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Jenny Strikes Back - A Set of Letters and a Meeting about the Unnecessary Cesarean

Copy of a letter sent to Patient Relations

I had a baby at Happy Moron in August of 1995. I wanted to write and let you know how I felt about your hospital's service. It has taken me some time to gather my thoughts and talk with the hospital employees who took care of me, which is why I am just now writing you.

First, let me congratulate you on the quality of the nursing care provided by the postpartum nursing staff. So much time has passed that I can't remember names, but the nurses were, without exception, professional, compassionate, and skilled. I had a cesarean and found the pain to be overwhelming. All the nurses were so kind to me, always telling me what they were doing when they came in and being as gentle as possible.

As for the care my newborn son received in the nursery, my husband and I were both very happy. The nursery nurses were knowledgeable, but more importantly, seemed dedicated to the personal care of each infant. They all did their best to nurture our baby. Harry and Kim were outstanding. Kim was usually on duty at night during my stay and she came to my room often, answering my questions about breastfeeding and baby care, doing her best to help me get comfortable with my baby and to comfort me on my cesarean. She spent an entire hour one night just talking with me and cuddling my fussy son, going way beyond the call of duty.

I also appreciated the concern of the nurse-midwifery staff on the severe postpartum depression I experienced, especially that of Wanda M.. They were all worried about me and Wanda took extra care, referring me to UK hospital for mental health care. Her kindness was a real blessing at that awful time.

Unfortunately, I cannot say that I am as happy with the care I received at Happy Moron prior to recovery. I have four major complaints with the service I received. First, although the prenatal care was professional and personal at the clinic, down to the kindness of Ann, the receptionist, I do question the attitude toward the client which I felt was occasionally shown. During my prenatal care, I had difficulty getting some specific answers from the staff. They seemed either unwilling or unable (I can't say which) to provide statistics about birth practices at your hospital. The only number I ever got was a C-section rate (which I have since learned from an independent source was inaccurately low), and I had to ask at several visits before I got an answer. When asking CNM S. after my son's birth how often they see CPD, she said not very often (interesting coincidence that the only other lady in my childbirth class also had a section for CPD). When I asked what t! he VBAC success rate was, I was told she could give me the numbers, but it wouldn't really mean anything to me as it was such an individual thing. Statistics should be a matter of public record. When you don't provide them on request, it looks like you're hiding something, and it is condescending to the client to imply that she "doesn't need to think about that." That's not to say I haven't had the same problem getting actual numbers from other area hospitals, but....Another example of this tendency to withhold information occurred when I saw a book I wanted to check out from the CNMs' library. The CNM I was with at that visit said, "I don't want you to read that book yet." She never told me later that I could read it; of course I read it anyway. I found it to be a useful reference. I am sure the CNM meant well, but I don't believe it is a care provider's role to tell clients what they can and cannot read during pregnancy! Clients are adults and should be treated as such!

My remaining concerns have to do with what happened during my labor. Here's a brief summary of labor: CNMs H. and S. were on duty and during first stage, there were no problems. About midnight of August 23rd, CNM H. checked me and encouraged me to start pushing as I was at 10 centimeters and completely effaced. I did so, following her instructions, although I had no urge or desire to do so. I had pushed for two hours and my baby's head was showing at a couple centimeters when CNM H. came in and informed my husband and me that things were not progressing quickly enough and she needed to consult the OB on call.

She did so and Dr. S. recommended either Pitocin augmentation to strengthen contractions or the vacuum extractor to deliver the baby. I strongly wanted a natural birth and was not convinced of the safety of Pitocin, so we asked for some time to think about it. I continued to push with contractions with no further progress while the CNMs said we had to "do something." We finally agreed to Pitocin after Dr. S. said we could not consider vacuum extraction because the baby might be too big. Within a half hour of the Pitocin augment, the baby's heartrate overshot to 165 and we were told this meant I had to have a cesarean right away because our baby had fetal distress. We were also told I was having general anesthesia. At the time, we accepted all this as unfortunate but necessary. However, once given time to think about what happened and discussions with the above mentioned personnel, I am not convinced it really was.

