Monday, December 31, 2012

Luckier Than I Appreciated

I've been reading my medical file with respect to my daughter's birth - and knowing what I know now, my doctors and the hospital are lucky that a worse outcome is not part of the litigation - and I am lucky (fingers crossed) to have what appears to be a neurologically normal toddler.

One of my greatest fears about vaginal childbirth, is the potential for it to result in lifelong neurological disability. Not everyone gets through vaginal childbirth unscathed - some are left with lasting physical and mental disabilities. I understand that it is rare for such things to happen, but the reality is that someone is that one in a thousand person. I have personally known people who did not make it through birth unscathed. It was one of the reasons I was choosing cesarean for the birth of my daughter. I was happy to trade some increased risks for a decreased risk of that particular outcome.

So when I read the following in my medical record - I was taken aback, because the outcome I feared the most was much closer to becoming reality than I had thought.

My daughter had a tight nuchal cord (it could not be reduced over her head), had no spontaneous respiration for the first minute of her life, cord blood gases were ordered with the notation of gases 7.0, bicarb 17 and BE -15.

I'm a little more thankful for my daughter and a little more livid at what happened.

Friday, December 28, 2012

Mrs. W's Comment Policy

Readers should know that I have a very liberal comment policy - basically unless it is spam, I do not delete. Readers should also know that I do not take responsibility for the comments that are made (they are the responsibility of those making them), as such I cannot vouch for the credibility of the comments made. It is up to the reader to assess the credibility and accuracy of the information they are reading (I will note that if I am making a factual claim in my blog, I will cite the source of the claim and would think that when a commentator makes a factual claim, they too should cite the source if they are wanting anyone else who reads it to give any weight to it).

I've taken this policy because maternal request cesarean is controversial and while I have decided it is an appropriate way for me to give birth, I will not assume that it is a good choice for all women - and that they should hear both sides of the debate and make such decisions for themselves in conjunction with their health care providers (people who are licensed and appropriately trained to provide medical advice in specific circumstances). I have an interest in women making decisions that are best for themselves in their own personal circumstances - and as such will not prevent women (or others) from reading or providing opposing views and opinions, even on my own blog. As such, I do not personally agree with or approve of all of the comments that have been made on this blog - some are perfect illustrations of the prevailing ignorance, misconceptions and misinformation that persists when it comes to maternal request cesarean and birth in general.

I love comments when they are left by readers and appreciate the purpose that having a comment section provides - I love the good, but also appreciate the bad and sometimes downright ugly ones too (and will admit that I love when I am not the only one to counter the bad or ugly comments that are left from time to time). The comments section has proven to be one of the most rewarding aspects to blogging - so please continue to leave them!

Thursday, December 20, 2012

Hindsight is 20/20

Somewhere between my doctors and the hospital and health authority involved in my daughter's birth, we slipped through the cracks.  I have looked back on what happened countless times, and have come to the conclusion the it should not have been that way, that it was not my fault that it was that way, and that it should not happen again.

I get that maternal request cesarean is controversial and that while there are many doctors who will accede to a woman's request, there are many that won't.  I also get that some hospital policies are more accommodative than others.  I get that health care resources are limited. However, there is an obligation to respect bodily autonomy and ensure that access to medical care is available in timely fashion.

I believe women who wish to plan a cesarean delivery (or an epidural assisted vaginal delivery for that matter) after being informed of the risks and benefits of cesareans AND the risks and benefits of vaginal delivery should be able to do so.  These women should be able to make their plans without fear that their birth plan will be frustrated and that they will be subjected to a vaginal delivery (or an unmedicated delivery) against their clear wishes and without medical cause.  Just as women who desire a unmedicated vaginal delivery need to be able to plan and to know the limitations and conditions of their plan, women who desire cesareans or epidurals need to be able to plan and know the conditions and limitations of their plan.

So, with the benefit of hindsight, what do I think should have or could have been done differently to prevent what happened to me?

1. I think my maternity doctor should have ordered an ultrasound at the earliest possible date to establish a more certain EDD.  I estimated my due date to be July 13 - I had been keeping track of my cycles and was using an ovulation prediction kit.  Yet my care provider decided it was prudent to use a due date based on a 28 day cycle and set it to July 17 - which while consistent with later ultrasounds that I had, it should be noted that when it comes to ultrasound they become less accurate at dating as a pregnancy progresses.  I believe a EDD of July 13 would have also been consistent with those later ultrasounds and should have been used.

2. I think an earlier referral to an OBGYN would have been prudent.  Waiting to refer until I was late in my pregnancy meant that despite my clearly stated desire to deliver by way of cesarean, that there was a risk that the OBGYN would decline to perform the procedure and that insufficient time would remain to make alternate plans.  Further, anxiety about being able to access my desired delivery mode caused undue anxiety during the pregnancy.  Shared care is not necessarily a bad model, but for women who are planning cesarean delivery, knowing that a GP or midwife cannot perform a cesarean, arrangements for the delivery are best made early on.

