Re: Guest Post - Forced c-section

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Worth noting, for those who don't read the article, that the police say the threat was probably unenforceable:

Tampa police couldn't recall a case in which they were sent to bring a pregnant woman to the hospital for an unwanted caesarean. Spokeswoman Laura McElroy said the only possible legal grounds would be if the doctor established the fetus' life was in immediate danger, which would be difficult under patient privacy regulations.

I still think it's appalling but . . .


Posted by: NickS | Link to this comment | 03-12-13 2:11 PM
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The threat doesn't seem like great bedside manner, but the story leaves me without much sympathy for the mom.


Posted by: heebie-geebie | Link to this comment | 03-12-13 2:13 PM
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My first OB showed me a graph - I wish I'd xeroxed it - that showed fetal mortality as a function of time. According to Dr. Asshole, the safest time to give birth was at 38-39 weeks, and according to his Magic Graph with its misleadingly stretched y-axis, you were already pushing your luck by daring to go full term. By 41 weeks, you were just asking for a dead baby

On the other hand, an article Blume found reported that every cup of coffee you drink reduces birth weight by a pound, so just drink an extra cup of coffee or two and delivery'll be a cinch whenever you try it.


Posted by: Sifu Tweety | Link to this comment | 03-12-13 2:13 PM
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The threat doesn't seem like great bedside manner, but the story leaves me without much sympathy for the mom.

I would be inclined towards that view if this story wasn't in the context of increasing attempts to criminalize women's prenatal behavior. But I'm too busy lazy to look up stories right now, so I'll just say that Heebie is probably right.


Posted by: NickS | Link to this comment | 03-12-13 2:18 PM
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My first OB showed me a graph - I wish I'd xeroxed it - that showed fetal mortality as a function of time. According to Dr. Asshole, the safest time to give birth was at 38-39 weeks, and according to his Magic Graph with its misleadingly stretched y-axis, you were already pushing your luck by daring to go full term. By 41 weeks, you were just asking for a dead baby.

From what I've read, yeah, the outcomes after 42 weeks (when did the two-week window before you absolutely "have" to induce shrink to one week?!) are much worse, percentage-wise. But if the infant mortality rate is double what it is at 40 weeks, that's still a really small percentage.


Posted by: Blume | Link to this comment | 03-12-13 2:22 PM
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The threat seems really wrong to me, even if the woman was ill-advised.


Posted by: LizardBreath | Link to this comment | 03-12-13 2:23 PM
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I read that as "her uterus is really scared" which, yeah, probably at this point.


Posted by: SP | Link to this comment | 03-12-13 2:27 PM
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I would be inclined towards that view if this story wasn't in the context of increasing attempts to criminalize women's prenatal behavior.

If the woman sounded like she were poor and black or Hispanic, I'd probably have more question marks about the story. But she sounds white, and pretty able to navigate the world of OBs and find the chair of the USF department to be her OB, and able to advocate on behalf of herself. So I don't know what their financial situation is, but she's not intimidated by the establishment.


Posted by: heebie-geebie | Link to this comment | 03-12-13 2:27 PM
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3: If someone drinks, like, 20 cups of coffee while pregnant, does the baby turn into a tremendously destructive antimatter bomb?


Posted by: Benquo | Link to this comment | 03-12-13 2:30 PM
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So I don't know what their financial situation is, but she's not intimidated by the establishment.

The establishment is threatening her with the use of force unless she lets the establishment cut her abdomen open against her will. She may be willing to stand up to the intimidation, but I think you've got to admit that the establishment is putting the intimidation-related-effort in.


Posted by: LizardBreath | Link to this comment | 03-12-13 2:30 PM
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I gotta run, but I'm happy to be a jerk against this woman when I get back.


Posted by: heebie-geebie | Link to this comment | 03-12-13 2:33 PM
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This doctor was exaggerating in order to bully the patient into doing what he wanted. This is not unusual in my field.

Our facility has at least 3 ultrasound-indicated inductions ("fetus in possible distress") every weekday. Those babies all turn out OK. In fact, the most common diagnosis, oligohydramnios, often resolves during the labor as we hydrate the woman with IV fluids for the epidural--leading one to wonder whether she just needed a couple of glasses of water.

There are no ultrasound-indicated inductions on weekends, as the ultrasound facility is closed, yet we seem not to be inundated with intrauterine demises on Monday mornings.

If she had immediately reported for surgery, she would have been told that it would take place 8 hours after she last ate, and at some facilities if that meant after the anesthesiologist for elective cases had left, she would be scheduled for the next day.

I would bet that the baby ends up just fine despite the dire threats.


Posted by: Shamhat | Link to this comment | 03-12-13 2:33 PM
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This doctor was exaggerating in order to bully the patient into doing what he wanted.

I felt paranoid saying it first, but given that you're an L&D nurse, yeah.

I really don't have anything against doctors, generally, and I'm all for medical science, and C-sections save lives. But given that the C-section rate in the US is over double what it is in other countries with the same or lower rates of neonatal mortality and morbidity, but pretty much everyone who gets a C-section is told that it was a medical necessity, someone's got to be exaggerating the dangers. And by someone I mean an awful lot of OBs.


Posted by: LizardBreath | Link to this comment | 03-12-13 2:38 PM
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every cup of coffee you drink reduces birth weight by a pound

Every pound of baby you eat keeps you up an extra hour at night.


Posted by: apostropher | Link to this comment | 03-12-13 2:39 PM
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an article Blume found reported that every cup of coffee you drink reduces birth weight by a pound

That article was hilariously poorly written.

