Friday, January 14, 2011

Defensive medicine and the c-section assembly line

Apologies for the long posting silence. I have so many drafts in progress. In the meantime, I want to direct people to the excellent and thought-provoking posts and comments at the Unnecesarean's series Defending Ourselves Against Defensive Medicine.

I thought I would tell a little story to go with it. My last CenteringPregnancy group had their reunion today. The midwife organizes it so that the reunion takes place at the meeting of a group who is about to have their babies. Then the new moms can share their experiences of birth, breastfeeding, and baby care with the moms-to-be.

One of the reunion moms had quite the story. She had 3 days of labor and was finally at the hospital making very slow progress with a posterior baby. The midwife who facilitated the group was working with her and the doctor came in to tell the midwife that the woman should have a c-section.

The midwife took him out into the hallway to discuss it. Turns out he had a morbidly obese patient who was also going to need a c-section, and would need the OR and a number of staff for a significant amount of time. The doctor's take was, "Let's get this one out of the way, then we'll do the more complicated surgery." The midwife went to bat and said "No. Mom is fine and baby is fine. I know my patient is stalled, but you do this longer surgery and THEN, if she's still not progressed, you can take her to the OR." They argued and (thankfully!) the midwife won. She went back in and put mom in a knee chest position (keep in mind this was a mom who had an epidural! these positions are possible under many circumstances!) The baby rotated to OA, and after that labor progressed and baby was born easily.

Thank goodness for guardian midwives in the face of not just defensive but assembly-line medicine.

4 comments:

Enjoy Birth said...

Great story. It is a wonderful example of how important your care provider is!

sarahvine said...

Glad to have a good ending to this story! However I'm intrigued by the knees to chest position with an epidural - I had a birth where we got the mother on her knees holding on to a raised headstead of the bed, and the midwife was alarmed because they'd just had a birth with an epidural mother who was on her hands and knees but her chest was lower than the epidural site and the epidural started flowing UPWARDS and he heart and lungs stopped working. You can just imagine. They saved her life, but she warned the other doula and myself to be careful not to let the mother's head drop below her waist if she has an epidural. Anyone heard of this before??? How long did she have the mother in the knees to chest position, maybe it wasn't very long, just long enough to facilitate a rotation??

Well-Rounded Mama said...

Wonder if a midwife could have advocated for and given more choices to the "morbidly obese" patient so she would have been able avoid the c/s too.

Obviously, there's no way for us to know that from the story; perhaps her c/s really WAS needed. We have to be fair; it's certainly possible.

But it just struck me to wonder who was advocating for, helping, and trying to assist the woman of size to avoid HER c/s.

Considering the higher rate of complications that surgeries entail in "morbidly obese" women, I wish more "guardian midwives" were advocating for these women too.

Some are, and thank heavens for every one of them! But we need more. Far too many women of size get convinced into (or intervened into) cesareans they don't really need.

Rebecca said...

@Sarah: I can see that potentially being a concern, for the same reasons you turn a mom over to, for example, her left side if she has poor epidural coverage on her left. I will ask the midwife next time I see her what the position was exactly, but when she demo'ed it, it looked like a "lower" knee-chest position than the ones in some of the photos in the link I posted - like the photo with Penny Simkin, but with the knees pulled up towards her shoulders and her bottom resting towards her heels. I'll also ask her about the epidural question. I've definitely had moms on hands and knees with an epidural before and zero problems, but never with their heads below their waists, so I've never had it mentioned to me as a concern.

@Well-Rounded Mama: Great point! I don't think the morbidly obese woman was a midwife patient, but she deserved advocacy and support as well, and I doubt know that she got it.