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.

 

 

AAAAAAHHHHHHHHHHHHHHHHHHHHHHHHHHHH!!!!!!!!!!!!!!!!

 

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

Advertisements
 

Don’t Let This Happen To You #22: Gina & Tony’s “Elective” Primary Cesarean Section PART 2 June 12, 2009

Continuation of the “Injustice in Maternity Care” Series

 

Throughout my time as a labor and delivery nurse at a large urban hospital in the Northeast, I have mentally tallied up a list of patients and circumstances that make me go “WHAT!?!  Are you SERIOUS!?  Oh come ON!”  Because of this I was inspired to start the “Injustice in Maternity Care” blog series, or more appropriately the “Don’t Let This Happen to You” series.  If you are pregnant or planning on becoming pregnant, this series is dedicated to you!  If haven’t already read it, I invite you to check out part 1 of this post: DLTHTY #22: Gina & Tony’s “Elective” Primary C/S  PART 1.

 

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

And now the story begins…

 

 

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

 

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

 

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

 

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

 

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

 

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

 

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

 

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

 

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

 

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

 

 

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

 

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

 

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

 

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

 

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

 

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

 

Me:  [dumfounded & speechless]

 

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

 

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

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

 

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

 

 

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

 

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

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

 

 

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

 

 

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

 

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

 

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

 

3)     Elective Induction of Labor by Henci Goer

 

 

 

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

 

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

 

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

 

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

 

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

   

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

   

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

 

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

 

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

   

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

 

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

 

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

 

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

 

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

 

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!

 

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

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…..

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

 

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.”

 

Don’t Let This Happen To You #22: Gina & Tony’s “Elective” Primary Cesarean Section, PART 1 June 8, 2009

Continuation of the “Injustice in Maternity Care” Series

 

Throughout my time as a labor and delivery nurse at a large urban hospital in the Northeast, I have mentally tallied up a list of patients and circumstances that make me go “WHAT!?!  Are you SERIOUS!?  Oh come ON!”  Because of this I was inspired to start the “Injustice in Maternity Care” blog series, or more appropriately the “Don’t Let This Happen to You” series.  If you are pregnant or planning on becoming pregnant, this series is dedicated to you!  If haven’t already read it, I invite you to check out the first addition to the countdown: DLTHTY #25: Sarah & John’s Unnecessary Induction.

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

Sometimes I feel like I am starting to sound like a broken record….  Why?  Because I am about to start this post the same way I started my last “DLTHTY” post.  But with a national cesarean section rate of approximately 32% and a c-section rate rapidly approaching 35% at my place of employment, I feel like I cannot write about our country’s cesarean crisis enough! 

 

You might be thinking to yourself, “Why is it the case that when I or a loved one enters the hospital in the United States to have a baby we have a 1 in 3 chance of ending up with major abdominal surgery?  One thing I hear often, both from health care professionals and lay persons is that women are the cause of our country’s embarrassing cesarean section rate; that women are requesting and demanding cesarean sections as just another way to have a “designer birth.”  I hear this all the time.

 

For example, the other day I was at a birthday party and I was conversing with the grandfather of the birthday boy.  We got to talking about our careers, which were quite different being that I am a labor & delivery nurse and he is a computer engineer.  Long story short he remembered an article that he had read in TIME magazine in the beginning of the year, and from his description I have concluded it was probably Using C-Section Scars to Predict Future Deliveries by Kathleen Doheny.  He said he was surprised and concerned to read that the c-section rate in the U.S. was approximately one third of all births!  I echoed his concern but stated that a big part of it is related to the way we practice obstetrics in this country, mainly defensive medicine and control obstetrics.  “Yah! I know!” he said as if we were on the same wavelength, “It’s because of all those 40+ women who chose career over family for all those years that have now decided to use fertility treatments to get pregnant.  And then they go and demand a cesarean section so they can complete their quest for a ‘designer birth’ and ‘designer baby.’  It’s ludicrous!!”  With all due respect I had to disagree with him and it turned out that in doing so I inadvertently ended the conversation.  I guess it’s not politically correct to call someone out at a birthday party, no matter now nice you do it!

 

But is this really true?  Does the research support the hypothesis that women are driving the cesarean rate up?   

 

The answer is a big fat N – O, NO!  In the DVD Special Features section of the amazing 2008 documentary Orgasmic Birth, Dr. Eugene R. Declercq, PhD, a professor of Maternal and Child Health at the Boston University School of Public Health, is featured in a 20 minute clip entitled “Birth By The Numbers” where he presents the sobering statistics of birth in the United States today and shares the most recent data available from the National Center for Health Statistics as well as Listening to Mothers II, the largest survey of women’s experiences during pregnancy, childbirth, and the postpartum period.  Dr. Declercq shares that one quarter of the survey participants, who had undergone either a primary (first time) or repeat (second or more) cesarean section reported that they had experienced pressure from a health professional to have a cesarean section (more on that below). 

 

The following is a list of other mind-blowing statistics and research results that I learned from watching “Birth By The Numbers.”  I have posted about this video clip before and I am posting about it again because it is that important to watch it!  If you have any questions about any of these bulleted points, please watch the video for yourself first, look at all the graphs and tables presented (since I could not directly post the images here), and then feel free to comment!

 

Lets Talk About Stats

 

  •  
    • In 2005 there were 4,138,349 births in the United States therefore even a 1% change in any statistic impacts approximately 40,000 births a year!
    • In 2005 there were 1,248,815 cesarean surgeries performed on women in the United States.
    • Cesarean surgery is a valuable and potentially life saving operation but is an overused intervention in the U.S.
    • In low income/developing countries, an increase in the cesarean section rate is related to a lower neonatal mortality rate, since access to this life saving operation can address the tragic situations that occur because of a lack of resources.
    • In middle income countries, regardless of the cesarean section rate, the neonatal mortality rate is not affected either positively or negatively.
    • In high income countries, like the United States, there is a slightly positive relationship between the cesarean and neonatal mortality rates.  That is, the higher the cesarean section rate, the higher the neonatal mortality rate which means that there comes a point in time where more and more cesarean sections are not helping and are even hurting our mothers and babies!

 

 

Cesarean Sections for Low Risk Moms Just Don’t Add Up!

