Thursday, February 26, 2009

Just another c-section

A dear friend of mine works as a nurse in labor and delivery in a nameless hospital somewhere in the USA. She gets so frustrated by what she sees there, and as a woman of size herself, she gets particularly irate at how so many big moms get railroaded into c-sections.

Recently she wrote about a supersized patient, a first-time mom, conned into an "elective" primary cesarean at, you guessed it, 38 weeks. We'll leave out a lot of the details to protect the mother, but her story could be so many big moms' stories. I can't tell you how often I've seen stories similar to this one. Especially in supersized moms, who face particularly strong bias in obstetrics.

[For those who don't know it, "supersized" is a term from fat acceptance groups and basically refers to anyone over around 300 lbs. or so. It's not an insult, just a way to distinguish different sizes of fat when it's relevant to a story. Not the best term, IMO, but better than "morbidly obese" or "grotesquely obese" or the equivalents I've seen used in the medical research.]

The Cliff Notes Version of the Story

Mom was supersized (mid-300s) but had a healthy pregnancy. The doctor's reason for the cesarean was that she was "huge," had gained a "huge" amount of weight (about 30 lbs., normal for women of average size but considered excessive in obese women by some), and was going to have a "huge" baby. So he talked her into a planned cesarean.

Like I said, an extremely common story for supersized moms these days.

Of course, as many doctors mistakenly do, he assumed that because of her size, she needed a vertical (up and down, belly-button to pubic bone) incision on her skin. This, despite research that shows that outcomes are better in fat women with a low transverse (side to side, just over the pubic bone) incision.

And he put in a Jackson-Pratt drain, despite recent research showing worse outcomes with drains in "obese" women.

(Ugh. Save me from ignorant OBs who won't believe the research.)

The operative report reads that the procedure was "uneventful and easy" and that the baby was delivered "without complication."

As my friend the nurse says, "No complication for him, no."

As is common with 38-week cesareans, the baby went into respiratory distress and went to the Neonatal Intensive Care Unit (NICU). He'll be there at least a week. That's a week without his mama and proper bonding, a week where he's probably getting mostly formula (making breastfeeding more and more unlikely), and a week full of exposure to all kinds of bacteria common to NICUs. He's also jaundiced now and getting treatment for that.

Mom is "miserable," with a lot of post-op pain, despite a truckload of drugs. My friend says the incision looks "ugly" and was leaking serous fluid in at least two places.....but the doctor was unconcerned. We'll just have to wait and see if she develops an infection or a wound separation or other complication.

But Was It Justified?

Now, the baby did turn out to be big. So often doctors predict big babies for big moms and are totally off; ultrasounds are a very poor way of predicting macrosomia (big babies). But in this case, the predictions were correct. So I'm sure a lot of doctors would say....See, this doctor was right. This was a shoulder dystocia (where the baby gets stuck) waiting to happen.

Yeah, the baby was big.... around 10 lbs. And big babies are at more risk for shoulder dystocia. Yet what they "forget" to tell you is that the majority of big babies are birthed vaginally without shoulder dystocia or injuries of any kind.

Doing major surgery on all babies above 9 lbs in order to potentially avoid injuries for a very few is not a very good risk trade-off.....because the surgery also carries risks and harms. Better would be to train doctors to handle shoulder dystocia better, instead of cutting so many women in a futile effort to avoid lawsuits.

The way the medical community hyperventilates about big babies is overdone. Research is clear that unless the baby is at least 11 lbs or more, a planned cesarean is NOT justified. All the medical reviews on macrosomia have noted this.....yet doctors still continue to cut whenever they have the slightest fear about the possibility of a big baby.

To which I say, feh. I had a big baby, over 10 lbs., and I had her vaginally. My friend the nurse also had a big baby, no problems. We both know MANY women who have had big babies without problems. To enforce a cesarean for all babies over 9 lbs means a LOT of women exposed to the substantial risks of surgery, and research simply doesn't support this tradeoff.

Instead, you treat it like any other risk should be treated. You explain to the mom the possible risks of shoulder dystocia, and also the possible risks (present and future) of cesareans. You tell her about the research reviews, which strongly recommend against early induction or planned cesareans for macrosomia. You review the pros and cons of each choice. You share your concerns and opinions, and then you step back and let the mother make the final decision.

