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

 

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?

 

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.

 

Don’t Let This Happen To You #24 PART 2 of 2: Jessica & Jason’s Back Door Induction April 21, 2009

Continuation of the “Injustice in Maternity Care” Series

 

Please see, Don’t Let This Happen To You #24 PART 1

 

My first hour with Jessica & Jason was spent getting to know them, tidying up the room, setting it up the way I like it (I know, sometimes I can be a bit anal about clutter!  I don’t know how some nurses can work in so much clutter!!), and turning up the pitocin a couple of times.  Around 4:00pm I had left the room to scrounge around for a few more pillows for Jessica.  This took me about 10 minutes since pillows are pretty much like gold in the hospital: rare to find and very precious to have!!  Haha!  Anyways, as I walked into the room Dr. T was leaning over the trash can throwing something away and Jessica was lying flat on her back in bed, spread eagle, completely uncovered, and sitting in a big puddle.  It took me a few seconds to piece together what had happened.  Turns out Dr. T was throwing away the amniohook he used to BREAK Jessica’s water WITHOUT me being in the room!  I quickly stepped towards the bed to raise her head and cover her up.  The entire bed was soaked.  It was getting harder and harder for me to contain myself and I could feel the blood boiling up into my head. 

 

Me:  “What’s going on?”  (said in the nicest voice I could muster up)

 

Dr. T:  “Oh, are you taking care of Jessica today?”

 

Me:  “Yes.”

 

Dr. T:  “Well, I just got out of the OR and I wanted to check her progress and apparently the residents hadn’t ruptured her yet!  So I just did.”

 

Me: “Oh, well, what nurse came in here with you?  I’d like to thank her.”  (also said in the nicest voice I could muster up but clearly my sarcasm was piercing through all my attempts to stay calm)

 

Dr. T:  “No, it was just me.”

 

Me:  “Oh really, well you should have come and got me.  I would have been more than happy to assist you.  It would have liked to lay some more chux pads down under her so that when you broke her water it wouldn’t cause so much of a flood.  I’m going to have to change all the sheets now, all of them.  And what if the baby had a decel…”

 

Dr. T:  (interrupting me)  “Well I couldn’t find you.”  (turns towards Jessica)  “I’ll come back in a couple of hours to check you.”  (turns to walk out of the room and then spins around and turns towards me)  “Why is her pit only at 8mu?”

 

Me:  “Jessica didn’t even get to the hospital until 1:30 and policy states we can’t start pitocin until the patient is fully admitted.”

 

Dr. T: “Well she’s still only 4cm so you are going to have to keep going up on the pit if she is going to get anywhere.”  (This statement really takes the patient right out of the equation doesn’t it!  Outrageous!)

 

Me:  “What’s the baby’s station?  Is the baby still high?”

 

Dr. T: “Um yes, but the head is now well applied.  She’s 4cm/50%/ -3…..maybe -2.”

 

At this point all I can think of is “Liar, liar, liar!”  Dr. T turned to leave the room and after he left I assisted Jessica out of bed to the bathroom so that I could change all of her sheets and help her into a new dry gown. 

 

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

 

I need to digress for a moment to explain exactly how outrageous it was for Dr. T to check the patient and rupture her membranes without me or any other nurse in the room.

 

#1 Although this might seem like a silly thing to be upset about, the fact that he ruptured her membranes without even putting down a few extra chux pads (which were sitting right on the counter) is very rude in my opinion.  It’s like saying “You clean up my mess because I am above that.”  Honestly it wasn’t that difficult to change the bed over and help the patient into a new gown but it’s the principle of it that bugs me.

 

#2  It is an unwritten rule at my hospital that a nurse is to accompany any doctor or midwife during a vaginal exam.  Even the residents are taught this during orientation.  Is a doctor or midwife fully capable of performing a vaginal exam solo…of course they are!  But it isn’t about that.  It’s mostly about touching base with the nurse first to see how things have been going all shift with the patient.  It’s about good communication and team work.  And sometimes another vaginal exam isn’t necessary and the nurse can advocate against it!!!  I haven’t met one doctor or midwife that attends births at my hospital that has a problem with this arrangement….unless they are trying to do something that they know the nurse will question them on….like performing an early amniotomy on a patient whose baby is still high!!  The fact is that that is the ONLY reason Dr. T didn’t come and get me…because he knew that I, and many other nurses, would question the necessity and safety of such an intervention.  So he had to SNEAK it.  What he did was so SNEAKY and it infuriated me! 

 

#3  The other most important reason to obtain the assistance of the patient’s nurse (or ANY nurse at the desk really) is just in case something bad was to happen.  Although something acutely bad is unlikely to happen from just a vaginal exam, the nurse’s role in assisting with the vaginal exam is to maintain the patient’s comfort and protect the patient’s modesty.  (As you can see, Dr. T did none of those things, and things like that happen a lot with some of the docs I work with.  All of the pregnant readers I know understand how uncomfortable it is to lay flat on your back for any length of time when you are pregnant!)  But there ARE acute risks with performing an amniotomy, especially an early or prelabor amniotomy. 

 

Risks related to amniotomy that have emergent consequences include:

1)     Umbilical cord prolapse

2)     Fetal heart rate decelerations related to umbilical cord compression

3)     Change in presenting part

 

Let me give you an example.  One time I had a doctor that ruptured a patient with polyhydramnios and a high presenting part.  (That means, the baby’s head was not well engaged into the pelvis and was still “floating”.)  After the gush of water flooded the bed, the baby started to have pretty serious heart rate decelerations with every contraction related to compression of the umbilical cord.  When the doctor did a vaginal exam to check her dilation, he found that he was no longer feeling a head, but a HAND.  Since the baby was high and floating in a large amount of fluid and the head was not well engaged when he ruptured her membranes, the first thing to rush out was the baby’s hand.  The doctor was unsuccessful at moving the hand back.  And that woman, a grandmultip (G6P5) who had had FIVE previous spontaneous normal vaginal deliveries ended up with an emergency cesarean section.  And it was VERY IMPORTANT that I was in the room when all of this happened since I was the one who ended up almost single handedly assisting her into knee chest, throwing on some oxygen, and wheeling her down to the OR as the doctor rushed to scrub in.  Yes, emergencies can happen that fast.  (This one however was almost completely avoidable!!)  Please know that I am not telling this story to scare anyone.  But the LESS interventions you have, the significantly LESS chance you have of that kind of emergency happening.  And if a physician or midwife is going to take the chance with any intervention like amniotomy, it is very important that he or she has assistance from a nurse in the room. 

