Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

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.

 

 

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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. 

 

 

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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.

 

 

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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.

 

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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.

 

 

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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…

 

7  POUNDS,  9 OUNCES

 

 

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?”

 

AHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH!

 

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!

 

 

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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?”

 

 

TO BE CONTINUED…..

 

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STAY TUNED FOR PART 3 WHERE I WILL REVIEW…

 

* 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.”

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63 Responses to “Don’t Let This Happen To You #22: Gina & Tony’s “Elective” Primary Cesarean Section PART 2”

  1. Adrienne Says:

    “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

    why is there a difference for diabetic and non-diabetic mothers?

    • nursingbirth Says:

      Adrienne, you write “why is there a difference for diabetic and non-diabetic mothers?”

      That is a GREAT question. Its all about body proportions. Babies born to mothers with gestational diabetes, especially mothers that do not have good control of their blood sugars, tend to have a body that assumes more adult proportions with the width of the fetal shoulders exceeding the biparietal diameter of the fetal head (that is, diameter across the developing baby’s skull, from one parietal bone to the other). Also, babies that are LGA (large for gestational age) that are born to gestational diabetic moms tend to have increased fat mass and decreased lean body mass compared to LGA babies born to moms that do not have gestational diabetes. All of these factors put babies of moms with gestational diabetes at a greater risk for shoulder dystocia. However, it is very important to point out that research has shown:

      1) 99.5% of babies weighing 4000-4500 gms had a safe vaginal delivery without shoulder dystocia. (Cunningham, author of Williams Obstetrics)

      2) Although rare (complicating 1.4 percent of all vaginal deliveries), shoulder dystocia is the most serious complication associated with fetal macrosomia. When birth weight is more than 4,500 g, however, the risk is increased to 9.2 to 24 percent in pregnant women without diabetes and to 19.9 to 50 percent in pregnancies complicated by diabetes. However, while macrosomia increases risk, shoulder dystocia also occurs unpredictably in infants of normal birth weight. (ACOG Practice Bulletin No. 22, November 2000)

      3) Pushing in an upright position (that is not in the dorsal recumbent position (on your back) or in the lithotomy position (on your back feet up in stirrups or being held by nurse) increases the diameter of your pelvis by as much as 30% and can be helpful in both preventing and relieving shoulder dystocia. (See: http://www.ican-online.org/pregnancy/pushing-positions)

      Thanks for your great question!

  2. Diana J. Says:

    Thank you for all the great information… What a tragedy and an injustice!

    However, your blog is getting “out there,” and it will make all the difference. Keep up the great work!

  3. Krista Says:

    Yay! Part 2 is here…I’ve been checking back for a couple days now. Can’t wait for part 3! Thanks for all your work on this blog….its been very educational for me (and you’re right….my friend’s cesarean doesn’t fit the maternal request criteria). My only question now is, does maternal request really exist? I mean, are there really women who would choose a cesarean without doctor pressure/prejudice and knowing there was no medical indication?

    • nursingbirth Says:

      Krista, it does exist (Britney Spears/ Posh Spice anyone?) But as the Listening to Mothers II Survey revealed, it is a very very VERY small percentage of the population. Thanks for reading!

  4. Laura Says:

    Isn’t there any authority to report these types of “Dr’s” to so that their “practices” get reviewed by a medical board? I can’t believe someone can get away with this! Keep up the good work, your blog is full of great information!

    • nursingbirth Says:

      Laura, at my hospital there is a board like you describe. It is made up of other OBGYNs who work on the floor or did in the past. Its a “boys club” for lack of a better (less sexist) term. No one wants anyone looking over their shoulder. Everyone wants to be able to do whatever the hell they want. So these docs get at most a slap on the wrist. It’s infuriating and pathetic.

  5. QoB Says:

    I’m curious (and not from the US, so ignorant of legalities etc.): what – if anything – can a nurse or other healthcare professional who isn’t the patient’s doctor do in this situation? would you be within your rights to tell them Dr. M is talking bullcrap?
    just thinking, as a patient, i’d definitely want to know if a doctor was compromising my health this way.

