Yesterday’s post, OMG! OMG! OMG! I was pressured to have a C-section just because I was a 40 year old insulin dependent diabetic with pre-eclampsia and bloody urine, was about Dr. Carla Keirns and her attempts in the professional and lay press to shoehorn her high risk birth into the natural childbirth narrative of the “unnecesarean.”
As I explained:
Dr. Keirns and her pregnancy were extremely high risk. She was 40 years old, which put her at risk right from the get go, but in addition she had a very serious pre-existing medical condition. Although Dr. Keirns implies that her diabetes was related to pregnancy, her need for insulin in the first trimester suggests that she may have type II diabetes unrelated to pregnancy. Furthermore, although she doesn’t explain the diagnosis, the fact that she was on magnesium sulfate to prevent the seizures of pre-eclampsia, and was spontaneously bleeding from her bladder, suggests that she was developing HELLP syndrome, a particularly dangerous variant that also affects blood clotting and liver function.
Nonetheless, Dr. Keirns wants us to believe that she was being pressured into a C-section that she didn’t need. How does she know that she didn’t need it?
… 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 …
After we were both stabilized, they handed the baby to my husband; I was too exhausted to safely hold him.
As I said yesterday, if nearly killing your baby and yourself qualifies as a “successful” vaginal delivery, I’d hate to see what failure looked like.
The people I really feel sorry for in this story are Dr. Keirns’ providers, not because I’m sure that they did everything right, but because they are being publicly humiliated without any chance to defend themselves.
Therefore, in one of several Twitter exchanges, I suggested to Dr. Keirns what is shown in the tweet below:
Dr. Keirns should absolve her providers of their obligation of confidentiality and let them tell what they think happened and why they repeatedly recommended a C-section. If the story that Dr. Keirns blared to the medical and lay press is true, they will be able to confirm it. If not, they’ll be able to defend themselves. Seems only fair, right? Otherwise, Dr. Keirns is just a very high risk patient trying to shoehorn her experience into the approved natural childbirth narrative.
I find it incredibly ironic that Dr. Keirns, a specialist in preventive medicine, utterly failed to understand that C-section in HER case was recommended as a form of prevention. I’d love to know whether her providers saw it that way, too.
I also find it deeply unfair that Dr. Keirns has publicly humiliated them without giving them an opportunity to explain what they thought was happening and why they made the recommendations that they did. As a physician, she knows that doctors are often subjected to second guessing by patients, and, when given a chance to explain their reasoning, can often help the patient understand why they did what they did, and said what they said. Since she publicly second guessed the doctors and nurses who cared for her, she should give them an opportunity to provide a public explanation.
How about it Dr. Keirns? Are you willing to allow your providers to speak publicly about your case? Think of it as a public version of Morbidity and Mortality Rounds. M & M’s are incredible learning opportunities. Everyone could learn something from your story: the public, your providers, and, I dare say, YOU.
All it takes is your consent, and we can hear both sides. Will you give that consent?
I imagine a rather frosty atmosphere in the room when she attends for her post-natal visit, in the course of which neither side says anything about the article but actually thinks of nothing else.
It will definitely be awkward… I wouldn’t be surprised if after her post-natal care is complete, they present her with a “divorce” letter..
So I just went to re-read her full post on Health Affairs. I do think it’s a bit different than the WaPo summary, which because of editing read as though she did not accept the fact that she was high-risk. The Health Affairs post is more focused and IMO reasonable: that we should reduce the rate of “failure to progress” c-sections. That seems to me to be a reasonable view in light of the evidence.
But the big problem with the Health Affairs piece is that she suggests that fetal monitoring is ineffective (which we know is untrue anyway ESP for high-risk situations) and then simultaneously says that she would have accepted a c-section if there were any indication of fetal distress (which contradicts her complaints about fetal monitoring).
And probably the biggest problem is that, given that her baby was born in distress even with monitoring, she seems to be in denial about the fact that an early, pre-labor c-section might in fact have been the safest result for her child given all her risks. She seems fixated on the “epidemiological evidence” and the idea that the ONLY reason people were suggesting a c-section was failure to progress, without recognizing that her particular high-risk situation was unique and not resolvable just by reference to “epidemiological evidence.”
That said, I am appalled that for such a high risk case, she was pushing alone with just a nurse for so long, with no pediatric team ready.
Can anyone point me towards the study(ies?) that show EFM improves outcomes? My mom is an FNP, former L&D nurse (it’s been awhile), and she’s convinced that EFM is not helpful. I’d love to show her the evidence this isn’t true. Thanks!
http://www.skepticalob.com/2011/06/new-study-shows-that-electronic-fetal.html
Perfect! I just emailed the study to her! Thanks!
