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Wednesday, November 24, 2010

The myth of the emergency c-section

It seems like when you're talking about a c-section, it often comes down to a question of semantics. The word "emergency" gets thrown around an awful lot, and I can't help but wonder if there's any validity anymore to the "If I didn't have a cesarean, my baby and I would have died!" argument.

Nowadays it seems that everyone has had an "emergency" cesarean. Come to think of it, depending on who you ask, I've had two of them.

To some, it seems like if labor has started and it's obvious a vaginal delivery won't take place, it suddenly becomes an emergency. I read one comment on a birth forum about a woman asking what happens when you go into labor before a scheduled cesarean, and the response - from a labor and delivery nurse, no less - was, "Your scheduled cesarean becomes an emergency cesarean. No big deal." Aren't emergencies usually a big deal? And what about this is indicative of an emergency?

In my situation, I went into labor before a scheduled cesarean. I came to the hospital in plenty of time, and was 4 cm upon arrival. Even if they had left me sitting there for a few hours, I probably would have been just fine. Was this an emergency? Not really.

Even after my second cesarean, when a nervous soon-to-be-new dad asked me if it was an emergency after hearing the hairy details of the birth, I sort of shrugged. "Yeah, I suppose you could say it was emergent," with an air of hesitation. I was already fully dilated when I got there, but had no urge to push and no little feet were sticking out. Emergency? Probably not.

Nothing confirms my suspicions about the true nature of emergency cesareans more than this comment from My OB Said What?!?:
“It’s extremely urgent we do the cesarean now before your baby goes into stress and it becomes life-threatening. Let me just deliver the woman across the hall and then we can get things ready.”
Seriously? If you have that much time to wait, then it must not be an emergency. If this comment had come from anyone else (assuming that most contributors to MOBSW "get it" and see it for what it really is), I'd probably smile and nod and walk away muttering something. It seems like once you throw the word "emergency" in there, suddenly everything comes to a grinding halt and "your baby would have died had you not had that cesarean!" Are you sure about that?

I've heard countless comments like that from so many people and wonder what the real back story was. I wasn't there, obviously, but the minute they mention the words "induction" or "Pitocin," I cringe inside. They don't even realize their "emergency" was likely brought on by the actions of their physician, who either meant well or was deliberately putting them at greater risk for his or her own purposes. Putting on a sympathetic face and frowning while saying "You're going to need an emergency cesarean!" sounds better than, "I need to catch a plane and I need you to push out this baby." (Although some physicians no doubt don't bother to cloak it in concern and just tell it like it is.)

I read one such account from someone commenting on a blog post about a teenager who was in labor, and the doctor was pressuring her to consent to a cesarean. As the physician walked out, this person overheard her say, "Thank God she finally consented. Now I have just enough time to catch my flight." Unfortunately, because of this experience, this young mother will forever have the word "emergency" emblazoned on her mind and think her body failed, and it was the only way. Which is a lie.

It's hard, as a birth advocate, to hear these stories. I think for some, it's a mixture of several things: pride, ignorance or misinformation, and a blind trust in their physician. They do not want to admit that they believed their doctor would tell them everything and that he lied. They do not want to admit that perhaps they made a decision that could have turned out better had they only known more. Or they just had no idea that things could be different. Birth stories are something that are shared between women, even strangers, who otherwise have little if any connection to each other and yet are willing to talk about those intimate moments with a woman they don't even know. And thus not only is the birth of a child talked about, but the birth of a myth is, as well.

One mom I know told me that when she delivered her only child in the 1980s, she was induced. Her baby went into distress and she had a cesarean. Another mom had AROM with her first, which produced cord prolapse and an emergency cesarean. (She was, however, able to VBAC twice after that with the same doctor.) Still another talks about how a friend is going in for an "emergency" cesarean at 37 weeks because the baby is "small" (estimated at five pounds, three ounces by an ultrasound, which can be a pound off, either way). (What baby isn't small with three to five weeks to go?!) This mom tried to birth vaginally after being induced, but her doctor, from the looks of it, rushed her into a cesarean after she was dilated to 8 cm after only two hours with a posterior baby. Now she feels like a failure and that her body is "defective." How can you explain to someone that perhaps your "emergency cesarean" was an "iatrogenic emergency cesarean"? That sounds a bit clunkier and hard to pronounce, and still few are ready to listen when told their doctor might have been the initiator.

