A dear friend of mine works as a nurse in labor and delivery in a nameless hospital somewhere in the USA. She gets so frustrated by what she sees there, and as a woman of size herself, she gets particularly irate at how so many big moms get railroaded into c-sections.
Recently she wrote about a supersized patient, a first-time mom, conned into an "elective" primary cesarean at, you guessed it, 38 weeks. We'll leave out a lot of the details to protect the mother, but her story could be so many big moms' stories. I can't tell you how often I've seen stories similar to this one. Especially in supersized moms, who face particularly strong bias in obstetrics.
[For those who don't know it, "supersized" is a term from fat acceptance groups and basically refers to anyone over around 300 lbs. or so. It's not an insult, just a way to distinguish different sizes of fat when it's relevant to a story. Not the best term, IMO, but better than "morbidly obese" or "grotesquely obese" or the equivalents I've seen used in the medical research.]
The Cliff Notes Version of the Story
Mom was supersized (mid-300s) but had a healthy pregnancy. The doctor's reason for the cesarean was that she was "huge," had gained a "huge" amount of weight (about 30 lbs., normal for women of average size but considered excessive in obese women by some), and was going to have a "huge" baby. So he talked her into a planned cesarean.
Like I said, an extremely common story for supersized moms these days.
Of course, as many doctors mistakenly do, he assumed that because of her size, she needed a vertical (up and down, belly-button to pubic bone) incision on her skin. This, despite research that shows that outcomes are better in fat women with a low transverse (side to side, just over the pubic bone) incision.
And he put in a Jackson-Pratt drain, despite recent research showing worse outcomes with drains in "obese" women.
(Ugh. Save me from ignorant OBs who won't believe the research.)
The operative report reads that the procedure was "uneventful and easy" and that the baby was delivered "without complication."
As my friend the nurse says, "No complication for him, no."
As is common with 38-week cesareans, the baby went into respiratory distress and went to the Neonatal Intensive Care Unit (NICU). He'll be there at least a week. That's a week without his mama and proper bonding, a week where he's probably getting mostly formula (making breastfeeding more and more unlikely), and a week full of exposure to all kinds of bacteria common to NICUs. He's also jaundiced now and getting treatment for that.
Mom is "miserable," with a lot of post-op pain, despite a truckload of drugs. My friend says the incision looks "ugly" and was leaking serous fluid in at least two places.....but the doctor was unconcerned. We'll just have to wait and see if she develops an infection or a wound separation or other complication.
But Was It Justified?
Now, the baby did turn out to be big. So often doctors predict big babies for big moms and are totally off; ultrasounds are a very poor way of predicting macrosomia (big babies). But in this case, the predictions were correct. So I'm sure a lot of doctors would say....See, this doctor was right. This was a shoulder dystocia (where the baby gets stuck) waiting to happen.
Yeah, the baby was big.... around 10 lbs. And big babies are at more risk for shoulder dystocia. Yet what they "forget" to tell you is that the majority of big babies are birthed vaginally without shoulder dystocia or injuries of any kind.
Doing major surgery on all babies above 9 lbs in order to potentially avoid injuries for a very few is not a very good risk trade-off.....because the surgery also carries risks and harms. Better would be to train doctors to handle shoulder dystocia better, instead of cutting so many women in a futile effort to avoid lawsuits.
The way the medical community hyperventilates about big babies is overdone. Research is clear that unless the baby is at least 11 lbs or more, a planned cesarean is NOT justified. All the medical reviews on macrosomia have noted this.....yet doctors still continue to cut whenever they have the slightest fear about the possibility of a big baby.
To which I say, feh. I had a big baby, over 10 lbs., and I had her vaginally. My friend the nurse also had a big baby, no problems. We both know MANY women who have had big babies without problems. To enforce a cesarean for all babies over 9 lbs means a LOT of women exposed to the substantial risks of surgery, and research simply doesn't support this tradeoff.
Instead, you treat it like any other risk should be treated. You explain to the mom the possible risks of shoulder dystocia, and also the possible risks (present and future) of cesareans. You tell her about the research reviews, which strongly recommend against early induction or planned cesareans for macrosomia. You review the pros and cons of each choice. You share your concerns and opinions, and then you step back and let the mother make the final decision.
Doctors (and ACOG) like to say they are all about informed consent and respecting women's choices, but the truth is that in childbirth, women are infantilized and given very little choice in anything. Either they are outright told what they "must" do, or they are emotionally manipulated, scared, or even bullied into the choice the doctors want them to make.
This is NOT informed consent and this is NOT respecting women's autonomy to make their own informed choices.
A Rough Way To Start Motherhood
So here's this first-time mom, in a huge amount of pain that the drugs aren't really touching, looking like she might be on her way towards a wound complication, away from her baby most of the time just when she most wants to be with him, up against steep odds for making breastfeeding suceed, and looking at a significant post-op recovery.
So much for the c-section being the easy way out. Frankly, it's the easy way out for the doctor, not so much for the mom.
As my friend said, "This is how she's been introduced to motherhood. She was led to expect a neat, clean, simple procedure that would end with her being handed a perfect baby and having a pain-free recovery. She got none of those. Who's to blame?"
I think we all know.
*p.s. Yeah, a lot of doom and gloom posts lately. I promise I have an uplifting one coming soon, as soon as I have time to put it together! Stay tuned.