 

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

 

Okay, thanks for letting me rant there for a minute.  Back to the story…

 

So after I helped Jessica clean up I offered to help her out of bed into any position she liked.  After all, it’s important to use gravity to help you and not work against you!  Jessica decided that she wanted to get up into a rocking chair.  I continued to titrate the pitocin to obtain an “adequate” contraction pattern.  Jessica’s body was actually pretty resistant to the pitocin so I ended up eventually getting all the way up to “max pit,” or 20mu/min, around 6:00pm.  Jessica was contracting about every 2 ½ -3 minutes each lasting for about 40-60 seconds.  Jessica complained most about her back pain and so we tried a variety of positions to ease this for her including using the rocking chair, standing at bedside, birthing ball, back rubs, slow dancing etc.  Jason was an excellent birth coach and the two of them really worked well together.  Jessica did not feel comfortable walking in the halls (some women prefer a bit more privacy and I can’t really blame them!) so she did a lot of pacing in the room.  Around 6:45pm, Jessica was getting really tired and asked if she could get back in bed.  We tried a few positions in bed (side lying, kneeling, etc.) but the back pain was too intense. 

 

I wished at that moment we could have gotten her into the Jacuzzi but despite what some other people might tell you, trying to continuously monitor a patient in the Jacuzzi is almost impossible, especially since there are no monitors in the tub room at my hospital so I cannot see or hear what the baby’s heart rate is doing when I am in there manually holding the monitor to her belly so the bubbles don’t knock it off.  This is yet another reason why back door inductions frustrate me.  If she was in true labor and not on pitocin, I could have done intermittent auscultation which is very compatible with using the Jacuzzi.  Some women think they can have it all (for example their induction and the Jacuzzi).  But fact of the matter is that agreeing to an unnecessary induction automatically makes a natural birth plan harder, NOT impossible, but harder. 

 

Turns out the only position that Jessica liked at that time was sitting straight up in bed, leaning forward on the squatting bar, with the foot of the bed lowered so the bed looked like a “chair.”  She was moving and breathing very well in this position with Jason and me as her coaches, and she seemed to start to drift off into “Laborland.”  At 7:00pm Dr. T came into the room and stated he was going to do a vaginal exam to check for progress.  Jessica had started to complain of some intermittent rectal pressure so I had assumed that the baby had moved down some.  Turns out she was 5cm/100% effaced/-1 station!!  “This is great!,” I said to Jessica, “You are doing such a great job!  Not only are you 5cm now but you have thinned all the way out AND you have moved the baby down a lot!!  You are doing so well!!” 

 

Both Jessica and Jason seemed excited about the progress which is great because I was afraid that Dr. T would say something annoying like “Oh bummer, you are only 5 cm.”  But the truth is that in order for your cervix to dilate you have to thin out first and therefore progress in effacement and station are also signs of great progress, not just dilation. “Do you want anything for pain?,” asked Dr. T.  “No, not yet, I want to try to go longer,” she replied.  Jessica spent the next two hours sitting straight up in bed, leaning over the squat bar, with the bed in the “chair” position.  Jason was standing beside her rubbing her lower back while I was helping her to stay focused on her breathing.  She had a couple mini “freak outs” like “I can’t do this anymore!,”  “This is it, I can’t take one more contraction!”  “How much longer is this going to be?!”  What is important to remember is that these “freak outs” are NORMAL and it doesn’t mean you are weak or a wimp.  Far from it!  Labor is one of the most intensely physical experiences of your entire life.  It is comprised of sensations that are unlike any others you have felt before.  And that is why positive encouragement is so important.  I know it is hard to see someone you love in pain but Jessica had said she did not want any pain medication or an epidural at this point so providing her with unconditional support was what was needed.

 

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

A quick story…

 

When I used to run cross country in high school we would often have “distance days” were our workout consisted of running a 13-18 mile long run.  We would start right after school and often not get back until it was dusk.  Those runs were grueling especially since we lived in a very hilly town.  I remember thinking or saying things like “I can’t do this anymore!” or “No, just go on without me!”  I remember feeling so many times during those runs like I wanted to “quit” and walk.  But I knew that if I did, it was just going to take me that much longer to get home.  And one of the things that kept me going the most was the support from my teammates.  “Just run until that phone pole” then “just run to that fire hydrant” then “just run to that stop sign.”  I got through it because I took it one small stretch at a time.  When I thought about how much farther I had to go, when I thought about the whole run as a whole, the task at hand seemed overwhelming and insurmountable.  But when I took it “one phone pole at a time” I felt like I could handle it.  There was no other way to get home but to run.  And it hurt.  And the cramps in my sides made it hard to breathe.  And sometimes I would have to lean over into the woods and throw up.  Every bone and muscle ached, from my ears to my toes.  I remember my knees stinging with each footstep.  But there was no other way to get home but to run….  And when I finally crossed onto the track at the high school to run the last stretch I felt like I could do anything.  I did it! 

 

I am not trying to claim that running a long run is exactly like labor.  For one I was only running for a few hours, not hours and hours and hours.  And I knew exactly how much I had left, unlike moms in labor.  And genital pain was not involved at all!  Haha!  But the point is that a great mix of positive encouragement from my teammates, self determination, and the technique of taking it one step at a time was the reason I succeeded.  If my teammates just left me in the dust every time I said “Just go on without me!  I have to walk” then I wouldn’t have been as successful and I wouldn’t have gotten as much out of the run.  So ladies, it’s NORMAL to “freak out” a bit, which is why surrounding yourself with positive, helpful, and supportive coaches (not just “specators”) is so important, ESPECIALLY in a hospital birth.