I posted these terrific articles recently about a hospital in Minnesota that has a very low c-section rate because they use midwives. They show a mom laboring in a tub, without pain medication, and also talk about midwives repositioning a mom in order to birth her baby vaginally. Yet, based on the comments from some people, they still don't get it. Another article - this time from England - talks about the "myth of too posh to push," and still others don't understand. Most are probably in denial that their doctor, the person they have trusted, could ever do something to hurt them or their babies. Many like to put the onus of elective cesarean on the mother and her choices, and to some extent, we can't discount that. But I can't stand the mentality that no doctor will ever do an unnecessary cesarean in the US, because that's obviously not true. If only we could better discern which ones were true emergencies versus those in which the doctor only said they were, for dramatic effect in encouraging you to make your decision faster (i.e. the "Catch my plane" cesarean mentioned above).

When looking at cesarean rates over the last few decades, they have increased steadily just within the last 20 years, in which time we've still had "modern" obstetrics to save us from ourselves in case of just such an emergency. Considering the rates are continuing to climb, what does that mean? That we're evolving into a species that suddenly can't give birth vaginally? That suddenly birth is much more dangerous than it used to be only two decades ago? I wonder, if people bother to look at the stats, if they even for a moment think about the absurdity of what they're saying. And can we quit blaming the mother for everything - from her "preference" to her weight and stature - and for once look at how her labor and delivery are managed by her doctor?

We use the term "emergency" so casually - paralleling the casual attitudes towards surgical birth in general - and water down its meaning until we don't even know what is normal and what isn't, or how to define a life-threatening situation. These attitudes, myths and misconceptions have totally changed not only our attitudes about what constitutes a real reason to have a cesarean, but clouded our view of birth as a whole.


Brittany said...

My doula training book talked about how cesareans are classified as either "emergency" or "elective." This implies that all c-sections are either needed or wanted, and it is not true. The alternative technology that would be more appropriate is the cesarean was either "planned" or "unplanned." A c-section done because the doctor has decided during labor that the baby is not fitting is not an emergency, and the mom who has a scheduled c-section because her doctor tells her the baby is going to be too big to fit is not elective in the sense we think of as "maternal request." You are right that this is very misleading terminology.

Anonymous said...

Someone I know just told me that she had an "emergency" c-section. She was 39 weeks, water broke at home, in labor for 24 hours, got the epidural and "couldn't" push. Emergency?

I was admitted to L&D after an ultrasound at 30 weeks showed my cervix was .9 cm and dynamic with funneling. I was complete at 31 weeks 4 days despite terb, mag and procardia. I stayed pregnant until 32 weeks 1 day when I felt moisture between my legs, saw quite a lot of blood, and felt an increase in pain. I called for a nurse - an OB tech came in, screamed in horror, and left the room. Nurse came in, wheeled me to the OR, doctor wanted to check things out, stuck his hand in and WHOOSH broke my water. Feet came out. Down to the shoulder. Doctor and nurse shoved baby boy back in, prepped me for a c-section (all while I'm screaming, "NO! NO! NO!") and put me under general. Emergency?

One of the NICU nurses told me that her daughter was born via emergency c-section for a heart rate above 190. Emergency?

My sister's friend had a c-section for a NST with a non-variable strip. Emergency?

A friend of mine was born via c-section after mom's water broke because her older sister had been born via c-section. Emergency?

I hate the term. I don't know how to describe my son's birth because I feel like such a jackass when I say "emergency".

The Deranged Housewife said...

Wow Anonymous - out of all of those, yours was probably the most emergent - and at that rate, they probably could have just proceeded onward as "normal." I'm so sorry!

I agree with you, Brittany - the idea that they're either always wanted or always needed is so cemented in people's minds - simply because they can not get over the idea that their doctor, in his divine wisdom, would ever decide that a plane trip is more important than your birth. It's quite disgusting how people justify certain things in labor because staff is waiting on the mother to deliver, like slow labor with VBAC, etc. and the staff whining about having to be there all day to accommodate her. So you're saying their schedules mean more than a person and her baby? That one more uterine scar is no big deal? Sheesh.

The Deranged Housewife said...

And yeah, you'd think the first thing to try would be to turn off the epidural/Pitocin. *sigh*

Anonymous said...

I guess I just don't think childbirth is an emergency. It's a natural physiological process.

The doctors/nurses/social workers/administration said that had I birthed my son vaginally, his head would have gotten stuck and he would have died.

Kind of funny they say that when my son was damaged due to "difficult head extraction".

