Elective Cesareans/On Demand

Published

Do you know if Elective Cesareans/On Demand are legal? I thought they were not but I remember watching "Birth Day" on the discovery channel and a woman had a schedule cesarean because her OB was going out of town. I am taking a political science class so I can transfer for a BSN and have to write a paper on a political issue. I thought this could be a good one but if it is still illegal no sense in arguing that it should be.... Does any one know? I tried to look it up on line but got no where.

Summary of Recommendations

The following recommendations are based on good and consistent scientific evidence (Strength of Recommendation Taxonomy [sORT] = A; see page 1201 for an explanation of SORT):

* Most women with one previous cesarean delivery with a low-transverse incision are candidates for VBAC and should be counseled about VBAC and offered a trial of labor.

* Epidural anesthesia may be used for VBAC.

The following recommendations are based on limited or inconsistent scientific evidence (SORT = B):

* Women with a vertical incision within the lower uterine segment that does not extend into the fundus are candidates for VBAC.

* The use of prostaglandins for cervical ripening or induction of labor in most women with a previous cesarean delivery should be discouraged.

The following recommendations are based primarily on consensus and expert opinion (SORT = C):

* Because uterine rupture may be catastrophic, VBAC should be attempted in institutions equipped to respond to emergencies with physicians immediately available to provide emergency care.

* After thorough counseling that weighs the individual benefits and risks of VBAC, the ultimate decision to attempt this procedure or undergo a repeat cesarean delivery should be made by the patient and her physician. This discussion should be documented in the medical record.

* lady partsl birth after a previous cesarean delivery is contraindicated in women with a previous classical uterine incision or extensive transfundal uterine surgery.

http://www.aafp.org/afp/20041001/practice.html is the ACOG recommendations (even though its aafp).

Rural/small hospitals aren't like that out of choice, the reality that we've seen in my state is that if the hospital closes their OB ward, the emergency room physician becomes a OB by default.

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Specializes in pedi, pedi psych,dd, school ,home health.
The decision of so many hospitals to disallow VBAC is unsupported by medical evidence and bespeaks a truth about smaller and rural hospitals in general; that is, if it isn't "safe enough" to VBAC there, is it going to be safe enough to birth there at all, given that obstetric emergencies can happen to primips and multips with no history of cesarean?

I thought it was 30 minutes from "decision to incision" by ACOG standards, though I could be wrong. Anyone? SBE?

When I logged onto this board tonight, I saw the thread and inwardly groaned a little. As the local PITA representative for natural birth :) I thought I would hear a bunch of lame defenses for elective cesarean from some of the nurses, including my personal pet peeve, elective cesarean as a feminist and reproductive rights issue. :angryfire The argument that it's a "woman's right to choose" her c/s is remarkable only in its uncritical viewing of what the body politic has become. And I say that as a former women studies minor.

Imagine my suprise when I read so many fiery defenses of VBAC - no suprise at all that SmilingBlueEyes led the charge. :) :) I was just tickled to read all the responses and wish each and every one of those OB nurses could help make policy decisions about VBAC. It warmed the cockles of my heart, ladies.

And heaven knows I need it tonight. At 39 wks + 5 days pregnant, I am feeling a tad cranky anyhow. I mean, even the gas station lady said when I walked in for some ice, "You're still pregnant?!". And a complete stranger asked me my due date in Target tonight. :rolleyes: (My husband joked he was suprised that she didn't ask if I had any cervical dilation yet!) Although I am obviously not going to schedule an induction anytime too soon, and certainly not an elective cesarean, my time as Gestating Goddess is coming to a close, and I'm ready to begin my new role as Lactating 24-Hour Buffet.

So I can see why some ladies get impatient. But it's no reason to schedule major abdominal surgery for mere convenience, and ACOG should be ashamed of itself, bowing to the lawyers and their own conflicts of interest. Apparently, "do no harm" now applies more to the docs than to their patients.

For those who know Henci Goer and those who don't, here's a link to a variety of articles written by her on VBAC and other childbirth subjects. She is a medical researcher and childbirth advocate with some impressive books to her credit. They are noteworthy for their medical thoroughness, intelligence and passion.

http://hencigoer.com/articles/

You guys made my night. :)

Alison

Alison, best wishes for a wonderful birth experience and a happy, healthy baby.

I have a sil who "schedules " her inductions and goes into the hospital with a birth plan that starts " I will have an epidural as soon as humanly possible" " I will not use a rocking chair, ball, tub or other alternative labor tool" I MAY decide to walk in the hall if i so choose, if not i will lay in bed and let things happen as they may"

surprisingly enough, she has had 2 uneventful, faily quick labors and looks fantastic after ward!(she's only 4'11 and has 71/2 lb babies, so she's doing something right! )baby # 3 is scheduled to arrive next week..cant wait! after my one preemie with easy. quick labor and a post term horrible induction, i dont blame her for having a plan!

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Nationally the c/s rate is about 50%. ACOG (assoc. of OB's) put out a statement last year which essentially said that c/s on demand was acceptable medical practice.

