By Georgia Ragonetti-Zebell, MD
Making headlines this week is the $16 million verdict against Alabama’s Brookwood hospital for false advertising and injury during childbirth. But what is not being discussed is the impact this verdict will have on maternity care.
Pregnant with her fourth child in 2012, Caroline Malatesta made the decision to switch hospitals. She noticed the advertising of Brookwood Medical Center, which claimed to have a “unique ability to deliver your personalized birth experience.” Malatesta’s previous births had been more “traditional”, with an epidural and her feet in stirrups. Her friends spoke of very positive natural birthing experiences. She was looking for something different, so she asked her doctor at St. Vincent’s Health System. He told her that she didn’t have to get an epidural, but that was it. No water birth tubs or extra childbirth support. Continuous monitoring and delivery in stirrups. The rest was “silly”.
So she switched.
The night of her delivery at her new hospital, Brookwood Medical Center, did not go as she had planned. She had created a birth plan with her doctor, but her doctor was not on call that night. When she arrived, close to delivery, the nurses insisted that Malatesta lie down on her back to be monitored. When she got on her hands and knees, which was more comfortable, the nurse tried to move her to her back. This resulted in a struggle, during which Malatesta claims her baby was held in for six minutes. Once the on call doctor arrived, the baby was quickly born and was healthy.
Malatesta claims that the struggle with the nurses resulted in chronic pain, a condition called pudendal neuralgia, which has severely affected her life, including her sex life. She attempted to discuss her case with the hospital, but when her efforts were ignored, she resorted to a lawsuit.
The trial ended this week with a verdict of $16 million, $10 million for the false advertising of the hospital, $5 million for punitive damages for Caroline and $1 million for loss of consortium for her husband, JT.
Many are thrilled about this verdict, hoping that it will change the way women are treated in maternity care. I’m not so sure.
Three sides to every story
I have thought about this case quite a bit since I first read Caroline’s account. My initial thought was, “No way. No way a nurse held a baby in for six minutes.” She must have been “protecting the perineum”, supporting with a hand the skin beneath the vaginal opening to help prevent tearing. The hospital staff apparently did not deny that this happened, but simply said they could not recall the details of this case. Well, I can’t recall the details of the thousand or so deliveries I’ve done, but I can say with certainty that I’ve never held a baby in. It just not something I’ve ever seen or even heard of being done.
Caroline also states that the nurses tried to physically move her to her back. This also struck me as odd. I couldn’t envision nurses physically moving a woman to her back and holding her down, especially a woman without an epidural with control of her own limbs. Caroline describes the position she delivered in, with her right foot planted on the bed and her left knee being pushed into her chest. Ah. Now that I have seen. The nurses were trying to position her legs in lithotomy position, knees bent, pushed back, the typical delivery position.
I suspect Caroline’s injury is not necessarily from the length of time to delivery, but from the struggle. Babies sit in the vagina for far longer than six minutes all the time. In gynecology, we treat women with chronic pain on a regular basis, and it often stems from a traumatic event, such as sexual abuse or a difficult vaginal delivery.
The more I thought about why would the nurses do this or that and how Caroline must be mistaken, the more I decided that it didn’t matter. It doesn’t matter whether the nurse was protecting the perineum or was pushing the baby’s head back in. It doesn’t matter whether the nurses were forcing her down onto her back or were simply positioning her legs for delivery. What matters is that the nurses were touching Caroline in a way that was hurtful to her, that she asked them to stop and they didn’t. If there was some safety issue, that should have been communicated clearly, at the time, immediately after and during the trial.
That is what I can’t understand. I’m a gynecologist. It is implied by the nature of my profession that I will at some point touch a woman’s vagina. But if I start a pelvic exam, which is my job and the exact reason the patient came to see me, and she says “No…stop!”…I stop. Every time. So even though the assumption was there that Caroline agreed to the normal happenings of labor and delivery, at some point that agreement ended.
Many women have contacted Caroline with similar stories. So how did we get to this place of a “power struggle” during childbirth, where the wishes of the momma are at odds with the policies of the hospital? And why did the hospital advertise services that were not offered?