    • nursingbirth Says:

      QoB, according to my boss, the nurse manager of the floor, “I cannot do or say anything to the patient that will make her lose confidence in her physician.” I SWEAR TO GOD those were her exact words. I am still currently looking into this because to me, that sounds like a whole lot of hospital political bullcrap! And on the flip side, the times that I have, in the “most politically correct, most gentle, none of my own opinion just present the facts” way possible, tried to say something to a patient, I often get the “Who the hell are you? I have been seeing this doctor for “x” years/months and I don’t even know you! Why should I take your word over my doctors? After all you are “just a nurse” look/talk from them or their partner. Yes, I have had patients tell me I am “just a nurse” before. And it makes me feel like shit.

  6. Anne Says:

    I KNEW that 7 pounds 9 ounces was coming. KNEW IT! Well, okay, not the *exact* weight, but I knew it would be something similar. I read these stories over and over and over again – mom is told she’s going to have an enormous baby, maybe even a 10 pounder, and is going “over her due date” by a few minutes, and is scared into accepting either an induction into a likely c-section, or just plain proceeding straight to c-section. And then, of course, the baby turns out to be a petite little thing after all. *headdesk*

    Just a personal anecdote: While pregnant, I was part of a home birth support group. During one month we had 4 babies due. Three of the four were over 10 pounds, all totally normal (home) births, and only one had any tearing at all, and it was so little I think she needed maybe two stitches. I swear this is true.

    I agree with the others – keep up the great work!

  7. Anne Says:

    Oh, and the “boy’s club” you speak of in re: the OB internal review boards? Marsden Wagner describes the way these boards work as “omerta”, the Sicilian code of silence, exclusion, and protecting one’s own.

  8. kangaroo Says:

    i. love. your. blog.

  9. QoB Says:

    wow. scary stuff. thanks for the insight.
    please keep up the good work, you write very well, for someone who’s “just a nurse” !!!:)

  10. Molly Says:

    I LOVE this blog! Thank you thank you thank you for doing the work you do! I wonder what would happen if you made up a fact sheet, or printed a study on the risks of unessissary c-sections and gave it to Dr. M. I’m sure she would hate you… but do you think she’d read it? Educating pregnant women is so awesome and important… but how cool would it be if some how you could educate the OB’s. Not that thats your job…. but you would be great at it!
    -Your #1 fan

  11. With a 74% C/S rate and a 90%(!) vacuum rate, Dr. M would statistically speaking, have a very high rate of NICU admissions in her practice. You already posted on the effects to the newborn of C/S (increased NICU admissions, transient tachycapnea, etc). What worries me even more is the rate of vacuum usage, which can be catastrophic and fatal to a newborn. With that rate of vacuums, this Dr. M would have had to have a least one fatality/catastrophic event from vacuum usage.
    Every state is different on how they conduct peer review. It sounds like your hospital only has an internal review process, which is bogus. It will always stay a good ole’ boy network if it remains internalized. My perinatal network conducts quarterly reviews of outcomes of it’s network hospitals. If a physician had the kind of outcomes that Dr.M had, the hospital would be advised to revoke his privileges. If we didn’t, then our public health department could deny us payment for medicaid patients, which would essentially shut the hospital down. It is hard to believe that states allow this kind of practice, but you only need to look to Florida to see that it does exist.

  12. cam Says:

    Thank you for this blog…I’ve been reading for a while now. I just wanted to let you know that the ICAN link at the end is linking with the end-parenthesis attached, and leading to a bad link page.
    LOVE the blog. 🙂

  13. jenny Says:

    WOW just WOW I do not even know what else to say!

  14. Jackie Says:

    I love reading your blog. I wish that there were more nurses like you. I have never had any nice nurses with any of my deliveries that would sit and explain things to me. My c/s was the worst of them all. I am all about natural childbirth with no drugs and I will gladly have a baby with no drugs then go thru another c/s like I did with my 4th baby cuz she was footling breech.

    Keep up the good posts and the statistics. I really enjoy reading and am grateful that at least some women are really taken care of by their nurse. I feel that you are not “just a nurse” because the nurse spends more time with the patient during labor and delivery than the Dr. does. Thank you for all the wonderful work that you do as a nurse. I just wish that there were more like you.

