Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

Don’t Let This Happen To You #23: Alona & Dmitry’s Unnecessary Repeat Cesarean Section April 29, 2009

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.

 

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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…

 

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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.”

 

Sally: “What?”

 

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!” 

 

AAAAAAAAAAAHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH!!!!!!!!!!!!!!

 

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!!

 

In their Patient Choice Cesarean Position Statement, the International Cesarean Awareness Network (ICAN) writes,

 

“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.

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65 Responses to “Don’t Let This Happen To You #23: Alona & Dmitry’s Unnecessary Repeat Cesarean Section”

  1. I strongly believe women who are poor, speak another language, and have lower educational levels, have higher C/S rates (and other interventions, like episiotomy, etc). I have no research to back this claim up, only what I see every day at work (like yourself). The hard part is reaching women like this, probably not the one’s who read your blog. Especially when a patient comes from another country and is brought up to not question a physician. BTW, do you have midwives at your hospital? If you do, I would try and promote patients like the one’s you profiled to see a midwife.

    • nursingbirth Says:

      Realityrounds, I hear what you are saying although in my experience the women who are from a lower socioeconomic status, speak another language, and/or have lower educational levels don’t have the most C/S because most of them go to the local clinic which had physicians and midwives that aren’t so intervention happy. I think it really depends on who their care provider is more than anything. Also, to answer your question, we do have some midwives that practice at my hospital but I only see patients in hospital if they are more than 20 weeks along, and most are way into their third trimester. So not a lot of time to promote them the see a midwife. Its a vicious circle. I am a stranger to them and they have been seeing their care provider for months at this point. *SIGH*

  2. Marissa Says:

    Seems like the doctor considered the language barrier a reason not to even attempt to get informed consent.

    • nursingbirth Says:

      Marissa, I think that it could have been part language barrier but I also think that it is related to impatience and this very fake idea that he was supporting her “autonomy” by going along with the “original plan” even though the original plan (RC/S) was the only plan that got him to his golf game! *GRRRR*

  3. Lauren Says:

    I am not a health care professional, but really enjoy your website. I was floored when I read the part about rushing her to the OR before she gives birth to the baby. It’s things like that (and my own birth experiences) that leave me without trust for some OB’s. Wow.

    • nursingbirth Says:

      Lauren, I am so happy you like my blog 🙂 I hope that more so than mistrusting OBs you will take from this story to not follow ANY Birth attendant blindly, to do your research regarding your birth attendant and your birth choices, and you make sure you make informed choices in childbirth!

  4. Rini Says:

    Good Lord. I would be on my feet throwing punches, labor or no labor, if someone was trying to cut me open while I’m progressing like that.

    But then, that’s why I read blogs like this. 🙂

  5. Joy Says:

    Part of me wishes that she had pushed that baby out before getting to the OR! Seriously! Some women don’t have to push long at all. He may have still “made his golf game” if he had allowed her to push. Oh the arrogance of it all!

    My previous doctor said she was going to give me a c-section 2 weeks EARLY with my next baby when I had just given birth to my second child (both girls were born vaginally) because her collarbone had snapped during delivery (because she was PULLING hard on her, according to witnesses). I was literally sitting in the hospital bed holding my one-day old infant when she told me this!

    When I told my new doctor this I could tell he was shocked she said that. He’s an older doctor but very sensitive to his patients. He said, “I am not going to sect a woman who has a wide pelvis and has given birth vaginally without complications in the past.” THANK GOD!

    • nursingbirth Says:

      Joy, thank you for sharing your story! Your previous doctor is OUTRAGEOUS! To tell someone she would have to have a c/s after two vaginal delieveries is crazy. I am so glad you had that little “light bulb” go off when you heard that instead of ignoring your gut feeling. You did the right thing by switching doctors and I know that isnt easy because you start to feel comfortable with someone. KUDOS TO YOU!!

  6. MM Says:

    Language barrier, SES, age, and the like have NOTHING to do with this RCS or any other RCS under similar circumstances.

    This c/s was done to CYA. To cover the doc’s ASS. No other reason.

    Sick. Sick. Sick. My stomach is just churning for this woman and every other woman who didn’t believe she had a choice.

    Sick.