First, the manner in which we were treated was unkind. There was an arbitrary time limit (which I was previously unaware of) on how long I could push (two hours), despite the fact that my baby's heart rate was okay before Pitocin was used. The staff on duty spent more time telling us they had to intervene than they did helping me to give birth. Also, CNM H. came into my room a day or two after delivery and in an attempt to comfort me, told me I had the birth experience I wanted. This was hardly true. Also, the labor nurse on duty, Joy Overall, was not helpful after the time the Pit was in use. She then came in to the room when the baby's heart rate overshot, turned off the Pit, and left the room again without a word to me, my husband, or my labor assistant. Not being stupid, we gathered that this meant I had to have a section. What a way to find out.

Her rudeness and hurry would be understandable if there had really been imminent danger to our son, but we were deliberately lied to on that count. My reasons for this conclusion follow: 1) In further reading and research, I have learned that a baby’s heart rate may overshoot in late second stage. It is not necessarily a sign of confirmed fetal distress, and other things can be done to alleviate it besides surgery to the mother. 2) The baby's heart rate was stable at 120-130, an average and normal level, following the discontinuation of Pitocin. 3) The baby's Apgar scores were 9 and 9. He was in excellent condition at birth. 4) An interval of 80 minutes elapsed from the time we were told I needed a section to the time of my son's birth. Clearly, those who prepared for and did the surgery did not believe there was an emergency. 5) And finally, the surgeon, Dr. S., did not mention fetal distress at all on the surgical report. CNM M. told me in February 1996 he just forgot to write it on the report. However, during my consultation with Dr. S. on August 14, 1996, I learned there was no distress to write about.

As parents, we would not have chosen to have a major abdominal surgery unless that was the only way our son could be born. We were completely misinformed at the time of the surgery as to the reason it was being performed. Since fetal distress was not the true reason, I have certainly wondered what the actual reason was. I won't list my ideas here, but I'd be happy to share my thoughts. We would never have allowed the surgery had we known then what we know now about oued no reassurance at all from the CNMs. They did not speak to me during transfer to the OR or once there. I understand that surgical situations like that require busy preparation, but how much time would it require to give verbal reassurance or a squeeze of the hand? I felt alone and afraid. So much for the humanizing touch of midwives which I had counted on and which was why I picked your hospital in the first place. CNM S. said my eyes were closed at the time and she didn't know what I wanted, so ! she left me alone. How could my eyes help but be closed after 30 hours of labor? How alert did I have to be to get compassion? My gut feeling was then, and still is, that the CNMs were angry with me for not complying with their wishes earlier and that is why they had nothing more to say to me.

Next, I do not understand why I was forced to have general anesthesia. I was personally told by Dr. S. at an August 14, 1996 consultation that general was unnecessary and that he denied any responsibility for its use. CNM H. has told me she chose it because she thought our baby could rapidly "go downhill." How can a CNM choose what type of anesthesia is used? This does not seem to be in line with legal and medical protocol. Also it is clearly unreasonable to use a more dangerous anesthesia when there is no fetal distress necessitating an emergency delivery. Beyond all these reasons, however, I fail to see why we, the parents, were given no input and no choices. There was nothing remotely resembling informed consent "operating" here. I didn't want general anesthesia. I do not understand why Dr. S. did not determine for himself what anesthesia was needed when he arrived at the hospital but instead went with what the CNMs had already chosen for me. I asked the nurse anesthetist why I had to have it, when on the operating table. I fail to see why it was administered to me against my will.

ACOG's Standards for Obstetric-Gynecological Services state that informed consent is operating if the patient is informed of both "the risks and hazards of the treatment" and "the necessity of the treatment" (pages 66-67). These topics were not even discussed relevant to the general anesthesia nor was I given any chance to make a decision about how my son would be born. It seems both inhuman and inhumane to treat another human being like this. I have contacted CNM H., CNM M., and Dr. S. about this question by mail after some verbal discussion. I have received no response from them to these questions which I now put before you.

