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 induction. Show all posts
Showing posts with label induction. Show all posts
Sunday, January 8, 2012
Monday, May 4, 2009
BIB!
Babies have an impetus to be born. They have no concept of time; "due dates" and calendars mean nothing to a developing infant. They come when they're ready, in their own good time. Unforunately, most obstetricians do not respect this intrinsic wisdom, and try to fit babies into their own schedules by encouraging (insisting upon?) inductions for no readily apparent (or blatantly made-up) reasons. Babies resist these interferences; a baby who is not ready to be born will hold out against even the most aggressive induction, and their mothers' bodies will instinctually act to hold their infants in. All the pitocin in the world will fail to evict a baby who is unready to be born; the result is "failure to progress" and an unplanned, or even "emergency," cesarean.
The OBs present these elective inductions as the conscientious, convenient, and compassionate choice. "You look miserable... aren't you tired of lugging that belly around? Your blood pressure is a little elevated, too. Let me induce you-- let's just go ahead and get that baby out of there. I'll pick a day that's good for all of us. We'll just get you taken care of, and you won't have to worry about waiting for labor anymore."
Sounds delightful, yes? Appear at the hospital at the appointed time. Check in with the cheerful, unharried staff. Trade your clothes and dignity (oops, is my bias showing?) for a hospital gown, climb up on the bed and receive your IV and monitor belts. Fluid drips into your veins; you perspire prettily. The Clooney-esque OB arrives, checks you ever so gently, and announces with a flourish that you're ready to push. You strain daintily, and out pops your beautiful baby. No fuss, no muss. All done. Ready for that close-up, Mr DeMille!
If you believe that scenario, there's a bridge in Brooklyn I'd like to discuss with you. It's much more likely that you'll work like a dog all day (they call it "labor" for a reason, especially when it's chemically created and interfered with and mucked up, even with the ubiquitous epidural), the OB will materialize in the last five minutes or so, then suction the baby out with vaccuum, or drag her out with forceps, inflicting a large episiotomy on you in the process. This last indignity will be "necessary" (or unnecessarily necessary, as I usually think of it) because your epidural has been cranked up to the max and you can't feel the lower half of your body well enough to push effectively. Besides, you've been splayed in the frog-like lithotomy position and gravity is, to say the least, unkind to birthing mothers who are stranded on their backs.
If an induced birth is difficult for Mom, it's as hard-- or harder-- for baby. Too often, those conveniently scheduled inductions occur before baby is "cooked"-- in other words, ready to be born. Remember, babies can't read calendars! Sure, "term" is defined as "37-42 weeks," but it's a rare infant who's good to go at the early end of that range. The lungs are the last organs to develop; consequently, many induced babies experience respiratory distress-- hopefully, but not always, transitory. The March of Dimes has been addressing this issue lately, noting the sad and shameful fact that so many NICU patients are near- or later-preterm infants (ie, 35-38 weeks' gestation), and there are special considerations to keep in mind when caring for these babies. Iatrogenic prematurity-- babies born too early for no reason other than because the OB couldn't or wouldn't wait any longer-- is epidemic in this country, and in almost every case it's preventable.
Regardless of reason-- and there are a few legitimate reasons to induce labor-- inductions are geared to the convenience of the physician. The ideal scenario of for a pregnant mother to arrive at 6 am, get hooked up, pitted, and medicated: epidural at 10, complete at 2, pushing and delivered by 3 pm. This gives the OB a morning free for office visits and consultations, then gets him home for dinner at 5. Perfect. Moms, of course, don't always cooperate-- they may not conform to the neat labor curve that the OB expects, and thus may well end up a c-section for "fetal distress," "failure to progress," or the dreaded "CPD" (officially "cephalopelvic disproportion," more often "care provider dysfunction"). For the obstetrician, who is a trained surgeon and relishes the opportunity to wield a scalpel, this is a logical and agreeable conclusion to the day. He's not the one who has to hobble home, guarding an abdominal incision and trying to care for a newborn.
Sometimes moms go faster than the doc expects. The pitocin or cervidil or, heaven forbid, cytotec, work too well. Like yesterday: the nurse who was laboring Jane (names changed to protect the innocent), who had come in at 6:30 a.m. for a pit induction, went to check on her around 9. Jane told her that she felt "something down there." The nurse calmly checked her-- saw a fuzzy little head crowning-- and calmy proceeded to catch the 7 lb 4 oz little girl. We call this a "BIB" delivery-- "baby in bed." It went swimmingly: baby had excellent APGARs, mom's perineum was intact, the placenta delivered spontaneously and intact. Textbook. The physician, who had been paged, arrived shortly thereafter-- and chewed the nurse out for letting his patient BIB!