 

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

 

Jessica labored like this for about two more hours.  She was definitely in Laborland, kinda spacey, like she was in a trance.  At around 9:00pm Jessica said that she was feeling a lot more rectal pressure and wanted an epidural so I went out to the desk to page a resident.  Lucky me Dr. T happened to be sitting at the main desk chatting with another doctor.  I told him that Jessica would like to be checked to see how far along she was because she was considering an epidural.  He came into the room and low and behold, she was 6cm/100% effaced/ 0 station.  Woohoo!  Jessica stated she wanted the epidural so I proceeded to get things set up so that we would be ready when anesthesia came in.  I had already reviewed with her the risks and benefits of an epidural earlier on (when she was more comfortable), so now I just had to explain to her what to expect from the procedure. 

 

After setting up the room I walked out to the desk to see how long it would take anesthesia to see her.  Turns out that anesthesia was tied up in a cesarean section so Jessica would have to wait.  (Unfortunately, even in a hospital that has 24/7 anesthesia like mine, they are not always available for epidurals.  So if this is your only reason for deciding to have your baby at a high-risk hospital, I would make sure you review all of your options.  And if your only labor preparation is deciding you want an epidural, it is imperative that you prepare for the possibility of not getting one!)  When I was at the desk, I checked the orders to make sure Dr. T had written for the epidural.  And that’s when I found his progress note:

 

X/X/XXXX

2115

S: Complains of more pain, wants relief

O: Cervix 6 cm dilated, completely effaced, 0 station

     EFM shows Ctx every 3 min x 60, baseline 140, +accels, Æ decels, moderate variability

A: Active phase labor with unsatisfactory progress

P:  Anesthesia notified for epidural

     Recheck in one hour, if no significant progress, anticipate primary cesarean section for arrest of dilatation

                                                                                              Dr. T

 

 

 

I was floored.  I couldn’t believe he was basically already throwing in the towel for Jessica.  It was her first baby for goodness sakes!  Babies come in their own time!  I mean, she hadn’t even gotten the epidural yet and the pitocin has to be shut off for the epidural so by the time the “hour” was up, it would have been completely unfair to expect her to have made any “progress.”  And what does that mean anyways?  So I called him out on it:

 

Me:  “Dr. T.  You are already throwing in the towel for her!?  Why does the plan even mention a cesarean at this point?!”

 

Dr. T:  “You’re kidding right, she has only changed 2cm in the last 7 hours.”

 

Me:  “Well that’s not really true because I didn’t even get her contractions into an adequate pattern until about 6pm.  And it’s her first baby.”

 

Dr. T:  “Jeeze, you call that progress?!  I can’t be here all night you know…”

 

(YES he really did say that.  This is also the doctor that told me once to tell a multip who was 8cm and feeling pushy to “Not push” because he wanted to finish the ice cream he had just ordered with his wife and kids.  I mean, I’m all for him spending time with his kids but he was ON CALL and this was a third time mom who was feeling RECTAL PRESSURE and was 8 CM!  There is NO telling her “Don’t push!”  It’s called the fetal ejection reflex for goodness sake!  And guess what, not only did he missed the delivery, but he then chewed me and the resident out for it.  I’m not making this up…In fact I can’t make this stuff up!)

 

Me:  (getting pretty upset but trying not to scream at him)  “Are you kidding me!  She wasn’t even in labor when she got here!  If she was, you wouldn’t have started her on pitocin.  She wasn’t even in labor!  You didn’t have to be here at ALL but YOU were the one who sent her in for induction.”

 

Dr. T:  (smirking)  “Induction!  She was 4cm!”

 

Me:  “But she couldn’t feel any of her contractions!  And now you are just going to cut her without at least seeing if the epidural helps?!  This is her first baby!  This delivery has consequences for the rest of her life!”

 

I was afraid I was going to strangle him at this point so I just left the desk to go back into the room.  Anesthesia didn’t show up until 10:30pm and at 11:00 pm Penny, the night nurse, came in to take over.  I stayed until the epidural was finished and tucked her in.  The next day I got the full scoop on what happened from Penny and the patient’s chart.

 

Apparently Jessica got great relief from the epidural and slept like a rock for 2 hours.  Luckily the baby tolerated the epidural well and remained happy on the monitors. Dr. T must have fallen asleep in his call room or gotten distracted because he never came back to check her.  At 1:30am Jessica woke up feeling a lot more rectal pressure.  Penny called the resident to check her and her exam revealed she was fully dilated (HOORAY!!) but that the baby was still at a 0 station.  Since the resident was busy with other patients she agreed, per Penny’s request, to NOT call Dr. T and wake him up but rather to shut off the epidural, allowing it to wear off a bit, and use passive descent to help get the baby down more before they started pushing.  (Although Jessica was feeling more rectal pressure, a practice push revealed that she could not feel her bottom enough to push.  If she had started to push at that time, she would have just tired herself out).  Also, Penny knew that Dr. T was notorious for only “letting” patients push for about an hour (even if they can’t feel their bottom) and then if the baby isn’t out he performs a cesarean for “failure to descent.”  Phooey! 

 

One hour later at 2:30am Jessica was feeling an uncontrollable urge to push and a vaginal exam by the resident revealed that she was 10cm/100%/ +2 station!!  Yay!!  Penny said that she felt it was best not to make Jessica wait for Dr. T to rise and shine so she instructed Penny to push whenever she felt she needed too.  She said that Dr. T didn’t even make it into the room until about 10 min before Jessica pushed out her 8lb, 6oz baby boy at 3:05am after only approximately 30 minutes of pushing!!!!  The baby was also found to be in an occiput posterior position, which explains all that back pain Jessica was experiencing and perhaps the length of her labor as well.  Dr. T did cut an episiotomy but the baby delivered before he could get his hands on a vacuum J.  According to Penny, baby Christopher James nursed like a champ and stayed skin to skin with mom for almost a whole two hours! 

