Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

A Very Inspirational Update March 30, 2010

This one is for all you VBAC mommas out there!!!

In October of 2009 I posted a letter sent to me by Kelly, a mother who, at 35 weeks of pregnancy, was startled, hurt, confused, angry, and scared to find out that her supposedly VBAC friendly obstetrician was actually leading her on the whole time….

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Dear Nursing Birth,

 

I’m a day short of 35 weeks pregnant today and went in for an OB appointment this morning. My doctor said that if I don’t go into labor on my own in my 39th week that (depending on how much and if my cervix is dilated) she might put me on pitocin- although she did say that “they don’t induce labor for VBAC patients”. But that they won’t let me go to 40 weeks, and that by 40 weeks they will have to schedule another c-section for me. (I live in Cedar Falls, IA)

 

I am shocked and angry! First of all- since when is 40 weeks, too late? My OB says it’s not wise to go to beyond 40 weeks due to increased risk of uterine rupture. But this just sounds like B.S. to me!

 

And how does the doc get away with not telling me something important like this until NOW? Unbelievable!!  My doctor and I have already gone through my birth plan, line by line, because I want as few interventions as possible and no drugs, seeking a natural vaginal childbirth. I’ve taken 12 weeks of Bradley method birth classes to help my husband and I be better prepared this time.  I also have a fantastic, knowledgeable, and supportive doula. But I can’t believe what a fight it is to have a VBAC!

 

If I had known sooner that this was the doctor/hospital policy for VBAC, I probably would have gone somewhere else. Since it’s so late in the game now, I’m probably going to stick it out. I don’t have to do anything they say, I can always stay at home and come in when I’m ready, and that will be after I am already in deep labor on my own.

 

I was just wondering if perhaps this reflects a change in my hospital’s policy for managing VBAC? One of the other OB’s I met with at the hospital said that after a high maintenance VBAC patient a few months ago (who also insisted on a natural vaginal childbirth, and did it, but most of the hospital staff were very unhappy dealing with this patient…?) that the hospital is reviewing whether to allow VBAC at all. I’m probably not helping the situation by openly trying to avoid their planned interventions. I KNOW I’m required to have continuous electronic fetal monitoring… but I’ve also been told that my labor has to be pretty much “text book” regarding continuous dilation of my cervix, and of course no tolerance for fetal distress…or else!

 

I just wish all women would know this before their first c-section. If you thought recovering from a c-section was bad, wait till you try to have a VBAC and deal with the red tape and lack of support from the medical community. It’s just so frustrating to have to be prepared to battle, and yet relax at the same time! 

 

Have you heard of this kind of change in management of VBAC? That VBAC isn’t even allowed to go to 40 weeks?? Thanks for writing such an informative, educational blog and for being so supportive of natural childbirth! I have enjoyed your tips and insight from the hospital perspective (about writing birth plans, and managing your OB, and also the many ways hospital staff really will be supportive- even if you barf!).

 

Sincerely,

Kelly

 

 

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I replied to Kelly in my post entitled “The Ol’ Bait and Switch, OR Finding Out Your OB Has Been Leading You On” with words of encouragment and some information about other scare tactics that some health care providers use to intimidate VBAC planning mommas.  My main message was this:

“You deserve the opportunity to have the unmedicated, intervention-free birth that you have planned for.  Your desires for said unmedicated, intervention-free VBAC are well supported by the research.  You deserve to be cared for by a birth attendant who shares your philosophy regarding (among other things) childbirth and VBAC.  You deserve to NOT have to worry about fighting anyone to be given a fair chance at having the birth you have been planning…not the hospital, not the nursing staff, not your obstetrician, NOT ANYONE.  You deserve it for THIS birth. “

 

Fast forward 4 months.  I was struggling with the thought of returning back to blogging as NursingBirth.  I was working for a hosptial with a 40% C-section rate.  I was feeling powerless.  Until I saw this in my inbox…..

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Hi Nursing Birth!

Hope you still plan to come back after you settle in from your move- we miss your great posts!

 

Also, just wanted to say thank you -again- for posting about my comment awhile back!  I wanted to update you and tell you that I had a successful VBAC!  Thanks for your suggestions, resources, and support!