Doctors (and ACOG) like to say they are all about informed consent and respecting women's choices, but the truth is that in childbirth, women are infantilized and given very little choice in anything. Either they are outright told what they "must" do, or they are emotionally manipulated, scared, or even bullied into the choice the doctors want them to make.

This is NOT informed consent and this is NOT respecting women's autonomy to make their own informed choices.

A Rough Way To Start Motherhood

So here's this first-time mom, in a huge amount of pain that the drugs aren't really touching, looking like she might be on her way towards a wound complication, away from her baby most of the time just when she most wants to be with him, up against steep odds for making breastfeeding suceed, and looking at a significant post-op recovery.

So much for the c-section being the easy way out. Frankly, it's the easy way out for the doctor, not so much for the mom.

As my friend said, "This is how she's been introduced to motherhood. She was led to expect a neat, clean, simple procedure that would end with her being handed a perfect baby and having a pain-free recovery. She got none of those. Who's to blame?"

I think we all know.

*p.s. Yeah, a lot of doom and gloom posts lately. I promise I have an uplifting one coming soon, as soon as I have time to put it together! Stay tuned.


Anonymous said...

That's absolutely heartbreaking - as a "supersized" (and I *do* hate that term) mother who was told by an ultrasound tech at 36 weeks that my baby already was over six pounds, and I should hope that he didn't gain any more weight...I will always be grateful to the *consultant* in my NHS hospital who never weighed me, told me I could go as late as I wanted so long as NSTs didn't show any distress to the baby, and, while he might not have been happy about my size, never let me know that.

My son was 6lbs, 9oz, by the way.

And, even if he hadn't been, they did everything they could to make sure I had the vaginal birth I wanted - and I did.

I hope this lady heals quickly and that her son doesn't suffer any long-term complications as a result of *bad medical practice*.

That story is so appalling - I'm still shaking my head.

Jill Arnold said...

Hi. My reply is on my blog:


Anonymous said...

I had gestational diabetes with my middle child; and one of the worries the doctors had was shoulder dystocia, but I was never clear on exactly what it was or why it was so bad. They did use it as a reason to stick to my diet and glucose numbers, which I did anyhow; she ended up only 7.75 pounds and perfectly healthy.

The other thing they insisted on was that I not go past 40 weeks, so I had an induction scheduled for nine the morning of that day. She had other things in mind and decided to initiate labor herself at five that morning, stubborn little lady. Anyway, why is it so bad to let babies go a little over with gestational diabetes. That is a question, my question mark isn't working right now, hmph.

Anonymous said...

That makes me so sad for the mother, and furious at the doctor.

MJK said...

(Ugh. Save me from ignorant OBs who won't believe the research.)

And this is why I'm planning a home birth.

Anonymous said...

This is why I'm so scared of having to go to the hospital to have my baby. I'm 31 weeks right now and planning a home birth. I am also a "woman of size." I'm not supersized but I am over 200 lbs. Most of the OB's I've interviewed see me as a walking c-section. Sometimes I feel so helpless in the face of modern obstetrics. Thankfully I've got a homebirth midwife that is sensitive and has a great track record. Even so, I still wake up at night, freaked out about the thought of having a team of "medical professionals" cutting me up and abusing my poor innocent babe all in the name of junk science. What's a girl to do?

mamaraby said...

Wow - I guess I always thought the OB who did my c/s was unique in giving me a vertical skin incision (what a pain in the rear that is for recover), but suspected there might be something to it that was more common. The JP drain...I had no idea on that one. I also had one - another pain in the rear to make recover more complicated than it already was.

My son was 9lbs even more than a pound off of their dire prediction. The sad thing? Three years later, after a very easy labor, my daughter was born 8lbs 12oz and plenty of room to spare.

Here's to one day being able to call these stories "rare" instead of so very common.

Ashley said...

"Doctors (and ACOG) like to say they are all about informed consent and respecting women's choices, but the truth is that in childbirth, women are infantilized and given very little choice in anything. Either they are outright told what they "must" do, or they are emotionally manipulated, scared, or even bullied into the choice the doctors want them to make."

This seems to be standard operating procedure for any woman throughout her pregnancy, not just birth. I'm 25 weeks pregnant and an 'in-betweenie,' so the smallest end of 'obese' and I've had medical staff outright bully me at every visit. I'd told them, repeatedly, that I don't respond well to "but you don't want to hurt your baby, do you?" and yet it continues.