  7. Autumn Says:

    We need to stand up and start screaming like our mothers and sisters did in the ’70’s and ’80’s!!

    I’m a PP nurse in a community hospital in Northeast nowhere, We are seeing a rise in our section rates driven in part by forces that have nothing to do with OB practice, namely that our hospital is having a tough time finding and keeping anesthesiologists and one way they are coping is to say no VBAC since that requires an anesthesiologist in house… There are work-arounds but they’re highly dependent on which OB mom chooses and then, who’s on call!!

    Several older OBs retired and that was when this slide started happening. I’m glad I’m done having babies but it’s crushing to know what I know and not be able to warn folks.

  8. I agree and disagree with MM. It is much easier for providers to get away with unnecessary C/S, inductions, whatever, if their patients do not know enough to question them. It is near impossible for the L&D nurse to change the patients mind at the time of delivery, when they are virtual strangers to the patient. Of course the couple will believe the provider who has been with the patient for 6 months giving care. I agree with you that this doctor is not only trying to CYA, but he may also have been happy about the increased reimbursement for the C/S. Helps pay for his golf club membership.

  9. Lesley Says:

    These posts make me more and more grateful for tripping on a doula halfway through my pregnancy. Finding her and my subsequent change to a midwife based practice allowed me to avoid a C/S. I would have most definitely been induced and probably C/S if I had stayed with my previous O/B. My motto throughout my pregnancy was “You can’t cut me if you can’t find me.” So, I made sure to only be at the hospital for 45 minutes before delivery.

    Love your blog!

  10. Mama Kalila Says:

    Seriously… This made me want to cry…

  11. Krista Says:

    Oh, here we go….unnecessary c-sections get me SO riled up! I am very grateful that mine was necessary, but I’ve sat in so many ICAN meetings listening to so many women’s stories…..so many of them are similar to this one. Its just so sad. I definitely used to be one who would never question my doctor’s authority, but so many things have happened since that I’ve learned that I need to stand up for myself. I just wish it didn’t take extreme circumstances to teach that lesson.

    Oh and the golf game…….unbelievable!!!!!!!!!

  12. atyourcervix Says:

    Yep. Seen it, heard it, participated in it before. It’s sickening. Some docs aren’t giving women all of their options – they just tell them – “repeat section!”. Doesn’t matter if that baby is crowning, away we go to cut you open!

    That’s when this labor nurse suddenly starts dragging her feet….and trying her best to talk to the patient about what SHE wants. Sometimes, yes, coming right out and telling her that she does not have to have a repeat c/section, if she doesn’t want to.

  13. Missy Says:

    This story made me want to cry. It’s a shame the mother wasn’t informed enough (ahead of time) to make a more educated and well thought out decision about her birth. It seemed that the labels the doctor gave her for her first c/s (being too small) made it hard for her and her husband to even consider her body having the ability to do it naturally. What a shame.
    As a mom preparing for a future vbac it’s ob’s like these that scare the heck out of me. Definately a worse nightmare.

    Thanks for sharing:)

  14. Missy, do not focus on the negative stories. They will drive you crazy and make you lose confidence. I had a VBAC and it was great. You can do it!

  15. BirthingBeautifulIdeas Says:

    Oh…my…God. I have heard so many similar stories from mothers’ perspectives, but to hear your nurse’s perspective–to hear about the freakin’ golf game comment–gaaaaaah, it just makes me want to SCREAM! She could have (and WOULD have) pushed her baby out of her perfectly sized “vagina.” It’s just…so shocking and sad.

    And Missy–while it’s good to know what to look out for when selecting a care provider, I agree with realityrounds in that you should put most of your focus on the *positive* VBAC stories. I too had a VBAC last year, and it was AMAZING. Just incredible. You CAN do it indeed!!

  16. Danielle Says:

    NursingBirth – I absolutely love your blog and check in for new posts daily. I’m part of an online community of women trying to get pregnant and who are pregnant. I’ve passed along your link many times.

    Today I ran across a woman’s post that made me cringe and I thought of your blog (and directed her to it). Maybe you could help point her in a better direction, towards resources to reassure her and to give to her Dr? She’s considering scheduling an elective c-section as a FIRST TIME MOM!