And finally, I am simply not convinced the C-section itself was necessary. I was informed by my surgical report (not by a hospital employee, though I asked) that my diagnosis was cephalopelvic disproportion. I have researched this subject in an attempt to determine how things might go with a subsequent pregnancy. During my research, I have talked with two midwives and done a great deal of study. Both midwives informed me that based on the statistics (complete dilation, +4 station), my baby's delivery was imminent and could possibly have been completed normally had certain procedures been used to help me. Squatting, walking around, "dialing" the fetal head, the pelvic press, and fundal pressure are all techniques that can be routinely used to overcome the problem of a baby who won't just pop out.

You should know that neither the CNMs nor Dr. S. ever suggested or implemented any of these very simple procedures. Instead, I was told the only option I had was major abdominal surgery. How can it fairly be said that I have CPD and will not likely succeed at VBAC when basic helping measures were withheld from me? I have contacted the CNM clinic with questions about these techniques to no avail. I do not know whether your staff is not familiar with them or whether they refuse to use them. Either way, I am incredulous. When I employed the staff of Happy Moron, I assumed they were professionals who knew what to do to help me have a baby, a process that has been occurring naturally for a long, long time. At this time, I feel my trust in your staff was sadly misplaced.

I am writing you as patient relations director to inform you of these complaints about the care I received at your hospital and to inform you I will not be choosing Happy Moron in the future. I also do not sit back and say nothing when others ask me my opinion of your maternity care. I can hardly be contented with the quality nursing care I received when I doubt the necessity of needing such care. I have tried to resolve my questions with the staff members involved but they will not respond to me. At this point, receiving no answers, I am left to conclude that both the surgery and the anesthesia accompanying it were unnecessary. I also find the outright lies used to intimidate me into having the surgery incredible in a profession that prides itself on its high ethical and scientific standards. The way I have been treated by Happy Moron employees is unacceptable.

If I saw any effort on the staff's part to respond to my questions, that would give me some relief. However, at this point, it appears to me that the staff is uninterested in pursuing the application of non-surgical techniques to assist birth, and that they would prefer to continue seeing mothers like me undergo expensive, dangerous, traumatic, and unnecessary surgeries. We can all talk about how the C-section rate is too high in our country, and how we can all "trust in birth" at our local "birthing center," "family maternity suite," or whatever name Labor Hall goes by at the moment, till we're blue in the face, but if we continue to practice interventionist medicine, it's all just TALK.

Yes, I'm angry, but you should know that I very much want some communication. I personally like each one of the people involved. I am doing all in my power to "live in peace with all men" but I am getting nowhere.

I would appreciate a response from you on my complaints. I also would like to know what Happy Moron's section rate was in 1995, what percentage of those women had general anesthesia, and what percentage of those sections were for CPD. If I can provide any other information you might need beyond what is available in my inpatient chart, please let me know by mail. I will also be contacting the local AMA about my complaints, and am currently consulting with my lawyer about the contents of this letter.

Thank you very much for your attention to my complaints. I look forward to hearing from you soon.

Sincerely,
 

Jennifer L. Griebenow

Enclosures

cc [Many appropriate people]

[After a meeting to discuss concerns about unnecessary surgery.]

Dear Dr. X:

Thank you for taking the time to meet with me June 30th. I felt the meeting to be very productive for me personally and I hope you found it to be informative as well.

I wanted to follow up on that meeting with some comments so you can respond to my conclusions. The opportunity to tell staff and doctors how a client likes the services received was invaluable, as I know you don't often get feedback. Decisions that are made have long-term repercussions for the mothers who live through them. I want to remind you to think of this every time you work with a mother.

