c-section « Nursing Birth

Consent for Anesthesia: Do You Know What You Are Signing? May 5, 2009

Filed under: Ideas & Information,Ramblings — NursingBirth @ 2:35 PM
Tags: anesthesiologist, anethesia, c-section, C/S, cesarean section, epidural, epidural risks, hospital birth, informed consent, L&D, labor, labour, midwife, midwifery, natural birth, nursing, obstetrician, pain medication, Silent Knife

As an L&D nurse, one of the first questions we ask of our patients during their admission interview is if they have a birth plan and what their plans are for pain management during labor. Here are the 5 most common responses to that question:

#1 I would like to have a natural/unmedicated childbirth, Please do not offer me any medications/epidural because I will ask for them if I decided I need them.

#2 I am pretty sure I want to have a natural/unmedicated childbirth, but I haven’t ruled out the possibility of any medications/epidural because I don’t know what to expect. However, I’d like to go as long as possible without them.

#3 I definitely want pain medication but I do not want an epidural because:

a. I don’t like the idea of a needle in my back,

b. My best friend/sister had a horrible experience with it.

#4 I want an epidural as soon as I can have one but I want to try to avoid pain medication because:

a. I heard it can make you feel out of it/loopy,

b. My best friend/sister had a horrible experience with it.

#5 I want everything and anything you can give me as soon as you can give it to me…I don’t want to miss my “window” for an epidural either! Can’t I just have the epidural now?

What I have always found interesting is that except for some women who answer #1, I rarely hear reasons for not wanting either pain medication or an epidural that include the very real risks of:

“Because it can negatively affect my baby.”

“Because it can negatively affect me.”

“Because it can negatively affect my labor progress.”

“Because it can negatively affect my chances for a vaginal delivery.”

After hearing the mothers’ responses and if time allows, I typically ask them how they prepared for labor and childbirth and how they came to their plan of wanting or wanting to avoid pain medications or an epidural. Not surprisingly, the most common responses for women who answered #2 through #5 are: “I only took the hospital tour/childbirth class,” “I only read ‘What to Expect When You’re Expecting’”, “I only talked to my other friends/family who have had a baby,” or “I didn’t do anything really.”

I am going to be quite honest here. It pretty much baffles me that women who are planning on utilizing pain medication and/or an epidural during labor typically have not learned much more about them besides when they can be given and how they are given. That is, in my experience as an L&D nurse, the RISKS of the procedure are rarely if ever fully understood and the BENEFITS are often exaggerated. Whenever I get the chance, if I feel that a woman has not researched the risks and benefits of pain medication/epidural during her pregnancy, I will try to go over them fairly and accurately if time and circumstances allow. I typically only get this chance if they are being admitted for an induction. On the contrary, if they come in during active labor and are very uncomfortable, I try to do my best to explain risks and benefits but I also struggle with trying to be sensitive to the fact that they are uncomfortable and probably aren’t or can’t completely pay attention to everything I am going over. It’s really quite the predicament.

I guess what I am trying to get at is that women need to start taking control of their own bodies and health care decisions. The fact of the matter is, “TRULY INFORMED CONSENT IS ONLY POSSIBLE BY CONSUMER INITIATIVE. PERSONAL EDUCATION IS A PERSONAL RESPONSIBILITY.” ~ David Stewart, founder and director of NAPSAC***

What does that mean you ask? To me, this quote means that true informed consent is only accomplished and insured when the health care professional (e.g. obstetrician, anesthesiologist and sometimes even the midwife or nurse) AND the consumer (i.e. the pregnant woman/childbearing family) are BOTH active participants in the informed consent process.

Regarding the role of the health care professional, the American Medical Association defines informed consent in the following way:

Informed consent is more than simply getting a patient to sign a written consent form. It is a process of communication between a patient and physician that results in the patient’s authorization or agreement to undergo a specific medical intervention. In the communications process the physician providing or performing the treatment and/or procedure (not a delegated representative), should disclose and discuss with [the] patient:

(1) The patient’s diagnosis, if known;

(2) The nature and purpose of a proposed treatment or procedure;

(3) The risks and benefits of a proposed treatment or procedure;

(4) Alternatives (regardless of their cost or the extent to which the treatment options are covered by health insurance);

(5) The risks and benefits of the alternative treatment or procedure; and

(6) The risks and benefits of not receiving or undergoing a treatment or procedure.

In turn, [the] patient should have an opportunity to ask questions to elicit a better understanding of the treatment or procedure, so that he or she can make an informed decision to proceed or to refuse a particular course of medical intervention.

Now that you are informed about the role of your health care provider, I would like to remind all consumers of health care that might be reading this blog (i.e. pregnant women/childbearing families) that if you forfeit or ignore your personal responsibility to educating and preparing yourself for pregnancy, labor, childbirth, and postpartum, then IT IS YOU THAT HAS TO LIVE WITH THE DECISIONS YOU LET YOUR HEALTH CARE PROVIDER MAKE FOR YOU! David Stewart writes,

“Professionals do not always have the best answers. This is not a criticism of professionals, but a simple recognition of the fact. It serves neither professionals nor patients to disregard this fact. All have limited experience and limited education. The best health care is available to consumers who participate in medical decisions pertaining to themselves and their families. …To be fully informed requires preparation and education before [the fact]. Doctors and medical institutions have a clear obligation to assist patients by providing unbiased pros and cons of policies and procedures. They do not have the obligation to be a patient’s sole and complete source of education.”***

I know I would be better able to sleep better at night if more of my patients who come in requesting an epidural/pain medication (or really any labor intervention for that matter) have actually done their own personal research on the risks and benefits of the procedure and have made their decision based on a complete set of facts as opposed to just coming into the hospital requesting an epidural with the only “education” obtained on the matter being “my sister said she had one and it was awesome/nothing bad happened so I want one too.” Ugh!

One circumstance that I always find particularly bothersome is the fact that at many hospitals (including my own), the woman is typically signing the Consent for Anesthesia (which has to be signed with the anesthesiologist in the room) when she is extremely uncomfortable and demanding an epidural be given immediately! So even if the anesthesiologist properly reviews all the risks and benefits with the patient, she is typically not listening, telling us she is not caring, and signing the consent without even reading it over. Since I often feel as if I have little influence over this fact (I don’t always get the chance to show the patient the consent for anesthesia to read over when she is comfortable), I would like to take this opportunity share with all of you an actual hospital Consent for Anesthesia that is used for labor epidurals and cesarean anesthesia (including spinals and general anesthesia) so that you may read it over in the comfort of your own home and maybe even discuss it with your birth attendant and labor companions way before you ever feel your first contraction.

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Anesthesia Consent

I consent to the administration of anesthesia under the direction of an anesthesiologist and to the use of such anesthetics and techniques as he/she may deem advisable. I understand that anesthesia residents and/or certified nurse anesthetists may be involved in my care under the direction of the assigned anesthesiologist. I understand that the type of anesthesia and/or the assigned anesthesiologist may have to be changed during the procedure due to changing circumstances.

The anesthesiologist has fully explained to me the risks and discomforts that may arise as a result of the proposed administration of anesthesia, as well as possible alternatives, for my labor/procedure. I have been given an opportunity to ask questions, and all my questions have been answered fully and to my satisfaction. The risks discussed include, but are not limited to: headache, nausea, pain, vomiting, aspiration, dental or voice injury, awareness during anesthesia, heart or breathing complications, unanticipated or prolonged hospitalization, blood clots, infections, adverse drug reactions, I.V. infiltrations, nerve damage, paralysis, blindness, brain damage, and death. Since I am pregnant, I understand these risks extend to the unborn child I carry. I understand and acknowledge that no guarantees or assurances have been made to me concerning the outcomes from the administration of anesthesia.