    Here’s her situation:

    I need some advice, ladies! At yesterday’s OB appt (38 weeks), there was no change in my cervix from last week.. still high and closed. Doc seemed a little concerned only because it’s typical that first time moms have started to dilate and efface at least a little by now. I was hoping that I wouldn’t have to keep my appointment for next week, but my OB thinks I will not only be at my appointment, but I may even be overdue from my due date!

    Also, he mentioned that my pelvic bones are a little more narrow than he would normally like to see.. he said not to let it worry me, but it could mean a C-Section when the time comes! This is not really news I wanted to hear, and it also wasn’t the first time an OB has told me this about my pelvic bones. At my first exam when I was a teen, my GYN mentioned that my cervix was narrow and it may cause problems when having babies. And the funny thing is, I reminded my mom of this a few days before my appointment yesterday.

    So when it was brought up again, I thought it was worth a discussion with DH. DH asked what I thought about scheduling a C-Section.. although it obviously isn’t my first choice option, and I’m not happy about the thought of the extra recovery time and pain.. I’d prefer to know what I’m in for that day rather than to go through a long labor and a few hours of pushing only for them to tell me it’s useless and haul me in for surgery anyway.. my other concern, especially if there is a possibility the baby will be overdue, is that she will probably be on the large side for a first baby.. in that case, I know I probably will not be able to push her out.

    A friend of my MIL was told 18 years ago before having her first son that she had a narrow pelvis that may cause problems in childbirth. She opted for the C-section with both her boys and was told she did the right thing and she couldn’t be happier with her decision.

    I called the OB office yesterday after talking with DH and the OB I had seen called me right back. He said he regretted even mentioning his observation of my narrow pelvis and he in no way was trying to worry me.. He definitely thinks I should “sit tight” and let it happen naturally, even if it means I end up having a C-Section after a long labor and pushing. I respect his professional opinion and all.. and I’m sure he doesn’t want to be the one who convinced me to have a scheduled C-Section.. but after I got off the phone with him, I felt very discontent and confused.

    Of course I turned to my mom, but I don’t think she is very supportive of the idea of me scheduling major surgery.. I think it’s best that stop talking to her about it, because it seems that at this point DH is the only one who is open-minded about it and knows it’s my decision..
    Sorry this was so long! My question is: WHAT WOULD YOU DO?!? Any advice would be appreciated!! TIA!

    *and this is her follow up post after being told that a c-section is not necessary*

    Thank you so much everyone! I know that I sorta panicked after my appointment and I definitely don’t want a C-Section that isn’t necessary. I know I shouldn’t have jumped to conclusions, I was just terrified by the concept of being overdue and a possible C-Section after labor and pushing. As of now, I have decided that if nothing has happened and there has been no change in my cervix by my next visit when I will be 39 1/2 weeks, then I will get a second opinion from this OB about a possible induction. I would love to have an estimated measurement for the baby, so we can have a better idea of if she is on the big side or not. But I know most people don’t find that out until it’s too late. So I’m trying my best to remain calm and praying that things progress naturally and soon! I know if I ultimately have to have a C-Section, I won’t be the first and definitely won’t be the last! Thanks again for the advice and well wishes!

  17. Anne Lenzi Says:

    Wow. I am so happy there are nurses like you in L&D!

  18. Dollie Says:

    Ok here is a questions wouldn’t it have been just as fast to break her water and less than 15 minutes later she would be pushing her baby out. I mean really. I can’t believe that. I would have been so frustrated… don’t you wish she had pushed the baby out while they were wheeling her out of the room then what would Dr. W do?

  19. Evie Says:

    I was just wondering what the legalities are when nurses and other attendants are aware that there has not been valid consent for a procedure which has been carried out, or there has been a downright refusal of a treatment which was carried out? When these instances happen, is it written down in the patient’s chart? Is a report filed by the attendant? Is there a requirement for nurses and other attendants to report instances of non-consensual physical contact written into AWHONN and other associations? If so, how many instances go unreported, and why?

  20. jen Says:

    1. Where you work sounds pretty horrible in terms of how people practice, and also how you don’t seem to like it all. Have you ever thought of leaving?

