As one of my New Year's projects, I've decided to try to informally track the deliveries at my hospital and watch the trends over 2012. This is not a rigorous scientific study, by any means; it's really little more than anecdotal. I plan to record our deliveries daily, and to make note of method of delivery, primary vs repeat cesarean, indication for surgery, etc. This will only include babies who are admitted to the well baby nursery, so there will be a good chunk of missing information right there; we do have a Level IIIb NICU, and it will be difficult to obtain delivery notes on those infants admitted directly to them on days I'm not actually here. So, as I say, this is just a sort of exercise-- in observation, data recording, and preliminary analysis.
I started recording delivery stats on December 19; I have 21 consecutive days of data, as of today. Just for giggles, so to speak, I decided to glance over them-- to see what I had. Here's my data:
n= total deliveries= 68
v= vaginal deliveries= 39 (57.4% of total births)
x= c-sections= 29 (42.6% of total births)
r= repeat c/s= 11 (16.2% of c/s)
p= primary c/s= 18 (26.4% of c/s)
The cesareans were done for a small number of predictable reasons. I broke the indications down into four categories:
1. "failures"-- labeled as such by the OBs, including "FTP (failure to progress)," "FTD (failure to descend)," "failed induction," and the ever-popular, vague, and widely inclusive "NRFHT (non-reassuring fetal heart tones)"
2. primary elective for breech-- no one here will do vaginal breech deliveries on purpose, so for all intents and purposes, these are physician-elected c/s
3. primary elective for maternal reasons-- there were three of these, including one mom who was HSV+ with a current outbreak, one mom who had a history of spina bifida and attendant multiple back surgeries, and one mom who was urged to elect her c/s for that fabulously accurate diagnosis, "suspected macrosomia"
4. other-- only because I wasn't sure where else to put it; I didn't have enough history in the report I got or on the chart; it was presented as a primary nonelective, nonemergent cesarean due to oligohydramnios and "placental issues, nonspecific"
The majority of the primary c-sections fell into the first category: 10/18, or 34.5%. There were 4 breech sections-- three scheduled, one discovered in labor (when mom was ready to push!)-- so 13.8% of the total. The other 4 were also scheduled, for the reasons listed above. That nonelective, nonemergent one resulted in a completely normal newborn with no signs of distress . That allegedly ginormous baby weighed a whopping 8 lbs 4 oz. Oh, and most of those NRFHT sections (ie, for fetal distress) produced babies with APGAR scores of 8/9 and 9/9. Sigh.
So, in the past three weeks (covering Christmas and New Year's), we had a cesarean rate of almost 43%-- well above the national average. I'll be curious to see if this trend continues. I've long suspected that our facility's c/s rate was that high, but I've never been able to demonstrate it. If I can keep this up, at least I'll be on my way to documenting outcomes for one mid-size hospital in Middle America. That's the plan, anyway.
Showing posts with label hospital birth. Show all posts
Showing posts with label hospital birth. Show all posts
Sunday, January 8, 2012
Tuesday, August 30, 2011
Capitalizing on Loss and Risk
My dear friend Shannon at BirthAction wrote this post that everyone should read. Go on, read it. I'll wait.
Capitalizing on Loss and Risk
It brings up so many good points... the main one being that, for women birthing in hospitals, the playing field is never level. True informed consent does not exist in our current system; without it, women "choose" interventions and procedures that damage them and their babies-- and sometimes kill. How can we increase awareness? How can we make women understand that they have choices? That labor starts and progresses without dangerous drugs-- that babies can be born without drips and wires and gleaming metal instruments? How can we convince women that they are strong and capable, and they do not have to lie down for the knife? Most of all, that birth is safe... interference is risky?
Capitalizing on Loss and Risk
It brings up so many good points... the main one being that, for women birthing in hospitals, the playing field is never level. True informed consent does not exist in our current system; without it, women "choose" interventions and procedures that damage them and their babies-- and sometimes kill. How can we increase awareness? How can we make women understand that they have choices? That labor starts and progresses without dangerous drugs-- that babies can be born without drips and wires and gleaming metal instruments? How can we convince women that they are strong and capable, and they do not have to lie down for the knife? Most of all, that birth is safe... interference is risky?