  15. enjoybirth Says:

    Ahhh, the Big Baby Scare Tactic. I had a guess that was it.
    I had so many moms on the Hypnobabies Yahoo Group I moderate get this tactic from their OB I made up a page about Big Baby Bull. http://www.pregnancybirthandbabies.com/Big_baby.htm
    I will have to link to this post now.
    I SO agree that their need to be different and DEFINED definitions of cesareans so that we can get a clear picture of what is going on. Why they are rising.
    That mom didn’t “choose” to have a cesearean, she was “scared” into having one.

  16. MM Says:

    You could be describing at least three of my very good friends here, to the T.

    Sick, sick, sick.

  17. Renee Says:

    So so sad. And worse that it is so common. I can’t even say how angry and sad this makes me without rambling.

  18. Joy Says:

    That doctor needs to have her license revoked. She seriously needs to be brought before some board, reviewed, and questioned as to WHY her c-section/vacuum rates are so incredibly high. Then she needs to be FIRED and never be allowed to “doctor” anyone ever again. That is DUMBFOUNDING and ANGERING. I can’t even speak right now. I am THAT upset.

    I had a friend whose doctor was going on vacation when she was due. So they induced her early because of macrosomia. Her baby was UNDER 7 POUNDS! She was about 6 lbs 9 ounces. Unnecessary medical intervention so her doctor could go on vacation.

  19. Joy Says:

    Oh and I know I’ve told you a couple times now already that my former doctor wanted to cut me open with my next baby because my daughter was 8 lbs 8 ounces and her collarbone snapped during delivery (BECAUSE SHE WAS PULLING ON HER SWEET LITTLE HEAD to the point it freaked my mom-in-law out).

    And yet my new doctor, who is more seasoned and is one of the best in this city, has told me time and again my pelvis is more than adequate to deliver larger babies and that he’d never unnecessary section a woman whose had 2 perfect vaginal deliveries (minus the broken collarbone, of course). He said he’d leave the choice up to me but felt that, pending there weren’t any other issues, c-section was not necessary.

    That is probably why this upset me SO much. Thank God I switched to a different doctor!

  20. Rebekah Says:

    I’ve been reading for a while. This makes my blood boil! Excuse me while I go scream into a pillow. (eek!)

  21. Barb Says:

    Wow! Literally that just sickens me. I was not very informed with my first but I did request not to have a c-section unless absolutley necessary. I am so glad that I actually had the one doc in the practice that listened to me otherwise I would have had a c-section because I was in Labor for over 12 hours. The doc that admitted me has had a history of getting them in and out, all I can think is poor Gina! I don’t know what I will do with my next, is there anyway to refuse a c-section if they are really pushing one? I mean if the baby is not in any imminent danger.

  22. Disconnect Says:

    You might want to look at your “possibly related links section.” One of which is advocating elective sections, and has 70+ comments all in favor of scheduling a second section.

    LOVE. LOVE. LOVE. You are awesome. I am throughly enjoying every one of your posts. You rock. KEEP IT UP!

    I am wondering if you have considering going for your certified nurse midwife degree to allow you to put all these awesome ideas into practice with less interference.

    • nursingbirth Says:

      Disconnect, funny you should say that. I did notice that my “possibly related links” had that article in it. Unfortunately that is automatically generated by wordpress via my “tags” and I can’t change it. I read all those comments and they make me really sad 😦

      THanks for the support re: becoming a midwife. that is a goal of mine one day!

  23. 1. Yes, I smell the BULL CRAP through the internet.

    2. This is a wrong diagnosis, although technically it’s a lie. It’s malpractice and sadly, unless Gina has deep pockets, she has no way of suing Dr. Douchebag. She can try but if she’s alive and the baby is alive, she’d be at the mercy of the jury and their possibly skewed notions about birth and medical authority.

    3. I’m really concerned that Dr. M is using vacuum deliveries for no reason and increasing her (non-diabetic, birth weight of 7.7 lbs+) patients’ risk of shoulder dystocia by 35% to 45% (Nesbitt, 1998).

    4. THANK YOU for clarifying “elective” and “maternal request.” That’s one of he big blunders that reporters make. C-Section Rate Rises Because 20 Percent of Women Request C-Sections (fake example). A handful do. Not the same.

