple of decades, really) fetal monitoring became routinely available. These inventions changed the whole game for pregnant diabetics. With diabetics surviving their pregnancies, we (ok, not me, I wasn't even born then, this is ancient history) noticed that a large portion of their babies died as they got closer to term. We tightened their glucose control, and then we were able to monitor their babies for problems. (The mechanism of diabetic stillbirth is still somewhat subject to debate, but the prevention of it is not) Now, we work towards tight glucose control through pregnancy and twice weekly fetal monitoring after ~32 weeks in all pregnant diabetics. This has resulted in a fairly dramatic decrease in diabetic stillbirths, to the point where diabetic stillbirths, once expected, are now rare. This improvement in pregnancy outcomes for diabetics is the first real success of Maternal-Fetal Medicine.
Most diabetic stillbirths, in fact, occur in patients who are non-compliant with their blood sugars, insulin, and their fetal monitoring regimens. During pregnancy, I give them my "You need to do these things, otherwise your baby could be seriously damaged or die" talk (dead baby talk for short). And despite the dead baby talk, a subset of our patients will not follow our recommendations. Now, I know most of our patients are very poor, but they all get free care through us. We have a baby van that tracks them down and brings them to their appointments. We make sure that they have the appropriate emergency Medicaid so that they can get their insulin. And in fact, few of them have jobs, which makes it easier for them to make their appointments. And we never ask them not to bring their 12 screaming children into the waiting room. We just want them to come however they can, with or without screaming children. Without hospitalizing them for their entire pregnancy and administering their insulin to them (and sometimes we do that, but it's not practical to keep people hospitalized for 9 months of pregnancy because they're non-compliant), we could not do more to make them able to comply. And, rather than telling us they're not taking their insulin, etc. they bring in fake blood sugars. I think it is a case of denial...they don't believe it will happen to them. That combined with the fact that many diabetics don't feel bad until they're really really sick.
So, these noncompliant patients get dead baby talk after dead baby talk. And they have a much higher rate of fetal death than the compliant patients (whose rate of stillbirth is still higher than the general population, but not by a lot). So, when these women come in with their stillbirths, although part of me wants to say (just to be compassionate), "This is not your fault", the other part of me keeps me from saying those words, because they're not true.
I don't know that it really helps the patient to hear "This is not your fault" when it is kind of is their fault. In some ways, these women are suffering a consequence of their lack of personal responsibility (I know it sounds pretty harsh to put it like that). If these women choose to get pregnant again, they deserve to know that they increased their risk of having a stillborn child by their bad behavior. Because if they behave the same with the next pregnancy, they may very well get the same result. And the only thing that's worse for a mom than a single stillborn baby is recurrent stillbirths.
In fact, when women come in for their postpartum visit, and I get to the part of the visit where we talk about the pathology/autopsy results and talk about what caused the stillbirth, I will tell women, "We know that diabetics are at a high risk for stillbirth. And we know that taking your insulin regularly and showing up to have your ultrasounds and have your baby monitored decreases that risk. I see here that your blood sugars weren't well controlled and that you didn't come in for your monitoring visits. My recommendation to you, so that you don't have to go through this again, would be that you avoid pregnancy until you're able to do the things we recommend you do to decrease the risk of stillbirth. If you want to have a safe pregnancy as a diabetic, you have to do these things." At which point I launch into my contraceptive spiel and make sure they have an internist who takes care of their diabetes between pregnancies. We can never get diabetic stillbirths down to 0, but we could get them pretty low, if we had the assistance of the patients.
The thing is, this feels very much like telling the patients that their dead baby is their fault. And in many ways, it is. Telling them that seems unkind. Not telling them that seems unkind. I just worry that laying it out like that does more damage than it prevents. At the same time, I worry that not laying it out like that will do more damage. For now, I'll continue to tell them that they may have been able to prevent the stillbirth, simply because it seems like maybe the best thing for me to do is to empower them to avoid having a repeat stillbirth.