I confirm that I have read and fully understand the above prior to my signing.

____________________________________

(Patient signature/legal representative)

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Do you know what you’re signing?!?!

In conclusion, as you prepare for your labor and childbirth experience, it is very important to remember that it is ultimately YOUR OWN responsibility to become educated on your options regarding pain management, including both non-pharmacological as well as pharmacological interventions. Likewise, waiting to “learn all about it” once you get to the hospital is not very responsible. It is also important to remember that any pharmacological intervention, including pain medications and epidurals, carry many risks to both you and your unborn baby and therefore you owe it to your unborn baby, your partner, and all of the people in your life that love you to LEARN about it before you consent to it. Like author Henci Goer, one of my goals in writing this blog is to never hear another women ever say, “But I didn’t know that was a risk” or “I never would have agreed if I had known that could happen.”

For fair, balanced, research-based facts and information about pain medication and epidural use in labor please check out the following resources:

By Dr Sarah J. Buckley MD’s Epidurals: risks and concerns for mother and baby

American Pregnancy Association’s Using Narcotics for Pain Relief During Childbirth

American Pregnancy Association’s Epidural Anesthesia in Labor

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***As quoted on page 137 of Silent Knife by Nancy Wainer Cohen & Lois J. Estner. NAPSAC stands for “National Association of Parents and Professionals for Safe Alternatives in Childbirth”

Comments (52)

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

Filed under: Don't Let This Happen to You!: The Injustice In Maternity Care Series,Nursing Notes — NursingBirth @ 5:41 PM
Tags: c-section, C/S, cesarean section, delivery, failed induction, failure to descent, failure to progress, hospital birth, ICAN, informed consent, informed refusal, L&D, labor, labour, medical model of maternity care, midwife, nursing, obstetrician, pregnancy, Silent Knife, Vaginal Birth After Cesarean, VBAC

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

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

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

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

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

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

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

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

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

Me: “Sally, she’s pushing.”

Sally: “What?”

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

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

Me: “Was she pushing 20 minutes ago?”

Sally: “Well no but…”

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

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

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

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

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

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

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

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

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

Kate: “Dr. W wants to do a cesarean.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

(1) ICAN’s Cesarean Fact Sheet

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

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

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

And find a local ICAN support group near you!

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

Comments (65)

Great Birth Story April 25, 2009

Filed under: Nursing Notes — NursingBirth @ 10:34 AM
Tags: birth story, c-section, C/S, cesarean, hospital birth, natural birth

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

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

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

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

Comments (2)

My Philosophy: Birth, Breastfeeding, and Advocacy April 25, 2009

Filed under: Ramblings — NursingBirth @ 9:02 AM
Tags: breastfeeding, c-section, cesarean, delivery, epidural, home birth, hospital birth, L&D, labor, labour, midwifery, midwives, natural birth, nurse, nursing, OBGYN, obstetrician, pain medication

I am honored, humbled, and excited to report that just a few days ago my blog had over 1,500 hits in just one day. I was floored when I saw the number and almost choked on my Cheerios J! When I started this blog in February I was feeling lost, frustrated, burnt out, defeated, and disempowered regarding my role in the current maternity care system in America. The day I wrote my very first post, NursingBirth is BORN!, was only one week after I almost up and quit my job after I had witnessed a very traumatic assault and battery against a woman I was caring for as her obstetrician performed a pudendal block against her will as she and her husband were screaming for him to stop.

(Side Note: This is one situation that I still have not been able to bring myself to write about. The fact is that assault & battery on patients in health care happen DOES happen and it was the first time I had ever witnessed such an event. I cried for days, ran the story over and over and over again in my head, wondering what I could have done differently, wishing I had the courage to throw myself over her to physically prevent him from violating her, instead of just saying “Stop!”. I am getting pretty choked up even thinking about it so for now, I will have to continue to process that event and hopefully one day, I will be able to write about it.)

My intention for this blog was simple…if I could reach one mother, just one, who might stumble upon my blog and be inspired to learn more about labor, childbirth, and birth options, to realize that she has options and rights regarding her experiences and her body, I would then feel triumphant. I had convinced myself that for months or maybe even years the readers of my blog would probably only be my husband and sister-in-law J. I conceded to using this blog as just catharsis and a way to process my experiences. What I never imagined was that more than just a few people would ever read, never mind enjoy and keep reading, this blog!

So MANY THANKS are owed to all of my readers, who have turned out to not only be moms, but grandmothers, nurses, doctors, doulas, childbirth educators, midwives, and other people in the birth advocacy community. THANK YOU, for reading! Thank you to those who find themselves sharing many of my interests and beliefs!! I love networking with all of you and learning more every day about how to better serve childbearing families. And thank you to those of you who not only disagree with me but tell me about it too!! You keep me thinking and on my toes. Great things come out of great discussions and a discussion isn’t quite as interesting if everyone has the same opinion.

THANK YOU! THANK YOU! THANK YOU!

With all of that being said I feel that it is time to share a bit more about my personal philosophy regarding birth, breastfeeding, and advocacy. Of course my opinions do shine through in my writing (after all, it is my blog J) but with all of this “success” (haha, take that with a grain of salt please J) I have found that many people are beginning to label me with thoughts, feelings, and beliefs that I do not hold. Contrary to what some readers have implied, my goal in writing this blog was not to push my own agenda or to bully women into believing everything I do. (For example, one mom linked to a lighthearted post on my blog entitled Top Ten Things Women Say/Do During Labor on a popular baby website and wrote something to the effect of “Beware of the rest of her posts because she is pretty hippy-crunchy.” Another person commented that my blog was something to avoid because I was a “crunchier than thou/more natural than thou natural birth Nazi.”) Please note that I am NOT writing about these comments to start a flame war, nor did they hurt my feelings (I work in L&D after all, I have a pretty tough skin! Haha!)

However, I did feel compelled to outline what my personal philosophy is so my intentions are clearer in future posts and since it is my blog that is exactly what I am going to do! I feel that it is better for me to “fill in the holes” rather than have readers “guess” at where I am coming from. That being said, I DO NOT expect everyone in the world to share the same philosophy. The beliefs I have written below are meant to be provocative, that is, I am not trying to hide or sugar coat anything to make it have universal appeal. Also, although I strongly believe in these statements, I can also understand the other side of the story. For example, although I am a supporter and advocate of spontaneous, un-medicated labor and birth as well as VBACs, I do not condemn any woman for getting an epidural, taking pain medication, or scheduling a repeat cesarean. I know there are some people out there that would, but I do not feel that way. In reality more so than anything else, it’s not the epidural, pain medication, or repeat cesarean that bothers me; instead, it’s the women who request these things but have never even researched their safety or risks. Like author Henci Goer, one of my goals in writing this blog is to never hear another women ever say, “But I didn’t know that was an option” or “I never would have agreed if I had known that could happen.” You wouldn’t believe me if I told you how often I actually hear women speak these exact words because I hear it ALL THE TIME. Also, I would like to point out that this is not a completely exhaustive list. Regardless, here it is!!

