Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

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


36 Responses to “Don’t Let This Happen To You #22: PART 3. A Discussion About Elective Primary Cesarean Section & Cesarean Delivery on Maternal Request (CDMR)”

  1. OK, I have a question. With my first birth I pushed for three hours and could not take it anymore. My OB said I could push for another hour, but I said no way. So off to the OR. Would I be considered a maternal request or a primary elective C-sec, or neither?

    I must say that maternal request C-sections are rare. The ones I have seen may not be medical, but certainly ethical. One was a mom with a history of sexual abuse. She was adamant about not wanting a vaginal delivery. Another was a woman from Africa who had undergone female genital cutting (which was repaired here in the US), but she did not want a vaginal delivery. Something I see a little more frequently is a mom who is pregnant with twins who do not want to try a vaginal delivery. They may be afraid of pushing one out, then ending up in the OR for the second. (worst case scenario).
    BTW: It is usually the legal department that writes the consent forms, with medical/nursing consultation.

    • nursingbirth Says:

      realityrounds, remember that for it be be an elective primary cesarean section or a maternal request cesarean section it has to be PLANNED ahead of time BEFORE labor. So no, yours would not count as a EPCS or a CDMR. Technically yours was probably for “failure to descent” which, whether or not there were interventions that might have caused it that could have been prevented or not, “failure to descent” is considered an obstetrical indication. Now again, I think that the diagnosis of “failure to progress”, “failure to descent”, “CPD” and stuff like that are way OVER diagnosed and incorrectly diagnosed and many times preventable, but still, no matter how you get there, in the end if the C/S becomes “necessary” for one of those reasons, its NOT considered EPCS or CDMR.

      p.s. things are starting to make a lot more sense now that you point out the legal department drafts up these consents. Hmmmmm…

  2. Jackie Says:

    I would like to thank you for writing this blog. I am learning a lot from the things that you are writing about. When I had my c/s I was not informed at all. I went into labor on my own was only told that if baby didn’t turn head down then I was going to have to have a c/s. I signed all the papers while in transition. I had no idea what I was signing. Luckily I haven’t had any problems from my c/s. But just reading the consent form made me sick that I actually signed something like this. My baby was footling breech and she was my 4th baby. I know that I had a pretty good chance that I could deliver her breech but the Dr. said no way was he delivering a breech baby vaginally. So off to the OR with me 100% ready to push. I am not kidding either. It was horrible and another story in itself.

    Thank you for being such a wonderful nurse to those you do work with while they are in labor. I wish that there were more nurses like you.

    • nursingbirth Says:

      Jackie, thanks for reading! I really appreciate your comment. It is a really big shame that more physicians will not do vaginal breech births and that this skill is literally becoming extinct since it is not being taught in residency programs anymore. This is in large part related to a very flawed study called the “Term Breech Trial”. I wrote about it in my post entitled “Why Is Vaginal Breech Birth Going the Way of the Dodo?”

      According to the Coalition for Breech Birth website ( :

      “Vaginal breech birth was practically banned following a significant international research study in 2000. This study, the “Term Breech Trial” or TBT, appeared to prove that caesarean section was substantially safer for the delivery of all breech babies. The trial was highly criticized, but many birth care providers took this opportunity to do what they wanted to do anyway – to stop offering vaginal breech birth to their clients, and to insist instead upon a surgical delivery. In addition to all the professional criticism, the TBT’s own two year follow up negated the original results, suggesting that any difference in safety between vaginal and surgical birth of a breech baby is negligible – for both mother and child. Despite this evidence, many birth care providers (BCPs) still avoid balanced informed choice discussions with their clients, denying them the opportunity to make an informed choice.”

      Also I don’t know if this will make you feel better or worse but technically because your baby was breech (which is considered an obstetrical indication for C/S in the United States because of the Term Breech Trial which gave doctors an excuse (*cough*) I mean reason to do a C/S) your cesarean was not considered “elective”. It was a primary cesarean but not “elective”.