Given that Tweety was quite a big baby at the time of his birth, and also that every ultrasound we've had has shown Zardoz measuring ahead and/or at the top of the percentile range for just about everything, I spend more time worrying about having a really big baby than a really small one. So when I read about something causing low birth weight, there's a little part of me that thinks, Hmmm... More coffee for me! A pack of Nat Shermans! Maybe some lead exposure!


Posted by: Blume | Link to this comment | 03-12-13 2:47 PM
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But she questioned their alarm.

This is the entire discussion of the medical reasons that the woman thought her doctor was wrong. Seems like more could have been said.


Posted by: politicalfootball | Link to this comment | 03-12-13 2:55 PM
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They did a C-section on the Friday. The baby was fine but huge.


Posted by: LizardBreath | Link to this comment | 03-12-13 3:02 PM
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Of course, how far past term you are 'allowed' to go varies from country to country, because presumably uteri also vary. Or not. Here, you can get to 42 weeks with little bother, and I know 3 or 4 (at least, including my own mother) who have gone past 43. I do know a lot of awkward women though.

I lied about my dates with kid D, because I knew it was my last, and I wasn't prepared to even have any conversations about "what will we do if you're still pregnant in a week?".

And yeah, 16.


Posted by: asilon | Link to this comment | 03-12-13 3:07 PM
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When we were dealing with the induce/not to induce debate in our household (2008), I actually went to the local medical school library and flipped through OB textbooks. Heebie's chart was the first or second figure in the relevant chapter.


Posted by: Klug | Link to this comment | 03-12-13 3:09 PM
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Huge babies scare me, and I'm not even the one at risk of birthing them. (He says, with the baby at 50th percentile height and 15th percentile weight).


Posted by: Nathan Williams | Link to this comment | 03-12-13 3:12 PM
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I had pretty much memorised the Guide to Effective Care in Pregnancy and Childbirth. Evidence-based medicine for the win, motherfuckers! And, it turned out that my instincts were all right. Obviously, I had midwives, and no one to argue with. I think I would hate to have a baby in the States.


Posted by: asilon | Link to this comment | 03-12-13 3:13 PM
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I think I would hate to have a baby in the States.

Well, right. If you look at the stats, US doctors have to be systematically very, very C-section happy. But all of the C-sections are 'medically justified'. So if a US doctor is telling you that a C-section is necessary, you know that's not terribly reliable. But you're not a doctor, and sometimes C-sections are necessary. So what are you going to do?

In practice, generally, what the doctor tells you. But it's a difficult position to be in. (I mean, I personally was very well treated by Anna the scary Czech midwife and Dr. Morrow the random OB who happened to be on call and was great.)


Posted by: LizardBreath | Link to this comment | 03-12-13 3:18 PM
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So what are you going to do?

Find a practice with a very low c-section rate to start with. (Obviously not an option for everyone, depending on where they live.)


Posted by: Blume | Link to this comment | 03-12-13 3:22 PM
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Yeah - the UK c-section rates have (roughly, I'm not looking them up right now) doubled in the last thirty years, and considering everything else, they're clearly not all essential. It's pretty crap. Our infant mortality rates aren't as bad as yours (yet?) though.


Posted by: asilon | Link to this comment | 03-12-13 3:24 PM
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Well, right, that's what I did going to a midwife practice. But having to take that sort of defensive approach is lousy.


Posted by: LizardBreath | Link to this comment | 03-12-13 3:24 PM
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It's hard to overemphasize the terror doctors have of being sued for doing something slightly abnormal. Granted this is mostly a phantom fear that helps them feel put-upon despite their guaranteed massive salaries, but it's real.


Posted by: Cryptic ned | Link to this comment | 03-12-13 3:32 PM
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Going by weeks alone is dumb because its based on date of last period which if you don't have 28 day cycles means gestational age is incorrect. Now, they do adjust gestational age based on ultrasound which means they're setting deadlines by size, but that's what they should use, not what they think is "42 weeks."


Posted by: SP | Link to this comment | 03-12-13 4:01 PM
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Don't they have a little formula for adding or subtracting days depending on the length of cycle?


Posted by: asilon | Link to this comment | 03-12-13 4:33 PM
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IIRC, there's a significant (thought still rare overall) increase in the risk of still birth after 41 weeks. But the law enforcement thing is just plain bullying.

Not that midwives are perfect. I just returned from an appointment in which my midwife had the wrong chart pulled up for most of the appointment. We figured it out when she was insisting that I'd gained four pounds in the past two weeks which made my total weight gain 26 pounds, which was not correct on either count. Touchpad problem, basically, compounded by the fact that the next woman she was seeing after me is due the same week, so nothing set off the bullshit detector until I was insisting I wasn't 170 pounds. Lesson: be insistent. Also check computer myself first next time.

(She's been a great provider otherwise, so this was mostly just silliness. Still.)


Posted by: Cala | Link to this comment | 03-12-13 4:42 PM
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I'll take Shamhat's knowledge and Asilon's supplementary experiences as proof that she nor the baby weren't actually in danger and the doctor was being a bully.

If, medically, the facts had been murky, I'd be sympathetic to the doctor. Yes, he's threatening her in order to get her to let him cut her open. But there is a full-term baby in there who (in my made-up counterfactual) is in danger.