(Note: Many of these statements are taken or adapted from the following resources)

v Childbirth Connection’s Rights of Childbearing Women

v BirthNetwork National’s Mission & Philosophy

v Coalition for Improving Maternity Services’ Mother-Friendly Childbirth Initiative (MFCI)

My Personal and Professional Birth, Breastfeeding, and Advocacy Philosophy

Pregnancy, Birth, & Breastfeeding

1) I believe that pregnancy and birth are normal, healthy processes and should not be treated as illness or disease.

2) I believe women and babies have the inherent wisdom necessary for birth.

3) I believe that pregnancy, birth, and the postpartum period are milestone events in the continuum of life that profoundly affect women, babies, fathers, and families, and have important and long-lasting effects on society.

4) I believe that breastfeeding provides the optimum nourishment for newborns and infants which does NOT mean that I am not grateful for the advancements in artificial milk for those mothers and infants who truly require it.

5) I believe that every woman has the right to virtually uninterrupted contact with her newborn from the moment of birth, as long as she and her baby are healthy and do not need care that requires separation.

6) I believe that for the majority of women, VBAC (or vaginal birth after cesarean) is a safe option that should be available to all women in all birth settings who safely qualify.

The Obstetric vs. Midwifery Model of Care

7) I believe that uncomplicated, healthy pregnancies far outnumber pregnancies that have complications and hence, the technology and techniques utilized to maintain the safety of mother and baby in high risk pregnancies should not be automatically or routinely applied to low risk pregnancies.

8.) I believe that the current maternity and newborn practices in the United States that contribute to high costs and inferior outcomes include the inappropriate application of technology and routine procedures that are not based on scientific evidence.

9) I believe that although you cannot make blanket generalizations about the model of care that a birth attendant follows just by their credentials, typically speaking I believe OBGYNs tend to follow an obstetrics model of care while midwives tend to follow a midwifery model of care based on the very nature of their education. After all, obstetricians are surgical specialists trained in the pathology of pregnancy and women’s reproductive organs.

10) I believe that per the very nature, philosophy, and experiences of medical education/obstetrical residency and midwifery education/apprenticeship, midwives should be the only health care providers attending normal, healthy, uncomplicated labors & births while obstetricians should be called to consult or transfer care to if and only if a problem or complication out of the scope of midwifery practice arises.

11) I believe that women need access to professional midwives whose educational and credentialing process provides them with expertise in out-of-hospital birth as well as hospital-based and clinical care that extends beyond the childbearing cycle.

12) I believe that midwives can obtain quality education and experience in a variety of ways and programs, including certified nurse midwifery and direct-entry midwifery.

13) I believe that integrity of the mother-child relationship as well as the safety of our mothers and babies is compromised by the pervasive over-medicalized, obstetrics model of maternity care in this country.

Interventions & Natural Birth

14) I believe that research supports the reality that both a mother’s body as well as her baby will initiate the beginning of labor when the baby is ready to be born and that women should not have their labor induced for any elective reason unless the health of the woman or baby is found to be in immediate danger if the pregnancy is allowed to continue.

15) I believe that empowering and safe births can and do take place in a variety of settings including birth centers, hospitals, and homes.

16) I believe that every woman should have the opportunity to give birth as she wishes in an environment in which she feels nurtured and secure and her emotional well-being, privacy, and personal preferences are respected, whether that be in a hospital, birthing center, or at home.

17) I believe the research supports that a minimal to no intervention, medication free, spontaneous vaginal delivery is the safest birthing option for the vast majority of both mothers and babies.

18) I believe that the obstetrical model of maternity care plus a pervasive American cultural phenomenon that teaches women to fear childbirth, doubt their innate ability and power to give birth, and be ashamed of their bodies and their sexuality is responsible for many women opting relinquish all control over their birth experiences to others and consent to unnecessary interventions that seem to provide a way to escape.

19) I believe that every woman has the right to create her own birth plan and that her birth attendants and labor companions have the responsibility to assist her in making it a reality as best and safely as they can. I also understand that for some women, their birth plan does not include a medication or intervention free labor and childbirth and I support this as long as the women has been provided with informed consent, including all the risks and benefits of her requests.

Autonomy & Empowerment

20) I believe women are entitled to complete, accurate, and up-to-date information that is supported by evidenced based research on their full range of options, including all procedures, drugs, and tests suggested for use during for pregnancy, birth, post-partum and breastfeeding.

21) I believe that women have a right to make health care decisions for themselves and their babies and that this right includes informed consent as well as informed refusal.

22) I believe that interventions (i.e. many standard medical tests, procedures, technologies, and drugs including narcotic medications for pain relief in labor, epidurals, labor inductions, primary & repeat cesarean sections) should not be applied routinely during pregnancy, birth, or the postpartum period and in my opinion should be avoided in the absence of specific indications and true necessity for their use.

23) I believe that said interventions have life saving potential and are necessary in certain circumstances (which I am entirely grateful for) but are often abused and misused.

24) I believe that maternity care practice should not be based on the needs of the caregiver or provider, but solely on the needs of the mother and child.

25) I believe that every woman has the right to health care before, during and after pregnancy and childbirth.

26) I can admit that (probably related to my educational background, experiences, and values) I am not entirely comfortable with the “free-birth” or “unassisted childbirth” movement but I can also admit that I know little to nothing about the movement and I am open-minded to learning more.

27) I believe that every woman has the right to receive continuous social, emotional and physical support during labor and birth from a caregiver who has been trained in labor support and I believe that the current obstetrical education in this country does not train physicians to provide labor support.

28) I believe that every women has the right to have how ever many supportive labor companions and birth attendants of her choice (as she deems necessary) attend her labor and birth, has the right to change her mind at any time, and has the right to decline the care or presence of any unnecessary personnel during her labor and birth.

In closing, I am NOT anti-obstetrician, anti-hospital, anti-intervention, anti-induction, anti-epidural, anti-pain medication, or anti-cesarean. Quite the contrary I am PRO the appropriate use of such interventions when they are necessary to support the health and safety of the mother-baby unit and facilitate a safe and empowering (hopefully vaginal) birth. I have found my passion in assisting women and families during the intrapartum period and my number one goal in my job is to support, facilitate, and encourage a natural-as-possible, empowering, and safe birth experience, however that may be, for all those involved.

Thanks for reading.

Comments (58)

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

Filed under: Nursing Notes — NursingBirth @ 11:00 AM
Tags: birth, breastfeeding, c-section, C/S, cesarean section, childbirth, epidural, hospital birth, L&D, labor, nursing, OBGYN, obstetrician, pitocin, vaginal birth

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Kristen writes:

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

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

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

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

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

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

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

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

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

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

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

Comments (49)

Why Is Vaginal Breech Birth Going the Way of the Dodo? April 9, 2009

Filed under: Ideas & Information,Ramblings — NursingBirth @ 9:36 AM
Tags: birth video, breech birth, c-section, cesarean section, early cesareans, external version, hospital birth, midwife, midwifery, obstetrician, turning my baby, vaginal birth

I recently was sent a link to The Coalition for Breech Birth website and I wanted to share it with all of you because it is both interesting and informative.

I learned in nursing school and have since witnessed as an L&D nurse the hard truth that all breech babies are born by cesarean section in the United States nowadays unless 1) the baby turned from vertex to breech during the labor and no one realized it or 2) the baby actually delivered in the bed before her doctor could wheel her into the operating room. I knew from books and stories told to me by older nurses that in the “old days” they used to deliver breeches vaginally but never learned why it isn’t even presented as an option for the women of today.