 

  •  
    • To get a cesarean rate of over 30% (which the U.S. currently has), you have to be doing cesarean sections on low risk mothers!
    • When you perform a cesarean section (which carries many risks for both mothers and babies) on a mother because either the mother or the baby has a true medical indication that requires surgery to assure the safety and wellbeing of all, then and only then do the benefits of the surgery outweigh the risks.
    • When you perform a cesarean section on a low risk mother and there are NO true, unavoidable, or untreatable medical indications for the surgery, then the mother and baby carry all the risk of the surgery without any of the benefits to her or her baby.  (Side note:  I like to think of this point in this way.  If you are on the 3rd floor of a burning building and not jumping would certainly result in serious physical harm, disfigurement, or even death, then the risks of staying in the building outweigh the risks of jumping out the window and hence, even though you might acquire some serious injuries in doing so, jumping out the window is the best option for you.  On the other hand, picture yourself on the third floor of that same building but this time there is no fire.  Do you think it’s a good idea to jump out that window?  I didn’t think so.)

 

 

What Is NOT To Blame For Our Cesarean Rate?

 

  •  
    • It is NOT the case that the rising U.S. cesarean rate is because of U.S. women requesting cesarean surgery (a.k.a “Maternal Request” cesarean section).
    • It is NOT the case that the rising U.S. cesarean rate is because of age related factors (i.e. more very young or older moms are having more and more cesarean sections and therefore throwing off the rate.)  In fact from 1996 to 2006, the rates of cesarean section jumped the same amount (a 50% increase!) in every single age group at the same rate. 
    • It is NOT the case that the rising U.S. cesarean rate is related to the gestational age (how old the baby is at the time of birth) of babies being born by cesarean.  In fact, from 1996 to 2006, the rates of cesarean section jumped the same amount in every single gestational age group at the same rate. 
    • It is NOT the case that the rising U.S. cesarean rate is caused by upper middle class white women demanding their cesarean by appointment (aka “Maternal Request” cesarean).  In fact from 1996 to 2006, the rates of cesarean section jumped the same amount in every single racial/ethnic group, but not at the same rate.  Cesarean sections rates for black mothers are higher than for any other race/ethnic group. 
    • State by state, strong regional patterns exist regarding cesarean section rates.  That is, some areas of the country boast cesarean section rates that are greater than 30%…with some regions higher than 50%!…while others are less than 25%.  While this may be related to local obstetrical culture, it is NOT a reflection of evidenced based medicine being practiced at the same level in every state.  If evidenced-based medicine was being practiced at the same level in every part of the country, different regions of our country would not vary so wildly in their c-section rates!

 

 

Maternal Request Cesarean Section:  Are They To Blame?

 

  •  
    • According to the Listening To Mothers II survey “Maternal Request” cesarean was defined as a cesarean that 1) the mother had made a planned request for before labor began, and 2) was performed for NO medical indications (either mother or baby).
    • The survey found that only 1 respondent out of 1600 survey participants (252 of which had had a cesarean) had planned a primary cesarean for no medical reason.  Research studies from England and Canada confirm very low rates of maternal request cesareans as well.
    • While they do exist and are being carried out in the United States, MATERNAL REQUEST CESAREANS ARE NOT TO BLAME FOR OUR COUNTRY’S SKYROCKETING CESAREAN RATE!!!

 

 

So What IS To Blame For Our Skyrocketing Cesarean Rate?

 

  •  
    • PRACTICE CHANGES, that is, changes in the nature of maternity care in the United States, ARE TO BLAME FOR OUR RISING CESAREAN RATE!
    • The current philosophy of contemporary maternity care in the United States is much like the “One Percent Doctrine.”  That is, when you set up a system that focuses on the 1% of problems that might occur, you undermine the care of the 99% of mothers who don’t need those services and interventions.  

 

 

Mothers Feel Pressure From Health Professionals to Have Cesareans!

  •  
    • In the LTM II survey, 26% of women that had had a primary cesarean section, 25% of women that had had a repeat cesarean section, 35% of women that had had a successful vaginal birth after cesarean (VBAC), and 7% of mothers that had had a vaginal birth reported that they DID feel pressure from a health care professional to have a cesarean section.

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

 

“Unfortunately history shows that advances in the practice of medicine and surgery are rarely attained in a thoroughly rational manner, but that a period of undue enthusiasm, or even of almost reckless abuse, usually precedes the establishment of the actual value of a given procedure.  [Cesarean Section] requires only a few minutes of time and a modicum of operative experience: while [vaginal birth] often implies active mental exertion, many hours of patient observation, and frequently very considerable technical dexterity.”

~John Whitridge Williams, MD [1866-1931], early 20th century pioneer of academic obstetrics & author of biggest selling obstetrics textbook ever

 

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

 

So let’s talk a bit about what these “Practice Changes” are that are causing our very scary and embarrassingly high cesarean section rate.  The Childbirth Connection is a national not-for-profit organization founded in 1918 whose mission is to improve the quality of maternity care through research, education, advocacy and policy. They promote safe, effective and satisfying evidence-based maternity care and are a voice for the needs and interests of childbearing families.  The Childbirth Connection is the group that developed the “Listening to Mothers” surveys which were conducted by Harris Interactive and carried out in partnership with Lamaze International

 

In their article, “Why Does the National U.S. Cesarean Section Rate Keep Going Up?”, the Childbirth Connection lists SEVEN evidenced based interconnected factors that appear to be pushing the cesarean rate upward.  (Please refer to the original article for explanations of each factor.)

 

#1   Low priority of enhancing women’s own abilities to give birth.

 

#2   Side effects of common labor interventions.

 

#3   Refusal to offer the informed choice of vaginal birth.

 

#4   Casual attitudes about surgery and cesarean sections in particular.

 

#5   Limited awareness of harms that are more likely with cesarean section.

 

#6   Providers’ fears of malpractice claims and lawsuits.

 

#7   Incentives to practice in a manner that is efficient for providers.

 

 

All of these factors contribute to the current national cesarean section rate of over 30%, despite recent studies that reaffirm earlier World Health Organization recommendations about optimal cesarean section rates. According to the WHO and the research that supports its recommendation, the best outcomes for mothers and babies appear to occur with cesarean section rates of 5% to 10%.  High-risk hospitals have the best outcomes with cesarean section rates of less than 15%.  Cesarean rates above 15% seem to do more harm than good.

 

 

Bottom Line:  Our rising cesarean section rate is a BIG problem for our mothers and babies!

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

Up For Next Time: 

 

* What is the difference between “Primary Elective” cesarean section and “Maternal Request” cesarean section?

 

* Are “elective” cesarean section, that is without medical indication, the same as “maternal choice” cesareans or should they really be called “physician choice” cesareans?

 

* Why were Gina & Tony scheduled for a cesarean section and was it really their choice?