Posted by: heebie-heebie | Link to this comment | 03-12-13 5:04 PM
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My mum went nearly 4 weeks over with my brother, but he was her third and the previous labours had all been quick and uncomplicated. As it happened, he was huge, and my Mum bled out pretty badly (although was fine within a few hours after a transfusion). She'd certainly have died if it had been a home birth. However, the baby was fine.

We are in week 40 now. We have an appointment on Friday at which they will schedule/discuss options for induction if he doesn't turn up in the next seven or eight days. The impression I have is [at our hospital] they'll routinely wait until end of week 41 and still let you go for the midwife led birthing centre, to week 42 but they'll insist you'll deliver in the labour ward, and that they basically won't let you go later than that, esp. with a first baby.


Posted by: nattarGcM ttaM | Link to this comment | 03-12-13 5:07 PM
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re: 29

We had a 12 week check at which the midwife kept giving us a due date of early January. No matter how insistent we got that she was wrong, she wouldn't budge. The midwife on reception took one look at the form and marched back in to give her a bollocking as it was obvious to her it was wrong. She'd mistyped a digit into the initial calculator.


Posted by: nattarGcM ttaM | Link to this comment | 03-12-13 5:09 PM
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Have you said here if you're having a boy or girl?

(have any of the babysplosion parents - GB excepted - said? I know it's the patriarchy but I'm always super curious.)(We're having a girl.)


Posted by: heebie-heebie | Link to this comment | 03-12-13 5:10 PM
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re: 33

Boy.


Posted by: nattarGcM ttaM | Link to this comment | 03-12-13 5:14 PM
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Congrats! Obviously congrats either way, but still. Yay!


Posted by: heebie-heebie | Link to this comment | 03-12-13 5:31 PM
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28- In my experience they just adjust it for size at the 20 week ultrasound even if you tell them the exact date (in one case, 1-20-2009; OooooohBama.) For our first kid SPouse was having 3 month cycles. I think we had a discussion previously about the stupidity of things like 8-week abortion bans because all women are 2 weeks pregnant.


Posted by: SP | Link to this comment | 03-12-13 5:50 PM
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We're having a brrrrrrrr grrrrr brrrr grrrr rrrrrrrrrrrrrrr


Posted by: Sifu Tweety | Link to this comment | 03-12-13 5:52 PM
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We're having a brrrrrrrr grrrrr brrrr grrrr rrrrrrrrrrrrrrr girl.


Posted by: Blume | Link to this comment | 03-12-13 5:58 PM
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I was eating a lot of marshmallows.


Posted by: Sifu Tweety | Link to this comment | 03-12-13 6:03 PM
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You're having a chubby bunny?


Posted by: SP | Link to this comment | 03-12-13 6:04 PM
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I thought you'd name the kid Aaron Burr.


Posted by: fake accent | Link to this comment | 03-12-13 6:21 PM
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named


Posted by: fake accent | Link to this comment | 03-12-13 6:21 PM
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A relative of mine gave birth to a baby who weighed something like 11 pounds (definitely at least 10 and closer to 11 if not 11). I think she had a c-section, but I don't know.


Posted by: fake accent | Link to this comment | 03-12-13 6:22 PM
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You're having a burger? YUM.

Soon-to-be-ex and I went to the hospital on a Valentine's Day Friday night so she could be induced (she was at almost 32 weeks, but it was a high-risk twin pregnancy, so the obgyn [Dr. DiFe/derico, whom we called "The Fed"] wanted it done with). The pitocin didn't take, so we spent a couple of sleepless nights and were about to be sent home when The Fed said she was seeing signs of stress. We had planned on a natural birth, but by that time our defenses were demolished and we said fine, storm the womb. STBE was prepped and under the knife in about 20 minutes, and we had our girls about 20 minutes after that.


Posted by: Jesus McQueen | Link to this comment | 03-12-13 6:27 PM
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13: "pretty much everyone who gets a C-section is told that it was a medical necessity"

The infant mortality rate in Mali is around 11%. You have to assume that some of those are preemies and low birth weight babies that would survive here with medical care. The US preemie rate is 11%. One might guess that Mali might have a higher rate due to starvation and no medical care. There's also neonatal infection that they can't treat with antibiotics. Doesn't it seem fair to guess that at least half of those neonatal deaths are not from difficulty with the birth process? The WHO thinks that a reasonable cesarean rate is 10%, which meshes with this back-of-the-envelope calculation.

There is no way you can believe that 30% of American babies would die if they had been born vaginally. In my Upper East Side setting, all of our mothers have had prenatal care, many of them "the best money can buy," yet 42% of them have to be saved from certain death. Either that, or their private OB's have waited as long as they can afford to and need to get out of there.

The "brain damage" was speculation in the 70's that oxygen deprivation during the birth process caused cerebral palsy. That turned out not to be the case. In fact, despite a rise in c/secs from 5% to 32% nationally, cerebral palsy has increased (due to more preemies surviving, mostly).

As for calculation of "due date," a term which implies docking a letter grade for each day you're late, there are many factors known to affect gestation. First there is conception date, which is often not know. Then there are factors like the mother's height, race, and parity. However, doctors just use "the wheel" of Naegele's rule, from the 1830's. Seriously.

A review of evidence about outcomes for 38 weekers has led to a push to prevent elective inductions and c/sections before 39 weeks. Our institution requires a medical indication to be charted. Evidence-based management of post-dates pregnancy would be induction between 41-42 weeks.

Occasionally when an induction fails, the doc will send the mom home instead of sectioning her. These moms are usually very confused: "But I thought the baby was going to die if I wasn't delivered immediately?"