According to the Coalition for Breech Birth website:

“Vaginal breech birth was practically banned following a significant international research study in 2000. This study, the “Term Breech Trial” or TBT, appeared to prove that caesarean section was substantially safer for the delivery of all breech babies. The trial was highly criticized, but many birth care providers took this opportunity to do what they wanted to do anyway – to stop offering vaginal breech birth to their clients, and to insist instead upon a surgical delivery. In addition to all the professional criticism, the TBT’s own two year follow up negated the original results, suggesting that any difference in safety between vaginal and surgical birth of a breech baby is negligible – for both mother and child. Despite this evidence, many birth care providers (BCPs) still avoid balanced informed choice discussions with their clients, denying them the opportunity to make an informed choice.”

It is disappointing enough when a woman is not given the choice and is just scheduled for an elective pre-labor cesarean section (often at about 39 weeks, which could still be early for many babies) related to her baby being breech. It’s also frustrating when a provider doesn’t even offer the patient an external version before scheduling her for surgery. But what I find really upsetting as an L&D nurse is when a woman comes in 8, 9, or 10 centimeters dilated and because she is found breech is rushed of for an emergency cesarean section. Many doctors say that one of the reasons they don’t “do” vaginal breech births is because the buttocks are not as effective at dilating the cervix as a nice round head is and labor can be too long and difficult. But when a woman comes in at 10 centimeters dilated clearly her body did just fine!! And when a woman “accidentally” delivers a breech baby in the bed before we could get her to surgery, everyone (doctors, nurses, midwives) seem to be so excited that the patient was able to “avoid” surgery, yet this hasn’t EVER made ANY doctor think twice about scheduling every one of their breech patients for surgery anyways. So frustrating!

If you have never seen a breech delivery before, this site has links to pictures and videos as well as other resources for mothers wanting to be more informed of their birth choices.

The sad thing is that if things continue the way they are now, less and less doctors and midwives will be properly trained to assist in the delivery of a breech baby and by this vicious cycle, less and less opportunities for women to make this birth choice will exist.

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

Filed under: Don't Let This Happen to You!: The Injustice In Maternity Care Series,Nursing Notes — NursingBirth @ 12:26 PM
Tags: c-section, cesarean section, childbirth, delivery, hospital birth, induction, L&D, labor, labour, midwife, midwifery, nurse, nursing, obstetrician, things during labor, vaginal birth

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

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

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

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

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

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

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

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

Sarah: “I’d really rather wait.”

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

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

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

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

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

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

Me: “No, I have her at 10mu/min.”

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

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

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

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

Dr. F: “I was being generous!”

Me: “So you lied…”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The morals to the story are this:

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

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

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

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Don’t Let This Happen To You #25 PART 1 of 2: Sarah & John’s Unnecessary Induction April 5, 2009

Filed under: Don't Let This Happen to You!: The Injustice In Maternity Care Series,Nursing Notes — NursingBirth @ 3:23 PM
Tags: c-section, cesarean section, childbirth, delivery, hospital birth, induction, L&D, labor, labour, midwife, midwifery, nurse, nursing, obstetrician, things during labor, vaginal birth

Introduction to 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!”

What do I mean? If you have ever watched the amazing documentary The Business of Being Born and thought to yourself, “Oh no, that can’t be true? That must be an exaggeration,” I am here to tell you that it is NOT an exaggeration.

The fact is, the current state of maternity care in the United States is in a crisis and many times I find myself feeling defeated and helpless regarding it all. I mean don’t get me wrong, I take my job as a nurse and patient advocate very seriously and protecting the health, safety, and autonomy of my patients is very important to me. So seriously in fact that I have all but thrown a screaming fit at times when faced with particularly outrageous obstetricians and unjust circumstances. (Oh wait, I have thrown screaming fits before…Haha! J ) In the end I often find myself working with nurses that I feel are dedicated and fantastic, but who none the less have had to put up with this bullshit for so long that they sort of become complacent to it.

So where does that leave me? I feel my position as an L&D nurse really puts me at the end of the line when it comes to affecting change in how woman and families approach pregnancy and childbirth. One of the things that really inspired me to start this blog was that I realized I really only get my “hands” on families after they have already been sucked in to the medical model of maternity care. One particularly hard pill for me to swallow is this country’s epidemic of women undergoing unnecessary interventions, including but not limited to, the inappropriate use of labor induction and augmentation and unnecessary primary and repeat cesarean sections. But the more and more I have worked in this “culture” and talked with these women and families, the more and more I have realized that all too often these women are really lured in and duped into these interventions! That true informed consent is not really obtained and alternatives to the obstetrician’s (and even some “med-wives’ ”) proposed course of action are NOT provided. And a few days ago I took care of a patient that was really just the straw that broke the camel’s back.

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! Since I prefer countdowns instead of count ups, I decided to start at a random number. I have no doubt I will be able to come up with 25 situations I have found myself or my patients in that could easily make the list. (Hmmm, maybe I should start at 1000! J )

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Don’t Let This Happen To You #25: PART 1 of 2

Sarah & John’s Unnecessary Induction for “Oligohydramnios” and “Post-dates”

I came to work for 11:00 am as usual one cold and rainy Monday morning and despite the many obvious reasons to be in a bad mood, I was actually pleasantly optimistic about my upcoming shift. Things seemed to be going my way when I saw my assignment. I would be taking over a laboring patient of Dr. F’s in room 11 for a nurse who was only working a half shift. Since assisting women during labor is my favorite part of being an L&D nurse, I was happy.

So I went to the desk closest to the patient’s room and started to look over her chart until her current nurse was ready to give me report. Let’s see here…26 year old first time mom, first pregnancy (G1P0), no medical risks in her health history, no complications during this pregnancy. According to her LMP she is 40 weeks and 5 days (“aka” still 9 days away from 42 weeks or true “postdates”). A quick look at her most recent ultrasound report (performed 3 days earlier) showed a Grade II placenta (“aka” normal, healthy and well functioning), an amniotic fluid index (AFI) of 8.4 (“aka” normal, since at term a normal AFI is anywhere from 5-25), and an estimated fetal weight (EFW) of approximately 3628 grams (or 8 lbs 3oz). (Note: It is well documented in the medical literature that third trimester ultrasound scans can be off by as much as +/-2 pounds when estimating fetal weight!). Looking at the fetal heart rate pattern on the computer showed a reactive and reassuring strip with moderate variability, presence of great accelerations and absence of decelerations. Her vaginal exam on admission was 3cm, 70% effaced, minus 2 station. Hmm…she must have been admitted for labor….oh wait…what’s this in the doctor’s admission note?….

Indication for admission: Induction for oligohydramnios (low amniotic fluid) and post dates.

Plan: pitocin and early amniotomy.

WHAAAAAAAAAAAAAAAAAAAAAAAT?!?!

A double, triple, quadruple take proved to me that my eyes were not failing me. And to top it all off the patient had provided us with her birth plan. Now I don’t mean that to be sarcastic because I am not against birth plans. It’s that her birth plan was basically requesting things that because she was being induced with pitocin, were prohibited, discouraged, or generally made very difficult by our hospital’s policy and her physician’s orders/philosophy.

