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 Looking for a career in NICU.
Read an article stating nationwide c/section rate was 30% in 2005. This is a scary trend to me.

I'm not concerned with the increase in c-sections, because I believe the majority of OB-GYN's are c-sectioning patients more quickly when they are running into valid medical issues with either the mother or the baby and at the same time, infant mortality rate is going down, and this is most-certainly contributing to it.

As a mother, no amount of pain or surgery is too great in order to ensure that I give birth to the healthiest baby I possibly can. It makes me physically ill to hear about cases where a baby was fine and then something goes wrong with the birth that leaves the baby permanently damaged for life.

I'm just against convenience c-sections and feel they are medically unethical.

PS: Another thought...wouldn't convenience c-sections also be insurance fraud? I guarantee the insurance companies are getting told they are medically necessary, otherwise, why would they pay for them?

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

Well, the increase in c/section rates should concern us.

As an OB nurse, I am privvy to some pretty rotten situations you may not have seen as a person not in nursing just yet---- I have seen cases whereby csections were performed hastily and unduly---due to things as petty as physician impatience and/or unnecessary intervention. I have seen a rise in non-medical necessity inductions for labor, which guess what, raises the chance a woman will have a csection hugely. Surgery carries inherent risk that lady partsl delivery (in low risk situations) does not.

I have also learned in my years in nursing that interventions tend to pile up and create problems, leading to increased chances of ----you guessed it---csection. I have seen situations that made csections necessary due to inappropriate intervention/haste, NOT legitimate medical need, as you refer to. In other words, the medical need arose due to our intervention, not as a result of a pregnancy complication that was discovered that needed intervention in the first place.

I am concerned that the rate of csections is predicted to reach 50% in the next 5 to 10 years. I should think we all should be. This isn't right.

PS: our infant mortality rates in the USA are dismal, when compared to other industrialized nations, where csection rates are less than half ours---and the majority of healthy women give birth at home or in midwife-run birthing centers. So I do not believe the rise in csection rates is doing our moms or babies any huge favors; I can't be convinced when I read the grim statistics.

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I think its just horrible. I can't believe our society has come to this. :scrying:

I'm surprised that insurance companies are paying for them.

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I have to agree with the spinal/epidural thing. There's NO WAY IN, well, no way, I'd ever agree to having either. It just freaks me out and in 30 years of labor nursing I have seen few, very few indeed, c/sections which were done so slowly as to compromise the infant. They are fast, no matter what, so why not let the patient truly decide, instead of pressure them into having that needle stuck in their back.

First of all, I agree that the whole notion of a primary elective c-section is not only silly, but a dangerous trend. I think it is a result of patients' desires to be "more involved" in their own healthcare decisions. While I support the patient's right to decide, often they don't have, and don't want to go get, the necessary information to make a truly informed decision.

Having said that, I would also offer the thought that the desire to have a general anesthetic over a spinal or epidural falls into the same category as choosing an elective c-section in order to avoid the pain of labor. In this case, the patient simply is not in possession of all the facts. Most anesthesia providers I know will go a long way to avoid doing a general anesthetic for c-sections in all but truly emergent cases. In fact, I know a lot of anesthesia provider who will tell the mom that they don't get the option of choosing their anesthetic. There are several reasons for this.

First of all, in pregnancy, the tone of the lower esophegeal sphincter is decreased, and there is an 8 pound ball of kicking, wiggling infant putting pressure on the stomach. That's why so many women who have never had heartburn in their lives have so much heartburn during pregnancy. This puts the mom at a significantly increased risk of aspiration during induction of general anesthesia. At a minimum, a significant aspiration will leave mom in the ICU and on the ventilator for a prolonged period of time, and could leave her with lifelong respiratory problems owing to scarring in the lungs. At worst, it will send mom straight to the morgue.

Secondly, as we all know there can be significant swelling, even in the healthy parturient, near the end of pregnancy. This swelling occurs not only on the outside, but in many mucous membranes that you can't normally see. This means that the anesthetist may get the patient to sleep, only to find that he or she cannot intubate the patient. Yes, we could put in an LMA, but that still leaves the problem of potential aspiration, which only an endotracheal tube can prevent. And, there are no guarantees that you will be able to ventilate the patient with an LMA.

Finally, when given intravenously, the drugs we use to induce general anesthesia get to the baby at a much faster rate, at a higher dosage, than anything we might give to the mother via the spinal or epidural route. So, you get floppy babies. Statistically, babies of moms getting general anesthesia have significantly lower APGAR's than babies whose moms got neuraxial anesthesia. They are significantly more likely to need more aggressive intervention, including prolonged supplemental O2, ventilatory support with an ambu bag, and even intubation.

