Reply turned post, tired-of-pushing style

Pinky has a great post up about women who can’t push adequately because of their epidural who then ask for cesareans. (And, may I add, they may have an unrealistic idea of what the normal pushing a.k.a. 2nd stage of labor should take, which is, on average, 48 minutes or so for a first time mom. Up to 2 hours is definitely normal and safe if the fetus does not appear to be in distress. If they’re asking for cesareans after 30 minutes, there is a misconception there that needs to be corrected.)

Here is my reply-turned post:

I do not believe in the patient-as-customer paradigm in which a patient can request a non medically justified intervention, like a cesarean section in a slow but within-normal-range 2nd stage (or as an elective section without labor, for that matter.)

I am going to try to refuse to attend these kinds of deliveries when I get to make the calls. I have a feeling as a student on rotations and as an intern I will probably have to participate in many procedures like unwarranted inductions with poor Bishop’s scores and good biophysicals.

But, when I call the shots, I will tell the patient the pros and cons of all of their options. I will make it clear from early on in their pregnancy that I do not choose to perform cesarean sections (or any other medical interventions, for that matter) that do not have good evidence of improved health outcomes.

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8 Comments

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8 responses to “Reply turned post, tired-of-pushing style

  1. I was just talking to someone about using the terms “customer” and “consumer” in health care. I didn’t like it, then started using it, then shyed away from it again when I realized that it was tied to the wave of people that go to urgent care and demand antibiotics or other drugs marketed to consumers and get pissed off when their doctor says no.

    One thing I’ve wondered is whether or not limiting planned CDMR’s would mean less power for women walking into a hospital wanting to give birth vaginally in this anti-VBAC, fearful climate.

    I don’t think there’s anything abnormal or nutty (as many imply) about wanting a c-section. I don’t think a doctor should have to perform something as major as abdominal surgery without any medical indication, however. I think of all of the people I know, have met over the years and friends of friends and I know of ONE true maternal req primary c-section. For her it was no doubt a positive. I haven’t seen her in years but I was shocked to find that she even got pregnant based on how she used to talk about having kids. I don’t believe that more than a tiny percentage of women would really elect for a primary c-section. I guess I’ll believe it when I see it.

    VBAC or birth of a suspected big baby are events that are going to happen spontaneously, but are viewed (as are all births) as procedures. My friend was screamed at by her doc while in labor for a VBAC, then abandoned and the hospital had to call the (immature) doctor back to catch the baby. She was totally furious that she would not consent to a c-section on the spot, yelled that the shoulders would get stuck and that there was no way this baby was coming out through her vagina. It did, of course, and that beast caught the 10 lb. baby.

    I could see how it could possibly be a positive to perform a planned c-section on a woman who requests one IF *every* other choice across the board is opened up. No VBAC bans, no suspected macrosomia bullshit, access to midwives, water births and support for home birth. People choose elective surgery for a lot of reasons. What if the cost of the difference between vaginal birth and c-section were paid by the woman and she produced signed legal docs indicating that she fully understood that she was electing for a totally unnecessary surgery?

    I have embarrassed myself in the past with a bad slippery slope. A greasy, slick slope. I fear that if the option to officially elect for a c-section is on the table, the docs who love c/s and view them as superior to vaginal birth will take the next step to offer them to their patients as if they’re apples for apples. Believing her doc’s advice that she might like a c/s to spare her pelvic floor (no evidence) or prevent permanent birth injuries (no evidence– Erb’s Palsy happens with c/s babies, too), more women might be goaded into unnecessary surgery and the accompanying morbidity that goes along with it.

    Obviously I don’t have much trust that doctors will not push women toward c/s. And with a rate of 31.8%, I don’t think my lack of trust is just paranoia.

    What do you think? Could “allowing” true maternal req c/s open the door to real choice for everyone?

  2. MomTFH

    That is a really good point. I have discussed this with my faculty adviser at school. He thinks elective cesarean section is a valid choice in the patient choice spectrum, and is an integral part of reproductive rights and patient autonomy. I sometimes wonder if I am rigid in my ignorance of what the “real world” is like in practice, and if I would consider doing some elective cesareans in the future.

    Even when I was writing this post, I paused at the last paragraph and thought a lot about my language. I will tell people that I don’t think cesareans are medically justified in many situations, and that I would advise against them in situations that are medically normal (like a not-even-prolonged 2nd stage) when the risks outweigh the benefits.

    The only person I know well who opted for a true maternal request elective cesarean had a family history of complications in labor and delivery. From what I have heard, none of these would indicate that she would have similar issues (I think one was a severe shoulder dystocia with a poor outcome), but I can clearly see her fear of vaginal delivery. I have strong faith in genetic issues with labor and delivery. Women deliver like their mothers and sisters, and I take do not take these concerns lightly.

    I think this is a fine line that needs a lot of cooperation between patient and doctor, and an acknowledgment that this is a gray area. (OK, I have a feeling this is turning into a reply-turned-post). I know many people want a strong balance of maternal rights with practitioner or government legislation. Limiting women’s choices for elective cesarean might also limit her access to homebirth. Or VBAC. Or selective reduction. Or abortion.

    I think this is a topic that needs to be discussed with a lot of nuance (der) and there is room for a balance between evidence based medicine, patient autonomy, informed consent, and yes, sigh, provider conscience. I am strongly in favor of all of these thing with a passion that sometimes makes ethical hypotheticals (as of now, who knows what I will be facing in the next few years very challenging.)

    I strongly support the right of refusal of care. I am not as fervent about the right to interventions that are not evidence based. That is one of the ways I base my ethical decision making. I am much more willing to listen to an argument against intervening rather than for intervening, for the most part. This consideration seems more likely to prevent an overzealous practitioner from pressuring someone into an unwarranted procedure or medication. Or, an uneducated or emotional patient or guardian insisting on an invasive procedure that is either elective or not indicated, that has inherent risks over any potential health benefits. Or, less likely to favor patients who insist on the latest advertised medication for PMDD or the latest compounded hormone recommended on Oprah. Most favorable health outcomes based on available literature is also a large factor for me. Luckily, for obstetrics, these two things tend to go hand in hand.

    As of right now, this is how I think I will handle maternal request for elective cesarean. I will inform them of the risks versus the benefits of all of their options. If they seem to understand that cesarean section on a healthy mother and fetus with no medical indications for surgery has more risk than benefit to the mother and fetus (according to current literature), and still want a cesarean, I think I will politely refer them to one of my peers who I think is an excellent surgeon and wish them the best.

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  4. Well that sounds like a good plan. I think it is perfectly acceptable to refer a woman to another doctor who can perform her informed wishes. And I agree that if we won’t give a woman a requested C-section, we are also in the boat of not doing VBACS, not providing water births and homebirths. Well, providing water birhts and homebirths are actually not something I would or could do because the AAP has given it the thumbs down and the ACOG has strong opinions on homebirth. I don’t personally agree with homebirth but I don’t want women’s rights banned and if you start banning one thing, the others will follow suit. I guess I have a responsibility to be respectful of women’s decisions when they know the cost benefit analysis. Even thought those decisions might not be my own.

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  6. Anon

    Why should you have you have to participate in procedures for which you have moral qualms? Others are able to opt out of abortion and birth control for moral reasons, why not medically unnecessary procedures? There must be a few of them at least which are medically necessary to satisfy your program. Just a thought.

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