labor nurse has been reborn and shares her experiences as a new nurse-midwife, woman, and blogger

Monday, October 13, 2008

Vertex

Imagine all our surprise when the baby is pulled from the mother's abdomen from a vertex position during a c-section for breech.

First of all, I'd be pissed if I were that woman.

During my most recent shift at work (remember, I am still working as an RN) I was assigned to care for the scheduled c-section patient. Things during the prep were going along just smoothly, the woman and her husband were really responding to me and I found that the anxiety level they walked in with was soon next to nothing. During my prep, I asked the resident if she wanted to scan the woman to ensure that in fact this baby was breech. She said she would, asked if I would get the bedside ultrasound machine while she went to get the attending.

A few minutes later the resident said the attending felt it wasn't necessary; his Leopold's in the office the previous day along with an ultrasound at 37 weeks (she was 39 weeks now) confirmed the breech position. For a brief second I contemplated performing Leopold's maneuvers myself but decided against it as I didn't want to overstep my RN boundaries. The resident did them, however, and I could tell she was double checking herself...but she never said anything to me about what she was feeling.

And so all goes on without a hitch. When the doctors get to the uterus I always go around to watch- I find it fascinating watching a baby emerge via vagina or abdomen- and so I parked myself towards the foot of the surgical table. The resident reaches in to grab the fetal part in the pelvis and pull it through the incision. It's a head.

The room goes quiet.

Then as usual, baby is handing over to the awaiting baby nurse and pediatrician and the father goes over to the warmer to see his baby for the first time. Baby is taken to the woman and all goes well with the suturing and closing.

We then go to the recovery area, and things continue to go without a hitch. The woman feels well, the spinal working well for her pain, and her vital signs are stable. As I am assisting her with breastfeeding the baby for the first time, the attending and resident come in. The attending is more congenial than usual, and he's got a big smile on his face.

"Well!" he booms, "That baby must have done a last minute turn."

"What do you mean?" the husband asks.

"The baby was actually in a head down position," the attending answers.

Again, silence.

The conversation moves on and the attending continues to discuss the c-section; that in fact, it was perfectly fine that they did a c-section on a baby that was vertex because, well, the baby was a little on the big side (8lbs 6 oz) and her pelvis was "questionable". I knew the pelvis thing was grasping at straws because I had reviewed all the prenatal records when doing my nursing assessment and read the physical exam section. The doctor checked "gynecoid" under pelvis type- this is the most preferable pelvis type for childbirth. The baby's size would likely not have been an issue either, as many woman give birth to 8 pound plus babies. Not to mention that 8lb 6oz is not considered "macrosomia".

After a little more discussion between the patient, her husband, and the doctor they seemed ok. They were in the middle of being excited and overwhelmed of meeting their brand new baby. I continued my recovery assessments and said nothing about the vertex thing.

When the woman was about to be transferred to postpartum, the husband said to me, "So that c-section wasn't needed, was it?"

I paused. What do I say? I was conflicted. Do I try and support the doctor by saying something vague? Do I claim ignorance? Ultimately I decide to do best- tell it like it is:

"No," I say, "It wasn't."

The husband slowly nodded, taking in what I said.

36 comments:

womantowomancbe said...

Congratulations on your honesty. It makes me feel good to know that there are care providers who value honesty over saving face. I wish the doctor had been as honest as you.

-Kathy

Doreen said...

That's so sad. I would have been furious. What's even more sickening is the dr. fishing for more reasons why the c-section was a good thing, anyway. He could have just said the baby flipped last minute, and left it at that. Why find more excuses?

BTW, I like your playlist. Brings back a lot of memories. :)

Jennylou's Projects said...

I hope they find ICAN.

yasmara said...

Wow - interesting story. Reading it reinforced to me that we always have to be our own best advocates in our health care.

I have to say, that if I had been that patient I would like to think that I would have required an u/s before a c-section if the only reason for it was a breech baby. Better to "waste" a few minutes ($$) before major surgery than do an unnecessary surgery. Then again, I had both my babies with a CNM practice and always felt like I was very involved in the care I received so I probably (never can say for sure) would have felt comfortable speaking up (and I have good health insurance).

