Continuation of the “Injustice in Maternity Care” Series
Throughout my time as a labor and delivery nurse at a large urban hospital in the Northeast, I have mentally tallied up a list of patients and circumstances that make me go “WHAT!?! Are you SERIOUS!? Oh come ON!” Because of this I was inspired to start the “Injustice in Maternity Care” blog series, or more appropriately the “Don’t Let This Happen to You” series. If you are pregnant or planning on becoming pregnant, this series is dedicated to you! If haven’t already read it, I invite you to check out the first addition to the countdown: DLTHTY #25: Sarah & John’s Unnecessary Induction.
I was recently part of what I consider to be an absolutely unnecessary repeat cesarean section and a true example of what I consider the “control phenomenon” in today’s maternity care culture. This very real trend stems from the fact that obstetricians (trained surgeons who are the only birth attendants capable of performing a cesarean section) have professional motivation and incentive to promote and perform interventions that only they can provide, hence increasing their control (e.g. vacuum or forceps deliveries and cesarean sections) as well as discourage and lobby against choices in childbirth that decrease their control and increase the control of the childbearing family (e.g. homebirth, natural/unmedicated birth, and VBAC). After all, any properly trained birth attendant can attend a VBAC (including midwives and family practice physicians) but ONLY obstetricians can perform cesarean sections. In their groundbreaking book Silent Knife: Cesarean Prevention & Vaginal Birth After Cesarean, authors Nancy Wainer Cohen & Lois J. Estner describe this phenomenon,
“Cesareans are done for many reasons. In addition to the legitimate ones, they include power, control, money, fear, and prestige. However, we believe that the most important reason is that most physicians totally lack understanding and respect for women and for birth. [Routine] Repeat cesareans are done for the same reasons, with risk of uterine rupture the excuse for this deplorable crime. Vaginal birth after cesarean (VBAC) is not only safe, but generally safer than its alternative. In spite of the research and evidence and documentation that appear on this subject, most obstetricians in this country continue to perform repeat cesareans simply because a woman has been previously sectioned. There is always an excuse, it seems, why a woman cannot be a candidate for VBAC. We know that most women who have had a cesarean are capable of delivering vaginally. This includes women with a diagnosis of cephalo-pelvic disproportion (CPD), prolonged labor (failure to progress), or more than one previous cesarean.”
Now that the stage is set, let’s begin the story…
It was a beautiful and sunny weekend morning and I arrived to the hospital, changed into scrubs, and punched in at 11:00am as usual. As I was looking over the patient assignment sheet, a young Russian** couple came to the desk. Both had very thick accents and it was quickly evident that the husband spoke better English than his wife. The husband described a “large gush of water” that fell all over the floor as she was making breakfast. The young woman stated that she had put a towel in her pants that was now “very wet” and that she started having “pains” about 10 minutes after the leaking started, which happened to be around 10:40. While at their house they then called their doctor who instructed them to come right to the hospital since, if she did break her water, she was going to be sent for a cesarean section today because she had a history of a previous cesarean section. (In fact her “repeat” date was scheduled for the next week where she would be 39 weeks in gestation.)
I was asked by the charge nurse to escort the patient and her husband down to one of the triage rooms near the operating room (OR) (just incase she was indeed ruptured) and to pass her off to another nurse who would be waiting for her there. I introduced myself to both the woman and her husband and asked the woman if she wanted a wheelchair. She declined and although she was very quiet, almost stoic during our short journey, I could tell by her walk that she was very uncomfortable. After I gave the woman a gown and assisted her into the bathroom, I told all I knew to her nurse Sally and went back to the main desk.
For the next hour I was unassigned to any patients so I spent that time assisting other nurses. Around noon I was assisting a fellow nurse whose patient was delivering when I got called out of the room by the charge nurse. “We’ve got to run two rooms in the back and I’m going to need you to be ‘baby nurse’ for Dr. W’s case, the patient in room 2.”