 

You can read my story over at my blog:  http://chun-beeks.blogspot.com/2009/12/happy-birthday-john-carl-fischer.html

 

Hugs and best wishes,

Kelly

 

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Needless to say I was touched, proud, empowered, honored, and ESTATIC!!!   There is no doubt in my mind that Kelly’s email was a main factor in my decision to return to blogging as well as take the plunge and start yet another new job!  So thank you Kelly for being just as much of an inspiration to me as I was to you!!!  I am so lucky to be a part of this awesome community we call the “birth blogosphere” 🙂

Congrats again Kelly!!  You rock!!

NursingBirth

 

No Doula in the Name of Privacy? Oh Come On! September 26, 2009

This comment was recently left by a reader named Jessica under one of my older posts.  Since I read every comment that is posted on my blog I happened to stumble upon it this morning.  When I read it I couldn’t help but think “I Hear Ya Sister!!!”and felt that it was so well stated that it needed to be its own post!  I know that there are quite a few doulas out there that read my blog and I just wanted to take this opportunity and give a shout out to them all and say thank you for all you try to do to educate women before they get to me on L&D!  Unfortunately, they don’t all listen but I hope you know that there is at least one L&D nurse out there that appreciates your efforts, both before and during labor!!!

 

For all you expecting moms out there please check out DONA’s website to learn a bit more about what a doula is, how you can find one, the effects a doula can have on your birth outcome and experience, and how a doula can advocate for you!

 

And just for the record, there is NOTHING private about a hospital birth experience.  Even in the most well meaning hospitals with the most well meaning birth attendant and the most well meaning nurse(s).  Albeit some women’s hospital births might be more private than others and I personally have had the priviledge to be a part of a few totally amazing hospital births.  But to not hire a doula for your hospital birth (especially at a university hospital!) because you want a “private” experience is a very VERY naive and misguided idea!  I am not saying that to hurt anyone’s feelings and I am certainly not judging anyone out there who decided not to hire a doula for one reason or another.  I am just telling it like it is.  Some food for thought…

 

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Hi NursingBirth!

I am a certifying doula and have recently had an interview with a perspective client. She is 36wks pregnant with her first. She was strongly considering a doula, but everyone else in her family was on the fence, and pushing a “private” birth experience. However, they are planning a delivery at a university hospital, she has yet to see the same health care provider throughout her prenatal care, she has no idea which one will be at the birth, or if it will even be someone she has met. They are planning a natural birth. She assured me that the hospital she is birthing at offers a multitude of birth options, including water birth, birth ball, position changes, etc… and the childbirth education from the hospital has given them confidence in their ability to get what they want from this birth. After much “deliberation” they decided that they were not going to hire a doula, based solely on their confidence in the hospital to give them what they want, and their desire for privacy. While I can completely respect their privacy request, I fail to see how birthing in a university hospital will give her much if any privacy…AND if she doesn’t even know who will be her health care provider at the birth…how is she confident that the hospital will give her what she needs? I wish there was some way to help open her naive eyes to the reality of birth in hospitals today. Her chances of getting to work with a mother friendly doc that understands and respects natural birth have got to be low! Reading your blog was comforting (because I know there are others who struggle with this) and depressing(because we have to struggle with this). I don’t want to have her hire me for her VBAC next time around. I want her to have the birth she desires now. I realize there isn’t much I can do for her at this point, which is why I am here, leaving my frustration with a bunch of like minded individuals. I am hoping things will go well for her and in the mean time, I’ve let her know that I am and will be available until the baby is born. just in case. Thanks for the space to rant.

  

Sincerely,

Jessica

  

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Jessica, you can rant here anytime!!!  I Hear Ya Sister!  Loud and clear!!

 

And now I leave you with one of my FAVORITE Monty Python skits of all time.  I have seen it a million times but it is still as hilarious (and eerily true) each time I see it.  Notice how the doctor invites in an army of people to watch.  It often feels like that where I work no matter what I do!!!

 

 

The WORST Idea Since Routine Continuous Fetal Monitoring for Low Risk Mothers September 7, 2009

My husband (being the techie cutie that he is) reads CNET news, a website about computers, the Internet, and groundbreaking technology as part of his morning routine.  The other day, while I was enjoying my Kashi cereal and checking out the latest blog posts on my Google Reader, my husband hollered over to me from his office and said,“Hey Melissa, have you heard of LaborPro?”  Until that moment I was having a pretty good Sunday morning.  I mean, I woke up refreshed and smiling, the sun was shining, and I was looking forward to what I felt was going to be a “good” day at work.  But my attitude quickly turned from happy-go-lucky to blinding rage when he uttered those eight little words. 