 

Fortunately for all those involved, Jessica and Jason’s story had a wonderful ending!  However, despite the fact that Jessica’s birth did not end in a cesarean section doesn’t mean that there were not many injustices in the way her care was managed by her birth attendant.  Stories like this always get me thinking…what if?  What if Jessica had been sent home from the office instead of sent in for a back door induction?  Would the baby have eventually turned around so that he was no longer occiput posterior?  Would her natural contractions been easier to handle and therefore would she still have opted for the epidural?  If she was not induced with pitocin and therefore not required to be on continuous monitoring, would the freedom to move around more in labor and the ability to use the Jacuzzi tub helped to alleviate her back pain if the baby stayed occiput posterior?  What if she had had a different nurse that encouraged her to get the epidural earlier on?  What if Dr. T had gotten his way and started to make the patient push before she had regained use of her legs and feeling in her bottom?  What if Dr. T had kept her membranes intact until much later in the labor?  What if Dr. T had checked her one hour after she was found to be 6cm and she hadn’t made “satisfactory progress”….would she have been given a cesarean for “failure to progress?” 

 

In summary, I would just like to say that unlike what many OBGYNs, nurses, friends, family members, moms, journalists, etc will tell you, the journey matters just as much as the outcome.  The fact is that women truly amaze me no matter how they give birth.  Whether it is a natural home birth or a scheduled cesarean section, the bottom line is that women have superpowers!  They can grow people inside of them after all!!  And my greatest wish is that all women will feel in control of the decisions regarding their birth and in the end feel empowered no matter the mode of delivery.  But as a society we have to be more conscious of how our overly medicalized maternity care system affects the thoughts, feelings, and emotions of our patients and families as well as their outcomes.

 

Don’t Let This Happen To You #24 PART 1 of 2: Jessica & Jason’s Back Door Induction April 13, 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

 

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

There are so many things about the current state of maternity care in the United States that frustrate, infuriate, sadden, and annoy me but one particular thing that really gets my goat is the back door induction.  As you might have already read, I am a labor & delivery nurse in a large urban hospital and we are BUSY!  Although I know there are hospitals that way more deliveries a year than we do, for the capacity of our hospital, 4500 deliveries a year is almost more than we can handle with our current facility and staffing.  (By the way, 4500 deliveries a year breaks down to about 375 deliveries a month and about 12 deliveries a DAY!  (Jeeze, I am exhausted just looking at the statistics!) 

 

One way to help organize all the chaos is to have an induction book in which doctors have to schedule all of their inductions at least 24 hours in advance.  This way we have somewhat of an idea about appropriate staffing and room assignment for our patients for each day (in theory).  (The exception to this rule is the induction in which there is a documented medical reason related to either mom or baby’s health that requires an urgent delivery of the baby.  For example, severe intrauterine growth restriction (IUGR) with a non-reassuring nonstress test (NST) and biophysical profile (BPP) or worsening preeclampsia.  We obviously don’t make these mom’s sign up for a spot.  They are usually a direct admit from the office to the hospital.) 

 

However, when a doctor is either lazy, anxious, rushed, or overall feels he is above the rules, he (or she) will send a patient in from the office as a direct admit to the hospital for labor when she actually is NOT in labor and will the proceed to INDUCE her under the guise of augmentation.  When providers do this, it increases the amount and acuity of our patient census and puts an unnecessary strain on our staffing which compromises the amount of individualized care we can give to our patients.  What these doctors don’t tell you is that inductions can take up to three days to complete!  If you are truly in spontaneous natural labor, even a slow labor, you won’t be in the hospital for 3 days.  Inductions take MORE time, MORE money, MORE staff, MORE resources and hence are MORE risky.  Let’s digress for a moment so that I may clarify the difference between induction and augmentation:

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

 

Labor: Regular, noticeable, and painful contractions of the uterus that result in dilation (opening) and effacement (thinning) of the cervix.  Therefore if you are having regular uterine contractions that are noticeable or even painful but are not making any change to your cervix, it is NOT labor.  Likewise if your cervix is dilated and effaced but you are NOT having uterine contractions that are noticeable and painful then you are NOT in labor.  (Note: I have had low intervention doctors and midwives send multips (a woman who has given birth at least once) home at 4 or 5 cm if they are not having any contractions or not changing their cervix.  One particular patient I can remember was a G5P4 and was 5cm dilated when she came to the hospital.  We kept her for 4 hours but she never changed her cervix…she couldn’t even feel her irregular contractions and she was comfortable.  So she was sent home.  Two weeks later she came back 8cm dilated in hard labor and I assisted with her very quick birth.  She did amazing and the baby was happy and healthy!  Clearly, even at 5cm, she wasn’t in labor.)

 

Induction: the use of medications or other methods to start (induce) labor before the woman’s body has spontaneously begun true labor on its own.

 

Augmentation: stimulating the uterus with medications or other methods during labor that has already begun naturally to increase the frequency, duration and strength of contractions, the goal of which is to establish a pattern where there are three to five contractions in 10 minutes, each lasting more than 40 seconds. 

 

So just to be clear (and to adequately set up my story) if a woman is 4cm dilated but is not having regular, noticeable, and painful contractions that are causing cervical change she is NOT in labor.  If said woman is sent into the hospital and any interventions to stimulate contractions are started, then it is by definition considered an induction NOT an augmentation.  And if said patient was not scheduled to be admitted on such day, then it is considered a backdoor induction.   

 

Let’s continue with the story…

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

 

It was a Friday morning before my weekend off and I came in to work at 11am as usual.  I was looking forward to the weekend since it had been a really busy week and I was exhausted.  For the first four hours of my shift, I triaged a few patients but ended up sending them all home for one reason or another.  As I was finishing up some paperwork at the desk around 1:00pm, Dr. T came off the elevator and over to the nurses station.  I overheard him telling the charge nurse that he was just at his office and was sending over a primip (a woman who has never given birth) for us to admit for labor who was 4cm dilated/50% effaced/-3 station by his exam in the office.  He then slinked towards one of our second year residents who, in my opinion, will definitely be joining the ranks of the aggressive labor management elite, and uttered, “I’m sending over a patient from the office, 4cm.  Could you break her water when she gets here and start her on pit.  I know you’re the only one who will do it.  The baby is still high.”