Friday, February 26, 2010
VBAC Viability
Other, better commentators (Henci Goer, Marsden Wagner, Sarah Buckley, Kmom, Rixa, Laureen Hudson, Jen of vbac.com, and many more) have written extensively about VBAC and why it's preferable to repeat cesareans for most mothers. Anyone who has done even the most casual reading on the subject knows that surgical deliveries carry with them a significantly increased risk of injury, infection, hemorrhage, and other complications for mothers and babies. Cesareans require longer hospital stays, more pain, more drugs, more risk of respiratory problems. NICU stays are more common; so are post-op transfusions, deep vein thromboses, and hysterectomies. Recovery is substantially longer-- those first few weeks of motherhood are challenging enough without adding the debilitation of major abdominal surgery to the mix! Babies are less likely to continue breastfeeding-- mothers who are exhausted and in pain, who can't lift their infants or even sit up straight, often give up and bottle feed. Consequently, cesarean-delivered babies are more likely to experience jaundice shortly after birth, and asthma, allergies, and obesity later in life. And while the initial cut is bad enough, each subsequent cesarean raises the risk of long-term complications for mama: placentation problems (placenta previa, abruptio placentae), secondary infertility, miscarriage, and ectopic pregnancy. Any of these are potentially devastating issues-- and yet mothers are told, time and again, "It's just a c-section."
"Just" a c-section? I've heard this phrase over and over, both as a mother and as a nurse. When completing a history and physical for a new family doctor, I checked the box that said "Prior surgeries" and wrote in "cesarean times two." The medical assistant who reviewed my chart commented, "So you've had surgery? Oh, no, I see-- you've just had c-sections." I had to bite my tongue to keep from screaming, "What part of major abdominal surgery aren't you getting? Have you been splayed open like a fish, your guts exposed to all and sundry, your abdominal muscles split and left to reapproximate in whatever slapdash fashion they choose? Have you dragged yourself up and down a flight of stairs, clutching the banister with one hand and your belly with the other, convinced that you're going to open up and spill your internal organs on your shoes? Sure-- just c-sections!"
Hollywood and the media are responsible in large part for the public perceptions of birth and cesareans. Everyone has seen the TV version of labor and delivery: mom rolling around in a hospital bed, screaming, cursing her husband's name, swearing "He'll never touch me again!" Comic sidekicks rush in and out while mom groans and shrieks and generally does her best Exorcist impersonation before delivering a bright-eyed three-month-old to the general adoration of all in attendance. Celebrity moms-- Victoria Beckham, Britney Spears, Madonna-- all those "too posh to push" mums, who get tummy tucks at delivery, who have personal trainers to get them back in shape fast and personal chefs to feed them and nannies to take care of their newborns and older children-- they make cesareans look like the easy, chic way to have babies. None of the fuss and muss of labor-- just show up at the hospital on the appointed day, coiffed and made up and manicured, pop into the operating room and get that oh-so-lovely epidural, and wait for your surgeon to hand you your clean, scrubbed, blanket-wrapped newborn.
Unfortunately, we don't get to see the all-too-common aftermath: a mom too drugged to hold her new infant; when the epidural comes out, in too much pain to put him to breast. The indignity of having a Foley catheter removed, only to have it reinserted when she can't urinate on her own. The agony of hobbling to the bathroom like an octogenarian, terrified of falling or opening her incision. The frustration of having to tell her toddler that she can't pick him up because of the ouchie on her tummy. The days and weeks of lingering pain, muscle weakness, helplessness.