 

An Interesting Encounter With A Medical Student May 8, 2009

Yesterday while I was at work, I had an interesting encounter with a medical student.  It was about 9:00pm and for me the shift was finally beginning to wind down.  I was taking care of a patient who was being induced for *post-dates* at 40 weeks and 1 day (don’t even get me STARTED on that!  Sheesh!) who had received a cervidil a few hours earlier.  I had just assisted her up to the bathroom and then tucked her in so she could try an get some rest.  As I came back to the desk, there was a medical student flipping through the book I had been reading called Silent Knife: Cesarean Prevention and Vaginal Birth after Cesarean (VBAC) by Nancy Wainer Cohen & Lois J. Estner.***   Typically the medical students do not spent much time talking to the nurses, at least in my hospital they don’t!  In my hospital, they generally can be found in the back lounge either sleeping or reading for class and they only pop out if a woman is about to deliver (they need to fulfil their quota after all ,so they can “pass” their OB rotation).  So for one to actually be sitting at the desk with me was a rarity, never mind actually talk to me!  (God forbid fraternizing with the enemy! Haha!  I kid!)  The following is our (brief) conversation:

 

Med Student:  “Is this your book?”

 

Me: “Yah.”

 

Med Student: “Do you have to read this book for work or school or are you reading it for fun?”

 

Me: (chuckling) “I’m reading it for fun.”

 

Med Student: (Holding my very reasonably sized book as if it weighed 500 pounds)  “I can’t believe you are reading this book for fun…It seems pretty intense.”

 

Me: “Well to be honest, I believe that the rising rate of unnecessary cesarean sections and the lack of VBAC opportunities for women in this country are pretty intense.”

 

Med Student: (quite perplexed yet in a “know-it-all” kind of tone)  “Well they are worried about a uterine rupture with a VBAC.  That means “vaginal birth after cesarean” right?”

 

Me:  (amused that she seems to be “schooling” me but doesn’t know what VBAC stands for)  “Who is the ‘they’ that you are referring to?”

 

Med Stuent:  “Well the medical community of course!”

 

Me:  (very calmly)  “The funny thing is my friend is that the research does not support this unnecessary, unfair “fear” of VBAC, especially for a spontaneous labor that is not being influenced by uterine stimulants such as misoprostol, cervidil, or pitocin.  RATHER decades of research have shown time and time again that the risks of unnecessary (especially repeat) cesarean surgery far outweigh the risks of a vaginal delivery, even if it is a VBAC.  It’s just that obsetricians in this country prefer to just cut people open instead of “wait around” for a vaginal delivery.  It’s quick and easy, for them anyway, not for the woman.  You see, with a cesarean, they can be home in time for dinner.  The only people that our skyrocketing cesarean rate is benefitting in this country are obstetricians.”

 

Med Student:  (completely and utterly dumbfounded)  “Well that is certainly not the impression they give you in medical school!”

 

At this point I could help myself, I laughed and laughed!  The med student was laughing too!  I told her that when I was finished with the book she could borrow it from me.  I don’t think she’ll take me up on the offer but at least I can take some comfort in knowing that I might have shaken her world up, even if just for one moment.

 

The moral of the story:  Any moment can be a teaching moment!

 

 

***Side Note: Silent Knife is an AMAZING BOOK and a MUST READ for anyone who had had a cesarean section or is being told she needs to have a cesarean section.  I am about 3/4 of the way through the book and I have a hard time putting it down.  It was written in the 1980s so some things are a bit dated but overall it is scary how little has changed for the better in our maternity care system in 25 years.  They might not be cutting as many episiotomies as they once were in this country but our skyrocketing cesarean rate and relatively poor maternal and fetal outcomes compared to other countries is makes this book as pertanent as ever!!

 

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

Continuation of the “Injustice in Maternity Care” Series

 

Throughout my time as a labor and delivery nurse at a large urban hospital in the Northeast, I have mentally tallied up a list of patients and circumstances that make me go “WHAT!?!  Are you SERIOUS!?  Oh come ON!”  Because of this I was inspired to start the “Injustice in Maternity Care” blog series, or more appropriately the “Don’t Let This Happen to You” series.  If you are pregnant or planning on becoming pregnant, this series is dedicated to you!  If haven’t already read it, I invite you to check out the first addition to the countdown: DLTHTY #25: Sarah & John’s Unnecessary Induction.

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

I was recently part of what I consider to be an absolutely unnecessary repeat cesarean section and a true example of what I consider the “control phenomenon” in today’s maternity care culture.  This very real trend stems from the fact that obstetricians (trained surgeons who are the only birth attendants capable of performing a cesarean section) have professional motivation and incentive to promote and perform interventions that only they can provide, hence increasing their control (e.g. vacuum or forceps deliveries and cesarean sections) as well as discourage and lobby against choices in childbirth that decrease their control and increase the control of the childbearing family (e.g. homebirth, natural/unmedicated birth, and VBAC).  After all, any properly trained birth attendant can attend a VBAC (including midwives and family practice physicians) but ONLY obstetricians can perform cesarean sections.  In their groundbreaking book Silent Knife: Cesarean Prevention & Vaginal Birth After Cesarean, authors Nancy Wainer Cohen & Lois J. Estner describe this phenomenon,

 

“Cesareans are done for many reasons.  In addition to the legitimate ones, they include power, control, money, fear, and prestige.  However, we believe that the most important reason is that most physicians totally lack understanding and respect for women and for birth.  [Routine] Repeat cesareans are done for the same reasons, with risk of uterine rupture the excuse for this deplorable crime.  Vaginal birth after cesarean (VBAC) is not only safe, but generally safer than its alternative.  In spite of the research and evidence and documentation that appear on this subject, most obstetricians in this country continue to perform repeat cesareans simply because a woman has been previously sectioned.  There is always an excuse, it seems, why a woman cannot be a candidate for VBAC.  We know that most women who have had a cesarean are capable of delivering vaginally.  This includes women with a diagnosis of cephalo-pelvic disproportion (CPD), prolonged labor (failure to progress), or more than one previous cesarean.”

