C-section Primer for Writers

Today, Heidi Creston gives some nursing insight into the world of obstetrical nursing.

Welcome, Heidi!

STAT Sections, TOLAC, VBAC, Let’s think about all that . . .

STAT C-sections definitely give your story drama, critical hysteria in some cases, just what you need to keep your readers turning pages except . . .

The patient who has had only one prior cesarean section for an indication that no longer presents itself in her next pregnancy may ask the physician for a trial of labor termed trial of labor after cesarean section or TOLAC. For example, if her first baby was breech but the second baby is not. These patients that deliver vaginally are then referred to as successful VBAC (vaginal birth after cesarean section). The patient, however, will undergo a TOLAC for each succeeding pregnancy thereafter.

Midwives, physicians assistants, and nurse practitioners cannot manage the care of these patients alone. There must be a physician present during the labor process. It is important to note that the physician has to agree to the TOLAC. If the doctor does not agree to it then it is the patient’s responsibility to find another physician who will. Some physicians do not carry the insurance for TOLAC or VBAC. There are some states and countries that do not offer TOLAC or VBAC option regardless. Some hospitals do not carry TOLAC or VBAC insurance due to the maternal risks and expenses associated with these procedures. If you’re writing a novel set in a real life state, city, and or hospital with this type of scenario then it would be important to check out these specifics for those locations.

The first thing writers should keep in mind is that cesarean sections are major abdominal surgeries. There is nothing lackadaisical about it. Given that information, any time a muscle in our bodies is cut, torn, or otherwise altered, that muscle is weakened permanently. During a cesarean section the abdominal muscles are both cut and then torn. The uterus is also a muscle. The physician cuts into the uterus in order to remove the baby.

There are two commonly used incisions: Lower Transverse (aka the bikini cut) and the Classical Incision (aka the T-cut). Lower Transverse is the preferred, most common and least damaging of the incisions.

The uterus can develop a uterine window, a fragile site on the uterus that can lead to medical emergencies for the mother and baby. Partial and full abruption of the placenta and ruptured uterus are the most lethal and common complications associated with TOLAC and VBAC procedures.

An abruption is when the placenta dislodges from the uterine wall prior to delivery. In this case, without emergency intervention (imminent birth or emergency cesarean section), the baby will die.

A ruptured uterus is a breakdown of the uterine wall, in which case both mother and baby are at risk for sudden death. Cesarean sections leave the uterus in a compromised state. The more c-sections a patient has, the more compromised the uterus is, which leaves the patient more at risk for abruption and or rupture.

In my experience, patients having had two or more cesarean sections, regardless of the indication, a TOLAC or VBAC are not an option. At this point the risks outweigh the benefits. This risk is so prevalent neither the hospital nor the physicians are willing to accept that responsibility. The physician and hospital will go to great lengths to explain the risk associated with a TOLAC to the patient.

Ultimately the decision is up to the patient. The patient can go against medical advice. Proper paperwork must be filled out indicating that the patient is cognitively aware of their decision and understands the risks involved. The physician and hospital can also file a legal petition to a judge concerning the patient’s decision.

What plot scenario can you think of using these guidelines that will still have a lot of conflict?

C-section Primer for Authors. Click to Tweet.

*Originally published 4/25/2011.*


Heidi Creston is former military and married military as well. Her grandmother was a WAVE and inspired her to become a nurse. Heidi spent some time as a certified nursing assistant, then an LPN, working in geriatrics, med surge, psych, telemetry and orthopedics. She’s been an RN several years with a specialty in labor and delivery and neonatology. Her experience has primarily been with military medicine, but she has also worked in the civilian sector.

Author Question: Motorcycle Injuries

Tory Asks:

I’m currently writing a fan fiction and the two main characters get in a motorcycle crash. The female just found out she was pregnant. I have three (very unrelated) questions. Could the crash send her into cardiac arrest? Would the male (who was driving) be able to survive with just a broken arm and a sprained ankle? And would the baby survive?

Jordyn Says:

Hi, Tory. Thanks for sending me your questions.

1. Yes, a motorcycle crash could send someone into cardiac arrest.

2. Could the male survive with just a broken arm and a sprained ankle? Sure, this is possible, but I don’t know if it’s probable. When looking at accidents, medical people always look at the injuries of the other people involved to determine how serious everyone’s injuries might be.

If the female in the accident suffers a cardiac arrest, it would be surprising that the male walks away with just, essentially, a broken arm. You could make it more believable in the description of how the accident happens. For instance, the female is thrown from the bike, but the male is trapped underneath it. You could also have them differ in the type of protective equipment they’re wearing (helmet, jackets, etc.)

