Elective Primary C/S

Specialties Ob/Gyn

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On our unit, Primary Elective C/S have become pretty popular, for this main reason, "I don't want to go through the pain of labor". Now, with that said some of these young ladies insist on also having a general anesthetic because "I don't want a needle poking me in my back". I find myself getting fustrated with these pt's, I don't like to feel that way towards them. A small percentage of these young ladies don't even know why the Doc has even scheduled them for a primary c/s, and then the advocate comes out in me and when the patient asks the doctor for a trial labor, the doc talks them out of it. It really frustrates the hell out me. What do other's feel about this new trend? I really need to see if this is occurring more frequently nationwide or if this is a local issue. I understand if there is true CPD, breech, or maternal complication that would require a primary, but too many times these babies are vertex and average birth weight that are delivered. It's one thing when a pt has gone through labor and is FTP, failure to descent, or fetal distress that send them packing into an OR, but this Primary elective issue has just grated my nerves. My other co-workers are frustrated as well and the response from my peers is "we just have to accommadate the docs order". Please share some insight regarding this issue.

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

Our anesthesia providers are EXCELLENT at discussing all aspects/types of anesthesia with their patients, benefits/risks and expectations/limitations of each-----and I have seen them allay the fears of many a panic-sticken lady. I have faith in their ability to decide, along with the patient and her s/o, which course is the best way to go and why-----and I have seen the results. They are an amazing group, IMO.

Just had gallbladder out myself 2 weeks ago. I have been "asleep" several times for various surgeries. HORRIBLE experiences, all of them, emerging from the general. Just horrible. BUT---Have to say, this was my best experience ever. Simply because the MDA listened to my concerns over prior extreme nausea/vomiting and hangover after anesthesia. This time, when I emerged, it was like waking from a deep sleep, nothing more.

I am glad there are providers like gasspasser and Lou to take care of our parturients in their most vulnerable and special moments. You guys make the difference in many cases, between a great experience and out and out ordeal. Carry on!

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Specializes in L & D; Postpartum.
tntrn

First of all, rational or not, your fears are real to you. As an anesthesia provider, I recognize that fact, and have dealt with this very situation several times. I would not dismiss your fears, neither would I ignore them. You have the right to an anesthesia provider who would, at the very least, sit and discuss your fears with you to try to relieve you of some of the stress you are experiencing.

Though you would never elect to have a c-section, both of us know that there are times where a c-section, though neither emergent or urgent, is medically indicated. For example, if a woman has had a prior c-section, and is presented with all the facts regarding VBAC vs repeat c-section, it is perfectly valid for her, and medically sound for her OB doc, to decide not to take the risks associated with VBAC. I actually took care of such a woman, who because of the emergent nature of the situation with her first child, had to be put to sleep for that section. She presented for a repeat section, and she had many of the same fears you have regarding neuraxial anesthesia. In my interview with her, after taking her history, I told her we would be doing a spinal technique for her second section. She let her fears be known, and I had a long talk with her about the various kinds of anesthesia, and why general anesthesia for c-sections was reserved for only truly emergent cases. (This discussion lasted a good 30 minutes.) I answered all of her questions, and by the time we were done, she elected to have the section, with the spinal I recommended.

The point of this little story is to let you know that I never dismiss a patient's fears out of hand, but I also never allow a patient to steer a clearly dangerous course, when safer options are available. That's why I went to school for such a long period of time. I would far rather deal with a patient's psych issues, both in the pre-operative interview, and during the section, than to deal with a woman who has aspirated, or worse got into a can't ventilate, can't intubate situation because I allowed her to dictate anesthetic technique over my better judgement.

Thank you for your thoughtful response. I'll bet your patients, and staff, really appreciate you too. That being said, in 30 years of nursing, I have NEVER seen an anesthesia provider spend 30 minutes with a patient, except for during the procedure or surgery.

Our guys do "talk" to the patients, but it's to mumble a little mantra that they've mumbled a million times before and they say it so fast, I doubt if anybody can really know what was said. I honestly don't think it's fair to the patient, especially when it's done during labor and the attention span is already compromised.

Often, one of them will come through, ask if anybody is wanting an epidural, and if we say, "well, Mrs. SO and SO, is interested, but not yet, or she's not sure, they'll get all huffy and say, well, she'd better get it now or never. And then there are a couple of them who think that it IS their job to convince a labor patient that they should get one. All of this, perhaps, along with those who take 30 minutes just to get one placed, with multiple sticks that leave backs looking like hamburger, might be part of my own personal fear.

Admittedly, it's not a completely rational fear. I won't watch them place one. Luckily, I am on the other side, helping my patient with positioning, holding still and all of that.

Also, I'm almost 58 so I'm never going to have to deal with it. Equally lucky, for my own surgeries, I've never had any N & V afterward so that's definitely a plus. There's always a payback though---I can only take Darvocet for pain as I'm allergic to all the heavy hitters, so I've managed through two orthopedic surgeries and a breast reduction with that and Motrin.

If nothing else, maybe my own fears and my telling of them, will bring it to the attention of other nurses and "gas passers" that although the accepted and recommended procedure, it is not without repercussions. Please, to all of you, do not overlook or dismiss patient fears or concerns as "having the willies" It just might be so much more than that. Thanks.