(Note: At my hospital we have three operating rooms on labor and delivery. We try our best to only run one room at a time, if urgency and time allows us, since running two rooms can really put a strain on the staff. To run two rooms at the same time you need 6 nurses total, three for each room (a scrub nurse, a circulating nurse, and a baby nurse). The scrub nurse actually scrubs into the surgery and assists the surgeon by passing him/her instruments and sutures. The circulating nurse usually is the nurse that knows the most about the patient and her job is to coordinate procedures and ensure the patient’s safety and comfort. The “baby nurse” assists the anesthesiologist with administering anesthesia, preps the patient for surgery, and the gowns up to “catch” the baby from the surgeon, and then brings him over to the warmer to assess him. Even though we have an OR team Monday through Friday during the day shift, between running the OR, staffing the recovery room, and admitting the next case, the OR team doesn’t always have enough nurses to run two rooms and in that circumstance the charge nurse has to pull nurses from the floor. Therefore if we were running two rooms, I knew that something must be happening with one or both of the cases that increased their urgency.)
I grabbed my OR hat and mask and walked down towards the OR to talk to the circulating nurse and re-introduce myself to the patient (something I try to do if at all possible before they enter the OR). The circulating nurse, Sally, was at the desk and gave me a very abbreviated report, “Her name is Alona. She is a G2P1 at 37 weeks and 6 days and her first baby was delivered via cesarean for ‘failure to progress/failure to descent’ per her prenatal summary. Her husband, Dmitry, told me that the doctor told them the reason she needed a cesarean the first time was that his wife’s ‘vagina was too small.’ They are both graduate students at XU. She’s got an unremarkable history. She’s scheduled for a repeat cesarean next week so we’re going to the OR. We’re gonna move in about five minutes.”
As I walked into the patient’s room, I quickly realized why everyone was rushing around…the patient was huffing and puffing through her contractions. She was still on the monitors at this time and I noticed that her contractions were coming every 2-3 minutes with nature as the only influence acting upon them. As I stuck out my hand to re-introduce myself to the couple I had escorted here not one our ago, I realized that the patient was uncontrollably grunting and pushing at the peak of her contractions. At this point the circulating nurse came in to administer her pre-operative antibiotic, followed by the anesthesia resident who started to unplug the bed from the wall. My mind was racing…this woman is in LABOR! This woman is PUSHING! Why is everyone ignoring this?! At this point the anesthesia resident and the circulating nurse started to wheel the patient out of the room and I was having none of that!
Me: “Sally, she’s pushing.”
Me: “She’s pushing! We need to get her checked. We can’t wheel her back there like this.”
Sally: “We just checked her 20 minutes ago and she was 5cm/90%/0 station.”
Me: “Was she pushing 20 minutes ago?”
Sally: “Well no but…”
Me: “Well then I don’t care how long it has been since you last checked her! We need a resident in here to check her!!!” (Note: At our hospital, because we have residents, we are actually not allowed to check our own patients even if we have the skills to do it! I am not exaggerating. The head of the residency program feels that if nurses check their own patients then residents won’t get enough “experience.” Therefore new nurses are not even taught how to perform a vaginal exam during orientation. I feel that this is absolutely absurd and just another way the OBGYN department attempts to maintain the utmost control over all situations. But I digress…)
At this point Sally poked her head out of the door and motioned for the resident to come in. I was holding Alona’s hand and trying to coach her breathing, in, out, in, out, in, out…
Me: “Alona, we are going to do a quick vaginal exam to make sure the baby isn’t coming, is that okay?”
Dmitry (the husband): “The baby can’t come out! Her vagina is too small!”
Me: “Sir, it’s going to be okay. Every baby is different. Her vagina is not too small.”
And then the resident said the most OUTRAGEOUS thing I have ever heard…
Kate, the resident: “She’s 8cm/100%/ +1 station and that’s without a contraction. If we don’t get her to the back right now, she’s going to have this baby! Let’s go!”
[Have you ever watched a show and the cartoon character does a “double take” where they shake their head really fast back and forth and it makes a sound like something is rattling in their head? I swear I did that when I heard the resident say that and I actually said out loud, “WHAT?!!? That is ridiculous!”]
Me: “Kate, we’ve got to get Dr. W in here to talk to her.”
Kate: “Dr. W wants to do a cesarean.”
Me: “Yeah, but don’t you think it’s more important to do what the patient wants?! I think circumstances have changed enough to where someone should reevaluate this situation with her!”
[Kate left the room to go talk to Dr. W, as I think I made her really uncomfortable by calling her out and bringing up the patient’s needs. God forbid!! I poked my head out of the room to hear his answer.]