All this adds up to a significantly increased risk of morbidity and mortality to both mom and baby as a result of general anesthesia over neuraxial anesthesia. Of course, I would never force any woman to do anything, but any time I have a parturient who insists on general anesthesia for c-section, I go a long way to try to explain these risks to them. I am very blunt about the risks, and tell the mom that both she and her baby are at an increased risk of death if they insist on general anesthesia. Usually, when given accurate information, the mom's will choose the spinal or epidural route.

In the end, any anesthesia provider who does general anesthetic for no other reason than needles in the back give mom the willies are taking an enormous risk.

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I'm not concerned with the increase in c-sections, because I believe the majority of OB-GYN's are c-sectioning patients more quickly when they are running into valid medical issues with either the mother or the baby and at the same time, infant mortality rate is going down, and this is most-certainly contributing to it.

Actually the infant mortality rate hasn't changed significantly since the 1980's, aside from slight fluctuations. It certainly hasn't improved relative to the rise in the number of c-sections. We are also ranked very low (22nd I think) among developed nations in perinatal mortality.

http://www.cdc.gov/nchs/data/hus/hus06.pdf#025

Although it might seem like no big deal to have a c-section that may have been unnecessary for one birth, consider the effects on future pregnancies and the mother- increased stillbirths, miscarriages, ruptures, placenta accreta, and placenta previa not to mention bladder injuries, adhesions, etc. And future c-sections and all the risk they carry.

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Specializes in OB, lactation.

Good thread...

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I think it is a result of patients' desires to be "more involved" in their own healthcare decisions.

I disagree. I think that the reason that many women are getting sectioned is because the believe that the Dr knows best, and will follow whatever he says, and they don't ever question the Dr, and many don't even know that they can refuse things.

i occasionally read through some of those "Expecting" message boards at places like ivillage. There are so many posts that make me cringe. Many women will say things like "My Dr is going to induce at 37 weeks because the baby is too big"....and they say this when they are 16 weeks! Or they will say "I am having a c-section because the baby is breech" and will be already scheduled for one when they are only 30 weeks.....when the baby still has time to turn. I have known women who have Drs that tell them that they will be induced at 38 weeks, and they pick the date on the 1st or 2nd prenatal visit. It's just insane.

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More MD's are doing elective C/s due to insurance. If a patient utters the phrase "I want a C/S" and there's a difficult vag delivery, the MD is wide open for litigation. Fair? No.

Especially, if the patients reasons are unrealistic.

I don't want to have contractions

I want to know exactly when I'll delivery

Sometimes the doctors scare them:

This is going to be a big baby (ends up being 6lbs)

You'll need an episiotomy (hmmm 1 inch cut vs 6in cut)

I might not be here for your delivery (I'm on vacation in Tahoe)

I don't think they realize that C/S is major surgery, sure you "miss out" on labor, but after surgery.... It's really hard to not throught their post-op pain back in their faces, what did they expect?

I have not problems with C/S, if there's a valid medical necessity.

I do have problems with uneducated patients and ignorant MDs

:specs:

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Specializes in NICU.

I don't understand women who think that a c-section is going to be less painful than a lady partsl delivery. Don't they realize that having their abdomen cut open is going to hurt a lil' bit postpartum?! :confused: Plus they're going to have an epidural for the c-section - so why not just get the epidural and try for a lady partsl delivery? That way they get pain relief during labor and delivery without having to deal with incision pain afterwards.

My doctor told me the other day that the earliest our hospital electively induces moms is 39 weeks. She also said that if the baby measures 9-10 pounds at that time, she'll "just schedule a c-section" instead. :scrying: I really don't want a section, so I did ask about inducing early for size. She said it was a no go - that there were more complications with preterm delivery than there were with c-sections, and as a NICU nurse I should know that. So I feel like I have absolutely no options here. An elective c-section for any reason is not something I agree with.

That said, let me tell you...it's been a banner baby year around me. Lots of friends and coworkers having lil' ones. And you know what? Everyone who was induced ended up with a c-section for failure to progress. Everyone who went into labor naturally had a lady partsl delivery. Now, I know this is just my personal experience, but it really stands out to me.

About the epidural thing - I do understand! I am terrified of them, but not of general anesthesia because I've been under that before and did fine. There are risks with both types of anesthesia, and people fear each type for different reasons. I would agree to an epidural for a c-section because I know in that case it's more safe, plus I'd get to keep it for a bit post-delivery for pain relief. But if I was going for, say, a hernia repair and they offered both options, I'd pick general over epidural in a heartbeat. People just have different fears, that's all. And I'm apparently not alone in my fear of having a needle shoved into my back! Makes me nauseous just thinking about it!