(Okay, okay, so I think I am being a bit dramatic.  Maybe blinding rage is a bit strong.  But I was pretty upset!!)

So what is LaborPro and why did it put me into such a tizzy you ask?  According to Trig Medical’s website (the Israeli company that is developing and recently won a Frost & Sullivan Technology Innovation of the Year Award for this GARBAGE), LaborPro is “a novel labor monitoring system that using ultrasound imaging measures continuously and objectively fetal position, presentation and station along with cervical dilatation. LaborPro quantitatively assesses and records vital labor parameters in real-time to enable obstetricians to make informed and accurate decisions throughout the labor process to improve both the quality and cost of obstetric care.”

 

 

 

The website lists LaborPro’s capabilities as able to:  

  • Determine continuous station & position of fetal head by ultrasound imaging,
  • Provide radiation-free pelvimetry & birth canal modeling.
  • Perform one-step computerized “non-invasive” trans-vaginal digital examination (I’ll touch on that in moment)
  • Determine intermittent or continuous accurate measurement of cervical dilatation
  • Record comprehensive labor data recording

 

It also toutes its “unique benefits” as the following: 

  • Non-invasive, precise measurement of station & position
  • Improves assessment of non-progressive labor
  • Supports decision-making before operative delivery
  • User friendly, on-screen display of all labor parameters
  • Enhances patient comfort and sense of security

 

Okay okay okay….Just HOW does it do this you ask?  Well it’s EASY!  (*rolling eyes*)  Well according to the website’s one mintute educational video (check it out here, it’s worth it).  FIRST you have to place “just four little electrodes” externally on the mother’s pelvis in order to continuously assess fetal station and position and also enables the user to “recognize CPD early”.  SECOND you just have to clip (or screw) “just a few position sensors” to the woman’s cervix to accurately and continuously measure cervical dilation.  And THIRD you just have to screw “just a small little electrode” into the baby’s head.

Fetal Scalp Electrode  (notice the little corkscrew tip)

Close up of a fetal scalp electrode, or FSE (notice the little corkscrew tip, that screws into the baby's scalp.)

According to Frost & Sullivan, the organization that awarded Trig Medical for the LaborPro technology writes, “The LaborPro is staff and mother-friendly and requires only basic training in ultrasound usage, obviating the need for an obstetric ultrasound expert,” adds Ms. Prabakar. “Moreover, the technology employs non-invasive, radiation-free pelvimetry as well as a single-step computerised digital examination. All labor progress tracking data including the fetal heart rate monitor are integrated in the LaborPro display and automatically recorded by the system, which helps reduce staff workload.”

 

Oh great!  We only need “basic ultrasound skills” to work it!  (*double eye rolling*)  Here’s a novel idea!  How about every hospital (including my own) in the United States that has a L&D floor actually provide labor support training to their nurses instead!  That would go a lot farther for us than freaking ultrasound skills!! 

(Just for the record, my hospital does NOT include labor support training as part of orientation and we are NOT alone.  At my hospital, if you want to learn how to provide labor support you have to seek out other learning opportunites on your own, like I had to.  But we do get extensive training on how to work and interpret the fetal monitor.  Oh and about 1/3 of our three month orientation is dedicated to learning how to care for a patient who is being induced.  In fact, I had to teach myself how to do intermittent auscultation and hence, I am one of the only nurses that I work with that isn’t “scared” of intermittent auscultation and will actually advocate for it!) 

The most terrifying thing is that although at this time LaborPro is not available in the United States (Oh Hallelujah!!!) there is another company called Barnev based out of Andover, MA that has developed an almost identical product they call BirthTrack™ Continuous Labor Monitoring System which they describe as “a revolutionary continuous labor monitoring technology that provides obstetric caregivers invaluable, precise, objective, real-time information about the physical progress of labor. The BirthTrack System provides tools for a more informed decision making process through which hospitals can reduce the risks and costs of childbirth and assure the safety and comfort of mothers-to-be and their babies.”  I remember hearing about this product a couple of years ago when it was still in “development.”  Well guess what?!  Development is over!!  Marketing here we come!!  (GAG me!)