I would be embarrassed to reveal the worst reasons that a woman has ended up with a c/sec.


Posted by: Shamhat | Link to this comment | 03-12-13 6:27 PM
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What is the blog for if not embarrassment on behalf of others?
There was a recent analysis that showed delivery dates are not evenly distributed, they're correlated with things like long weekends, doctor's vacations, etc. Something something vacations survival on the veldt.


Posted by: SP | Link to this comment | 03-12-13 6:41 PM
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My parents tried to schedule my birth for the first of a month, but the doctor said no. Also, something something three-day weekend.


Posted by: fake accent | Link to this comment | 03-12-13 6:49 PM
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I would be embarrassed to reveal the worst reasons that a woman has ended up with a c/sec.

I am curious!


Posted by: Blume | Link to this comment | 03-12-13 6:53 PM
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For real, Shamhat probably was there for mine.


Posted by: oudemia | Link to this comment | 03-12-13 7:02 PM
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Evidence-based management of post-dates pregnancy would be induction between 41-42 weeks.

Just to be persnickety, that's exactly how far along this woman was. So it's possible there was actual fetal distress. No matter what, this doctor is already more flexible than most US doctors on VBACs and holding patients to an arbitrary 40 week deadline.

The woman has gestational diabetes and has had four c-sections, which is a whole lot of medical history that we don't have access to. ("Baby not in a good position" probably means sunny-side up and back labor, I'm assuming, and not breach.)


Posted by: heebie-geebie | Link to this comment | 03-12-13 7:11 PM
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Hypothesis: a year to year comparison within a particular metro area would show more c sections In late january and early february in years the home team is in the superbowl. Anyone have access to the appropriate database?


Posted by: Unimaginative | Link to this comment | 03-12-13 7:17 PM
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My birthday is often on Superbowl Sunday and I'm here. Are you calling me dead?


Posted by: heebie-geebie | Link to this comment | 03-12-13 7:20 PM
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45

... have to be saved from certain death ...

Otherwise certain death is not the appropriate threshold for deciding when to perform a C-section.


Posted by: James B. Shearer | Link to this comment | 03-12-13 7:32 PM
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I must admit that I really dislike the woman, for arguing that she doesn't have childcare and that her husband would be stranded at work. That's just so disingenuous, given that she could easily spontaneously go into labor at any point.


Posted by: heebie-heebie | Link to this comment | 03-12-13 7:33 PM
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I was disappointed about having to have a C-section the second time, but I had unexplained bleeding starting at the 19th week (I nearly had a heart attack and died, seeing the fresh pink blood) and they couldn't figure out the source. the baby seemed fine, so they decided to let her cook up good, till 36 weeks, and then whisk her out. after tap dancing on my diaphragm in agonizing ways the whole pregnancy she stubbornly shifted into the breech for the last two weeks. so, it was meant to be. turned out to be plain old placenta previa (in which the placenta forms over the cervical os and there's no way for the baby to get out--she can't get through, unless she macguyvers through like apo riding an IUD*), but the placenta had formed very wide and thin, and they couldn't see it despite repeated attempts with excellent sonograms. in retrospect I wondered, "well, if they couldn't see the placenta, shouldn't they have been worried about where it was, given that it had to be somewhere? shouldn't they have seen where the umbilical cord led to?" but apparently no? I didn't ever want a c-section, but I'm one of those cases where the baby and I would both be dead if I were giving birth in rural afghanistan or in the past.

it made me think of how devastated my family would be, having this excited new hope turn into tragedy, how sad it would be for my husband. I usually just do doctors without borders because neil the ethical werewolf told me to, but does anyone know of a good charity that's devoted to decreasing the rates of peri-natal death for mothers and children? (how awesome is neil? he once rented me his apartment while he was out of town, for my brother and his GF to stay in, in exchange for a donation to doctors without borders. that's awesome. I also spiffed the place up with some furniture from my store and a black christmas tree with ornaments hand-painted with the names of DC punk bands, so it was win-win all around.)

*noted for the non-splosion readers.


Posted by: alameida | Link to this comment | 03-12-13 7:36 PM
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52: [checks Facebook and superbowl website] Nope, you were born more than two weeks after the superbowl. It was in mid January back then, so it is possible that you are not dead.


Posted by: Unimaginative | Link to this comment | 03-12-13 7:40 PM
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28: Here they tend to go by measurements in the first trimester. Last menstrual period estimates my due date to be about five days after the one we're working with based on ovulation, and as the kid is measuring consistently a week ahead of that... we'll see.

54: Absent the law enforcement threat, I think the doctor wasn't that bad.

Here they won't allow elective c-sections before 39 weeks, or 41 weeks if this is the first baby. My hospital's rate is around 20%, which isn't awesome, but is better than a lot.


Posted by: Cala | Link to this comment | 03-12-13 8:42 PM
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I gave Partners In Health money on several occasions for perinatal initiatives in... Africa? And other places? They were doing a Mother's Day campaign and I would just hemorrhage money over that stuff. I had no defenses while pregnant.

I did what I could to avoid scheduling an induction for my own birthday. We ended up five days apart: the baby spontaneously emerged on the due date I had calculated from my ovulation chart, and is an accordingly fastidious person. (She also crossed her legs and hid for most of the gender-determining ultrasound, which made me genuinely feel like a perv for demanding to know. Did anyone else feel that way?)