The power struggle
Caroline hits the nail on the head when she said “power struggle.” There is a power struggle happening in healthcare, and in society in general, and it is manifesting in the way some mommas are treated during their hospital stays. In the broader picture, women are told by lawmakers what they can and can’t do with their bodies. Power struggle. Women are limited financially, by way of their insurance carriers, or even state law, to certain care providers and hospitals, even though they might prefer to deliver somewhere else. Power struggle. Doctors are limited by insurance providers in what medications they can prescribe for their patients. Power struggle. Nurses and doctors are stretched thin, while hospital administration pushes to increase volume (by advertising services that aren’t offered, perhaps?). Power struggle. Nurses are working to provide compassionate care to their patients, only to be restricted by hospital policies. Power struggle. Doctors and hospitals struggle to provide evidence based care in a litigious environment, limiting appropriate interventions and overusing others. Power struggle. No wonder mommas are feeling it too.
Does all this mean that what happened to Caroline was okay? ABSOLUTELY NOT. But we need to address the roots of a problem to make it go away. I tend to give all parties the benefit of the doubt. I truly believe (because we actually sit around and talk about it) that all OBs and hospitals want their patients to have a beautiful birth experience. I believe that nurses have caring hearts and want nothing more than beautiful, healthy deliveries for their patients. And I believe that Caroline is just a momma who wants to know why she is in pain every day.
Why the verdict won’t change obstetrics
Unfortunately, this case won’t improve the problems that exist in obstetrics and healthcare in general. That is the problem with lawsuits. They may help the plaintiff feel vindicated, but often have unintended consequences. While I have no problem covering the medical costs of a complication, these large verdicts only further limit appropriate care. Sure, Brookwood might change their advertising, though from what I can see online, it seems just vague enough to apply to anything. But I fear the “winner” in this case is the St. Vincent’s OB. The one who said no. The one who said you can’t plan, your choices are limited, and this is how we do things, “silly” woman. I fear that OBs, at Brookwood and beyond, will now follow his example, because he didn’t get sued.
Every now and then, I read about a lawsuit that seems appropriate. Gross negligence, medical misconduct, lack of consent. And I absolutely support the patient’s right to sue in those cases. But most of the lawsuits I read about are simply bad outcomes despite everyone trying their best.
We have seen how lawsuits limit care. Large payouts for uterine rupture cases limit the availability of VBACs. Cases of alleged neurologic damage from deciding to do a cesarean too late have contributed to our skyrocketing section rate, and have made continuous monitoring the standard. If there is a gap in the strip, then something was must have been missed. These cases aren’t improving care; they are making it worse. It doesn’t seem to matter what is medically appropriate, but simply what is least likely to cause a lawsuit. And that goes both ways- doing whatever the patient wants, despite medical recommendations or pushing unnecessary and unwanted interventions to prevent lawsuits.
The Malatesta verdict will not give women more choices in maternity care. It will not make more doctors and nurses focus on evidence based medicine. The focus shifts to lawsuit prevention medicine. It will limit the number of doctors willing to accept a birth plan, because if the expectations in the birth plan don’t meet the reality of the delivery, you may end up writing a $16 million check. It will limit the number of hospitals trying to accommodate requests such as birthing tubs. It will not lead to more education of nurses and doctors on how to deliver sensitive, compassionate care. It will use up the already limited resources by costing the hospital millions in payout and increasing malpractice rates. And it certainly doesn’t improve the lack of respect that is rampant on all sides of healthcare.
I feel for Caroline and I absolutely understand why she chose to sue the hospital. But this is not a win. I understand that many women feel validated by the verdict, but in the broader picture, we are all still losing.
Georgia Ragonetti-Zebell, MD is an OB/GYN practicing in Upstate South Carolina, and is mommy to four (yes, FOUR) boys. She is a graduate of the Women’s Health Pathway at Drexel University College of Medicine in Philadelphia, Pennsylvania and completed her residency in Obstetrics and Gynecology with the Greenville Health System in Greenville, South Carolina. She has a special interest in natural childbirth, breastfeeding, and alternative methods in labor and delivery. She enjoys yoga, crochet, and reading, but spends most of her free time cleaning up poop while trying not to step on Legos.