What would you have done? Episiotomy

Red Kryptonite · Jun 4, 2015

The woman in the video served the MD in a lawsuit today, alleging assault and battery, according to the Improving Birth website that initially posted the video. The lawsuit comes after a fundraising and nationwide search for an attorney that would take the case.
Press Release: Woman Charges OB with Assault & Battery for Forced Episiotomy | ImprovingBirth

Good for her.

Glycerine82, LPN · Jun 4, 2015

Just curious, how do you know her tearing would have been that bad? Generally tears that occur naturally heal better and faster than an episiotomy.

Well, I guess I don't really know, but from where I was standing I had a full view of everything and It surely did look like she was going to tear.

So, I have a confession..... I was just commenting on consent during episiotomies before, I didn't actually watch the video..... I just wanted to chime in because I just watched my sister give birth (sooo cool) and they gave her one and didn't ask her permission......

BUT

The episotomy I saw was WAY faster than that AND the perineum was COMPLETELY stretched out. I mean to the point where I truly thought her rectum was going to turn inside out. The baby was completely crowned and just didn't have enough room to come out. It was NOTHING like this video.

Also, WHY in tarnation do we ask women to lay down to push a human out of their body? I'll never understand it as long as I live.

PS My lady parts hurts from watching this.

Now that I am thinking about it, I also noticed the doctor cutting something INSIDE her lady partsl canal and I swear the nurse told me she was cutting the "bands" which I looked up, but could never get an idea of what exactly went on there.

If any L&D nurses know the answer to this, I'd love to know.

Red Kryptonite · Jun 4, 2015

Well, I guess I don't really know, but from where I was standing I had a full view of everything and It surely did look like she was going to tear.

And the research is clear she would have been better off with a natural tear. I've had a 3rd degree natural tear and would take that any day over having the muscles of my perineum cut with a scalpel.

AspiringNurseMW · Jun 4, 2015

http://jama.jamanetwork.com/data/Journals/JAMA/4974/JCR50003.pdf
ACOG Recommends Restricted Use of Episiotomies - ACOG
There are really a couple of different issues being discussed here, right?
- Evidence-based indications for episiotomies.
- Obtaining consent to cut a woman's genitals.
If a woman 'doesn't mind' that she got an episiotomy, and she feels that she ultimately benefitted from it, does that absolve the provider of the the obligation to get consent to do it?

I would answer a resounding no. Because had she had true informed consent, her decision might be different. Informed consent is not retroactive.

And I think evidence-based practices on episiotomies are pretty clear by now, which makes this worse.

musingmom · Jun 5, 2015

I've followed this case since the video first got shared online, since I am a member of a birth advocacy group and an unofficial birth junkie. Having said that, like Red Kryptonite, I can never work in OB because "I'd do murder in my heart," every shift.

So, it bears repeating: I am not an OB nurse. I am an ICU nurse, and still in my first year of practice. So my perspective is drawn from my own 4 birth experiences (4 births, 5 children) that span the spectrum from high intervention to no intervention and just about everything in between. I also attended the births of two family members, and I volunteered over 500 hours in an L&D unit prior to nursing school... plus of course: nursing school clinicals. So I have been present for dozens of live births, but never as a licensed nurse. I also live and practice in the same state as the woman in the video, though I have never been inside Providence Tarzana, the hospital identified in the lawsuit.

In my opinion, even if the woman in the video signed a consent for an episiotomy, she clearly withdrew it, and this is bothersome. I have seen women ask for the pitocin to be turned off and the dr and nurse refuse. 100% of the births I witnessed in my OB clinical had an episiotomy performed. Ironically, my OB clinicals were in the same hospital I gave birth to my twins in, 10 years before. One male classmate was horrified at the high episiotomy rate and said "It's like they just fillet them all, for no reason!" In no other specialty would a practitioner proceed in the context of someone saying at the last minute, "No, don't do it!" But women are told the "health" of their baby trumps their personal wishes (those two things do not have to be mutually exclusive, and the 'health' of the baby being a subjective conclusion at best), and we all know that provider convenience drives OB practice in many, many cases. I also put forth that women of means have WAY more influence in how their birth goes, and I truly believe that some of these issues disproportionately affect minorities and women of lower socioeconomic status.