    I know you’re obviously anonymous for HIPPA reasons. If you have an anonymous e-mail as well, would you mind e-mailing me? I have an idea. =) unnecesarean at gmail dot com.

  24. Candice Says:

    Ugh. All too familiar with this type of situation and it breaks my heart every time. 😦 I need to look through some of my literature and find the stats on sections and the physical trauma afterwards (i.e. worse pelvic prolapse and bladder problems). I’m such a rebel 😉 questioning why we must continue to do a procedure with such poor morbidity and mortality rates for mom and baby that doesn’t even protect mom’s pelvic organs in the process. Keep up the good work, I really hope more and more women can get educated for their births from the experiences of those of us who see the broken system from the frontlines!

  25. KAS Says:

    I am 34w and a few days, and my fundal height is measuring at 42w. At my last ultrasound, I was told my baby weighed a good pound more than he “ought to” at that stage, and IF my OB cannot determine his position at my next appointment by external palpation, I will be having yet another ultrasound (my fourth) to determine his position. My husband and I are both “big”, and my older son was 8 lbs 4 oz at birth. Yet, I’m not at all worried about having a c-section or being scared into one. Why? 1) Because if my OB tells me I need one (which I doubt she will), I will simply tell her, “No.” The end. 2) I have a supportive husband and a doula who both understand and respect my desire for an intervention-free, drug-free birth – and after the hell I experienced with my older son’s birth (spontaneous water break, 18 hours of no contractions, pit started at hour 18, upped to the hospital’s max dosage before ANYTHING happened, Nubain and an epidural administered with no ability to change position or move because my hospital does not do “walking” epidurals, ending in a third-degree tear) I have no desire to have the typical, intervention-riddled hospital birth. Unfortunately my options are limited – no midwives here, no birth center, and only one hospital to deliver at – but I have faith in my experience. Also, my hospital has banned VBACs exclusively – so a c-section is, in my mind, NOT an option.
    Thank you for a wonderful blog. You’ve been added to my blogroll!

    • nursingbirth Says:

      KAS, I love everything about your comment. Your determination, your belief and trust in your own body and your support system, your kick ass attitude, and your desire to have a birth that is your way on your terms. LOVE IT! And thank you for pointing out that your first baby was “big”. I think too many people (including docs and moms) forget that everyone is different. An 8 lb baby might be “big” for one mom and “small” for another!!! Thanks for reading and thanks for giving me hope that there are moms out there that will advocate for themselves. I hope to give more moms the tools they need to advocate for themselves as well because too many moms feel disempowered and naive about their options!

      P.S. CONGRATS ahead of time on your birth and new baby!

  26. Joanna Says:

    **Mouth Hanging Open**

    I belong to a very large Parenting Forum and am shocked by the mis-information that is given there every single day. And it’s the women who try to give the correct information that get attacked. I see over and over again “Don’t scare first time Mom’s. Do whatever your OBGYN tells you and you will be fine.” Well after my first labor and delivery I applaud the ones that are not afraid to tell the truth. I wish someone had stood up to me when I was getting ready to get induced, told me the truth, and scared the hell out of me! I might have thought twice about doing it and avoided one of the most traumatic experiences of my life.

    Thank you for having that courage. I am sure that there is tons of pressure on you for doing it. I applaud you for your efforts and wanted you to know that it is SO appreciated!

  27. Hannah Says:

    Oh man! This just makes me mad!! I am seriously considering nursing school in hopes of becoming a L&D nurse. I think I would be like you…almost in tears during that completely unnecessary section. Why on earth are they still letting that doctor practice medicine!? A nearly 75% c-section rate is ridiculous!!

    I have mentioned this before, but I am so thankful that I found an OB who is so anti induction and anti c-section. My second son measured BIG at my 32 week ultrasound, 95 percentile, I think. My doctor told me that he wouldn’t even consider induction because it could make things worse. The only thing he would consider was a c-section if baby made it to 10lbs 15oz. In the end, I went into labor naturally and easily delivered an 8lbs 10oz boy. I actually tore less than I did in my first birth, thanks to my doctor’s expert help in pushing slow and easy.