When and if a patient demands an elective primary c/section, a physician would be a fool NOT to go along with this (in our litigious society). Hopefully, most physicians would try and talk their patient out of this, but to flatly refuse would be folly.

A physician could get around this by suggesting the patient to go to another physician who will do this (that is not abandonment). Hopefully, the physician would review the risks of any type of surgery.

We have only ever had two patients (that I can think of) in that category. We are low risk, midwife friendly, and have great low intervention doctors. It would not be our philosophy to have many patients who would demand that. They would likely go elsewhere.

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Well, to me, for strictly "maternal discomfort" no, it is NOT legitimate........

for other reasons related to it, maybe. I think all women are quite uncomfortable in that last 4-6 weeks of pregnancy----some discomforts are severe and need relief (badly pinched sciatic nerves come to mind right off the top)----and your example of arthritis may well be, too. The case of a breech baby puts her in the category of "medical necessity" anyhow!

That is not what I was talking about when I brought up unnecessary inductions; there are legitimate medical concerns that need to be considered, obviously......

However----- Being "tired of being pregnant" or citing "maternal discomfort" for the convenience of the obstetrician or the patient, are to me, NOT legitmate reasons to play around with Mother Nature by inducing labor.

I know about discomfort; I contracted from 31 weeks' on w/my daughter. I am only 5 feet 2 and had a baby who was 9lb. at 38 weeks (she was breech and kicking my bladder). I waited as long as I could before having my csection, for her benefit and safety. It certainly was NOT comfortable having her feet in my pelvis and bladder and her head in my ribs for 9 weeks, all while contracting every day, often frequently enough to send me to the hospital.

I know from the OB's standpoint, there are patients who literally "park it" at their offices, whining and begging "to get it over with" or come to the hospital time after time after time, for little to nothing going on, and leave angry we are not inducing them cause "it's time"....no medical considerations or complaints, they just are "ready" for it to be done

Heck----some as soon as 30 weeks have asked why can't they get it over with, they know "so and so's cousin's kid" who did GREAT in the NICU at 30 weeks....and on it goes.......I have had others want it over cause they have an out of town wedding or some other event they want to make. Yep it gets that silly!

From MY standpoint: Labor induction is NOT without some risks of its own----and serious liabilities for all personnel involved. I don't take labor-inducing agents such as pitocin or cytotec and their potential side effects lightly, EVER. Nor should our patients. Truly informed consent is one of my great concerns regarding labor induction and its indications. I think matters of convenience are being considered and weighted much more than they should be, these days. If a person wants convenience, she should not have kids or----from a medical standpoint, maybe should consider why he/she is practicing OB medicine ! :angryfire

At my place, if they "park it and whine" they still get sent home. We just sent a G3P2 home because her induction didn't start anything. She'll be back all in good time.

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The decision of so many hospitals to disallow VBAC is unsupported by medical evidence and bespeaks a truth about smaller and rural hospitals in general; that is, if it isn't "safe enough" to VBAC there, is it going to be safe enough to birth there at all, given that obstetric emergencies can happen to primips and multips with no history of cesarean?

I thought it was 30 minutes from "decision to incision" by ACOG standards, though I could be wrong. Anyone? SBE?

When I logged onto this board tonight, I saw the thread and inwardly groaned a little. As the local PITA representative for natural birth :) I thought I would hear a bunch of lame defenses for elective cesarean from some of the nurses, including my personal pet peeve, elective cesarean as a feminist and reproductive rights issue. :angryfire The argument that it's a "woman's right to choose" her c/s is remarkable only in its uncritical viewing of what the body politic has become. And I say that as a former women studies minor.

Imagine my suprise when I read so many fiery defenses of VBAC - no suprise at all that SmilingBlueEyes led the charge. :) :) I was just tickled to read all the responses and wish each and every one of those OB nurses could help make policy decisions about VBAC. It warmed the cockles of my heart, ladies.

And heaven knows I need it tonight. At 39 wks + 5 days pregnant, I am feeling a tad cranky anyhow. I mean, even the gas station lady said when I walked in for some ice, "You're still pregnant?!". And a complete stranger asked me my due date in Target tonight. :rolleyes: (My husband joked he was suprised that she didn't ask if I had any cervical dilation yet!) Although I am obviously not going to schedule an induction anytime too soon, and certainly not an elective cesarean, my time as Gestating Goddess is coming to a close, and I'm ready to begin my new role as Lactating 24-Hour Buffet.

So I can see why some ladies get impatient. But it's no reason to schedule major abdominal surgery for mere convenience, and ACOG should be ashamed of itself, bowing to the lawyers and their own conflicts of interest. Apparently, "do no harm" now applies more to the docs than to their patients.

For those who know Henci Goer and those who don't, here's a link to a variety of articles written by her on VBAC and other childbirth subjects. She is a medical researcher and childbirth advocate with some impressive books to her credit. They are noteworthy for their medical thoroughness, intelligence and passion.

http://hencigoer.com/articles/

You guys made my night. :)

Alison

If it makes you any less cranky, we still do VBAC's: usually quite successfully!