 

Situations like this one are exactly the reason why I shouldn’t eavesdrop!  The reason why Dr. T was concerned that “no one else” would break her water was that when a baby is at a minus 3 station and is “too high,” if the membranes are ruptured artificially the umbilical cord could slip down before the baby’s head, getting pinched between the baby’s head and the cervix, cutting off all blood flow from the placenta to the baby.  This is called a cord prolapse and it is a surgical emergency requiring an emergency cesarean section.  This emergency is very unlikely if your water breaks naturally at term during labor because typically when it happens naturally the baby’s head is well applied to the cervix which puts pressure on the bag causing it to break.  I wanted to turn around and shout at Dr. T, “If you are so concerned “no one else” will take the chance, why won’t you do it yourself?!  Is it really so wise if it is so unsafe?”  Furthermore, the thought of sending over a patient for “labor” and then immediately starting her on pitocin and breaking her water makes my head feel like its going to explode!  If she is really in labor then she does NOT NEED pitocin!  And if she “needs” pitocin, then she is NOT in labor!  This is a BACK DOOR INDUCTION and ladies, it happens all the time.  Think about it, it was a Friday and Dr. T happened to be on call that weekend.  Looks like he didn’t want to get a page over Sunday brunch that one of his patients was in labor!  AHHHHHHHHHHHHHHHHH! 

 

Sorry, I lost it there for a minute J.  But it is just these kinds of injustices that make my blood boil!  Let’s continue…

 

Come change of shift at 3pm I was patient-less since I had sent all my triages home and hence was assigned to the patient in room 9.  And guess whose patient it was!  None other than Dr. T’s “labor” patient!  Oh brother!  This was going to be an interesting night! 

 

From report I got most of the details:  Jessica was a 25 year old first time mom (G2P0) just a few days past her “due” date (40 weeks and 3 days).  Here health history was unexceptional: exercise induced asthma as a child that did not require any medications, tonsillectomy at age 7, and one miscarriage at 5 weeks two years ago.  Her pregnancy was normal, healthy, and uncomplicated.  The patient had arrived to the hospital at 1:30pm with her longtime boyfriend Jason.  Jessica’s day shift nurse had completely admitted her and started her on pitocin but because the floor was crazy busy all day, she had only gotten the pitocin up to 4mu/min and the residents had only gotten the chance to write orders and not to rupture her membranes.  (My thought = Yes!!)  [Note: For a description of how pitocin is administered check out: Don’t Let This Happen To You #25 PART 2: Sarah & John’s Unnecessary Induction].

 

Next I went into the room to meet Jessica and Jason.  Jessica was a bubbly young woman with big rosy cheeks.  Her boyfriend Jason was living proof that you can’t judge a book by its cover.  He was super funny and down to earth and very supportive of Jessica in every way, yet a bit intimidating at first because he was almost completely covered in tattoos and had multiple facial piercings J.  They looked like total opposites and yet were so perfect for each other.  We chit-chatted for awhile and really seemed to hit it off since we all had the same sense of humor.  I took the opportunity to satisfy my curiosity about how Jessica had ended up in the hospital since she seemed very comfortable the whole time we were talking.  The monitor strip revealed that she was having contractions about every 6-8 minutes but she was not even flinching as I saw them come and go on the monitor.  To gain a bit more information I started to ask some questions.  I kept the conversation light in tone, like “So tell me about your day today?” instead of “Why the heck are you here!  Run!  Run away!!”  J  Here’s our conversation:

 

Me: “So how did you end up at the office today?  Did you have a scheduled appointment or were you having contractions?

 

Jessica: “No I was feeling great!  I had a scheduled appointment and when they put me on the monitor for a non-stress test, the nurses told me that I was having contractions!  It was so crazy because I didn’t even know I was having them!  So then Dr. T decided to check me since I was contracting and I was 4 centimeters!”

 

Me: “Can you feel any of your contractions now?”

 

Jessica:  “I think so, well, am I having one now?  Wait, no, maybe now?  (Looks towards monitor) Yeah, I am having one now.

 

At this point I’m thinking: If you have to look at the monitor then the answer is no, no you are not feeling contractions!  Sometimes I turn the monitor screen off so the patients or family members can’t “contraction watch.”  J

 

Me: “So what happened next?  Did Dr. T tell you to come right over or did he say you could go home first?”

 

Jessica:  “He said we could go home first and get our stuff together but not to “dilly dally” because they were waiting for us here.  So we rushed home and grabbed our bags.  Good thing we packed last week!”

 

Me:  “Yeah, it’s great you were prepared.  What did Dr. T tell you the plan was for when you got here?”

 

Jessica: “He said that once we got here that he would break my water but they haven’t done that yet.  I guess it’s really busy today, huh?”

 

Me:  “Yeah, It’s a busy day.  Did he say anything about starting you on pitocin?”

 

Jessica:  “He mentioned that I might ‘need a little pitocin’ because my contractions weren’t in a regular pattern and were pretty far apart.”

 

Me:  “I bet it was a big surprise to you to be induced today, huh!”  (I couldn’t help myself!)

 

Jessica:  (confused)  “Well I didn’t expect to find out I was in labor today  that’s for sure!”

 

Me: “Do you guys have a written birth plan or any thing I should know about regarding your labor and birth preferences?”

 

Jessica:  “No nothing written.  Well, I wanted to try to go as natural as possible.  I don’t want any narcotics and I don’t think I want an epidural.  I mean, I’m not ruling it out, but I really want to go as naturally as possible……………I mean, I guess that’s not totally going to happen now because I am on pitocin but, well, you know…”

 

(Yes!  The “in” I’ve been waiting for! Sometimes I wish I could tape patients and then play back what they say to me to see if once they hear it back, they then realize how illogical their doctor is.  I mean sometimes I feel like a mom who has to sneak spinach into her kids’ favorite foods to trick them into eating vegetables.  I can never just come out and say my intentions, I have to play this “game” and hope they figure it out themselves.  This is something of a daily internal struggle for me.)

 

Me:  “Well that is not necessarily true because although we are limited by the fact that with the pitocin running I have to have you on the monitors, as long as I can trace the baby’s heartbeat I can help you into any position that makes you most comfortable.  Unfortunately pitocin is not a good as the “real” thing you know? What I mean is it makes contractions artificially stronger and longer than natural contractions.  But I will do my best to titrate the pitocin so that we get an effective labor pattern that both you and the baby can tolerate well.  We can all work as a team, sound good? J

 

Jessica & Jason: “Yeah sounds good!”