I will add that the fetal-head-size-to-maternal-pelvis-size ratio was not something I worried about while pregnant; but after delivering, I had plenty of time to look at the heads of my in-laws and the relative breadth of various family members' hips. I did not end up on the right end of that calculation. (One nurse remarked sadly, "No one your size should have a baby that size." The baby was under eight pounds. It was the head.)

Are C-section rates higher in teaching hospitals?


Posted by: lurid keyaki | Link to this comment | 03-12-13 9:04 PM
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Evidence-based management of post-dates pregnancy would be induction between 41-42 weeks.

Which seems to be standard for the UK, as far as I can tell. The UK has NICE, though, producing quite a lot of those clinical guidelines, so it's fairly evidence-based.

So, NICE guidelines on induction:

http://publications.nice.org.uk/induction-of-labour-cg70/guidance

Plus the NICE guidlines on C-sections:
http://www.nice.org.uk/CG132

i.e.:
http://publications.nice.org.uk/caesarean-section-cg132/guidance#planned-cs


[Plus general antenatal guidelines:

Summary of the NICE Guidelines:

http://publications.nice.org.uk/antenatal-care-cg62/guidance#management-of-specific-clinical-conditions

Standard appointment schedule:
http://publications.nice.org.uk/antenatal-care-cg62/appendix-d-antenatal-appointments-schedule-and-content
]


Posted by: nattarGcM ttaM | Link to this comment | 03-13-13 1:43 AM
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every cup of coffee you drink reduces birth weight by a pound

So if you drink eight or nine ups of coffee you're at risk of Flying Baby Syndrome?

Induction != Caesarian. You know that, obvs, but it seems to have got lost in some of the discussion upthread.


Posted by: chris y | Link to this comment | 03-13-13 3:39 AM
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Sure. I was just responding to some of the induction conversation above. The differences are quite present in the mind at the mo'!


Posted by: nattarGcM ttaM | Link to this comment | 03-13-13 3:49 AM
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"Not in a good position" probably means the head is floating, which is not uncommon in multips. Very few doctors actually pay much attention to sunnyside-up before the woman is pushing.

I find that at my hospital, the "service patients" being cared for by the residents are less likely to be sectioned, because the doctor covering them is in the hospital for as assigned shift and thus doesn't get to go home when a particular patient delivers. Thus no incentive; in fact, if you wait long enough, it's the next guy's problem.


Posted by: Shamhat | Link to this comment | 03-13-13 3:52 AM
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61. I bet they are.


Posted by: chris y | Link to this comment | 03-13-13 3:53 AM
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Since it involves the removal of a baby, deduction would probably be a better word than induction.


Posted by: ajay | Link to this comment | 03-13-13 3:54 AM
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Eliminate all factors, and one of the things that came out must be the baby.


Posted by: OPINIONATED SHERLOCK HOLMES, OB-GYN | Link to this comment | 03-13-13 4:21 AM
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I'll take Shamhat's knowledge and Asilon's supplementary experiences as proof that she nor the baby weren't actually in danger and the doctor was being a bully.

Not nearly enough information to say there was no danger ( my guess would be not particularly, although I'd expect a fair amount of observation/management in her situation), but I think threatening legal action is bullying, yes.

Neither of the health authorities where I had babies did routine 12 week dating scans, and they wouldn't change dates at the 20 week scan because there's too much variation by then. So my lie was never challenged. She came along at 41 weeks according to my medical notes, 10 lb 8, no problem.


Posted by: asilon | Link to this comment | 03-13-13 5:13 AM
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I online-know some of the people who run Heartline Ministries in Haiti and they have an awesome maternity center and the beginnings of a transitional house for teen moms and despite some of my worries about Christian missionaries, I think they do outstanding work. It only reaches a small number of people, but is the kind of work I think has a major impact on the individuals they serve and their families and communities.


Posted by: Thorn | Link to this comment | 03-13-13 5:28 AM
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I will agree with over-the-top language by him. But, if anything is wrong with the bad, the doctor is getting sued. I would almost rather him tell her that if she does not come in now, he is not going to be her doctor any more. I'm not sure whether you can fire your patient at that late date.

When the standard seems to be one of almost strict liability, then I am willing to give the doctor a little more slack.

Shamhat makes a lot of excellent points.

I am a little biased as the son of an ob/gyn. He is known for waiting it out and not letting the woman try to avoid a c-section. He likes to repeat that the problem isn't that he thinks he is God, but that the patients think that. The birthing process is both incredibly dangerous and incredibly simple.


Posted by: will | Link to this comment | 03-13-13 7:53 AM
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I meant that his language was over-the-top bad.


Posted by: will | Link to this comment | 03-13-13 7:53 AM
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Regarding the criminal threats:

I fully support the women's right to decide what to do. She is the boss. I do not believe in criminally charging her for neglect even if she ingests cocaine. Her body. Her decision.

I also support the doctor's right to not be involved in her decision if he disagrees.


Posted by: will | Link to this comment | 03-13-13 8:00 AM
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The birthing process is both incredibly dangerous and incredibly simple.

And this is exactly the crux of the problem: who has the expertise to tell when it goes from the latter to the former? Doctors, one would hope. Except that the trend in the last several decades has been toward unnecessary medicalization / pathologization, so there ends up having to be a lot of pushback.


Posted by: Blume | Link to this comment | 03-13-13 8:52 AM
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Since it involves the removal of a baby, deduction would probably be a better word than induction.

And if you have to go into unstructured dreamspace to deliver it, that's called inception.


