Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

New Study Shows C-Section Births May Increase Odds For Developing Diseases Later In Life June 30, 2009

Filed under: In The News — NursingBirth @ 12:05 PM
Tags: , , , , , , , ,

A new study published in the July issue of Acta Pædiatrica, a peer-reviewed monthly journal at the forefront of international pediatric research, found that babies born by cesarean section experience changes to their DNA in their white blood cells (called leukocytes) which they believe could be related to negative stresses around birth, particularly the cesarean section.  The study, entitled Epigenetic modulation at birth – altered DNA-methylation in white blood cells after Caesarean section, was led by a team of Swedish researchers who sampled umbilical cord blood (collected at the time of birth) and venous blood 3-5 days after birth from a total of 37 newborn infants, 21 of which were born by spontaneous vaginal delivery and 16 by elective cesarean section. 


According to the Medical News Today article, one of the authors of the study, Professor Mikael Norman, was quoted in saying:


“Delivery by C-section has been associated with increased allergy, diabetes and leukaemia risks.  Although the underlying cause is unknown, our theory is that altered birth conditions could cause a genetic imprint in the immune cells that could play a role later in life.  That is why we were keen to look at DNA-methylation, which is an important biological mechanism in which the DNA is chemically modified to activate or shut down genes in response to changes in the external environment. As the diseases that tend to be more common in people delivered by C-section are connected with the immune system, we decided to focus our research on early DNA changes to the white blood cells. 


 Animal studies have shown that negative stress around birth affects methylation of the genes and therefore it is reasonable to believe that the differences in DNAmethylation that we found in human infants are linked to differences in birth stress.  We know that the stress of being born is fundamentally different after planned C-section compared to normal vaginal delivery. When babies are delivered by C-section, they are unprepared for the birth and can become more stressed after delivery than before. This is different to a normal vaginal delivery, where the stress gradually builds up before the actual birth, helping the baby to start breathing and quickly adapt to the new environment outside the womb.


 In our study, neonatal DNA-methylation did not correlate to the age of the mother, length of labour, birth weight and neonatal CPR levels – proteins that provide a key marker for inflammation.  However, although there was no relation between DNA-methylation and these factors, larger studies are needed to clarify these issues.”


 Although this study has its limitations (recognized by it authors) including its small sample size, it is fascinating to me as it is part of a growing sector of developmental biology dubbed “primal health” by French obstetrician Michel Odent in his book by the same name in 1986.  “Primal Health Research” explores correlations between the ‘primal period’ (from conception until the first birthday) and health in later life.  Since opening the Primal Health Research Centre in 1990, Odent has also created the Primal Health Research Database, available free online, which is a public collection of all the medical and scientific literature that belong to the framework of primal health research.


In her book Pushed: The Painful Truth About Childbirth and Modern Maternity Care, author Jennifer Block writes:


 “[Odent] is interested in looking far beyond the 5-minute Apgar score to what we might call the 5-year, 25-year, 50-year Apgar.  He’s put a database online, where one can search studies that have connected narcotics at birth with addiction in adulthood; induction of labor with autism; and cesarean section with immune disorders.  The research is far from conclusive, but it points to the large, unknown territory of the impact of medicalized childbirth. 


Odent places value on the process of physiological childbirth itself, of which we still have only limited understanding.  How can we fully appreciate the risks of intervention, he asks, if we don’t funny understand what is normal?  The mother’s body has spent 9 months growing and sustaining fetal life, and millennia of evolution have depended on spontaneous labor and its timed release of several hormones to transition the fetus from the womb to the outside world.  Odent has compiled scientific evidence that each one of these hormones serves as an important function in guiding the progress of labor and supporting the fetus—and that these hormones are interdependent.  ‘What we’re understanding today is that what happens at birth seems to be important,’ says Odent.”



In my opinion, it should NOT be the case that the burden of proof lies on the supporters and proponents of unmedicated physiological childbirth (which is, as defined by author Jennifer Block, “[a birth where] labor begins and progresses spontaneously, the woman is free to move about for the duration, and she pushes in advantageous, intuitive positions.”) that “their” way is the safest and healthiest option for mothers and babies!  It SHOULD BE the responsibility of proponents of unnecessary inductions, unnecessary cesareans, and outdated and harmful labor & postpartum practices (i.e. routine episiotomy, early and frequent vaginal exams, early amniotomy, flat-on-back/lithotomy/recumbent pushing positions, separation of mother and baby, manual pressure on the uterus, and “directed,” hold-your-breath-and-count-to-10 pushing) to have to prove, beyond any doubt, that their way is superior.


 Because as far as I, and any credible research, is concerned it is NOT!  And if it ain’t broke, why fix it?!


The Big Push For Midwives Campaign 2009 June 25, 2009

I believe that pregnancy and birth are normal, healthy processes and should not be treated as illness or disease and that women and babies have the inherent wisdom necessary for birth.


I believe that midwives can obtain quality education and experience in a variety of ways and programs, including certified nurse midwifery and direct-entry midwifery.


 I believe that women need access to professional midwives whose educational and credentialing process provides them with expertise in out-of-hospital birth as well as hospital-based and clinical care that extends beyond the childbearing cycle.


 I believe that empowering and safe births can and do take place in a variety of settings including birth centers, hospitals, and homes.


 I believe that every woman should have the opportunity to give birth as she wishes in an environment in which she feels nurtured and secure and her emotional well-being, privacy, and personal preferences are respected, whether that be in a hospital, birthing center, or at home and I believe that women in every part of the United States DESERVE THAT CHOICE!


  (Excerpts from my post My Philosophy: Birth, Breastfeeding, and Advocacy)




Because of all of these things I support The Big Push For Midwives Campaign 2009 and I want to share with all of you a bit more about it!!


According to BigPushTube:


“The Big Push for Midwives Campaign builds state-level advocacy campaigns to license Certified Professional Midwives (CPMs) in all 50 states, D.C., and Puerto Rico, and educates national policymakers about out-of-hospital maternity care.


 [The Big Push for Midwives Campaign] works tirelessly to:


1) Educate state and national policymakers about the reduced costs and improved outcomes associated with out-of-hospital maternity care. $9.1 BILLION IN SAVINGS PER YEAR.


2) Support advocacy groups working for state licensure in the 24 states where out-of-hospital practice by CPMs is under threat of criminal prosecution.


3) Encourage mothers to tell their stories because only grassroots activists will be able to topple the money/power vested in keeping the status quo.


