The other day I had the privilege of taking care of a couple who was in labor with their first baby. Denise, a G1P0 at 41 weeks and 3 days, broke her water at 1:00am with contraction starting about 8-10 minutes apart at 4:30am. She and her boyfriend, Ralph, labored at home until about 8:00am when the contractions were coming about every 3-5 minutes apart. When she arrived to the hospital at 8:30am, a resident’s vaginal exam revealed that she was 3cm/50%effaced/-3 station!! Since she was a young healthy woman (her health history only comprised of PCOS, or polycystic ovarian syndrome) and had had an uncomplicated, normal, healthy pregnancy, she was “allowed” to ambulate in the halls all morning but required to stay on continuous telemetry monitoring and not allowed to labor in the tub per her physician’s direct order.
(Side Note: This particular physician, Dr. O, is an older physician who is part of a group that is well known for aggressive labor management. They induce almost all of their patients for one reason or another, often once they hit 39 weeks, and if a patient is not already ruptured once they get to the hospital, they will artificially break their patients’ water regardless of dilatation. That’s right, I have personally refused to give them an amniohook when a patient is only 1 or 2 centimeters and they sneak in the room without me and break her water anyway! One time, Dr. U (another doctor in that group) ruptured a patient who was still in triage! They are notorious for setting up “post dates” inductions at 40 weeks and 1 day and although they advertise that they attend VBACs, their statistics show something quite different: Almost NO “successful” VBAC vaginal deliveries and a cesarean rate that is at least 40%. Myself and many other nurses have bombarded them with research and position statements from a variety of sources, including their OWN association (American College of Obstetricians and Gynecologists, or ACOG)) that states intermittent auscultation is the standard of care for low risk, uncomplicated pregnancies, but they refuse to listen. So Denise’s situation is unfortunately not uncommon. To be honest, I am surprised they “let” her get past 41 weeks! I think they view it as a slap in the face to attend any delivery after 40 weeks!)
When I came on at 3:00pm, Denise was in the middle of getting an epidural. Turns out that at 12:30pm, Dr. O’s vaginal exam revealed that the patient was “only” (his words) 4cm/80%/-3 so he ordered pitocin augmentation and the pit was started at 1:00pm. Although the patient had originally told the nurse it was her plan to labor without an epidural, pitocin lead to stronger, longer, and closer contractions which lead to the patient requesting one. And an epidural was granted. For the next 3 hours I was instructed to continue to turn up the pitocin to obtain 5 contractions in 10 minutes. I titrated appropriately until I obtained moderate to strong contractions (per my palpation) every 2-3 minutes, where the baby was still looking good on the monitor. I changed the patient’s position every 30 minutes: right side, sitting up high, left side, sitting up high, etc. in hopes that I would help the baby makes his way down the birth canal and not get “stuck” in any acynclitic position. (According to the patient, she was complaining of severe back pain the last few hours so I was concerned about an occiput posterior baby. So since Denise could no longer move herself to help move the baby, I was doing the moving for her!)
At 7:00pm Denise was feeling a lot of rectal pressure, so much that she was breathing through it (even though the epidural was still effective at taking away her back and abdominal pain). We all were very excited!! Since Denise was only feeling rectal pressure during contractions I told her it would be best to wait until she was feeling rectal pressure at all times, with our without a contraction, before we called the doctor. Well Dr. O must have had ESP because he came into the room to perform a vaginal exam. His exam revealed that Denise was 4cm/100%/ -1 station! The patient was a bit disappointed that she was still only “4cm” but I assured her that he was completely thinned out and that she had brought the baby down a whole bunch! However, Dr. O had a different take on it, “You are still only 4cm, he said, “And if you don’t make any significant progress within the next hour we will have to talk about a change in the plan.” (Could he have BEEN any more vague?!) And then he turned around and walked out. “What does he mean by change of plan?” Denise asked me. “Well I’m not sure,” I said back, “let me go find out.”
