dr. adam wolfberg is an obstetrician, a runner, and a writer.

Deciding to operate: the danger of certainty

This is what happened: a woman arrived at the hospital where I practice with contractions. She thought she might be in labor, although an examination would prove she was not. She felt well, had no other complaints, and her vital signs were normal, including her temperature, which was 98.6F. However, on the monitor, her fetus’ heart rate was 180-190 beats per minute, significantly above what is considered normal for a full-term fetus. The on-call obstetrician recommended a cesarean, which we performed expeditiously and without complication. A vigorous, crying baby boy emerged, did well, and went home with his mom four days later. In the O.R. following delivery, heartfelt congratulations were offered to the nurses and doctors for avoiding a bad outcome: we were confident we had saved the baby.

I’m not saying we made the wrong decision, and I’m not saying we didn’t save the baby. We may have. What concerns me is the confidence that surgery at that time was the right decision.

An elevated fetal heart rate - tachycardia - is not normal, and when the mother is full-term, the baby should be delivered. The most common cause of fetal tachycardia is an infection in the uterus, although other explanations such as a low fetal blood count, a heart arrhythmia, or endocrine disorders are among other causes.

The standard of care is delivery, although the recommended method of delivery is not so clear cut. One option is cesarean, which is the fastest way to get the baby out. The other option is to induce labor with medication, which takes much longer, but can potentially avoid mom having a major abdominal surgery.

The challenge is the time required to get from the beginning of an induction of labor to a vaginal delivery.

Put yourself in the shoes of the mom, the dad, and the nurses and doctors taking care of the mother and fetus and collectively deciding what to do: If you choose induction of labor, and six or 12 or 24 hours later the baby boy is delivered vaginally and mom and baby are healthy, you will know you made the right decision. However, you won’t know that for many hours. Meanwhile, if signs of trouble emerge during labor, or worse yet, mom or baby are not fine after delivery, you might regret the decision not to operate for the rest of your life.

Alternatively, if you choose cesarean, and the baby is not fine, you know you did everything you could possibly have done to assure a good outcome. In our case, the good health of both mom and baby reinforced that decision enormously.

What goes unconsidered is that cesarean is more dangerous for the mom than a vaginal delivery, and that she will likely have a cesarean with each subsequent child. This is one of the reasons why maternal death rate in the United States is actually rising.

No obstetrician knows with certainty after performing a cesarean that they made the wrong decision because it’s impossible to know what would have happened if the woman was allowed to go through labor.

As a consequence, choosing labor, or allowing labor to continue when signs of health - particularly fetal health - are equivocal, is always the riskier choice.

It bears remembering that a cesarean with a good outcome doesn’t make cesarean the right choice.

In this case, it isn’t the decision to operate that gives me pause; it’s the confidence that it was the right choice.

Is your hospital ready to induce most patients' labor?