I wonder if there could be a short paper written looking at the numbers (and $$s) comparing how many u/s confirmations add up to 1 unnecessary c-section, i.e., a c-section costs the hospital X and it takes 20 u/s to equal X. On average, a c-section is done "unnecessarily" (i.e., baby flips back to vertex) 1 out of every Y times...then again, you'd only want to publish if the numbers come out on the side of u/s confirmation!

curdiemer said...

:(

As a person who knows what lengths one has to go to get a chance at a VBAC (and I had it much easier than some). I am mourning her loss.

When I got to L&D one of the residents felt around to ascertain the position of the baby even though the baby had been head down since week 36. My OB always made me feel the baby's head at appointments. I always thought breech was pretty easy to figure out.

curdiemer said...

I forgot to add my question at the end. 3 year olds are distracting :)

Do you think the resident feeling around couldn't feel anything conclusive or do you think she felt the vertex position but decided not to question the attending?

Molly said...

Oh, God.

Well, I'm glad you told them the truth; they deserve to know. (And if she may have other babies, she certainly shouldn't have this weird idea that her pelvis is "questionable" implanted in her mind. In fact, even if she's NOT having more babies, 'it's-not-that-we-screwed-up-it's-that-your-body-is-inadequate' is not cool.)

Blech. Stories like that upset me.

Renee said...

How sad and scary! I totally understand you not wanting to overstep your bounds, don't feel bad about that. I hope they are ok with what happened. I did some research lately and and found out that it may have not been necessary, but it was a different situation. I am ok with it now, but I don't think I would be if it was due to a doctor screw up.

Julia said...

Oh man. I would be pissed if that happened to me. So many things to say about that. I know, I would be searching for a new provider for any future children.

Laura said...

Slightly off-topic, but what are your thoughts on delivering breech babies? It seems like the current standard is breech=c/s, no discussion allowed. Are breech births really all that dangerous? I've known or read about a number of vaginal births that were inadvertently breech (twin flipped after the first was out, that sort of thing) and they all turned out fine. Have I only heard about the lucky ones or is a c/s for breech just a CYA thing?

evil cake lady said...

man oh man. i have had several clients who, the day of their scheduled cesarean, discover via the ultrasound that the baby had turned down! then they were given a choice--wait for labor to begin naturally, or go ahead with the cesarean. so sad this couple didn't get that opportunity.

Unnecesarean.com said...

Unbelievable.

Paula K said...

That is sooooo wrong! Good for you for being straight with them.

Anonymous said...

Shame no scan was done in the room before ever going to the OR. The U/S machine is in the room before the patient even arrives and the O does a scan right then. This is what we always do. Such a simple thing-----It would have saved this woman a very unnecessary cut. A stinking shame.

Labor Nurse said...

curdeimer, my impression is that the resident (several months into her first year) really wasn't sure. I think she had it in her head that this baby was breech as it was documented everywhere in her records, trusted the attending's findings from the previous day (why wouldn't she- many years vs several months?), and so was just not sure what she was feeling. But I am just speculating because I didn't ask.

Laura- my thoughts on breech are just thoughts as I really haven't done much scholarly work on it for the sheer fact that no one does breech vaginal unless it's dire emergency (ie,baby is half out already) and I was taught what to do. My understanding is that breech vaginal birth has gone by the wayside because the risks to mother and baby are higher than with c-section birth. So both physicians and insurance companies alike decided to go with the lower risk option. I've only seen breech birth with second twins who don't turn once first twin is out but it is a very controlled situation. There are some providers that do offer an external cephalic version in term breech pregnancies to avoid the c-section, but of course there are risks with that and it doesn't always work.

Cory said...

Good for you to tell them your opinion.

Cory

Anonymous said...

I appreciate that you had the courage to tell the parents the truth. Can't say whether I would have had that same courage, to be honest. I can see some of the docs I have worked with pulling the same garbage but no parents have questioned them. I will say that I have worked @ hospitals that would have considered your actions a mark towards dismissal, since docs are "Always right." That's the politics I always hated.

KathyH said...

I know just how she feels. Happened to me in the OR me right after they announced that my "suspected macrosomia" baby's weight was "eight pounds even!"

Three and a half years later and I'm still not over it.

Leah said...

Just had the same thing happen to me a couple weeks ago... You can read about our experience if you want at my blog... Yes, in this day and age, things like this should not happen.

