Willow's Rest

Monday, April 26, 2010

Sunday, April 4, 2010

Cesareans: A Rant for CAM

I have opened the "new post" page half a dozen times, meaning to start something (anything!), but I keep getting distracted and forget what I was thinking about or where I was going with it. Nothing seems to stick... I know I have stories to tell, opinions to elaborate upon, but when I actually sit down to write, my mind goes blank. It's like Blockbuster Syndrome: a well-documented (by me, at least) disorder in which one wants to rent a movie, one has a mental list of several films one would like to see, and then when one enters the video store, it's "Movie? I wanted a... what? Video? What's that? Um..." Very, very frustrating.

(If I were clever, I would now present some interesting obstetrical analogy here. Rest assured, I have nothing.)

So. It's Cesarean Awareness Month once again! Yes... let's go with that.

I kicked off CAM with an elective primary section. Well, not me, personally, of course. My patient, a 24-year-old primigravida, delivered her son by cesarean on Friday... for absolutely no reason at all. There were no indications-- nothing in her history to necessitate major abdominal surgery. The OB's dictation states "The patient, over the course of this pregnancy, has requested a cesarean." There is no indication that he counseled her about her apparent fear of labor and delivery, or tried to dissuade her in any way from taking what is unquestionably a more dangerous route for herself and her child. He finishes, rather weakly, "She does show some signs of CPD."

Um... CPD? Really? Really?? Forgive me; I know "CPD" is a convenient label, the diagnosis of choice for physicians wanting to justify their surgical terminations of their patients' pregnancies. But shouldn't one give a baby a chance to negotiate the pelvis before pronouncing it "disproportionate"? How, exactly, does one diagnose "cephalopelvic disproportion" without allowing the passenger to give it a go, so to speak?

This gargantuan baby, by the by-- so monstrous as to be unable to fit through his mother's pelvis, according to the OB-- weighed in at a whopping 7 lbs, 11 oz. And the mother came from recovery complaining of intractable pain-- pain that took several doses of morphine to manage,leaving mom too groggy to breastfeed initially-- so baby is now on formula. Chalk up one more success for the American way of birth.

Here's another one: a 17-year-old sectioned on Friday-- a few hours after my patient-- is walking the halls. When asked, "Why did you have your cesarean?" she replied, "Because I was 38 weeks and my baby wasn't in the birth canal."

/jawdrop/

Honestly, what is wrong with these obstetricians? Why is that acceptable-- to cut open a teenager and give her such a ridiculous reason for it? In reality, this girl was a failed induction: after 12 hours of pitocin (cranked up to the max, no doubt), she did not dilate past 3 cm. Why? Because she wasn't ready to go into labor. Her baby was not ready to be born!

Does she know that? Of course not. She trusts her doctor. He said so; it must be true. I happen to know-- because a friend of mine was at the nurses' station and heard the conversation-- that the three cesareans that were performed back-to-back-to-back last Friday (that's not including the scheduled elective primary I alluded to above) were done for no more pressing reason that the respective OBs (including the 17-year-old's doctor) wanted to be done with their patients. In the words of my friend, another obstetric nurse, "They didn't want to mess with them all weekend."

That's right. Three babies were surgically removed from their mothers because three OBs didn't want their weekend plans interfered with. Tell me, please, whatever happened to "First, do no harm"???

The mom who elected her cesarean is hurting. She asked me earlier, with tears in her eyes, "How long is it going to hurt like this?" I could only tell her that I didn't know, it varied from woman to woman, but that it would get better... slowly but surely. And in my heart-- I shouldn't admit this, but I'm human-- I couldn't feel totally sorry for her... because she chose this, you see. She elected it.

Cesareans suck. Recovery hurts, even without the added challenges of caring for a newborn. Didn't she think to ask? Did she think that by circumventing labor, she would avoid pain? Why didn't her doctor tell her what she was in for?

Judging by the patients recovering from cesareans today on this floor, doctors play all their cards close to the vest. They don't see fit to share much information with anyone. Can I blame a primip for fearing labor-- something she's probably seen only in idiotic Hollywood depictions-- when it's the OB, the so-called expert in birth, who perpetuated the fear and granted her wish for an unnecessarean?