 

I’m sure, my savvy reader, you have already recognized why I started this post with the difference between induction and augmentation!!  The TRUTH is: If you are at term and someone has to “tell” you that you are “in labor” then you are NOT in labor!  I just feel so badly for these women!  I truly don’t think it is their fault!  I think that they put all their trust in their birth attendant and most of the time are just naïve and don’t know any better.  And I don’t say that to be patronizing, I say it out of love and concern.  And as I mentioned in the first post of this series, I don’t want to start off my first interaction with these patients by going off on a tangent about unnecessary induction because I don’t want to make them defensive, doubtful, untrusting, or upset because these emotions do not facilitate labor!

 

*Sigh* 

 

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

 

Up For Next Time: Don’t Let This Happen To You #24: PART 2 of 2 

 

Read about Jessica’s labor, the birth of her baby, and Dr. T’s upsetting prediction about her birth too early in the game.

 

 

(Research for this post was aided by my trusty OB textbook from nursing school:  Maternal-Child Nursing (Second Edition) by Emily McKinney, Susan James, & Sharon Murray Ó2005)

 

Don’t Let This Happen To You #25 PART 2 of 2: Sarah & John’s Unnecessary Induction April 8, 2009

Please see, Don’t Let This Happen To You #25 PART 1

 

After our conversation about her birth plan and induction, I focused my attention on providing Sarah & John with the support they needed to have a successful, empowering, and fulfilling labor and vaginal birth, despite the less than optimal circumstances. 

 

The first thing I did for Sarah was get her out of that bed!  At that time all of the portable telemetry monitors were in use by other patients (unfortunately we only have a few on the floor) so I couldn’t let her walk the halls.  But I explained that I could let her go as far as the cords would take her; basically she could sit in a rocking chair, stand at the bedside, and take “unlimited” trips to the bathroom for as long as she wanted (my own personal way of getting around the continuous monitoring.)  Sarah said she was most comfortable in the rocking chair since her back was bothering her in bed. (I bet!)  She reported at that time that the contractions mostly felt like “bad menstrual cramps.”  The next few hours I was in and out of the room since Sarah and John had things pretty much under control and I do believe that couples deserve privacy.  They were really cute together I have to admit.  While Sarah was rocking John was reading her poetry out of one of her favorite books.  It turned out to be the perfect amount of distraction for Sarah.  And Sarah did say to me that being in the rocking chair made her feel like she was actually “doing” something, as opposed to “just sitting in bed.”  Isn’t it interesting how just getting a mother out of bed can change her perspective for the better!

 

Over the next few hours I titrated the pitocin up or down depending on how frequent her contractions were coming, how Sarah told me she was feeling, and how strong the contractions felt when I palpated them.  Since we had talked extensively about her birth plan, I let Sarah know that Dr. F was planning on coming in around 2:00pm to check on her and break her water and that she had the right to refuse that procedure.  I explained to her that it was not an unreasonable request to ask him to wait.  I also told her that despite what Dr. F would probably say, it was NOT going to “slow down her labor” if she wanted to wait until she was more active, maybe even 7 or 8 centimeters, or just wait until her water broke on its own.   I also told her that I would support her decision and “stick up for her” with Dr. F, but that she was the one that had to tell him what she wanted first.  If not, it just makes the nurse look “pushy” and the doctor is less likely to abide.  

 

At 1:30pm, right on schedule, Dr. F came into the room.  After some quick small talk he asked Sarah to get into the bed so that he could perform a vaginal exam and break her water. 

 

Sarah: “Umm, I was hoping we could wait a little bit longer to do that, until I am in more active labor.”

 

Dr. F: “Well, if I break your water it is really going to rev things up and put you into active labor.”

 

(Side note:  Dr. F is just plain wrong.  He, like so many mislead obstetricians, was utilizing his own anecdotal evidence instead of scientific research when he made his claim that amniotomy would “rev up” her labor.  A 2009 landmark study published by the Cochrane Database of Systematic Reviews concluded (after reviewing 14 studies involving 4893 women),“There was no evidence of any statistical difference in length of first stage of labour [between the amniotomy alone vs. intention to preserve the membranes group].  Amniotomy was associated with an increased risk of delivery by caesarean section.  On the basis of the findings of this review, we cannot recommend that amniotomy should be introduced routinely as part of standard labour management and care.”  This study hangs in the doctor’s lounge at my hospital and I have actually shown it to quite a few physicians who believe in early and routine amniotomy.  And they ignore it and do what they want anyways.  It’s infuriating!  It’s like they only care about research that supports what they already do and if it goes against their practice, they pretend it doesn’t exist!)

 

Sarah: “I’d really rather wait.”

 

Dr. F: (visibly frustrated) “Well I at least have to check you!”

 

(Oh lord, I love the “have to”!)  Dr. F’s exam revealed that Sarah was 4 centimeters!  Yay!

 

After helping Sarah to the bathroom and back to her rocking chair, I stepped out the catch Dr. F at the desk.  “Thanks for holding off on the amniotomy, it was really important to her birth plan,” I said, trying to “smooth things over” and (gently) remind him that the patient was in charge!  “Yeah well I’ll be back around 4:00pm to check her again and if she hasn’t made any progress I am going to break her water,” he said, grudgingly. 

 

He started to walk towards the elevator but then turned around to me and said:

 

Dr. F: “You have the pit at 20 right?”

 

(Note: The way pitocin is administered for induction in my hospital (and many others) is that you start the pitocin at 2mu/min (or 6mL/hr) and increase by 2mu/min every 15-30 min (or more) to a maximum of 20mu/min (or 60mL/hr) until you obtain an adequate contraction pattern (or, 3-5 contractions in 10 minutes).  So what does that mean?  That means that you do NOT just crank the pitocin until you get to “max pit,” rather you TITRATE it until you get 3-5 contractions in 10 minutes that are palpable and are causing cervical change.  Bottom line is everyone is different.  I personally could take a whole box of Benadryl and not so much as yawn while my husband can take one tablet and all but hallucinate!  It is no different for pitocin.  Some people are extra sensitive and only need a little bit, and others tolerate “max pit” very well.  I seem to have this same “fight” with physicians all the time at work.  They insist you “keep cranking the pit” when all you are going to do is hyperstimulate the uterus and cause the baby to go into distress.  But I digress….)