      Also although some practitioners argue of the safety of a breech vaginal birth with an experienced and educated practitioner, they typically are referring to “complete” or “frank” breeches where the buttocks, not the feet, present first. Here’s a quote from a midwife that speaks to this:

      “Yes, it is dangerous to try to have a vaginal birth with a footling breech. “Footling” means the baby is more or less standing up in the uterus, with his feet hanging down at the cervix. When the cervix starts to open, this leaves space around the feet, and the umbilical cord can drift down into that space and “prolapse,” or fall out into the vagina. If it does this, it will become strangulated, and blood flow to the baby is cut off. There is a high risk of stillbirth. The other breech, or butt-first presentations, frank (legs straight up) and complete (legs tucked up) are not likely to cause this problem, as the butt is filling out the space over the cervix and keeps the cord from falling down, just as the head does in a “vertex” birth. So, I would not recommend that anyone try a vaginal delivery with a footling breech.”
      by Nancy Sullivan, CNM, MS, FACNM (

      So Jackie, I guess what I am trying to say is please don’t beat yourself up about having your C/S. Your type of breech baby was a particularly high risk breech. You would not considered an “elective” or “maternal request” cesarean by any standard. I feel so badly that you had to have an “emergency” cesarean and since it was your 4th baby, I know there is no doubt in your mind that you could have pushed your little one out if things had been different. I wish things could have been different for you around your cesarean that wouldnt have made it so disempowering for you. Good luck to you and I hope you continue to visit this blog and keep commenting! I really appreciate your comments!!

  3. Joy Says:

    So… what happens if a woman does NOT sign that release while she’s in L&D? What if she refuses?

    Because when you arrive at L&D and are admitted, they have you sign EVERY piece of paper while you’re laying there in pain. Or, in my case, after they give you a medication that makes you feel so loopy and out of it.

    So just wondering… do they refuse care? Do they shrug and say whatever?

    • nursingbirth Says:

      Joy, you are right, I hate that papers are often signed when women are in the throws of labor, trying to keep their “center”, and are in pain. However remember for planned C/S like EPCS and CDMR these papers are not signed when a woman is in pain as it is a scheduled procedure. The are either signed at the office, at the hospital, or at both.

      About refusing care, it is a patient’s right, any patient (not just women in labor) to informed refusal. How many women actually get to refuse treatment however is another story since there is a lot of bullying (You know the “If you were my wife.” and “Don’t you care about your baby” crap) that goes on if a woman tries to refuse treatment. But it is a her right. Please check out the Childbirth Connections “Right of Childbearing Women” at

      Thanks for reading!

  4. kangaroo Says:

    I refer to your blog often when compiling and presenting my own research, and I thank you, wholeheartedly, for your unique and firsthand experience.

    We do have the right to informed consent AND informed refusal, though as you said, it becomes buried and difficult to clearly obtain. VBAC’s are a prime example; should a hospital even ‘allow’ VBAC’s (meaning these few hospitals that actually ‘allow’ women to use their own vaginas), women are clearly feared into repeat c-sections by being repeatedly told the risks of VBACs…but what about the risks of repeat sections?

  5. Missy Says:

    Wow! I honestly don’t remember reading those risks on my consent form, but I guess they must have been there. They went over things so quickly, it’s hard to remember what exactly was said. I was pretty out of it at the time too. You would think that those risks alone would be a red flag to women who thought that a c/s was the “safe” option. Great post!

  6. thefeministshopper Says:

    There was a mom in our VBAC support group meeting last night who had an “Elective Maternal Request” cesarean. She had no idea what she was asking for – and the doctor PERSUADED her to do it, with ZERO medical indication to do so.

    The story goes: She showed up at 40 week appointment, they said she wasn’t dilating/effacing, did an ultrasound, said baby “looked” big, and told her she should schedule a cesarean. She asked the doctor what SHE would do, and the doc said “If it was me, I’d have a cesarean.” She THEN asked the doctor if she could have a normal, vaginal birth the next time and the doctor said “Absolutely!” – which was a flat out lie. The doctor refused to take her as a VBAC patient when she showed up pregnant 2 years later (which is why she’s in a VBAC support group meeting looking for references for providers now.)

    This situation was every bit the Elective Maternal Request – and even though it was there in black & white, she still had no idea what she was in for. She had no idea she’d have so much trouble VBACing, and she had NO idea what kind of psychological effect that cesarean would have on her.

    She went from being a “trust the doc, do what they say, who cares how they come out” mom, to being one of “us.” So tragic. Every day I wake up hoping another mom will not have to join our VBAC support group.

    Having said all that – would you mind if I republished that consent form on my blog? (I’ll link you, of course) 🙂

    • nursingbirth Says:

      thefeministshopper, I hear stories like your friends a lot. Especially when women dont realize a) what a VBAC is and b) that there are so many hospitals and doctors who (without evidence to back them up) refuse to do them. It is so sad. I agree, everytime I go to ICAN I am happy and sad when we have new members! Happy that they found us, sad that they had a cesarean! Also, I have no problem with you linking to my site! 🙂 Thanks for asking!

