A reader of this blog who was extremely helpful during my recent foray into high-tech library research has alerted me to a discussion about Birth Story #478 currently taking place in the comments of another blog. I have too much on my plate to respond to discussions taking place outside of this blog--heck, I can't even keep up with the comments here--so I will confine my remarks to the following:
a. Nola "wanted a C-section," and we persuaded her to have another trial of labor. During prenatal care, Nola asked if a C-section was a good idea, given her first birth experience, and we discussed the risks and benefits of a C-section with her over several prenatal visits. We were open to referring her to an OB for elective C-section if she'd decided to pursue this path, but ultimately Nola herself preferred to attempt a vaginal delivery because she didn't want to have surgery unless it were necessary.
b. The prenatal team used bad judgement in not consulting with an obstetrician. Actually, we discuss all our higher-risk patients with the OBs who back us up. One of them sees patients at our clinic and is aware of all issues arising during prenatal care. Neither of our OBs felt an elective C-section was warranted. When Nola was in labor, a midwife colleague and myself consulted with the OB on call and he was completely supportive of the plan to induce with Pitocin and attempt a trial of labor. I don't mind being the subject of criticism but I will not have my team called incompetent because of what I write on this blog.
c. A certain hypocrisy prevailed in the decision to induce Nola at 39 weeks, given the recommendation against elective C-section. I can't really argue the decision to induce was based upon evidence, because it wasn't. Here, the team decided to proceed with induction as Nola wanted, after much discussion with her and with the backup OBs. This decision was very much directed by Nola's preference as well as local standard of care. Because we live hundreds of miles away from a Level 3 NICU, doctors will often recommend an intervention if they think it will avoid an outcome requiring neonatal transfer, especially if the intervention is relatively low risk. I think our OBs agreed with induction at 39 weeks, but I wasn't present during the discussion.