Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

Nature Knows Best: The Problem with Unnecessary and Early Induction/Cesarean February 27, 2009

I recently stumbled upon an article on TIME.com published back in January 2009 (I know, I know, a bit late J) entitled The Risks of Early C-Sections by Alice Park.  If you haven’t seen it, it’s a short article and a quick read.  In the article, Park reports on a study conducted by researchers at University of Alabama at Birmingham (UAB) and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) that was published in the New England Journal of Medicine which found out of a sample of 13,258 pregnant women who had had a prior cesarean section, 36% elected to schedule their next c-section delivery (with the support of their physicians) before 39 weeks of gestation, which is the safety cutoff recommended by the American College of Obstetrics and Gynecology (ACOG).  Park writes, “ACOG’s guideline is based on studies showing that prior to 39 weeks, babies’ lungs are often too undeveloped to function properly outside the womb, and babies at this age tend to have difficulty regulating their blood sugar.

 

Park quotes Dr. Alan Tita from the research team in saying, “The fact that one-third of elective cesareans were done before 39 weeks was surprising.”  After all, the research shows that babies delivered at 37 weeks by elective C-section were twice as likely as those born at 39 weeks to have complications, “ranging from respiratory problems, heart issues, sepsis and seizures — conditions that typically require resuscitation or ventilator support in a neonatal intensive care unit”.  Contrary to Dr. Tita’s reaction however, when I read about the findings of the study, my reaction was completely opposite; I wasn’t surprised at all.

  

What the article did not touch on is the scary fact that there is a growing trend among the obstetrical community of both scheduling cesareans AND elective labor inductions (that is, inductions with no maternal or fetal health indication) BEFORE the recommended guideline of 39 weeks.  So to the OBGYNS of this country I have a question for you: Let me get this straight… you mean to tell me that you are willing to aggressively defend and follow guidelines adopted by ACOG that are UNSUPPORTED by research (for example, that planned homebirths for low risk uncomplicated pregnancies, attended by a qualified and licensed midwife are more dangerous than hospital births) BUT when your organization actually adopts an appropriate guideline that is supported by research, you just ignore it? 

 

Does anyone else find this hypocrisy as OUTRAGEOUS as I do?  The scary truth is that this mind-set is (regrettably) just another common thread among the over-medicalized obstetrical model of care that sadly controls the maternity care system of our country.  Too many OBGYNs just do whatever they want, with complete disregard for maternal and fetal safety (even though they claim that it is their main concern) as well as complete disregard for evidenced-based research. 

  

I will digress for a moment to share with you a situation I found myself in as a labor and delivery nurse this past Christmas.  (As always, the names and any identifying information have been changed to protect confidentiality).  I arrived to work in the late morning as usual and was informed by the charge nurse that I would be admitting an induction into room 12.  Since it was Christmas I asked why she was being induced; After all, we do not schedule any inductions on holidays unless there is an urgent medical indication for delivery.  “I don’t know, because Dr. N is sick of listening to her I guess,” she frustratingly stated as she rolled her eyes.  Turns out the patient was triaged at our hospital the day before and was sent home for “false” labor since she remained only 2 centimeters dilated with an irregular contraction pattern after two hours of walking the halls.  Apparently after yet another sleepless night she had called Dr. N and stated “I am coming into the hospital today and if you don’t agree to induce me, I will refuse to leave!  I am too uncomfortable and am DONE with this pregnancy.”  When I questioned Dr. N about the situation, pointing out the fact that there was no medial indication for this induction and in fact, the patient was still only 2 centimeters and contracting irregularly every 8-15 minutes he said, “I have to give her what she wants.”  Excuse me…WHAT?  And furthermore when I pointed out the fact that the patient’s gestational age was only 38 weeks and 1 day he snidely remarked, “Don’t you worry, I’ll take the rap for it when it gets flagged and brought up in the peer review board.”  And do you know why he said this so nonchalantly?  Because that committee is made up of a bunch of other OBGYNs who don’t like anyone breathing down their backs and therefore, will only give him, at most, a slap on the wrist.  And that is EXACTLY what happened.  Talk about driving up healthcare costs; Not only were they were paying me double time and a half to be there on Christmas day but that baby boy ended up going to NICU for a “pitstop” for grunting and retracting (a sign of respiratory distress) within an hour of delivery!

 

 I would like to take a moment to share the fact that I have never been pregnant and therefore have never personally experienced the discomforts of pregnancy first hand.  Despite this I personally hold all pregnant mothers in high regard and have the utmost respect for the physical and emotional sacrifices that a pregnant mother has to make in the weeks that she is with child.  I feel that as a professional who works with pregnant mothers it is my responsibility to support and aid a mother through her journey in any way possible and if any woman complains or comments about her discomforts and pains, I make a conscious effort to provide compassionate and empathetic care and comfort to that mother.  In my opinion they certainly have good reason to grumble at times! 