Posted by: Mister Smearcase | Link to this comment | 03-13-13 9:02 AM
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73

Induction implies that if you have one baby, you have an infinite number of babies.


Posted by: Benquo | Link to this comment | 03-13-13 9:04 AM
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71: My sense is the trend is toward less intervention, but there's already a lot of interventions.

I really don't want to be cut open, but my kid has a large head. (Very round, which throws off the BPD reading a little.) He's in a good position at least, and my midwife is confident he'll squish, but I think it's going to take a lot of maneuvering to get him out.


Posted by: Cala | Link to this comment | 03-13-13 9:08 AM
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My sense is the trend is toward less intervention, but there's already a lot of interventions.

When looked at over the last several decades? Say, since the 70s?


Posted by: Blume | Link to this comment | 03-13-13 9:14 AM
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76

My impression of size readings from late pregnancy ultrasounds is that they're not very accurate at all -- I've heard a lot of anecdotes about 6lbs predicted, 8lbs actual (that was Sally. And Newt as well) as well as the reverse.


Posted by: LizardBreath | Link to this comment | 03-13-13 9:15 AM
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77

That was meant as a 'don't necessarily worry' to 74.


Posted by: LizardBreath | Link to this comment | 03-13-13 9:19 AM
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78

It is definitely reaching the mainstream conventional wisdom that too many interventions are a bad thing. How this is playing out across different populations by wealth and geography, I have no idea.

Frex, our dinky hospital considered it a PR disaster that the c-section rate was around 40% and hired a new director of nurses who was supposedly going to address that, and they got a birthing tub, and they at least have been spending money addressing the high rate. This is my evidence that pushback against too many interventions has gone mainstream.

OTOH, I keep hearing anecdotes about upper class women wanting their births on a certain day, or wanting c-sections, etc. Enough to make me believe there are pockets of every kind of experience at every class level.


Posted by: heebie-geebie | Link to this comment | 03-13-13 9:23 AM
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I think there's a big difference between mainstream and majority or universal. There are a lot of people where Shamhat is or I am in that they think there's an awful lot of unnecessary intervention out there, and that position is visible and mainstream. But that doesn't mean that it's dominant enough to be driving the actual trends in medical practice.


Posted by: LizardBreath | Link to this comment | 03-13-13 9:27 AM
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But I'd contrast our local hospital as being more mainstream, compared with where you guys are. I mean, I found it really difficult to find a doula here when I was pregnant with Hawaii. This is not Austin.


Posted by: heebie-geebie | Link to this comment | 03-13-13 9:29 AM
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On a moderately related note, I just saw a surprisingly tense circumcision conversation at a baby shower. It's funny, I'd thought all the energy in this one was from the anti-circumcision side: that there were people who planned to circ for religious reasons or because it just seemed normal, but that circers generally didn't care much what other people planned to do, while anti-circers had a lot more "why would anyone mutilate a defenseless baby" going on. This one went the other way, though -- it came up, the pregnant woman said they weren't planning to circ, and one of the guests got very, very tense and started interrogating her about why she thought that was a reasonable course of action.

No one actually got angry, but it was surprisingly intense.


Posted by: LizardBreath | Link to this comment | 03-13-13 9:32 AM
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And if you have to go into unstructured dreamspace to deliver it, that's called inception.

Becoming pregnant by your husband is known as proprioception (if you aren't married, it's improprioception).


Posted by: ajay | Link to this comment | 03-13-13 9:37 AM
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83

Should someone other than the OB or midwife catch the baby, that is an interception and stops the clock.


Posted by: LizardBreath | Link to this comment | 03-13-13 9:40 AM
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84

surprisingly tense circumcision conversation

I have some friends who are a bit hostile on this - that is, hostile towards the anti-circumcision types - because to accept even a little of the "why would anyone mutilate a defenseless baby" logic implies that they are mutilated, and they don't want that to be the case.

Otherwise it seems like just another your-different-choice-calls-mine-into-question sensitivity, of which there is no shortage and it's not surprising that this is one of them.


Posted by: Nathan Williams | Link to this comment | 03-13-13 10:10 AM
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I could see that, but the tense person was a childless woman, so as little as possible of her own skin in the game*. I guess people just get wound up about the things they get wound up about.
____
*I crack me up.


Posted by: LizardBreath | Link to this comment | 03-13-13 10:16 AM
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She didn't fall pregnant? Inconceivable!


Posted by: Opinionated Vizzini, Ob-Gyn | Link to this comment | 03-13-13 10:18 AM
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I enjoy referring to my IUD-enhanced self as impregnable.


Posted by: LizardBreath | Link to this comment | 03-13-13 10:21 AM
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88

Or unbearable.


Posted by: ajay | Link to this comment | 03-13-13 10:22 AM
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Nice.


Posted by: LizardBreath | Link to this comment | 03-13-13 10:23 AM
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That was about the only joke I remember my grandfather ever telling, in which a Polish pilot is trying to explain that he's married but doesn't have any children, because his wife is unbearable. "No... impregnable. No... inconceivable."


Posted by: ajay | Link to this comment | 03-13-13 10:26 AM
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76: I'm not worried about weight, just head diameter. But you're right that they're very inaccurate.

79: Of course I'm just working from anecdotes, but my sense usually that if it's being talked about here, it's mainstream enough. My hospital is not superfancy and I'm not living in a particularly wealthy area, and yet reducing C-section #s is a big deal. (Perhaps some kind of mandated target?)


Posted by: Cala | Link to this comment | 03-13-13 10:54 AM
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83 is very funny. (As is the expression "catch the baby.")


