Q: Are there guidelines for ob/gyns doing cosmetic procedures, such as laser hair removal, body piercing, tattoo removal, and liposuction?
A: Since training for cosmetic procedures is not officially required in ob/gyn residencies, the American College of Obstetrics and Gynecology (ACOG) does not provide guidelines or recommendations for them. Physicians must always remember that if litigation arises from the performance of cosmetic procedures, they will be held to the standards of the specialty that govern the practices. Physicians should notify The Doctors Company if they intend to offer these services.
Q: When using a consent form for vaginal birth after cesarean (VBAC), how much information should be disclosed regarding possible risks and complications?
A: The consent form should list the common material risks, including the remote risk of serious disability or death to the mother and baby. When listing the risks, use “the risks include but are not limited to…” or similar language to denote that the list is not all-inclusive. Consider adding any risks that are applicable to a particular type of patient (for example, a diabetic patient may have delayed healing). For a sample VBAC consent form, go to our Informed Consent Resource Center at www.thedoctors.com/informedconsent.
Q: What is the physician’s responsibility when faced with a patient requesting a C-section (CDMR—cesarean delivery on maternal request)?
A: The physician’s responsibility includes a complete discussion of the benefits and risks of both vaginal and C-section deliveries. This discussion should take place during the prenatal period and should include such topics as damage to the pelvic floor, fear of neonatal injury or death, and increase in maternal morbidity during the present and future pregnancies. Due to the limited data available, ACOG does not have an official position on CDMR. The physician should determine the type of delivery that is in the patient’s best interest. If the physician objects to performing the procedure, he or she should refer the patient for a second opinion. The rationale for the plan of care should be documented.
Q: Does a physician need an informed consent form for use of an off-label drug, such as Cytotec for induction of labor?
A: Physicians should utilize an informed consent document whenever off-label drugs are used. Explain general information to the patient, including the manufacturer’s warnings, along with any ACOG affirmations regarding the drug’s safety and effectiveness. Encourage questions from the patient, and answer them fully.
Q: What is the physician’s responsibility when a parent requests confidential information about the treatment of his or her minor child (contraception, STDs, pregnancy, etc.)?
A: Physicians should be familiar with the statutes in their particular state. A policy and procedure specific to protected health information and the minor patient should be in place. For state-specific information, please contact your Patient Safety representative at (800) 421-2368, extension 1243.
Q: When is the proper time to address consent issues that might arise during labor and delivery, such as C-section and operative vaginal delivery?
A: The best time to address concerns about the birth process is during the prenatal period. At that time, the information can be discussed in a relaxed manner rather than during the stresses of the labor and delivery process. A written consent form should be used to document the process and should be an integral part of the prenatal record. Remember that the mother may revoke her consent at any time during the process.
Q: What does “immediately available” mean in ACOG’s VBAC guidelines?
A: ACOG has not defined immediately available in this context. Synonyms for immediately include instantaneous, at once, and now, so it is reasonable to interpret immediately available as follows:
In-house implies that the providers are able to come at once, without delay. Therefore, in some circumstances, in-house may be extended to include the hospital campus. Likewise, the physician and anesthesia and operating personnel may not be involved in another activity that stops them from coming at once, without delay. This means that there must be a dedicated physician, an anesthesiologist/anesthetist, and operating personnel at all times. If any of these providers are involved in other activities that they cannot leave right away, an immediate backup must be available.
Q: If a midwife is planning to perform a delivery under a physician’s supervision, who is responsible for obtaining the informed-consent document?
A: The person delivering the care is responsible for the informed-consent process. The patient should be informed that if problems arise during the pregnancy, labor, or delivery, the supervising physician will be available to intervene and provide medical treatment as is deemed necessary. If this situation occurs, the supervising physician would be responsible for the informed-consent process covering his or her involvement.
Q: What is the physician’s responsibility for follow-up on patients who have been ordered to have a yearly screening mammogram?
A: The responsibility remains the same as for any tests ordered by the physician. All testing should have a tracking system. If results are not received within a reasonable time, the patient should be contacted to see if the test was performed. The degree of physician responsibility depends on whether the test is screening versus indicated. If a screening test is ordered, a simple reminder may be considered a reasonable follow-up attempt. However, if the test is indicated by abnormal signs or symptoms, as in the case of a mammogram, the physician is obligated to continue with the follow-up procedure. Detailed documentation is necessary for all follow-up attempts.
The guidelines suggested here are not rules, do not constitute legal advice, and do not ensure a successful outcome. The ultimate decision regarding the appropriateness of any treatment must be made by each healthcare provider in light of all circumstances prevailing in the individual situation and in accordance with the laws of the jurisdiction in which the care is rendered.