4) Advocate for CPM guaranteed reimbursement in National Health Reform, the Federal Employees Health Benefit Plan, Tricare, and Medicaid/Medicare.


5) Support freestanding birth centers seeking guaranteed Medicaid reimbursement, and midwives advocating for equitable Medicaid reimbursement rates.


The Big Push for Midwives Campaign empowers midwife advocates and moms groups as they promote increased access to out-of-hospital maternity care and the Certified Professional Midwives (CPMs) who are specially trained to provide it.


Our dedicated campaigners, or “Pushers” as they are affectionately known, help to educate the people in power (at the insurance companies, in the hospital associations, in the Statehouses, and on Capitol Hill) about the reduced costs and improved outcomes associated with using out-of-hospital maternity care and CPMs, who are specially trained to provide it, and works to widely share the stories of U.S. citizens who choose CPMs as their maternity care providers.” 



I found this video on YouTube and I got all verklempt watching it!!  (Perhaps it was partly related to the beautiful song that was playing throughout the movie!  I’m such a sap!)  It’s only about 4 minutes long so if you have a chance please take a look!




 Our mothers and babies in this country DESERVE better care than what they are receiving!!  They DESERVE a midwifery model of care (whether that is provided by a certified nurse midwife, a certified professional midwife, a family practice physician, or an obstetrician).  They DESERVE to have CHOICES in childbirth that are proven to promote the best outcomes for both mothers and babies.  And they deserve these choices to be LEGAL!


Have you ever heard the term “lay midwife”?  Are you under the impression that a “lay midwife” doesn’t have any education and that all midwives who attend out of hospital births are “lay midwives?”  Do you want to know what the term “lay midwife” is really referring to?  Are you interested in learning what the real differences are between the different types of midwives?  Are you interested in learning more about how midwives train and what type of education they obtain?  If so please check out:  FAQ about Midwives and Midwifery by Citizens for Midwifery (CfM) and Midwifery Definitions by the Midwives Alliance of North America (MANA).


 Have any of you ever received care from a certified professional midwife?  I’d love to hear about it!


Home Birth and Midwives in the News! June 24, 2009

Today I read an article on, the website for the newspaper The Journal Gazette based out of Fort Wayne, Indiana that really gave me the warm and fuzzies.  


The article is entitled For some, life begins at homeby Emma Downs and it tells the story of a local family that researched, planned, and ultimately had a positive and empowering home birth after a dis-empowering hospital birth with many interventions.  The article also touches on the growing demand for home births that some midwives are reporting in many communities and how for families that chose home birth, it is about personal responsibility and research and most importantly, informed choice.  I really liked this article as opposed to other articles I have read on home birth in other major media outlets because it just tells it like it is without over-sensationalizing it.  A GREAT read!


Thank you to Christina from the Massachusetts Friends of Midwives Blog for alerting me to this story!


Preventing Maternal Deaths: An Interview with Ina May Gaskin June 23, 2009

Today an avid reader sent me a link to a few short interviews with the great Ina May Gaskin conducted by Mindful Mama Magazine about a very sad, but very real phenomenon: maternal deaths in the United States.  I felt that these interviews were so well done that I just had to share them with all of you.


Ina May Gaskin is a Certified Professional Midwife (CPM) and is the founder (along with her husband) and director of The Farm Midwifery Center in Tennessee.  She is the author of Spiritual Midwifery (1975) and Ina Mays Guide to Childbirth (2003), two incredible books that every woman who has ever had a child, is pregnant, or is thinking about becoming pregnant should read!!  


Spiritual Midwifery is THE book that changed my life, my outlook on the birth process, and my career goals.  Ina May’s Guide to Childbirth is similar in style to Spiritual Midwifery, but has a much broader appeal and a more modern style.  Ina May has been a home birth midwife for more than 35 years and is the founder of the Safe Motherhood Quilt Project, a national effort developed to draw public attention to the current maternal death rate, as well as to the gross underreporting of maternal deaths in the United States, and to honor those women who have died of pregnancy-related causes since 1982.
These interview clips are part of Rites of Passage, an exclusive video series and art/photo/ essay contest hosted by Mindful Mama Magazine that engages mothers across the country in a dialogue about childbirth and the transformation of new motherhood.  During the interview Gaskin speaks to the disturbing reality that 1) the United States lacks of a comprehensive, confidential system of ascertainment of maternal death designed to record and analyze every maternal death that occurs in the United States and 2) not all 50 states have questions on their death certificates that specifically ask about a woman’s pregnancy status (i.e. was she pregnant, postpartum, or within 1 year of delivering a baby) making our countries maternal mortality rates based solely on vital statistics data.  (And as an registered nurse who has had to fill out death certificates a time or two as a medical-surgical nurse I can attest to the truth of this!)  In reality the Center for Disease Control (CDC) estimates that our current maternal mortality rate is actually an underestimate and that our true maternal mortality rate could be as much as 3 TIMES HIGHER related to misclassification of the number of deaths that are truly happening. 


Please also see my post: Super Comment!: Maternal Death in the U.S., or TOP TEN Ways to Reduce Your Risk For Complications in Pregnancy and Childbirth


So check out these videos and let me know what you think!!














Women’s First-trimester Working Conditions Impact Infant Birthweight June 22, 2009

Filed under: In The News — NursingBirth @ 10:12 AM
Tags: , , ,

A new study that will be published in the August 2009 edition of the American Journal of Public Health has found that high levels of job strain during early pregnancy are associated with reduced birthweight and an increased risk of delivering a small for gestational age (SGA) baby, especially if mothers work 32 or more hours per week.  The study included questionnaires from and conducted follow-up on 8266 pregnant women participating in the Amsterdam Born Children and Their Development study.


I find these findings particularly interesting because many mothers, if they have the luxury of being able to take some time off of work during their pregnancy, typically take the time off during the end of their third trimester.  The results of this study make me, and the authors, wonder if perhaps women who work in high strain jobs and/or work a long work week should consider reducing their hours or workload during the first trimester instead or as well.


Remember, the first trimester is the most critical time in a woman’s pregnancy.  Although at the end of the first three months the fetus is only about 4 inches long and weighs less than 1 ounce, that tiny little baby has already begun to form all of its major organs and nervous system, has a heartbeat, and already has formed its arms, fingers, legs, toes, hair, and buds for future teeth.


To check out the article’s abstract visit the American Journal of Public Health website.


To check out a summary of the article visit Medical News Today.


