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?”
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.”