  

That being said…I personally feel that the physical and emotional discomforts of pregnancy (although intense and very real) are all part of the deal and it is just one of the many sacrifices parents will have to make in their lifetime for their children.  Just ask any new mom…If you think it is hard to get a full nights sleep while pregnant, just wait until you have a newborn!  Basically what I am getting at is this: although I have the utmost respect and empathy for how uncomfortable pregnancy can be (heartburn, Braxton-Hicks, morning sickness, hemorrhoids, stretch marks, fatigue, backaches, leg cramps, varicose veins, swelling, shortness of breath, dizziness, the list goes on and on), these discomforts are NOT a good enough reason to end a pregnancy early when the risks for the baby are so high.  Likewise, for a physician to agree to an early induction or elective cesarean or even worse, to promote it (trust me, it happens!) is sooooooo wrong.  Although I agree with the article when Park writes, “Although most obstetricians are disinclined to schedule c-sections prior to 39 weeks, they still feel pressured by their patients to do so,” there are also many women who feel pressured by their physicians to undergo unnecessary labor inductions and elective cesareans, often under the guise of a bogus medical indication.  (My personal favorite is when physicians set up an induction for a woman for “preeclampsia” when every laboratory test we do on the patient shows that at most she might have “pregnancy induced hypertension” (which can be watched and controlled with simple medications and is NOT an indication for urgent delivery) and at least she might have had just one out-of-wack blood pressure in the office!  The list of these flagrant offenses goes on and on…) 

 

I have heard it with my own two ears; Doctors saying things similar to “Well you’ve got to give these women what they want or they will sue!”, or “The patients are calling the shots not me, it’s out of my hands!”  I mean COME ON!  Are they serious??!!!  That is so far from the truth it is LAUGHABLE.  First of all these types of excuses are LAME and UNACCEPTBABLE.  Doctors take the Hippocratic oath to “First Do No Harm” and agreeing to order, manage, and perform unnecessary early elective cesareans and labor inductions is negligent, irresponsible, and dangerous.  Tell me, if the fear of litigation is so strong in this country as to so powerfully influence a “defensive” and “litigation driven” approach to obstetrical care, why o why would any OBGYN agree to any unnecessary procedure that is shown, through research, to place the baby at high risk for complications?

 

Furthermore, if a physician refuses to perform an unnecessary early induction or cesarean for a mother who is demanding one, what can she really do?  It is very unlikely that she could change doctors since there are very few practices that will accept what is referred to as a “late transfer of care.”  Some doctors say they fear litigation.  Could you imagine that?  How absolutely unfounded and preposterous!  On what grounds could the mother actually win the suit?  I can see the opening statement now: “My client is suing this doctor for not performing an unsafe early labor induction/elective cesarean.  You see, your honor, her back hurt ‘really bad’ and she was ‘just sick of being pregnant.’  Clearly this doctor should be locked up for correctly following the evidenced based research that supports his decision!” Absurd!

  

In conclusion, I would like to say one thing to all the women and obstetricians out there desiring and performing unnecessary early elective cesareans and labor inductions: Nature Knows BEST!

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4 Responses to “Nature Knows Best: The Problem with Unnecessary and Early Induction/Cesarean”

  1. Renee Says:

    I figure if you are not willing to stick it out for the few extra weeks, after making it all that way, to protect your baby’s health, why bother having kids? (I know it’s not always planned, but don’t you feel some sense of obligation to them at that point?) I would cut my arm off for my daughter if I had to, pregnancy discomfort is nothing compared to protecting them.

  2. Stephanie Says:

    I remember the last time I was pregnant everybody due near the same time as me ended up being induced for some reason or other weeks early. I couldn’t believe how these women would just let their doctors do that without asking for any other opinions (my favorite being my cousin who’s baby was suddenly ‘past-due’ at her 37 week check up then was delivered via c-section with under developed lungs…sure sounded ‘past due’). As well as those who just weren’t comfortable anymore…it drove me nuts as well as making it feel like mine was even longer because these women were supposed to be having there babies close to mine – not a month earlier. It seems like the risks of preterm delivery are down played a lot with doctors pushing more and more that you are ‘past due’ way before your really are. Thanks for raising awareness on this.

  3. Katherine Says:

    I am an L&D nurse (on hiatus at the moment), and I see the complaints all the time! Thankfully, my career has been all in military hospitals, and most of the time the teaching hospitals have no problem whatsoever turning TOBP people away if they’ve no other complaint than that, but the staff clinic doctors will sneak some in if they get a good sob story. (TOBP–Tired Of Being Pregnant)

    I think people just don’t understand that 37 weeks isn’t some magical point where everything is absolutely risk-free and clear sailing. They just don’t get it. Of course, I do understand some of the fears the doctor has–one pointed out to me that if she sends someone away for what seem to be minor complaints, how is she going to deal if that woman shows up IUFD next week? They are haunted with the fear that something bad will happen when the patients are badgering them.

    I really enjoy your blog and will be browsing more!


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