Fourteen years I have been practicing OB/GYN. I live in Frisco, Texas one of the fastest growing cities in the United States I really enjoy living and working here. It is a great place for my family and for the first time my office is attached to the one hospital I practice in. This is the third and final place I will practice medicine. I trained with some of the most respected academic OB/GYN’s in the country. These physicians contribute to the books on Obstetrics, create the practice guidelines for the American Congress of Obstetricians and Gynecologists (ACOG), and taught me to practice medicine based on scientific evidence.
I follow a few simple rules; do no harm, give your patients options, and provide information so they can make informed decisions. So, last night I was sitting in my office looking at the fourth Cesarean Section (C/S) operative report of the day for yet another patient who wants to have a vaginal delivery following a previous C/S. I am frustrated and feel like I am fighting a losing battle.
When did Cesarean Sections (C/S) and elective inductions at 39 weeks become the standard of care? That is not what I was taught, that is not in any textbook or ACOG practice bulletins. So why in Dallas, Texas do people have to drive more than an hour to find a doctor who actually has no interest in doing a C/S.? It has become obvious I cannot attend every vaginal birth a patient wants to have after their traumatizing C/S experience. If close to 50% of the patients are getting a C/S each day and there are hundreds of practicing OB/GYN’s in the Dallas Metroplex, the math is not difficult. I know at least one physician who only does C/S’s, vaginal delivery is not an option. If one of his patients delivers vaginally it is only because it came faster than he could get to the hospital.
This is the only place I have lived where C/S and elective inductions are king. So women of the world I am giving you the knowledge to stand up for yourself before you get that first C/S!
Top Ten Signs Your Doctor Is Planning To Perform An Unnecessary Cesarean Section On You*
1) Arrives to L&D immediately after office hours and says, “I just don’t think this baby is going to fit”
2) Third Trimester, Routine Office Visit, “I think this is going to be a big baby you should just have a C/S” – Did you know? ACOG has very specific guidelines for when it is appropriate to offer a patient an elective C/S for MACROSOMIA (fancy word for large baby). ‘Prophylactic (elective) cesarean delivery may be considered for suspected fetal macrosomia with estimated fetal weights greater than 5,000 gms (11 pounds) in women without diabetes and greater than 4,500 gms (9.9 pounds) in women with diabetes.
3) “We should induce at 39 weeks your baby is getting too big” – Did you know? According to ACOG,
‘Induction of labor at least doubles the risk of cesarean delivery without reducing shoulder dystocia (rare situation where baby’s shoulder can get stuck at delivery) or newborn morbidity(complications). Suspected fetal macrosomia is not an indication for induction of labor, because induction does not improve maternal or fetal outcomes.’
4) Performs routine ultrasounds at end of pregnancy to see how big your baby is. Did you know? Ultrasounds at the end of the pregnancy can be 1-2 pounds off. Ask some VBAC patients who were talked into a C/S for this, then had a vaginal delivery of a bigger baby the next time.
5) “You have a positive herpes titer (or history of herpes); the baby will get it if you deliver vaginally.” Try some Valtrex for the last month of the pregnancy that is pretty much standard of care now. It prevents outbreaks and allows for a normal vaginal delivery.
6) “Your baby is breech you need to have a C/S” Ever heard of or performed an External Cephalic Version? It really does work.
7) “You have pushed for 2 hours” (with an epidural that prevents you from feeling anything so you are probably not pushing effectively; this is evident on exam because the baby’s head is still perfectly round, but you do not need to know that) it’s just not going to come out”
8) “I scheduled you for an induction at 39 weeks, it is just soooo… much more convenient for you!” (and so much higher risk of ending in a C/S, especially if you are not dilated when you start the induction). At least 80% of my VBAC patients were induced the previous pregnancy. For whose convenience was the induction?
9) First Visit (7 weeks), “Congratulations you are having twins. I will go ahead and schedule your C/S at 38 weeks, but don’t worry if you go in to labor early I will cut you right away!” Translation, “I am scared out of my mind for you to deliver your babies vaginally because I am not trained on what to do when the second baby is coming, plus it pays more to cut you open. Oh yeah, I don’t have that great a rapport with you because I only spend 2 minutes (fundal height, heart beat and ‘I’ll see you next time’) with you each visit, so I am afraid I will be sued for trying to do the right thing.”
10) First Pelvic Exam in Office (7 weeks), “Hmm, your pelvis is pretty narrow”
11) 38-week visit, “Your blood pressure is a little up today you are probably developing preeclampsia or toxemia. That can cause you to have a SEIZURE! The treatment is to deliver the baby. You need a Cesarean Section this is the quickest way to resolve it. Let’s get you up to L&D NOW!” Translation – Preeclampsia or Pregnancy Induced High Blood Pressure is a pain in the butt. If I induce you, it could take 24 hours or more and then I would have to manage your blood pressure, and put you on Magnesium. This is way too inconvenient. Do not worry you can try to have the baby vaginally next time. Yeah right!
Well, I hope you future moms find use for these tidbits of info. If anyone wants to add anything please feel free. Your experience may help other women in the future. Remember, there are only a few emergent reasons for a C/S such as fetal distress, unexplained heavy vaginal bleeding, etc. It is okay to ask your doctor questions. We are not supposed to bite.
Jonathan Weinstein, MD, FACOG
Husband to a Labor and Delivery Nurse with 27-years’ experience
Father to two beautiful children, Zoe and Ashton
*Dr. Weinstein no longer taking new VBAC patients.