 

So now there are at least TWO companies that are actively marketing this HORRIFIC, INHUMANE, and OUTRAGEOUS product.  Just wait  until LaborPro makes it to the United States (which according to their website they are actively persuing).  Then they will probably start to compete with eachother!  Now now only will labor & delivery wards around the country have to deal with Similac and Enfamil representatives competing for our money and attention in house (which already makes me sick to my stomach), but now I have to worry about this??!!  THIS IS TERRIFYING!!!

 

I’m telling you right now, I will UP AND QUIT my job and never look back if either LaborPro or BirthTrack EVER  appears in even just one, JUST ONE of my hospital’s labor rooms.  QUIT ON THE SPOT!  And I will make a Hollywood exit too!  A HUGE scene!!!  Hooting and hollering!  You just wait!!  LOL!  As if our moms aren’t already strapped down enough with the often unnecessary and sometimes downright harmful technology we already have.  This is just TOO MUCH TO BEAR!

I have taken care of MANY a laboring woman (often as a result of an induction, mind you) who are connected to:

 (1)  an IV line with IV fluids and Pitocin running through,

(2) an electronic fetal monitor to measure fetal heart rate,

(3) a tocodransducer to measure contraction pattern

(OR a fetal scalp electrode to measure fetal heart rate and an intrauterine pressure catheter to measure contraction frequency and strength),

4) an epidural catheter in the back giving a continuous flow of anethetic and narcotic medications into the spinal column,

(5) a foley catheter in the bladder since it is very rare that one can empty their bladder with an epidural,

(6)  a pulse oximeter to continuously measure blood oxygen level (necessitated by the epidural),

(7) a blood pressure cuff to record one’s blood pressure every 15 minutes since an epidural can drop your blood pressure dangerously low, and finally

(8) if the baby has shown any signs of distress, an oxygen mask for your face!

 

Well I have a message for both Trig Medical and Barnev, LABORING WOMEN DO NOT NEED ANY MORE THINGS SHOVED UP THIER VAGINA!!!!  And furthermore,  CLIPING ANYTHING TO A WOMAN’S CERVIX OR SCREWING ANYTHING INTO A BABY’S HEAD DOES NOT COUNT AS “NON-INVASIVE”!!!  LABORING WOMEN AND BABIES ARE NOT ROBOTS THAT DON’T FEEL ANY PAIN OR DISCOMFORT!!!!  RESEARCH HAS SHOWN TIME AND TIME AGAIN THAT LESS IS MORE WHEN IT COMES TO LABOR FOR HEALTHY MOMS AND BABIES!!!  CONTINUITY OF CARE IS MUCH MORE EFFECTIVE, LESS PAINFUL, LESS INVASIVE THAN ANY “COMPUTERIZED FINGER.”

Furthermore, LaborPro and BirthTrack are a slap in the face to every labor and delivery nurse that cares about giving appropriate, effective, competent, physiological, and compassionate care to childbearing families.   Unfortunately I would bet my hard earned money that at least half of the doctors I currently work with would think that this is a good idea. 

Okay, okay, now that I am all riled up again I have to go to work  😦   Please check out Rixa’s post over at Stand and Deliver about BirthTrack.  It was written about a year ago and I stumbled upon it when I was searching for a picture of a fetal scalp electrode!!

Change has GOT to come!  It’s GOT to!  For the health and wellness of our mothers and babies!!  Remember ladies, YOU actually have more power than ME and all the other L&D nurses out there!!  That’s right!  If you do not hire birth attendants that do not support evidenced based medicine and physiological birth and do not patronize hospitals that do not support a family-centered approach to maternity care then and only then will they start to listen.  You know why?  Because when the customers aren’t comin’, it hits them where it hurts… in their WALLET!!

 

“Pit to Distress”: A Disturbing Reality July 8, 2009

Dear NursingBirth,

 

I just saw a couple of posts about “pit to distress” on Unnecessarean and Keyboard Revolutionary’s blogs. Can you comment on that as an L&D nurse?! Is the intent really to distress the baby in order to “induce” a c-section?  I’m distressed that such things may actually happen, and am holding out a little hope that it’s a misunderstanding in terms….

 

Thanks!!!

Alev

 

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Dear Alev,

 

I wish I could put your heart and mind at ease and tell you, from experience, that this type of outrageous activity (i.e. “pit to distress”) does not happen in our country’s maternity wards but unfortunately it does.  I know that it does because:

 

1) I have read and heard stories from other labor and delivery nurses who have worked with birth attendants who practice “pit to distress,”

 

2) I have read and heard stories from women (and their doulas!) who have personally experienced the consequences of “pit to distress,”

 

and, most importantly…

 

3) I personally have worked with attending obstetricians who subscribe to this philosophy. 