In the years since my two cesareans (ten years ago and seven and a half, respectively), I've gained a bit of perspective. I don't rant much anymore; I don't brood often, or for long when I do. I take care of new mothers who actively choose their c-sections, and seem reasonably satisfied with the results; mostly I'm able to keep my feelings to myself. I slip referral cards into teaching packets with links to ICAN and vbacfacts.com. When families ask "is this much pain normal?" or "what can she expect when she goes home?" I tell them the unvarnished facts: Cesareans hurt, surgery is painful, recovery takes time. Occasionally I'm asked if a mother might ever reasonably expect to birth a subsequent child vaginally; on those rare occasions I offer my (heavily edited) stories and the assurance that VBAC is possible and definitely worthwhile, but it takes work. The sad fact is that most of the women I meet aren't willing to do the work-- their doctors tell them no, it's too much hassle, it's dangerous, etc., and they accept that answer as gospel. Society supports the status quo; those of us who are willing to educate ourselves, take responsiblity for our health and our births, are regarded as hippies, zealots, weirdos. Good girls don't buck the system. Good girls do what they're told, lie down and allow themselves to be sliced open for their obstetricians' convenience. Good girls put themselves and their babies at risk by choosing repeat cesareans-- or, probably more accurate, allowing repeat cesareans to be chosen for them. True informed consent is rare: as one OB famously stated, "If one went to the extreme of giving the patient the full details of mortality and morbidity related to cesarean section, most of them would get up and go out and have their baby under a tree..." (Neel, J. Medicolegal pressure, MDs' lack of patience-- cited in cesarean 'epidemic.' Ob.Gyn.)
Cesareans are forever. No matter how good one's experience, the effects remain. Scars heal, fade, but mothers ever after will experience statistically higher morbidity and mortality. I had a life-altering vaginal birth after two cesareans, but my triumph was marred by a retained placenta. Was it caused by my cesareans? I don't know for certain, but I strongly suspect so. I managed to push a baby out of my vagina, but I still had to turn to medpros for a D&C-- another uterine surgery, which in itself increases my risk of complications should I ever plan another birth-- all thanks to an OB who wanted to get home sooner than later.
I will never go into labor without that CNN-style ticker tape in my head, reminding me of the warning signs of uterine rupture; I will never welcome a baby in blissful ignorance, as so many of my patients seem to do. I envy them sometimes, the mothers who have never had a reason to question their doctors, who go to the hospital with the first twinge of labor, accept all the interventions, and still pop out their babies with very little trouble and no apparent lasting effect. Still... there is something to be said about the journey. And there's no question that my journey has been valuable-- priceless, even. That's the intangible reward of pursuing VBAC: the self-searching, the questioning, the obtaining of knowledge. I learned more about myself in the years that I struggled against depression and PTSD than I ever would have if I'd been one of the "lucky ones," the women who make it through the birth mill unharmed. I survived the inferno and emerged from the crucible, tempered and, I think, strengthened. Certainly I would not be the person I am without my fight to VBAC-- and after a good many years, I'm finally able to say that, yes, I like that person. That's worth almost as much as my children.
"Just" a c-section? I've heard this phrase over and over, both as a mother and as a nurse. When completing a history and physical for a new family doctor, I checked the box that said "Prior surgeries" and wrote in "cesarean times two." The medical assistant who reviewed my chart commented, "So you've had surgery? Oh, no, I see-- you've just had c-sections." I had to bite my tongue to keep from screaming, "What part of major abdominal surgery aren't you getting? Have you been splayed open like a fish, your guts exposed to all and sundry, your abdominal muscles split and left to reapproximate in whatever slapdash fashion they choose? Have you dragged yourself up and down a flight of stairs, clutching the banister with one hand and your belly with the other, convinced that you're going to open up and spill your internal organs on your shoes? Sure-- just c-sections!"
Hollywood and the media are responsible in large part for the public perceptions of birth and cesareans. Everyone has seen the TV version of labor and delivery: mom rolling around in a hospital bed, screaming, cursing her husband's name, swearing "He'll never touch me again!" Comic sidekicks rush in and out while mom groans and shrieks and generally does her best Exorcist impersonation before delivering a bright-eyed three-month-old to the general adoration of all in attendance. Celebrity moms-- Victoria Beckham, Britney Spears, Madonna-- all those "too posh to push" mums, who get tummy tucks at delivery, who have personal trainers to get them back in shape fast and personal chefs to feed them and nannies to take care of their newborns and older children-- they make cesareans look like the easy, chic way to have babies. None of the fuss and muss of labor-- just show up at the hospital on the appointed day, coiffed and made up and manicured, pop into the operating room and get that oh-so-lovely epidural, and wait for your surgeon to hand you your clean, scrubbed, blanket-wrapped newborn.