Don’t Let This Happen To You #22: PART 3. A Discussion About Elective Primary Cesarean Section & Cesarean Delivery on Maternal Request (CDMR) June 16, 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 part 1 & 2 of this post: DLTHTY #22: Gina & Tony’s “Elective” Primary C/S PART 1 and PART 2.





I would like to start this discussion with some definitions I offered at the end of Part 2.



* Elective Primary Cesarean Section (EPCS): A planned first or “primary” cesarean section in a healthy woman for the birth of a baby when there is no medical, fetal, or obstetric reason for the surgery. May be influenced by non-medical issues, such as physicians’ personal beliefs (not facts) about safety, liability, insurance coverage, liability fears, hospital economics, efficiency, convenience, and reimbursement rates, as well as other factors not listed. (American College of Nurse-Midwives, Position Statement: Elective Primary Cesarean Section & Citizens for Midwifery, News Release: “Patient Choice” Cesareans Almost Non-Existent)



* Maternal Request Cesarean Section or Cesarean Delivery on Maternal Request (CDMR): A subcategory of elective primary cesarean sections. A planned (before labor begins) first or “primary” cesarean initiated by the mother with the understanding that there is no medical, obstetrical, or fetal indication requiring cesarean delivery, and after a through review of the risks and benefits of cesarean delivery vs. vaginal birth by the obstetrician, the woman’s decision is to have a planned cesarean section. The primary decision maker for a CDMR is the woman. (National Institute of Health (NIH) Cesarean Conference definition, March 2006 & Childbirth Connection, Listening to Mothers II Survey)


To reiterate, according to these definitions, it is misleading and inaccurate to assume that every woman who has an “elective primary cesarean section” actually had a “maternal request cesarean section.” In order for a c-section to be truly considered a “maternal request” cesarean, the following FIVE criteria must be met:



Necessary Criteria for Maternal Request Cesarean Section:


#1 The request for the cesarean and the scheduling of the cesarean must have been made prior to the onset of labor.


#2 The request for the cesarean must have been initiated by the mother.


#3 The mother must have the understanding that there is NO medical, obstetrical, or fetal indication requiring a cesarean delivery.


#4 The obstetrician must personally review and assure the mother’s understanding of the risks and benefits of elective cesarean surgery vs. planned vaginal birth.


#5 The woman is the primary decision maker.



So what does a consent form for an “elective primary cesarean section” look like? Since my post “Consent for Anesthesia: Do You Know What You Are Signing?” was such a big hit, I have decided to follow suit and post a copy of an actual hospital consent form for this type of surgery. At my hospital, every mom undergoing an elective primary cesarean section (EPCS) has to sign a form like this. However at this point in time, any mom undergoing a scheduled or unscheduled cesarean section for an obstetrical, medical, or fetal indication just signs a generic hospital operative consent form (with a “fill-in-the-blank” for the type of procedure). This unfortunately includes any mom undergoing a repeat cesarean section who is a candidate for but declined (or was bullied to decline) a vaginal birth after cesarean (VBAC).


What is worse is that at my hospital and many many others, if a mom desires a VBAC many of the obstetricians make them sign an additional consent form (not required by the hospital) special for VBAC that explicitly outlines all of the risks of VBAC (with the phrases “catastrophic uterine rupture” and “fetal death” smeared all over the page) but is conveniently lacking of any risks of cesarean section. I am currently working (so far unsuccessfully) with the “powers that be” on my floor to change this; I would like to see every mom who is a candidate for VBAC have to sign a form that specifically lists the risks/benefits of repeat cesarean section side by side of the risks/benefits of VBAC if they chose to have an elective repeat cearean.



So here it goes…an actual hospital consent form for elective primary cesarean section:




Consent for Elective Primary Cesarean Section


A cesarean section (c-section) is the surgical delivery of a baby through an incision in the abdomen and uterus. An incision is made on the abdomen just above the pubic area. The second incision is made in the wall of the uterus. The physician can then open the amniotic sac and remove the baby. The patient may feel tugging, pulling, and pressure. The physician detaches and removes the placenta; incisions in the uterus and abdomen are then closed.


I authorize and direct _______________________________, M.D. with associates or assistants of his/her choice, to perform an elective cesarean section on _______________________________.

(Print Patient Name)


Patient’s Initials


_____ I have informed the doctor of all my known allergies.

_____ The details of the procedure have been explained to me in terms I understand.

_____ Alternative methods and their benefits and disadvantages have been explained to me.

_____ I understand and accept the possible risks and complications of a cesarean section, which include but are not limited to:

* Pain or discomfort

* Wound infection; and/or infection of the bladder or uterus.

* Blood clots in my legs or lungs

* Injury to the baby

* Decreased bowel function (ileus)

* Injury to the urinary tract of GI tract

* Increased blood loss (2x that of a vaginal delivery)

* Risk of additional surgeries

* Post surgical adhesions causing pain/complications with future surgeries

* Increased risk of temporary breathing problems with the baby that could result in prolonged hospitalization

_____ I understand and accept the less common complications, including the risk of death or serious disability that exists with any surgical procedure.

_____ I understand in a future pregnancy that I have an increased risk of complications including, but not limited to:

* Placenta previa, where the placenta covers the cervix.

* Placenta accreta, where the placenta grows into the muscle of the uterus.

* This may lead to a hysterectomy and excessive blood loss at the time of the cesarean section.

* An increased risk of uterine rupture (with or without labor) and that this risk increases with each subsequent cesarean section. Uterine rupture can lead to the death of the baby or myself.

_____ I have been informed of what to expect post-operatively, including but not limited to:

* Estimated recovery time, anticipated activity level, and the possibility of additional procedures.

_____ The doctor has answered all of my questions regarding this procedure.

_____ I am aware and accept that no guarantees about the results of the procedure have been made.



I certify that I have read and understand the above and that all blanks were filled in prior to my signature.


________________________________ Patient Signature/Date

 ________________________________ Witness Signature/Date


I certify that I have explained the nature, purpose, benefits, and alternatives to the proposed treatment and the risks and consequences of not proceeding, have offered to answer any questions and have fully answered all such questions. I believe that the patient fully understands what I have explained.



Physician Signature/Date



________copy given to patient ________copy placed in office chart

(Initial)                                                    (Initial)





I hope that every mother out there who is reading this post takes a good hard look at what exactly women are agreeing to when they sign a form like this. That is why when my readers get upset at the stories I write about and leave comments like, “Clearly this mother was not given full explanation of the risks and benefits! Can’t you bring this to someone higher up!? Can’t you get this doctor in trouble!? Can’t this woman sue!?” I feel like my hands are tied BECAUSE IT’S RIGHT THERE IN BLACK AND WHITE! When a woman puts her initials next to each one of those bulleted points and signs her name at the bottom she is basically signing away all of her control over to the physician. So if the case comes before a review board or a judge in court, they are going to see, right there on the paper, what the woman agreed to, whether her rights to informed consent were truly upheld or not. This is no different than any other CONTRACT.