    2. While I’m all for offering VBACs (and my hospital has the highest VBAC rate in the state), don’t laugh it off like it’s not a little more risky. Catastrophic uterine rupture has been the scariest thing I’ve seen so far. Will I still offer VBACs? Of course. Do I respect them more, and make sure we’ve got signed consents for both modes of delivery after full discussion? You bet.

    3. This story also made me laugh bc it reminded me of a patient who came in exactly the same and was INSISTING on a repeat C-section. And yet we, the (evil, right?) OBs, were trying to tell her how silly it was because she was 8cm already and could do this vaginally. I was doing all I could to get the baby out before rolling her back to the OR bc she was practically crowning. Once again, not all OBs are pure cutters, but it sounds like your place is kind of a joke in that regard…

  21. Rebecca Says:

    I just found your blog today and nearly cried with your post. What you described about Alona happened to me, but it was worse b/c my doctor had agreed to a vbac, I had a previous vaginal birth, my c/s was due to breach and was 6 years prior. The on call dr refused to let me vbac. My water broke on its own and I was 4 cm w/ contractions 2 min apart when I entered the hospital. It was screaming match with the oncall, and I finally consented to the c/s because I was in incredible pain and the dr was extraordinarily hostile to my vbacing. There was no one supporting me and no one would allow me an epidural and it was just a bad scene.

    And I’m not sure that education has much to do with a patient getting a repeat c/s. I think it’s the medical profession pushing them. I have a PhD and am an academic and it happened to me. Horrible, horrible experience. I felt incredibly violated by the experience.

    • nursingbirth Says:

      Rebecca, thank you so much for sharing your experience with us. I am deeply saddened to hear of your traumatic birth experience. I can only hope you will one day be able to make peace with the past and I encourge you to continue to speak out about your experiences because it is voices like yours that incite change!!

  22. Evie Says:

    “If so, how many instances go unreported, and why?”

    1. Where you work sounds pretty horrible in terms of how people practice, and also how you don’t seem to like it all. Have you ever thought of leaving?

    3.This story also made me laugh… sounds like your place is kind of a joke in that regard…

    Thanks “dr.” Jen, the OB? for partially answering one of my questions. Being told to lump it or leave it, or in other words, finding no support for airing and reporting grievances, even under a pen name on-line, goes along way in suppressing problems and creating a hostile work environment. And finding criminal instances of non-compliance with laws governing consensual contact during medical procedures a laughing matter is no joke. With a response like that from an OB?, no wonder we are seeing such poor practice patterns.

  23. jen Says:

    Easy Evie. I just meant in my comments that the place from what I’m reading sounds like it barely follows basic care guidelines in a lot of ways, it is a ‘joke’ in that respect, not a ‘ha this is so funny!!” joke. And it seems like somewhat of a concerning substandard place in regards to what goes down there, so has the owner of this blog ever really considered that this place isn’t right for her? i.e. she can work at a hospital with docs who practice good medicine and that she actually can support bc she feels like a team member?

    Sheesh! But thanks for the judging.

  24. Mama Kalila Says:

    Throwing my two cents in…

    I see your point there Jen (and if it was me, I’d seriously consider that) but… If she left for a better job in a wonderful hospital like you mentioned… What would happen to the women who were stuck at this hospital? There are women that she has managed to help one way or another. Obviously this story was not in that category, but others she’s mentioned have been. If she’d left, those women wouldn’t have had her support and things could’ve gone very differently for them.

  25. Alev Says:

    “Catastrophic uterine rupture has been the scariest thing I’ve seen so far.”

    Dr. Jen’s statement seems to reveal the root of the problem. If uterine rupture is a scary thing for an OB, and if it is relatively rare (which statistics I’ve read seem to indicate), then OBs are most likely not as comfortable dealing with it. C-sections, on the other hand, are a known quantity for them. Add to that the liability issues and time/money incentives, and it makes sense that most OBs are not encouraging VBACS (and often discouraging or refusing them).

    So what’s the solution? Reducing the number of primary c-sections and avoiding the situation completely! I personally feel the way to do that is to bring in more midwives (who don’t have a financial incentive to do a c-section), take birth out of the hospital for most, and leave OB care to those who really need it – a very small percentage of birthing mothers. Asking surgeons to attend all births is a great way to increase the number of surgeries.