I am not satisfied with the answer to the question "Who chose general anesthesia?" When Ms. London pushed the group to answer this question, you took responsibility for it. However, nobody at the meeting claimed that they chose it originally. It is unacceptable that this is how decisions about anesthesia are made. Dr. G.'s statement that the physician does not have to justify his anesthesia choice in the records is ridiculous. It should be clear that the parents who are paying for the hospital's services and who will have to live with the consequences of the decision should have a say.

After the meeting I found myself wondering why you accepted responsibility for the general, when at our August 14, 1996 conference, you stated that general was unnecessary and directed me to the midwives and the anesthesiologist. I didn't mention it at the time, but I would imagine you can see why I'm asking about it now. Surgeons should be sure that anesthetic evaluation is done by appropriate staff members and not rely on a nurse's evaluation of the patient's condition, but it appears this is exactly what happened in our case.

In our discussion about the use of general anesthesia, Dr. G. said and you concurred that there was fetal distress necessitating its use. I was astonished to hear Dr. G. admit that the Pitocin caused the fetal distress. Amazing! Who was it that forced me to use Pit in the first place? The CNMs who were following your orders. Why should I be required to have surgery because of an intervention I never wanted? Dr. G. also stated that on the baby's stabilization, we were informed there would be a delay before surgery. Let me state again that this "informing" did not occur. Yes, my husband and I were upset about the events occurring, but we were never so out of it that we couldn't remember or understand what was said about our baby’s status.

I find the explanation of "fetal distress=general anesthesia necessary" to be weak for several reasons: fetal distress is mentioned nowhere in your surgical report, your pre-operative diagnosis is cephalopelvic disproportion, and the "brief history and physical" says "she will be planned [italics mine] for cesarean section." Interesting wording considering that my husband and I thought I was having an emergency section for fetal distress. Either there's fetal distress necessitating an immediate surgery and you move as fast as you can, or there isn't. You can't have it both ways, saying that the baby was stable so you didn't have to rush to surgery, and at the same time that you were so concerned about fetal distress that you could not take me off the EFM for even 20 minutes to put in an epidural so I could see my baby born.

It was stated that constant monitoring is impossible with an epidural and that this is part of the reason why I couldn't have one. If this were true, the rate of general anesthesia use in the c/s population would be much higher than it is because fetal distress is such a common problem. Reliable sources confirm that spinal and epidural are safe for cesarean with fetal distress and that it is used on a regular basis all over North America. Also, it is common knowledge that general anesthesia is far too dangerous to use in any but the most unusual and dire of circumstances. Since Zachary's surgical removal was delayed 90 minutes after he stabilized, I fail to see the dire nature of our circumstances. I do not accept this excuse as a reason why I required general anesthesia. Also, on perusing the nurse's notes, I find "EFM off" at 4:55 am, which is right before I was transferred to the OR. It appears despite claims made in the meeting, the EFM did not magically travel with me downstairs, and I was actually unmonitored. What can I say to this?

I also would like to respond to Dr. G.'s comments that general is used when the physician feels the client could not tolerate the sensations of being cut open or if the client is emotionally unstable. This appears to be an attempt to make me look bad, as this concern has never before been mentioned. I would like to state that though I was not happy I had to have a cesarean, I was not "emotionally unstable" at the time I was taken to the OR. Rather, I was calm and quiet, which I think my husband, Laure Schadler, and Bill Deemer could verify.

Also, I think it's clear from the group discussion that "informed consent" is a medical joke. With a baby at +3 station with late decels, an obvious choice would be forceps or vacuum extractor to expedite delivery. However, we were told you would not use vacuum on me because of concerns about shoulder dystocia, which was described as a potentially "horrible problem." This was not an accurate description of shoulder dystocia, and hardly a full description of the risks and benefits of both vacuum extraction and cesarean delivery. Performing a c-section because you personally think it is the safest legal option is not practicing informed consent.

About my surgical diagnosis which was discussed: I was surprised to learn that 85% of the cesareans your practice does are for cephalopelvic disproportion. Dr. G. stated that the obesity of women in Kentucky justifies a 20% section rate at Happy Moron. This doesn't make much sense because the c-section rate all over the country is at least 20%. Also, a woman's weight has little to do with her ability to give birth vaginally.