If you have a minute, take another look at that consent form. Just LOOK at what a woman is acknowledging when she signs it:


  1. She authorizes the doctor to perform the surgery with any associates/assistants (and yes, that means residents) that HE chooses (NOT the patient).

  2. She acknowledges and confirms that all the details of the procedure have been reviewed in terms she understands.

  3. She acknowledges and confirms that alternative methods (which includes vaginal delivery) have been explained to her.

  4. She acknowledges and confirms that she understands and accepts the risks and possible complications of the cesarean section.

  5. She acknowledges and confirms that the doctor has answered all of her questions.

  6. She acknowledges and confirms that she is aware and accepts that there are NO GUARANTEES about the results of this procedure!



The physicians who drafted this consent and consents like it are really friggin’ smart. Why? Because this consent completely protects the interests of the physician and assures that the physician maintains complete control over the situation. Guess what ladies, unless you were in a coma at the time of signing, you can’t go before a judge and cry “But I just didn’t KNOW!!” when your signature is on the paper in black and white. I am not commenting on this to upset anyone. I just wish that all women really knew how important it is to KNOW WHAT YOU ARE SIGNING!





Okay so now that we have all learned a bit more about elective primary cesarean sections (EPCS) and cesarean delivery on maternal request (CDMR), it’s time to see what major health organizations and groups are saying about them across the country and the world. The following is a list of quotes from published committee opinions, position statements, official editorials, journal articles, and other media from FIFTEEN major health organizations/advocacy groups. Full text of the articles referenced can be obtained (where available) by clicking on the links below each quote:


#1 American College of Nurse-Midwives (ACNM):


Elective primary cesarean section has recently been proposed as a substitute for vaginal birth. It is the position of the ACNM that this practice is not supported by scientific evidence. The ACNM identifies vaginal birth as the optimal mode of birth for women and their babies. Cesarean section is valued as a surgical procedure used to decrease morbidity and mortality in specific clinical situations. The ACNM promotes decision-making about mode of delivery that is evidence based and not unduly influenced by factors such as liability, convenience or economics.”

Position Statement: Elective Primary Cesarean Section,

ACNM, 2005



#2 Association of Women’s Health, Obstetric, and Neonatal Nurses (AWHONN):


Cesarean deliveries on maternal request (CDMR), a subset of elective Cesareans, are a reality in the United States and one we need to take seriously and investigate thoroughly. Consistent with the NIH State-of-the-Science expert panel’s conclusions, the AWHONN strongly supports dissuading women from having non-medically indicated c-sections prior to 39 weeks due to the risk for prematurity related to imprecise estimation of gestational age. Such c-sections contribute to the prevalence of near-term (most recently referred to as late preterm) birth and its associated serious health concerns including neonatal respiratory distress.


[AWHONN urges women] considering non-medically indicated c-sections to thoroughly discuss this choice with their health care providers and ask about how the surgery might affect their babies. AWHONN agrees with the NIH State-of-the-Science expert panel’s conclusion that CDMR is not recommended for women desiring several pregnancies. AWHONN also supports research that will help the health care community support and promote a women’s choice of planned vaginal birth.”

Nursing Association Urges More Research into Elective Cesarean Sections and Health Impact on Mothers and Newborns, AWHONN, 2006



#3 Midwives Alliance of North America (MANA):


It is ironic that the AMA should have a quarrel with a known safe birth option such as homebirth at the same time when the epidemic rise in coerced or elective cesarean sections puts healthy mothers and infants at greater risk than normal vaginal birth and causes excess strain on the limited resources of our healthcare system. The rate of cesarean sections in the United States is unacceptable—one in three pregnancies end in major abdominal surgery—and the decline in availability of vaginal birth after cesarean (VBAC) is deplorable. It is unethical to expect that women and infants should continue to bear the brunt of increasing medical malpractice risks by over-treating them with obstetric technologies such as c sections while denying them safe evidence-based options such as VBAC.


Modern medical ethics have evolved to embrace autonomy—patient choices and patient rights— over medical recommendations based on paternalism or physician preference. In almost all areas of modern medicine, except obstetrics, the locus of control rests firmly with the client or patient and not with the medical provider.


All maternity care providers should band together to reduce the unacceptably high rates of maternal and infant mortality and morbidity in the United States, increase access to maternity care for all women, reduce unnecessary cesarean sections, encourage vaginal birth and VBACs for healthy women, reduce health disparities of women and infants in minority populations, and promote increased breastfeeding.”

President’s Editorial: Doctors Ignore Evidence, AMA Seeks to Deny Women Choices in Childbirth, MANA, 2008



#4 The Society of Obstetricians and Gynaecologists of Canada (SOGC) (Note: The “ACOG” of Canada):


Some women or health professionals may elect to have a scheduled C-section, rather than attempt a vaginal birth. The SOGC is concerned that there may be an emerging trend towards more scheduled childbirth and routine medical intervention.


The Society of Obstetricians and Gynaecologists of Canada has always promoted natural childbirth, believes that the decision to perform a C-section during labour and delivery should be based on medical indications, [and] believes that the safety of a woman and her baby should be the driving factors in a decision to conduct a C-section.

Media Advisories: Elective C-Sections Add Risks During Pregnancy, SOGC, 2008


#5 International Federation of Gynecology and Obstetrics (FIGO):


Cesarean section is a surgical intervention with potential hazards for both mother and child. It also uses more resources than normal vaginal delivery. Physicians have a professional duty to do nothing that may harm their patients. They also have an ethical duty to society to allocate health care resources wisely to procedures for which there is clear evidence of a net benefit to health. Physicians are not obligated to perform an intervention for which there is no medical advantage.


Available evidence suggests that normal vaginal delivery is safer in the short and long term for both mother and child. Surgery on the uterus also has implications for later pregnancies and deliveries. In addition, there is also a natural concern at introducing an artificial method of delivery in place of the natural process without medical justification.


Physicians have the responsibility to inform and counsel women in this matter. At present, because hard evidence of net benefit does not exist, performing cesarean section for non-medical reasons is not justified.”

Recommendations on Ethical Issues in Obstetrics and Gynecology, FIGO Committee for the Ethical Aspects of Reproduction and Women’s Health, London, 2003.



