Court Opinion

ID: 9638272
Source: CourtListenerOpinion
Date Created: 2023-08-22 15:39:21.363648+00
Date Added: 2024-06-11T18:10:05.191806
License: Public Domain

THOMPSON, Associate Judge,
concurring:
I join in the opinion written by Judge Fisher, but I write separately, in response to Judge Ruiz’s dissent, to underscore several points.
First, there is no dispute that Dr. Mio-dovnik’s review of the nurse-midwife’s notes on Ms. Abdul-Haqq was a routine review. Ms. Abdul-Haqq’s case was one of several presented at the meeting with Dr. Miodovnik, and nothing in the record suggests that anyone viewed this as a complicated case, a case of a type the nurse-midwives had not seen before, or a case involving risks with which the nurse-midwives were unfamiliar. Quite the contrary, the record shows that DCBC had given Ms. Abdul-Haqq a consent form that particularly addressed the risks associated not only with a first VBAC, but also with a vaginal birth after two cesarean sections.
Second, it is important to describe in detail what the DCBC consent form signed by Ms. Abdul-Haqq disclosed to her. It disclosed inter alia that:
A tear or opening in the uterus (womb) occurs in 5 to 10 women out of every 1,000 low risk women who try VBAC (0.5% to 1.0%)_Risks to the baby if there is a tear of the uterus are brain damage and death.... About 10% of the time the baby is harmed when the uterus tears.... The risk of your uterus tearing during labor is increased with any of the following: ... More than 1 previous cesarean section .... If a vaginal birth cannot occur, then a cesarean birth must be done. The risk of infection is doubled when a cesarean delivery is done after labor rather than before labor.
(Italics added.) Given what DCBC told its patient Ms. Abdul-Haqq on this form (which she signed), I see no basis for holding that Dr. Miodovnik’s differing perception of the risk a VBAC presented gave rise to the claimed duty to Ms. Abdul-Haqq.
Third, an important fact in this case is that Ms. Abdul-Haqq “very much wanted to have a vaginal birth.” That was her choice to make, notwithstanding the risks and notwithstanding the statement in the American College of Obstetricians and Gynecologists (ACOG) Practice Bulletin that a trial of labor is “contraindicated” after a cesarean section. Cf. Miller-McGee v. Washington Hosp. Ctr., 920 A.2d 430, 442 (D.C.2007) (rejecting, as premise of claim that patient would have had no choice but to consent to a forceps-assisted vaginal delivery, argument “that a c-section was not an alternative for appellant because ‘a *998c-section is not offered to a patient as an alternative to vaginal delivery or assisted vaginal delivery unless for some reason surgery is medically necessary,’ ” since the argument “suggests that professional custom or practice alone [to the exclusion of patient self-determination] may dictate whether the obstetrical patient has an alternative”). And, the record does not contain standard-of-care testimony that allowing a trial of labor after two cesarean sections where the patient understands the risks and chooses that course violates the standard of care.1 So it cannot be assumed that Dr. Miodovnik had a duty— whether arising from knowledge that the nurse-midwives took his advice very seriously, or from knowledge that the nurse-midwives “did what he advised them to do,” or from his persuasive abilities — to make some type of effort to assure that the course of treatment was a cesarean.
Fourth, contrary to the statement in the dissent that Dr. Miodovnik did not “record the request he claims he made for Nurse-Midwife Alexander to impress on Ms. Abdul-Haqq the serious risks of attempting labor and vaginal delivery,” Dr. Miodov-nik’s notes do corroborate his statement. His recommended plan was that the “patient understand”2 the risk of VBAC after a second cesarean section (and that prophylactic antibiotics be given during labor, if the patient continued to want a trial of labor). Assuming that Dr. Miodovnik had a duty to recommend a plan, I think there is no genuine issue that he did so.
Fifth, although plaintiffs alleged in their complaint that Dr. Miodovnik “fail[ed] to recognize the risks associated with allowing Plaintiff to deliver vaginally,” the record belies that claim. As to plaintiffs’ claim that Dr. Miodovnik “fail[ed] to give proper advice in consulting with [DCBC],” I believe Judge Fisher has aptly characterized the claim as one that Dr. Miodov-nik did not intervene — either by “ordering] the scheduled surgical delivery that Ms. Abdul-Haqq clearly required” (a quote from appellants’ brief), instructing the midwives not to assist Ms. Abdul-Haqq with a vaginal delivery, ordering that Ms. Abdul-Haqq be told that she must have a cesarean, following up with the nurse-midwives to make sure they had reiterated the risks to Ms. Abdul-Haqq, or, perhaps, making sure that Ms. Abdul-Haqq heard an opinion attributed to Dr. Miodovnik. I believe the majority opinion rightly declines to recognize a duty to do any of those things in light of the nurse-midwives’ independent responsibility for the care of their patients. I find persuasive the comments of amici American College of Nurse-Midwives and American Association of Birth Centers that, although *999only a surgeon may perform a cesarean section, it is within the scope of practice of certified nurse midwives to “determin[e] whether a client requires a cesarean section.” And, as Judge Fisher correctly notes, “nothing in [the] MOUs either authorized or obligated Dr. Miodovnik to usurp control over the care and treatment of DCBC clients.”
Finally, I respond to the observation in the dissent that Ms. Abdul-Haqq “readily agreed” to a cesarean section after Dr. Leslie advised her of the risk of attempting a vaginal delivery, and the statement that “had [such advice] been given timely, [it] likely would have averted the tragedy in this case.” I would observe (and I think anyone who has undergone labor can attest) that a woman’s readiness, once labor is upon her, to consent to a procedure she did not previously want, probably says more about the pain and anxiety attendant to labor than about the adequacy or inadequacy of previous warnings and advice.3 More to the point, the fact that Ms. Abdul-Haqq readily agreed to a cesarean after she went into labor does not support a conclusion that Dr. Miodovnik owed a duty to her.

. Both the majority opinion and the dissent note Dr. Miodovnik's testimony that VBAC "under standard of care ... was not allowed ... [bjecause it’s clearly said, by ACOG, that if you have two caesarean sections without vaginal delivery, it is contraindicated of VBAC.” But Dr. Miodovnik was not testifying as a standard-of-care expert, and to say that a procedure is "contraindicated” is not necessarily to say that allowing it or performing it violates the standard of care. Cf. Wyszomierski v. Siracusa, 290 Conn. 225, 963 A.2d 943, 950 (2009) ("The word 'contraindicate' simply means 'to make (a treatment or procedure) inadvisable.’ ... [W]e reject the plaintiff's argument that testimony regarding contraindications implicated the relevant standard of care”).

. My colleagues add a “[sic]” to the quotation at this point, as if Dr. Miodovnik was merely observing that the "patient understands the risks.” I think the notation in the "Plan” section of Dr. Miodovnik’s notes is more reasonably read to reflect use of the subjunctive: Dr. Miodovnik’s recommended plan that "the patient understand” — i.e., be made to understand — "that the risk of VBAC after two cesarean section is much higher for uterine rupture — fetal death.”

. I note that in addition to signing the DCBC consent form, Ms. Abdul-Haqq initialed a line stating, "If I choose a VBAC, this consent will be reviewed as needed during the labor. I may want to ask for a repeat cesarean section or my doctor may find a need to deliver my baby by cesarean section."