Dr. G. stated that increasing fetal weight has caused the increase in CPD. As I responded before, the actual average birth weight has only increased by a couple of ounces over the past thirty years. It's interesting that midwives see CPD less often than doctors do. Elizabeth Davis, author of Heart and Hands, states that she has only had one case in her practice. Ina May Gaskin, head midwife at a community in Tennessee, rarely sees this problem. Over 24 years, the c-section rate there was only 1.8% with infant mortality of 6/1,000. Everyone has emphasized how "big" Zac was at 8 pounds, 11 ounces. While I'll agree he was not tiny, he certainly was not huge. Also, as far as the size of babies contributing to the increased diagnosis of CPD, this same phenomenon is not occurring in other industrialized countries with similar populations. Many European nations have lower infant mortality rates than ours along with lower cesarean rates. How can this be accounted for?

It appears to me Dr. G.'s comments that the legal climate of our country is a big part of the problem hit the proverbial nail on the head. I was amazed to learn that had Dr. G. been on call, I would not have been "allowed" to go beyond two hours in second stage. I was never informed during prenatals that there was a time limit for second stage dictated by the "standard of care." Dr. G. mentioned studies showing there are problems for babies who are born after more than two hours of pushing. To what specific studies did he refer? Studies show that in deliveries complicated by dystocia, maternal mortality is several times higher with cesarean sections than with vaginal births. I find it hard to believe that prolonged pushing by itself is more dangerous to baby and mother than a cesarean section.

I will be direct: I think you and Dr. G. should ask yourselves why you see cephalopelvic disproportion in 16% of all women (19% c/s rate at Happy Moron x 85% of c/s for CPD). Could it be because you are not allowing women enough time to push their babies out, and because women are not being helped to get their babies out by pushing in alternative positions, the pelvic press and similar non-interventive measures? When I mentioned these alternatives in the meeting, nobody responded to me or explained why they weren't used. When you know of other options, it is wrong to continue to do sections on women first.

I would encourage you to examine the beliefs that drive the obstetrical system in our country and to determine what you can do to make it better. I think the legal issues which Dr. G. addressed during the meeting are the actual problem I faced. He said you feel pressure to "deliver a perfect baby" or get sued. I am sympathetic; however, it's possible to have good outcomes for both mothers and babies, rather than doing anything and everything to the mother in the name of the "perfect" baby. For example, look to the midwifery model of care which has been proven to provide good outcomes, the Frontier Nursing Service of rural Kentucky a case in point. Look to countries like the Netherlands which have a low infant mortality rate and a low cesarean rate.

In closing, the complaints I had with your practice and with Happy Moron are as follows: I was not treated in a compassionate way during second stage or surgery. I was not informed of the real reasons procedures were performed upon me. I was never, at any time, informed that legal concerns had any bearing on my medical care, but this is exactly what happened when I "ran out of time" for pushing. You may think it is acceptable to practice in this manner, but I think it is wrong to tell a woman her only option to deliver is a cesarean section, and then admit two years later that there were any other factors in the decision making process.

I know much of what I have to say is hard to take, as I am questioning what you believe as a doctor. However, please know, I am not questioning your intentions toward your clients. I believe that you care about your clients and want to provide them with the best possible maternity care available. I am simply questioning how you go about it.

With this letter I will enclose a copy of the CIMS document for the Mother-Friendly Childbirth Initiative, and a post from a midwife about a labor with a long second stage which I thought you might find informative. Thank you for your time at the meeting and during the conversations we have had over time.

Sincerely,
 

Jennifer L. Griebenow

Enclosures

cc [Many appropriate people]

This is the cover letter I sent to the hospital CEO along with his carbon copy of the letter to the OBs which I already shared with you all. Maybe I shouldn't share this, and maybe I was too harsh and maybe I'll regret saying what I said when I see the man on the street ten years from now. But I don't know....I guess I felt compelled to get his attention and I probably did it too harshly.