 

Now that the stage is set, let’s begin the story…

 

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

 

It was a beautiful and sunny weekend morning and I arrived to the hospital, changed into scrubs, and punched in at 11:00am as usual.  As I was looking over the patient assignment sheet, a young Russian** couple came to the desk.  Both had very thick accents and it was quickly evident that the husband spoke better English than his wife.  The husband described a “large gush of water” that fell all over the floor as she was making breakfast.  The young woman stated that she had put a towel in her pants that was now “very wet” and that she started having “pains” about 10 minutes after the leaking started, which happened to be around 10:40.  While at their house they then called their doctor who instructed them to come right to the hospital since, if she did break her water, she was going to be sent for a cesarean section today because she had a history of a previous cesarean section.  (In fact her “repeat” date was scheduled for the next week where she would be 39 weeks in gestation.)

 

I was asked by the charge nurse to escort the patient and her husband down to one of the triage rooms near the operating room (OR) (just incase she was indeed ruptured) and to pass her off to another nurse who would be waiting for her there.  I introduced myself to both the woman and her husband and asked the woman if she wanted a wheelchair.  She declined and although she was very quiet, almost stoic during our short journey, I could tell by her walk that she was very uncomfortable.  After I gave the woman a gown and assisted her into the bathroom, I told all I knew to her nurse Sally and went back to the main desk. 

 

For the next hour I was unassigned to any patients so I spent that time assisting other nurses.  Around noon I was assisting a fellow nurse whose patient was delivering when I got called out of the room by the charge nurse.  “We’ve got to run two rooms in the back and I’m going to need you to be ‘baby nurse’ for Dr. W’s case, the patient in room 2.” 

 

(Note: At my hospital we have three operating rooms on labor and delivery.  We try our best to only run one room at a time, if urgency and time allows us, since running two rooms can really put a strain on the staff.  To run two rooms at the same time you need 6 nurses total, three for each room (a scrub nurse, a circulating nurse, and a baby nurse).  The scrub nurse actually scrubs into the surgery and assists the surgeon by passing him/her instruments and sutures.  The circulating nurse usually is the nurse that knows the most about the patient and her job is to coordinate procedures and ensure the patient’s safety and comfort.  The “baby nurse” assists the anesthesiologist with administering anesthesia, preps the patient for surgery, and the gowns up to “catch” the baby from the surgeon, and then brings him over to the warmer to assess him.  Even though we have an OR team Monday through Friday during the day shift, between running the OR, staffing the recovery room, and admitting the next case, the OR team doesn’t always have enough nurses to run two rooms and in that circumstance the charge nurse has to pull nurses from the floor.  Therefore if we were running two rooms, I knew that something must be happening with one or both of the cases that increased their urgency.)

 

I grabbed my OR hat and mask and walked down towards the OR to talk to the circulating nurse and re-introduce myself to the patient (something I try to do if at all possible before they enter the OR).  The circulating nurse, Sally, was at the desk and gave me a very abbreviated report, “Her name is Alona.  She is a G2P1 at 37 weeks and 6 days and her first baby was delivered via cesarean for ‘failure to progress/failure to descent’ per her prenatal summary.  Her husband, Dmitry, told me that the doctor told them the reason she needed a cesarean the first time was that his wife’s ‘vagina was too small.’  They are both graduate students at XU.  She’s got an unremarkable history.  She’s scheduled for a repeat cesarean next week so we’re going to the OR.  We’re gonna move in about five minutes.” 

 

As I walked into the patient’s room, I quickly realized why everyone was rushing around…the patient was huffing and puffing through her contractions.  She was still on the monitors at this time and I noticed that her contractions were coming every 2-3 minutes with nature as the only influence acting upon them.  As I stuck out my hand to re-introduce myself to the couple I had escorted here not one our ago, I realized that the patient was uncontrollably grunting and pushing at the peak of her contractions.  At this point the circulating nurse came in to administer her pre-operative antibiotic, followed by the anesthesia resident who started to unplug the bed from the wall.  My mind was racing…this woman is in LABOR!  This woman is PUSHING!  Why is everyone ignoring this?!  At this point the anesthesia resident and the circulating nurse started to wheel the patient out of the room and I was having none of that! 

 

Me:  “Sally, she’s pushing.”

 

Sally: “What?”

 

Me: “She’s pushing!  We need to get her checked.  We can’t wheel her back there like this.”

 

Sally: “We just checked her 20 minutes ago and she was 5cm/90%/0 station.”

 

Me: “Was she pushing 20 minutes ago?”

 

Sally: “Well no but…”

 

Me:  “Well then I don’t care how long it has been since you last checked her!  We need a resident in here to check her!!!”  (Note: At our hospital, because we have residents, we are actually not allowed to check our own patients even if we have the skills to do it!  I am not exaggerating.  The head of the residency program feels that if nurses check their own patients then residents won’t get enough “experience.”  Therefore new nurses are not even taught how to perform a vaginal exam during orientation.  I feel that this is absolutely absurd and just another way the OBGYN department attempts to maintain the utmost control over all situations.  But I digress…)

 

At this point Sally poked her head out of the door and motioned for the resident to come in.  I was holding Alona’s hand and trying to coach her breathing, in, out, in, out, in, out…

 

Me:  “Alona, we are going to do a quick vaginal exam to make sure the baby isn’t coming, is that okay?”

 

Dmitry (the husband):  “The baby can’t come out!  Her vagina is too small!”

 

Me:  “Sir, it’s going to be okay.  Every baby is different.  Her vagina is not too small.”

 

And then the resident said the most OUTRAGEOUS thing I have ever heard…

 

Kate, the resident: “She’s 8cm/100%/ +1 station and that’s without a contraction.  If we don’t get her to the back right now, she’s going to have this baby!  Let’s go!”

 

[Have you ever watched a show and the cartoon character does a “double take” where they shake their head really fast back and forth and it makes a sound like something is rattling in their head?  I swear I did that when I heard the resident say that and I actually said out loud, “WHAT?!!?  That is ridiculous!”]

 

Me:  “Kate, we’ve got to get Dr. W in here to talk to her.”

 

Kate: “Dr. W wants to do a cesarean.”

 

Me: “Yeah, but don’t you think it’s more important to do what the patient wants?!  I think circumstances have changed enough to where someone should reevaluate this situation with her!”

 

[Kate left the room to go talk to Dr. W, as I think I made her really uncomfortable by calling her out and bringing up the patient’s needs.  God forbid!!  I poked my head out of the room to hear his answer.]

 

Kate: “Dr. W, she is 8/100/+1.  Should we counsel her about a vaginal delivery?”

 

Dr. W: (really frustrated and almost offended at even the thought) “NO!  We’re doing a repeat!  WHAT ARE YOU WAITING FOR, GET HER TO THE BACK!”