  

Before I start my discussion on this topic I would like to quote a blog post I wrote back in April entitled “Don’t Let This Happen To You #25 PART 2 of 2: Sarah & John’s Unnecessary Induction”.  This post is actually the first post I ever wrote for my Injustice in Maternity Care Series.  It is a TRUE story (although all identifying information has been changed to adhere to HIPPA regulations) about a first time mom who was scheduled for a completely unnecessary labor induction and the following excerpt is a good example of how “pit to distress” is ordered by physicians, EVEN IF they don’t actually write it out as an order (although some actually do!)

 

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“…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.”

  

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.  However, this is not what many physicians I work with ask you to do.   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.”

 

 

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Ladies and gentleman the account that you have just read is called “Pit to Distress” whether the pitocin order was actually written that way or not.  What Dr. F gave me was a VERBAL ORDER to increase the pitocin, regardless of contraction or fetal heart rate pattern, until I reached “max pit,” which he acknowledged would hyperstimulate her uterus.  This goes against our hospital’s policy and the physical written order that this doctor signed his name under.  However, like some other doctors I work with, none of that mattered to him.  What he wanted was for me to “crank her pit” regardless and from my experience with this doctor, at the first sign of fetal distress we would have been crashing down the hallway for a stat cesarean!

 

Hyperstimulation of the uterus (more appropriately called tachysystole) is harmful and dangerous for both mothers and babies: 

 

“If contractions are persistently more often than 5 contractions in 10 minutes, this is called “tachysystole.” Tachysystole poses a problem for the fetus because it allows very little time for re-supply of the fetus with oxygen and removal of waste products. For a normal fetus, tachysystole can usually be tolerated for a while, but if it goes on long enough, the fetus can be expected to become increasingly hypoxic and acidotic.

 

Tachysystole is most often caused by too much oxytocin stimulation. In these cases, the simplest solution is to reduce or stop the oxytocin to achieve a more normal and better tolerated labor pattern.”

Electronic Fetal Heart Monitoring” by Dr. M. J. Hughey

 

The truth, however, is that many times stopping tachysystole is not as easy as just shutting the pitocin off.  Although the plasma half-life of pitocin is about 6 minutes, it can take up to 1 hour for the effects of pitocin to completely wear off.  And for a baby in distress, one more hour in a hyperstimulated uterus is too much!  So guess what?!  The physician has two choices:

 

#1 Administer yet another drug (like terbutaline) to decrease contractions and wait and see (unlikely to happen), or

 

#2 Administer yet another drug (like terbutaline) to decrease contractions while heading to the OR for an emergency cesarean section (much more likely to happen.) 

 

Because in the end…who wants to “sit” on a compromised baby?!

 

 

What is also unsettling is that my encounter with Dr. F regarding the most appropriate administration of pitocin for that mother was downright pleasant as compared to some of the other encounters I have had with much more intimidating and hot-headed physicians.  Labor and delivery nurses all over this country (including myself) have been bullied, yelled at, cursed out, and down-right humiliated by birth attendants who want you to “keep cranking the pit” regardless of maternal contraction or fetal heart rate patterns or in general, refusing to be a part of or questioning other harmful obstetrical practices.

 

I once had an obstetrician, while in the patient’s room, call me “incompetent” in front of the patient and her entire family because I had not continuously increased the pitocin every 15 minutes until I reached “max pit” and instead, kept the pitocin at half the maximum dose because increasing it anymore caused my patient to scream and cry in pain and her uterus to contract every 1 minute without a break.  Who wants a nurse to take care of them that was just called “incompetent” by their doctor??!? 

 

Another time I had a physician (who via this program called “OBLink” can watch her patient’s monitor strips from her own home or office) call me on the phone from her house to chew me out about not having the pitocin higher.  When I explained that I had to shut the pitocin off an hour earlier and start back up at a slower rate because the baby started to have repetitive and deep variable decelerations despite position changes, IV fluid bolus, and 10 liters of oxygen via face mask, I was told that the decels “weren’t big enough” to warrant such a “drastic measure as shutting of the pitocin” and I was “wasting her time” because “at the rate [I] was going [her] patient wouldn’t deliver until after midnight.”