Posted by: Sir Kraab | Link to this comment | 03-13-13 11:12 AM
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I don't actually know anything about recent trends at all -- I haven't looked at stats. But I think there's a lot of room for "We value bringing down our C-section rate and are taking initiatives to make that happen" (which I agree is a very mainstream thing for a hospital to say) to co-exist with "All of our actual policies are compatible with the C-section rate staying high or increasing further." If you see what I mean -- something can be a mainstream value to pay lip service to without affecting results much.


Posted by: LizardBreath | Link to this comment | 03-13-13 11:14 AM
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93 strikes me as dubious, unless the former is pure lip service. I think there are actual policies like "no elective inductions before 38 weeks" that many (most?) hospitals have begun enforcing.


Posted by: heebie-heebie | Link to this comment | 03-13-13 11:19 AM
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Oh, I really meant that I haven't looked at the stats -- individual hospitals may be doing something effective. But I'm pretty sure that any mainstream project of bringing C-section rates down hasn't had a broadly noticeable effect yet.


Posted by: LizardBreath | Link to this comment | 03-13-13 11:24 AM
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C-section rate is 32% nationally as of 2011.


Posted by: LizardBreath | Link to this comment | 03-13-13 11:28 AM
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Sure. People think there are a lot of unnecessary c-sections. Until something is wrong with the baby and they decide to sue, alleging that a c-section should have been performed earlier.

You are not likely to get sued for doing a c-section too soon. If you wait, then you get sued. (I think it is common that the doc has a $25,000 deductible as well.)

Which one would you choose?


Posted by: will | Link to this comment | 03-13-13 12:07 PM
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I really do sympathize with doctors who are afraid of being sued. But given that that fear leads to their, in many cases, performing medically unnecessary abdominal surgery on women who'd just as soon leave their peritonea intact if that were an option, I find it hard not to divide my sympathy among all of the involved parties.


Posted by: LizardBreath | Link to this comment | 03-13-13 12:11 PM
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I have some friends who are a bit hostile on this - that is, hostile towards the anti-circumcision types - because to accept even a little of the "why would anyone mutilate a defenseless baby" logic implies that they are mutilated, and they don't want that to be the case.

O hai. Not quite how I'd frame it, but.


Posted by: Mister Smearcase | Link to this comment | 03-13-13 12:13 PM
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98:

Of course that assumes that it is medically unnecessary.

Plus, it assumes that the doctor says that it has to be done.

Defining risk or defining probability of difficulties is tough. "I would recommend having a c-section."

"You can keep trying or we can do a c-section. I would recommend a c-section."

I don't know about you, but I don't tell my clients that there is a ___ percent chance of winning. It is too difficult to determine.


Posted by: will | Link to this comment | 03-13-13 12:31 PM
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Of course that assumes that it is medically unnecessary.

Well, yeah. That there are countries with C-section rates at 10% or lower without higher rates of neonatal mortality and morbidity seems to make it clear that a very significant percentage of them are, and that it is not impossible for doctors to figure out which ones.

(It's not very practical for untrained patients to figure out if a C-section is necessary in the moment, of course.)


Posted by: LizardBreath | Link to this comment | 03-13-13 12:45 PM
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Pet peeve: There is no analytical distinction between doctors who act in a particular way because they are afreaid of being sued, and doctors who whoi don't give a shit about being sued, but act in the same way becaue they are afraid of a patient dying. They're not going to be sued unless someone dies or is seriously injured. It's kind of insulting to doctors to assume they would take greater risks with their patients' lives if they were less afraid of being sued.


Posted by: unimaginative | Link to this comment | 03-13-13 12:56 PM
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I think the issue here is that there are some actions believed by doctors to be infallible insulation against lawsuits (that is, doing a C-section) even under circumstances where there's no good medical evidence that they actually reduce the likelihood of a bad medical outcome for the patients. Now, if this is true, it's putting them in a bad spot where their financial interests aren't aligned with their patients' interests in bodily integrity, and it's not surprising that it affects patient care negatively -- we shouldn't expect doctors to be saints. But it also means that, while any individual case may be hard to parse, you can look at the stats and be pretty sure that US OBs, as a class, are making the decision to do surgery on some basis other than their patients' best medical interests.


Posted by: LizardBreath | Link to this comment | 03-13-13 1:01 PM
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102:

Risk is not some hard science. Each patient is different. A doctor is not saying "I will agree to my patient having 15 percent more risk of a baby with problems."

Also, it is also sometimes the patient saying that they don't want a c-section and the doctor advising her what her risks are.


Posted by: will | Link to this comment | 03-13-13 3:06 PM
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I think the issue here is that there are some actions believed by doctors to be infallible insulation against lawsuits (that is, doing a C-section) even under circumstances where there's no good medical evidence that they actually reduce the likelihood of a bad medical outcome for the patients.

There's a HUGE number of such actions. Any number of diagnostic tests that the patient seems to have no chance of needing, but couldn't hurt.


Posted by: Cryptic ned | Link to this comment | 03-13-13 3:18 PM
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94: Here they've adopted a lot of birth center-like amenities (though I'm told that most women here opt for epidurals and so they don't get the special room with the tub which is reserved for hippies like me) meant to aid natural childbirth, and elective inductions aren't permitted before 41 weeks for a first-timer. My hospital's rate is 20% which is somewhat high for the region.

100: Part of it, too, is that a c-section is thought of as a routine thing (which for the surgeons it is!) instead of a major surgery (which it still is!), and that it's sometimes a decision that needs to be made quickly.