  7. Autumn Says:

    To me, one of the most heartbreaking statements I ever heard was “If I knew yesterday what I know today I NEVER would have agreed to this!” Her “macrosomic” baby was 7# 5oz!!

    I was stuck, she had to get up post-operatively and I was the lucky nurse who had to push, beg and cajole her out of bed.

    • nursingbirth Says:

      Autumn, the entire reason I write this blog is because I dream of a world where I never hear another women every say If I knew yesterday what I know today I NEVER would have agreed to this!” again!! Thanks for reading!

  8. I think this blog is the most important blog on childbirth. I would like to create a sidebar ad for people to share this on their blogs. I’ll e-mail you.

    The ACOG ethics/physician belief loophole is actually the basis of the home page of The Unnecesarean. It’s also the reason I feel compelled to pick away at cultural beliefs about birth. And it is gross.

    • nursingbirth Says:

      Jill-Unnecesarean, WOW you are so nice! I really really love your blog too and I really appreciate all of the work you do too! Thanks for being so encouraging! I have no idea what you are describing when you talk about “sidebar” but I’m totally in to it anyways 🙂 Email me!

  9. ladydilee Says:

    I find it interesting that in other legal type documents, everything is spelled out exactly and nothing is left to hearsay. If you have a rental agreement, there are clauses in there covering just about EVERYTHING, protecting both the renter and the leasee.

    But in this form, it is virtually blank. How do you know the mother recieved a full and complete description of the surgery? If she didn’t, how can she say she fully understood it? The issue with future births being restricted isn’t even directly addressed. And questions? I think part of that should be that she was given the opportunity to ask them. I don’t know…it just seems like an awful lot is left nebulous, and the only person that benefits is the doctor, with little or no benefit to the mother.

    Like you said, “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.” And that is scary. I also think that it is part of the problem. After the fact, most mothers feel like they have no recourse because they signed these forms. How do you argue that your doctor never discussed X possibility with you, when you signed that he did? Even though you didn’t know X possibility was possible? I can imagine that you feel helpless to do anything about it, and you just go back to your life with your new, hopefully healthy baby to try and get over whatever injustice you felt occured.

  10. Kathy Says:

    thefeministshopper — in response to the doctor telling the woman she could VBAC to refusing to take her 2 years later… It’s possible that the doctor *did* attend VBACs at the time of the surgery, but thanks to ever-tightening rules, regulations, and malpractice insurance requirements (or a close call or a lawsuit), the doctor changed. She may have told a bald-faced lie, too; I certainly don’t discount that. But this is why ICAN’s database for VBAC policy is important — it can tell the woman which hospitals and doctors in her area attend VBACs and which don’t. Some hospitals won’t allow it; some doctors won’t allow it; some insurance companies won’t allow it — all these factors play into whether a VBAC is allowed or not.

    And if VBAC is not allowed locally, perhaps the newspapers would like to know…

  11. WheresMyCape Says:

    Hi. I’m a non-professional, childbirth junkie and recently was made aware of your blog on an online VBAC support group in which I participate. I appreciate your viewpoint very much and have loved everything I’ve read so far! Thank you for all your great info and perspective!

  12. anon Says:

    I don’t know if it’s okay to publish a link of your website (if not you can just delete my comment) – but anyway, you might have read this article already, but I think it’s important, because with this kind of information (ie that the healthcare industry is expensive because of its overuse of medical intervention that is a) not necessary and b) DANGEROUS) childbirth advocates can link the issue of childbirth/ c-sections to larger issues of health care reform, thus making it not just a “small”specialized concern, but part of the larger pattern of Bad & Dangerous Behavior on the part of many physicians.

    I also wanted to repeat the question asked by an earlier poster about refusing care. I know you responded that it’s the patient’s right – but is it? What on earth would happen to a woman in labor in a hospital who refused to have a C-section that the OB wanted her to have? Does the OB exercise his “right” not to be involved in a situation he’s not happy with and leave? Who delivers the baby? What standard of care does that mother received? Is she forced to leave the hospital? Have you ever seen or heard of an example of a mother refusing an “emergency” C-S? “Refusal of care” sounds to me like something that looks good on paper but never actually happens, at least in the realm of childbirth. Even refusing something small at a hospital (I refused IV anti-nausea medication once) can be a big drama.