    BTW, the story made me want to cry.

  26. Evie Says:

    “…it seems like somewhat of a concerning substandard place…”

    “…so has the owner of this blog ever really considered that this place isn’t right for her?…”

    The question of substandard care will only be answered if instances like these are reported. In the interests of the patients, a “real” Dr., upper case and all, would suggest pathways to create better practice patterns. Instead, the blogger’s Rx for this problem is to quit so her place can be filled by someone who has no problem with sadism? What malarkey.

    Uterine rupture is rare in women who are not given uterine stimulants, and many VBACs are induced and augmented, only to be sectioned later for fetal distress and failure to progress. Dr.s are comfortable trading safety away for convenience by utilizing uterine stimulants which are known to rupture uteri, cause major blood loss, fetal distress, and death. If dr.s really had health in mind, we’d see a shift away from this type of practice. If nurses’ organizations unionized and demanded better working conditions, including guidelines calling for mandatory reporting of situations which include failure to gain consent and refusal of treatment, it would go a long way in improving outcomes for women and babies, and in creating a safe workplace.

  27. birthjunky Says:

    I feel that there is a bit of attacking going on in the comments section – I really don’t think Jen’s comments were meant to be quite so controversial! As a future CNM, I cringe a bit at this kind of “fighting”. The ideal world would be one in which ob/gyns, nurse midwives, midwives, nurses, etc respected one another and all worked together to give women and babies excellent care. We clearly know that maternity care is in crisis but it is a multi-faceted problem and I truly don’t think it can be solved until we are all willing to work together. Let’s try to keep in mind that there are many excellent ob/gyns out there that would be just as horrified by nursingbirth’s story as any of us.

    Nursingbirth, thank you for sharing these stories. I think they reinforce the need for change and for people to become activists and lactivists and SPEAK UP! The absurd csection rate in this country is disturbing not just because they increase risk to mother and baby but also because we forget to tell moms that one csection is most likely going to be mean future csections. It shouldn’t be so hard to find good providers that are willing to take on VBACS!

  28. Birthjunky beat me to the punch. The comments section has turned into a mosh pit. Everyone needs to work together to create change in how birthing is practiced in hospitals. It is possible to have compassionate centers for birth (I work in one such hospital). OB’s are not the enemy. Yes, there are impatient and hostile OB’s, just like their are impatient and hostile midwives! (Say it aint so!). I think transparency will help. Hospitals should be made to publish their C/S, induction, episiotomy rates etc. Just like medical floors publish infection rates. Maybe then their will be some consumer driven change to the state of maternity care in the US.

  29. Tina Says:

    Wow, this story just made my stomach turn. Probably because Dr W could have been the OB who I saw with my first pregnancy (and was, in factm, a Dr W). When I read the line about “If we don’t get her back there soon we’re going to have a baby” I did the “double-take head shake” before I read your reaction. Just makes me sick to think that so many doctors treat the laboring woman like a complete non-entitywhen it comes tomaking labor/birthing decisions.

    (BTW, Baby finally decided to make her appearance at 40 weeks and 4 days via completely unremarkable VBAC).

  30. scout234 Says:

    thanks for trying…

    what an upside-down world

  31. Kay Says:

    This is why I’m so terrified of having a c-section. My hospital does not offer a VBAC as an option, and because I am on state aid I cannot use a midwife in a home birth or birthing center (although it’s a moot point because there are no midwives or birthing centers here, just one hospital). So I will have to deliver in a hospital with an OB. I am terrified that #2 (EDD end of July) will end in a c-section, because it’s practically a guarantee here that I will forever have c-sections.. And I will be a broken woman if that’s the case. I may seriously consider never having children again.

    • nursingbirth Says:

      Kay, it saddens me that you are without many birthing options, and that insurance plays a part in it, in your area. What is even more upsetting is that you are not alone, there are thousands of women in this country who are without many birth options. Have you ever checked out the ICAN website? (International Cesarean Awareness Network : http://www.ican-online.org/ They have information about YOUR RIGHT to INFORMED REFUSAL of a cesarean and YOUR RIGHT to a VBAC! THey actually have a entire page entitled : “My Hospital Is Currently Not Allowing VBAC” and you can find it here: http://www.ican-online.org/vbac/My-Hospital-Is-Currently-Not-Allowing-VBAC I hope you get a chance to check it out. please know that the RESEARCH is on YOUR side about the safety of VBAC vs Repeat Cesarean. My thoughts are with you!