Here is an excerpt from her birth plan. Although I don’t have a copy of her actual birth plan, since almost every pregnant woman with a birth plan seems to find the same website (www.birthplan.com), I can confidently replicate it quite easily. My responses to why each of these reasonable requests were prohibited, discouraged, or generally made very difficult are provided in italics after each bullet:

§ I would like to be free to walk around during labor. (Although walking is not contraindicated during an induction, since the use of pitocin requires the use of continuous external fetal monitoring (EFM) and a good tracing of the fetal heart rate (FHR) and contractions, a portable telemetry monitor must be used. And since it is a machine with limitations, as the baby swish, swish, swishes in her amniotic fluid womb bath, more often than not adequately tracing the fetal heart rate is impossible or extremely difficult, especially if the woman has a lot of extra “cushion”.)

§ I wish to be able to move around and change position at will throughout labor. (Tracing the FHR with continuous EFM is virtually impossible sitting on a birthing ball or leaning forward, positions that many women find comforting, unless you hold the monitor constantly with your hands, something that is very difficult for even the most well intentioned nurse, especially if she has more than one patient. It is also often annoying for the patient.)

§ I do not want an IV unless I become dehydrated. (Since pitocin is a medication administered via an IV infusion, it necessitates an IV.)

§ I do not wish to have continuous fetal monitoring unless it is required by the condition of the baby. (Induction with pitocin requires continuous EFM, even in the most lenient of hospital policies.)

§ I do not wish to have the amniotic membrane ruptured artificially unless signs of fetal distress require internal monitoring. (Was the doctor’s plan even discussed with this patient?!)

§ I would prefer to be allowed to try changing position and other natural methods (walking, nipple stimulation) before pitocin is administered. (Ummm…hello!)

§ Unless absolutely necessary, I would like to avoid a Cesarean. (One of the best ways to avoid an unnecessary cesarean is to avoid an unnecessary labor induction!! See #8 in my post: Top 8 Ways to Have an Unnecessary Cesarean Section)

§ Even if I am fully dilated, and assuming the baby is not in distress, I would like to try to wait until I feel the urge to push before beginning the pushing phase. (We’ll get to this one later.)

So then came the nurse I was supposed to get report from. “Umm, why the hell is she being induced?!,” I said. “Oh brother, I know. Its bullshit isn’t it! We started the pit this morning at 8am but Dr. F couldn’t rupture her membranes at that time because the baby’s head was still high. He said he’d be back around 1:00 pm to do it.” she replied. “Like hell he will,” I thought to myself. And after a quick report I entered Sarah’s room to try to get some answers.

Upon entering the room Sarah was sitting up comfortably in bed while her husband, John, was typing on his laptop in a chair beside her. First I introduced myself and let them know that barring an emergency, I would be their nurse for the next 12 hours and probably for the birth of their baby! We engaged in some small talk for a bit, the typical “Where’re you from? What do you do? What’s the baby’s name going to be?” “How has this pregnancy been for you? yaddy yaddy yada. We then talked about their birth preparation. Turns out they had taken a childbirth preparation class and had read two of my favorite books: Ina May’s Guide to Childbirth and The Birth Partner. Good start! Next I pulled up a stool and with their birth plan in hand, went over all of their plans with the both of them before things started to rev up for Sarah.

Whenever a couple has a birth plan, whether it be a birth plan for as natural a birth as possible, as medicated a birth as possible, or anything in between, I like to actually sit down and review each point with them to let them know what is totally doable or what must be modified related to the patient’s condition or hospital policy. I let them know that my main jobs as a nurse are to provide support, assure the safety of the mother and baby, and be a patient advocate. That way everyone is on the same page and I think it helps build some trust between couple and nurse. Kind of like saying “Hey, I am going to take your birth plan seriously since this is your experience, but we might have to compromise on some things.”

So I started to go over the couple’s birth plan with them and basically tell them how induction with pitocin makes many of their requests impossible or very difficult but that I would do the best I could under the circumstances. And this is where things got interesting. The following is our conversation:

Sarah: “Oh yeah, I know. We had this big birth plan for a natural birth but that’s okay, I mean, when Dr. F told us two days ago that we needed to be induced, I realized that we couldn’t have everything we had planed for.”

Me: “Oh, what did he tell you was the reason you had to be induced today?”

Sarah: “Because the baby’s amniotic fluid was too low and I was overdue.”

John: “Yeah, umm, about that… Two days ago was the only appointment I had missed and it’s when they set her up for an induction. I didn’t even get a chance to ask the doctor what the normal levels for AFI were. I mean, he told us our level was 8. What is normal?”

Me: “5 to 25 is normal for a term baby,” (stated matter-of-factly)

John: “SEE! Then 8 is totally fine! And technically we still have a week left before we are considered really ‘overdue’, right?”

Sarah: “John, really, relax. It’s no big deal (awkward laugh). We’ll know better for next time. Really, it’s okay. Let’s not cause any trouble.”

John: “Melissa, what are some really important reasons for induction. Like, what are some real medical reasons where induction is necessary?”

Melissa: “Umm, do you truly want me to go into this? Because I can but…”

John: “Yes please.”

Melissa: “Well to name a few off the top of my head: If the baby is showing serious signs of distress on a non-stress test and biophysical profile, an AFI consistently less than 5 over multiple readings, worsening preeclampsia, signs of intrauterine growth restriction, a placenta that shows signs that it is getting too old too early in the pregnancy, etc.” (This is where things started to get awkward for me. I mean, I didn’t want to upset Sarah or make her feel self-conscious or distrustful of her physician because those feelings are certainly NOT going to facilitate a smooth labor. But then again, I secretly wanted to tell her, “You don’t have to be here!”)

John: “Well, the baby has had a great non-stress test every time we went to the doctor and he told us the placenta is healthy, and Sarah is healthy and her pregnancy has gone off without a hitch, she didn’t even really get morning sickness, and they said the baby is probably 8 lbs, which certainly isn’t too small! This is really frustrating!!”

Sarah: “John, it is okay. Dr. F must have thought it was important that I deliver. So we’ll just know better for next time. Next time we’ll be more prepared. But we’re here now and I am already being induced.”

I could see that there certainly was some tension between them regarding this issue and it seemed to me that although Sarah agreed with what John was saying, she was worried about causing any conflict or confrontation between her and Dr. F. But I have to admit that it really bothered me that she kept repeating “We’ll know better for next time,” because THIS time is important and THIS time could have negative affects on NEXT time.

Situations like this are one of the things that frustrate me the most about my job. Sarah and John were both intelligent people. (The were high school teachers with master’s degrees for goodness sake!). They read the right books. They attended childbirth classes. They wrote a birth plan and showed it to their obstetrician earlier in the pregnancy. (Of course I can almost guarantee that he briefly looked at it, gave them a blanket “okay” but didn’t really take the time to go over it piece by piece with them.) And yet they were still duped into an unnecessary induction. It is such a shame that there are so many women I care for that are more afraid of being considered a “difficult patient” for sticking up for themselves than the risks of unnecessary intervention. It’s like being afraid to tell your hair dresser you don’t like the hair cut she gave you TIMES A MILLION! In my opinion they were NOT provided with informed consent and NOT given the opportunity to give informed refusal. And in my opinion once they were told they “needed” to be induced, they felt trapped and didn’t want to “cause any trouble” with the doctor.

To be continued….