The fact of the matter is that I knew exactly what Dr. O meant….he meant that he was going to do a c-section. But I didn’t want to tell her that for two reasons, 1) it is NOT my responsibility to tell a patient that someone else is going to perform a cesarean section on them, it’s the SURGEON’S responsibility, and 2) I hate even talking about the possibility of a cesarean section when someone is in the middle of labor because it is like you are telling the patient you are already “giving up” on them. Of course I understand that some cesareans are necessary, but I know that if I was in her position and someone gave me a “cesarean ultimatum” during labor, I would feel like people were giving up on me! I mean here she is, basically being given a one hour ultimatum, and because of the limitations of the epidural it is not even like she can “do” something to play an active role: she can’t walk around or get in the tub, we’ve already got her hooked up to pitocin and an epidural, we’ve already tried the position changes, her water is already broken, and I am pretty sure she doesn’t know magic. So here I am feeling like my hands are tied, but trying to stay positive and encouraging so that the patient does not feel upset, passive, defeated, or worried. Because those emotions do NOT facilitate labor, and in fact, those emotions can actually release hormones in your body that directly work AGAINST labor.
So I walked out to the desk to find Dr. O but he had already left. (I don’t think he went very far, maybe into another patient’s room, but nonetheless, he was no where to be found.) I felt an obligation to tell Denise something so I went back into to the room and said this:
Me: “Denise, I think Dr. O is with another patient right now but once I find him, if you would like, I can ask him to come back in to answer any questions you might have.”
Denise: “Yeah, I would like him to come back in because I don’t want a c-section.” (starting to get a bit teary eyed) “I mean, is that what he meant by change of plan? Can they give me any other medicine to help with my contractions?”
Me: “Well I don’t know what he meant exactly but he could have meant he would like to try an IUPC which stands for intrauterine pressure catheter. It is a thin tube that lies beside the baby’s face and actually measures in millimeters of mercury how strong your contractions are. If I have an IUPC, I might be able to go up on the pitocin if the contractions aren’t “strong enough.” Right now the external monitor only tells me when they are coming and when I feel your belly it is all subjective. Unfortunately there isn’t any other medicine we can give you to help “speed up” labor besides pitocin. He could also have meant a cesarean. But we won’t know until we talk to him.”
Denise: (almost in a scared tone) “But I don’t want a c-section! I want to push my baby out! Oh I don’t want a c-section!”
Me: (feeling like I wish I could help but don’t know how) “Well let’s talk about what you can do. If Dr. O comes in to check you, you have the right to refuse his vaginal exam and request more time. You also have the right to ask him about all of your options, if there are any, besides a cesarean. You have the right to ask him his reasons for why he thinks a cesarean is necessary. You have the right to hear all that information and then take as much time as you need to decide what you would like to do. If you need some alone time with Ralph or if you need to call your mom or any other family members you have that right. I just want you to know that if you and Dr. O decide together that a cesarean is the best option, it will NOT be an emergency and therefore you can take as much time as you need to prepare. The baby is not in distress and in fact, has looked beautiful on the monitor all day. If you both decide that a cesarean is the right course of action, I promise I will go over everything to expect with you, I will make sure anesthesia sees you before you get to the OR so you can ask them any questions, and barring any other emergency, I will be with you the entire time, from the moment I wheel you in to the OR, to the moment I wheel you out of the recovery room. I’ll help you breastfeed as soon as possible. I will stay with you the whole time…”
At this point I was starting to get a bit emotional and realized I was rambling so I excused myself and went out to the desk. I just knew in my heart what was going to happen and I was deeply saddened by it. And don’t get me wrong, I am not trying to be overly dramatic but I just knew that when she broke her water at 1:00am and came to the hospital at 3cm, she was not expecting to end up with a cesarean.
Well exactly one hour later Dr. O came back into the room to do a vaginal exam. I turned towards Denise and I said, “Is that okay with you, Denise?” and she said “Yes.” According to Dr. O, Denise was still the same and had made no “progress.” Dr. O, while standing at the foot of the bed, looked up at Denise and said “Well Denise, we’ve run out of options here. If we continue to keep you on pitocin eventually the baby is going to run out of gas and crash. Uteruses can only take so much and your uterus is going to get thinner and thinner and will be at risk of rupturing if we continue like this. You have essentially been 4cm for 7 hours and for a primip, you need to progress at least one centimeter an hour. We need to do a cesarean and as soon as I tell the charge nurse we’ll get going on it.”