Sunday, March 7, 2010

How to Have a Hospital VBAMC

It's difficult-- nearly impossible, in some parts of the country-- to find an obstetrician who will agree to "let" a mother attempt to use her vagina for its biologically mandated purpose once she has had a cesarean. As access to hospital VBAC gets more and more rare, many moms opt to stay home, choosing to labor and birth with a midwife or on their own. Others, though, still want to have their babies in the hospital, but refuse to submit to a repeat cesarean. These mothers may plan to stay home as long as possible in labor, waiting until the last moment to notify their OB and go to Labor & Delivery. Sometimes this works-- "showing up pushing" can mean that even a VBAC-wary doctor won't have time to object, when they walk into the room and the baby is already crowning. Other times, though, the ploy fails: there are many horrible stories (see Jennifer Block's Pushed for details) of mothers arriving in the emergency room in hard labor, and being forced instead to undergo a stat section. One dear friend experienced just that: as she neared the end of a perfectly normal labor, she was wheeled into the OR, screaming, "I do not consent!" No one listened; she was cut against her wishes. Another brave mom I know had her crowning baby shoved back up the birth canal and then removed surgically-- again, without my friend's consent.

If having a hospital VBAC is difficult, finding someone to attend a VBAMC (vaginal birth after multiple cesareans) is that much harder. Even though ACOG itself admits that two c-sections are not an absolute contraindication to VBAC, it's a rare OB who will agree to attend a trial of labor for a VBA2C, and only then if the mother has had a previous vaginal birth (not necessarily a VBAC). Higher-order VBACs(those occurring after three, four, and even more cesareans, as documented here) by Kmom in hospitals are nearly unheard of; the majority of OBs, and even many midwives, consider the risks unacceptable. In fact, there are few studies that look at VBAMC, and a recent study even suggests that VBA3C moms face risks comparable to any other VBAC mother. Of those risks, the most loudly trumpeted is uterine rupture-- something a mom who wants to labor after multiple cesareans is likely to be told is nearly inevitable in her case, even though this assertion is not supported by the evidence. Faced with this fearmongering tactic (referred to by birth advocates as the "dead baby card"), most would-be VBAMC mamas back down, defer to the "expert" obstetrician, and schedule a repeat cesarean-- which will be coded as "elective"-- and honestly, who can blame them? Aren't doctors supposed to know best-- aren't they there to protect our interests as patients, to keep us safe? To do no harm?

It is well to keep in mind that physicians are human, and humans, no matter their ideals or sense of altruism, are ultimately most concerned with their own best interests-- precisely why every pregnant woman, regardless of circumstance or desired birthplace, must educate herself and become her own number-one advocate. ACOG is, first and foremost, a trade union, and it does what such organizations do best: it protects its members. Obstetricians, because they deal intimately with such a life-changing (life-beginning!) process, are targets of litigation- because in our society, if something goes wrong with a delivery, if a family is presented with a so-called "bad baby," they naturally look for someone to blame. It's common wisdom among OBs that "the only c-section you get sued for is the one you don't do"-- in other words, if a baby sustains injury or lasting damage during a vaginal birth, the first question a lawyer seeking reparations will ask the OB is, "Why didn't you do a c-section?" (Or, in this day and age, even "Why didn't you do a c-section sooner?")

Fear of litigation drives medical care in this country, especially where mothers and babies are concerned. Obstetricians pay some of the highest malpractice insurance premiums in the business. So perhaps it's understandable that they panic in the fact of what they see-- what they are conditioned to see-- as unacceptable risk, such as VBAMC.

Dr Wells (note: all names and a few details have been changed, in compliance with HIPAA laws) must have experienced a chill when he got the call from the medical exchange Wednesday night: his 25-year-old patient, Anne, was in labor. Anne has three older children: five, three, and eighteen months. Anne has had three c-sections.

At just 37 weeks' gestation, Anne hadn't expected to go into labor. Her (arbitrarily and probably unwisely) scheduled fourth c-section was still a week away. When she realized that she was having regular contractions only a minute or so apart, it dawned on her that she might behaving this baby sooner than later. She went to the nearest emergency room-- at a small local hospital with no L&D and no maternity services. She was triaged, and the ER nurse quickly determined that she was definitely in labor: Anne was completely dilated, with a bulging amniotic sac. Dr Wells was paged and implored to come, stat!

Dr Wells hit the road running. As soon as he arrived at the emergency department and checked Anne, he called for her to be taken to the nearest OR at once. The staff balked; they did not have the necessary equipment on hand for a cesarean, much less to care for a late preterm infant. Dr Wells-- who, it must be said, is well known for his colorful vocabulary-- cursed and called the nearest large hospital with a level III neonatal intensive care unit, demanding that they send a team at once. The NICU staff demurred, stating-- quite reasonably-- that they would be unable to provide a comprehensive neonatal resuscitation team, with all the requisite personnel and equipment, in time. The physician argued, insisting that a nurse and respiratory therapist must jump into an ambulance at once and drive at full speed to attend a stat section fifteen miles away. Again, the NICU declined, at which point the nurse manager was treated to an unexpurgated rant by the OB.

