By Carla C. Keirns
I had been at the hospital for two days in induced labor, unable to get out of bed or eat, tethered to a labor-inducing oxytocin drip. The doctors started to talk about stalled labor, a stuck baby, and going to the operating room. I had assisted at dozens of Caesareans when I was a medical student, but I didn’t think I was there yet. I started flipping through numbers on my cellphone, looking for friends who were obstetricians and pediatricians. I needed another opinion to keep me from a C-section.
As a physician, teacher and health policy researcher, I thought I was pretty savvy about health care in the United States. But nothing prepared me for the experience of delivering a baby in the U.S. health-care system. As a mother-to-be, I felt what all mothers feel: responsible for the life I was bringing into the world and willing to do anything to increase the chances that I would have a healthy baby. But I was also concerned that the medical technology my doctors and I were relying on to keep me and my baby safe might lead to interventions that weren’t necessary.
Admittedly, I was a more complicated case than the average. I became pregnant with my first child at the age of 40, an “elderly” first-time mother in the jargon of obstetrics, and my pregnancy was complicated by gestational diabetes. Dietary changes and exercise prescribed for me weren’t enough to keep my glucose levels optimal for my baby, so in my first trimester I started taking insulin and went to see a maternal-fetal-medicine obstetrical practice, which specialized in high-risk pregnancies. I was impressed with these specialists’ thoughtful rather than reflexive use of technology and their willingness to admit uncertainty.
Labor is an intricate dance of hormones, muscles and emotions, usually triggered by the baby when he or she is ready to breathe outside the womb. A few months into my pregnancy, a friend warned me that some obstetricians induce labor early in diabetic mothers for fear of complications. When I asked one of my doctors about this during an early clinic visit, she assured me that they wouldn’t do that.
There was no more mention of the plan for my delivery until I came to the clinic for a routine visit at 36 weeks, with swollen feet and a round belly.
This appointment was with a doctor I had never met before. She was flipping through my chart as she walked in. She furrowed her brow, and looked me up and down. She looked at my chart again and fretted about my sugars and blood pressures. She seemed surprised when she saw they were normal. “I hope you go into labor on your own,” she said, “because if we induce, the chance of a C-section is 50 percent.”
She seemed to already be planning my Caesarean, the one I didn’t want to have unless my baby needed it. The appointment left me deeply unsettled. A week later, I saw the senior obstetrician who had been managing my pregnancy since the ninth week, and he was much more reassuring. As long as the baby and I were safe, they would let labor unfold naturally.
In the hospital
A few weeks later, with no labor pains yet and 39 weeks and five days into my pregnancy, my husband drove me to the hospital, where the doctors were going to induce labor.
I’d get two hormones: first, prostaglandin to soften, or “ripen,” the cervix, and then synthetic oxytocin to trigger or augment contractions. Monitors were strapped to my abdomen to track my baby’s heart rate and the strength of my contractions. Such devices are now routine in the United States.
The monitoring helps determine whether the fetus can handle the stress of labor. Research has shown that, compared with having a doctor listen to fetal heart tones with a fetascope or a hand-held ultrasound device, electronic monitoring decreased the rate of seizures in babies but did not change infant mortality or cerebral palsy rates. It also has been found to increase the rates of Caesarean deliveries.
In my case, the baby kept moving and it was difficult to get a consistent reading of the heart rate. The nurses would rush into the room in a panic and say, “We’ve lost the baby!” My sister, who was keeping me company, found this hilarious, and when they left she would say to me, “I know where the baby is,” pointing to my basketball-size belly.
Twelve hours after the induction began, I was only three centimeters dilated. The doctors started the oxytocin drip to strengthen the contractions, and by mid-morning I was at six centimeters. We were still a long way from the goal of 10.
My doctor suggested we break the amniotic sac, which tends to hurry things along, and I agreed. But breaking the sac also starts a clock toward potential C-section, since infection rates increase in both mothers and babies if delivery does not occur within 24 hours. Happily, I soon was at eight centimeters, and my doctor was optimistic that I would deliver later that day.
When my obstetrician’s partner, along with a resident physician, saw me four hours later, though, they found my cervix only four to five centimeters dilated; perhaps labor had stalled or regressed. I wondered whether their measurements were off. After all, it was a measurement determined by fingertips.
A bit later, a third doctor, the general obstetrician on call for the night, came by and said that if things hadn’t progressed in a couple of hours, “we’re going to talk about a Caesarean. When things stop, there’s usually a reason.”
An obstetric anesthesiologist friend on call that night came by soon after and warned me: “They’re looking at the clock. They’re not looking at you.”
At that point, I suddenly realized that, despite my medical training and experience, I might lose any say in what was happening. Was I at the mercy of doctors who didn’t know me and had already made up their minds? Looking for support, I called three friends from medical school — a pediatrician, a family practice physician who delivers babies and a specialist in maternal-fetal medicine, or MFM.
With an intravenous oxytocin line in one arm, magnesium in the other, an intrauterine pressure catheter monitoring my uterine contractions and a fetal scalp electrode monitoring my baby’s heart rate, I reviewed the situation with them. We all agreed that there didn’t seem to be an urgent clinical reason for a Caesarean: My baby’s heart rate tracings were described by the labor and delivery team as “beautiful,” and I was tolerating labor fine. My friends counseled patience and advised me to point to the objective data. I resolved to push for more time.