3. A fixed OR date and time.  The OB involved in my care has claimed that there was a hospital policy in place that did not allow for maternal request cesareans to be scheduled and that as a result my case was added to the add board.  At the time I really did not appreciate how much risk this introduced to my birth plan - I assumed that I would know the day of delivery, but not necessarily the time and when asked what I would like should I happen to go into labour prior to surgery - I indicated that I would still prefer a cesarean.  In fact, I did not worry much when my surgery got bumped the first day, or even the second, as at the time I believed that if I did happen to go into labour that my case would then be considered urgent and would be completed without undue delay (ie. within 2 hours).  I also believed that should I go into labour that an epidural would have been available to manage labour pain prior to delivery.  I should have been warned that if I did go into labour that there was a chance that cesarean delivery would have an undue delay (in excess of two hours) and that an epidural may not be available. I believe if this policy was in place, the effect of the policy led to an inability to access timely medical care and resulted in a contravention of my charter rights.

4. Assessment for the risk of going into labour.  From the time I was admitted to hospital until the time I went into labour I was not physically assessed.  My case was bumped and bumped again without any physical assessments as to the likelihood that I would spontaneously go into labour.  If an assessment had been done, it might have been found that labour was imminent and my case could have been managed accordingly.

5. Upon presenting to the nursing station with signs and symptoms of labour - my OBGYN should have been called immediately.  According to the records - I presented at the nursing station at around 11:45.  This was shortly after I noticed a second contraction after a first contraction 15 minutes prior and wiped bloody mucous when I went to the washroom.   According to the statement of defense submitted my OBGYN was not called until 130 - nearly 2 hours after I first presented to the nursing station.

6. I was told an OR and an anaesthesiologist was not available.  I laboured under the belief that should things go sideways, and the knowledge that if things did go sideways, that my child or myself could suffer serious adverse consequences.  I was not told that there was a back-up on-call anaesthesiologist in the event of life or limb emergencies - and that he/she would be available within 15-30 minutes if needed.  I was terrified. 

7.  Staff and doctors should be trained to respect and support all pregnant mothers.  Pregnant mothers have a diverse array of values and beliefs with respect to birth and not all pregnant mothers desire a vaginal birth without epidural pain relief.  I was told by nursing staff  "my body was made to do this", and that "if I wanted a maternal request cesarean, I should have gone to Brazil", and to "direct my screams into pushing".  From an on-call OB I saw regarding complications after the birth that he "was happy the c-section did not occur" - although he immediately apologized when I responded that I was not happy the c-section did not occur, the words still hurt.  Women choosing cesarean or epidural pain relief are not well supported - the deserve (and should be entitled to) timely access to these desired medical resources - especially when they have indicated well in advance of their deliveries that they would like access to these things.

The sad thing is that maternal request cesarean was available in British Columbia - it was even available on the island at the time I had my daughter.  There are doctors and hospitals that will accommodate women who choose to deliver by way of cesarean - who will schedule a date and time for delivery.  The sad thing is, that what happened to me did not need to happen.  I would have been both willing and able to travel to access care if that was what was needed.  I clearly communicated my preferences early in my pregnancy and throughout my pregnancy.  I did my part.

Somewhere, somehow, the system and my doctors failed us - and for that, there must be some accountability and retribution for the wrong that was done. Further, measures need to be taken to ensure the same wrong is not done again, and again, and again. Access to timely medical care during labour and delivery should not be uncertain - and that includes access to cesarean delivery and epidural anesthesia on maternal request. 

Saturday, December 15, 2012


I was busy most of yesterday and after I dropped the girl off at daycare, I spent my day working on a variety of things - and was away from the internet and television. When I was finally done, I checked in on Facebook and my heart sank. Connecticut. How? Why? There is no sense to be made of it.

I cried.

Parents had dropped their children off at school that morning. Teachers went to work. All were no doubt confident that at the end of the day, after recess and lunch and math and reading and playtime that they would go home. Home to their parents, to their spouses. Home to suppers and baths and bedtime. Home to the mundane things that as parents and spouses we take for granted.

Twenty children did not go home yesterday.

Six spouses, brothers or sisters, mothers or fathers - did not go home yesterday.

We take it for granted that our schools and workplaces are safe places where students go to learn and teachers go to teach.

Yesterday proved that it only takes one to shatter that delicate presumption - one man, with access to efficient weapons of destruction can perpetrate an act so violent, so beyond the pale, on victims so innocent.

I hugged my children a little closer yesterday. I tolerated the chores of motherhood, with a little more gratitude that my mundane life was intact. And I thought about how important it is to better understand what has happened - how important it is to ensure that the risk of such things happening is minimized.

What happened in Connecticut yesterday should never happen again - it did not need to happen, and it does not need to happen again. It is time to look at the tragedy with a critical eye and determine what needs to be done - what might be necessary to restore faith that when parents send their kids to school and spouses to work that they will come home home at night.