And Anne? She was still in labor, and within twenty minutes of the irate doctor's arrival, she delivered a healthy seven-pound baby girl-- vaginally, without complications of any kind, right there in the ER. Mother and daughter were transported to the larger hospital, to our mother-baby floor, where I was privileged to care for them until they went home yesterday. When I asked her how her recovery was going, she laughed and said, "It's a world away from a c-section!"

When her OB rounded, he spent less than a minute in his patient's room-- and nearly half an hour with her chart. Dr Wells's main concern, it seemed to me, was to fully document the incident-- concerned, as always, that a lawsuit of some kind might be in the offing. He wasn't interested in the implications: Anne had escaped major surgery-- a surgery he had mandated-- and had instead had an uncomplicated VBAC. She and her baby were happy and healthy-- isn't that all that matters?

Not to this obstetrician. He had lost control of the situation. Instead of a calm, routine cesarean, he was forced to race across town in a mad dash to catch a baby in a hurry. Apparently, non-bankers'-hours obstetrics are not his cup of tea. Will he encourage VBACs for future patients? I doubt it. Will he permit Anne to labor again, if she becomes pregnant in another year or so? Unlikely... he will probably scare her to death with what-if tales of horror, and insist that she submit to a cesarean at 36 weeks. What's one more preemie, if he can continue to circumvent birth?

I'm at a bit of loss, myself, as far as how to feel about this story. I'm thrilled for Anne, who had a quiet everyday miracle of her own in a rural emergency department. But I'm honestly not sure she understands what she accomplished-- or how she did it. I don't know for certain that she's ever even heard the term VBAC-- I'm positive, given that Dr Wells has delivered all her children, that she has never been offered the opportunity to even go into labor, much less have a vaginal birth. If she gets pregnant again, will she go back to Dr Wells, knowing what she does now? Will she demand a VBAC, or will she schedule another section?

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.

Thursday, July 16, 2009

Another quick I'm-not-dead post

... and a truly excellent link: Pit to Distress This kind of garbage goes on at my hospital all the time... it's just never been given a formal name. Women ought to be up in arms over this-- it's one thing to go after mamas as easy targets, but when the OBs start in on babies...

The gloves are off. Please, mothers, daughters, sisters, aunts-- fathers, brothers, grandfathers-- everyone who cares even an iota about mamas and babies-- take up the call. Women of Earth, take back birth!!

Saturday, June 6, 2009

Barbarism, 2009

Let's play pretend. Let's say that there's an operation that everyone undergoes at age 21-- removal of the left pinky finger, for example. There's no reason for it; it's just something everybody does. There are ostensibly scientific-sounding people who point out that people with left pinkies have 100% higher risk of left pinky finger cancer than people without left pinkies. Besides, everyone does it, and most people agree that people who've had the procedure are just more attractive. It's neater, you see-- more streamlined, more aesthetically pleasing.

When you reaches your 21st birthday, you goes to your-- oh, let's say, dentist. Doesn't make a lot of sense, but you're probably getting their wisdom teeth out too, so it can all be done at once. And the longer it's put off, the worse the recovery, so-- there you are. The dentist straps your left arm down-- and your right too, for good measure. He stabs you a few times with the novacaine hypodermic, which has no time to take effect because he follows immediately with a big scalpel. He hacks off your pinky while you scream bloody murder and the assistant offers you a sip of sugar-water to calm you down. It's over in a minute or so-- the dentist holds some pressure, then checks the site to make sure it's not bleeding, then wraps some vaseline-soaked gauze around it. "Leave that there till later today. Then you can rewrap it with some more vaseline later."

You slump in your seat while the assistant removes the restraints and pats you on the shoulder. "See, it wasn't so bad... you're not even crying." You look at her dazedly; you're in shock, and couldn't produce a sob to save your life. But it's all over, and you're grateful. Your parents got through it. Your siblings, friends, coworkers... everyone manages, so surely you'll be all right. They all say you won't remember when all's said and done... and now you look just like everybody else.

Well... there is that one whack-job at work who insisted on keeping his left pinky. Weird. He says he came with ten fingers, so why forfeit one just because it's what's done? But he's in the minority and clearly insane-- no one keeps their pinkies except for certified granola-crunching flower children, after all.

Your head is swimming and your hand aches. You ask feebly for some pain medication, but the assistant, who keeps coming back to make sure your stump isn't bleeding, shakes her head. "Sorry," she says with sympathy, "I can't give you anything. You might get an infection, and anything I give you for pain could mask the symptoms. You'll be okay." Pat, pat.