(image credit)
Labels: bad outcomes, Culture of Medicine, diabetes, medical systems
posted by Midwife with a Knife @ 3/21/2008 06:25:00 PM
30 comments
links to this post
30 Comments:
This is a really interesting and well written post. I am drawn to OB/GYN for so many reasons, not the least of which is that it's so happy. Most of the time, the patients are glad to be there and are otherwise relatively healthy. Most of the time, things go fine with the pregnancy and delivery and the doctor is there just to see it through. Most of the time, people seem to be really happy in this, a seemingly happy field.
Except. Except when it's not. And when it's not, it is the worst and most devastating field.
I think you did (and always do) a great job of presenting the problem and analyzing it from an ethical and medical standpoint. I appreciate that you struggle with this kind of thing because, though I'm not a doctor yet, I think about these things and wonder what people do, wonder what I will do.
Thanks for sharing. And I'm glad you're feeling better!
I wish we could get the world "Fault" out of the language. "Consequence" is a better word, in my mind. It links actions to results, without placing judgement on them.
Because you are right - whether or not it is their fault, these mothers are grieving. Adding guilt to that grief usually gets us nowhere.
At the same time, I well know the frustration and the anger that results whenpatients don't comply, despite our doing practically everything we can to support them.
There is a level of helplessness that some patients have that I find so difficult. Patients who say things to me like "Isn't it written there?" when I ask them a question about their medication history, or who ask me to remember something for them because they don't want to do it themselves. "Can't you just write it somewhere?" they say when I tell then that next time they call to schedule a mammogram they should also schedule a sonogram because the radiologist is recommending it.
As if I have space in my brain to remember everything for the over 2000 patients I see a year because they can't remember it for themsselves.
Sorry to rant - I had three patients today ask me to just "write it down and remind them." It drives me crazy.....
If I go to my doctor he can see I'm over-weight. He knows I smoke. He knows I don't always make healthy choices. It would be irresponsible of him to not tell me what I'm doing is dangerous and could have XYZ consequences.
You can't force patients to comply. You can tell them what could happen if they don't. You can give them the facts about diabetic stillbirth, whether they've had a stillborn baby or not. You can certainly tell them that comliance lowers the risk of having a stillborn baby. I think it would be irresponsible not to tell them.
I'm sure it's not a happy conversation and maybe it makes some women feel guilty. Having had 2 miscarriages and preemie babies (after doing everything "right") I have a hard time having much sympathy for a "mom" who didn't try to do everything she could to give her baby the best chance of a healthy start.
These must be incredibly difficult and frustrating conversations.
I think TBTAM's desire to get rid of "fault" in favor of "consequence" makes good sense, at least in the way I imagine one approaches this sort of discussion.
My first reaction is to be very negative, to wonder why people don't take better care of themselves. But then I think about my difficulties with weight, or this, or that. I hope I never learn how difficult it is to manage diabetes.
As a woman who did everything right and still miscarried at 13 weeks a month ago, it makes me angry that these women did not take better care of themselves. I monitored my bp, took it easy, took my vitamins, aspirin, bp meds. I still lost my baby. I don't like the word fault, but agree with TBTAM, that a better word to use would be consequence.
No matter what you say to a woman, even if they know it wasn't their fault, somewhere in the back of their heads, will be the if I had only done this, or did that, or took this maybe it wouldn't have happened. My ob has told me I don't know how many times it wasn't my fault. He has told me to not think for one minute that it was my fault. Somewhere deep down, I sometimes wonder if I had done something different the situation would have been different.
Fortunately I have an awesome ob. The next time he has told me he would put me on a reduced schedule of commuting and doing some work from home immediately (Chronic HTN. Controlled outside of pregnancy. This last time it was kind of up and down. Commuting makes it worse. Also, history of severe pe, pih, and preterm birth). So we will try to prevent rather than react next time. He has agreed to an early US for my reassurance (I'll get them in his office - old machine and the peri's - new machine, but he is sending me for a hospital one too early) . He has told me I can come in whenever I feel like I need to for a heartbeat check. He also did my d&c during his lunch hour and sat with me in recovery till a few minutes before I went to the floor.