Kate: “Dr. W, she is 8/100/+1. Should we counsel her about a vaginal delivery?”
Dr. W: (really frustrated and almost offended at even the thought) “NO! We’re doing a repeat! WHAT ARE YOU WAITING FOR, GET HER TO THE BACK!”
(Note: “The back” is hospital lingo for the operating room)
On that note Sally and the anesthesia resident continued to wheel her out of the room and through the double doors to the operating room. At this point I really thought I was going to start to cry. There have only been a few times that I have cried at work (I’ve cried a lot more at home!) but this situation was really hitting a cord with me. As we were wheeling the patient down the hall I looked at her and her husband and said, “Alona, you are 8 centimeters. You do not have to have surgery if you do not want to. This is your choice.” Alona just stayed silent, and kept looking at her husband. Perhaps this was a cultural thing, perhaps she was scared, perhaps she was too much in the throws of transition to hear any word I was saying. We entered the OR at 12:30pm. Sally and the resident pushed the bed up against the OR table and instructed the patient to move over. Again, I held onto Alona’s hand, looked her in the eye, and said, “Alona, it’s not too late. If you need more time to think about things we can give it to you. If you want to talk to Dr. W about your options we can do that.” Then I looked at Dmitry and said, “Dmitry, she is 8 centimeters now. We do not have to do this surgery if she want to try to have the baby vaginally.” But Alona just kept looking at her husband (who was allowed in the OR at this point because we needed him to help translate since Alona kept throwing down the language line phone during a contraction!) and he looked back at me and said “No, the doctor said she must have surgery!”
And you know what?! I don’t blame them one bit for not even listening to me. After all, I am essentially a stranger, perhaps some kooky nurse to them whom they have never even met, while Dr. W was their “trusted” doctor. If he couldn’t take (or didn’t want to take) the time to come in and talk about their options, then why should they listen to me!? I found out after the surgery, when I looked back into Alona’s prenatal summary and previous OR report, that Alona’s first cesarean was performed after a 2-day “failed induction” to where she only progressed to 3cm/50% effaced/ -3 station. A thorough review of the patient’s first OR report revealed a classic “cascade of interventions” including elective induction at 40.2 weeks with an unfavorable cervix for “postdates,” early amniotomy and pitocin administration after one cervidil placement, epidural for pain relief, fetal scalp electrode and intrauterine pressure catheter placement, and eventual cesarean section for “failure to progress/failure to descent.” Although I support women’s rights, patient autonomy, and choices in childbirth, if the only thing that Alona & Dmitry learned from their last delivery was that her vagina was “too small,” I highly refute any claim by ANYONE that this patient was provided with true informed consent and an honest debriefing on ALL the factors that did or could have contributed to her last cesarean section.
As I was assisting the anesthesiologist with the spinal by trying to keep a woman in transitional labor still (not an easy task), Dr. W burst through the OR doors, hands wet from scrubbing, and exclaimed in a most joyous way as he peered up at the clock on the wall, “Oh excellent! I can be out of here by half past one at the latest and still make it to my golf game!”
YES! HE ACTUALLY SAID THAT! AND THE PATIENT WAS AWAKE WITH HER HUSBAND IN THE ROOM!
After that I pretty much turned my emotions off; I couldn’t handle it and I had to focus on the task at hand. “Open” time for the surgery was 12:45pm. Alona & Dmitry’s baby boy was born at 12:50pm. “Close” time was 1:16pm. As soon as the last staple was placed, Dr. W ripped his gown off, thanked the resident and anesthesia, said a quick “Congratulations” to Alona & Dmitry, and bolted out of the room, leaving the resident as the only OBGYN to escort the patient out of surgery and write all the orders.
I gave the baby Apgars of 7 & 9 but at about 7 minutes old he started to have a bit of a difficult time clearing his secretions and his oxygen saturation started to dropped so I had to suction him a couple of times. The scale showed the baby weighed 7lbs, 3oz. When it was time to leave the OR, I wrapped up the baby and walked out with the patient and her husband. I had to keep him on the warmer in the recovery room for only about 10 minutes, basically, the time it took the team to hook her up to the monitors, do a fundal (“belly”) check, and give her some pain medication. I then put the baby skin to skin with Alona under her gown and his vitals stabilized quite well after that.