I was also told not to have any more pregnancies. Doc said he didn't make a large enough incision and couldn't get the baby out, so he had to rip my uterus with his hands which "nicked an artery" (???) which he then stitched to the round ligament. He said if I get pregnant again, my uterus and/or artery will rupture. HA.

Anyway, that's a lot of whining about my own experience when "I agree" would have been an adequate response to the original post. Sorry.

The Deranged Housewife said...

I don't think you're whining. Each story means something, and it seems like only those people who think doctors have free reign over their bodies think we're "whining." Just because we never participated in a study, didn't file a lawsuit, or didn't have a "bad" outcome by obstetrical standards (meaning, our baby didn't die) doesn't mean our experiences and stories aren't valid. I wonder sometimes if one of the reasons women don't have kids is because they've had such a dysfunctional, horrible birth experience that they don't want to repeat that again. That, or their doctor scares them into telling them not to ever have children again, even though he's probably not telling the truth. A subtle form of population control, perhaps. *sigh*

CR said...

In the L & D dept I work in, c-sections that are emergent are referred to as crash sections. I don't actually recall hearing our docs or midwives talk about emergency sections, but then our department is totally awesome. It's like homebirth in the hospital (except that there are doctors and ORs on the other side of the hall), we have birth balls, a birthing tub, squatting bars, etc. Also when the docs come running to say that someone needs a section, our midwives will call BS and fight for their patients if necesssary. We nurses are also fairly passive-aggressive with our pit. We 'forget' to turn it up an awful lot.

The Deranged Housewife said...

CR, that sounds totally awesome! I often find the L&D nurses to be awesome at holding the middle ground between a patient and an aggressive doctor. I had several nurses like that while I was admitted for observation a week before delivery because of high BP's. One nurse even refused to put my nasty OB through when she tried calling my room, which I thought was so freaking awesome!

Krystal said...

CR, what hospital is that? I want a home birth, but my husband is more comfortable with the idea of being in a hospital. I'd like to figure out a compromise, and your hospital sounds perfect! How do I find out if one near me is like that? I live in Boston.

The Deranged Housewife said...

Krystal, You might want to post a question about this on my wall and see if you get some responses - someone there might know where the best option is! :) Good luck.

Raisin4Cookies said...

I'm pretty confident that my son's c-section birth was an emergency, but if the midwife had realised he wasn't head down until I was 10 days overdue, things might have turned out differently.

He was sort of sideways, tummy down, and when my waters burst the night before my planned c-section (I was in the hospital) I was told that his umbilical cord was prolapsed. I was put under GA and he was born quickly after.

I am grateful we are both alive to tell the tale, and my other three births have been completely normal and without any issues (my c-section was the second of four births).

Anonymous said...

In all of the lay literature distributed by my hospital, c-sections are divided into three categories:

Planned - a woman knows in advance she is going to have one. This may be medically necessary (such as in the case of placenta previa) or elective.

Unplanned - This is the kind that happens when something goes wrong during what was intended to be a vaginal delivery, but the situation is not immediately life-threatening (i.e. there is time to establish an epidural and proceed in an orderly manner). Most of the so-called emergency c-sections actually fall into this category.

Emergency - These happen quickly and usually under general anesthesia because there is an immediate risk the life of the mother and/or child. These are rare but very real.

Also, I'm sorry to hear that so many of you have had bad luck with your doctors. Not all OBs are out to get you or part of some anti-birth, profit-driven conspiracy. The hospital environment that CR describes is fairly typical in my area (and has been for at least 5 years or so) and many doctors refuse to schedule elective c-sections. Some medical doctors do also recommend external torsion and alternative medicine in order to attempt to rotate a baby.

That said, I will probably have to have a caesarian birth with my twins. All of the rotation techniques recommended by my OB have failed because they are just too crowded to move. They're currently transverse. My OB still wants me to go into labor naturally and to try for a vaginal delivery if they can be rotated into a more favorable position with the help of contractions.

My great grandmother did not have the option of a caesarean delivery when she had my great uncle. He was born breach and had a large head. As a result he was stuck very much like Anonymous's son. He was forced out vaginally, but not without injuring my grandmother. She lived to be 99 and was one of the healthiest and most active people I have ever known. However, the damage she sustained from that delivery lasted for the rest of her life. Cesarian births are not all evil. An unplanned c-section might have spared her more than 70 years of bladder, intestinal, and pelvic difficulties.

The Deranged Housewife said...

I agree - breaking it down into those three categories is the most reasonable approach, I think.