Now, bear in mind that when the nurse walked in, the baby was crowning. Birth was immiment-- there's no going back at this point. What was she supposed to do? Answer: stop the pit and tell mom, "DON'T PUSH!! Breathe... breathe...relax..."
Seriously. Baby is on the perineum-- hell, through the perineum-- and Jane is not meant to push??!?!??!? She's supposed to just lay there and endure the titanic forces of labor until the OB deigns to appear?
Yes.
That's the OB's feeling on the matter. The nurse should be able to control labor to the nth degree-- regulate it perfectly, so that it's fast, but not too fast. Speed up as needed-- if it gets away from her, she should manage to slow it back down to wait on the physician. And if, gods forbid, a mother actually has the gall to deliver without him, he'll make sure the nurse catches an earful.
Occasionally an OB will punish the patient as well. Not too long ago, we had a mother who BIB'd and was perfectly happy about it. The OB was furious. The nurses all got chewed out, but worse, the patient spent the next two days being harassed and even verbally abused by the physician. The OB insisted that the precipitous delivery must mean that the patient had a retained placenta, therefore she was in imminent danger of bleeding out. Dr M ordered an ultrasound to check for placental fragments, and for an indwelling catheter to be placed. The patient (smart mama) refused: she knew she'd delivered an intact placenta, that she was having scant lochia and no trouble voiding, and that the catheter only increased her risk of urinary tract infection. When informed of the patient's informed refusal, Dr M screamed down the phone at the nurse, "You MAKE her take that catheter!" The nurse reminded the doctor that patients are in fact free to refuse any medication or procedure (at least in theory) and it's illegal to force said medication or procedure on a person who has refused it. Dr M then demanded to be connected to the patient's room, and browbeat the mom, telling her she was "negligent" and clearly cared nothing for her baby, since she was likely to hemorrhage and leave her infant motherless. The patient, bless her, held out-- she never did take the catheter. Dr M retaliated by informing her that, once discharged fron the hospital, she would no longer provide care for her (the mother). No big loss, in my opinion.
I couldn't stop thinking about that particular case for a long time. Why was the physician so hostile? Why do OBs get angry when nurses catch their babies, when women give birth on their own, without the doctor to strut in and look important?
And then I realised why: when a woman BIBs, when babies are born in their own time, without assistance (interference) from the OB, it's glaring proof that the OB is not indispensable to the process. Jane didn't need her doctor. Dr M's smart, courageous patient didn't need her OB either. Obstetricians want control, they want to think they've beat nature into submission, that they can do better than women's own bodies.
The simple truth? They're wrong.
The OBs present these elective inductions as the conscientious, convenient, and compassionate choice. "You look miserable... aren't you tired of lugging that belly around? Your blood pressure is a little elevated, too. Let me induce you-- let's just go ahead and get that baby out of there. I'll pick a day that's good for all of us. We'll just get you taken care of, and you won't have to worry about waiting for labor anymore."
Sounds delightful, yes? Appear at the hospital at the appointed time. Check in with the cheerful, unharried staff. Trade your clothes and dignity (oops, is my bias showing?) for a hospital gown, climb up on the bed and receive your IV and monitor belts. Fluid drips into your veins; you perspire prettily. The Clooney-esque OB arrives, checks you ever so gently, and announces with a flourish that you're ready to push. You strain daintily, and out pops your beautiful baby. No fuss, no muss. All done. Ready for that close-up, Mr DeMille!
If you believe that scenario, there's a bridge in Brooklyn I'd like to discuss with you. It's much more likely that you'll work like a dog all day (they call it "labor" for a reason, especially when it's chemically created and interfered with and mucked up, even with the ubiquitous epidural), the OB will materialize in the last five minutes or so, then suction the baby out with vaccuum, or drag her out with forceps, inflicting a large episiotomy on you in the process. This last indignity will be "necessary" (or unnecessarily necessary, as I usually think of it) because your epidural has been cranked up to the max and you can't feel the lower half of your body well enough to push effectively. Besides, you've been splayed in the frog-like lithotomy position and gravity is, to say the least, unkind to birthing mothers who are stranded on their backs.