#6,#7,#8,#9 The Association of Women’s Health, Obstetric, and Neonatal Nurses of Canada (AWHONN Canada), The Canadian Association of Midwives (CAM), The College of Family Physicians of Canada (CFPC), The Society of Rural Physicians of Canada (SRPC), & The Society of Obstetricians and Gynaecologists of Canada (SOGC):


Professional associations are concerned about the increase of intervention during childbirth, as it introduces unnecessary risks for mother and baby. According to a review of the evidence by Romano and Lothian, social and cultural changes have fostered an insecurity in women regarding their ability to give birth without technological intervention.


A normal birth does not include: elective induction of labor prior to 41+0 weeks, spinal analgesia, general anaesthetic, forceps or vacuum assistance, caesarean section, routine episiotomy, continuous electronic fetal monitoring for low risk birth, and fetal malpresentation. Childbirth is considered to be natural childbirth if there is little or no human intervention.


[We] believe health care professionals should be committed to protecting, promoting, and supporting normal childbirth according to evidence-based practice. Normal birth should be accessible and encouraged in all hospital settings. [We] believe all candidates for normal birth should be encouraged to pursue it.


[We] believe vaginal birth following a normal pregnancy is safer for mother and child than a Caesarean section. [We] believe Caesarean section should be reserved for pregnancies in which there is a threat to the health of the mother and/or baby [and] caesarean section should not be offered to a pregnant woman when there is no obstetrical indication.”

Joint Policy Statement on Normal Childbirth, SOGC, 2008



#10 International Cesarean Awareness Network (ICAN):


Recently, a few physicians have claimed that elective primary cesareans and elective repeat cesareans are safer for babies, and even for mothers, than vaginal birth. While selective use of the medical literature might seem to back up this claim, a review of the studies which consider short- and long-term risks of cesareans does not. Elective cesareans put babies and mothers at risk, use valuable and limited healthcare resources, have negative psychological and financial consequences for families, and substantially increase serious risks in subsequent pregnancies. The high rate of cesarean in the United States has not resulted in improved outcomes for babies or mothers. Additionally, vaginal birth after cesarean (VBAC) is still less risky for mothers and babies than cesarean section, despite recent claims to the contrary. ICAN is opposed to cesarean sections performed without true medical indication.”

Position Statement: Elective Cesarean Sections Riskier than Vaginal Birth for Babies and Mothers, ICAN, 2002



#11 Lamaze International:


The concept of “maternal request” cesarean presents a number of serious problems: Elective cesarean surgeries, that is, surgeries without medical indication, should not be equated with “patient” or “maternal choice” cesareans because they could equally well represent “physician choice“ cesareans.


Studies of maternal preference for cesarean fail to assess whether women were told of the potential harms of cesarean surgery, whether alternatives were discussed, the accuracy of the information women were given, and what opinion the care provider held. What women hear from obstetricians powerfully influences what they think. Some obstetricians think so little of the risks, pain, and recovery of cesarean surgery that they feel that “convenience,” “certainty of delivering practitioner,” and “[labor] pain” justify performing this major operation on healthy women.


Obstetricians champion a woman’s right to choose elective surgery on grounds of “patient autonomy” but deny her right to refuse one. Access to vaginal birth after cesarean (VBAC) has declined precipitously in recent years and is currently unobtainable in whole regions of the United States. This has occurred despite numerous studies concluding that VBAC is a reasonable option for most women. Until such time as obstetricians support a woman’s right to refuse as well as choose surgery, the promotion of “maternal request” cesarean must be viewed with extreme suspicion.”

The Problem with “Maternal Request” Cesarean, Lamaze International



#12 Doulas of North America (DONA):


While we appreciate your coverage of the alarming all-time high rate of cesarean births in the United States, the American College of Obstetricians and Gynecologists’ (ACOG) recent statement on elective cesareans also calls attention to the need for women to be cautious when making that decision. No evidence supports the idea that cesareans are as safe as vaginal births for mother or baby, and pregnant women should be given the facts they need to make an educated decision.

Letter to the Editor: The Washington Post, DONA, November 5, 2003



#13 Coalition for Improving Maternity Services (CIMS):


CIMS is eagerly anticipating the results of the upcoming NIH State-of-the Science Conference: Cesarean Delivery on Maternal Request, March 27-29, 2006 and trusts that the NIH will provide much needed guidelines and recommendations for decreasing cesarean surgeries performed for no medical indications (elective cesareans). Existing evidence that both women and babies are at increased health risks with a cesarean surgery is clear. A key objective of the US Public Health Service Healthy People 2010 initiative is to reduce the number of cesarean sections for low risk women. Additional objectives are to lower overall maternal deaths and reduce the number of babies born preterm and low-birth weight, all factors associated with cesarean surgery. [Also] The Centers for Disease Control (CDC) has identified cesarean section as having a negative effect on breastfeeding. Mothers are less likely to initiate and successfully continue to breastfeed.


To reduce current maternal deaths by 50% is a major goal of Healthy People 2010. The risks of [cesarean section] itself substantially increase the risk of maternal death compared with women having vaginal births regardless of their health status.

Elective Cesareans Defy US Department of Health and

Centers for Disease Control Goals for Improving Maternal and Infant Health, CIMS, 2006



#14 Citizens for Midwifery (CfM):


Although NIH has just completed a conference on “Cesarean Sections by Maternal Request,” recently-released results of a new “Listening to Mothers” survey from Childbirth Connection indicate that it is extremely rare for a woman to ask for a cesarean section.


Most obstetricians sincerely care about their patients and do their best to provide what they believe is the best care. However, non-medical issues, such as physicians’ personal beliefs (not facts) about safety, liability insurance coverage, liability fears, hospital economics, efficiency and convenience, and reimbursement rates, may influence physicians to try to perform more cesarean sections.


Citizens for Midwifery suggests that NIH recommend research to find out what is driving the wasteful and unconscionable increase in cesarean sections for no medical reason, and why women are being given misunderstood, incomplete or inaccurate medical justifications for them.

Patient Choice” Cesareans Almost Non-Existent, CfM, 2006



#15 Childbirth Connection:


Emphasis on “maternal request” is generating confusion in the media, within the general public and among health professionals and pregnant women. The only national data collected from women themselves has found that this was a highly infrequent occurrence among women who gave birth in the U.S. in 2005. Continuing misplaced focus on “maternal request” cesareans draws attention from the legal, clinical, financial and social factors that continue to drive the U.S. cesarean rate to unprecedented heights in an overwhelmingly healthy population.