3. Would the baby survive? Again, it depends on a lot of factors. How far along is she in the pregnancy? Cardiac arrest— how long is she pulseless? What other injuries does she get in the accident? The sicker she is from her injuries, the more likely she will miscarry the pregnancy. The body will defer energy and resources to the mother over the pregnancy. Then again, some women have maintained a pregnancy through terrible injuries so you would have some leeway as an author here.

If the mother is far along in the pregnancy (at least 22-24 weeks along) and in cardiac arrest the providers might consider C-section to save the infant. So, without more details as to the nature of the accident, her injures and the state of her pregnancy, it would be hard to say if the baby would likely live or die.

Good luck with your story!

A Sad Story of Royal Obstetrics: Part 4/4

Today, JoAnn Spears concludes her fascinating observations on Queen Anne’s obstetrical history. I know that I sure learned a lot. You can find the previous installments of this series by following the links: Part I, Part II, and Part III.
Thank you JoAnn for such a wonderful look into this woman’s life.

Part Four: Was Diabetes the Cause?

Diabetes may be the most likely culprit in Queen Anne’s story. Her first three pregnancies went to term, and resulted in two healthy children. Statistically and fertilely, Anne, at that point, was par for the 17th century reproductive course. From there, though, things went terribly wrong.

The beginning of this downhill descent, 1687-88, coincided with the death of two of Anne’s daughters from smallpox. It also coincided with her father’s ascent to the throne and his loss of it during the Glorious Revolution. The familial loyalties and betrayals involved in this were deep and complex, and Anne was not a deep or a complex person. The compound stress must have been enormous. She was eating, and probably drinking, heavily. Might Anne have developed diabetes around the time of, or during, her 4thor 5th pregnancy?  Anne’s lifestyle was characterized by overindulgence. She was not very active; her preferred recreation was playing cards. She would certainly be at greater risk than most for developing diabetes during a pregnancy, and unconsciously fueling the diabetic trajectory with her personal habits.

Uncontrolled diabetes is associated with a host of poor fetal and neonatal outcomes. Unusually low or high birth weight, premature birth, cardiac or skeletal anomalies, neurological problems, cerebral palsy, lung immaturity with RDS (respiratory distress syndrome), and even intrauterine death are some of the sad set of possibilities that Anne may have run the gamut of. Unfortunately, medical descriptions of the babies Anne lost or miscarried are sadly lacking.

Diabetes is a progressive condition. Anne became increasingly obese and debilitated as she aged, bringing to mind her distant relative Henry VIII. Both Henry and Anne had pains in their lower extremities that prevented them from moving about well. This may have been peripheral neuropathy associated with diabetes in both of their cases. Anne and Henry also had chronic, non-healing leg ulcers, another diabetes symptom, in common.

As his desperate attempts to father sons were ended by his declining physical condition, the morbidly obese Henry VIII had lifts and other machinery devised to move his unwieldy body around. It’s said that Queen Anne had this machinery refitted for her own use as her own health began to fail. If it’s true, it’s an ironic footnote to the two saddest stories of infertility in English history.
JoAnn Spears is a registered nurse with Master’s Degrees in Nursing and Public Administration. Her first novel, Six of One, JoAnn brings a nurse’s gallows sense of humor to an unlikely place: the story of the six wives of Henry VIII. Six of One was begun in JoAnn’s native New Jersey. It was wrapped up in the Smoky Mountains of Northeast Tennessee, where she is pursuing a second career as a writer. She has, however, obtained a Tennessee nursing license because a) you never stop being a nurse and b) her son Bill says “don’t quit your day job”.

A Sad Story Royal Obstetrics: Part 3/4

JoAnn Spears continues her series on Queen Anne’s very interesting obstetrical history. You can find Part I and Part II by following the links.

Part Three:  How could this happen?

One or more of the following conditions may have played a part in Anne’s hauntingly tragic obstetrical history.

Rhesus incompatibility occurs when an Rh positive baby is carried by an Rh negative mother.  The pattern with this condition, untreated, is one of normal initial pregnancy or pregnancies, followed by miscarriages and stillbirths in a progressive pattern. A normal later pregnancy, while statistically less likely than a problem one, could occur if an Rh negative child were conceived; perhaps young William of Gloucester was such a child.