 

(Note: “The back” is hospital lingo for the operating room)

 

On that note Sally and the anesthesia resident continued to wheel her out of the room and through the double doors to the operating room.  At this point I really thought I was going to start to cry.  There have only been a few times that I have cried at work (I’ve cried a lot more at home!) but this situation was really hitting a cord with me.  As we were wheeling the patient down the hall I looked at her and her husband and said, “Alona, you are 8 centimeters.  You do not have to have surgery if you do not want to.  This is your choice.”  Alona just stayed silent, and kept looking at her husband.  Perhaps this was a cultural thing, perhaps she was scared, perhaps she was too much in the throws of transition to hear any word I was saying.  We entered the OR at 12:30pm.  Sally and the resident pushed the bed up against the OR table and instructed the patient to move over.  Again, I held onto Alona’s hand, looked her in the eye, and said, “Alona, it’s not too late.  If you need more time to think about things we can give it to you.  If you want to talk to Dr. W about your options we can do that.”  Then I looked at Dmitry and said, “Dmitry, she is 8 centimeters now.  We do not have to do this surgery if she want to try to have the baby vaginally.”   But Alona just kept looking at her husband (who was allowed in the OR at this point because we needed him to help translate since Alona kept throwing down the language line phone during a contraction!) and he looked back at me and said “No, the doctor said she must have surgery!” 

 

And you know what?!  I don’t blame them one bit for not even listening to me.  After all, I am essentially a stranger, perhaps some kooky nurse to them whom they have never even met, while Dr. W was their “trusted” doctor.  If he couldn’t take (or didn’t want to take) the time to come in and talk about their options, then why should they listen to me!?  I found out after the surgery, when I looked back into Alona’s prenatal summary and previous OR report, that Alona’s first cesarean was performed after a 2-day “failed induction” to where she only progressed to 3cm/50% effaced/ -3 station.  A thorough review of the patient’s first OR report revealed a classic “cascade of interventions” including elective induction at 40.2 weeks with an unfavorable cervix for “postdates,” early amniotomy and pitocin administration after one cervidil placement, epidural for pain relief, fetal scalp electrode and intrauterine pressure catheter placement, and eventual cesarean section for “failure to progress/failure to descent.”  Although I support women’s rights, patient autonomy, and choices in childbirth, if the only thing that Alona & Dmitry learned from their last delivery was that her vagina was “too small,” I highly refute any claim by ANYONE that this patient was provided with true informed consent and an honest debriefing on ALL the factors that did or could have contributed to her last cesarean section. 

 

As I was assisting the anesthesiologist with the spinal by trying to keep a woman in transitional labor still (not an easy task), Dr. W burst through the OR doors, hands wet from scrubbing, and exclaimed in a most joyous way as he peered up at the clock on the wall, “Oh excellent!  I can be out of here by half past one at the latest and still make it to my golf game!” 

 

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

 

YES!  HE ACTUALLY SAID THAT!  AND THE PATIENT WAS AWAKE WITH HER HUSBAND IN THE ROOM! 

 

After that I pretty much turned my emotions off; I couldn’t handle it and I had to focus on the task at hand.  “Open” time for the surgery was 12:45pm.  Alona & Dmitry’s baby boy was born at 12:50pm.  “Close” time was 1:16pm.  As soon as the last staple was placed, Dr. W ripped his gown off, thanked the resident and anesthesia, said a quick “Congratulations” to Alona & Dmitry, and bolted out of the room, leaving the resident as the only OBGYN to escort the patient out of surgery and write all the orders. 

 

I gave the baby Apgars of 7 & 9 but at about 7 minutes old he started to have a  bit of a difficult time clearing his secretions and his oxygen saturation started to dropped so I had to suction him a couple of times.  The scale showed the baby weighed 7lbs, 3oz.  When it was time to leave the OR, I wrapped up the baby and walked out with the patient and her husband.  I had to keep him on the warmer in the recovery room for only about 10 minutes, basically, the time it took the team to hook her up to the monitors, do a fundal (“belly”) check, and give her some pain medication.  I then put the baby skin to skin with Alona under her gown and his vitals stabilized quite well after that. 

 

All in all despite the fact that Alona, Dmitry, and baby all appeared to be happy and healthy after surgery, my personal belief is that they were victims of medical malpractice and the current unjust maternity care system in this country.  I know malpractice is a loaded term but I think it describes the situation very well: “mal” = bad practice.  That is one of my biggest concerns with the rising rate of scheduled repeat cesarean sections.  Once the date is set it’s like everyone has blinders on;  the excuse “But she is scheduled for surgery” doesnt mean she qualifies for it now!  For one, consenting a patient for major abdominal surgery PRE-LABOR in the office and treating it as the absolute only course of action regardless of what situations might arise to the contrary is WRONG.  I can safely bet that when Alona “agreed” to a repeat in the office that she was mislead into thinking or mistaken that things were automatically going to go exactly the way they did last time .  I can safetly bet that she did not expect to show up to the hospital after going into labor spontaneously and progress from 5 to 8 centimeters in a matter of 20 minutes when she was “counseled” (term used VERY lightly) about her options and “consented” (again, used lightly) to a repeat cesarean section months before.  And you know what, if she had shown up at 10 centimeters with a head on the perineum I KNOW that her doctor would have STILL rushed her off to surgery even so because I see it happen at work ALL THE TIME.  It’s outrageous, it’s meddlesome, it’s arrogant, it’s tragic, and it’s untrusting of a woman’s natural and innate ability to push her own baby out!!

 

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

 

“The International Cesarean Awareness Network opposes the use of cesarean section where there is no medical need. Birth is a normal, physiological process. Cesarean section is major abdominal surgery which exposes the mother to all the risks of major surgery, including a higher maternal mortality rate, infection, hemorrhage, complications of anesthesia, damage to internal organs, scar tissue, increased incidence of secondary infertility, longer recovery periods, increase in clinical postpartum depression, and complications in maternal-infant bonding and breastfeeding, as well as risks to the infant of respiratory distress, prematurity and injuries from the surgery.

 

All physicians take an oath to “Do no harm”. This means choosing the path of least risk to patients. Medically unnecessary elective cesareans increase risk to birthing women. It is unethical and inappropriate for obstetricians to perform unnecessary surgery on a healthy woman with a normal pregnancy.”  