All mothers should have access to safest vaginal birth practices. We should not ask mothers to choose between vaginal birth with avoidable harms and cesarean section.


[The NIH panel concluded] that ‘Until quality evidence becomes available, any decision to perform a cesarean delivery on maternal request should be carefully individualized and consistent with ethical principles.’ [However our position is that] without clear justification based on confident results about this comparison regarding the full range of outcomes of interest, extreme caution is warranted when considering elective major abdominal surgery in healthy mothers and babies.

NIH Cesarean Conference: Interpreting Meeting and Media Reports, Childbirth Connection, 2006





As you can see there are a plethora of organizations that represent obstetricians, family practice physicians, certified nurse midwives, practical midwives, nurses, childbirth advocates, and childbearing families that DO NOT SUPPORT elective primary cesarean sections and cesarean delivery on maternal request. You might be left thinking, however, about ACOG (American College of Obstetricians & Gynecologists). How does the “almighty” ACOG feel about elective primary cesarean sections? Funny you should ask…


Based on these principles [beneficence, autonomy, nonmaleficence, veracity, and justice] is it ethical to agree to a patient request for [or offer] elective cesarean delivery in the absence of an accepted medical indication? The response must begin with the physician’s assessment of the current data regarding the relative benefits and risks of the two approaches. In the absence of significant data on the risks and benefits of cesarean delivery, the burden of proof should fall on those who are advocates for a change in policy in support of elective cesarean delivery (i.e. the replacement of usual care in labor with a major surgical procedure).


If the physician believes that cesarean delivery promotes the overall health and welfare of the woman and her fetus more than vaginal delivery, he or she is ethically justified in performing a cesarean delivery. Similarly, if the physician believes that performing a cesarean delivery would be detrimental to the overall health and welfare of the woman and her fetus, he or she is ethically obliged to refrain from performing the surgery.


Given the lack of data, it currently is not ethically necessary to initiate discussion regarding the relative risks and benefits of elective cesarean delivery versus vaginal delivery with every pregnant patient.”

ACOG Committee Opinion: Surgery and Patient Choice, ACOG, 2008



Two things jump out at me with this statement:


#1 ACOG flat out denies that there is any “ significant data on the risks and benefits of cesarean delivery” which is outrageous, misleading, harmful, and untrue.


#2 Although ACOG claims that one of their main legislative objectives is to “maintain high-quality patient care” and two of their mission statements include “Promoting excellence in maternal and neonatal health care” and “Facilitating direct patient awareness and education in women’s health” it seems like on the topic of elective major abdominal surgery, it is more important for them to protect their own interests and open and maintain an ethical loophole so that physicians like Dr. M can continue to promote unnecessary cesarean surgery as long as she personally feels it will “promote the overall health and welfare of the woman and her fetus.” However, I hope that the above quotations from 15 other major health organizations have shown you that there are some obstetricians that think so little of the risks, pain, and recovery of cesarean surgery that they personally feel the “convenience,” “certainty of delivering practitioner,” and “labor pain” actually justify performing this major operation on healthy women. By ACOGs committee opinion, these “Dr. Ms” would be ethically justified in promoting, offering, and performing unnecessary elective cesareans sections without medical, fetal, or obstetrical indications. Gross.





In closing I leave you with a quote from Dr. Robert K. DeMott, MD:


Let’s face it-someone is trying to get away with something. This ultimate intervention (cesarean section), which is relatively dangerous and potentially life-threatening (compared with vaginal delivery), interferes with a normal physiologic process (labor) that we have no right to circumvent without evidence of compelling benefit. The compelling benefits simply are not present in most pregnancies.


Why are we treating pregnancy as a disease? “Offering” cesarean delivery or consenting to perform it electively at term is irresponsible, dangerous, and ultimately unfair to many women. The lack of fairness centers about informed consent. Like it or not in medical care a great deal of perceived power and influence is present, and the advice of physicians is seriously heeded by many under our care. Are we truly able to relate all of the surgical risks of cesarean delivery versus a vaginal delivery to the majority of patients? I would suggest that only a small number truly understand the relative risks. The less informed woman is merely agreeing to our recommendation without true knowledge of the consequences. This is inherently unfair and a blatant misuse of power.


Simply put, it is not worth it. Who is trying to get away with something and for what reason? Stay the course of the normal physiologic process. Use cesarean delivery for truly indicated obstetric conditions and no more. It is medically inappropriate, unfair, and unethical to offer anything less.

Commentary: A Blatant Misuse of Power? By Robert K. DeMott, MD, Birth 27:4 December 2000


Don’t Let This Happen To You #22: Gina & Tony’s “Elective” Primary Cesarean Section PART 2 June 12, 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 part 1 of this post: DLTHTY #22: Gina & Tony’s “Elective” Primary C/S  PART 1.





And now the story begins…



Not too long ago I was part of an absolutely outrageous and unnecessary cesarean section.  I arrived at work at 11:00am as usual and noticed that I had been assigned to the OR team.  My hospital averages about 10-15 births per day, and depending on the day, 4-6 of those births are by cesarean section…sometimes more.  Monday through Friday from 7am-3pm we have an OR team comprised of about 5 nurses or so, that handle all of the scheduled cases and even any emergency cases that happen during the day shift.  However, if there is a call in for the OR team or they have a particularly large case load (for example, a full schedule of scheduled cesareans plus some unexpected add-ons) I often get pulled off the floor to join the surgical team. 


So after reading the assignment I moseyed on down to the surgical wing to get the scoop from the OR charge nurse, Linda.  Linda informed me that I would be scrubbing the 11:30 case (that is, assisting the surgeon by passing him/her instruments and keeping an accurate count of all instruments, sharps, and sponges).  Next I looked over the patient’s chart so I would better understand what to expect during the case. 


The patient was Gina, a 24 year old G1P0 at 39.2 weeks with an unremarkable past medical history (tonsillectomy at age 6, mild exercise induced asthma) and a normal healthy pregnancy.  She and her husband Tony were expecting their first baby, a boy that they planned on naming Giovanni after her late grandfather.  Gina was about 5’6” and approximately 155lbs while her husband was about 5’10” and slender.  I scoured her admission assessment for a medical indication for her cesarean section.  Did she have active genital herpes?  Nope.  How about placenta previa?  Nope.  Was she breech, brow, or transverse lie?  Nope.  Problems with her first delivery?  Well no because this was her first baby.  Did she undergo previous extensive abdominal or uterine surgery?  Nope.  Was she abducted by aliens who sewed her vagina shut?!  NO!  NO!  NO!


