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

Thursday, August 20, 2009

Being Pushed

Recently I was having a discussion with a woman who was 2 week postpartum. She had an elective repeat c-section for her sixth child. The fifth was her unplanned primary c-section for fetal distress. The first four were vaginal deliveries that went smoothly (this is how she describes them, and her chart would support this as she had uncomplicated pregnancies and births with normal postpartum courses). During the visit we discussed how she had been recovering and how her planned c-section went. As it turns out, the morning of her planned c-section she went into labor. She arrived to the hospital several hours earlier because she was concerned that she might actually deliver before her scheduled time for surgery.

It was found that she was 6 centimeters on arrival. Her water broke 30 minutes later. Her baby was tolerating the labor just fine, and she said she was ok with her contractions. The nurses caring for her were simultaneously prepping her for surgery quickly while telling her that she can change her mind and have a VBAC. Clearly her body was doing well and there were no signs of uterine rupture (the big looming risk associated with VBAC which in her case is considered to be <1%). The doctor comes in and briefly says the same thing, but also states that anesthesia is on their way so they can just go to the OR right then.

Now, the patient tells me that she felt that she would have been able to give birth via VBAC without problems. She contemplated choosing the VBAC last minute, but since anesthesia was coming she didn't want to inconvenience anyone. And besides, the doctor had had several cesareans herself and did just fine with that.

I was really disappointed to hear this. I felt this woman was an excellent candidate for a VBAC. Spontaneous labor, her previous c-section was 3 years ago, she'd had 4 prior uncomplicated vaginal births. And she felt she could do the VBAC, but felt committed to the surgery because she didn't want to inconvenience anyone, not to mention that she felt that a repeat c-section was a good choice because her doctor had them, too.

I wonder how often women feel compelled to make a decision based on such factors? When counseling women on VBAC versus elective repeat c-sections, I am (I hope) as unbiased as possible. I quote them the literature on the risks and benefits of each, if they meet the criteria that is considered most safe for a VBAC, and then let them know that it is solely their choice. When asked what my opinion is for what they should chose, I do tell them that I can't answer this, but rather point out that they need to assess is what risks they are comfortable with and go from there. If pushed, I do tell them I would chose VBAC for myself because I feel comfortable taking the risk of uterine rupture of <1% in the ideal case; but point out that might be too much risk for other women to feel comfortable about. But again, I will almost never discuss what I personally would do because I am afraid their decision will be made based on my personal decisions. This is why I was bothered that this particular woman felt she should chose the elective repeat c-section because her doctor did.

As a clinician, I think it's hard to be unbiased all the time. But I can see how your counseling would be swayed by your own personal experiences. I mean, if you were ok with your chosen path, why wouldn't everyone else?


Mrs. Spit said...

How in the world does a doctor sign off that they got informed consent, when the only information they gave a patient was "I had a repeat c-section and I'm fine?".

Did they indicate the risk of infection? Problems with breast-feeding? Adhesions?

I'm a huge fan of c-sections for fetal distress, but really, why would they even have called anesthesia? How do you ethically put your patient through a more dangerous and significantly more invasive procedure, when the procedure is clearly not yet required?

Labor Nurse, CNM said...

In this particular case the consent was already signed because she was a planned repeat c-section. Her consent process was already completed antenatally. It just happened that she went into labor prior to the section.

However, I know that a simple "we can do the repeat c-section" is the extent of it for many.

Renee said...

I think this goes with many women in general just wanting to go along with what's best for others and not make waves. Sad that it even affects situations like this.

Reality Rounds said...

I have seen this same situation multiple times. The "unplanned" VBAC does not go over well in a hospital. It can be hard and scary for a mom to change her mind in the last minute and try for a VBAC that was not planned. The mom you posted on sounded like a great candidate for a VBAC. I wonder why they did not go that route to begin with.

Anonymous said...

I talk about this here. I would tell her that once labor is started, it is best to attempt a vaginal delivery, as far as recent literature indicates.

I know it's hard to change your mindset about how a birth will go, but I think once labor starts, the outcome difference doesn't warrant a cesarean, especially if she has prior successful vaginal deliveries and there are no other indications.

Sarah said...

Hi Labor Nurse, CNM. Thanks for this post and for sharing your experience. I've highlighted this post on the ICAN blog's weekly feature "Best of the Birth Blogs" for this week (ending 8/23):

All best,

Bethany midwives said...

Sad sad sad! I think the fear is that if a provider appears to be "pushing" or convincing the patient to have a VBAC and something goes wrong, then they may be sued. I can easily see that as a rationale for just doing the section.