    • nursingbirth Says:

      anon, I think your question is a very very good one. I wish I could give you an answer that is satisfying but unfortunately I cannot. Why? Because there are so many variables in your question (since it’s such a good question!) I (unfortunately) just don’t have answer to all of your “what ifs”. You ask, “What on earth would happen to a woman in labor in a hospital who refused to have a C-section that the OB wanted her to have?” Personally I have heard of stories of women who were in this situation and their doctors tried to get emergency court orders to force them into having surgery (for more on stories liket that check out the book “Born in the USA” by Marsden Wagner. It will blow your mind and infuriate you as it did me!) Other times I have heard stories where a woman requested/demanded a second opinion and had another doctor (usually the “house doctor”) take over her care. Although I am not sure all hospitals have a “house doc.” I have heard of other mothers threatening to leave and after they threatened, nurses and doctors backed down and let them do what they wanted. A mother always has the right to leave AMA (against medical advice) however, in many circumsances, especially with Medicaid, you risk losing your insurance coverage for the time you spent in the hospital since you left AMA. So that doesn’t really seem very fair does it! And I agree with you when you write, ” Even refusing something small at a hospital (I refused IV anti-nausea medication once) can be a big drama” and “Refusal of care” sounds to me like something that looks good on paper but never actually happens, at least in the realm of childbirth.” But technically ALL patients have the right to informed consent and informed refusal. Some have sued under this and won. Others have (unfairly) lost. It all really sucks. Bottom line is that our maternity system is in CRISIS. I bet we both agree on that.

      sorry I couldnt be of more help! please check out the book “Born in the USA”

  13. khalilaann Says:

    Speaking of unnecessary C-sections, Canada just had a dramatic change in policy regarding breech births. It changed for the better!

    I also heard that OHSU just began training their OBGYN’s in breech birthing techniques this year, in an effort to decrease the cesarean rate. But I haven’t found a solid link for it yet, I just know some people at OHSU and was told this. I’ll keep looking though. 🙂

  14. Linette Says:

    I LOVE your blog. It’s quite well written, highly informative, and yet sad, because it shouldn’t have to exist. Oddly enough, I keep a personal blog, and I wrote a post just yesterday about pregnancy and unnecessary medical intervention.

    The true capabilities of our bodies are ignored in this country. And the tragic thing is, so many women don’t even know they have options. We’re conditioned to believe that the doctors are omniscient, and that pregnancy is a medical condition which must be monitored and controlled. And it is costing lives.

    I don’t have children (yet) but I feel fortunate that I’m able to arm myself with information long before I become pregnant.

    You’re doing a great service. Thank you for writing.

    Knowledge is power!

    • nursingbirth Says:

      Linette, I am so pumped that you are doing so much reading and research BEFORE you have kids. I hear from many mothers very often the “I wish I knew then what I know now” line and it always breaks my heart. Readers like you give me hope! Thanks for reading!

  15. Aisha Says:

    I finished my “Prepared Childbirth” class at the hospital where I will be delivering in shortly. I went through the hospital’s maternity tour and I was highly impressed, they had every single toy or contraption needed in order to have a natural birth and if necessary they can wheel you into the OR in less than 8 minutes (detect the sarcasm on that one). The L&D nurse that did the tour and class was a huge advocate of natural deliveries and she made me feel a whole lot better about the hospital respecting me not wanting much intervention.
    She mentioned that the rate of Epidural use has decreased significantly (from 95% a few years ago to 68% now), the induction rates are somewhere around 30% including enhancement. And that vacumm extraction use was around 5% episiotomy use was even less than that. All of those numbers meant to ME that the trend was that women are getting more informed about their choices and the hospitals are becoming more flexible about childbirth.
    HOWEVER, after all those polls and numbers, I asked what the c/s rate was at that hospital and she admitted a 28%, highly dissapointing TO ME, but as my husband exclaimed “Well that’s pretty low compared to 70% vaginal deliveries!”, so, I guess it depends on how you look at it. I still don’t want to end up in the 28%. However, I am a patient of the midwives at the hospital and their vaginal delivery rate is over 85% 🙂 that’s even better 🙂

    • nursingbirth Says:

      Aisha, I am so happy you asked all about your hospitals (and your birth attendants) stats!!! And I am so happy you have found out that the most important predictor of your risk of c/s, episiotomy, vacuum, induction, and augmentation is mostly about the PROVIDER you choose!! Happy Birthing!! 🙂

  16. […] surprised that ACOG would take such a position without evidence… remember their stance on elective C-sections, as well as on home […]

  17. Renee Says:

    I have a question- sorry it’s not related to the post, but I didn’t know where to just send a message. I got my records from the hospital and found some things that didn’t seem right so I also got my daughter’s. It looks ok except for one thing listed under meds given. It says that 1 ml of 24% sucrose was given. Is this sugar water? And what would it be given for? I was breastfeeding and had it in my plan to not give anything that I did not approve of. Thank you, I know I’ll get a knowledgeable answer from you!

    • nursingbirth Says:

      Renee, that is a great question. The good news is, 24% sucrose solution is given in very small amounts (1 mililiter is like a few drops from an eye dropper) to neonates for pain relief. Here’s an article that explains it more:

      For example, it is often given to baby boys during circumcision either on a gloved finger or a pacifier because the sucking action is very soothing. Obviously they did not do a circumcision on your daughter but perhaps they gave it to your daughter following a vaccination, heel stick, on injection of some type?

      I agree with you that parents should be told what is being given to their babies. However since sucrose solution used for pain relief is not considered a drug, it does not require special permission from moms or dads to be given in most hospitals so that is probably why you didnt know. However, I can understand if you are still a bit miffed. The good news is that the 1mL of sucrose solution is NOT the same thing as giving a baby a bottle of “sugar water” (something that most breastfeeding moms (and lactation consultants for that matter) do no appreciate and often specifically request for it NOT to be given). That is called “Dextrose 5%” and it is given in a bottle. Sucrose solution for pain relief is NOT given in a bottle.

      Thanks for your great question!

  18. Renee Says:

    Thank you so much! That makes me feel better about her records, anyway!

  19. Thank you for your blog. I had a necessary c-section with my first (due to a vasa previa that was not detected by ultrasound) and it saved her life. So I can actually say that I am thankful for my Dr’s decision to act quickly and get her out. But I was definitely disappointed when pregnant with #2 and recommended a repeat c-section. I was told of the “catastrophic” risks of a VBAC over and over (and this is hard for any expectant mother to hear especially after nearly losing one child), but not one word about the risks of multiple c-sections. So I just want to thank you for doing all that you can to change the birthing culture in this country.

    ps. I had a successful VBAC! …minus the episiotomy they performed w/o asking but that is another story.

  20. Jessica Says:

    The important thing to also remember is the way that the information is conveyed from the doctor. They totally minimize the risks of the cesarean and exaggerate the risks of a vaginal birth, especially a VBAC. *gasp*

  21. Wendyrful Says:

    That consent form you show here is much more plain, and shows a list of bulletted points of possible risks durring the c-section. I’m pretty certain that our hospitals around these parts don’t have anything like that spelled out.
    On a slightly different note, I attended a birth once, where the anesthesiologist came in and told the mom thata she’d explain everything ‘AFTER’ the epidual was in place, since mom was clearly in pain at that time… afterward, when mom was ‘comfortable’, the Dr. stated she teaches med school, actaully drew a whole diagram of the pocedure for mom to better understand, WHAT WAS ALREADY DONE TO HER!!!!!!! How is that right?!?!?!?!?!?!

  22. cyrell Says:

    I am from germany and i think the hospitals here are on the same way as the one you describe.

    I was the typical case, everything normal, baby healthy, no problems during pregnancy, no risks, first baby/pregnancy.

    For 4 days i felt during the night hours some cramps and at the fourth day they got hard enough for me that i thought, better get to the hospital.

    When i was there the pain got away, i could not really feel the contractions and then the midwife(one of them has always to attend a birth in hermany) came and talked about getting something to get the contractions stronger and all the crap and they made such a fuss when my pains did not return(contractions did not get stronger) and instead of telling me to go home and come again later they said i had to get a drip or a cesarian.

    i resufed the cesarian but.,.well..i was young and had no experience and i did not open up with the drip and was nearly 20 hours in pain and because of the drip i nearly bleed out after i gave birth because the muscles were too tired to contract and stop the bleeding.

    my daughter was fine and i am proud and happy that i could refuse the cesarian and not let me get pushed into it.

    when i look at what happend after 3 years i can tell 100% that there was no reason for these so called midwifes to panik, to give me a drip or suggest a cesarian.