Chronic Listeria infection is also congruent with Anne’s reproductive clinical picture. Listeria is associated with improperly handled cheeses and meats, and food safety in Anne’s day and age was sadly lacking. She ate, however, what everyone else at her court ate, in quality if not quantity. A coinciding rash of female infertility in the women of Anne’s court is not reported.

Cephaolpelvic disproportion occurs when a mother’s birth canal is too small to accommodate delivery of the largest part of the fetus, its head. Some believe that Anne’s anatomy may have had something to do with her troubles. A later Stuart descendant, the wildly popular Princess Charlotte, fell victim to this condition. She died after three days in unsuccessful labor with her first pregnancy.

Medical records from Queen Anne’s physicians are maddeningly vague. It is unclear if young William of Gloucester developed hydrocephalus shortly after his birth, or if he was born with an abnormally large head, or macrocephaly, to begin with. A spontaneous, unidentified congenital or genetic syndrome may have caused this symptom, and affected other of Anne’s babies. Interestingly, the hemophilia that the later Queen Victoria would introduce into Europe’s royal houses was probably caused by a spontaneous genetic aberration in Victoria.

Anne’s obstetrical history and her physical attributes, specifically her obesity and red, round face, are congruent with Cushing’s Syndrome, a hormonal imbalance. However, Cushing’s is associated with menstrual irregularities. One of the few clear, objective medical statements we have about Anne comes from a physician who commented that, even when she was in her 40s, her menstrual cycle was as regular as that of a twenty year old.

Systemic Lupus Erythematous, or SLE, was discussed in Part Two of this series. It can lead to issues with fetal health, but statistically not to the extent that this occurred with Anne. Flare ups of poor maternal health would be more expected.

Porphyria was the cause of the madness of the post-Anne monarch, King George. Certainly, the catch-all term ‘gout’ would have been used by Anne’s medical men for the painful symptoms of porphyria’s metabolic derangement. However, Anne’s symptoms seem to have been more of a chronic nature than those of poor King George, and she was not emotionally labile.
JoAnn Spears is a registered nurse with Master’s Degrees in Nursing and Public Administration. Her first novel, Six of One, JoAnn brings a nurse’s gallows sense of humor to an unlikely place: the story of the six wives of Henry VIII. Six of One was begun in JoAnn’s native New Jersey. It was wrapped up in the Smoky Mountains of Northeast Tennessee, where she is pursuing a second career as a writer. She has, however, obtained a Tennessee nursing license because a) you never stop being a nurse and b) her son Bill says “don’t quit your day job”.

A Sad Story of Royal Obstetrics: Part 2/4

JoAnn Spears is doing a four part series on Queen Anne’s obstetrical history. It’s very fascinating. You can find Part I here. Part III here.

Part Two:  What happened to Queen Anne?

A health history marked by seventeen or eighteen pregnancies and no surviving children staggers the modern mind, but it is only one part of the medical history of Queen Anne the Good.
In terms of childhood health, Anne was probably like she was in so many other ways–middling. She survived smallpox. She suffered from some sort of eye ailment, described as a defluxation, or preponderance of tears. It sounds like a fairly minor problem, but apparently was concerning enough for the child to be sent to France for treatment at a time when travel could be dangerous.
The young adult Anne was healthy enough to marry at the usual age, and by all accounts thoroughly enjoyed conjugal relations. Married in 1683, she was pregnant pretty much annually until 1700.
Anne’s obstetrical history is variously reported. It appears her first child, a girl, was stillborn. Her next two children, daughters, were born healthy. Unfortunately, smallpox claimed both daughters within days of each other when they were tots.

Three unsuccessful pregnancies followed. Then, in 1689, William, Duke of Gloucester, was born, and survived.