  32. Erin Haag Says:

    Thank you sooo much for this blog post. It’s given me more encouragement. I am 31 weeks pregnant and hoping to have a VBAC with my baby – my first was vaginal, 2nd was Csection (my labor stopped after they started me on magnesium when I was 9 cms – they said my blood pressure was high, but every report I have it doesn’t mention the blood pressure being too high).

    I am mind-set on a VBAC and stories like these keep me focused on my point of a natural birth WITHOUT medical interventions.

  33. Birth_Lactation Says:

    Melissa- Very well written– I feel like I was there and actually have witnessed many similar situations. I think I agree with RealityRounds in her opinion of the lower economic group/ ethnic background possibly having more interventions.. few people actually take the time to talk to them clearly/ language line etc.. It’s awful sometimes. At least where I am. Right now, we only have one MD group delivering. In my area we get many people coming in from the cities, varying backgrounds, little to no prenatal care.. Are you guys seeing much of that?
    Another thing… Those impatient, “should have been a dermatologist with no on-call” doctors calling for C/S without a real medical need. We once had a cut happy doc whose name started with a “C”. We the staff decided that CPD (cephalopelvicdisproportion) for him meant “Charlie’s-Personal -Decision” and that FTP (Failure to progress) for him meant “F**k- The -Patient”. It is so very awful for excellent nurses and birth advocates out there to have to work with these arrogant doctors. You are an awesome nurse and I’m glad to know you!

    • nursingbirth Says:

      Birth_Lactation, although I am sensitive to the seriousness of your story, the CPD and FTP acronyms you set up for Dr. C are hilarious, sad that they are true, but comical! We have a very large low socioeconomic population of minority families in our city but we are interesting in the fact that we don’t have as high a rate of non english speaking patients as other cities, we certainly have some, but some other hospitals I’ve worked at have been like 50% spanish only speaking, etc. Anyways, what is also interesting about my hospital is that the city health clinics have a team of low interventionist OBs and nurses. THey rarely induce women unless its for something medical and serious and promote VBAC. They have one of the lowest C/S rates out of any group that practices at our hospital. The women that are getting cut left and right at our hospital, belive it or not, are the lower middle class to upper class women who have private insurance and go to private practices. There are more reasons than this but the health clinic doctors don’t have any financial incentive to do unnecessary surgery, they are getting reimbursed by medicaid. The doctors in private practice on the other hand, make BANK for every intervention they do. Interesting isn’t it….

  34. Tiff Says:

    I am currently 38 weeks, and had a previous c-section. I told the doctor that I wanted a repeat c section thinking it would be best. As the date got nearer I told my husband that I would at least like to try to have a vag birth. I told my Doctor this and she said it is too late to change my mind. She also said that they were doing away with VBAC’s, and that in the last 2 weeks they had 2 ruptures due to this. (She was so upset, that she knocked over my cup of urine that was sitting on the counter.) I told her that I really wanted to try VBAC, and now I don’t know what to do. She said at this point in care no other Doctor would take me on, but she finally said she would schedule my next appt. with another Doctor in her practice to get another opinion. I feel like when I go to this appt. that Doctor will just try to talk me into getting a c-section. Is it really too late to change my mind?

    • nursingbirth Says:

      Tiff, It is NEVER too late to change your mind. PLEASE check out ICAN’s website http://www.ican-online.org and even look up a local chapter. there might be one near you and one of the members might know of a more supportive doctor that you can transfer care too. A very good friend of mine transfered her care at 37 weeks because her doctor, who was going to support her VBAC, changed his mind and couldnt back it up with research. I wish I was there to give you a big hug right now!! If your doctor does not support VBAC they she does NOT support EVIDENCED BASED MEDICINE. unfortunately you are not alone. You are not crazy and you are not selfish and you have the right to make decisions for YOUR body. this doctor doesnt have to live with yet another scar from major abdominal surgery and care for two kids….YOU do! maybe you could call a local doula agency to get some advice on supportive doctors in your area too. My thoughts are with you! Please let me know how things turn out! Don’t give up!