  28. atyourcervix Says:

    Very very sad. However, I’ve seen and heard very similar situations at work too. Baby is “too big”, MD recommends (pushes) a primary elective c/s. Baby turns out to be 7-ish lbs. Too big? Really? How do we know the baby was “too big” to fit through a “too small” pelvis? Did we do pelvimetry? I’ve even flat out asked one women – “do we have your pelvic xrays to confirm your ‘contracted’ pelvis?” They look at me with a question on their face….”xrays?”

    Sigh. By the time the women get to us on L&D, it’s already been drilled in their brains that their baby is too big, or their pelvis is too small. They believe the almighty MD. They don’t question the preop diagnosis.

  29. Thanks for keeping it real! I love the rants with the facts to back it up!

    Very frustrating stuff indeed! Most of the moms I hang with are natural leaning…but I have a sister-in-law who is “too posh to push” and she can’t be told. Despite the stats, she just doesn’t want to hear it. And I suppose Dr. M is just her kind of doc. Unfortunate indeed.

  30. KhalilaAnn Says:

    That’s so awful! 😦 Sadly I’m hearing a lot of stories like this on the birth board I’m a part of. “My OB said we should induce at ((insert a date a week or two BEFORE their due date)) because my pelvis is too small, my baby is growing too fast, etc…” I wish more women took the time to educate themselves about these things so that these cases weren’t so common.

    I did have a question for you though, which is about L&D but I have to say way off topic. Do you ever get women who are planning a NCB come in/call in and specifically ask for an NCB-friendly nurse to be their L&D nurse? Someone mentioned this to me the other day and I have to say the thought never occurred to me! Just wondering how common it was.

    • nursingbirth Says:

      Hi KhalilaAnn, I have read many books and websites where the author suggests asking for a NCB friendly nurse when they get to L&D. I can only speak from experience at my hospital. We have had a handful of moms ask for a NCB friendly nurse when they get to L&D but it is still a pretty rare thing to hear. Not that I dont think its a good idea. I mean hey, what have you got to lose! If I am there the charge nurse usually will assign any patient that asks for a NCB friendly nurse to me if possible, however, she doesnt do it without rolling her eyes at some point. The truth is, just like doctors, some nurses feel threatened by an educated empowered mom, not all but some….some nurses desire the control of an epidural/pitocin and feel uncomfortable with a mom that is going through unmedicated labor. Labor support is not somethign that is usually taught on orientation…it certainly wasnt a part of my orientation! I had to seek out that information and learning on my own, on my own dime too. Its part of the culture they have worked in for so long and trained in for so long. its sad but its true. So really, it couldnt hurt to ask. Because even if there is some eye rolling going on, hopefully you will have a nurse assigned to you that is supportive of your birth plan!!

  31. briome Says:

    You, not the commonality of it!

  32. NHmomma Says:

    WOW! That could have been MY “elective primary cesarean” !!!!! I mean really!

    OB scared the crap out of me since I had a LGA baby, and gasp failed ONE (the two hour) timepoint on my 3 hour GD test. They never could make up their mind about calling me Insulin resistant or GDM. It depended on the OB and their motive. In the end they coerced me into a cesarean using all the dead baby cards they could pull out. Not to mention the “If you were MY wife” speach!!!

    I fought them off till 40w3d when they had me coming in every other day for BPP ultrasounds and explaining how FAT my baby’s thighs were! Then I caved… I consented to something I knew I did not want!

    The end results, a perfectly proportioned 8lb14oz baby girl with out a drop of glucose or jaundice issues. And you know what they stated when they pulled her out! OOOPS! She does not look like 9.5lbs! Plus after the extraction, I was told “well you really were not GD anyways” by one of the OB’s… WTF!!!

    Tired of this crap! Tired that now I am a walking exploding uterus and have to fight like mad to be treated as normal! All because of OB fear! And yes, I hate the fact that ELECTIVE is all over my records, because it was NOT elective.

    • nursingbirth Says:

      NHmomma, Thank you so much for commenting and sharing your story. Your frustration is pouring out through your words! And I hate that they are treating you like an “exploding uterus time bomb” now because of a C/S they scared you into having. If I had a dollar for every mom that was called “Gestational Diabetic” or “Preeclamptic” when really they just had one bad sugar or really just had pregnancy induced hypertension (PIH) I would be a rich girl. I HATE that that doctor just so casually informed you afterwards that you were not, infact GD. ERRRRRRRG! And I really hate the “my wife” speech!! It isnt used for any good! Only evil! Haha!