At this point Denise burst into tears, “OH GOD, BUT I DON’T WANT TO HAVE A C-SECTION! I WANTED TO PUSH HIM OUT! I WANTED TO PUSH HIM OUT! I REALLY THOUGHT I COULD DO IT! I WANTED TO DO IT! I WANTED TO PUSH MY BABY OUT!” Ralph gave her a big hug and I kept squeezing her hand trying to bit my lip so that I didn’t start to cry myself. She was sobbing. And then Dr. O said “Listen, Denise, there is no reason to get like this. I mean, when you came to the hospital this morning I also had 4 other patients that came in around the same time. Everyone else has already delivered…you’re the only one left. And some women even came in with cervixes more closed than yours. You see, the baby just isn’t coming down enough in the birth canal to dilate your cervix, and it’s just a failure to progress. It’s just failure to progress that’s all.” Then he turned to me and said “As soon as I tell the charge nurse we’re going to go.” So then I said, “Well I am not at all ready to go yet. And I think she deserves a minute to come to terms with all of this, Dr. O. She deserves some time to make her decision and call her family.” And then Dr. O looked straight at me, baffled, said “Whatever” and then stormed out slamming he door behind him.
I threw myself onto Denise and have her the biggest hug I could. I whispered over and over in her ear, “You are NOT a failure Denise, I know you wanted to push him out. I know you did. You have done so much work today and you never gave up. You are a strong woman, Denise, you did not fail and your body did not fail. NOBODY is a failure here. It’s okay to cry. It’s okay to cry, Denise. Please know you did so much for your baby and you never gave up. You are a strong woman…”
I stayed there for about 10 minutes with her and Ralph, letting her cry. When she calmed down a bit I encouraged her to take her time to talk with Ralph and call her mother or family if she needed too. I told her that I needed to get some things ready and that I was going to give them some privacy.
So by this point I was pretty upset. For one, I think the way Dr. O went about the whole thing was so cold and insensitive. Um hello, do you think telling a patient that “everyone else” has already delivered is going to make them feel better!? Because in my opinion, it just stresses the insane notion that her body is in someway a “failure.” I could mull over and over and over again in my head everything that surrounded this whole situation and I have almost made myself sick over wondering if this was really a necessary cesarean for “true” arrest of descent/dilatation. But regardless, I feel like he completely took Denise and Ralph out of the whole process and it should have been handled better. Second, Dr. O did NOT go over the risks and benefits of the cesarean with them, claiming later that the residents “review that” on admission (which, by the way, they don’t…they just have everyone sign a consent for “vaginal delivery possible cesarean section”). Third, Dr. O did not at all go over other options besides cesarean, and even if he thought the safest course of action was a cesarean at that point in time (which I am not disputing), he didn’t even say anything like “and our other options, X, Y, & Z, are not the best course to take because of A, B, C, so it is in my professional opinion that the safest course of action is to perform a cesarean section. But please take your time to talk it over.”). I have seen other doctors do this before. Even in situation where everyone agrees that a cesarean is absolutely necessary, it is still the patients right to make the final decision. And finally, he didn’t even give them a chance to talk it through and when I asked for “some time” he got pissed.
So I walked out to the desk to get my paperwork ready and Dr. O was writing a note in her chart:
Dr. O: (sarcastically and not even looking up from what he was writing) “So when do you think you’ll be ready to go?”
Me: (frustrated) “It’s not about me being ready, it’s about Denise and Ralph being ready! I think it is more than just a courtesy to allow them some time to come to terms with this new development. They have a RIGHT to some time, Dr. O. This isn’t an emergency. The baby has looked great on the monitor all day and I shut the pitocin off.”
Dr. O: (frustrated) “I don’t know why you are fighting me on this!”
Me: (increasingly frustrated) “I’m not fighting you on ANYTHING Dr. O, but you have to understand, she is devastated that she is going to have a cesarean. We owe it to her to let her calm down and not wheel her down the hall as a sobbing mess! Her whole family lives in a different state, including her mother, and I think that it isn’t too much for her to ask for some time to call her family before she goes in for MAJOR ABDOMINAL SURGERY!”
