“Forced” delivery

18 02 2012

 

Of all of the medical specialties I can think of, I have encountered the largest gap between physician’s knowledge and patient understanding with obstetrics.  I can’t tell you how many people I have heard get upset that the doctors were “too impatient” to wait for them to go into labor naturally, who “forced” them to take pitocin, who wanted to do C-sections “unnecessarily, because it was quicker and easier.”  It’s funny, I’ve heard and read so much of this opinion before my month on the other side of the fence that I was one of those people once, too.  I thought it was stupid that doctors in hospital maternity wards treated pregnancy as a pathological condition rather than a physiologic one.  I was opposed to pitocin, couldn’t see the reason for induction of labor, and was very convinced that the C-section rate in this country was far too high.

Having been in obstetrics—or, as they call it, maternal-fetal medicine—for three weeks now, I have learned of an incredible number of circumstances in which labor should be induced, or a C-section should be performed, simply because the risks to both mom and baby with conditions that seem simple and mild are often much more dangerous than people can realize.  I mean, come on, I’m in medical school and I was never taught these things in the first two years of schooling.  In fact, my understanding is that many non-Ob docs don’t know these things, either, simply because obstetrics seems to be an intrinsically unique specialty with its own set of abbreviations and priorities that the physicians who focus on every other organ system don’t pay attention to.

So then if there are legitimate reasons for the increased numbers of inductions and C-sections, why does it seem that the women who undergo them don’t understand why?  The doctors are explaining it—I have never been in a situation where the doctor just went into the room and said “well, we have to cut you, we can’t wait anymore” and that was that.  Almost every woman asks why, and the situation is always explained.  While in the hospital, the patients always voice understanding.  It’s only after they leave, it seems, that women become angry at how their birth experiences were, at which point they can no longer ask specifics of the people who cared for them in the hospital.  At that point, the only place left to go is the internet.  And y’all know how I feel about people trying to answer their medical questions on the internet.

In case you are wondering, the increase in labor inductions and C-sections can be attributed to two factors:  research, and the L-word.  Lawyers.  Lawyers seem to be, by far, the biggest influence.

Let’s talk about VBACs for a second.  VBAC (vaginal birth after Caesarean) seems to be a totally normal thing these days.  Back in the 80’s, it wasn’t so common.  In those days, it was felt that if a woman had to have a C-section, she could never give birth “the normal way” again.  It’s not because the uterus doesn’t work anymore, but out of fear of uterine rupture.  The old way of doing C-sections involved a big ol’ vertical slice right in the middle of the belly right through the part of the uterus that contracts the strongest during labor.  When the muscle is damaged, scar tissue is formed, and this area becomes weak in the future.  So if the strength of subsequent labor contractions is too much, the uterus could rupture.  This could easily result in death of the mother from massive hemorrhage, death of the baby from suffocation, or both.  The risk is so high with what they call “classical” C-sections that these women are not even allowed to try what they call a TOLAC (trial of labor after Caesarean, the step to make sure a VBAC is okay).  With the newer technique, called low transverse C-section, the cut is made through the low, non-contractile part of the uterus, so the risk of rupture is 0.5-1%.  Even this is too high a risk for a lot of smaller hospitals, and in those places TOLAC (and therefore VBAC) is completely out of the question because if they were to rupture, lawyers can still sue and win (even though between 99-99.5% of these women will be fine).  Personally, I think that’s ridiculous!

You may be asking why people get C-sections in the first place.  There’s giant list in my textbook, so I’ll list a few and then expand a little on some of the more nebulous things.