Laura Jane said...

Just found your blog, great but infuriating story of this couple who SHOULD have been offered the chance to dodge the CS bullet but weren't due to a chickenshit attitude by the doctor who did the palp and didn't insist on the scan.

re breech birth - Breech is just a variant of the normal position, and the hiccups with birthing a vaginal breech are not that many more than the cephalic birth- just the skills and familiarity with it has been lost due to overestimation of risks and defensive medical dominated practice. This was greatly 'helped' along by the infamous "Term Breech Trial" which has since been thoroughly discredited. This piece of "research" has been responsible for a major increase in the CS rate, and subsequent repeat CS rate.

It is time to reclaim the right for women to birth a breech positioned baby vaginally. It is our job as midwives to work towards this. The personal IS the political.

Good for you for being honest with this couple. You should never be afraid to be honest like this, especially when the facts are well documented and indisputable, and the remedy could have been so easy and inexpensive - i.e. a SCAN for heaven's sake!

Best of luck in your career. I am a Nurse and Midwife in Australia - I qualified just over a year ago and work only in a midwifery setting - and I just love it!

Anonymous said...

Can I just add to the discussion that as an SNM during my very first (ever) prenatal care visit I was able to diagnose a breech at term?

All I had was a doppler and my own two hands. (And no instruction, I'm only in my GYN clinical rotation!)

God Bless the poor Resident.
I hope she scans folks in the future before sections or at least learns to trust her hands...

I am a Monkey's Mama said...

Sounds to me like the perfect lawsuit for an unnecessarian.

I'm so sorry this happened to this woman and her family. I'm sure at this point she doesn't even realize the repercussions of this OB's mistake. I wonder what a few months of people saying to her "at least you have a healthy baby" will do to her mindset. Maybe she'll believe them. Hopefully she won't. And I hope she finds ICAN.

Wow.

Jessa said...

Wow. Just wow. But thank goddess you told them the truth! Too many people end up leaving the hospital without knowing completely what was done to them and why. You go, sista! ;)

On another note, one of the nurses at my hospital also just passed her CNM exam. She conveyed her experience of the exam as "horrible." But, she passed!

karaonthenet said...

I delivered my daughter via vaginal breech 19 mos ago today. It is just as safe as c/s breech if your health provider knows what they are going. ACOG reversed their breech = c/s standing in July of 2006 stating (in essence) that after ~20 yrs of doing breech by c/s that the outcomes for both mother and baby were not improved over vaginal delivery. Therefore, it doesn't matter. BUT since they haven't been training med students to deliver vaginal breeches in ~20 yrs, c/s is probably safer since that's what your provider knows. Ugh!!! I found the one "old school" doc in my large metro area and he delivered my stubborn darling butt first with a room packed full of med students and residents there to learn some "old" new tricks.

Anonymous said...

Given that many OB's don't recommend doing more than 3 c/s's due to scar tissue and complications, etc. and that it is hard to find VBAC-friendly hospitals and doctors, this primary c/s might very well limit this couple's family. As a woman who's just had her 6th child, this would be EXTREMELY upsetting to me. I am not a litigious person, but this was an unecessary surgery with serious potential ramifications. Would this be a situation that you would feel justifies a lawsuit?

Fawn said...

From what I understand, certain breech presentations have equal risk factors to C/S, and that's not even taking into account the healing/breastfeeding/future pregnancy issues that go with C/S.

My local hospital recently reviewed research that resulted in a change to their breech policies; they will now allow a trial of labour for breech babies.

A friend of mine has worked very hard to make women more educated on pros and cons of vaginal breech birth. You can check out her site at: http://www.breechbirth.ca/Welcome.html.

evil cake lady said...

Laura and Labor Nurse: there are still many homebirth midwives who still catch breech babies...

midwifewithoutborders said...

Well,
I think that informing that you could have done an assement yourself, then stepped out to talk with the resident or dr and continued the request for the untrasound. Certainly and experienced L&D nurse, and CNM's opinion would have given the Dr. food for thought. So stepping outside the RN thing could have been handled.
Also i have been a certified midwife for 22 yrs, delivered many breech babies, plus twins. C-sections are not needed in most cases for these births. Fear of lawsuits is running America, and also no training is given in a hospital environment for these skills. I learned mine from Birth Center and home birth midwives. Research supports that no better outcomes from c-sections for these families. So why is it still being done?
Gail Jonhson
I wonder if this comment will be posted?

babybutterflies said...