About Britney Spears - I read it was four weeks early, not six for her sections. Her last son was 6-11, so there is no way he was a 34-weeker. Either way, it's sick. Do you think the same thing happened to Angelina Jolie? I was shocked when I heard she had a section - she is so fit that I thought she'd push that baby out in record time. Maybe they do tummy tucks at the same time? I seriously wouldn't put it past them...

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Specializes in Maternal - Child Health.

My doctor told me the other day that the earliest our hospital electively induces moms is 39 weeks. She also said that if the baby measures 9-10 pounds at that time, she'll "just schedule a c-section" instead. :scrying: I really don't want a section, so I did ask about inducing early for size. She said it was a no go - that there were more complications with preterm delivery than there were with c-sections, and as a NICU nurse I should know that. So I feel like I have absolutely no options here.

Maybe they do tummy tucks at the same time? I seriously wouldn't put it past them...

My heart goes out to you in this overly-interventional and C-section happy age! Please plan an extra long visit and have a heart-to-heart with your OB at your next appointment. Let her know your very reasonable and strong desire to have a low-intervention birth, if at all possible. Let her know that YOU know that size estimates of babies on U/S near term have an error margin of as much as 25%, so that your "10 lb" baby could very well be a svelte 7-1/2 lbs. Ask her to recommend another practitioner if she can't or won't accomodate your reasonable requests. Consider investigating doula services so that you'll have extra support during your labor. On admission, ask for a nurse who is comfortable working with couples who prefer low intervention. (Not all are, sadly enough!)

As for elective C-sections coupled with tummy tucks... They do exist, and one hospital in my area even advertises (much to my utter disgust) a one-stop service for C-section, tummy tuck and breast lift. Sad, isn't it?

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Arrgghh . . . :coollook: For 24 years I've hated the term "cesarean SECTION". It sounds like women are beef about to be cut up into steaks or something. :stone

Just my own personal prejudice . .. but I wasn't "sectioned". :nuke:

I've mentioned this on another thread like this one but I had three natural vag deliveries w/o an epidural and so when I found myself preggers in my 40's I told the doc I wanted an epidural. I also found myself secretly hoping for a cesarean.

I handled labor ok - I didn't freak out and stand up on the bed and scream the "F" word. But I hated the feeling of labor pains. I hated that there was nothing I personally could do to stop them, the pain was coming no matter what I did, I had no idea how long this would last, there was no end in sight. The feeling of having no control over my body freaked me out. I guess like you Gompers with your terror of epidurals, I was not crazy about labor.

I did get my epidural and an emergency cesarean because I started leaking green amniotic fluid and my baby started experiencing serious decelerations.

I have to say that the pain from the surgery was doable for me. I actually could do something about it - there were pain meds that lessened the pain and at times took it away so I could rest. Recovering from the surgery was different than laying there not in control with labor pains.

Now, this is just my own personal experience. I breastfed my son w/o problem after he had a short stay in the NICU. He roomed in with me, most of the time was on my chest asleep. I will say that first shower was heaven.

We rarely have to do cesareans with inductions. Seems like for us the mom is able to rest and relax and that cervix just opens right up.

I do think elective cesareans for cosmetic reasons or vacation scheduling or to not get stretch marks is wrong. (In my experience, those who do get stretch marks get them early in the pregnancy so delivering a few weeks early would be of no use).

The epidural itself was a piece of cake - I only felt the initial sting of lidocaine, like with an IV start and didn't feel anything but pressure after that.

Everyone is different - we have to, within limits, allow for individual needs and wants.

steph

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My heart goes out to you in this overly-interventional and C-section happy age! Please plan an extra long visit and have a heart-to-heart with your OB at your next appointment. Let her know your very reasonable and strong desire to have a low-intervention birth, if at all possible. Let her know that YOU know that size estimates of babies on U/S near term have an error margin of as much as 25%, so that your "10 lb" baby could very well be a svelte 7-1/2 lbs. Ask her to recommend another practitioner if she can't or won't accomodate your reasonable requests. Consider investigating doula services so that you'll have extra support during your labor. On admission, ask for a nurse who is comfortable working with couples who prefer low intervention. (Not all are, sadly enough!)

As for elective C-sections coupled with tummy tucks... They do exist, and one hospital in my area even advertises (much to my utter disgust) a one-stop service for C-section, tummy tuck and breast lift. Sad, isn't it?

Great advice here for Gompers . . . please do have a heart-to-heart with your doc.

As to your last paragraph Jolie . . . . . my cesarean was over 5 years ago - do I still qualify for that tummy tuck and breast lift? :coollook: :chuckle (jk)

steph

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