 

The fact of the matter is that I do not believe that Alona’s c-section was necessary and I believe that her doctor did do her harm by performing her surgery without at least revisiting her options with Alona before he ordered for her to be wheeled into the operating room.  She needed to hear and deserved to hear her options from Dr. W at that time and not anyone else.  Although the above position statement was written regarding patient choice elective cesarean section, I feel that it also pertains to elective repeat cesarean sections since I do NOT believe that “prior cesarean section” is an automatic indication that is well supported in the literature as being a good enough reason to just schedule another major abdominal surgery.  I agree with author Norma Shulman as she was quoted in the book Silent Knife, “Those who favor repeat cesarean because of its ‘ease’ and ‘safety’ need to be reminded that ‘all the factors that make cesareans so safe nowadays also serve to make VBAC safe, and more rewarding.”  To me, many other childbirth advocates, and to thousands and thousands of women in this country, the birth of a child is not the only goal of labor, it’s a very important one, but it’s not the only one.  Women aren’t just “fetal vehicles” and their experiences in labor and childbirth have profound effects on their self-esteem as well as their relationship to their partners, their babies, and their families for the rest of their lives. 

 

Are you pregnant and have a history of a previous cesarean section?  Did you know that you have the right to informed consent and informed refusal regarding repeat cesarean section vs. VBAC?  Did you know that there are resources out there to help you?  Please check out:

 

(1)  ICAN’s Cesarean Fact Sheet

(2)  ICAN’s Vaginal Birth After Cesarean (VBAC) Fact Sheet

(3)  Silent Knife: Cesarean Prevention and Vaginal Birth After Cesarean by Nancy Wainer Cohen & Lois J. Estner

(4)  DON’T CUT ME AGAIN! True Stories About Vaginal Birth After Cesarean (VBAC) by Angela, J. Hoy (Editor)

 

And find a local ICAN support group near you!

 

 

**As always, all identifying information including names, dates, times, ethnicity, etc. have been changed or omitted to protect privacy and adhere to all HIPPA guidelines.

 

Great Birth Story April 25, 2009

Filed under: Nursing Notes — NursingBirth @ 10:34 AM
Tags: , , , , ,

One of the readers of my blog alerted me to her birth story that she wrote about on her blog Reality Rounds: Get a Second Opinion.

It is a hilarious, true-to-life, personal, and very honest account of her birth experience that she had with her first pregnancy.  She also talks about the skeptics she encountered at said “big city hospital” just because “she’s a nurse.”

She writes, “Moral of this story:  Nurses are not nurses when they are patients, they are human beings.  They are scared, and naive, and looking for you for help. Let’s not forget that when we are taking care of our fellow sisters.”

I couldn’t agree more and as an L&D nurse, I thank realityrounds for reminding me of that.

 

The “All That Matters” Phenomenon: Grieving the Loss of a Vaginal Birth April 24, 2009

The other day I had the privilege of taking care of a couple who was in labor with their first baby.  Denise, a G1P0 at 41 weeks and 3 days, broke her water at 1:00am with contraction starting about 8-10 minutes apart at 4:30am.  She and her boyfriend, Ralph, labored at home until about 8:00am when the contractions were coming about every 3-5 minutes apart.  When she arrived to the hospital at 8:30am, a resident’s vaginal exam revealed that she was 3cm/50%effaced/-3 station!!  Since she was a young healthy woman (her health history only comprised of PCOS, or polycystic ovarian syndrome) and had had an uncomplicated, normal, healthy pregnancy, she was “allowed” to ambulate in the halls all morning but required to stay on continuous telemetry monitoring and not allowed to labor in the tub per her physician’s direct order. 

 

(Side Note:  This particular physician, Dr. O, is an older physician who is part of a group that is well known for aggressive labor management.  They induce almost all of their patients for one reason or another, often once they hit 39 weeks, and if a patient is not already ruptured once they get to the hospital, they will artificially break their patients’ water regardless of dilatation.  That’s right, I have personally refused to give them an amniohook when a patient is only 1 or 2 centimeters and they sneak in the room without me and break her water anyway!  One time, Dr. U (another doctor in that group) ruptured a patient who was still in triage!  They are notorious for setting up “post dates” inductions at 40 weeks and 1 day and although they advertise that they attend VBACs, their statistics show something quite different: Almost NO “successful” VBAC vaginal deliveries and a cesarean rate that is at least 40%.  Myself and many other nurses have bombarded them with research and position statements from a variety of sources, including their OWN association (American College of Obstetricians and Gynecologists, or ACOG)) that states intermittent auscultation is the standard of care for low risk, uncomplicated pregnancies, but they refuse to listen.  So Denise’s situation is unfortunately not uncommon.  To be honest, I am surprised they “let” her get past 41 weeks!  I think they view it as a slap in the face to attend any delivery after 40 weeks!)  

 

When I came on at 3:00pm, Denise was in the middle of getting an epidural.  Turns out that at 12:30pm, Dr. O’s vaginal exam revealed that the patient was “only” (his words) 4cm/80%/-3 so he ordered pitocin augmentation and the pit was started at 1:00pm.  Although the patient had originally told the nurse it was her plan to labor without an epidural, pitocin lead to stronger, longer, and closer contractions which lead to the patient requesting one.  And an epidural was granted.  For the next 3 hours I was instructed to continue to turn up the pitocin to obtain 5 contractions in 10 minutes.  I titrated appropriately until I obtained moderate to strong contractions (per my palpation) every 2-3 minutes, where the baby was still looking good on the monitor.  I changed the patient’s position every 30 minutes: right side, sitting up high, left side, sitting up high, etc. in hopes that I would help the baby makes his way down the birth canal and not get “stuck” in any acynclitic position. (According to the patient, she was complaining of severe back pain the last few hours so I was concerned about an occiput posterior baby.  So since Denise could no longer move herself to help move the baby, I was doing the moving for her!) 

 

At 7:00pm Denise was feeling a lot of rectal pressure, so much that she was breathing through it (even though the epidural was still effective at taking away her back and abdominal pain).  We all were very excited!!  Since Denise was only feeling rectal pressure during contractions I told her it would be best to wait until she was feeling rectal pressure at all times, with our without a contraction, before we called the doctor.  Well Dr. O must have had ESP because he came into the room to perform a vaginal exam.  His exam revealed that Denise was 4cm/100%/ -1 station!  The patient was a bit disappointed that she was still only “4cm” but I assured her that he was completely thinned out and that she had brought the baby down a whole bunch!  However, Dr. O had a different take on it, “You are still only 4cm, he said, “And if you don’t make any significant progress within the next hour we will have to talk about a change in the plan.”  (Could he have BEEN any more vague?!)  And then he turned around and walked out.  “What does he mean by change of plan?” Denise asked me.  “Well I’m not sure,” I said back, “let me go find out.” 

