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Laboring against a cesarean
A doctor’s story of delivering a baby in the U.S. health care system
BY CARLA C. KEIRNS WASHINGTON POST
MICHELLE KUMATA - MCT
KATHERINE M. KEIRNS
Dr. Carla C. Keirns with her newborn son.
I had been at the hospital for two days in induced labor, unable to get out of bed or eat, tethered to a labor-inducing drip. The doctors started to talk about a C-section. I had assisted at dozens of cesarean sections when I was a medical student, but I didn’t think I was there yet. I started flipping through my phone, looking for friends who were obstetricians and pediatricians. I needed another opinion to keep me from the operation.
As a physician and health policy researcher, I thought I was pretty savvy about health care in the United States. But nothing prepared me for delivering a baby in the U.S. health care system. As a mother-to-be, I felt responsible for the life I was bringing into the world and willing to do anything to increase the chances that I would have a healthy baby. But I was also concerned that the technology we were relying on might lead to interventions that weren’t necessary.
Admittedly, I was a more complicated case than the average. I became pregnant with my first child at 40, and I had gestational diabetes.
A friend warned me that some obstetricians induce labor early in diabetic mothers for fear of complications, but one of my doctors assured me that they wouldn’t do that.
There was no more mention of the plan for my delivery until I went to a routine visit at 36 weeks. A doctor I had never met before was flipping through my chart as she walked in. She furrowed her brow, and looked me up and down. She looked at my chart again and fretted about my sugars and blood pressures. She seemed surprised when she saw they were normal. “I hope you go into labor on your own,” she said, “because if we induce, the chance of a C-section is 50 percent.”
The appointment left me deeply unsettled. A week later, I saw the senior obstetrician who had been managing my pregnancy, and he said as long as the baby and I were safe, they would let labor unfold naturally.
A few weeks later, with no labor pains yet and nearly 40 weeks into my pregnancy, my husband drove me to the hospital, where the doctors were going to induce labor.
I’d get two hormones: first, prostaglandin to soften, or “ripen,” the cervix, and then oxytocin to trigger or augment contractions.
Twelve hours later, I was only 3 centimeters dilated. The doctors started the oxytocin drip to strengthen the contractions, and by mid-morning I was at 6 centimeters. We were still a long way from the goal of 10.
My doctor suggested we break the amniotic sac, which tends to hurry things along, and I agreed. But breaking the sac also starts a clock toward potential C-section, since infection rates increase if delivery does not occur within 24 hours.
Four hours later, though, they found my cervix only 4 to 5 centimeters dilated; perhaps labor had stalled.
A bit later the general obstetrician on call said that if things hadn’t progressed in a couple of hours, “we’re going to talk about a cesarean.”
An obstetric anesthesiologist friend came by soon after and warned: “They’re looking at the clock. They’re not looking at you.”
I suddenly realized that, despite my medical training and experience, I might lose any say in what was happening.
Was I at the mercy of doctors who didn’t know me and had already made up their minds? Looking for support, I called three friends – a pediatrician, a family practice physician who delivers babies and a specialist in maternal-fetal medicine, or MFM.
We agreed that there was no urgent reason for a cesarean: My baby’s heart rate tracings were described by the labor and delivery team as “beautiful,” and I was tolerating labor fine. My friends counseled patience.
At this hospital, the obstetricians, anesthesiologists, neonatologists and nurses on Labor & Delivery meet twice a day to review the status of patients.
Urging a cesarean
The MFM physician reviewed the status of my labor. I needed more time. However, other physicians present – none of whom had evaluated me – said I should have a cesarean delivery as soon as possible.
Fortunately for me, the hospital was very busy that night with other urgent deliveries. We were left alone until 6 in the morning, when the chief resident returned. It had been 21 hours since the amniotic sac was broken. My cervix was more than 9 centimeters dilated. I was almost ready.
But when the attending obstetrician came by a few hours later, she checked my cervix and told me to call when I was ready to deliver the baby.
When I called out to say I could feel it was time, I was told to hold off pushing, despite a huge desire to do so; they needed to “get some things ready.”
Thirty minutes later, I made it clear I couldn’t wait. For the next hour and a half, a nurse coached me as the baby descended steadily. When the nurse saw my baby’s head coming into view, she got the obstetrician.
The obstetrician did not even stop to examine me before she said: “If you haven’t delivered by 2:30, we’ll have to go to the OR.”
“The hell with that,” I thought. And in seven minutes, she had the baby in her hands.
A blue baby
Yet after all that hurrying me up, the medical team seemed unprepared when my baby came. A team from the neonatal intensive care unit should have been on hand for the delivery because the insulin and magnesium I was on can affect the baby. But they hadn’t been alerted in time.
My son came out blue and not breathing. I listened for crying but didn’t hear any. I barely heard the doctors say it was a boy. Meanwhile, as the NICU unit was summoned to attend to my son, I began to hemorrhage. My physicians seemed so unprepared. Perhaps they really had already earmarked me for a C-section, and the delivery room simply wasn’t ready for a vaginal birth.
After we were both stabilized, they handed the baby to my husband; I was too exhausted to hold him.
There are circumstances where surgical births are necessary to protect babies, mothers or both. But there is broad agreement that the current U.S. rate of about 32 percent is too high – the World Health Organization sets 10-15 percent as the goal worldwide – and not warranted by concerns for fetal or maternal health.
According to a 2011 study in the journal Obstetrics and Gynecology, the most common reason for a first or “primary” cesarean in the United States is “failure to progress.” But judgments on what constitutes a “slow” or “stalled” labor are often subjective.
A subjective decision
Much has been said, written and done to influence cesarean delivery rates. Although we’ve been lamenting the increasing rate of cesarean sections since the 1970s, they keep rising.
I’ve seen mothers who have lost their babies and fathers who have lost their wives due to complications of pregnancy. As a doctor, I don’t discount the problems my doctors were worried about.
But I knew that the reasons I was being given to proceed with a cesarean delivery were subjective. I had friends with the right medical expertise to call on, and even then, I barely escaped a cesarean I didn’t need.
In the end, my son is healthy, I’m fine and we had the delivery data suggest was safest for both of us. Maybe that’s enough – it’s everything to me and my son – but I think we can do better.
Keirns (firstname.lastname@example.org) is assistant professor of preventive medicine, medicine and history at Stony Brook