  35. Tiff Says:

    I did see the other Doctor in the practice, and she said that there is no problem in going with a VBAC. She was so wonderful and reassuring. I wish I would have had her my entire pregnancy! Thank you so much! If I hadn’t found your site who knows where I would be.

    • nursingbirth Says:

      Tiff, I am SO HAPPY to hear that! Plus, you just made me feel like a million bucks! I am honored to have been a part of you finding the resources and know how to speak up for yourself, get a second opinion, and plan the birth you want without being bullied into major abdominal surgery!! AMEN!! I am so excited for you!!!

  36. Megan Says:

    So I found your website and just spent WAY too long reading your posts and all of these stories. LOL. I love it all. It is so refreshing to hear that it is okay to go past your due date, to not want an epidural because of the risks to mother and baby and that induction isn’t the ‘greatest thing’. My sisters think I am absurd for never wanting to be induced because they have been induced with all of theirs at 39 weeks because they were ‘done’ being pregnant.

    It is amazing how much I learned reading through all of your stories. I am almost 36 weeks pregnant with my second child and plan to go unmedicated. The main thing I learned with my first was that I DON’T want my water broken. I was 3 days past my due date with my first and had a 24 hour labor and handled the contractions fine (they hurt, but I was fine) until they broke my water at 8cm. Things changed immediately after that. At 9.5 cm I requested an epidural – I was so tired and didn’t know if I would have the energy to push. Now that I look back I wish the nurses would have talked me out of it or told me to change positions (I had been lying in the bed since I got to hospital at a 6.5cm). I still can’t believe I got an epidural that late. I rested for an hour afterwords to let the baby descend and then pushed for 2 hours. I am still positive that I pushed for so long because I had an epidural – which is why I don’t want one this time (and one of the reasons why I didn’t want one the first time, oddly enough).

    I have a great doctor who, when I mentioned my requests, said ‘Whatever you want. You are in charge.’ Hopefully that attitude stays true for the delivery 😉 After reading all of your stories I feel more educated about things they offer or do during delivery that I do or don’t want to happen to me. Do you have any suggestions on making a thorough birth plan? Or should I just bring my computer with me with access to your web site so I can know when they are trying to be ‘sneaky’ with me. Or perhaps your phone number? LOL.

    Longest. Comment. Ever.

    • nursingbirth Says:

      Megan, First of all I love you for loving my blog. Thank you! Second of all, dont worry…you did’t write the longest comment every! Hahaha (Plus I’ve been accused of writing some pretty long comments 🙂 ) Thirdy, it is very upsetting when girlfriends and sisters kind of “bully” you because they did things differently related to pregnancy and birth. I mean, if I bring hummus to work my coworkers call me a “hippy” so I can imagine how you feel! LOL I am working on a birth plan post right now because a) so many readers have asked me about it, b) there are a lot of different birth plan websites online that can be misleading or not at all helpful, c) I love writing about what people want to read!! But to hold you over try checking out this website:

      http://www.babycenter.com/calculators-birthplan

      I think it is helpful to see what is out there and to help with wording but a word of advice (If I may, humbly): Please dont just copy paste. A birth plan that is generated by checking off boxes and pressing print is something that most L&D nurses dont even pay attention to. Its not right, but its true. I say use websites like that to get some ideas and then dont be afraid to write up a letter/list in a word document that is more personal.

      Hope that helps!! Stay tuned!! Thanks for reading!

  37. Megan Says:

    Thanks for the advice and I look forward to the ‘birth plan’ post. Hopefully I can read it before I need it 😉 I had to laugh at your hummus comment because I just bought some yesterday. LOL.

  38. Jessica Says:

    I just wanted to say I have loved catching up on all your posts, and now that I’m caught up, your blog is now one of my favorite sites to check!! We don’t have children yet, but hope to in the near future. I’ve always known I wanted to have normal, natural births, thanks to my Mom. She had all of us naturally and is a big supporter. But I’ve become fascinated with the whole thing and love learning and reading all I can. The Business of Being Born is now one of my favorite movies! 🙂 Anyway, your site has become another great resource – it’s always nice to find others who feel like you do! Thanks for all you do!