 

Me: “No, I have her at 10mu/min.”

 

Dr. F: (sarcastically)  “What!?  What are you waiting for?! 

 

Me: (said while biting my lip so I didn’t say something I would regret)  “She is contracting every 2-3 min and they are palpating moderate to strong.  She has to breathe through them.  And the baby is looking good on the monitor.  I want to keep it that way!”

 

Dr. F:  “But she’s not going anywhere!  You have to keep going up if you want her to progress.”

 

Me: “But she has changed to 4 centimeters…”

 

Dr. F:  “I was being generous!”

 

Me: “So you lied…”

 

Dr. F:  (annoyed) “Listen, keep going up on the pit, even if she is contracting every 2-3 min.  They aren’t strong enough.  Keep going up.  If we hyperstimulate her, we can just turn the pit down.”  (Note: These were his exact words.  I know this because I was so flabbergasted that he said it, I wrote it down in my notebook that very moment!  The fact is sometimes the baby is in so much distress after hyperstimulating the uterus that just turning the pitocin down isn’t enough!  And it really bothers me when doctors start sentences off with “Listen…”  Grrrrr.)

 

Me:  (jaw dropped, completely dumfounded) If I turn the pit up anymore, I am GUARANTEED to hyperstim her.”

 

Dr. F: “We’ll cross that bridge when we get to it.  I’ll be back around 4:00pm.”

 

By this point I was more than annoyed with Dr. F.  I explained the situation to the charge nurse and told her that I would not be cranking the pit on room 11 unless Dr. F wrote me an order that read “Regardless of hyperstimulation or contraction pattern, continue to increase pitocin until the maximum dose is reached.”  (By the way, he wouldn’t’ write me that order.)  She basically told me to do what I felt was right because it was my license at stake too.

 

So since I had her blessing, I kept the pitocin at 10mu/min.  By this point about a half an hour had passed and I went to go check on Sarah in her room.  When I entered I noticed that Sarah was breathing pretty hard during contractions and John was no longer reading poetry.  In fact, John looked like a deer in headlights.  “The contractions feel so much stronger since the doctor examined me!” said Sarah.  “That’s great!” I said reassuringly.  “I think I want my epidural now,” she said as she breathed through a contraction.  “Where are you feeling the pain the most?” I asked.  “In my back, my back is killing me!” she said. 

 

Let me digress for a moment to explain my three rules regarding epidurals: 

 

#1  You can’t ask for an epidural during a contraction.

#2  If you say “I think I want,” we need to try something else first.

#3  You can’t ask for an epidural if you are lying or sitting in bed.

 

If one of the three circumstances above is present, I have two techniques that I employ:

 

#1 The 3 Contraction Technique:  You have to try at least one position change for three contractions first and then we reevaluate how you feel.

 

 

#2 The 15 Minute Technique: You have to try at least one position change for 15 minutes first and then we reevaluate how you feel.

 

Since Sarah said “I think I want” it was important to try something new first J.  I always explain to my patients that epidurals pose higher risk of cesarean section the sooner they are given in labor and I did reiterate this to Sarah.  In my opinion epidurals and pain medication should only be a last resort when everything else in my bag of “nonpharmacological comfort” tricks has been tried.  She agreed to the “15 Minute Technique” so I (finally) obtained and attached her to a portable monitor, got her on her feet, showed her how to drape her arms over John’s neck as if they were slow dancing, and the showed her how to sway/squat during a contraction.  While Sarah and John were “dancing” I was rubbing lavender Bath and Body Works lotion on her back and applying counter pressure to her sacrum to relieve her back pain during a contraction.  And guess what…Sarah slow danced for TWO HOURS!  She had definitely drifted off to Laborland, where time does not exist and you take life one contraction at a time J.

 

“I’m starting to feel more pressure in my bottom like I have to poop,” she said.  What a great sign!  I explained to Sarah that eventually that pressure would not only be felt during contractions but between them as well.  Sarah was getting tired so we tried some kneeling on the bed for about a half an hour while John rubbed her back.  Around 5:00pm Dr. F sauntered on in to check Sarah and as he had said he would earlier.  All that hard work certainly paid off, Sarah was 6-7 centimeters dilated!!  “I need an epidural now!” Sarah assertively told Dr. F.  “Okay sure!  I’ll write the order.  But first I am going to break your water,” he replied.  So I took a deep breath and with my best impression of an adorable puppy dog I cheerfully asked, “Could we please wait until she has the epidural in place first before you rupture her Dr. F?  That way she won’t be leaking all over herself as she is hunched over for the epidural?”  (Sometimes you gotta do what you gotta do!)  Surprisingly he agreed and after he left the room I helped Sarah to the bathroom to pee. 

 

However, it turned out that at that time, another patient was in the operating room for a cesarean section and there were two other patients “in line” for epidurals before my patient was.  And since we only have one anesthesiologist in house and no others were available to come in, Sarah would have to wait.  I explained all of this to her and showered her with support and encouragement regarding how far she had come, how much work she had done, and how she could make it any amount of time longer until she got her epidural because she was a strong woman!  I don’t know how much of it she bought at that point in time because she was really really uncomfortable but regardless I couldn’t get her an epidural “now” so she would have to wait anyhow!