Posted by: Cala | Link to this comment | 03-13-13 4:33 PM
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I think there are actual policies like "no elective inductions before 38 weeks" that many (most?) hospitals have begun enforcing

I think this is part of the Joint Commission's core measures on perinatal care, though I'm pretty sure the measure is 39 weeks. And it might just be about c-sections, not inductions.


Posted by: Blume | Link to this comment | 03-13-13 5:14 PM
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re: 106.1

The hospital we are going to has completely separate birth centre and labour wards. In the former no epidurals are available, and they don't do continuous monitoring. Most but not all of the rooms have pools, and all of them have tons of beanbags and mats and ropes, and birthing balls, and so on.

C-section rate in that hospital is over 30% but it's a (national) centre for difficult pregnancies, so they have a lot of high-risk births.


Posted by: nattarGcM ttaM | Link to this comment | 03-13-13 5:16 PM
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Since this is a medical thread, I feel compelled to share a somewhat WTF medical "situation" someone I know (Mrs. Teasdale) has had thrust upon her. Over the past 4-5 months she has experienced the following series of revelations* and events: 1) Elderly companion of an elderly relative becomes gravely ill, elderly relative is no longer mentally competent so Mrs. Teasdale learns she is medical proxy, and over the holidays duly navigates end-of-life decisions for the companion. 2) Learns she is the executor of the will which has various interesting twists but basically leaves 50% (relatively small potatoes, thankfully) each to elderly relative and distant semi-hostile beneficiary, but if either dies within 90 days essentially all of it goes to the other one. 3) Learns she is medical proxy for the elderly relative when elderly relative goes into steep decline. 4) Learns that she is executor of elderly relative's will. 5) Learns that since death of elderly companion she is now primary beneficiary of elderly relative's will. 6) Doctor of elderly relative (now on a vent in ICU) requests a discussion tomorrow which is likely to include end-of-life considerations (it is about day 71 since the companion's death). She is set to simply listen tomorrow and sort it out from there, but holy heck, quite the series of events and an unwelcome bit of circumstance.

Timing is the secret of everything.

*If she had thought about it, she probably could have figured out in advance that she might be tagged with some of these duties, but it is not necessarily something one asks about.


Posted by: Rufus T. Firefly | Link to this comment | 03-13-13 8:14 PM
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That sounds pretty brutal.


Posted by: heebie-heebie | Link to this comment | 03-13-13 8:17 PM
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Fortunately recently retired so has had time and energy to devote to it. Also relatively even-keeled which has helped; but this last twist was a bit much.


Posted by: Rufus T. Firefly | Link to this comment | 03-13-13 8:25 PM
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And actually 'know' as in 'is a family member', so I am actually a bit more than just an onlooker.


Posted by: Rufus T. Firefly | Link to this comment | 03-13-13 8:32 PM
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Ugh. Medical proxy issues are no fun. I thought I was the medical proxy for my (now late) grandmother, but when she went into serious mental decline and ended up at a nursing home, I discovered that she'd actually changed the proxy to my uncle, who was out of the country and hard to reach at the time. There was a lot of not-fun straightening out who was even allowed to make decisions, as well as some not-fun considerations of which, if any, of the medical proxy documents could be considered valid, given what was known about her state at the time.


Posted by: Nathan Williams | Link to this comment | 03-13-13 8:33 PM
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113: I had one "sprung" on me in less than ideal circumstances (to be fair I had been notified many, many years earlier but had forgotten all about it). Also featured the "crystal clear" directives which magically transformed into vague jumbles of poorly-defined terms in the actual event.


Posted by: JP Stormcrow | Link to this comment | 03-13-13 8:39 PM
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112: ... actually ... actually ...

Actually, I shot an elephant in my pajamas.


Posted by: Rufus T. Firefly | Link to this comment | 03-13-13 8:47 PM
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Failure to progress, arrest of dilatation, arrest of descent, cephalopelvic disproportion, and failed induction all mean "the process is taking longer than I think it should."

Would any of you imagine that a doctor would tell a patient that she needed a cesarean because she wanted to catch the last express bus to Riverdale?

Because his wife was embarrassed she wasn't with him at a shiva?

Because her son forgot to walk the dog, and if she didn't get home to walk him before office hours, there would be a mess to clean up when she got home?

Because he had a flight to catch?

Because it looked like another doctor was about to "call it," and if he didn't "call" his first, he would have to wait an hour until the other guy did his case?

Because his partner was coming on call in an hour and he didn't want the other guy to get to bill for the delivery when he was the one who was there all night?

Because her partner was coming on call in an hour and she didn't want to leave the other guy with extra work?


Posted by: Barbara Bush | Link to this comment | 03-13-13 9:57 PM
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114: The "springing" involved another interested party keeping it from me (and several others) during a few critical days because: 1) asshole, 2) fear, confusion, misplaced greed and asshole, 3) did not really understand what he had, and 4) asshole. Enraging to this day although it took place some years ago, and not even that close to the most asshole move pulled by the asshole during the period in question.


Posted by: JP Stormcrow | Link to this comment | 03-13-13 10:27 PM
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Recent goings-on in compulsory Caesarians in Ireland;
http://www.irishexaminer.com/opinion/columnists/victoria-white/sadly-mother-doesnt-know-best-in-irelands-rigid-childbirth-regime-225349.html


Posted by: emir | Link to this comment | 03-14-13 11:28 AM
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