Unfortunately, we don't get to see the all-too-common aftermath: a mom too drugged to hold her new infant; when the epidural comes out, in too much pain to put him to breast. The indignity of having a Foley catheter removed, only to have it reinserted when she can't urinate on her own. The agony of hobbling to the bathroom like an octogenarian, terrified of falling or opening her incision. The frustration of having to tell her toddler that she can't pick him up because of the ouchie on her tummy. The days and weeks of lingering pain, muscle weakness, helplessness.
In the years since my two cesareans (ten years ago and seven and a half, respectively), I've gained a bit of perspective. I don't rant much anymore; I don't brood often, or for long when I do. I take care of new mothers who actively choose their c-sections, and seem reasonably satisfied with the results; mostly I'm able to keep my feelings to myself. I slip referral cards into teaching packets with links to ICAN and vbacfacts.com. When families ask "is this much pain normal?" or "what can she expect when she goes home?" I tell them the unvarnished facts: Cesareans hurt, surgery is painful, recovery takes time. Occasionally I'm asked if a mother might ever reasonably expect to birth a subsequent child vaginally; on those rare occasions I offer my (heavily edited) stories and the assurance that VBAC is possible and definitely worthwhile, but it takes work. The sad fact is that most of the women I meet aren't willing to do the work-- their doctors tell them no, it's too much hassle, it's dangerous, etc., and they accept that answer as gospel. Society supports the status quo; those of us who are willing to educate ourselves, take responsiblity for our health and our births, are regarded as hippies, zealots, weirdos. Good girls don't buck the system. Good girls do what they're told, lie down and allow themselves to be sliced open for their obstetricians' convenience. Good girls put themselves and their babies at risk by choosing repeat cesareans-- or, probably more accurate, allowing repeat cesareans to be chosen for them. True informed consent is rare: as one OB famously stated, "If one went to the extreme of giving the patient the full details of mortality and morbidity related to cesarean section, most of them would get up and go out and have their baby under a tree..." (Neel, J. Medicolegal pressure, MDs' lack of patience-- cited in cesarean 'epidemic.' Ob.Gyn.)
Cesareans are forever. No matter how good one's experience, the effects remain. Scars heal, fade, but mothers ever after will experience statistically higher morbidity and mortality. I had a life-altering vaginal birth after two cesareans, but my triumph was marred by a retained placenta. Was it caused by my cesareans? I don't know for certain, but I strongly suspect so. I managed to push a baby out of my vagina, but I still had to turn to medpros for a D&C-- another uterine surgery, which in itself increases my risk of complications should I ever plan another birth-- all thanks to an OB who wanted to get home sooner than later.
I will never go into labor without that CNN-style ticker tape in my head, reminding me of the warning signs of uterine rupture; I will never welcome a baby in blissful ignorance, as so many of my patients seem to do. I envy them sometimes, the mothers who have never had a reason to question their doctors, who go to the hospital with the first twinge of labor, accept all the interventions, and still pop out their babies with very little trouble and no apparent lasting effect. Still... there is something to be said about the journey. And there's no question that my journey has been valuable-- priceless, even. That's the intangible reward of pursuing VBAC: the self-searching, the questioning, the obtaining of knowledge. I learned more about myself in the years that I struggled against depression and PTSD than I ever would have if I'd been one of the "lucky ones," the women who make it through the birth mill unharmed. I survived the inferno and emerged from the crucible, tempered and, I think, strengthened. Certainly I would not be the person I am without my fight to VBAC-- and after a good many years, I'm finally able to say that, yes, I like that person. That's worth almost as much as my children.
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