I would have killed for more US, visits, etc to reassure me. I agree, don't make it worse for them. Use consequences with them :)
You know, maybe step out of that talk for a minute. It is respectful to tell the patients that the consequences of their noncompliance was fetal death. To ignore the behavior is to be okaying it since you are the doctor. I don't mean castigate them, just spell it out - if you know for sure then as her doctor you owe her the respect to tell her what happened, and that it will happen again if she acts in the same manner again.
It's Adlerian (Alfred Adler), natural consequences are appropriate for children and adults. We can't stop folks from doing things that are not okay, and sometimes they need to fall badly before they do it again. If they don't know how the fall occurred, they can't stop it the next time. Illumine them.
Do the uncontrolled diabetics who have these negative outcomes all have Type I, or is it possible for any type of diabetes (Type I, Type II, gestational)?
This is really a great post. As patients we often wonder if our docs are "holding back" telling us the whole scoop for fear of one thing or another. Personally I had to beg for answers as to why I lost 3 girls over a period of about 12 years. Since we had been so extremely careful and had been trying for kids for years and years, I found it sad but fascinating that all the babies I lost were girls. I did have 2 successful full term boys (and we threw in an adoption in there too:) I will always thank the one MD that told me that sometimes there is no reason but that sometimes a woman isn't genetically able to carry one sex or the other. He didn't go into details but it sort of gave me an answer to cling to when all the self doubts kicked in. Personally I never have and never will understand a pregnant woman not doing EVERTYTHING possible to nurture her baby to a healthy birth. I credit you for even thinking about how your patients perceive your explanation, I would probably want to yell and ask them what they expected for not taking care of themselves.
katie: Thanks. It usually is a great field, and even the bad times sometimes are good in their way.
TBTAM: I'm working on another post about patient noncompliance/helplessness right now, but I may not post it out of fear of inciting a riot. I know what you mean about fault vs consequence, although fault implies a mistake, and I do feel that these women are making terrible mistakes.
anon1: As a doc, I understand that nobody's perfect. Some people smoke. Some people (including me) are overweight. All I ask is that they try.
bardiac: I actually like fault because it implies mistakes. Consequences are what happens for any action, and these women are making huge mistakes.
I'm sure diabetes is tough to manage. I think about how hard it was for me to take the asacol three times a day. At the same time, we can help them find ways to control their diabetes, whether it's different insulin regimens that fit into their lives better, or helping them trouble shoot their way into better control. In order to do this, however, patients have to come to their appointments and tell us what's going on. A little honesty and effort would go a long way.
pe mommy: I'm sorry for your loss. When I see women with miscarriages or stillbirths who did everything right, it makes me even more angry at those who completely disregarded my doctorly advice.
ethel: Huh. Never heard of that Adler guy. I learn something new every day.
laura: Typically, only type 1 and type 2 diabetics are at risk for stillbirth (although gestational diabetics' babies are at risk for being extra large babies (macrosomia) and birth trauma, as well as possibly at increased risk for diabetes later in life). we lump those two together and call them "pre-gestational diabetics". However, the risk of pregnancy complications with Type 1 diabetes is certainly higher than with Type 2. Also, some gestational diabetics are really Type 2 diabetics who happen to get tested during pregnancy, and we suspect that those people probably have a risk for bad outcomes similar to Type 2 diabetics. I know, that probably doesn't make it any clearer.
ohn: Sometimes there are no answers. In your case (although remember, this is just the random musings of an internet perinatologist. For all you know, I could be a 12 year old boy, drinking mountain dew and eating dorritos while enjoying tricking everybody into thinking that I'm a doc), I suspect there's something wrong with one of the X's that you or your husband carry (probably his) that causes a problem in an area of the chromosome critical for development, of which there are many on the X chromosome.
As far as the patients, don't think I sometimes don't want to scream at them, "So, did you get what you wanted? Because you certainly acted like you wanted this!" or something similar. I don't deserve all that much credit.
