C-sections–elective? maternal request? medically indicated?

There are few reasons for a C-section that everyone can agree on–a prolapsed cord and placenta previa are among them. Most of the other reasons are subject to disagreement. Some doctors will require their patients to have C-sections if they think the baby is too big, or the mother’s pelvis is too small, or the father is big while the mother is little, or….or….or…..

When looking at reports of the C-section rate increasing, and looking at various studies on C-sections and their effects on mothers and babies, one thing is crystal clear–there needs to be standardization on how C-sections are coded. The problem with a lot of studies that look at C-sections is that sometimes the negative effect a baby has might be the result of a difficult labor (often induced; or perhaps the epidural sent the baby into fetal distress). So, when a C-section is done and the baby has breathing problems, or has a low Apgar score, it might be debatable whether the effect is due to the C-section or if it’s due to something else. So, most studies that look at this question will compare vaginal birth to planned, scheduled, or elective C-sections. (You can check out Jennifer Block’s “Pushed” blog and the International Cesarean Awareness Network links over on the right for a lot more information on this topic.)

Recently, a woman told me that her doctor had refused to allow her to have a vaginal birth with her second child because she had a C-section with her first. She argued and begged and pleaded, but he would not change his mind. After the operation, she discovered that he had coded her second C-section as “maternal request.” Needless to say, she was furious. She was not given an option, but the way her surgery was coded, it looked as if she had wanted it to be that way. So when I hear about the statistics of “maternal request” Cesareans increasing, it makes me wonder how many of these major abdominal surgeries are actually truly elective.

My sister-in-law planned a home birth and ended up with a C-section. She had a long and difficult labor, plus a few hours of pushing, and was just absolutely exhausted. Although the baby was tolerating labor fine, she was just done. Was this C-section “elective” or “medically indicated”? It seems to me that there is a gray area. She had not intended to have a C-section, so you can’t really say it was elective; but her baby was fine, so it wasn’t really “medically indicated.” I don’t know how this C-section was coded in her hospital record for statistical purposes, so I couldn’t say what the doctor thought of it.

There is also the questions of “emergency” C-sections. One of the many studies I’ve looked at recently noted a wide margin of “decision to incision” time in unplanned C-sections. While most hospitals strive for a 30-minute maximum, this study showed that there was no increase in fetal deaths when it went up to 90 minutes. (They divided the emergency C-sections into two groups–the first was surgery begun prior to 30 minutes after the decision, and the second was from 30-90 minutes.) However it was obvious from looking at the data (and the authors noted this as well), that the “true” emergencies (such as absent fetal heartbeat or known prolapsed cord, or sudden vaginal bleeding) were more likely to be in the first group, while the (I guess you would have to say) less emergent emergencies were in the second group. So, it seemed to me that doctors were hesitant to let the woman continue to labor, and just monitor the baby more closely when the fetal monitor zigged when it should have zagged, but they weren’t rushing down the hall yelling “Code blue,” either.

So there seems to be a gray area here, that I wish were better defined. Most unplanned C-sections are not true emergencies–either the mom just gets tired of laboring, or she takes longer than normal to push, or the fetal heartrate starts dropping a little too much (which indicates a possible problem, but is not a “code blue emergency”), or the induction fails, or the mom doesn’t dilate as fast as the doctors would like. I think it would probably clear up a lot of problems that currently exist–at least in my mind, and probably most of the public’s mind too–in figuring out why nearly one out of every three babies is born through a cut in his mother’s abdomen. You see, only when we understand what the problem is, can we figure out how to fix it. If it were clearly indicated why so many C-sections were performed–different codes for “too posh to push,” true fetal distress (and any known or suspected reasons for this), suspected fetal distress, cord prolapse, mom too tired, etc.–then we could get a better picture of what causes this, and what perhaps may be done about it.

4 Responses

  1. I agree, this is a huge problem. We need a better way of recording what type of cesarean it is. I have had moms say, “I had an emergency cesarean, but then when they explain their birth, I realize it wasn’t really an emergency, maybe urgent, but not an emergency AND they were all urgent because of interventions.