So I'm homebirthing. Fuck the medical practice. And I've been treated with perfect respect by my midwives, which is what I should have been getting with my doctor.

Jenny-Fair said...

That is SO frustrating. I had a c-section with my first and had a nurse practitioner try to force one on me with my second. I had him at home, in my living room-ten pounds of boy, no meds, and no sudden death from VBAC! I was around 250 the day I gave birth, I think. I tell this story to women, but unfortunately all I here is that THEY had no choice--and they really believe that. Yes, the doctors are pushing women, but women are not educating themselves and THAT is a huge part of the problem.

Well-Rounded Mama said...

Piffle, it's a good question, but a tough one to answer succinctly.

In the past, babies of women with diabetes tended to have a high stillbirth rate at term, and doctors developed this mentality that the placenta of a diabetic ages much faster (1-2 weeks faster) than the placenta of a non-diabetic.

I don't know if that's based on real research or just their assumptions; I've never seen any actual research to back it up, but that's not to say there isn't something in the older research I haven't seen. It's just something now that drs are often taught and no longer really question.

Problem is, that's based on babies of TRUE diabetics, as in type 1 usually, but sometimes type 2 also. The risk with GD is very different. And it was from the days when control wasn't very tight, like it is now, so the risk is not nearly the same. Women with excellent control now have much lower risks than in the past...but they are still elevated over the general population.

Drs tend to treat women with GD as if they are full-blown diabetics; it's not clear at all if that is justified. They think GD babies are all at high risk of stillbirth, and that the placenta is 1-2 weeks "older" than it really is. So they generally want that baby out by around 40 weeks if possible.

As long as the blood sugars have been well-controlled, I don't agree, but it's difficult to prove what the best timing is, and frankly, no one is doing really good studies on it to determine it because they are afraid of getting sued.

Another reason they like to get babies out by 40 weeks in GD is that the risk of shoulder dystocia IS higher with GD, and the longer the baby stays in, the bigger it grows, and so they assume the risk of SD will be higher the longer you wait.

There have been a couple of small studies showing that in women ON INSULIN, inducing at 38-39 weeks lowers the rate of c/s and shoulder dystocia. HOWEVER, I'd note that this really hasn't been proven in women without insulin, and there really haven't been the kind of large, well-controlled studies that you really need to see before adopting a practice widely.

I personally am NOT convinced of the need to induce all GD moms at 39-40 weeks but it is standard of care in many communities. Fear of stillbirth, fear of increasing baby size, and fear of shoulder dystocia are the reasons why. Also, they assume the risks of gestational diabetes are around the same as the risks of regular diabetes, and that's really not clear at all either.

I have a whole extensive section of information on my website about GD. It's a little older and needs some updating but the general information is still good. The section on GD: Management Protocols talk about all this, if you want further reading.

Thanks for writing, Piffle. It's an important question, but unfortunately, one which we don't have a really solid answer for yet. We really don't know what the best timing is for delivery of GD moms. I tend to err on the side of nature, not intervention, but I'd like to see some really qualitative research on the topic to know for sure.

Anonymous said...

Three months ago i gave birth to my first child. I did not have gestational diabetes but they wanted me to monitor my levels just in case, then it became you're measuring big, you might need a c section. Mind you I have several fibroids which could also have affected the measurement. I fought as hard as I could until my due date ( which is just an estimated guess as to when the child will arrive). Anyway I was railroaded into a c section. The medicial practice bullied and accused me of being negligent and ignorant and the head of the perinatal program went so far as to write a letter to be placed on file stating I was refusing medical assistance, placing my childs life in danger and just a slew of other negative things. So I gave in because I began to second guess myself, my knowledge, my gut feelig tht he wasn't ready to come out yet. I was kept in the hospital for 3 days prior to the c section because they first decided hey let's to attempt to induce. I was hooked up to all these machines, getting internal exams which I am against and ended up with a serious infection. Finally do the c section my son is 7 lbs and face up. It was too early for him to come out and he spent his first week of life in nicu because of my infection( its protocal to place the child in nicu if anything is wrong with the mother I was told) Thank heavens my child is happy and healthy and here now but I regret second guessing myself and am still dealing with the pain of surgery three months later