Go ahead and post. I would like to read it. Noncompliance drives me crazy. I know with my second daughter, I followed everything my dr said to a T. Pretty much by the time I delivered by emergency induction (he was prepared to do a csection if it didn't work that night), I was running a bp of 160/120-130 on 60mg of Procardia and 2000mg of Aldomet a day on strict bedrest. I was allowed to pee and get a bath and that was IT. The only thing I disagreed with was Mag. Simply because with my first I had a horrible reaction to it and I was given too much. (different dr and hospital). I'll never forget what my ob told me. If you have even a trace of protein on the day of delivery you are getting it. Because no matter how nasty a drug it is (it is one of the worst ones), it is the ONLY drug that will save your life. Got it. Yes sir. Fortunately he did not mag me. I spent the next 6 weeks terrified that I would seize though after delivery. So next time, I'll take the mag. After my daughter was born, the nurses in the office constantly commented on what an excellent patient I had been. Logged bps faithfully, called him most of the time when they went above threshold (sometimes I didn't, don't worry he let me know about it), took meds faithfully (7 times a day!!!). I just don't know what to say when a patient isn't compliant. It makes those of us that do very upset when something bad happens. It's really not fair.
What an insightful and interesting post which I'm sure will come in very handy for me one day. :)
I hope you will post on noncompliance. But please also talk about what you mean by noncompliance, and how you handle making sure women are going to be able to handle your orders when you give them.
I'm currently in the hospital on hemorrhage-watch. I have placenta previa, and I've had three bleeds, all tiny, so I'm probably in for the duration (I'm 27 weeks now, so it could be a long haul). I'm trying really really hard to do as I'm told, but it's frustrating when every doctor and nurse has a different idea of what I should do. My doctor has told me that I'm pretty much here so they can do emergency response if needed. I'm definitely not in preterm labor - my ultrasound on Tuesday showed a nice tight long cervix, and I haven't had any contractions yet. So he tells me verbally that it's OK to sit up and move around the room a bit, but the orders sheet just has the "bedrest with bathroom and shower privileges" checked, and the nurses grump at me whenever they see me sitting with my feet on the floor. One of them called a neonatologist consult to discuss outcomes for different gestational ages, which I'm pretty sure was to try to scare me (although it didn't, really - I didn't hear anything I didn't already know). I finally got the order expanded a little, and I haven't had as much hassle from the nurses.
I also am anticoagulating for MTHFR and Factor V Leiden, so it's a bit of a balancing act. Back when those tests came in, my perinatologist freaked out and insisted that I come in and start Lovenox and Foltx the very next day (he already had me on 3.8 mg; now it's 5.8). I missed a chunk of our family Christmas celebration because of it. But he chewed me out good in the office for even asking if it could wait a few days. Was I noncompliant just for asking? How about if I'd flat out said no, and made an appointment for a few days later, would that have been noncompliant? He also told me I "read too much" when I asked him what my homocysteine level was (it was on the low end of normal, for the record). I can't quite imagine you telling a patient that, but that kind of encounter with one doctor can poison the interaction with the next.
I guess I'm saying that you don't always know where these women are coming from, or whether they really understand the consequences of what they're doing. A few encounters with a doctor who really blows things out of proportion can leave you not inclined to listen even to the reasonable ones. And when they're asking you to do something that's really hard, like sugar control, and you feel like you can't really trust them to only give you these kinds of orders if they're actually necessary.... Well, it's just harder to make yourself actually take it seriously.
Personally, I respond well to statistics, like "poor sugar control increases your risk of miscarriage or stillbirth by n times." I don't know how others respond to such pronouncements. But one thing that makes it very difficult for me to comply, no matter how real and important the risk, is feeling that the doctor doesn't really know or care that what s/he's ordering is going to be burdensome.