Up For Next Time: Don’t Let This Happen To You #25: PART 2 of 2

Read about Sarah’s labor, the birth of her baby, and how all three of us had to fight to fulfill her birth plan!

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Top 8 Ways to Have an Unnecessary Cesarean Section April 3, 2009

Filed under: Ramblings,Top Ten Lists — NursingBirth @ 10:52 AM
Tags: amniotomy, birth, Birthing From Within, Born in the USA, c-section, C/S, childbirth, continuous monitoring, delivery, epidural, failure to progress, Henci Goer, home birth, hospital birth, ICAN, induction, International Cesarean Awareness Network, L&D, labor, labour, Marsden Wagner, midwife, midwifery, natural birth, OBGYN, obstetrician, oxytocin, pain medication in labor, Pam England, pitocin, The Thinking Woman’s Guide to a Better Birth, Top 10, top ten, unnecessary cesarean section, VBAC

(Adapted from Top 7 Ways to Have an Unnecessary C-Section)

Happy April everyone! As you may or may not be aware, the International Cesarean Awareness Network (ICAN) has declared April to be Cesarean Awareness Month. In honor of this, I decided to share with you a website I recently found that I thought was pretty amusing.

Blogger Esther Brady Crawford of faintstarlite.com recently wrote a post entitled “Top 7 Ways to Have an Unnecessary C-Section”. Not only is it amusing (and perhaps a bit cynical) but it is also: 1) sad that it is so true and 2) very true. I encourage you to read her original post since she gives her own hilarious explanations for each “pointer” but since I am a big research nerd, I have added my own comments to her original Top 7. At the end of this post I have included an eighth “pointer” to the list to make it a Top 8. Much of the research I cite in this post is from the book The Thinking Woman’s Guide to a Better Birth by Henci Goer.

So here it goes…

#7 Go the hospital in the early phases of labor.

Crawford is just plain right-on with this one! Too many obstetricians are quick to label a mom as having “dysfunctional labor” if she does not progress at least one centimeter an hour (for first time moms) or two centimeters and hour (for multiparous moms) immediately upon arriving to the hospital. I have even had some doctors I work with take a call from a mom at home that “sounds like she is in labor” and turn around and tell the residents to “start her on pit as soon as she gets here.” WHAT??!! Pam England, CNM, MA writes in her book Birthing From Within, “One advantage to laboring in the privacy of your home, with one-on-one midwifery support, is that should a problem arise that requires medical support at the hospital, you will not wonder whether your labor problems were caused by routine, unnecessary, or ill-timed hospital interventions.”

#6 Don’t eat or drink during a long labor.

Goer writes that dehydration and starvation caused by restricting food/drink intake during labor causes a woman not only considerable discomfort but can also lead to fever, prolonged labor, increased use of oxytocin (aka pitocin), instrumental delivery, and a non-reassuring fetal heart rate pattern/fetal distress. And what can all of these lead to…that’s right…a cesarean section! (Goer, 79-83)

#5 Get an amniotomy too soon.

Amniotomy (or artificially “breaking the bag of waters”) too soon can lead to umbilical cord compression/fetal distress, abnormal fetal heart rate patterns, cord prolapse (a surgical emergency where the umbilical cord slips out into the birth canal before the baby’s head), increased likelihood of maternal infection and hence a “race against the clock” to get a woman “delivered” before 24 hours is up, and lastly, a greater chance that the baby get “stuck” in a posterior (back of head toward your back) or acynclitic (head tilted off to one side) position which can stall labor and make pushing at best, difficult and at worse, unsuccessful. Bottom line, if it ain’t broke, leave it alone! Not obeying that rule could lead you to an unnecessary cesarean! (Goer, 99-104)

#4 Accept pitocin to induce or stimulate contractions.

The use of oxytocin (pitocin) for labor augmentation (aka “revving up a slow labor”) or induction (aka artificially starting a labor that hasn’t started on its own) has its own risks. Although oxytocin is quite effective at stimulating contractions, it often makes contractions stronger and longer than natural contractions, can cause too many contractions too close together (aka uterine tachysystole or hyperstimulation) which can lead to fetal distress, can double the chances of a baby being born in poor condition, and eventually can lead you to the operating room! (Goer, 65)

#3 Request an epidural.

Research has shown that epidurals 1) interfere with a mother’s natural release of labor hormones which can in turn (among other things) slow or stop her progress of labor, 2) increase her chances of needing pitocin augmentation for said slowed labor, 3) numb her pelvic floor muscles, which are important in guiding her baby’s head into a good position for birth , 4) can cause maternal fever than can be mistaken as a sign of infection, 5) can cause a significant drop in her blood pressure which can interfere with how much blood supply is getting to the baby and can lead to profoundly negative effects on the baby’s heart rate, 6) significantly impair in her ability to push her baby out effectively. All of these side effects/risks, as research has shown can, and often does, lead to a cesarean section. (See “Epidurals: risks and concerns for mother and baby” by Dr Sarah J. Buckley)

#2 Accept hospital staff’s comments on lack of progress without challenge.

In my opinion, nothing is more detrimental to a woman’s labor progress and ultimately her birth experience than negativity in the labor room from labor & birth attendants, especially the people who are the “professionals” like obstetricians, midwives, and nurses. As Marsden Wagner, MD, MS writes in his book Born in the USA, fear and anxiety stop labor. And giving a woman the impression that she is “failing” can lead to a helpless and hopeless attitude and eventually a cascade of interventions that might very well lead to a cesarean section.

#1 Just ask!

Believe it or not, there are some OBGYNs out there that will agree to perform a cesarean section on a first time mom without medical indication. Goer writes, “Popping up lately in the medical literature are arguments that women should be able to have first cesareans for the asking as well. Again, this is presented as a freedom of choice issue. But how much real freedom do women have in a culture that portrays labor as torture and C-sections as a ‘no muss, no fuss’ option?” Goer states that the obstetric belief that choosing between a cesarean and vaginal birth is like choosing “between chocolate and vanilla” is really about six things: money, impatience, convenience, peer pressure, hospital culture, and defensive medicine. What I find even more disturbing than this, however, is that women who do desire to avoid a cesarean and plan for a vaginal birth after a cesarean (VBAC) are finding themselves with less choice and opportunity to do so in more and more communities around this country as more and more obstetricians are refusing to attend VBACs and hospitals are either banning or placing de facto bans on VBACs.

And lastly here is my own addition…number 8!

#8 Agree to a labor induction without medical indication.

Induction of labor comes with risks and the BIGGEST risk is the risk of cesarean section. When induction of labor is done for a medical reason, either related to mom or baby, and the risks of continuing the pregnancy are greater than the risks of induction, then this is the only time when labor induction is appropriate and warranted. But when a woman agrees to a labor induction without any medical reason, then she is putting herself at risk for an unnecessary cesarean section, plain and simple.

Many obstetricians I work with claim that all the “elective” labor inductions (that is, inductions without medical indication) are because the woman “demands” it. And don’t get me wrong, there are some women out there who are a bit mislead. But all to often a woman shows up for a labor induction and it is overwhelmingly obvious that she: 1) wasn’t fully explained both the benefits AND risks of labor induction, 2) wasn’t told that labor induction can take up to three days to complete, 3) wasn’t told that comfort measures like using a jacuzzi tub or shower, walking, using the birthing ball, eating, drinking, and general freedom of movement are MAJORLY restricted during labor induction either because of hospital policy, obstetrician’s philosophy, or the requirement of continuous external fetal monitoring, 4) didn’t realize she had the option to say NO.