 

The next two hours or so (yup, the cesarean ran long and with two other epidurals in line, it took anesthesia two hours to get to Sarah) were spent walking around the room, hands and knees, side lying, kneeling, hunching over the counter, etc etc etc.  By this point Sarah was almost at her breaking point so I offered up one final suggestion: Let’s sit on the toilet.  Although skeptical at first, Sarah finally agreed to give it a chance and for the last 20 minutes before anesthesia arrived Sarah sat on the toilet, rocking back and forth.  (Turns out skeptical Sarah actually liked sitting on the toilet.  I asked for her to just give it “three contractions” and then we could get back to bed.  After three contractions she asked if she could just stay there until anesthesia came!  Hmmm, maybe this L&D nurse actually does know a thing or two J

 

By this point it was 7:00 pm.  The anesthesiologist had to poke Sarah twice to get the epidural in the right place, (Which happens a lot!  That’s another risk!  They are working blind after all!) and so we were not completely done with the epidural until 7:45-8:00pm.  I propped Sarah up on her side with a bunch of pillows, put the baby back on the monitor, shut off all the light and tucked her in.  She was snoring before I could leave the room.  At least she can take a little nap before she has to push, I thought to myself.  But what do you know, about 15 minutes later Dr. F came barreling down the hall.  I saw him coming so I jumped from the desk and said “Are you going into room 11? She just JUST feel asleep.  Please can we let her sleep for a bit?!”  No luck.  “What?!  No, I HAVE to break her water.  This is getting ridiculous now, its 8:00 for goodness sake!” he barked.  So I hung my head like Charlie Brown and followed him into the room.  He flipped on all the lights (is that really necessary) and Sarah sprung up from her sleep.  The good news however was that Sarah was 8 centimeters!!  I reluctantly passed the amniohook to Dr. F and he ruptured Sarah’s membranes.  Clear fluid…good!  I took the opportunity to change all the bedpads under Sarah and turn her to her other side.  “I’ll be back in a hour to check you again”, said Dr. F as he brushed out of the room.  I encouraged Sarah to take the next hour to try to rest as much as possible (no TV or talking on the cell phone!!) and went back out to the desk. 

 

As 9:00pm approached, I started to get a pit in my stomach.  I had a gut feeling that Sarah was probably going to be fully dilated when Dr. F came back and I was worried that because he wanted to get home (Sarah was his only patient on the floor) he would rush her into pushing before she could feel her bottom and we would end up with a cesarean section for “failure to descent.”  So at 10 minutes to 9:00pm I took a chance, went into Sarah’s room, and said the following:

 

“I remember reading in your birth plan that even if you are fully dilated you would like to wait until you feel the urge to push before you start the pushing phase.  Is this still true?  (Both Sarah and John answered yes.)  Okay, how are you feeling right now?  Do you feel the urge to push when you have contractions?  (Sarah told me that she couldn’t feel much of anything and did not have the urge to push).  Okay, so basically what I am trying to say is that I think it is a totally reasonable request to want to wait until you can feel the urge to push.  So when Dr. F comes to check you, if you are fully dilated it is okay to ask him to shut off the epidural and give you some time to start to feel the urge to push.  You don’t have to start pushing right away.  In fact, if you do, you will probably push for WAY longer than you have too.  I will back you up.   I know it sounds scary to shut off the epidural but trust me, pushing isn’t going to be so scary because you can actually DO something about all these contractions and pushing when you can feel the urge is a lot easier.”

 

Both Sarah and John agreed.  I had said my peace and turned to leave the room but at that time in came Dr. F.  He checked her and what do ya know, she was fully dilated!!!  (But still at a zero station).  “Okay, let’s start pushing!” he said as he pulled over the delivery table.  “Umm, I don’t really feel anything yet so can I wait until I can before we start?”  My whole face lit up with excitement; I was SO proud of Sarah for advocating for her birth plan!  So then I chimed in, “It’s part of her birth plan, Dr. F, can we shut off the epidural and give her at least an hour before you check her again?”  “Well let’s see how she does first,” he said annoyed, and asked Sarah to give him a “practice push.”  Thankfully this convinced him that she certainly could not feel her bottom and he agreed to come back in an hour.

 

The best part was that after Dr. F left the room John turned to me and said “Wow, did you call that one or what!”  I have to say it made me feel better that someone noticed how predictable doctors can be J

 

I shut off the epidural and for the next hour sat with Sarah and John and coached them through transition.  Although nauseous Sarah never threw up, but the pressure in her rectum was certainly getting more intense for her.  We worked on breathing for about 30-40 minutes and the last 20 minutes I showed her how to grunt during contractions and do little baby pushes to relieve some of the pressure she was feeling.  And then she said the magic words “I think the baby is coming!”  Those words ring like a choir of angels to my ears!  As I was leaning towards the call bell to page Dr. F into the room, the door opened and it was him.  He checked her and with a look of surprise said “Wow! You are a plus 2 station now!  You have done a lot of work in here!!”  I was smiling so big I thought my cheeks were going to explode! 

 

Sarah felt more comfortable pushing on her left side so John supported her right let while I supported her neck, applied cold washcloths to her forehead, and offered sips of cold water. 

 

At 10:45pm after only 37 minutes of pushing, Sarah (a first time momma) gave birth vaginally to Elizabeth Joy, weighing in at 9lbs 1 oz!!  She had a second degree perineal tear that required only a couple small stitches and never required an episiotomy, forceps, or vacuum extractor.  Sarah spent the first hour skin to skin with Elizabeth and got a great start with breastfeeding.  I only wished that I didn’t have to leave at 11:30pm and could have gotten to spend the whole 2 hour recovery time with them.  I left the hospital that night exhausted but empowered, drained but excited, and so incredibly proud of Sarah and John for sticking to their convictions and advocating for their birth experience.  I must have said to her a million times through my tears of joy, “You did it!  You did it!  You did it!” 

 

It is such a shame that it takes so much energy to fight for your right to your own birth experience during a hospital birth.  I think the mix between Sarah, John, & I was a great one, yet it still took a lot of effort on everyone’s part to avert unnecessary interventions and protect their birth plan.  And unfortunately, it was all made much more difficult starting from the very beginning when Sarah was scheduled for an UNNECESSARY LABOR INDUCTIION.  I thank God that Sarah ended up with a rewarding and empowering vaginal birth but things could have taken a turn towards CesareanTown at any point along the way, NOT related to natural labor, but related to INTERVENTIONS. 

 

The morals to the story are this:

 

1)     Remember LABOR & BIRTH are natural, INTERVENTIONS are risky, NOT the other way around.

2)     Even if you are planning on an epidural, uncontrollable circumstances may require you to labor without one for longer than you thought and therefore labor and birth preparation, whether it be reading books, taking a class, hiring a doula, or talking with other moms, is just as important if you are planning for an epidural as if you were planning for a natural birth.

3)     If you have had a healthy, uneventful, normal pregnancy up until your 37th week and your baby has a reactive non-stress test it is important to seriously question your doctor or midwife if they are suggesting, offering, or pushing a labor induction for you.