Oh I did think of something. Sometimes personality has a lot to do with it. My ob is a solo ob in practice with 2 certified nurse midwives w/delivery priviliges. He is always on call. Then the two midwives rotate. I am an established patient of my ob now. He does all my annuals, I saw only him through my last pregnancy, I saw only him for endo and gyn issues. So if you are a new patient, you automatically see the midwives unless they think you are high risk. Then after the 1st trimester they send you to the MD. When I called when I was pregnant this time, I had to see the MW because I was told my ob (even though I am his patient) did not do first appts. Um, ok, he told me I would be seeing only him but alright I'll switch back after the 1st appt. Had the 1st appt, mw has my file and instead of congratulations asked me when I was getting my tubes tied!!! It's not like I have 10 kids and even if I did who cares if I can support them. My ob when I saw him, automatically walks in and says Congratulations and was happy for me.
Which leads me back to personality. One MW I would not see at all. In my last pregnancy, she panicked and scared the crap out of me. It was the ONLY time I had left the office in tears before my M/C. I mean how was THAT helping my bp. She basically read me the riot act even though I was being a very compliant patient. Told me I had better call that office if anything had changed and not do it because I didn't want to go to Childrens (I would have gone if my ob said I needed to but I wanted to stay with him). That I had to get through the next 9 days to deliver there (I got 13). It was awful. She also told me at the second appt that I had before I switched to my ob that the severe MS I had (which turned out to be HG) was ok. That she had three boys and she just ate and threw up. My ob gave me meds because I had lost over 25 lbs in the first trimester. She also told me that I had no business seeing her (this was at 32 weeks when my ob was on vacation) and I was to see MD only. She wrote on the front of my file in big red letters to see MD only.
My ob is very kind and compassionate. He never scared me to death. In fact, I was upset because I thought he should be more worried. Turned out he was trying to do all the worrying for me. After my daughter was born, he told me, you have no idea how worried I was about you. That's why I told you if anything changed, call day or night (call hospital and they would page him). He told me I was one of those patients he wanted to hear from. I actually think he is a midwife in disquise.
So something coming from my ob I would be much more receptive to than something from one of the two midwives. I don't have anything against either one, in fact, the one I saw this last time w/ the tubes comment was there when I was sick helping my ob. I KNOW I have a personality conflict with the one. I don't have a personality conflict with the other.
I think how a dr relates to the patient is very important in how receptive they are. When I was pregnant with my daughter, I ended up in L&D for a NST because my bp was high. My ob came in and reviewed everything. He said go home. Go to bed. Do not move till your peri appt tomorrow. I want that US and she'll call if anything changed. Next day, emergency induction due to worsening bp, PIH symptoms, and decels. I did as I was told.
It's a tough ethical question. I think one thing to ask is why are you telling the patients the consequences. If they haven't asked, I'm pretty sure they know that they were at fault. You could also ask them What their thoughts are about the stillbirth, how it happened, how they are coping. That way you can assess their understanding about its relationship to their diabetes as well as express concern.
I think we have to question ourselves why we would give them a lecture detailing the consequences after a stillbirth has happened. If our goal is to encourage them to monitor their DM next time, I think a statement along the lines of "When/if you get pregnant again, we're going to have to be very careful about your diabetes. I don't want you to go through this again." The information is conveyed, but I believe it is less hurtful, conveys concerns, and preserves your relationship with them more. It's a really hard spot for you to be in.
Wow, great post. You have touched on one of the toughest things we face in OB (or any medicine). How do we counsel the patient whose poor choices have led to a bad outcome. I am looking forward to your post on non-compliance/helplessness.
It sounds like you handle things quite well, but it unfortunately isn’t up to you to decide what a “mistake” is.
I suspect that many of the women who frustrate you do not believe you and do not take responsibility for any outcomes.
If, for instance, a woman’s experience of life is such that she has learned that nobody cares about her and that in order to look after herself she shouldn’t care about anyone else — there may be very little you can do to persuade her to share your values.
She may not believe you when you talk about the consequences of uncontrolled blood sugar because she may be unable to believe that you actually care about her and her baby.