A doctors’ debate
At this hospital, the obstetricians, anesthesiologists, neonatologists and nurses on Labor & Delivery meet twice a day to review the status of each patient in labor. Neonatologists learn when they may be needed at a patient’s delivery, anesthesiologists review pain management strategies and the obstetricians and nurses review patients’ progress in labor. Unbeknown to me until later, I became the subject of intense debate at one of these meetings.
The MFM physician reviewed the status of my labor and the team’s management plan. The intrauterine pressure catheter revealed that, although I had been receiving oxytocin for almost 24 hours, my dose had been adequate only for the last two hours. I needed more time. However, other physicians present — none of whom had actually evaluated me — said I should have a Caesarean delivery as soon as possible.
Fortunately for me, the hospital was very busy that night with other urgent deliveries. My husband, my sister and I were left alone until 6 in the morning, when the chief resident returned and said, “It’s now or never!” It had been 21 hours since the amniotic sac was broken. She examined me and found my cervix was more than nine centimeters dilated. I was almost ready.
But when the attending obstetrician on call that day came by a few hours later, my heart sank. This was the doctor I had met at 36 weeks and had hoped not to see again. She checked my cervix herself and told me to call when I was ready to deliver the baby and left.
When I called out to say I could feel it was time, I was told to hold off pushing despite a huge desire to do so; they needed to “get some things ready.” Thirty minutes later, I made it clear I couldn’t wait any longer. For the next hour and a half, a nurse coached me as the baby descended steadily. When the nurse saw my baby’s head coming into view, she got the obstetrician. The obstetrician did not even stop to examine me before she said: “If you haven’t delivered by 2:30, we’ll have to go to the OR.”
“The hell with that,” I thought. And in seven minutes, she had the baby in her hands.
Yet after all that hurrying me up, the medical team seemed unprepared when my baby came. The instrument tray was still in the hallway outside my room. A team from the neonatal intensive care unit should have been on hand for the delivery because the insulin and magnesium I was on can affect the baby. But they hadn’t been alerted in time. My son came out blue and not breathing. I listened for crying but didn’t hear any. I barely heard the doctors say it was a boy. Meanwhile, as the NICU unit was summoned to attend to my son, I began to hemorrhage from the prolonged exposure to oxytocin. My physicians seemed so unprepared for the delivery. Perhaps they really had already earmarked me for a C-section, and the delivery room simply wasn’t ready for a vaginal birth.
After we were both stabilized, they handed the baby to my husband; I was too exhausted to safely hold him.
What the data says
There are circumstances where surgical births are necessary to protect babies, mothers or both. There is, however, broad agreement that the current U.S. rate of about 32 percent is too high — the World Health Organization sets 10-15 percent as the goal worldwide — and not warranted by concerns for fetal or maternal health.
Most commonly used criteria in the United States for assessing progress of labor come from observations of women in labor in the 1950s. But the Consortium on Safe Labor in 2010 published a retrospective study of 62,415 women who delivered a healthy infant vaginally and found that the cervical dilatation rate was about half as fast as seen in those 1950s studies. This means we risk labeling normal labors as slow or abnormal, and intervene unnecessarily.
Yet, according to a 2011 study in the journal Obstetrics and Gynecology, the most common reason for a first or “primary” Caesarean in the United States is “failure to progress.” A first birth by Caesarean usually means that a woman’s subsequent children will be delivered surgically as well.
But judgments on what constitutes a “slow” or “stalled” labor are often subjective. For instance, a 2012 expert panel of the National Institute of Child Health and Human Development, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine proposed that physicians should wait 24 hours after administering oxytocin and rupturing the amniotic sac before considering an induced labor “failed,” and the clock doesn’t start until cervical ripening is completed.
The first mention of “failed induction” in my chart was only six hours after the amniotic sac was broken. In March 2014, the American College of Obstetricians and Gynecologists and the Society for Maternal-Fetal Medicine suggested giving laboring women more time.
What should we do?
Much has been said, written and done to influence Caesarean delivery rates. We should recognize first that although we’ve been lamenting the increasing rate of Caesarean sections since the 1970s, they only keep rising.
Some groups have called for more use of midwives for low-risk deliveries, but this solution doesn’t address the growing number of women like me, who are considered high-risk for complications and therefore beyond their scope of practice.
Some have advocated that obstetricians should be required to get a second opinion from another obstetrician before performing a Caesarean. I’m not optimistic that this would help. Few hospitals are likely to have a second obstetrician in-house in the middle of the night, so in practice this would likely devolve into a perfunctory review by telephone. Additionally, physicians who frequently work together may be reluctant to oppose their colleagues’ decisions, at least openly.
In my work as a clinical ethicist and palliative care doctor, I’ve seen mothers who have lost their babies and fathers who have lost their wives due to complications of pregnancy. As a doctor, I don’t discount any of the problems my doctors were worried about. I know that our obstetric colleagues are working in territory that is fraught with risk, uncertainty and liability.
If policymakers hope to change the rate of obstetric interventions, we’re going to have to change the culture of medical practice.
I already knew, at least in theory, what the risks were when I was wheeled into the delivery room. If my baby had been breech or I had twins, the evidence supports Caesarean delivery as the safest approach. But I didn’t. I also didn’t have other complications that would have made C-section important for my safety. I knew that the reasons I was being given to proceed with a Caesarean delivery were subjective. I had friends with the right medical expertise to call on, and even then, I barely escaped a Caesarean I didn’t need. In the end, my son is healthy, I’m fine and we had the vaginal delivery that epidemiological data suggests was safest for both of us. Maybe that’s enough — it’s everything to me and my son — but I think we can do better.