      Keep on advoating for yourself momma!! You have the right to the birth experience you want and you deserve!!

  33. Liz Says:

    When I worked as a PP nurse, I remember a particular patient, 21 years old, fist time mom. Seceduled section for drum roll… “macrosomia” I think the baby was about 7lb even! Stuff like that used to drive me nuts. what drove me even more nuts was that all of the posh ladies in town birthed at my hospital and were obsessed with discussing “natural birth friendly” pushing positions but kept chosing the same C/S happy MD’s. Didn’t they compare notes? All this said, I am still not super comfortable with home birth. I know about all of the great statistics, but have heard from several moms in my area that they feel there is not enough follow-up and coordinaion of getting proper INFANT care in the fisrt days after birth. A friend had thick meconium at her birth and ended up taking baby to see a ped. per respiratory issues she picked up on. He had inhaled mec. and later also cultured + for GBS. Mom had tested negative but the midwife let her “swab herself” Not so sure that is a good idea. What do you think? My feeling is that in the hospital setting at least neonatology is on hand when there is thick meconium and a stressed baby. I am sure that you disagree and would sincerely like to hear more about what you have to say about infant care following homebirth.

  34. Roxanne Says:

    Thank you so much for sharing all of this with us. I know so many similar stories; its so frustrating to hear moms talk as if their Doctor “saved their life” or “I could never have given birth”.

    Another one I have heard alot is when an induction fails, mom gets c-section, and then Dr tells her it doesn’t look like she could give birth anyway, because she’s “too small down there.” MY sister in law is having a repeat c-section just because of this very reason. She honestly believes she CANNOT push a baby out. 😦

    Gag me. The almost reverent worship of OBs is one of the most ridiculous and saddest things to me and I wish women could WAKE UP and see the truth. Sadly, most of them will perpetrate the myth by telling all of their other mom-to-be friends how their doctor most certainly saved them from death.

  35. Randi Says:

    Love this blog! I wanted to share that I’m 5’4″ and medium build. All my children, other than my third, were between 6 and 7 pounds at birth (all full-term, no inductions). I am currently 35 weeks with my sixth child.

    My third child was 9 lbs 1 oz. The doctor guessed that he was probably going to be bigger, but he never made an issue of it. I went into labor a day after my due date (all the others were early). He came out the same as his two older petite sisters. No shoulder dystocia. No other problems (I was not GDM). I didn’t even tear any more than with my other kids. He just happened to inherit all of the tall genes from both my husband’s and my sides of the family!

    So, the big baby thing is such a hoax! I am living proof! I believe that 99% of the time the body will not grow a baby bigger than it can deliver.

    Dr. M. really shouldn’t be practicing at all. Unfortunately it’ll probably take an infant death at her hands with the parents’ ability to sue for malpractice before she’s stopped.

    Thanks for all of your information. I’ve done lots of research on childbirth, but it’s been so great to have a L&D Nurse’s perspective about what goes on behind the scenes that sometimes undermines the choices of the parents.

  36. Molly Says:

    This story really made me want to cry.

    In my opinion, this is malpractice! Is there anyway to expose or report this doctor? I don’t think I could do what you do, I’d NEVER be able to keep my mouth shut.

  37. thefeministshopper Says:

    If I were you, I’d be crying through the whole surgery too. I’d also throw up all over that f*cking doctor when the scale read 7-something pounds, and I’d punch the doctor in the face with that whole “we really made the right decision” bullSHIT!

    I run a VBAC support group meeting in Chicago, so I’m in the unfortunate position of hearing lots and lots and lots of cesarean stories. I’m also in the wonderful position of helping moms have amazing, triumphant VBACs. But as far as I’m concerned, a doctor like this should absolutely lose her medical license. HOW CAN SHE STILL BE PRACTICING with all the damage she’s doing to these women’s uteruses and labia??? This is insane!!!!

  38. Linda Says:

    Just a little shining light on this topic, from my own world…

    During my routine pregnancy appointments, my OB likes to share stories about various births he’s seen. Today he told us about how he’s seen someone give birth to a 12.5 pound baby vaginally (and relatively easily, as I recall). Clearly he’s not the sort to induce people for macrosomia!