She may figure that just as she turned out all right even though nobody looked after her, the baby will turn out all right if it wants to, even if nobody looks after it.
And if she loses the baby because she is unable to accept consequences or accept influence, then is it really a “mistake” that she doesn’t have a baby? If someone doesn’t have the material or psychic resources to carry a healthy pregnancy to term, then wouldn’t attempting to raise the child be the “mistake”?
I like Rebecca’s suggestion to start by asking questions about how the woman understands the stillbirth. Letting a woman know that she does in fact have agency might be very kind. “You lost the baby this time because of your hight blood sugar, but later if you are able to control your sugar you should be able to keep the baby. Would that be a good thing?”
Of course it all depends and the right thing to say is often different from one person to another — though it presumably will always involve sharing information in some way. But I’m not sure that judging someone for not making the same decisions you would in the circumstances favours clear communication.
Stillbirth is a fairly black and white issue: the baby either lives or dies. Smoking, drug and alcohol abuse likely to lead to a permanently injured baby must be an even more common situation that is difficult for a care provider to face with compassion.
This post has been removed by the author.
Like Alison Cummings, I think you have to look very hard at where your patients are coming from. This is one of those areas where having a physician who understands your socioethnic background is very, very important. It isn't about whether you care-it's the patient's perception of whether you care. So many of the folk that I treated in community health center settings did not expect a good outcome in any area of their life. They certainly didn't feel empowered to change any outcomes. Their life experiences hadn't given them any encouragement in that area. Many of them didn't expect to live very long lives themselves, and didn't connect their actions to health outcomes because it just wasn't in their upbringing. Dietary recommendations were exceedingly hard to follow, for a number of reasons, and insulin and needles were sometimes looked at with skepticism. Don't forget the Tuskegee project. Many times we are treating people who just don't have a reason to trust us. I say that from the perspective of someone with a multi-ethnic background, who still can feel separated from patients by the economic differences they perceive.
I love what Essie said. I was going to say something similar, but there is no way I could have phrased it as eloquently. Sociology of health does wonders in understanding a lot of health-related behaviours. All the same, it's a tricky situation that I'm sure has no definite "right" response.
Hi, I have been reading up on medical blogs and ran across yours. After going through a loss at 15.5 weeks, I had a cerclage, full bedrest for 5 months, progesterone shots and ultrasounds for my next pregnancy. My daughter made it full term and is now 18 months old. I have since had 2 early miscarriages. I have had great care and not so great care, but through all this I am finally going after my dream... the ultimate being OB to Perinatology. I am also considering NP/Midwife, but need to find out more of the differences between the tow fields. I am a "non-traditional" student, and started my general ed classes last summer. Any advice for my journey would be greatly appreciated. Hope you don't mind if I link to your blog from mine.
Just a thought: maybe all the "dead baby talk" is enough to put them in a frame of mind to bring on a dead baby. Positive thoughts bring positive outcoms, negative brings negative, you know? Maybe you could word it differently. Instead of "if you don't do this, your baby will die," you could say, "If you DO this, you are increasing the chances of your baby's survival!" Changing the wording from negative to positive usually does the trick in parenting, maybe it would have a good affect in doctor-client relationships also?
Sorry, Tracee, but as a retired physician I know that we owe patients all of the truth, all of the time. They need to hear very specifically "if A then B". I personally don't think negative thoughts bring on negative outcomes, and there isn't any science that will tell you that. I live on the other end, too, with a 16 year history of lupus. Knowing the possible "bads" doesn't make them happen, it just tells me how to avoid the potholes in the road.
Mwwak: one of your best topics. Thanks for the discussion.