Part of the problem of changing birth culture, is that the prevailing cultural viewpoint is, if the outcome was good... mom and baby are fine, then there is no issue. This is why it was difficult to find an attorney to take this woman's case: there is no loss, no permanent injury. Because it's birth, the lack of patient autonomy is not seen as an issue, as long as everyone survived. Women are told, well at least you got your baby! You should be happy he's healthy!

I don't mean to disparage the specialty, I had lovely L&D nurses for 3 of my births, one who nearly delivered the baby by herself, and another whom I completely credit my drug free VBAC to; without her, I would have had surgery. I had 4 different OBs for 4 births (different geographic locations), and I would recommend 3 of them unreservedly. My last birth, I did not have an episiotomy, and I did not tear, and I'm grateful my OB took a wait and see attitude. The recovery was SO MUCH easier.

I appreciate this thread, and the opportunity it gives us all to perpetuate the conversation about autonomy in birth. I have learned a lot from you all.

-Musingmom

melmarie23, MSN, RN · Jun 5, 2015

The woman in the video served the MD in a lawsuit today, alleging assault and battery, according to the Improving Birth website that initially posted the video. The lawsuit comes after a fundraising and nationwide search for an attorney that would take the case.
Press Release: Woman Charges OB with Assault & Battery for Forced Episiotomy | ImprovingBirth

I am happy that someone finally decided to represent her! It's taken over a year and a half, even despite the video evidence which clearly shows her not consenting to the procedure. Most lawyers refused to take he case because nothing was "wrong" with her or the baby. There are so many things wrong with this that I don't even know where to begin...

cayenne06, MSN, CNM · Jun 5, 2015

I've actually never seen an episiotomy cut in my 13 years working in L&D (granted, much of that was at a birth center!). I have, however, cut one myself due to fetal distress (i've caught about 300 babies, for reference).

As a CNM student I witnessed my preceptor perform a forced SVE on a teenage patient as she was crying and screaming NO and climbing to the top of the bed. She literally forced her legs opened, and even AROM'd her without telling her what she was doing. There wasn't even a clinical indication for an exam or arom (not that it matters)!!

It was terrible. I felt confused and unsure of what to do as a student in that situation. I cried in the bathroom, took care of the patient for the rest of her labor (and she ended up with a wonderful birth), and then went home and slept on it. I ended up reporting her to the nursing director on the unit, and the preceptor coordinator at my school. Let me tell you, it was awkward and scary because I knew the midwife would know it was me who reported her, and I was worried that it would affect my clinical placement.

I don't know what ended up happening (the midwife is still precepting and practicing), but I think it is our duty to speak up when something so egregious happens.

cayenne06, MSN, CNM · Jun 5, 2015

I also want to echo previous posters that not all LDRP units are bad. Some are incredible, evidence based and truly family focused. An example is the Birthplace at Baystate Franklin Medical Center in Massachusetts.

BloomNurseRN, ASN, BSN, RN · Jun 5, 2015

That is disturbing beyond words. The way the doctor speaks to the woman is completely inappropriate. The fact that the nurse encourages the woman to go along is mind boggling. So thankful my birth experiences were nothing like this. Wow.

klone, MSN, RN · Jun 5, 2015

The last two hospitals for which I've worked (different hospitals, but both affiliated with the local med school, so the same residents rotate through), this would NEVER have happened. So much emphasis is placed upon the woman's right to autonomy that there are instances where we've watched babies die on the monitor because the woman would not consent to a C/S. But you cannot do a procedure upon someone without their consent (to do so would be battery and malpractice), so we had no choice.

I'm glad that woman found an attorney. And just because the baby was fine does not mean permanent damage or harm did not come to the woman.

OrganizedChaos, LVN · Jun 5, 2015

This makes me want to go into L&D so I can stick up for women like this.

Red Kryptonite · Jun 5, 2015

Something I saw this morning:

Hospital Safety: Women Should Have Alternatives to Deliver Babies