    He also shared that he estimates baby size by feeling the baby through the mother’s belly, claiming that it’s every bit as accurate as an ultrasound (which is to say, not particularly, and he’s quite aware of this).

    It’s good to know that there are good doctors out there, too, who have their heads screwed on straight.

    • nursingbirth Says:

      Linda, you write “He also shared that he estimates baby size by feeling the baby through the mother’s belly.”

      That is called Leopold’s Maneuvers and you are right, studies have shown that it is on par with ultrasound estimates. I am so happy you shared a story of a doctor that’s got his “head screwed on straight”. Haha!! I am sure it is comforting for moms to know that if they do their research they too can find a supportive birth attendant who practices evidenced based medicine!

  39. […] Labor and Delivery nurse shares a story about a mom who has a cesarean because of a suspected big baby – “near 9 pounds” (which isn’t really even BIG) and the baby ends up being 7 pounds 9 […]

  40. Navessa Says:

    ugh.
    sooo frustrating to read.
    i just can’t go to nursing school after reading this stuff…

    my ? – has anyone done any statistical outcomes of Dr M’s births? with a rate that high you would think that there have been bad outcomes for the moms and babies. how often has she been sued? i wonder what her malpractice is?

    • NursingBirth Says:

      Navessa, I have hit many dead ends when researching those very questions myself. We have NO ACCOUNTABILITY or TRANSPARENCY in this country for our birth attendants and our maternity care. It is so wrong!

      • Navessa Says:

        that is even more upsetting to read. 😦

        postpartum complications for moms and babies should be recorded somewhere…

  41. Bitybabynurse Says:

    Thank you so much for taking the time to compile this. I have personally been struggling at work (newborn nursery) with these same stories and circumstances. I just can’t stand it! It is literally turning me into a bitter person, when i see these MD mistakes and personal bull crap every single day!

  42. Marianne Power Says:

    I am so glad I found your blog. I am an RN as well as a Licensed (DEM) midwife in Florida. After 10 years I left my job as a midwife in a “busy” birthing center to return to hospital nursing. I knew things had gotten bad but I did not realize how bad! This is my 3rd week in orientation. I quickly learned that I must keep a journal of my daily “occurrences” for my own sanity as well as my personal liability protection. One small example of an incident this week is the OB who left the OR for 20 minutes during a repeat elective cesarean in order to deliver a patient in L&D. This was not necessary because the CNM (employed by this OB’s group) was gowned and gloved and ready to catch the baby. The woman on the table had spinal anesthesia and was awake and aware when the baby came out but after waiting for this long her spinal began to wear off so the anesthesiologist had to give her IV meds to keep her comfortable. By the time we transferred her to recovery she was so out of it she did not even remember that she had had her baby, and did not remember even seeing the baby. The RN (my preceptor) filed an incident report against the OB and asked me if she could put my name down as a witness. Of course I said yes. This OB has now requested that I not be allowed to circulate during her cases! Three weeks and I am already in trouble!

    • NursingBirth Says:

      Marianne, OMG that is AWFUL! Unfortunately I can believe that that happened. To think that just because you were a mere witness to her professional negligence she has now “blacklisted” you from her cases is ridiculous!! Incredible! (*shaking my head*)

  43. Jessica Says:

    Can I hug you? 🙂 Being a hard core home-birther after my horrible hospital birth experiences, I’m so glad to know that there are nurses (and I do know a few) in the hospitals that still try to help women and are equally disgusted by doctors who behave this way! Keep up the good work!

  44. […] “You don’t have enough room in your pelvis to give birth to a baby that big” — said to scare a woman into an “elective” C-section that she thinks is medically necessary [estimated fetal weight 8lb 14 oz; actual birthweight 7lb 9oz]. […]

  45. […] grounds of fetal welfare, self-protection from malpractice suits, or mere convenience—manipulate women into compliance in ways that would be considered fraud in any other venue. Without fear of […]

  46. Cohen Says:

    Why don’t you report this doctor to the medical board in your state? Exposing her is the only way to protect others. This doctor should be jailed.


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