Baby William, according to medical report and portraiture, had a large head. Possibly, he had hydrocephalus, or fluid in the skull. Nowadays, hydrocephalus can be effectively treated with surgical shunting, but that was not the case in Queen Anne’s day. Brain damage of some kind would be expected.
Some sources describe young William as delicate and backward; others describe him as quite a clever child. He clearly had difficulty with balance, walking, falling down, and getting up. This was attributed by his caregivers to his disproportionate head size. It is worth noting, however, that Anne’s grandfather, Charles I, walked at a very late age, and only after his weak and rickety legs had been braced.
William’s birth was followed by at least ten pregnancies (one with twins), all resulting in miscarriages or stillbirths. Sadly, William of Gloucester eventually died in adolescence of pneumonia, leaving Anne childless.
Around the time Anne’s pregnancies ceased, other physical infirmities began. Gout was one of them. Nowadays gout refers to a specific metabolic problem that affects particular joints. In Anne’s day, it was a catch-all term for pain. Her ‘gout’ sounds more to modern medicine like migratory arthritis or arthralgia, pain making its way all around the body, caused by an autoimmune condition such Systemic Lupus Erythematous (SLE). Anne is reported to have had the facial redness or rash associated with such disorders.
Anne’s was also morbidly obese. She liked her food and drink, and was aided and abetted in overindulgence by her like-minded husband. Her being nicknamed ‘Brandy Nan’ at a time when a degree of abstemiousness was expected in women hints at the possibility of actual alcohol abuse or alcoholism.
Anne’s weight and debility necessitated her being toted to her coronation in a litter in 1702. She was unable to walk much on her own.
Anne died in 1714, a martyr to her ill health. She had become so overweight that her coffin was described as almost square; it required fourteen men to carry it. A contemporary commented that no sufferer would covet their rest as much as Anne would.
Surely, Anne’s phantom children–possibly as many as twenty of them–were on her mind at the very end. What was it that had made her reproductive history go so very tragic?

JoAnn Spears is a registered nurse with Master’s Degrees in Nursing and Public Administration. Her first novel, Six of One, JoAnn brings a nurse’s gallows sense of humor to an unlikely place: the story of the six wives of Henry VIII. Six of One was begun in JoAnn’s native New Jersey. It was wrapped up in the Smoky Mountains of Northeast Tennessee, where she is pursuing a second career as a writer. She has, however, obtained a Tennessee nursing license because a) you never stop being a nurse and b) her son Bill says “don’t quit your day job”.

A Sad Story of Royal Obstetrics: Part 1/4

I’m so pleased to host JoAnn Spears again. Her nursing musings on the medical ailments of some famous and not so famous royals has been a real crowd pleaser. In this series, she focuses on Queen Anne the Good and her very interesting obstetrical history. 
Personally, I found this fascinating.
Welcome back, JoAnn!

Part One: Who was the woman this happened to?

By the time Queen Anne the Good ascended the throne of Britain in 1702, she had been pregnant a remarkable seventeen or eighteen times. She died, twelve years later, childless. What was this remarkable woman’s story?

Part One: Who was the woman this happened to?
Henry VIII is the British monarch most associated with serious fertility issues. The failure of his first marriage to produce a surviving son led to the English Reformation, the execution of Ann Boleyn, and ultimately, six marriages. Henry in his youth was tall, healthy, vigorous, athletic and intelligent. In old age, he became markedly corpulent.
Queen Victoria is the monarch most associated with royal fecundity. Her nine pregnancies produced nine children and made her, through carefully orchestrated intermarriages, ‘The Grandmother of Europe’. Unfortunately, Victoria also appears to have been the point at which the hemophilia gene entered Europe’s royal houses. Victoria, like Henry VIII, was obese in later life.
Pretty much midway between these two extremes of royal fecundity, Britain was ruled by a queen named Anne, known as ‘the Good’. She is little remembered today. As a study in fertility and infertility, Ann deserves to be better remembered.

Ann was a Stuart, a descendant of the Tudors and of the romantic Mary Queen of Scots. Her father and mother were controversial figures. James II seems to have been always out of step. Anne’s mother, Ann Hyde, was a non-royal that James married, typically, against absolutely all advice. When Ann Hyde died–corpulent– in 1671, she had experienced eight pregnancies and left behind two living children.

The ‘good’ moniker is probably the best description of Anne as a child and young woman. In looks and intellect, it’s most likely that she was pretty average. She was a good and serious English Protestant. Her father, out of step as usual, was not. This political liability led to his losing his throne and to the reigns of Anne’s brother-in-law and sister, William and Mary. When Mary and then William died, childless, Anne ascended the throne.
At an appropriate age, Anne had married an appropriate young man: Prince George of Denmark, a cousin once removed. They were married for about twenty-five years and were a devoted couple. George seems to have been a lot like Anne, both unexceptional and unexceptionable. The wittier members of the English court found him boring, joking that the loud breathing caused by his asthma was the only way they had of knowing that he was actually alive.
Anne’s reign lasted from 1702 to 1714. It was notable for being the time when the two-party system emerged in British politics. It was also notable as a time when female friendships had more of an impact on government behind-the-throne than romantic alliances did. Anne’s friend Sarah Churchill, a distant relative of the modern Princess Diana, was a key political player of the day.
Anne’s obstetrical history was over and done with by the time she became Queen. The year 1700 had seen her final pregnancy. That pregnancy had been preceded by another sixteen or seventeen. The number of living children she had when she ascended the throne–sadly, and almost unbelievably to modern minds–was zero.