If an induced birth is difficult for Mom, it's as hard-- or harder-- for baby. Too often, those conveniently scheduled inductions occur before baby is "cooked"-- in other words, ready to be born. Remember, babies can't read calendars! Sure, "term" is defined as "37-42 weeks," but it's a rare infant who's good to go at the early end of that range. The lungs are the last organs to develop; consequently, many induced babies experience respiratory distress-- hopefully, but not always, transitory. The March of Dimes has been addressing this issue lately, noting the sad and shameful fact that so many NICU patients are near- or later-preterm infants (ie, 35-38 weeks' gestation), and there are special considerations to keep in mind when caring for these babies. Iatrogenic prematurity-- babies born too early for no reason other than because the OB couldn't or wouldn't wait any longer-- is epidemic in this country, and in almost every case it's preventable.
Regardless of reason-- and there are a few legitimate reasons to induce labor-- inductions are geared to the convenience of the physician. The ideal scenario of for a pregnant mother to arrive at 6 am, get hooked up, pitted, and medicated: epidural at 10, complete at 2, pushing and delivered by 3 pm. This gives the OB a morning free for office visits and consultations, then gets him home for dinner at 5. Perfect. Moms, of course, don't always cooperate-- they may not conform to the neat labor curve that the OB expects, and thus may well end up a c-section for "fetal distress," "failure to progress," or the dreaded "CPD" (officially "cephalopelvic disproportion," more often "care provider dysfunction"). For the obstetrician, who is a trained surgeon and relishes the opportunity to wield a scalpel, this is a logical and agreeable conclusion to the day. He's not the one who has to hobble home, guarding an abdominal incision and trying to care for a newborn.
Sometimes moms go faster than the doc expects. The pitocin or cervidil or, heaven forbid, cytotec, work too well. Like yesterday: the nurse who was laboring Jane (names changed to protect the innocent), who had come in at 6:30 a.m. for a pit induction, went to check on her around 9. Jane told her that she felt "something down there." The nurse calmly checked her-- saw a fuzzy little head crowning-- and calmy proceeded to catch the 7 lb 4 oz little girl. We call this a "BIB" delivery-- "baby in bed." It went swimmingly: baby had excellent APGARs, mom's perineum was intact, the placenta delivered spontaneously and intact. Textbook. The physician, who had been paged, arrived shortly thereafter-- and chewed the nurse out for letting his patient BIB!
Now, bear in mind that when the nurse walked in, the baby was crowning. Birth was immiment-- there's no going back at this point. What was she supposed to do? Answer: stop the pit and tell mom, "DON'T PUSH!! Breathe... breathe...relax..."
Seriously. Baby is on the perineum-- hell, through the perineum-- and Jane is not meant to push??!?!??!? She's supposed to just lay there and endure the titanic forces of labor until the OB deigns to appear?
Yes.
That's the OB's feeling on the matter. The nurse should be able to control labor to the nth degree-- regulate it perfectly, so that it's fast, but not too fast. Speed up as needed-- if it gets away from her, she should manage to slow it back down to wait on the physician. And if, gods forbid, a mother actually has the gall to deliver without him, he'll make sure the nurse catches an earful.
Occasionally an OB will punish the patient as well. Not too long ago, we had a mother who BIB'd and was perfectly happy about it. The OB was furious. The nurses all got chewed out, but worse, the patient spent the next two days being harassed and even verbally abused by the physician. The OB insisted that the precipitous delivery must mean that the patient had a retained placenta, therefore she was in imminent danger of bleeding out. Dr M ordered an ultrasound to check for placental fragments, and for an indwelling catheter to be placed. The patient (smart mama) refused: she knew she'd delivered an intact placenta, that she was having scant lochia and no trouble voiding, and that the catheter only increased her risk of urinary tract infection. When informed of the patient's informed refusal, Dr M screamed down the phone at the nurse, "You MAKE her take that catheter!" The nurse reminded the doctor that patients are in fact free to refuse any medication or procedure (at least in theory) and it's illegal to force said medication or procedure on a person who has refused it. Dr M then demanded to be connected to the patient's room, and browbeat the mom, telling her she was "negligent" and clearly cared nothing for her baby, since she was likely to hemorrhage and leave her infant motherless. The patient, bless her, held out-- she never did take the catheter. Dr M retaliated by informing her that, once discharged fron the hospital, she would no longer provide care for her (the mother). No big loss, in my opinion.
I couldn't stop thinking about that particular case for a long time. Why was the physician so hostile? Why do OBs get angry when nurses catch their babies, when women give birth on their own, without the doctor to strut in and look important?
And then I realised why: when a woman BIBs, when babies are born in their own time, without assistance (interference) from the OB, it's glaring proof that the OB is not indispensable to the process. Jane didn't need her doctor. Dr M's smart, courageous patient didn't need her OB either. Obstetricians want control, they want to think they've beat nature into submission, that they can do better than women's own bodies.
The simple truth? They're wrong.
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