    I know there are true emergency’s… but there should be different distinctions.

  2. WHEN I HAD MY FIRST CHILD I DIALATED TO A 10 BUT BECUSE THE DOCTOR WANTED A NATURAL BIRTH HE NEVER GAVE ME AN EPADURAL WHEN I ASKED FOR IT I WENT THREW 26 HOURS OF PURE HELL THE NEXET MORNING DR. K SAID THAT ALL MY WATER WAS OUT AND THERE WAS NOT ENOUGH TO HAVE A NATERAL BIRTH AS SOON AS I WAS GIVEN THE EPADERAL I DIALATED TO A 10 IN LESS THEN 20 MINETS AND WANTED A NATERAL BIRTH THE HEART RATE STAYED THE SAME AT THIS TIME AND HE SUGESTED A C-SECTION I SAID I WANTED A NATERAL BIRTH HE WHEELED ME IN TO HAVE A CESECTION INSTEAD. HE CUT A BIG HOLE IN MY STOMACH10 INCHES ABOVE THE NORMAL AREA OF A NORMAL CESECTION AND SAID AIN’T THAT NICE.IF I SAID WHAT I WOULD HAVE LIKED TO IT WAOULD HAVE GONE LIKE THIS YOU *$#@’& %@@ HOLE WHAT THE *$#@ IS WRONG WITH YOU WAS IT YOU IN LABOR DID YOU HAVE THIS BABY? AFTER 9 HOURS OF LABOR I ASKED FOR AN EPADERAL YOU SHMUCK! IN STEAD I SAID YAH IT LOOKS GRATE HUMM… AFTER I LEFT THE HOSPITAL I BLED MORE THAT 15 PADS A DAY AND AT NIGHT MY BED WAS SOKED IN BLOOD AFTER MY FIST WEEK I WENT IN TO MY RLPN AND ASKED HER HOW MUCH BLOOD IS TOO MUCH SHE NEVER AWSERED THAT QUSETION AFTER 5 WEEK SEVEAVE HEVY BLEEDING IT STOPPED FOR 1 WEEK MY RLPN ASKED ME WHAT KIND OF BIRTH CONTROL WOULD I LIKE I SAID I WAS BREAST FEEDING AND SHE SAID THE 3 MOUNTH DEPOPAVERA SHOT WOULD BE GOOD I SAID NO I HAVE BLED FOR THREE MOUNTH IN THE PAST ON THAT NURSE DOLENGER THEN TOLD ME THAT AFTER HAVING A BABY MY BODY HAS CHANGED AND IT PROBLY WOULD NOT DUE THAT SO I SAID OK. BIG MISTAKE THE NEXT 3 MOUNTHS WERE COMPLEATE HELL I GOT THE SHOT AND WENT HOME I STARTED TO BLEED MORE AND MORE I WAS GOING THREW 15 PADS A DAY AND IN THE NIGHT TIME IF I GOT UP TO GO TO THE BATHROOM I HAD TO CHANGED A PAD AND I BLEED STRAIT THREW IT ON MY SHEETS NOT A LITTLE BUT A BIG AMOUNT AFTER A WEEK I COULD NOT GET OUT OF BED BUT I TOOK CARE OF MY BABY AND THEN HE CRYED AND CRYED AND CRYED I COULD NOT FIGURE OUT WHAT WAS GOING ON I ASKED MY GRANDMA SHE SAID HE WAS NOT GETING THE FOOD THAT WAS NEEDED I WENT TO THE HOSPITAL FOR HIS PKU AND ASKED THE DR.S WHY HE WOULD BE CRING AS MUCH AS HE WAS AND ASKED THEM ABOUT MY BLOOD LOSS THEY SAID IT WAS FINE AFTER 2 1/2 MOUNTHS I COULD NOT FUNTION SO WELL I NEVER QUIT BLEEDING AND COULD NOT EVEN GET OUT OF BED I WENT TO MY DR AND ASKED HER TO CHECK MY IRON LEVELS AND SHE SAID SHE DID THE LAST TIME I WENT TO HER I SAID \IN THE LAST 2 1/2 MOUNTHS I HAVE BOUGHT
    \EN AT LEEST 10 PACKS OF PADS A MOUNTH I CAN;T GET UP I CAN’T FUNCTION I CANT’T HARDLY BREATH AND MY KIDS CRYING AND I HAVE TO FEED HIM BABY FOOD I AM DISSY I AM SICK TO MY STOMACH AND I JUST CAN’T FUNCION SO SHE GAVE ME SOME BIRTH CONTROL PILLS AND SAID SHE’D CHECK MY IRON AGAIN THIS TIME IN DOING SO I ASKED FOR MY RECORDS OF THE APPONT MENT AND FOUND OUT SHE DID NOT CHECK MY IORN LEVELS SHE SAID THAT I CAME IN COMPLANING ABOUT BLEEDING. AFTER NOT FUNCTONING PROPERLY FOR ABOUT 2 YEARS I BECAME VARY SICK I COULD NOT STAND FOR MORE THAN 3 HOURS I SLEPED CONSTANTLY AND I STARTED TO PASS OUT I HIT MY HEAD ON THE COUNTER WHEN I PASSED OUT AND HIT THE COUNTER AND I DON’T KNOW HOW LONG I WAS OUT BUT MY KID WAS INTO MY POTS AND PANS AND SCREMING AT THE TOP OF HIS LUNGS I TOLD MY BOY FRIEND THAT I HAD PASSED OUT WHILE HE WAS GONE AND I DIDN’T KNOW WHY. SO I WENT TO NEMOROUSE OTHER DR.S AND AFTER 1 YEAR OF WHAT HAPPENED AFTER MY C SECTION I GAVE BIRTH AGAIN AND MY PLACENTA FELL DOWN TWORDS THE BOTTOM OF MY UTERIS AND INSTED OF MYWATER BRAKING I HAD A BLOODY SHOW I WENT TO THE HOSPITLA AND THEY SENT ME HOME AT 7:00 AM I GAVE BIRTH THE NEXT DAY AT 7:00 AM I WENT TO A SPEATALEST AND HE ENDED UP GIVING ME 1050 MG. OF IRON IF I KNEW THIS WOULD HAVE HAPPENED I WOULD HAVE DONE MORE TO GET A DIFFERNT DR. FOR BOTH OF MY KIDS AND I WOULD HAVE WENT TO SEATTLE AND NOT IN A SMALL TOWN.