You close your eyes, sick to your stomach. All you can do is pray for sleep and time to ease your pain.

Sound ridiculous? Unnecessary? Downright stupid? Of course it does. No one would volunteer to have his finger chopped off, "just because." Certainly no one would think of inflicting such a procedure on a person who could not consent, could not even understand what was happening or why. And yet... we do it every single day, to defenseless baby boys who have no choice in the matter whatsoever. And we wonder why our society is getting more violent by the day?

I am sick to death of circumcisions. There, I said it.

It's not like my position on them is vague or unspoken-- everyone who works with me knows where I stand. I despise them. I think they are barbaric, horrible, hideous, disgusting, and appalling on every level. I loathe having to assist with them in any way, and I absolutely cringe when I have to clean up the mess afterward. It infuriates me that we allow people to perpetrate this kind of violence on helpless newborns!!

This morning, one of the OBs came in to circumcise two babies. He had a 12-year-old boy with him, shadowing him for a school project. "Now, Thomas," Dr H said to the boy, "I did this to you, remember. You sure you want to see this?" Thomas insisted that he did. One of the lactation nurses was passing and commented, "That's awful, how can he subject a little boy to that?" EXCUSE ME?? How can we subject INFANT BOYS to that??!?!?!

Seriously... it's grotesque. I know people say it can be done humanely, but I humbly beg to differ. There is nothing humane in mutilating the body of an hours-old baby: strapping him down on a cold plastic board, letting him scream his lungs out, offering no comfort but sugar-water on a pacifier or a gloved finger, providing nothing for anesthesia except-- maybe, and not even usually-- inadequate injections of lidocaine or a smear of EMLA (topical lidocaine that is, by the by, not recommended for use on infants under 1 month of age), and then brutally clamping his penis in a device that looks like it was developed by sadistic Inquisitors during the Dark Ages and hacking away one-third to one-half of the skin of his most sensitive organ. Don't believe this is what happens? Don't take my word for it.

And for what? There is no medical indication for routine infant circumcision: so says the American Academy of Family Physicians, so says the American Academy of Pediatrics, and so say I. So why do we do it? Because it's "cleaner"? (It's not. And cleaning an intact penis is no more difficult, and no harder to teach someone to do, than cleaning an ear.) Because it "prevents cancer"? (It doesn't. There's no evidence that an intact man who practices even minimal hygiene will induce cancer in himself or a partner.) Because we want baby "to look like daddy"? (That's important... why?) Because "the other boys will laugh"? (Not if they're intact too. And not once they find out what they're missing without their foreskins.)

With the overwhelming evidence falling squarely on the side of not circing, why is it still such common practice? This is something I simply can't figure out. Are people so brainwashed that they're willing to sacrifice their sons' physical (and eventually sexual) wellbeing to a misguided standard of social acceptance? I don't think parents wake up sometime during pregnancy and say to each other, "I know, honey! Let's mutilate our beloved baby boy as soon as he arrives!" I think they genuinely believe they're doing what's best for-- or at least, they're not harming-- their infants. I honestly believe that if these parents were given true informed consent on circumcision, if they really knew what their little guys would endure, most would choose to leave their sons' penises intact. Maybe if they were required to watch this video, produced in informative (and graphic, so be warned) detail, the appalling statistics would change.

I wish I could convince every expectant parent to thoroughly and comprehensively educate themselves about circumcision. I've seen some of the most informed parents-- loving, caring people who would no more put their children in danger than they would club baby harbor seals for sport-- who still opt to circ, with no more convincing rationale than "that's how it's done" or "hey, his dad survived it." I've seen a disturbing trend among immigrant families, whose home cultures have never routinely circumcised their infants, choosing the procedure in order to give the impression that they're really assimilating into American society. Most new parents give it no more thought than whether they'll choose to diaper their infant (bearing in mind, by the way, that there are those who don't, but the sad fact is that circumcision is not the benign procedure it's painted to be. Mishaps happen; there are risks. Moreover, allowing a surgeon to remove the prepuce of a male newborn is circumventing that new little person's right to bodily integrity. Does anyone honestly think that a brand-new baby boy, if we could ask him, would-- if given the choice-- declare with enthusiasm, "Sure, lop it off!!"

Friday, June 5, 2009

Blogging by Proxy

I'm being lazy, but this is the best, most concise summary of the whole cesarean situation that I've seen, thanks to the wonderful and always well-informed Kmom.

Check it out!