 

The fact of the matter is that I knew exactly what Dr. O meant….he meant that he was going to do a c-section.  But I didn’t want to tell her that for two reasons, 1) it is NOT my responsibility to tell a patient that someone else is going to perform a cesarean section on them, it’s the SURGEON’S responsibility, and 2) I hate even talking about the possibility of a cesarean section when someone is in the middle of labor because it is like you are telling the patient you are already “giving up” on them.  Of course I understand that some cesareans are necessary, but I know that if I was in her position and someone gave me a “cesarean ultimatum” during labor, I would feel like people were giving up on me!  I mean here she is, basically being given a one hour ultimatum, and because of the limitations of the epidural it is not even like she can “do” something to play an active role:  she can’t walk around or get in the tub, we’ve already got her hooked up to pitocin and an epidural, we’ve already tried the position changes, her water is already broken, and I am pretty sure she doesn’t know magic.  So here I am feeling like my hands are tied, but trying to stay positive and encouraging so that the patient does not feel upset, passive, defeated, or worried.  Because those emotions do NOT facilitate labor, and in fact, those emotions can actually release hormones in your body that directly work AGAINST labor. 

 

So I walked out to the desk to find Dr. O but he had already left.  (I don’t think he went very far, maybe into another patient’s room, but nonetheless, he was no where to be found.)  I felt an obligation to tell Denise something so I went back into to the room and said this:

 

Me: “Denise, I think Dr. O is with another patient right now but once I find him, if you would like, I can ask him to come back in to answer any questions you might have.”

 

Denise:  “Yeah, I would like him to come back in because I don’t want a c-section.”  (starting to get a bit teary eyed)  “I mean, is that what he meant by change of plan?  Can they give me any other medicine to help with my contractions?”

 

Me:  “Well I don’t know what he meant exactly but he could have meant he would like to try an IUPC which stands for intrauterine pressure catheter.  It is a thin tube that lies beside the baby’s face and actually measures in millimeters of mercury how strong your contractions are.  If I have an IUPC, I might be able to go up on the pitocin if the contractions aren’t “strong enough.”  Right now the external monitor only tells me when they are coming and when I feel your belly it is all subjective.  Unfortunately there isn’t any other medicine we can give you to help “speed up” labor besides pitocin.  He could also have meant a cesarean.  But we won’t know until we talk to him.”

 

Denise: (almost in a scared tone)  “But I don’t want a c-section!  I want to push my baby out!  Oh I don’t want a c-section!” 

 

Me:  (feeling like I wish I could help but don’t know how)  “Well let’s talk about what you can do.  If Dr. O comes in to check you, you have the right to refuse his vaginal exam and request more time.  You also have the right to ask him about all of your options, if there are any, besides a cesarean.  You have the right to ask him his reasons for why he thinks a cesarean is necessary.  You have the right to hear all that information and then take as much time as you need to decide what you would like to do.  If you need some alone time with Ralph or if you need to call your mom or any other family members you have that right.  I just want you to know that if you and Dr. O decide together that a cesarean is the best option, it will NOT be an emergency and therefore you can take as much time as you need to prepare.  The baby is not in distress and in fact, has looked beautiful on the monitor all day.   If you both decide that a cesarean is the right course of action, I promise I will go over everything to expect with you, I will make sure anesthesia sees you before you get to the OR so you can ask them any questions, and barring any other emergency, I will be with you the entire time, from the moment I wheel you in to the OR, to the moment I wheel you out of the recovery room.  I’ll help you breastfeed as soon as possible.  I will stay with you the whole time…”

 

At this point I was starting to get a bit emotional and realized I was rambling so I excused myself and went out to the desk.  I just knew in my heart what was going to happen and I was deeply saddened by it.  And don’t get me wrong, I am not trying to be overly dramatic but I just knew that when she broke her water at 1:00am and came to the hospital at 3cm, she was not expecting to end up with a cesarean. 

 

Well exactly one hour later Dr. O came back into the room to do a vaginal exam.  I turned towards Denise and I said, “Is that okay with you, Denise?” and she said “Yes.  According to Dr. O, Denise was still the same and had made no “progress.”  Dr. O, while standing at the foot of the bed, looked up at Denise and said “Well Denise, we’ve run out of options here.  If we continue to keep you on pitocin eventually the baby is going to run out of gas and crash.  Uteruses can only take so much and your uterus is going to get thinner and thinner and will be at risk of rupturing if we continue like this.  You have essentially been 4cm for 7 hours and for a primip, you need to progress at least one centimeter an hour.  We need to do a cesarean and as soon as I tell the charge nurse we’ll get going on it.”

 

At this point Denise burst into tears, “OH GOD, BUT I DON’T WANT TO HAVE A C-SECTION!  I WANTED TO PUSH HIM OUT!  I WANTED TO PUSH HIM OUT!   I REALLY THOUGHT I COULD DO IT!  I WANTED TO DO IT!  I WANTED TO PUSH MY BABY OUT!”  Ralph gave her a big hug and I kept squeezing her hand trying to bit my lip so that I didn’t start to cry myself.  She was sobbing.  And then Dr. O said “Listen, Denise, there is no reason to get like this.  I mean, when you came to the hospital this morning I also had 4 other patients that came in around the same time.  Everyone else has already delivered…you’re the only one left.  And some women even came in with cervixes more closed than yours.  You see, the baby just isn’t coming down enough in the birth canal to dilate your cervix, and it’s just a failure to progress.  It’s just failure to progress that’s all.”  Then he turned to me and said “As soon as I tell the charge nurse we’re going to go.  So then I said, “Well I am not at all ready to go yet.  And I think she deserves a minute to come to terms with all of this, Dr. O.  She deserves some time to make her decision and call her family.  And then Dr. O looked straight at me, baffled, said “Whatever” and then stormed out slamming he door behind him. 

 

I threw myself onto Denise and have her the biggest hug I could.  I whispered over and over in her ear, “You are NOT a failure Denise, I know you wanted to push him out.  I know you did.  You have done so much work today and you never gave up.  You are a strong woman, Denise, you did not fail and your body did not fail.  NOBODY is a failure here.  It’s okay to cry.  It’s okay to cry, Denise.  Please know you did so much for your baby and you never gave up.  You are a strong woman…”

 

I stayed there for about 10 minutes with her and Ralph, letting her cry.  When she calmed down a bit I encouraged her to take her time to talk with Ralph and call her mother or family if she needed too.  I told her that I needed to get some things ready and that I was going to give them some privacy.