  3. Can you cite a source that it takes 30-90 minutes to get a cesarean section? OB/GYN nurses tell me they start in less than ten minutes from decision-time.

  4. Here is one such study, which is from England and found that while most (66.3%) of babies were delivered within 30 minutes of the time of the decision that an emergency C-section was needed, and 88.3% were delivered within 40 minutes, 4% were still not born by 50 minutes. Further, “If the woman was taken to theatre in 10 minutes, 409 of 500 (81.8%) were delivered in 30 minutes and 495 (97%) in 40 minutes.” It includes a very interesting list of all the things that must take place between the time a decision is made that a C-section is necessary and the birth of the baby.

    (Unfortunately, I lost my computer bookmarks between the time I wrote this post and now, so I’ll have to find the study again that I mentioned.)

    This study from Australia showed a wide range of “decision to delivery” times — the fastest was in 17 minutes and the slowest was an astonishing 114 minutes. It said, “The main perceived reasons for delay in the delivery were staff unavailability in Level 1 hospitals, theatre access in Level 2 hospitals and anaesthetic complications in Level 3 hospitals. Therefore the decision-to-delivery reaction times in the majority of urgent emergency Caesarean sections are, in practice, much longer than the times commonly advocated and are influenced by the facilities and staff available.”

    Obviously, it depends on the hospital. For instance, in a large hospital that handles a lot of emergencies and high-risk patients, the nurses will see a lot more C-sections and also be better prepared to handle crash surgeries. In a hospital that keeps minimal staff, the operation may be delayed while waiting for an anesthesiologist to wake up and get to the hospital, for example.

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