I think the way you phrased it to these non-compliant patients who suffer from a still-birth is the best way, really. They need to know that their non-compliance very probably had a direct affect on this outcome. Maybe it would have still happened, but if they had been compliant at least they would have done all they can to prevent it. Unfortunately, you can't just bluntly say, "hey, you pretty much did this to yourself". At least you are giving them information for the future, and they can chose to be more compliant then. That's amazing your practice/hospital sends a bus around to take patients to appointments if they don't have transportation! What more can people ask for...you to visit their home 4x a day to give them their insulin? Its so frustrating to deal with non-compliance in any medical field, whether its the elderly not taking their meds (even though they are 100% aware of the need to do so) and putting their lives at risk, or a mom-to-be putting her unborn baby at risk. So sad. And who gets blamed, but the healthcare professional who according to some, should have provided more education, more this, more that. You can only do so much.
Dear Doctor,
I enjoy your blog. I am an internist with a medical news website, Hot Medical News http://hotmedicalnews.com which I think your readers would enjoy. If you agree, perhaps you could link to my site. Thanks.
Sincerely,
Brian Carty, MD
Years ago I anesthetized a woman for a D & C for a missed abortion. She woke up asking me not to be mad at her. I asked her why she thinks I would be mad at her and she replied that the miscarriage was her fault. I calmed her by relating the miscarriage that my wife experienced (it is not pleasant to say the least) and reassured her that it was not her fault.
I think you are making the right choice here. I am a third-grade teacher, and I try to teach my children that before speaking, one should ask oneself, "Is it true? Is it helpful? Is it kind?" Looking at what you are saying to these women, if it is not their fault, you ARE saying something true, helpful, and kind. For the women whose fault it IS, you ARE telling them the truth, but in a HELPFUL and KIND way. I think you are doing the right thing. I am impressed.
Madame Monet
Writing, Painting, Music, and Wine
winewriter.wordpress.com
Interesting post...
I have been following your blog for quite some time.
Trying to come up with the right words to eloquently say what I am thinking but they are not coming.
What I would say is that maybe you ought not put "All Diabetics" in one box. I am certain that each women who gets pregnant knows what they are doing, diabetic or not.
Fault is a tough word.
Mom to 1 healthy 10 month old little girl
Type 1 diabetic, 4 miscarriages, very tight BG control
"“You lost the baby this time because of your hight blood sugar, but later if you are able to control your sugar you should be able to keep the baby. Would that be a good thing?”"
This suggestion to me sounds great except for the final question - asking a woman who's just had her baby die whether not having her baby live next time (and btw, the baby is not "lost", they're dead) would be "a good thing" is just a tad on the patronising side.
Also, should say "but later if you are able to control your sugar you should be able to keep ANOTHER baby" - babies are not interchangable.
I found your blog by doing a google search for erythema nodosum & stillborn. My fifth baby was recently stillborn (the first four, 3 girls & a boy, were all born healthy). My doctors and I have no idea why this happened. It was a pregnancy packed full of stress because we moved overseas a couple months before my due date, but there were never any signs of trouble. The day after taking the flight from Chicago to Paris, I got erythema nodosum (July 4, 2008). The doctors did a ton of tests once they figured out what it was but never found any cause for it. On Aug. 13, 2008, I delivered a stillborn baby boy. My sonogram on Aug. 7 showed that everything looked great. Stillbirth was the absolute last thing I could've expected. Have you found that an incidence of erythema nodosum can be associated with stillbirth? I'm just looking for some answers, which I know I may never find. Thanks for any help you can give.
I am a type 1 diabetic and my son was stillbirth at nearly 38 weeks last month. I think you are absolutely right to tell patients the very strong reasons for working hard on their sugars - ie that uncontrolled diabetes severely increases their risk of stillbirth.
However, I think you are dead wrong to even hint at a promise that they can keep the baby if they achieve good control. With my first pregnancy, my HBA1C was just above ideal levels, and my daughter is 22 months old now. With my second pregnancy, my control was in the 'optimal' range yet my son died inside me anyway. To have been given that near-promise by my doctor and then lost him would have made me feel lied to, on top of all the other agony.
I realize your patients might not be highly informed or seem very 'smart' to you, but please do them the respect of being honest about the inherent risks of their condition, even as you emphasize the benefits of good control.
Post a Comment
Links to this post:
Create a Link
<< Home