    i am still so angry and want to strangle these bitches..i was in a hell of pain and had to get these drip in the spine which turned me numb and i could not pee and all the shit happend…i was 16 hours in pain that i screamed with each contraction befor they gave me something.

    they stressed me with this suggestion of a cesarian not even two hours after i arrived there.

    the doc cut me and i had problems and pains from the scar down there really bad for a year and even now i sometimes have problems.

    i am just happy my daughter was healthy and got all 10 points and there was never a bad sign for her on the horizon.

    i left the hospital the next day and because i wanted to go home and refused their *care* they did not even wheel me to the entrance..i had to walk all the way from the back of the basement and take the stairs and had lost so much blood the day befor i was so dizzy for weeks. i had to stop on the way and put my baby down because i had to catch my breath..and all the nurses did was criticize me because i refused the hepatitis shot for my daughter and their *care*

    if i had not asked about the medication they gave me, they would have given me a medicine which would have prevented the lactating…whcih was for the woman next to me…

    And god forbide they gave me any more painkillers…

    I had to call for a nurse because i bleed all over the bed and it did not stop …if i would have fallen aslep after 36 hours awake i would have bleed to death.

    than they gave me some stuff to lt the muscles contract and it was worse than the labor..i screamed so loud,….

    i told the doc i refused the drip until i get something for the pain…thesy did not want me to give anything because i could fall asleep then and bleed to death and the pain should keep me awake…and all the other patients at the floor because of my screaming..hell yeah…great.

    so i got my painkillers i.v. and the drip and fleed the next day without some proper night rest because..well…all the stress and the pain and i feared they would maybe switch my baby with the one of an other mom…really…

    ok that was too much panic but hell…who knows? there happend so much shit.

    the midwife/nurse never asked me if i wanted something to drink or eat while my contractions were low, never gave some good advise or such a thing…

    and this hospital was one of the best????

    i am still so angry and if i ever get pregnant again i will know better…and only get at the hospital when the baby is read to drop out

    i was so weak for months and had these pains where they cut me and could not go normal to the toilet..and sex, don´t talk about sex…the first two years there was always these horrible pain in the scar.

    and i know that it disturbed the relationship wit my daughter because of the pain.

    the pain also caused my milk to drop in really late and i had problems nursing for months.

    i never thought i would have problems because my breasts started oozing fluid at the 5 month…and at the eight month i was not dropping fluid, it was running like crazy, i could watch it flow in a steady stream.

    and after birth…nothing

    but like hell i would give up on, never.

    It was never really comfortable, in the beginning really painful for the first half year but i nursed her for 3 years.

    i am from a family with some issues like hay fever, asthmatic problems, skin problems, allergies…and she has none of this problems even when from both of her parents and grandparents she could have recieved something..nursing was the best i could do for her and she is the healthiest little girl.

    i went to an other doc because the first never listened to me and when i told about her allergic reaction to cow milk he said to feed her small ammounts and it would go away…

    what a cow crap….i still have these problems…and when should it go away, with 30, 50? when i am dead?

    i changed the milk susbtitute when i realised her stomach pain and skin issues came from the ingredients and got soemthing on soy base for the time when i could not give enough milk.

    the doc was oh soooo helpfull..and he too, like the hospital, is one of the *best*

    but my new one is gold…and he is really happy how well she is.

    she never got soemthing that had to be treated with antibiotics, not like all the other children.

    i just wish more people would make their own decisions and not do brainless everything the doc tells them..not the doc is the problem, it is the way how the costumer is.

    if people would question more the docs could not make such a fuss..same with the pig flu

  23. Clysta Says:

    This is a really!! late post, but I’ve been doing all the possible research I can on pregnancy and labor. (I’m a few months along with my first and am trying to figure out what to expect) I’m shocked that there are doctors that actually doing this stuff. I was reading the past posts of people, and was nearly in tears at some of it. I firmly believe that the body is more than capable of vaginal births unless there is an actual reason you need a c/s. (Certain birthing positions, risk to the child, etc) And even then I would get more than one doctor to say so. I’m hoping for as close to an intervention free birth as possible, and I’m nervous that I might find a hospital that does these practices. I’m praying my age won’t make them try to force me into anything as well. I’m barely 20, and “young and uneducated” as a past doctor once told me. How can I make sure the hospital is honest about what they do? Things could easily change once I’m actually in labour.

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