So there you have it, the Top 8 ways to have an unnecessary cesarean section. I wish it wasn’t true but unfortunately it IS!

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

“We have a secret in our culture, and it’s not that birth is painful; it’s that women are strong.” ~ Laura Stavoe Harm

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More Trouble With Repeat Cesareans February 23, 2009

On Thursday February 19, 2009, TIME.com published a remarkable article entitled The Trouble With Repeat Cesareans which takes a hard look at the rising cesarean rate in the United States, making C-sections the most common women’s surgery in the country. If you haven’t yet read the article I highly suggest you do!

There are many things about this article that I like. First off, to find an article tackling the lesser-known side of a debate, like the “VBAC-lash” as author Pamela Paul so aptly describes it, is uncommon in popular, highly circulated news magazines (“VBAC” for those that are not familiar with the term, stands for “Vaginal Birth After Cesarean”). Typically media outlets like these go for what I like to call the “rare & scare” stories like such nonsense as, “The 100 ways your baby could die at birth!” and “Midwives Going Postal!” The major and life-threatening consequences related to our country’s rising cesarean rate and the rapidly declining opportunities that women have to plan for a VBAC are serious public health and women’s health issues that need and deserve national attention!

The second thing I really like about this article is the title; “The Trouble With Repeat Cesareans” couldn’t be more appropriate. Kudos to the editors of TIME magazine for nailing it with this one, considering that currently 9 out of 10 births following a cesarean are also a cesarean. Clearly there are too many obstetricians and even many women not taking the risks of multiple major abdominal surgeries seriously!

Thirdly, I think author Pamela Paul does a great job emphasizing the risks related to repeat cesarean sections when she writes,

“With each repeat cesarean, a mother’s risk of heavy bleeding, infection and infertility, among other complications, goes up. Perhaps most alarming, repeat C-sections increase a woman’s chances of developing life-threatening placental abnormalities that can cause hemorrhaging during childbirth. The rate of placenta accreta–in which the placenta attaches abnormally to the uterine wall–has increased thirty fold in the past 30 years.”

Much too often articles related to this subject only report on the risks of VBAC and not the risks and complications of repeat C-sections which is both misleading and dangerous! I would like to take this opportunity to elaborate on Paul’s list by citing some other serious risks related to repeat cesareans, as outlined in the book The Thinking Woman’s Guide to a Better Birth by Henci Goer (pg 168):

1. Increased risk of injury to other organs, including bladder & bowels,

2. Anesthesia complications including spinal headache, low blood pressure, backache, infection, nerve damage (including paralysis, loss of bladder and bowel function, loss of sexual function), allergic reactions, seizures, cardiac arrest and death (see: Redding Anesthesia),

3. Scar tissue formation (called adhesions) resulting from every abdominal surgery leading to a more complicated surgery with each additional cesarean which increases a mother’s chance of chronic pain and bowel problems,

4. Increased risks for baby including poor condition at birth, breathing difficulties, bruising, and jaundice,

5. Increased risk of placental abnormalities including placenta accreta (described above) and placenta previa (where the placenta grows over the cervix) putting mother at risk for a life threatening hemorrhage during the pregnancy & delivery, which could result in hysterectomy in serious cases, and

6. Increased risk of ectopic pregnancy (a surgical emergency where a fertilized egg implants somewhere besides the uterus (e.g. in a fallopian tube)).

The Bottom Line: All of these complications increase a mother’s risk of prolonged hospitalization, hysterectomy, and maternal death.

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

Although I feel the article made some great points, I feel that some very important facts were either missed or not stressed enough in the article and at this time I would like to share some additional information that I feel will provide you with a more comprehensive picture of the VBAC/Repeat Cesarean debate. Here we go!

(1) FACT: The high-profile cases of uterine rupture during a VBAC in the 1990s were directly related to the use of the drug Cytotec (generic name misoprostol) for labor induction on women with a history of a prior C-section.

Marsden Wagner writes in his book Born in the USA: How a Broken Maternity System Must Be Fixed to Put Women and Children First that between the years of 1994 and 1999 approximately 25,000 women in the United States who had previously undergone a prior C-section were given Cytotec for labor induction and out of those women, 1,000 of them suffered ruptured uteruses, a rate that is a twenty-eight fold increase in the rate of rupture over having a VBAC without Cytotec induction. He also writes that despite years of mounting evidence and research studies reporting the risks of using Cytotec for labor induction on women with uterine scars, OBGYNs continued to use the drug (which was neither approved by the FDA for labor induction nor clinically trialed in a research study for a safe and effective dose) for this very purpose proving once again the pervasive anti-precautionary obstetrical culture of “assumed safe until proven otherwise.”

(2) FACT: Women can safely have a VBAC in a hospital, an out-of-hospital birth center, and even at home! (And they have too!) VBAC becomes more and more risky when you start to obstetrically intervene, like in the case of labor induction and augmentation.

Wagner writes,

“The phenomenon [with the increase in uterine ruptures during VBAC in the 1990s] was almost certainly related to the fact that the percentage of births in which powerful drugs, such as Cytotec, were used to induce labor had doubled, given that studies show there is an increased risk of uterine rupture with pharmacological induction. But instead of acknowledging and addressing this connection by recommending that obstetricians not use Cytotec for induction, the organization recommended that a women not be permitted to attempt a [VBAC] unless she was in a hospital where an anesthesiologist was [immediately available]. In other words, instead of preventing uterine rupture, ACOG said that we should surround the woman with experts to deal with the rupture when it happens. This is like trying to solve the problem of children drowning at summer camp by not teaching the children to swim, but rather by putting a couple of life preservers in the lake.”

(3) FACT: A cesarean section performed after an attempted VBAC is NOT necessarily an emergency cesarean section!

In the TIME article, author Pamela Paul writes:

“Yet as of 2006, only about 8% of births were VBACs, and the numbers continue to fall–even though 73% of women who go this route successfully deliver without needing an emergency cesarean.”

In other words, the 27% of women that Paul describes needing a C-section after an attempted VBAC did not necessarily have an emergency cesarean, contrary to what Paul writes. The high-risk urban hospital where I am currently employed as a labor & delivery nurse (which happens to have anesthesia and an attending physician in house 24/7) classifies the urgency of cesarean sections into 4 categories:

● Category I (STAT): Immediate threat to life of woman or fetus (e.g. prolapsed umbilical cord, uterine rupture, anaphylactoid syndrome, prolonged fetal heart rate deceleration with no return to baseline). Luckily, these are the most rare type of all cesarean sections; however, the risk of needing a STAT cesarean increases with more obstetrical interventions.

● Category II (URGENT): Maternal or fetal compromise, not immediately life threatening (e.g. non reassuring fetal heart rate pattern, like prolonged and repetitive variable decelerations or repetitive late decelerations caused by cord compression or utero-placental insufficiency). Indications for these types of cesareans allow for the physician and anesthesia to get to the hospital (quickly of course) and for nursing to prepare the patient. Don’t get me wrong, these cesareans are considered an emergency, but they allow for decision making and (rapid) preparation, unlike category I cesareans, which always require immediate transfer to the operating room and general anesthesia.