I don’t have a study, but I have an anecdotal story. My son was an attempted VBAC. In hospital, with a CNM acting as doula. I had EFM. It was blue-toothed, so I could walk, and I did. At about 20 hours labor, my cervix was closing (went from 6 cm to 3), and, my son was having early heart-rate decels. I’d had an ultrasound the previous day (labor was spontaneous, my water broke that evening and contractions started within 20 minutes). As a result of the ultrasound though, they knew it was not nuchal cord, though the EFM indicated that as a cause of the decels. We agreed, physician, CNM and me, that something was wrong, and we needed a C-section. My son was fine, but, his umbilical cord included two true knots. They were not tight, but they were constricting the cord with each contraction. EFM saved him, IMO.
http://www.nice.org.uk/guidance/cg190/chapter/1-recommendations#monitoring-during-labour
So, when it’s what you want to hear, it’s “advice,” and when it’s what you don’t want to hear, it’s “pressure.”
Upates:
She’s so confused.
“Follows their advice”–who is she kidding?! She shunned their advice at every opportunity.
What MFM specialist advises a 40+ yo insulin dependent type 2 diabetic to wait until 39+6 to induce? Not a single one. You know they advised induction far before this. And then once she is in labor and things are going south, they advise CS to the point of her saying they “pressured” her. But she gets on the phone and calls her med school buddies for a “second opinion” and refuses.
First she wants to paint herself as a brave birth warrior who stood up to The System. Now she wants to paint herself as the perfect little patient who just can’t catch a break.
Give us a break!
Nice backpedal attempt on her part… FAIL..
Updates:
If no pre-e, then why the mag? I’d like to see her explanation for that. at 39 weeks, it certainly wasn’t for preterm labor.
Dr. Keirns responds:
SHE put it out there in the public eye, screaming for attention…and now she doesn’t like the attention. Boo hoo.
Love it! I am envisioning a panel discussion with a Q&A session. Public.
No, most c-sections are absolutely necessary. They are done so that the baby and the mother survive without complications. There isn’t a 1% death rate for C-sections either. If you are clueless, do not make up stuff
“They are done so that the baby and the mother survive WITHOUT COMPLICATIONS.”
This latter part is the one that tends to be ignored. C/S is not needed only if or when it is “life-saving”, it is also well needed and justified when being merely a health-saving intervention.
I used to have a hard time explaining this to my Hungarian audience but I am slowly getting through. In 2015 we can and should aim for a lot more than bare survival.
You were probably speaking to more affluent, privileged Hungarian audiences. Mostly people here are geared towards not second guessing or refusing medical interventions because a good number of women are, due to corruption or racial prejudice denied access to timely interventions in hospitals. Sometimes this happens even in life and death situations.
Perhaps someone can explain this to me. People say, “This was a c-section I/you didn’t need.” But aren’t most c-sections procedures that women don’t “need”?
If there is a ninety percent chance that the baby and woman will live through a certain group of complications, then ninety out of a hundred women will talk about “escaping” a c-section they didn’t need. But ten will have births that resulted in serious injury or death to the mother or the baby. We can’t possibly think those odds are okay, right? In fact, if there’s a ninety-nine percent chance that both mother and baby will be okay, a one percent death rate is still pretty bad, isn’t it?
Am I estimating wrong?
There’s a difference between “indicated” and “necessary”. A C-section absolutely was “indicated” in an obese, 40 year old, nullipara with insulin dependent diabetes and pre-eclampsia. The author’s making the argument (in hindsight, of course) that it wasn’t “necessary” because she did manage to push the baby out vaginally and it wasn’t dead.
I will never, ever, understand how we got to the point where pushing out a baby that isn’t dead has become the main focus, with anything else regarded as failure.
I also wish there was a neurologist or two commenting here. I have some difficulty, myself, in accepting that “not dead” is the same as “completely unharmed” after this kind of labour.
The line of thought you are describing (a 1% risk of death is not an acceptable risk to take) is the one used by the 99% of women in the USA who give birth in a hospital which can be summarized as “better safe than sorry”.
It’s the same sensible line of logic that leads low-risk people to accept the minor discomforts of a flu shot to protect the elderly, the young and the high risk adults – “I will accept a minor irritation to protect others .”
Unfortunately, some people get so focused on their personal desires – in this case a vaginal birth – that everyone else is expendable.
IMHO, Dr. Keirns is re-writing history to assuage her guilt. My mom and mom-in-law had babies born with poor APGAR scores and felt guilt-stricken even though they complied with all medical advice. How much worse must Dr. Keirns have felt when the OB held up her silent, blue son…….because on some level, she knew then and knows now that HER choices caused that outcome.
