Guideline-Centered Care: A Two-edged Sword

Most maternity care providers have heard of (and some will remember) the days of physician-dictated obstetrical care: routine perineal shaves, enemas, twilight sleep, prophylactic forceps, and mandatory postpartum bed rest. Although based on medical opinion at the time of what was best for women (beneficence), these interventions were derived from dogma rather than evidence. Happily over the last several decades, we have moved away from physician-directed care (based on real or perceived beneficence) defined by evidence, dogma, or anecdotal experience. Maternity care has evolved. Our goal has now become patient-centered care, based on a woman’s informed understanding of her clinical options and her autonomous consent. Practitioners have discarded most interventions based solely on dogma and have moved into the era of evidence-based medicine. As evidence accumulates, its translation to front-line clinicians has become a logistical challenge. In response, guidelines based on evidence and drafted by experts have become a welcome mainstay of clinical practice in the 21st century. With the advent of evidence-based medicine, however, there is a danger of straying into guideline-centered care; and guidelines vary considerably in their quality, tone, and directivity. The pedantic, simplistic 2001 breech guidelines of the American College of Obstetricians and Gynecologists (ACOG) (1) and the Royal College of Obstetricians and Gynaecologists (RCOG) (2) are examples of poor guidelines—poor because they accepted the term breech trial (3) hook, line, and sinker without adequate scientific skepticism, but more importantly, poor because they ignored external validity and parturient autonomy. In the term breech trial, all women with all breech fetuses in all settings were deemed to have the same intrinsic risk in labor, when this is not the case. Poor results from centers with inadequate resources following a liberal protocol do not have external validity in settings with better support and more cautious protocols. In a Kafkaesque perversion of informed consent, ACOG stated that if a woman refused a cesarean section, informed consent should be obtained (1). Clearly, any modern understanding of parturient autonomy and informed consent involves an up-front discussion of all options, including doing nothing, as part of the consent process. Thankfully, many clinicians are beginning to look more carefully at the relevance of evidence in their own settings (external validity), and are becoming conversant with quantifying small risks, informing women of these risks, and letting them decide what is the right decision based on their own values (parturient autonomy). Sometimes, honoring parturient autonomy means consciously defying a guideline—either because the setting differs from the evidence on which the guideline is based or the interpretation and woman’s acceptance of a particular risk-benefit balance differ from those of the authors of the guideline. Guidelines are due for (and are undergoing) a quantum leap by: Putting patient autonomy first. Explaining external validity concerns and limitations in varied environments. Exploring what it means to a patient if she does not follow the guideline; the default, but erroneous, perception of many women and caregivers, including senior obstetricians, is that “disobeying” guidelines always carries a high risk, when often this is not the case. Acknowledging that today’s recommendations may soon be trumped by new evidence. Because guidelines are often taken as gospel, particularly by the more conservative professionals in a health care system, perhaps they should include a prominent disclaimer explaining that parturient autonomy based on informed consent trumps any recommendation. The recent A Cochrane Pocketbook: Pregnancy and Childbirth (4) is full of such disclaimers, and the RCOG website introducing their Green-top Guidelines also now includes a helpful disclaimer: The Green-top guidelines are produced under the direction of the Guidelines Committee of the RCOG. The recommendations are not intended to dictate an exclusive course of management or treatment. They must be evaluated with reference to individual patient needs, resources and limitations unique to the institution and variations in local populations. It is hoped that this process of local ownership will help to incorporate these guidelines into routine practice (5). The updated 2006 RCOG Green-top Breech Guidelines and the 2009 SOGC Breech Guidelines explicitly demonstrate a commitment to parturient autonomy: If a unit is unable to offer the choice of a planned vaginal breech birth, women who wish to choose this option should be referred to a unit where this option is available (6, p 9). …a woman with a breech presentation should be informed of the risks and benefits of a trial of labour and elective C-section, and informed consent should be obtained. A woman’s choice of delivery mode should be respected… Women with a contraindication to a trial of labour should be advised to have a Caesarean section. Women choosing to labour despite this recommendation have a right to do so and should not be abandoned. They should be provided the best possible in-hospital care (7, p 559). Guidelines have become an essential part of busy, modern, evidence-based practice, and few of us could consider practicing without them; but it is important to keep in mind their limitations. A keen awareness of the evidence and a firm commitment to patient autonomy can compensate for a “bad” guideline, but too often practitioners pay uncritical obedience to the cookbooks. As guidelines begin to integrate external validity and patient autonomy, they are evolving into more than cookbooks. Along the way, clinicians must remain aware of their limitations in an effort to keep care patient- and woman-centered.

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