Dear Mr. X:

I am writing to thank you for attending the meeting called June 30th to discuss the birth of my son at your hospital. I greatly appreciated your willingness to be there. Though I was glad to utilize that opportunity, I do not feel it lived up to its potential for several reasons, which I enumerate fully in the enclosed letter I recently sent Dr. S.. Briefly, my continuing research into the answers I received at the meeting has shown me that the statements that epidural anesthesia was not an option because of fetal distress and monitoring problems and that I was constantly monitored with EFM during my experience were both false. This makes me seriously doubt everything else that was said in that meeting, since your staff told me these lies with straight faces. Frankly speaking, as far as I can tell, my best interests have never been served by your staff and the truth has never been spoken from the time of my son's birth to the present.

Also, I am concerned that you find a 20% cesarean rate to be indicated! Other countries with comparable populations have lower cesarean rates and better infant mortality rates, and you cannot be unaware of the greater risk of death a mother faces with a cesarean. So where's the benefit? Is 20% acceptable purely because you think it keeps your lawsuit risk low and cash flow high? I ask this because you said nothing whatsoever to indicate that you were concerned for the women who undergo this surgery.

Thirdly, the attitude of everyone in the meeting struck me as odd. It appeared that the staff felt that you were doing me a big favor to talk with me. On the contrary: I am your customer. I did YOU a big favor coming to your hospital, not the other way around. I didn't come to the door of Happy Moron begging to be let in; I came because I thought I would get personal and professional midwifery care. Instead I got nurses performing doctor's orders. Doctors are not gods and they do not have the right to make decisions for their patients, as Dr. G. seemed to imply when he stated that he did not have to justify his choices in the records. I hope to see all these areas change in the future.

Sincerely,
 

Jennifer L. Griebenow

Enclosures

Sympathetic Response from Someone about Similar Circumstances

One of the midwives (MH) that I work with was doing a hospital labor support yesterday. It had been going on forever, first at home, and then in the hospital. Finally broke her water, which she probably needed, and then pit. Finally she pushed. I am not sure how long, but a long time.

MH made friends with the nurse, who was wonderful. The nurse was coaching the pushing. She asked MH for help, and she allowed MH to glove up.

MH discovered that the baby's head was right inside -- a +4! She was ecstatic--told the parents that they were indeed going to have a vaginal birth -- all was well -- etc. About that time the resident and a neonatologist came in, and the neonatologist examined the mom, and said she had been pushing too long, and that the baby's head was just caput. "How would you feel about a cesarean section?" she asked. The family was devastated, the father cried. MH, who is very soft spoken, and sweet as the day is long, turned around and said "Excuse me, but she is about to give birth!" The doctor said that she would wait a little while, and MH got them to say that they would give them 30 minutes. She then got up on the bed, put the mom's knees in her armpits, (which we use a lot, to get a baby down fast), and did some "fingers forceps" kind of pushing on her vaginal wall. (which she learned from me, because I do that a lot, during a long pushing stage) 30 minutes later, when the heart tones were really going down because of head compression, the docs came back in -- but they were too late -- she was crowning! MH took off her gloves before they saw her, and got out of the way. The doctor made a rude comment about preparing for a shoulder dystocia, because she thought that if they had worked that hard to get the baby out that it would be stuck. Doctor said "This is a big baby."

MH said "No, it is NOT a big baby!" and the baby was born -- 6 1/2 pounds, over an intact perineum. This was at IU med center in indianapolis--one of the most medical hospitals in the state. These nice people would absolutely have had a cesarean had it not been for MH.

She was with them 28 hours, during which time her little 6 yr old daughter witnessed a car accident that her friends were in, and which killed the driver of the other car. MH stayed with her clients instead of going to be with her daughter.

This is how your birth could have been, had you not had doctors and CNMs who were so worried about legal ramifications -- What happened to you was terribly unfair -- I hope that you can plan for a nice birth next time -- now.