And then he said it….he said that phrase that breaks my heart every time I hear it…
Dr. O: “She’ll forget all about it when she is holding a baby in her arms.”
This phrase comes in many forms but every one says the same thing, “All that matters is that you get a baby out of this deal… and your experience, your experience doesn’t matter.”
Kristen, a doula, graduate student, mom, and author of the blog Birthing Beautiful Ideas wrote an amazingly insightful and moving must read post entitled, “Scars That Run Deep: ‘All That Matters’ After A Cesarean” that explores this very topic.
“You have a healthy baby. That’s what matters.”
Mothers who express sadness, anger, or disappointment after undergoing a cesarean section often hear these words uttered by (presumably) well-meaning family, friends, and health care workers. In fact, these words seem to be one of the most common responses that people give upon hearing that a mother has had a cesarean. I presume this is because it can be jarring to witness the juxtaposition of the joy and wonder of a newborn life and the mother’s grief over her baby’s entrance into the world. And so, particularly in a culture that does not have a well-developed ritual for expressing and experiencing grief, people try to fill up the mother’s “empty grief jar” with an elixir of “healthy baby joy.” But, as we all know, grief and joy don’t work like that.
Kristen goes on to write about why having a healthy baby isn’t “all that matters” after a cesarean, the concept of mourning the loss of a vaginal birth, and why a mother’s birth experience IS part of “what matters” regarding the entire childbirth experience. Kristen also outlines step by step details about what a mother experiences when she undergoes a cesarean, from the minute the wheel her into the operating room to the first time she gets to hold her baby to caring for a newborn after major surgery. Kristen writes,
In addition, the de-valuing of the mother’s birth experience–a de-valuing implied by the “healthy baby line”–undermines the significance of one of the most transformative days of a mother’s life. For on the same day that her baby is born, she is “born” as a mother. And if this dual-birth is marked by passivity and separation, then it is no wonder that the mother grieves her birth experience. That having her healthy, miraculous, wonderful baby is not all that matters to her.
In fact, her sadness is partially a result of being separated from her healthy, miraculous, wonderful baby during the first few moments and even hours of that baby’s life. And it can be the result of a feeling that her body is “broken,” “unable” to bring her child into the world on its own. And it can be the result of a feeling that her body might not even “know” how to work properly to bring a child into the world. And it can be the result of feeling as if she has disappointed not only herself but also her partner and/or other friends and family. And it can be the result of the sheer difficulty of recovering from major abdominal surgery and simultaneously caring for a newborn baby, two of the most physically and emotionally demanding experiences that any person will ever undergo.
In other words, her sadness and her grief are understandable. They are normal.
Please check out Kristen’s post in it’s entirety on her blog. The excerpts I have provided here are only a small piece of this very eye opening composition.
In the end Denise gave birth to her 9lb 8oz baby boy, Rayne Nicolais, by cesarean section at 9:01pm. Baby Rayne was found to be in an occiput posterior position and still very high in the pelvis when he was born. I had the opportunity to stay with Denise, Ralph, and Baby Rayne for the entire experience and with the help of a ton of pillows, Denise breastfeed Rayne skin to skin in a football hold for an entire hour and 15 minutes in the recovery room. And boy was he a vigorous breast feeder!!
Although all in all, there was a positive outcome to Denise’s birth experience, I do wish that for Denise and Ralph, things could have turned out differently. I wish that Denise could have PUSHED her baby out like she so desired and worked so hard for. And of course I am grateful that at the end of the day Baby Rayne was a happy, healthy, chubby, bouncing baby boy. In the recovery room where Denise really held her baby boy for the first time, she welled up, looked at her boyfriend and said, “I think I am falling in love all over again!” It was so beautiful! As a nurse, experiences like this solidify what I feel in my whole being is true about pregnancy and childbirth; That the journey is as important as the destination.
In closing I would like to leave you with one of my favorite quotes…
“It’s not just the making of babies, but the making of mothers that midwives see as the miracle of birth.” ~ Barbara Katz Rothman.