I'm left feeling at a loss for words from your story. I hurt for this woman whose choices for childbirth were made more limited because of the arrogance of one person. Kudos to you for telling the truth. Congrats, by the way, on your CNM accomplishment.

Labor Nurse said...

Thanks to those who included info on breech vaginal birth. I obviously need to do some reading of the literature on this.

Gail- the argument could always be made that the RN can step out of her role, etc, and strongly encourage an ultrasound but I have been spoken to about not stepping out of my RN role now that I am a midwife (this came directly from a discussion I had with two doctors about a delivery where some things they did were not evidenced based and had a crappy outcome- I made mention of what the literature supports and this wasn't take well by the docs- they didn't want to listen to some nurse who happens to be a new midwife). I have taken this seriously given the fact that I need the job and have no midwife prospects in sight. I am in a tough spot right now, where I have a larger knowledge base but can't use it in a way that I'd like.

We also don't have a policy in place that mandates a bedside ultrasound prior to breech c-sections; there is one being worked on now though.

TanyaBee said...

What a sad, distressing tale! How cool that you are "opting out" of The System and looking for a new life as a midwife! I have had 4 unnecessary c/s, and I am having my first VBAC next month. We are excited! I will be back to your blog---could I entice you to show your support of VBAC by adding a link to the International Ceserean Awareness Network to your blog? THANKS for thinking about it! blessings!

Stephanie said...

When I was in labor at 35 weeks they checked to see what position my son was in before they even hooked me up to an IV. He was breech at my 32 week ultrasound, and the residents felt my belly and then wheeled in a portable ultrasound machine to verify that he had indeed turned to head down. I really don't understand how something like this could be missed!

Kelly said...

Given that you chose not to step out of your RN role due to previous discussions with docs and the fact that you need your job and have no midwifery prospects in sight, I'm a bit surprised you posted this story at all. IF the couple decides to initiate a lawsuit (I'm not expressing my opinion whether they have a viable claim), you will certainly become a witness and your testimony will be adverse to your hospital and its physicians. Plaintiffs may even name you individually once they learn you are a CNM, perhaps on the theory that you could have brought the error/omission to the attention to the doctors. Your blog post and its comments would also be relevant discoverable evidence in such a lawsuit, if the plaintiffs were savvy enough to ask the questions that would uncover its existence.

Labor Nurse said...

kelly, you have very valid points. I am sure that I would be called at the very least a witness if this couple ever chose to pursue legal action. And I am sure that my words about the lack of verfication of a breech position could be potentially fuel for lawyers but here are some things to consider:
-I was working as an RN, and despite also being a CNM now I can not be held to CNM responsibilities when working in my RN job. Even if I wasn't a CNM, and "just" an RN like the rest of the staff, it would not be my final responsibility to verify fetal position.
-I could have asked again for an ultrasound but the resident did do leopolds. Again, I didn't specifically ask what her what her assessment was, but I am not responsible for her assessments and management.
-If I was named in a suit, it would likely not be pursued because of the limited role as an RN in this situation.
-There was not a protocol to do an ultrasound for fetal position verification so ultimately the RN is not held to ask for one.

I am interested in reading other RNs thoughts on this aspect of this story. I've thought about what Kelly mentions before and am open to other thoughts on it.

mm said...

man...

I think we always ck with u/s in this situation. But I think I'm going to keep this story in mind and have the U/S machine conveniently already bedside from now on, just to make sure it's done/ make it harder for an MD to be tempted to skip it!!

I did have a breech mama just a couple of weeks ago who came in for her scheduled cesarean & ended up being induced with her flipped-to-vertex baby!

I feel for you in this situation! Some people that I work with would be flippant about it, they really don't care that much whether someone has a section or not, but I do.

Anonymous said...

Just found your blog and had to tell about my sister-in-law. The baby had been breech but the dr thought he had turned-not sure what she did to determine that, it was not an ultrasound. So, they induced and 18 or so hours later finally figured out the baby was still breech. Off for the c-section she went after almost a full day of miserable labor. Why, Why, Why take a chance when the wonderous ultrasound is available??