JoAnn Spears is a registered nurse with Master’s Degrees in Nursing and Public Administration. Her first novel, Six of One, JoAnn brings a nurse’s gallows sense of humor to an unlikely place: the story of the six wives of Henry VIII. Six of One was begun in JoAnn’s native New Jersey. It was wrapped up in the Smoky Mountains of Northeast Tennessee, where she is pursuing a second career as a writer. She has, however, obtained a Tennessee nursing license because a) you never stop being a nurse and b) her son Bill says “don’t quit your day job”.

Ectopic Pregnancies: Dr. Tanya Goodwin

Today I’m going to talk about ectopic pregnancy. An ectopic pregnancy really means any pregnancy not in the uterus. Mostly this refers to pregnancy in the fallopian tube or tubal pregnancy.

The uterus has a fallopian tube attached to each side. At the end of each fallopian tube are delicate fingerlike projections called fimbriae. These fimbriae function to catch ova (eggs) released from the ovary and help transport the egg(s) down the tube and into the uterus. Sperm actually meet the ovum (egg) in the tube. The resulting early embryo is then wafted down to the uterus where implantation normally occurs. Tiny little hair-like structures inside the fallopian tube called cilia beat rhythmically, also moving the embryo along the tube. If the embryo gets stuck along the way then an ectopic/tubal pregnancy occurs. The embryo grows in the narrow tube until the tube can no longer accommodate it. The tube then ruptures, causing bleeding into the abdomen.

An opened oviduct with an ectopic pregnancy at about 7 weeks gestational age. Wikipedia
Symptoms of tubal pregnancy include missed period (which may be a short irregular one), spotting, and pelvic/abdominal pain. The pregnancy test will be positive. OB/GYN’s specifically look at the blood (serum) pregnancy test result called a beta HCG. This result is typically abnormally low compared to a healthy pregnancy in the uterus. Normally this value, early in pregnancy, should double every 48 hours. If these values do not double appropriately, then a tubal pregnancy is suspected.

If a woman presents with a positive pregnancy test, a tender distended belly, low blood pressure, and rapid pulse, then she must be taken for emergency surgery as blood from the ruptured tube is spilling into the abdomen resulting in shock.

Most of the time, this scenario is not that dramatic. There may be blood leaking from the end of the tube, or the tube may not have ruptured. If caught early enough by pelvic ultrasound, and if the tube hasn’t ruptured, then the tubal pregnancy can be treated medically with Methotrexate. This is an anti-neoplastic medicine (meaning killing growing cells) that is injected into a muscle (ie usually buttock/hip). This hopefully should kill (dissolve) the ectopic pregnancy. Given the appropriate conditions, Methotrexate works well. The pregnancy hormone levels must be watched carefully until they decline to zero. Occasionally a second dose is needed. Sometimes Methotrexate fails and surgery to remove the tubal pregnancy is necessary.

Surgery for tubal pregnancy can involve removing the part of the tube affected if it is ruptured (salpingectomy). If the rupture is slight or not at all, then the tube may be surgically slit open, the ectopic pregnancy scooped out, and the tube heals over time (salpingostomy). These surgeries are usually done laparascopically.

Any woman having a tubal pregnancy is at risk to have another tubal pregnancy in the future. We tell these women to be checked out early the minute they know they are pregnant.

Risk factors for tubal pregnancy are previous tubal pregnancy, scarred tubes from tubal infections, endometriosis (also can scar tubes), smoking (causes the cilia to not beat properly, and previous tubal ligation (sterilization by tying tubes, burning them, or placing special clips/rings on tubes). Tubes can re-cannulize or grow back together. Also assisted reproduction such as in vitro fertilization (IVF) can increase the risk that the embryo can migrate up into the tube.

More rare and extremely dangerous ectopic pregnancies include cornual ectopics (getting stuck in the junction where the tube inserts into the uterus), cervical ectopics (in cervix), and pregnancies inside the abdomen. These pregnancies can get very large and when rupture occurs it can cause extensive blood loss.
Tanya Goodwin is an obstetrician/gynecologist and a novelist of romantic suspense with slice of medicine. She enjoys sprinkling unusual medical conditions in her writing. A character in one of her novels has the misfortune of contracting necrotizing fasciitis, and in her debut novel, If Memory Serves, due for release in November by Knight Romance Publishing, her main character, Dr. Tara Ross has dissociative fugue, a rare disorder as well. You can find out more about Tanya at www.tanyagoodwin.com