Just a Reminder
I had an interesting reminder when I was on call the other day. The reminder that every obstetrician needs on occaision. A cesarean section isn't necessarily atraumatic for the baby. We (the chief resident and I) did a c-section on a midwife patient. She was laboring and then pushing for a long time. The baby's head was high up. The midwife (one of my favorites) asked me to do a little consult regarding mode of delivery. I checked her, she had a condition known as deep transverse arrest: Where the baby comes into the pelvis (which they do when looking to the side because their head fits best in the pelvic inlet that way); but can't come out, at least not vaginally. People used to do forceps (Keillands and Bartons forceps were invented for this very indication) to rotate the baby and then get the baby out in this situation. I didn't train in rotational forceps, because they're so seldom done (because there's a higher risk of fetal or maternal injury if the provider makes a mistake) any more. Besides, this woman's pelvis felt small, and the baby seemed large.
That leaves really one option. C-section. Which is fine. We went back to the OR, the anesthesiologist put in a spinal, and we delivered the baby. A somewhat difficult delivery, because the baby was really stuck in the pelvis. But we got the baby out. Healthy mom, healthy baby. That's the whole goal of obstetrics. Everybody was pleased.
Except, I went to look at the baby after scrubbing out to let the chief resident and the intern finish. The baby had a cephalohematoma and some bruising from the delivery. Now, the baby will be fine, had to get some light treatment for jaundice (a common complication of a cephalohematoma), but went home with mom. The baby also had quite a bit of bruising from the delivery. I went over things in my head quite a bit, and I don't think anybody did anything wrong. We never attempted an operative vaginal delivery, she didn't push for too long, we delivered the baby as gently as you can when you're pulling a baby that's wedged into the pelvis out through the abdomen.
I think it's just one of those things that happens. It's also a good reminder that the forces of labor are powerful, and that not all birth trauma happens because of vaginal deliveries.
photo credit
Labels: bad outcomes, forceps, good things
posted by Midwife with a Knife @ 2/10/2008 11:15:00 AM
11 comments
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11 Comments:
Greetings MWWAK,
I have very much enjoyed your writings (you come up on my Google alerts) and thought I would pay my respects.
I think it is important to talk about these things. With the best efforts from all concerned, we cannot eliminate risk of both mortality and morbidity, even with the normalcy of birth and the great obstetrical process capability that has been developed.
Our safety analysis, while significant, is incomplete. We know that C/S can be life saving, but we also know there is a significant increase in the probability of hysterectomy with C/S along with other morbidities. For a woman carrying one of one planned child, perhaps she might not score the risk to her fertility that high. For a woman carrying the first of five planned children, should we score her uterus as equal to a neonatal bad outcome, or perhaps even higher, when we wrestle with the probabilities and analyze our 31.1 % C/S rate?
I’m a guy fighting for women to have access to care when they make the decision to birth at home. Our outcomes as measured in (intrapartum+neonatal) mortality are indifferent to hospital for healthy women and our C/S rate is 5x lower (~4% vs. ~20% for comparable women).
While obstetrics is part of the safety of all birth models, over application of interventions degrades safety.
We were attended by a MWWAK with our second child. He used to do home births. He opened up L&D floors to fathers in the 70’s. He was a great OB.
Best wishes to you as you grow and develop in your midwifery.
Russ
True, sonetimes %$&* happens and it's nobody's fault. But the point is that you got a healthy baby and a healthy mama. And I suspect that everybody involved, especially the lady, would agree that is the most important consideration. Women and babies used to die from the situation you describe. On a regular basis.
Thank you. I am so dismayed at the attitudes I encounter often in medical school. I love reading your blog, where cesarean is treated as an emergency intervention, not as a healthier alternative to that archaic and dangerous practice of vaginal birth.
You say that "not all birth trauma happens because of vaginal deliveries" -- whilst I acknowledge that C/S has its own incidence of injury, would these particular findings have occurred with an elective C-section?
The point that had a resonance with me was that, when I was a midwife in the 80s, it seemed that ALL the prolonged labours, all the forceps deliveries, all the emergency C sections happened to midwives. We used to talk about this aparrent skewing of results, but I am not aware that anyone carried out a study!
Trouble is most of the time you don't know transverse arrest is going to happen before the fact, so you won't know you need C- section
You did good. Get some rest.
midhusband: Thanks. :) I tell women who come in for a labor check something similar if they're not in labor. I say, "Even if you're just starting into labor, you're better off at home, that way we can protect you from all of us doctors. " I laugh, the patients laugh, but it really is at least a half truth.
anon: True. I don't wish I had done anything differently. :)
hilary: I do believe in vaginal deliveries when they're safe and possible. I think that until we have strong evidence that elective c/s are really better, it's best to deliver vaginally.
dhs: Maybe not, but elective (prelabor) c-sections are associated with increased risk of lung problems in the newborns. It seems that something about labor may help to trigger the very final steps in transition to extrauterine life.
elaine: I know! It's amazing, I've worked with some pretty great midwives (so I know it's not them), but I always look at midwife patients with suspicion for that very reason. We joke, "Midwives have the worst luck!"
anon: very true. We do offer c-sections for babies weighing more than 5000gm (~11 lbs) or 4500 gms (~10 lbs) in diabetics.
essie: Thanks. :)
Thank you for posting that. It gave me some much needed validation that concerns about the risks of c-section are not outside the realm of reasonable thinking. It's because I am concerned about my baby's health (and my health!) that I put so much effort into avoiding surgical birth if possible.
I'm so glad there was a healthy baby and healthy mama in the end.
hmmm..my baby's head looks JUST like that STILL (at 7 weeks, although it's A LOT smaller than when he was born) and I was never in labor (we flunked a BPP, and after being sent to get something to eat and drink, flunked the repeat BPP) The pediatrician says it's because he was so low he was sitting on my bones for weeks. It's never seemed to bother him-- apgars were 8 and 9 (even though I was under general for 20 minutes by the time they got him out)and as soon as I woke up he latched on and has nursed like a champ ever since!
--SarahC
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