 

So by this point I was pretty upset.  For one, I think the way Dr. O went about the whole thing was so cold and insensitive.  Um hello, do you think telling a patient that “everyone else” has already delivered is going to make them feel better!?  Because in my opinion, it just stresses the insane notion that her body is in someway a “failure.”    I could mull over and over and over again in my head everything that surrounded this whole situation and I have almost made myself sick over wondering if this was really a necessary cesarean for “true” arrest of descent/dilatation.  But regardless, I feel like he completely took Denise and Ralph out of the whole process and it should have been handled better.  Second, Dr. O did NOT go over the risks and benefits of the cesarean with them, claiming later that the residents “review that” on admission (which, by the way, they don’t…they just have everyone sign a consent for “vaginal delivery possible cesarean section”).  Third, Dr. O did not at all go over other options besides cesarean, and even if he thought the safest course of action was a cesarean at that point in time (which I am not disputing), he didn’t even say anything like “and our other options, X, Y, & Z, are not the best course to take because of A, B, C, so it is in my professional opinion that the safest course of action is to perform a cesarean section.  But please take your time to talk it over.”).  I have seen other doctors do this before.  Even in situation where everyone agrees that a cesarean is absolutely necessary, it is still the patients right to make the final decision.  And finally, he didn’t even give them a chance to talk it through and when I asked for “some time” he got pissed. 

 

So I walked out to the desk to get my paperwork ready and Dr. O was writing a note in her chart:

 

Dr. O:  (sarcastically and not even looking up from what he was writing)  “So when do you think you’ll be ready to go?”

 

Me:  (frustrated)  “It’s not about me being ready, it’s about Denise and Ralph being ready!  I think it is more than just a courtesy to allow them some time to come to terms with this new development.  They have a RIGHT to some time, Dr. O.  This isn’t an emergency.  The baby has looked great on the monitor all day and I shut the pitocin off.”

 

Dr. O:  (frustrated)  “I don’t know why you are fighting me on this!” 

 

Me:  (increasingly frustrated) “I’m not fighting you on ANYTHING Dr. O, but you have to understand, she is devastated that she is going to have a cesarean.  We owe it to her to let her calm down and not wheel her down the hall as a sobbing mess!  Her whole family lives in a different state, including her mother, and I think that it isn’t too much for her to ask for some time to call her family before she goes in for MAJOR ABDOMINAL SURGERY!” 

 

And then he said it….he said that phrase that breaks my heart every time I hear it…

 

Dr. O: “She’ll forget all about it when she is holding a baby in her arms.”

 

This phrase comes in many forms but every one says the same thing, “All that matters is that you get a baby out of this deal… and your experience, your experience doesn’t matter.”

 

Kristen, a doula, graduate student, mom, and author of the blog Birthing Beautiful Ideas wrote an amazingly insightful and moving must read post entitled, “Scars That Run Deep: ‘All That Matters’ After A Cesarean” that explores this very topic. 

 

Kristen writes:

 

“You have a healthy baby.  That’s what matters.”

 

Mothers who express sadness, anger, or disappointment after undergoing a cesarean section often hear these words uttered by (presumably) well-meaning family, friends, and health care workers.  In fact, these words seem to be one of the most common responses that people give upon hearing that a mother has had a cesarean.  I presume this is because it can be jarring to witness the juxtaposition of the joy and wonder of a newborn life and the mother’s grief over her baby’s entrance into the world.  And so, particularly in a culture that does not have a well-developed ritual for expressing and experiencing grief, people try to fill up the mother’s “empty grief jar” with an elixir of “healthy baby joy.”  But, as we all know, grief and joy don’t work like that.

 

Kristen goes on to write about why having a healthy baby isn’t “all that matters” after a cesarean, the concept of mourning the loss of a vaginal birth, and why a mother’s birth experience IS part of “what matters” regarding the entire childbirth experience.  Kristen also outlines step by step details about what a mother experiences when she undergoes a cesarean, from the minute the wheel her into the operating room to the first time she gets to hold her baby to caring for a newborn after major surgery.  Kristen writes,

 

In addition, the de-valuing of the mother’s birth experience–a de-valuing implied by the “healthy baby line”–undermines the significance of one of the most transformative days of a mother’s life.  For on the same day that her baby is born, she is “born” as a mother.  And if this dual-birth is marked by passivity and separation, then it is no wonder that the mother grieves her birth experience.  That having her healthy, miraculous, wonderful baby is not all that matters to her.

 

In fact, her sadness is partially a result of being separated from her healthy, miraculous, wonderful baby during the first few moments and even hours of that baby’s life.  And it can be the result of a feeling that her body is “broken,” “unable” to bring her child into the world on its own.  And it can be the result of a feeling that her body might not even “know” how to work properly to bring a child into the world.  And it can be the result of feeling as if she has disappointed not only herself but also her partner and/or other friends and family.  And it can be the result of the sheer difficulty of recovering from major abdominal surgery and simultaneously caring for a newborn baby, two of the most physically and emotionally demanding experiences that any person will ever undergo.

 

In other words, her sadness and her grief are understandable.  They are normal.

 

Please check out Kristen’s post in it’s entirety on her blog.  The excerpts I have provided here are only a small piece of this very eye opening composition.

 

In the end Denise gave birth to her 9lb 8oz baby boy, Rayne Nicolais, by cesarean section at 9:01pm.  Baby Rayne was found to be in an occiput posterior position and still very high in the pelvis when he was born.  I had the opportunity to stay with Denise, Ralph, and Baby Rayne for the entire experience and with the help of a ton of pillows, Denise breastfeed Rayne skin to skin in a football hold for an entire hour and 15 minutes in the recovery room.  And boy was he a vigorous breast feeder!! 

 

Although all in all, there was a positive outcome to Denise’s birth experience, I do wish that for Denise and Ralph, things could have turned out differently.  I wish that Denise could have PUSHED her baby out like she so desired and worked so hard for.  And of course I am grateful that at the end of the day Baby Rayne was a happy, healthy, chubby, bouncing baby boy.  In the recovery room where Denise really held her baby boy for the first time, she welled up, looked at her boyfriend and said, “I think I am falling in love all over again!”  It was so beautiful!  As a nurse, experiences like this solidify what I feel in my whole being is true about pregnancy and childbirth; That the journey is as important as the destination. 

 

In closing I would like to leave you with one of my favorite quotes…

 

“It’s not just the making of babies, but the making of mothers that midwives see as the miracle of birth.” ~ Barbara Katz Rothman.