No, I think you are absolutely right.
I’ve said the same thing in the past. Although most c-sections are not necessary, if you define “necessary” as being required in order to have a healthy baby and mother, our problem is that the chance of it being unsuccessful is too high, and we don’t know which ones will be unsuccessful.
That’s why we don’t take that chance.
You are right. Strictly speaking most C-Sections are unnecessary for the mother (mine was, I could have had a vaginal delivery) but most are absolutely necessary to get the baby out safely (mine was, my baby would not be alive today if it wasn’t for my CS). Most women decide to risk a 15/100.000 risk of dying because a CS instead of 5/100.000 for a vaginal delivery and not risking their babies lives or brain function. With a CS I knew my baby had a 100% chance of being OK after the delivery, but it was highly unlikely he would survive a vaginal delivery (he got decels in his heartbeat with Braxton-Hicks contractions that ai did not notice and his blood flow on the Doppler was not OK anymore). For me it was a no-brainer, I would not have accepted anything else. And yes, I knew about the gut bacteria, the epigenetic changes, etc, etc. I did not know about the inmune diseases later in life, but that would not have changed my decision either.
How is your little guy doing?
Thank you very much for asking. He is doing great! He is already at home, hitting milestones slightly earlier than expected, loves playing with us, eats A LOT and grows a lot too. We still have tons of hospital appointments and we need to follow some guidelines in order to avoid infections but apart from that he is a completely normal baby. I love being his mom!
So glad to hear that he’s doing well and that you’re having fun. It’s awesome.
I’m so happy for you! It’s great that he’s finally home and you’re getting to experience all the normal baby stuff at last.
Congratulations! So happy for all of you!
I wouldn’t even worry about “the gut bacteria, the epigenetic changes… the immune diseases later in life.” Those are from little tiny studies; there’s not even close to a consensus yet on any of them. And breast milk (even a little bit of it) provides the gut flora your baby needs.
As others have said, you’re right. Another way to think of it is that doctors are ethically bound to recommend the course of treatment with the highest likelihood of success (and thus the lowest likelihood of mortality or morbidity).
So when a doctor says a c-section is “indicated,” they are saying that a c-section is the least risky option for a woman in her particular situation. It doesn’t mean a woman can’t have a successful vaginal birth with a healthy baby and mom, it just means the overall odds are better if the baby is delivered surgically at that point.
I wouldn’t want an oncologist avoiding recommending chemotherapy because lumpectomy and radiation are usually good enough. I would expect an oncologist to recommend a course of treatment that is most likely to send cancer into remission. I don’t understand why people expect OBs to be any different when it comes to recommending treatment options – aside from the whole “pregnancy is not a disease” thing.
I really like how you explained this. Patients aren’t good at understanding risk, but I dare say that many doctors aren’t real good at or don’t have the time to thoroughly explain risks and benefits of certain produres, either. As the public is more and more misled to believe natural remedies are best and doctors (all doctors, not just OBs) order unnecessary tests and surgeries to increase profit, it’d be helpful if doctors got better at explaining risks and benefits.
YES, YES!!! Your second paragraph is an almost exact citation of the words of my OB, God bless her wherever she is today. She presented me real options to consider, offering her best knowledge and committed professional help should I choose to continue trying for a vaginal birth. It was not about life or death at that point.
Also a CNM is ethically bound to advise what seems best – my midwife was there (and also in the operating room), and she later explained that in case of any objection from her part, she would have been obliged to voice her concerns.
I so much agree with what you wrote.
Yes, absolutely correct. I have a couple of time had women refuse a cesarean section with an abominable fetal heart rate tracing and have a perfectly normal baby who either was vigorous on arrival or with minimal resuscitation. Lucky.
I’d like to amend medical privacy laws so that when a patient goes to the press, the treating institution or physician can immediately tell their side of the story.
Or make those records subject to FOIA requests.
Would a defamation suit give them access?
Not gonna happen…but if the patient sues, putting that stuff at issue, then it can become public unless the court seals the records.
No. Are you kidding? It’ll never happen. Being called to account for her half truths and misrepresentations wasn’t any part of her plan.
It’s highly unethical for a physician to use their own medical case in order to politicize medical issues.
I’m not sure about that. Physicians have used their own cases to advocate for tremendous improvements in healthcare.
The problem in this case is that she hasn’t given her providers an opportunity to explain their views.
They’d probably say, “I don’t really need to add anything, Dr. Amy nailed it.”
Look up laparoscopic fibroid power morcellation.
I just did. Wow.
Read the WSJ reporting on this. So incredibly sad.