It's time to look at what needs to be done so that schools do not need to be the equivalent of high-security prisons in order to provide safe places to learn and work. Maybe better gun control is part of the answer. Maybe better mental health resources and access to those resources (regardless of income or health insurance status) are needed. Maybe schools need to be a little more secure and extra vigilance is needed with respect to those who teach and learn there. Maybe communities need to pull together a little more to know each other a little better so that maybe a future gunman never gets to the point of donning a bullet-proof vest, arming himself with assault riffles, and perpetrating the kind of violence that should be impossible to perpetrate on dozens of innocent victims. Maybe taxes need to be a little higher to pay for the things that need to be done to ensure what happened never happens again.

It's time to focus on what matters - ensuring that parents can take for granted the mundane chores of parenthood matters, ensuring that students can go to school to learn and never have to worry about not going home matters, ensuring that when teachers go to work they can focus on helping children learn matters, ensuring that there is access to mental health resources matters, the families of the twenty children and six innocent adults who lost their lives on Friday matter - access to assault rifles does not.

I hope insult to injury is not added to this utterly tragic circumstance - I hope that America takes the opportunity to understand better what happened and the circumstances that made it possible in the first place and does what needs to be done.

Thursday, December 6, 2012

Targeting the Wrong Cesareans

It sometimes seems like a week does not go by without someone, somewhere bemoaning the high rate of cesarean births in developed countries. British Columbia was at one point so concerned with its reputation for having the second highest rate of cesarean sections in Canada that it struck up a Cesarean Task Force and has even put together two campaigns to address the issue - The Power to Push and Optimal Birth BC. Personally, I am not a huge fan of either. The main reason I am not an admirer of these campaigns is because of the emphasis on process rather than outcome. I care about healthy mothers and healthy babies - and I believe that the way an individual mother gets there is very individual - for some mothers planning and achieving a cesarean is just going to be a better path, for other mothers planning a vaginal birth is just going to be a better path - even knowing it has a risk to result in an emergent cesarean or operative vaginal delivery.

I am not opposed to strategies that seek to lower the rate of unwanted and unnecessary cesareans - women who neither want nor need cesareans, should not be needlessly subjected to them. For that reason I am thrilled that women in British Columbia who desire a vaginal birth and have been informed of the risks and benefits of planning a vaginal birth and the risks and benefits of cesarean birth in their individual circumstance and would choose a vaginal birth have access and support even if they have had a prior cesarean or their baby is breech. Being able to plan a vaginal birth after cesarean or a vaginal breech birth, in the safest circumstance possible (in a hospital with trained staff and resources available) is a great thing and reduces the potential for such circumstances to result in death or significant disability to either mother or child. In other parts of North America, women have difficulty accessing the care they need to plan a vaginal birth after a cesarean (VBAC) or a vaginal birth with a breech baby - and as a result many choose to birth unassisted, do not seek assistance with delivery until they are pushing, or choose home birth with an under-qualified birth attendant and lack of access to appropriate resources. These women are exposed to risks to both themselves and their children that could be mitigated if they can find a care provider and a hospital to accommodate them. For some of those women - avoidable death and disability results.

However, selling the idea that a vaginal delivery should be achieved whenever possible - is damaging to women and their children. This is what the "Power to Push" campaign does - it encourages women to pursue a VBAC, it encourages women to attempt a trial of labour with a breech baby under certain circumstances, it encourages the use of external cephalic versions (ECV), and it discourages maternal request cesareans. Rather than providing women with unbiased information regarding their birth options and the risks and benefits associated with those options and letting women decide what is best for them and their families in their individual circumstances - it pushes the idea that vaginal delivery is best - and that a cesarean is sub-optimal. Furthermore, it does this by targeting a group of women for whom cesarean delivery is more likely to be a better choice and targeting the safest and cheapest cesareans - scheduled cesareans. As a result, it is likely that it might succeed in reducing the rate of cesareans - but at the cost of increasing the share of cesareans that are unplanned or emergent, and potentially increasing the numbers of mothers or babies that are injured, disabled or die.

Further, I am disappointed at a system that fails to support all pregnant women - including those who would choose cesarean delivery or even epidural anesthesia and focus on the ultimate goal of maternity care - healthy mothers and healthy children. It's great that women desiring risky vaginal deliveries are supported to do so in the safest environment possible - however, it's a travesty that those seeking planned cesareans are not given the same support. CDMR in British Columbia continues to be difficult to access with women having difficulty finding care providers and facilities to support their informed request for cesarean delivery. It's time we had a maternity care system that didn't try to sell women on a particular mode of delivery - but rather supported a patient-centred model of shared decision making based on the best available evidence that supported the full spectrum of pregnant women to make the decisions and have access to the care they need for both mother and baby to be happy and healthy.