 

I had yet a third doctor tell me once that he wished that only the “older” nurses on the floor would take care of his patients because they aren’t “as timid” and “are not afraid to turn up the pitocin when a doctor orders them to.”  That younger nurses like me are “too idealistic” and don’t understand “how the world really works.” 

 

And yet another time I had a physician tell me that I needed to “crank the pit to make this baby prove himself either way” and that if I couldn’t do “what needed to be done” for his patient, then he would ask the charge nurse to “replace me with a nurse who could.”

 

And guess what, when I came in the next day and read the birth log, I discovered that 3 out of those 4 patients ended up with cesarean sections after I had left that night for “fetal distress.” 

 

AAAAAAHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHHH!!!

 

Although not one of these physicians actually wrote in black and white “Pit to Distress” and they didn’t have to; their words and actions speak to their true intentions.  These physicians are smart in the fact that they know that actually writing “pit to distress” like some practitioners do can land them with a law suit if an adverse outcome happens and they find themselves in court.  So while it is true that one’s medical record might not show “pit to distress” on the order form, it doesn’t mean that it didn’t happen to you!  What these doctors do instead are bully nurses into to doing their dirty work for them.  (And I would like to note that just like Dr. F, I have yet to encounter one physician who will actually physically put their hands on the IV pump and turn up the pitocin themselves when I refuse to do it!…..They know better!)

 

 

As a registered nurse my practice must adhere to the American Nurses Association Code of Ethics for Nurses.  Here is an excerpt:

 

“The nurse’s primary commitment is to the patient, whether an individual, family, group, or community.  The nurse promotes, advocates for, and strives to protect the health, safety, and rights of the patient.”

 

What these practitioners don’t realize is that when they work with nurses like me (and there are many out there!!), they are working with someone who values the health and safety of women and babies (as well as their nursing license) much more than a fake cordial kiss-ass relationship with some high-and-mighty doctor!  But let me tell you, its really frigging hard to work like that!  That is, to constantly battle with practitioners who have such a different philosophy about maternity care than you do!  I mean, even the best nurses will start to doubt themselves if they are constantly being bullied and told that they “can’t cut it” or are “incompetent” if they don’t follow the status quo!  Like many other nurses, sometimes I just don’t have the energy to argue and fight.  Sometimes I have down right lied to a doctor over the phone about how high the pitocin really is (telling them it’s running at a much higher rate than it actually is).  Other times I just “forget” to turn up the pitocin for hours at a time.  One time I actually disconnected the pitocin and discretely ran it into the floor!

 

Women of this earth…TAKE BACK YOUR BIRTH!!!  We need YOUR voice!  We need you to choose caregivers that practice evidenced based medicine, and BOYCOTT ones that don’t!  We need you to HIT THEM WHERE IT HURTS….in their WALLET!!  We need you to DEMAND better care!!  We nurses, birth advocates, doulas, childbirth educators, midwives, etc. etc. can’t make change without YOU!!

 

Thank you, Thank you, THANK YOU to Jill at Keyboard Revolutionary and Jill from The Unnecessarean for their blog posts on this issue!  I second their anger, outrage, and voice for change!!!

 

Are you an L&D nurse who has ever been ordered to “pit to distress?”  Are you a mother who has ever experienced the consequences of a birth attendant who followed a “pit to distress” philosophy?    Please share your story with us!! 

 

In closing I would like to say that I am NOT anti pitocin, but like ALL labor & delivery interventions, I speak out and advocate for the appropriate, evidencedbased, and safe use of them!

 

Please check out my next post!  “Pit To Distress” PART 2: Top 7 Ways to Protect Yourself From Unnecessary & Harmful Interventions

 

New Study Shows C-Section Births May Increase Odds For Developing Diseases Later In Life June 30, 2009

Filed under: In The News — NursingBirth @ 12:05 PM
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A new study published in the July issue of Acta Pædiatrica, a peer-reviewed monthly journal at the forefront of international pediatric research, found that babies born by cesarean section experience changes to their DNA in their white blood cells (called leukocytes) which they believe could be related to negative stresses around birth, particularly the cesarean section.  The study, entitled Epigenetic modulation at birth – altered DNA-methylation in white blood cells after Caesarean section, was led by a team of Swedish researchers who sampled umbilical cord blood (collected at the time of birth) and venous blood 3-5 days after birth from a total of 37 newborn infants, 21 of which were born by spontaneous vaginal delivery and 16 by elective cesarean section. 