All in all despite the fact that Alona, Dmitry, and baby all appeared to be happy and healthy after surgery, my personal belief is that they were victims of medical malpractice and the current unjust maternity care system in this country. I know malpractice is a loaded term but I think it describes the situation very well: “mal” = bad practice. That is one of my biggest concerns with the rising rate of scheduled repeat cesarean sections. Once the date is set it’s like everyone has blinders on; the excuse “But she is scheduled for surgery” doesnt mean she qualifies for it now! For one, consenting a patient for major abdominal surgery PRE-LABOR in the office and treating it as the absolute only course of action regardless of what situations might arise to the contrary is WRONG. I can safely bet that when Alona “agreed” to a repeat in the office that she was mislead into thinking or mistaken that things were automatically going to go exactly the way they did last time . I can safetly bet that she did not expect to show up to the hospital after going into labor spontaneously and progress from 5 to 8 centimeters in a matter of 20 minutes when she was “counseled” (term used VERY lightly) about her options and “consented” (again, used lightly) to a repeat cesarean section months before. And you know what, if she had shown up at 10 centimeters with a head on the perineum I KNOW that her doctor would have STILL rushed her off to surgery even so because I see it happen at work ALL THE TIME. It’s outrageous, it’s meddlesome, it’s arrogant, it’s tragic, and it’s untrusting of a woman’s natural and innate ability to push her own baby out!!
“The International Cesarean Awareness Network opposes the use of cesarean section where there is no medical need. Birth is a normal, physiological process. Cesarean section is major abdominal surgery which exposes the mother to all the risks of major surgery, including a higher maternal mortality rate, infection, hemorrhage, complications of anesthesia, damage to internal organs, scar tissue, increased incidence of secondary infertility, longer recovery periods, increase in clinical postpartum depression, and complications in maternal-infant bonding and breastfeeding, as well as risks to the infant of respiratory distress, prematurity and injuries from the surgery.
All physicians take an oath to “Do no harm”. This means choosing the path of least risk to patients. Medically unnecessary elective cesareans increase risk to birthing women. It is unethical and inappropriate for obstetricians to perform unnecessary surgery on a healthy woman with a normal pregnancy.”
The fact of the matter is that I do not believe that Alona’s c-section was necessary and I believe that her doctor did do her harm by performing her surgery without at least revisiting her options with Alona before he ordered for her to be wheeled into the operating room. She needed to hear and deserved to hear her options from Dr. W at that time and not anyone else. Although the above position statement was written regarding patient choice elective cesarean section, I feel that it also pertains to elective repeat cesarean sections since I do NOT believe that “prior cesarean section” is an automatic indication that is well supported in the literature as being a good enough reason to just schedule another major abdominal surgery. I agree with author Norma Shulman as she was quoted in the book Silent Knife, “Those who favor repeat cesarean because of its ‘ease’ and ‘safety’ need to be reminded that ‘all the factors that make cesareans so safe nowadays also serve to make VBAC safe, and more rewarding.” To me, many other childbirth advocates, and to thousands and thousands of women in this country, the birth of a child is not the only goal of labor, it’s a very important one, but it’s not the only one. Women aren’t just “fetal vehicles” and their experiences in labor and childbirth have profound effects on their self-esteem as well as their relationship to their partners, their babies, and their families for the rest of their lives.
Are you pregnant and have a history of a previous cesarean section? Did you know that you have the right to informed consent and informed refusal regarding repeat cesarean section vs. VBAC? Did you know that there are resources out there to help you? Please check out:
(1) ICAN’s Cesarean Fact Sheet
(2) ICAN’s Vaginal Birth After Cesarean (VBAC) Fact Sheet
(3) Silent Knife: Cesarean Prevention and Vaginal Birth After Cesarean by Nancy Wainer Cohen & Lois J. Estner
(4) DON’T CUT ME AGAIN! True Stories About Vaginal Birth After Cesarean (VBAC) by Angela, J. Hoy (Editor)
And find a local ICAN support group near you!
**As always, all identifying information including names, dates, times, ethnicity, etc. have been changed or omitted to protect privacy and adhere to all HIPPA guidelines.