And as I shut her chart to go and find her nurse and get some answers, my eyes fell upon her name plate and everything started to make sense….she was Dr. M’s patient!!!!  She was an elective primary cesarean section!  Let me digress for a moment to explain a little bit about Dr. M so that you get a better idea of the situation and why I just knew that Gina was scheduled for an elective cesarean. 






During my first week off of orientation as an L&D nurse, I admitted a patient of Dr. M’s for a repeat cesarean section.  I asked a fellow nurse, Sarah, if she could tell me a little bit about Dr. M since not only had I never worked with her during a birth before, but I had never even seen her in the labor wing during my entire 12 weeks of orientation.  Sarah looked right at me and said, “Let me put it this way.  Dr. M performs so many c-sections that it is almost as if she finds it personally offensive for a woman to deliver vaginally.”  I almost spit out my juice when I heard that!  Turns out, however, that she wasn’t exaggerating. 


Dr. M has the highest cesarean section rate out of any of the obstetricians that have privileges on our unit clocking in at a whopping 74% in 2007!  She has almost a 90% rate of vacuum assisted deliveries since she uses a vacuum on every cesarean and almost every vaginal delivery.  (And to be very honest, the only time she doesn’t put a vacuum on the baby’s head during a vaginal delivery is if the mother has a precipitous delivery and the nurse “accidentally” (*wink, wink*) forgot to bring a vacuum into the room!  Also whenever she uses a vacuum she cuts a giant episiotomy as well so you can do the math on her episiotomy rate!)  It is actually a joke among the residents and nurses on the floor (a really sad, sick joke, but a joke nonetheless) that Dr. M’s patients don’t ever have vaginal deliveries; they just have “failed cesareans.” 


Dr. M is one of only two doctors on the floor that will do primary elective cesarean sections and even so, the other doctor that will attend them will agree to it only in very rare circumstances.  But what exactly is an “elective primary cesarean section?”  Is it the same thing as a “maternal request cesarean section?”  That is, if a patient is scheduled for an elective primary cesarean section, does it automatically mean it was because it was by the patient’s request?  Are they the same thing?  Interchangeable terms?  And what does elective really mean?  Before I discuss the answers to those questions let me finish Gina & Tony’s story.






At this point I’m pretty frustrated.  It has been my experience with Dr. M that if her patient does not have a true medical indication for a cesarean section that she will literally make one up in order to convince the patient that a cesarean is the best way to go.  Think I’m exaggerating?  Well when I finally entered Gina & Tony’s room to introduce myself I found out the real scoop straight from the patient’s mouth.  After introducing myself to Gina & Tony and explaining my role as the scrub nurse, we got to chatting about her family, her job, and her pregnancy. 



Me:  “So how has this pregnancy been for you so far?”


Gina:  “Great!  I mean I had a little bit of morning sickness in the beginning but other than that everything has been great! 


Me:  “Is little Giovanni going to be the first grandchild for either of your parents?”


Gina:  “Oh well not for my side, I’m from a big family.  But he’ll be the first grandchild for Tony’s parents.”


Me:  “Oooh!  How exciting!!  It is so nice to hear that everything has been going well for you this pregnancy!  So what is the reason that you are having surgery today?”


Gina:  “Well last week I had a sonogram to measure the baby’s weight and it showed that he was really big, like over 8 lbs!!!  Dr. M also did an internal exam and said that I didn’t have enough room in my pelvis to give birth to a baby that big.  And she was my sister’s doctor too.  My sister had to have a cesarean after like two days of labor.  Dr. M  tried to induce her but her cervix just wouldn’t dilate past 1 centimeter so she had to have a cesarean for her first baby.  And for her second baby Dr. M just recommended a cesarean because she just can’t dilate.  So we were figuring I’m probably the same way too.  And I mean, I can’t give birth to no 8 lb baby!  Oh lord no! 


Me:  [dumfounded & speechless]


At that moment the anesthesiologist entered the room to go over what to expect during the spinal and I just said “Well I’ll see you both back there!” and left the room. 


I ran to the chart to find the sonogram report.  The estimated fetal weight per the report was 4025 grams (which is approximately 8lbs 14oz).  And sure enough in Dr. M’s admission note under “preoperative diagnosis” the following was written in black and white: elective primary cesarean section for suspected fetal macrosomia.





Okay, okay, okay, there are SO MANY things WRONG with what Gina was describing to me that I felt like I had been hit by a Mack truck.  Let’s take them one by one shall we!



FACT #1:  Third trimester sonogram reports are imprecise and inaccurate since they can be off as much as 2 POUNDS and they notoriously overestimate the fetal weight.


“Weighing the newborn after delivery is the only way to accurately diagnose macrosomia, because the prenatal diagnostic methods (assessment of maternal risk factors, clinical examination and ultrasonographic measurement of the fetus) remain imprecise. Leopold’s maneuvers and measurement of the height of the uterine fundus above the maternal symphysis pubis are the two primary methods for the clinical estimation of fetal weight. Use of either of these methods alone is considered to be a poor predictor of fetal macrosomia; therefore, they must be combined to produce a more accurate measurement. Ultrasonographic measurement of the fetus serves as a means to rule out the diagnosis of fetal macrosomia, which may aid in avoiding maternal morbidity, but is considered to be no more accurate than Leopold’s maneuver.” 

~American Academy of Family Physician’s (AAFP) publication of ACOG Practice Bulletin No. 22, November 2000, Obstetrics and Gynecology



FACT #2:  You cannot accurately determine the size of a woman’s pelvis during labor by doing a vaginal exam before labor begins.  The human body naturally releases hormones as it prepares for and begins labor which act to relax the joints and ligaments of the pelvis, increasing the diameter and flexibility of the pelvic outlet.  This type of misdiagnosis of cephalopelvic disproportion (CPD) accounts for many unnecessary cesareans performed in North America and around the world annually.  Also the sutures of a baby’s skull are not fused at birth for the very important reason of allowing molding of the baby’s head through the birth canal. 



FACT #3:  Labor induction increases a woman’s risk of cesarean section, especially if the woman’s cervix is not yet ripened and ready for labor (a.k.a. a Bishop’s score of less than 6 for a first time mom and less than 8 for a multiparous mom).  Therefore if a woman undergoes a cesarean section after a labor induction at 1 centimeter of dilation because she “can’t dilate anymore” it was the induction that failed NOT her body. See:


1)     Bishop score and risk of cesarean delivery after induction of labor in nulliparous women.