  1. Any multiple pregnancy with more than 2 babies gets a section.  Labor might suck for mom, but it’s way worse for baby.  Just imagine getting the air squeezed out of you for 2 minutes out of every 3-4 minutes for hours at a time, and that’s just one labor.  Healthy fetuses can tolerate this for a normal labor, and it’s even feasible for a twin to effectively have to go through two sets of labor contractions.  But once you get up to baby 3, or even 4, their brains just can’t take that lack of oxygen.  They are also already fragile because they are hardly ever term.  Women also get sections if they have twins, but the first one is breech.  With two babies, it isn’t always feasible to try to turn the first one.
  2. Placental issues are another one.  If the placenta is right over the cervix where the baby is supposed to come out, mom could easily hemorrhage and die.  If the placenta is implanted too far into the uterus, same thing.  These c-sections are all about keeping the mom from dying.
  3. If the water breaks way before labor starts.  This is one of the ones I’ve heard the most women complain about the doctor being impatient, cutting them because they didn’t want to wait.  The problem is that this poses the risk of a very serious infection called chorioamnionitis (infection of fetal membranes).  This one can be fatal to both mom and baby—in fact, about 1/3 of fetuses actually die from the infection, and another 1/3 end up with cerebral palsy or brain bleeds.  Bad, bad, bad.  Because it takes longer to induce labor than they can afford to wait due to the window of infection, the best option for these women is the big C.
  4. If the baby can’t take the stress of labor.  This happens more easily if the mother is a smoker, does cocaine, or has high blood pressure or diabetes.  This is because, due to issues with the blood vessels in the placenta, the baby has a lower fetal reserve—these kiddos just can’t tolerate the stress of labor without going too long without oxygen and risk brain injury.
  5. Some maternal illnesses, and some fetal illnesses.  If mom has active genital herpes, untreated HIV, or cervical cancer, the risk of transmissions skyrockets if a vaginal delivery happens.  [Sidenote, I actually had a patient last week with active genital herpes who didn’t want her partner or family to know.  She refused a C-section so she didn’t have to explain why.  The baby is now in the NICU being watched for herpes encephalitis].  If baby has a problem where it’s a bad idea for it to get squeezed through the birth canal, that’s another indication.
  6. Baby too big, or pelvis too small.  If it won’t work, it won’t work.
  7. Failed induction.  Induction is artificial, so the body doesn’t always respond.  Why induce?  Well, one of the biggest reasons is diabetes, because those babies get so huge that they (more specifically, their shoulders) often get stuck on the way out, requiring a lot of tough maneuvers and potentially resulting in permanent damage to the baby’s arm from the nerves between the neck and shoulder stretching out.  These moms are usually induced at 37 weeks.  Another common indication is a long gestation.  This seemed stupid and impatient to me at first, the idea of inducing at 40-ish weeks, until I learned the reason why: placenta.  The placenta is only designed to last 39 weeks, after which point it starts to die off (and with it goes baby’s blood supply).  After 40 weeks, the risk for what they call intrauterine fetal demise (read: dead baby) drastically increases.  One doctor told me that he saw a woman carrying a completely active, healthy baby one day and less than 16 hours later the baby had died.

There are, of course, a bunch of other reasons, but these are the big ones.  Can these complications arise during delivery with a midwife?  Absolutely.  Do patients with babies brain-injured during delivery ever sue midwives for the damage?  Absolutely NOT.  First off, women assume that everything was natural, so it couldn’t possibly have been the midwife’s fault.  Second, midwives have no money.  Hospitals do. And so do physicians (after they’ve been practicing for 20 years or so).  Because the parents of a baby an Ob/Gyn delivers tomorrow can turn around and sue until the kid is 18, there’s plenty of time for the kid to have learning disabilities or behavioral issues that can be blamed on the physician, which means that a lot of steps are taken to cover their butts during delivery.  These docs have a lot at stake, and they don’t like taking unnecessary risks with a potentially dangerous normal vaginal delivery even if the mother says it’s okay, because she can always change her mind and sue later if things don’t turn out 100%.  C-sections are viewed as the ultimate in “we did everything we could to protect the health of your baby,” which could be a reason why so many are done.  At the same time, though, C-sections are major surgery, which I think is something that women take for granted.

So now I understand much better why Obstetricians make the decisions that they make when a mother might want to have a natural birth experience more than anything else.  On top of everything else, the priority is to save the life and health of the mother and the baby (in that order).  Because the stress of labor is very time-sensitive, things can go very wrong, very quickly.  It’s not that the doctor is impatient, or has a golf game to go to (because, believe it or not, the vast majority of physicians feel a huge sense of responsibility for the well-being of their patients), or likes to cut people.

Next time a friend or family member has to have labor induced or undergo a C-section rather than the birth plan she had wanted, and they blame it on the doctor in charge of their care, take it with a grain of salt.  If I, a 3rd-year medical student with much more knowledge of this system than most people, didn’t understand why this occurs so often, they probably don’t, either.

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10 responses

19 02 2012
Laughter Brothers

Very well written. In practice its main factors in order are obstetricians time > money > impatient first time mothers > lawyers and complications > hospital management. Either ways there is now a shift in trend towards assisted and c-sections. Are you planning to pursue gynec in residency ?

19 02 2012
Journey through the Birth canal – Stage 2 labor « Laughter Brothers

[…] “Forced” delivery (scrubbedin.wordpress.com) […]

24 02 2012
Dr. G

Thank you for this post – EXACTLY how I feel about it.

28 02 2012
Gwen

Thank you for this post. I have been confused about why these things were the case – especially the risk of infection from a broken amniotic sac & was rather irritated.