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I just find it odd that you think a provider has a duty to provide you with whatever kind of care you demand, regardless of practice standards or risks involved. A provider does not have a duty to provide you with whatever you want just because you want it. They may not be able to force you to do anything against your will, however, they can refuse to provide unsafe care to you.

Amen! :yeahthat:

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Specializes in OB, lactation.

i don't know if anyone already brought this recent study up, but here's a synopsis:

infant deaths after c-sections rise even in low-risk pregnancies

..."researchers at the u.s. centers for disease control and prevention analyzed data from more than 5.7 million live births and nearly 12,000 infant deaths over a four-year period."

..."the study found that the death rate among neonatal infants delivered by caesarean section was more than twice that of infants delivered lady partslly. this held true even after the researchers adjusted for socio-demographic and medical risk factors."

here's the abstract: infant and neonatal mortality for primary cesarean and lady partsl births to women with "no indicated risk," united states, 1998–2001 birth cohorts

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

I have read that before, and it does concern me greatly, mitchsmom. Like I said before, push Mother Nature too hard, and she will give a hearty and ugly shove back.

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NIH State of the Science Conference:

Cesarean Delivery on Maternal Request

I attended this conference last spring as part of my work duties with the Federal Gov't and the whole conference was simply fascinating. The final statement and summary released by the panel is still controversial.

If you are truly interested in the subject check out the archived conference footage and final report.

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Granted I haven't read every response. I had a C/section with my first. (decels) a repeat section with BTL with my 2nd and last. We had an incident on our unit that resulted in a maternal death. let me just say a few words

previa (more incident after C/sections)

acreta (more incident after C/sections with a diagnosed previa)

percreta, increta procreta (have to have an acreat to have these)

pt bleeding stat C/section within 10 minutes baby out mom basically bleeds to death can't stop bleeding. (tried for a long time):(

With increased c/section rates we WILL see more of this. Granted still won't be enough to raise the attention of the public unless someone famous dies but C/sections have risks. Risks that are not immediate. I don't think people truely understand the risks. Sometimes I don't think we as nurses understand the risks.

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Granted I haven't read every response. I had a C/section with my first. (decels) a repeat section with BTL with my 2nd and last. We had an incident on our unit that resulted in a maternal death. let me just say a few words

previa (more incident after C/sections)

acreta (more incident after C/sections with a diagnosed previa)

percreta, increta procreta (have to have an acreat to have these)

pt bleeding stat C/section within 10 minutes baby out mom basically bleeds to death can't stop bleeding. (tried for a long time):(

With increased c/section rates we WILL see more of this. Granted still won't be enough to raise the attention of the public unless someone famous dies but C/sections have risks. Risks that are not immediate. I don't think people truely understand the risks. Sometimes I don't think we as nurses understand the risks.

:yeahthat: AMEN TO THAT!!! I have seen this situation a couple of times and it is one of the scariest things that can happen in OB. We had a pt that was prev c/s x 1 or 2(can't remember exactly). Was losing the baby at 20-22 weeks, so they let her go lady partslly.....They couldn't get the placenta out so started a D&C and all Hell broke loose. She got I think 9 units of blood, an emergency hysterectomy. She almost died from all this and lost her baby and uterus... SO SAD!!! This is a rare complication but we will definetly start seeing it more since the c section rate is rising. I think the national average is about 30%....It will be interesting to see how high it goes in the next 5 years.... And the maternal/infant mortality rate.

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Yea... and uterine rupture (greater chance with each c-sec.) doesn't always happen during labor. It can happen at home... at the mall... you get the idea.

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I don't care how any woman wants to deliver her baby- it's her right to choose and her wishes should be honored to the best of our ability.

It seems that we maintain that we are the patients advocate... unless the pt chooses something that we don't agree with personally. That's not right.

Thank you for that comment, judy. After reading the rest of this thread I was wondering if anyone else felt this way.

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I also have difficulty dealing with those who have chosen to elect a primary c/s. If they were really being informed properly, shouldn't their provider have impressed upon them that this is major surgery and also what how the risks increase with future pregnancies? I think everyone patient and provider are looking for an easy way out in their very busy lives regardless of consequences whether immediate or long term. Wouldn't it be nice to choose the date that your baby will be born, or work it around your schedule so as not to interfere with your life. Physicians don't want to be up all night with a laboring patient, they have office hours in the morning. I believe that good labor support, education of the patient and her significant others may make a difference, but our society seems to agree with the mentality "let's get in get it done". There are risks in all pregnancies and births, but why shouldn't we take the most natural route to get there?

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You know the way to put an end to "vanity c-sect" or for those who are just afraid of labor? Get teh insurance companies to stop paying for them. I bet that would nip it in the bud. I wouldn't be surprised if they're actually thinking about it and if it's not for a medically necessary reason, you get a c-sect - you pay for it. Probably the docs will stop pushing them as well. ;)

I think one of the other things they're doing is really pressuring mom with ultrasounds. I have had two friends who were told their babies were "very large" by ultrasound. One a first-timer. They told her that the baby was measuring over 8 pounds BUT this could be off and she could be almost 10! (I reminded her that the "off" part works the other way as well and she might only be 7 pounds). Well... it was New Years Eve morning and guess who was "talked into" having a c-sect?? yep... baby was just over 7 pounds. :trout: Almost identical thing with the other friend.

We'll see in the next few years what insurance companies have to say. If it's vanity, most of them don't pay for plastic surgery, why would they pay the needless expense of a c-sect?

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