    • nursingbirth Says:

      Jessica, I am so happy that you love the site and I am even more happy that you are reading it and you dont have children yet! Too often women do not start to research their birth options until they have had a bad birth experience. I am currently part of a grass roots community education program that may be starting to speak to college and high school age men and women about birth because it is THAT important for these youths to learn about birth! We need to start changing the culture of fear in this country and one important way to do it is to get to all the women and men who are NOT moms and dads yet!! AWESOME FOR YOU!

  39. K Says:

    Just had my second VBAC! 🙂 Definitely a supporter of them!

  40. Jessica Says:

    Missing your posts!! I think I’m in withdrawal, but I understand you have a busy life! 🙂 Just thought I’d let you know that I enjoy your site enough to really miss it during the quiet times. 🙂

  41. Jill Says:

    I just found your blog today via Rixa. I only had time to read this post but I will definitely be back for more! Your experiences make my blood boil – this is why I stayed the hell out of the hospital for my VBAC 10 months ago!

  42. Erinn Says:

    “Pemberton v. Tallahassee Memorial Hospital” is happening all over the nation, even as we speak. Over a decade after Laura Pemberton was section by force as her baby was crowning – has anything changed in the medical world??

    I recently met an acquaintance of Penny Simkin’s, who told a story about Penny literally crying her eyes out and feeling like a failure, overwhelmed by the fact that so much work has been done to make the women of this country see what’s really happening in the world of obstetrical “care”. But after a good cry, Penny keeps fighting for women’s reproductive rights through education.

    My deepest respect goes out to you for attempting to provide those parents with true informed consent.

    • nursingbirth Says:

      Erinn, thanks for reading and sharing. I often feel like crying too!!! But “meeting” moms like you who are reading and researching and fighting for their rights is VERY inspiring! Thanks to you!

  43. Wow that just makes me mad!
    I haven’t had any kids yet but when I do, I want to do the water birth.
    Women have been having births for thousands of years just fine before C-Section came along.

  44. Michelle Says:

    I gotta ask a question here…do you ever get reprimanded? I KNOW you are doing the best for the patient, and you know you are, but the doctors…they hate you don’t they ? I’m on your side…it’s like being a christian school teacher at a secular school. Do you get what I mean?

  45. LilRedMommy Says:

    This is just outrageous to me! It makes me really wonder how much I actually was informed during my first delivery. When I was 16 I delivered my son via c-section for failure to progress. I was always told that this was because I was so young and my son was very large (10lbs 11.5oz). That was 7 years ago, I am now pregnant with my second child and I am planning a VBAC, I thought that my OB was in support of this until just recently. I am now 30 weeks and it is like he had this about-face. He keeps warning me of the risks of uterine rupture, we had agreed that we would be keeping a close watch on this little one’s size but at my last appointment he kept saying things like “So, would you be ok with another c-section if we find that you are having issues progressing this time?”.. OR “What would be a realistic time frame for you to try to dliver before we go ahead with another section?”… I really dont know how to react to these things, he is my doctor, and I respect his opinion BUT my first delivery was a nightmare. I lost alot of blood, had a very hard time with my recovery, couldnt walk or stand up without help for a long time. I did not get to see my son until 2 hours later. I couldnt lift him when I did get to see him. Being in the hospital for 3 extra days is not my idea of a good time.

    These are the things I am trying to avoid, and yet it seems my doctor is now talking as if he EXPECTS me to fail!!! How can I express to him how important this is to me? How much I want to bond with my little girl? How much I want to be able to hold her and breast feed her and spend her first hours alert and not unconcious or puking my guts out? I want to do whatever is the most healthy for my baby of course, but is it impossible to find a doctor who actually BELIEVES in my ability to deliver this baby vaginally? How do I get through to them that this is not just me wanting to TRY, this is me wanting to SUCCEED at VBAC!?

    Sorry for the rant, obviously I am in a dificult place right now, any resources you have would be greatly appreciated, and thank you for the info that you have provided. You have given me a great deal to think about.


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