We’ve talked before about c-sections that are done for the provider’s convenience. But what about the c-sections where there really are some factors that increase risk–is the provider then justified in manipulating the facts to sway the mother in the direction of a c-section?
Take Kelly, for instance. Her first baby weighed in at 8 pounds, and was born after a quick, four hour labor. Her second baby was 8 1/2 pounds, another easy birth. When her third baby felt breech to me, I sent her for a quick ultrasound to confirm the baby’s position.
The ultrasound show the baby in a frank breech presentation–the baby’s feet up by his ears, and bottom coming first. I also noted that the ultrasound estimated Kelly’s baby at only four pounds, which is very small for 38 weeks. However, the baby’s proportions were all normal. There was no indication that the head was large in proportion to the abdomen, a finding which could indicate growth restriction. When I felt Kelly’s baby through her belly, I did not think the baby was only 4 pounds. I told Kelly the baby felt closer to 6 pounds to me, an average weight for 38 weeks. I also reminded her that ultrasounds in late pregnancy are very inaccurate for estimating fetal weight.
Kelly strongly wished to have a vaginal birth, even if the baby was breech, and at that time I worked with Dr. A, an OB who sometimes did vaginal breech deliveries. When I spoke to her about Kelly, she initially said that Kelly would be a great candidate for a vaginal birth–she had had two babies of good size without difficulty, this baby was definitely smaller than 8 pounds, and the baby was in a good position for a safe breech birth. However, she did think that Kelly might need to be induced because of the baby’s small size; she was concerned about growth restriction. When a follow-up ultrsound showed only minimal growth since the last one, the OB asked me to schedule an induction. Then she said, “I guess I will have to be on the labor unit for the whole induction”. I was surprised, because we have no hospital protocol that requires this, and I reminded her of that fact. I also told her that I would be there the entire time, and as she lives only five minutes from the hospital, I felt that there was no need for her to have to be on the unit the entire induction.
Later that week, I came in to the hospital with a woman in active labor. I was surprised to see Kelly’s name on the postpartum board. I asked one of the nurses what had happened. She informed me that Dr. A had brought Kelly in that morning for a c-section because of oligohydramnios (low amniotic fluid, usually defined as less than 4-5 centimeters of fluid). Dr. A had told the nurse that with the combination of oligohydramnios and a breech presentation, she felt it too risky to try a vaginal birth. Kelly had strongly protested, but when Dr. A presented all the “risks” of a vaginal birth to her, she agreed to a c-section because she did not want to put her baby at risk.
I went to see Kelly in her postpartum room, and she proudly showed me her SIX pound baby. ”Dr. A really wanted to help me have a vaginal breech delivery, but in the end she said there were just too many factors against me and it wouldn’t be safe,” Kelly said. I checked her last ultrasound report, and found her amniotic fluid level at 9.85 centimeters (10 centimeters is normal). She most definitely did NOT have oligohydramnios, and she had a normal size baby for 38 weeks.
I am convinced that this physician’s decision to recommend c-section was motivated not by concern for baby’s safety, but from a desire to accomplish a quick delivery and not have to stand by on the labor unit while Kelly was in labor. And Kelly has a scar on her belly and increased risk of stillbirth and placenta accreta with her next baby. 1, 2
1. Smith GC, Pell JP, Dobbie R. Cesarean section and risk of unexplained stillbirth in subsequent pregnancy. Lancet. 2003 Nov 29;362(9398):1779-84.
2. To WW, Leung WC. Placenta previa and previous cesarean section. Int J Gynaecol Obstet. 1995 Oct;51(1):25-31.