Lecture 15 Flashcards
Legally speaking, when does a fetus become a person?
not until its fully born, separated from the mother, and living independently.
What do obstetricians currently regard their fetus as?
as a second patient.
What are the problems with treating a fetus like a second patient? (4 things)
- Health care providers become responsible for negative fetal/newborn outcomes - and therefore vulnerable to lawsuits
- Creates a conflict between health care providers and pregnant women who decide to refuse medical treatment.
- providers see themselves as advocates for the
baby
-can resort to court orders to force invasive interventions on pregnant women for the perceived benefit of the fetus
Explain the Georgia case. Where did Jessie attribute her authority?
- Jessie Mae Jefferson was due to deliver her child in 4 days
- her religious belief was that the Lord had healed her body and whatever happened to the child was the Lord’s will
- the hospital where she was scheduled to deliver sought a court order authorizing it to perform a cesarean section should she enter the hospital and refuse
- at an emergency hearing conducted at the hospital, her examining physician testified that
- she had complete placenta previa, based on ultrasound scan
- there was a 99% chance that the fetus would die during a vaginal delivery
- there was a 50% chance the mother would die too
The parents immediately appealed the decision to the Supreme Court of Georgia
* On the evening of the same day as the emergency hearing, the Court denied their appeal (stayed the State Court order), stating:
“…we weighed the right of the mother to practice her religion and to refuse surgery on herself, against her unborn child’s right to live. We found in favor of her child’s right to live.”
- A few days later…
- Mrs. Jefferson uneventfully delivered a healthy baby without surgical intervention
- A second ultrasound scan after the emergency hearings found that her placenta had moved so that cesarean delivery was no longer indicated
- Doctors had testified at the emergency hearings that it was “highly and virtually impossible” for the condition to reverse itself
The woman attributed authority to god instead of the medical authorities.
What is placenta previa?
placenta previa. Previa means before so the placenta comes before the baby’s head. It’s an uncommon condition but it can happen.
LOOK AT DIAGRAM ON SLIDE 7
In the Georgia case, What do you think most likely happened?Why?
A) The first ultrasound and its interpretation was inaccurate
B) The second ultrasound and its interpretation was inaccurate
C) The placenta moved between the first and second ultrasound D) God intervened
the answer is probably A because it is very unlikely that the placenta can move. The testimony was accurate in that sense. I is nearly impossible because the blood vessels attach the placenta to the uterus. There is no way the blood vessels will grow, extend, remove themselves, and then reattach themselves. There is some movability of the periphery of the placenta but the general position will be the same.
What is complete previa? Partial previa? Marginal previa? Low-lying placenta?
LOOK AT SLIDE 12
Why can we be so wrong about what we see in ultrasounds? Why is this particularly true for the placenta?
This is why we can be so wrong aboit the ultrasound. It’s not a crystal clear image like the drawings. It’s a realy judgement call. If you have expertise you can tell things apart but there is still a lot of interpretation that goes into the ultrasounds.
bone is a lot easier to detect that the soft tissues like the placenta through an ultrasound. You can see the skull and cartilige but the soft tissue blends into the rest of the soft tissue which makes it very hard to get right.
How is ultrasound measured? What information do people use to interpret them? What is the frequency used? What is the signal we get back? What is difficult with ultrasound?
ultrasound is a form of sonography and it uses sound waves with frequencies higher than those audible to humans (>20,000 Hz)
Sends pulses of ultrasound into tissue using a probe
When a sound wave encounters a material with a different density (acoustical impedance), part of the sound wave is reflected back to the probe and is detected as an echo
the deeper the sound wave gets . The more the signal is lost from the acoustic absrption. Everytime the signal echoes, when there is a change in tissue less signal goes forward so there is less to bounce back meaning the deeper we go, it will be harder to detect.
the greater the difference in density, the greater the echo
as the sound waves goes to the fetus it goes through skin, amniotic fluid, bone, etc. When the sound wave encounters material with different density (AK one kind of tissue to another etc. (Aka tissue to fluid goes from high density to less density). When the thing passes through something higher density to less density it provides an echo.Thats why we get a good sense of the bones because the bones are a lot harder than the soft tissue.
- seeing deep into the body with sonography is very difficult: most of the signal is lost from acoustic absorption
- can produce false positives, as well as misses
What is the density of the placenta in relation to the density of the uterus? What implications does this have for ultrasounds?
the placenta has pretty siilar density to the uterus whihc is why it is so easy to make this mistake.
What did the ultrasoudn produce in the georgia case?
a false positive
What was the situation in which people believe that placenta previa was missed?What is one of the guesses for why the baby was okay?
The placenta previa was missed clinically and by ultrasound at 35 weeks
After successful vaginal delivery, a large hole in the middle of the placenta was noted, through which the fetus presumably delivered
from what we know about the vasculature, one of the guesses for why it ended up okay, because of the way the baby sits, the vasculature itslef may have remodeled.
Explain the pennsylvania case.
Amber Marlowe: The Pennsylvania Case
- went into labor on Jan 14, 2004
- after an ultrasound, doctors decided that the baby was to too big to deliver vaginally, ~13 pounds
In the case they made a diagnosis of the baby’s weight from the ultrasound based on the size of the baby.
- Amber was told she needed a cesarean
- She already had given birth to 6 babies babies vaginally, each close to 12 pounds
“All my others, I’ve done naturally,” Amber recalled telling her physicians. “I know I can do it.”
- Amber and her husband checked out against the doctors’ advice and went looking for another hospital
- meanwhile, the hospital’s lawyers obtained legal guardianship of her unborn child
- a court allowed the hospital to force Amber into surgery if she returned
(Once you get to the hospital you are admitted. it’s like a hospital. Typically you get discharged with formal permission but they just left the hospital)
- at another hospital, Amber had a quick, natural birth she described as “a piece of cake”
- she didn’t know about the first hospital’s action until her husband was told by a reporter
“They don’t know me from anything, and they’re making decisions about my body?” she said. “It was terrifying.”
In the penssylvania case, where did amber invest her authority?
in her own body.
What do the georgia and pennsylvania cases tell us?
This is a good case because it gives you a sense of how the spectrum of birth experience is based on where you invest authority.