Did my doctor tell me that he wanted to augment due to risk of infection – yes, but he didn’t really tell me what that meant or what the risk to my baby or myself was (either for the augment – I was a vba2c – or for the infection). I like him & he did a good job so I went along with what he wanted, but I never understood it until I read your post. The funny thing is that I didn’t even come here for that kind of info…

6 03 2012
Med School Odyssey

Great post – this is spot on. It’s also the reason for why teaching and communication are important qualities for physicians. If patients feel like they didn’t get their questions answered once they get home, they flock to the internet, which has no problem filling their head with nonsense, particularly on subjects like obstetrics and vaccines.

11 03 2012
speculativespeculum

I feel that communication is key. The woman needs to feel comfortable asking questions, and the doctor needs to be willing to explain the pros and cons of different interventions.

I was never told why I need to have pitocin when I was progressing just fine during labor. The doctor never made it for delivery because I went too quickly after that, and my daughter ended up being delivered by a nurse instead. The nurse said that my Dr. probably just wanted me to deliver before lunch time. I will refuse pitocin if ever placed in that particular situation again. Pitocin in my case was completely unnecessary and teaching was never given. My Dr. did say later that she knew that she shouldn’t have started Pitocin with me since I did have a precipitous delivery with my second (was at work in the ER and almost didn’t make it upstairs in time). I should have spoken up, but like many women, I assumed that doctors know best. Things turned out okay. Labor was more painful, but my baby was fine. In the end, that is all that matters.

And the old joke in OB goes that if you present with a birth plan that you will end up with a C-section. Never write a birth plan because they are pointless.

21 03 2012
Rebecca

With all the “research” women do on the internet before delivering their babies, I certainly hope this short piece becomes required reading. Well done.

22 03 2012
Stephanie Briggs

“And the old joke in OB goes that if you present with a birth plan that you will end up with a C-section. Never write a birth plan because they are pointless.”

Brilliant. Just brilliant.

1 06 2012
Gina

It was never explained to me why I “had” to have a C-section. My doctor simply said “I see no reason to wait–we have a full term baby here”. I did have pre-eclampsia, but it wasn’t an emergency(they told me that it wasn’t an emergency, anyway) as of yet, and since I am now suffering from PTSD because of the experience, I think it would have been ok to give me a few hours or a day at least. I would have been fine had it come to an emergency, but it hadn’t, and I at no point felt I had any choice in the matter. Of course they dropped the “oh…the baby doesn’t look good”. Bet it had absolutely nothing to do with me being stressed from not being allowed to leave the bed and not getting any sleep because of the constant interruptions. They wouldn’t even tell me what the hell they meant by her ‘not looking good’. I was having contractions, and beginning to dilate, but they wouldn’t even give me a chance. Plus, come to find out, my doctor was in a hurry to leave on his vacation to Vegas.

The truth of the matter is, there are reasons to have C-sections, but women shouldn’t be made to have them simply because of the chance of lawsuits. That is absolute bullshit. As you said, it is MAJOR surgery, and carries risks for future pregnancies. It is not always the safest option, but it seems to be really convenient for hospitals and more can be charged for the procedure. Win win for hospitals, I guess. There is no way that almost 40% of pregnancies would end in disaster without them (that’s where the C-section rate stands in the US). That’s just too damn high.

Just because you have medical training doesn’t mean you can make the best decision for someone else. People should be allowed to weigh the risks themselves, because after a C-section, your body is never the same, and it is often REALLY hard to be allowed a VBAC (even though hospitals cannot legally require a C-section), even though the risks are actually higher to the woman for subsequent C-sections. To all the women out there, be informed about your rights and be thorough in your questioning. Don’t be afraid to stand up for yourself! And get counseling if the experience is traumatic so that you don’t hurt yourself or God forbid your baby. Luckily I didn’t, but life was hell for a while…

3 06 2012
Glia414

First off, you CAN refuse a C-section. That’s what the woman in this post did.

And I agree. You should have the choice to make a decision that would endanger your life as well as the life of your child. Nobody’s stopping you. But, at the same time, I also very strongly believe that if this is the choice you want to make, to go against medical advice, you should have to sign Dr. Amy’s Dead Baby card or something similar (it goes something like this: I fully understand and acknowledge that the choice I am making may result in the death of my baby, and I assume complete responsibility for my child’s death).

I’m sorry about your PTSD, from what I have seen in combat veterans, it’s a terrifying illness. But I’ll take the PTSD over a dead baby any day.

So, what do you think?

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