● Category III (ASAP): Needing early delivery but no maternal or fetal compromise (e.g. “failure to progress,” “dysfunctional labor,” and “cephalopelvic disproportion.”) This category of cesareans is what the majority of women who have attempted a VBAC but ended up needing surgery will encounter. They require a timely delivery but these women often “sit” for hours if needed, like if the operating room is currently working on a more urgent case. These are NOT emergency cesareans.

● Category IV (INTRAPARTUM SCHEDULED): At a time to suit the mother and maternity team (e.g. scheduled primary or repeat cesarean sections for indications such as breech baby, stable placenta previa, and elective repeat cesarean).

As you can see, if you are one of the 27% of women who ends up with a C-section after an attempted VBAC it will not necessarily be an emergency, but unfortunately, that is what the public has been mislead into believing. Regrettably, fear clouds good judgment.

(4) FACT: The current medicalized culture of childbirth in the United States, as well as the territorial nature of obstetricians have resulted in the development and use of the so-called “informed consent” form for VBAC, but no such form is routinely given to patients who agree to scheduled repeat cesareans.

In The Thinking Woman’s Guide to a Better Birth, author Henci Goer writes:

“[The informed consent for VBAC form] details all the horrible things that could potentially happen should the scar give way during a VBAC. But this form is not really about informed consent because it says nothing about all the equally horrible things that could potentially result from an elective cesarean. In fact, the obstetrician editor of OBG Management, who devised its prototype and promotes use of such forms, openly admits that the motivation behind them is forestalling lawsuits and that using them will ‘send your C/S rates soaring.’”

Why are we teaching our women to fear birth but blindly accept risky obstetrical interventions and major abdominal surgery as no bid deal? We’ve got it backwards! When the operative consent for a repeat cesarean is reviewed with patients at my hospital, the residency staff is taught the following spiel, and I quote, “This is a consent for your doctor to perform a cesarean section for you today. The risks of the procedure include injury to your bowels or bladder, infection, and bleeding, all of which are very rare and can also occur in a vaginal delivery. Sign on the X please.” Talk about spinning the facts and lying by omission!

The obstetrical community spends a lot of energy arguing that it should be a woman’s right to choose whether they undergo the “risks” of VBAC or choose the more “controlled” and “predictable” option of the repeat cesarean section. While I agree with basic idea behind this (i.e. that a woman deserves the right to make choices about her own body), OBGYN providers in this country are NOT providing patients with true informed consent. In addition, these obstetricians are especially not letting women on to a very important and real phenomenon that is a direct result of the cesarean epidemic: The first cesarean is very easy but the second, third, forth, and fifth cesareans are exponentially more complicated and dangerous.

Which leads me to my next point…

(5) FACT: Women are notoriously bad at predicting how many children they will have at the time of their first delivery.

A 2008 research study published by physicians in the Division of Maternal-Fetal Medicine at the University of Michigan, Ann Arbor in the journal Obstetrics and Gynecology found that at the time of a woman’s first pregnancy, “many women underestimate their final parity,” meaning at the time of their first baby, almost 40% of women thought that they were eventually going to have fewer children than they actually ended up having. This research finding is very important to the VBAC debate because many women figure that if they are only planning to have one more baby, then it is “no big deal” to have a repeat cesarean.

…Until of course they separate from their partner or go through a divorce, meet someone new and want to have baby with their new partner. Or what about those women who never expected that “oops” pregnancy after what was supposed to be their last baby. Or the couples who decided that they really do want to try for that baby boy/girl they don’t have after all! Not only do these scenarios happen but they are common in today’s society. So what are we left with? A bunch of women who thought they were going to have just one more cesarean, that now are going for their third or forth, resulting in even less providers who will attend their VBAC and even more risk for complications if they even try.

Bottom line, we need to change our whole mindset when it comes to VBAC. When a woman undergoes her first C-section, everyone should just assume that if she gets pregnant again she will plan for a VBAC, NOT the other way around! North American obstetricians should not have to be dragged into doing VBACs. If there is a good reason why a woman can’t VBAC, like prior classical uterine scar/extensive uterine surgery or placenta previa, its then and only then that our providers recommend a repeat cesarean. OBGYNs tend to forget that the only way one can know that a VBAC will or will not be successful is to allow the woman to labor! In her book The Thinking Woman’s Guide to a Better Birth, Goer reports that several studies published in leading obstetric journals have found that when physicians “genuinely encouraged women to have VBACs, most of them did, and when they said nothing or acted neutral, most women didn’t.”

(6) FACT: Physician convenience should not enter into the VBAC debate at all! With the safety of our mothers and babies at stake, the “make it home in time for dinner” phenomenon among obstetricians is unsafe, selfish, and irrelevant.

In the TIME article, Paul writes,

“Among obstetricians, many solo practitioners are unable to stay for what could end up being a 24-hour delivery; others calculate the loss of unseen patients during that time and instead opt to do hour-long cesareans, which are now the most commonly performed surgeries on women in the U.S.”

I feel Paul has correctly captured the attitude of too many obstetricians in this country (and how outrageous it is!). First of all, putting “time limits” on how long a woman should be “allowed” to labor is preposterous and irresponsible and often leads to the unnecessary “cascade of interventions” too often seen during labor in a hospital setting. Newsflash! Labor takes time. This fact of life should not be an indication for cesarean section. This is why physicians and midwives form group practices, so one can be “on-call” while the others can be in the office seeing patients or have the day off. Perhaps “solo practitioners” need to rethink their business strategy instead of “opting” to perform unnecessary major abdominal surgery on the unsuspecting women of our country.

And lastly…

(7) FACT: BIRTH IS SAFE, INTERVENTIONS ARE RISKY!

I wish I could scream this from the rooftop of every labor and delivery ward in this country. In Paul’s article she reports, “Some doctors, however, argue that any facility ill equipped for VBACs shouldn’t do labor and delivery at all.” I hate to break it to these physicians but 24/7 in house anethesia is not necessary for a woman to have a VBAC. It seems like it is just impossible for many obstetricians to open their eyes and realize that the research and statistics of 26 other countries with better maternal and fetal mortality rates than our own have shown, time and time again, that birth can safely happen OUTSIDE of the hospital. You heard me right! For women with normal, low-risk, uncomplicated pregnancies, labor and delivery can safely and does safely occur in homes and out-of-hospital birth centers around this country (and the WORLD) every single day.

Look, if it was true that prominent national figures in power were never wrong, then John McCain wouldn’t have told the American people that “the fundamentals of our economy are sound” two days before our country began its slide down into the biggest economic crisis since the Great Depression!

So what does it all mean? In conclusion, whether you are a pregnant mom, partner, labor companion, concerned citizen, healthcare professional, or birth advocate, I just hope that when it comes to the “VBAC debate”, you will make a truly informed decision based on sound research and evidenced-based recommendations rather than become subject to the dangers of defensive medicine and poor or untrue information that currently plagues our existing maternity system in the United States.

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Nursing Birth

One Labor & Delivery Nurse’s View From the Inside

Great Birth Story April 25, 2009

My Philosophy: Birth, Breastfeeding, and Advocacy April 25, 2009

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

Why Is Vaginal Breech Birth Going the Way of the Dodo? April 9, 2009

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

Don’t Let This Happen To You #25 PART 1 of 2: Sarah & John’s Unnecessary Induction April 5, 2009

Top 8 Ways to Have an Unnecessary Cesarean Section April 3, 2009

More Trouble With Repeat Cesareans February 23, 2009

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