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When and if a patient demands an elective primary c/section, a physician would be a fool NOT to go along with this (in our litigious society). Hopefully, most physicians would try and talk their patient out of this, but to flatly refuse would be folly.

A physician could get around this by suggesting the patient to go to another physician who will do this (that is not abandonment). Hopefully, the physician would review the risks of any type of surgery.

We have only ever had two patients (that I can think of) in that category. We are low risk, midwife friendly, and have great low intervention doctors. It would not be our philosophy to have many patients who would demand that. They would likely go elsewhere.

Just to play devil's advocate, why should a doctor refuse a surgery that the patient requests? Elective surgery is very common- we take out tonsils, we do breast augmentation, we do myringotomies, we replace joints, etc. All surgery carries a risk. Is a doctor the only one allowed to weigh risk/benefits? or should patients be allowed to do that too?

As pro-natural childbirth as I am, I cannot think of a good reason, other than my personal belief about the amazing potential in a good birth experience, why a well-informed woman shouldn't have a cesarean section if she wants one. I do think an argument could be made that insurance companies shouldn't have to pay for elective cesareans, but that's very tricky because we, in general, don't like our insurance companies limiting our choices.

BTW, BETSRN, this isn't directed only at you. It's a general question.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Because inherent in surgery are HIGHER risks of hemorrhage, infection and maternal death. Those are VERY good reasons to turn them down absent of medical necessity, if you ask me.

It is still considered major surgery, not some sort of minor thing like ingrown toenail removal, as you know. And two people are involved in the risk equation (mom/baby), so that must be weighted as well.

Since when have we become so blase about surgery? It's still risky, even now.

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Because inherent in surgery are HIGHER risks of hemorrhage, infection and maternal death. Those are VERY good reasons to turn them down absent of medical necessity, if you ask me.

It is still considered major surgery, not some sort of minor thing like ingrown toenail removal, as you know. And two people are involved in the risk equation (mom/baby), so that must be weighted as well.

Since when have we become so blase about surgery? It's still risky, even now.

Yes, I know surgery is risky, but risk is relative concept. (Anyone ride in a car lately?). A risk is not an inevitability. As I said, we already allow major surgery for cosmetic reasons and other elective surgeries.

What concerns me is that elective c-sections are so frowned upon because many people have a particular personal agenda about what kind of births women "should" want. The truth is some women simply aren't interested in the ecstatic experience of a natural birth. Some women don't want their perineal areas stretched and torn. Some women don't want to labor. We may find their choices shallow, but their choices don't belong to us.

I think we need to distinguish unnecessary c-sections pushed on uninformed women by litigation-leery OBs, and elective c-sections by women who want them. I guess I'm still a big fan of the ICEA's motto: "Freedom of choice based on knowledge of alternatives."

I think we pro-natural birth types are better off debunking myths, arming people with information and reassurance, discouraging fear-mongering, *and* suspending judgment of people who make choices that are not our own.

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Specializes in Specializes in L/D, newborn, GYN, LTC, Dialysis.

Risk takes on a different twist when it's tied with liability. Who is truly liable for unnecessary risk? That is a good question, I think. And it's also a reason why physicians may want to think twice before offering csection demand. There ARE other risks inherent in csection, too that we did not even touch on here. Ever read the consents they sign before surgery? All this seems so "small" til it happens to someone. Then suddenly, it's not so small.

On the side, you discuss perineums torn and stretched....ever watch how they tear and streeeeeeeeeeettttch the abdomen to get a baby out???? It's positively brutal--seeing two adults pull the abdominal walls apart like a tug of war!!!! ouch.. :uhoh3:

I think it sad when we as a society have considered a csection something we can demand like "no special sauce on that burger" or something. I think women need to really consider what is best for their bodies and their babies...sadly, many do not, or are easily "led" by their HCP's for interests that are not always a good match between patient and HCP.

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I don't have any opinion on any woman's choice of delivery. Whatever she wants is fine with me. Sometimes I think there is too much emphasis on HOW the baby gets delivered when the delivery is such a very small part of parenting.

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I don't have any opinion on any woman's choice of delivery. Whatever she wants is fine with me. Sometimes I think there is too much emphasis on HOW the baby gets delivered when the delivery is such a very small part of parenting.

Man, I'm new- our names are so similar. Can I change mine so we don't get confused?

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I think women need to really consider what is best for their bodies and their babies...

Yes, that's the point. Women need to decide, and we need to respect those informed choices, even if they are different than our own. It isn't always easy to separate our passionate beliefs from what we should let come out of our mouths- as I said early in this thread, it annoys me when women choose elective c-sections, but that annoyance, frankly, is my problem, and I have no right to inflict it (either by giving an unrequested opinion or by working to limit their choices) on someone who doesn't have the same priorities as I do.

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