 

According to the Medical News Today article, one of the authors of the study, Professor Mikael Norman, was quoted in saying:

  

“Delivery by C-section has been associated with increased allergy, diabetes and leukaemia risks.  Although the underlying cause is unknown, our theory is that altered birth conditions could cause a genetic imprint in the immune cells that could play a role later in life.  That is why we were keen to look at DNA-methylation, which is an important biological mechanism in which the DNA is chemically modified to activate or shut down genes in response to changes in the external environment. As the diseases that tend to be more common in people delivered by C-section are connected with the immune system, we decided to focus our research on early DNA changes to the white blood cells. 

 

 Animal studies have shown that negative stress around birth affects methylation of the genes and therefore it is reasonable to believe that the differences in DNAmethylation that we found in human infants are linked to differences in birth stress.  We know that the stress of being born is fundamentally different after planned C-section compared to normal vaginal delivery. When babies are delivered by C-section, they are unprepared for the birth and can become more stressed after delivery than before. This is different to a normal vaginal delivery, where the stress gradually builds up before the actual birth, helping the baby to start breathing and quickly adapt to the new environment outside the womb.

 

 In our study, neonatal DNA-methylation did not correlate to the age of the mother, length of labour, birth weight and neonatal CPR levels – proteins that provide a key marker for inflammation.  However, although there was no relation between DNA-methylation and these factors, larger studies are needed to clarify these issues.”

 

 Although this study has its limitations (recognized by it authors) including its small sample size, it is fascinating to me as it is part of a growing sector of developmental biology dubbed “primal health” by French obstetrician Michel Odent in his book by the same name in 1986.  “Primal Health Research” explores correlations between the ‘primal period’ (from conception until the first birthday) and health in later life.  Since opening the Primal Health Research Centre in 1990, Odent has also created the Primal Health Research Database, available free online, which is a public collection of all the medical and scientific literature that belong to the framework of primal health research.

  

In her book Pushed: The Painful Truth About Childbirth and Modern Maternity Care, author Jennifer Block writes:

 

 “[Odent] is interested in looking far beyond the 5-minute Apgar score to what we might call the 5-year, 25-year, 50-year Apgar.  He’s put a database online, where one can search studies that have connected narcotics at birth with addiction in adulthood; induction of labor with autism; and cesarean section with immune disorders.  The research is far from conclusive, but it points to the large, unknown territory of the impact of medicalized childbirth. 

 

Odent places value on the process of physiological childbirth itself, of which we still have only limited understanding.  How can we fully appreciate the risks of intervention, he asks, if we don’t funny understand what is normal?  The mother’s body has spent 9 months growing and sustaining fetal life, and millennia of evolution have depended on spontaneous labor and its timed release of several hormones to transition the fetus from the womb to the outside world.  Odent has compiled scientific evidence that each one of these hormones serves as an important function in guiding the progress of labor and supporting the fetus—and that these hormones are interdependent.  ‘What we’re understanding today is that what happens at birth seems to be important,’ says Odent.”

 

  

In my opinion, it should NOT be the case that the burden of proof lies on the supporters and proponents of unmedicated physiological childbirth (which is, as defined by author Jennifer Block, “[a birth where] labor begins and progresses spontaneously, the woman is free to move about for the duration, and she pushes in advantageous, intuitive positions.”) that “their” way is the safest and healthiest option for mothers and babies!  It SHOULD BE the responsibility of proponents of unnecessary inductions, unnecessary cesareans, and outdated and harmful labor & postpartum practices (i.e. routine episiotomy, early and frequent vaginal exams, early amniotomy, flat-on-back/lithotomy/recumbent pushing positions, separation of mother and baby, manual pressure on the uterus, and “directed,” hold-your-breath-and-count-to-10 pushing) to have to prove, beyond any doubt, that their way is superior.

 

 Because as far as I, and any credible research, is concerned it is NOT!  And if it ain’t broke, why fix it?!

 

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.

 

 

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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. 

 

 

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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.

 

 

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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.

 

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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.

 

 

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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!

 

 

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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…..

 

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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.

 

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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

 

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    • 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!

 

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    • 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?

 

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    • 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?

 

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    • 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?

 

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    • 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!

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    • 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.

 

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“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

 

 

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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!

 

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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?