2)     Risk of cesarean delivery with elective induction of labor at term in nulliparous women.


3)     Elective Induction of Labor by Henci Goer




FACT #4:  According to the ACOG published practice guidelines, “suspected fetal macrosomia” should not be considered as an indication for cesarean section unless the estimated fetal weight is greater than 4500 grams (9lb 15oz) for a diabetic mother and 5000g (11lb 0oz) for a non-diabetic mother, and even so maternal risk factors and birth history must also be taken into account.  The ACOG committee (Practice Bulletin No. 22, November 2000, Obstetrics and Gynecology) provides the following recommendations for the management of fetal macrosomia:


Recommendations based on good and consistent scientific evidence (Level A):


* The diagnosis of fetal macrosomia is imprecise. For suspected fetal macrosomia, the accuracy of estimated fetal weight using ultrasound biometry is no better than that obtained with clinical palpation (Leopold’s maneuvers).


Recommendations based on limited or inconsistent scientific evidence (Level B):


* Suspected fetal macrosomia is not an indication for induction of labor, because induction does not improve maternal or fetal outcomes.


* Labor and vaginal delivery are not contraindicated for women with estimated fetal weights up to 5,000 g in the absence of maternal diabetes.


* With an estimated fetal weight more than 4,500 g, a prolonged second stage of labor or arrest of descent in the second stage is an indication for cesarean delivery.


Recommendations based primarily on consensus and expert opinion (Level C):


 * Although the diagnosis of fetal macrosomia is imprecise, prophylactic cesarean delivery may be considered for suspected fetal macrosomia with estimated fetal weights of more than 5,000 g in pregnant women without diabetes and more than 4,500 g in pregnant women with diabetes.


* Suspected fetal macrosomia is not a contraindication to attempted vaginal birth after a previous cesarean delivery.






So long story short, Gina had her cesarean section and I felt like I was going to cry the entire time.  (Sometimes I get myself really worked up about these types of injustices!  I know, I know, many of my colleagues tell me I need to learn to relax but turning the other way when this type of selfish and reckless obstetrical practice is going on in my community is just not something I can bring myself to do!)  Since I was the scrub nurse I was already scrubbed and in the OR before Dr. M even showed up to the case and since she blew out of that OR before we could even transfer the patient off the table to the stretcher, I unfortunately didn’t even get a chance to confront her about it.  And to be honest, I have seen her chew out so many nurses that I don’t know if I could have even stood talking to someone so irrational. 


Oh!  I can’t forget to tell you the best part of the story!  Dr. M is notorious for cutting the smallest possible incision, which one would think is a good thing, however, she cuts them so small that she always “has” to use a vacuum to pull the baby out of the uterus (and there is often a lot of straining and pulling and tugging involved on that little baby’s head!  It makes my stomach turn.)  She then, of course, brags to the patient about how “cute” her small little “smile” is (referring to the bikini cut skin incision the patient is left with.)  It really makes me sick when I hear her say that. 


So after the baby was delivered and Dr. M was suctioning her out with the bulb suction, I stared at the baby and thought to myself, “This baby is no where NEAR 9 pounds!”  And sure enough when the baby was weighed moments later, the red digital numbers burned into my brain as I saw them flash up onto the screen…





And to top it off, as Dr. M saw the weight for herself as that little baby wiggled around on the scale, she poked her head over the drape towards Gina and said, and I quote, “Well she’s just a bit smaller than we first thought, but Gina, I think you really made the right decision.  You don’t have a lot of room in here.  You wouldn’t have wanted an emergency cesarean now would you?”




As if she could tell how much “room” she had in her pelvic outlet from staring at her uterus propped up onto her abdomen as she sewed it shut.  Wait?  What’s that smell?  Oh yeah it’s BULL CRAP!





In conclusion let us review the definitions of some of the terms I have been referring to throughout this post.  Although one of the problems in obtaining accurate research on the phenomenon of “elective primary cesarean section” is that there is no standard universal definition, I have decided to use the following definitions after extensive research on the subject which will be presented in Part 3 of this post.  So for the sake of discussion on THIS blog, I ask that the following definitions be considered:


* Elective Primary Cesarean Section: A planned first or “primary” cesarean section in a healthy woman for the birth of a baby when there is no medical, fetal, or obstetric reason for the surgery.  May be influenced by non-medical issues, such as physicians’ personal beliefs (not facts) about safety, liability, insurance coverage, liability fears, hospital economics, efficiency, convenience, and reimbursement rates, as well as other factors not listed.  (American College of Nurse-Midwives, Position Statement: Elective Primary Cesarean Section & Citizens for Midwifery, News Release: “Patient Choice” Cesareans Almost Non-Existent)



* Maternal Request Cesarean Section or Cesarean Delivery on Maternal Request (CDMR): A subcategory of elective primary cesarean sections.  A planned (before labor begins) first or “primary” cesarean initiated by the mother with the understanding that there is no medical, obstetrical, or fetal indication requiring cesarean delivery, and after a through review of the risks and benefits of cesarean delivery vs. vaginal birth by the obstetrician, the woman’s decision is to have a planned cesarean section.  The primary decision maker for a CDMR is the woman(National Institute of Health (NIH) Cesarean Conference definition, March 2006 & Childbirth Connection, Listening to Mothers II Survey)


To reiterate, according to these definitions, it is misleading and inaccurate to assume that every woman who has an “elective primary cesarean section” actually had a “maternal request cesarean section.”  In order for a c-section to be truly considered a “maternal request” cesarean, the following FIVE criteria must be met:



Necessary Criteria for Maternal Request Cesarean Section:


#1  The request for the cesarean and the scheduling of the cesarean must have been made prior to the onset of labor.


#2  The request for the cesarean must have been initiated by the mother.


#3  The mother must have the understanding that there is NO medical, obstetrical, or fetal indication requiring a cesarean delivery.


#4  The obstetrician must personally review and assure the mother’s understanding of the risks and benefits of elective cesarean surgery vs. planned vaginal birth.


#5  The woman is the primary decision maker.




So what do you think?  Does Gina’s cesarean section fit the definition for a “maternal request cesarean section?”










* Types of cesarean sections and more differences between “primary elective” cesarean section and “maternal request” cesarean section.


* How 13 major health care organizations and nonprofit childbirth/maternity advocacy groups weigh in on “elective” cesarean section.


* An actual hospital consent form for “Elective Primary Cesarean Section.”