Tuesday, April 17, 2007

The Way We Give Birth, Part III

Last week on L&D, a crusty old doctor (which my school seems to keep in large supply) sat us students down for a little chat.

"You ladies all want scheduled inductions these days. In private practice, around 90% of childbirths are induced, and that's a good thing. We induce in the daytime, when the hospital's full, so it's safer. We have cervical ripening agents for an unfavorable cervix. If you want to induce your baby on a particular day, why not? I'll check the cervix--if it's too unfavorable, I won't do it, but if a patient comes in at term and her cervix has changed, I'll go ahead and schedule her induction. And if we schedule labor, especially during the day, I can attend more labors. I probably attend over 90% of my patients' deliveries.

"Did you know childbirth is the only type of pain that a doctor is allowed to withhold pain medication for? It's true. For any other pain as intense, a doctor would be committing malpractice to withhold pain medication. That whole 'natural childbirth' thing? Nonsense. All that Lamaaze crap--it doesn't work. I'm so glad that fad is over. Childbirth hurts! Epidurals are good!

"I don't see why labor is different from any other medical condition. We control our blood pressure, we control our cholesterol--now we control childbirth the same way."

I thought it was interesting to hear these viewpoints, as the other student and I had spent a good part of our time on L&D discussing alternatives to medical birth. Both of us had felt somewhat alienated by the medicalization of the whole process, but neither of us had really heard a justification for the medical attitudes. I was especially surprised to hear him admit that OB's schedule deliveries for their own convenience--he not only admitted it, he reveled in it. If you're going to be a medical OB, it's not a bad idea to be like this guy. Be passionate.

Nevertheless, I couldn't help but be turned off by his little speech (which went on for probably half an hour--I've abbreviated a good deal). He simply assumed that all patients would agree with this mindset, and he basically brushed aside any concerns--I know what's best, honey.

I'm turned off by the prevailing mindset in medical obstetrics, but I'll admit to being frightened of going totally the other direction. I've seen several stat c-sections where things were going fine and then BAM! prolonged decelerations of fetal heart rate, or cord prolapse, or shoulder dystocia, etc.

The reason we don't all give birth at home in comfort is that we've all heard a horror story from our mom, our aunt, our grandmother about the "bad old days". Despite the fact that our maternal and baby mortality rate is high for an industrialized nation, it's still better than it used to be. In the 1930's, up to 1 in 150 mothers died as a result of pregnancy. Now, fewer than 1 on 10,000 mothers die. We've come a long way.

I think one problem is that we don't really distinguish between low and high risk pregnancies. Sure, we talk about the difference between the two, but at my hospital, we strap them all to a continuous fetal heart monitor. Therefore, the difference is blurred for me; in looking back, it's hard to tell which pregnancies were high and which were low risk because they were all treated the same until fetal distress ensued. Thus, it's hard for me to remember which ladies were higher risk prior to delivery and then had trouble with delivery, as opposed to ladies who had no indication of trouble and then ended up with an unexpected complication.

Atul Gawande's new book, Better, has a whole chapter devoted to the history of obstetrics, the development of the forceps, and the rise of the current medical aura. He attributes a lot of it to the need to "standardize" OB. Only a highly skilled doctor may successfully use the forceps; almost any obstetrician can use a vacuum, or perform a cesarean section. In the right hands, forceps are as safe or safer than c-section; in the wrong hands, they are quite dangerous. In the interest of saving all babies, no matter the skill of the doctor, birth has become more standardized. It's an interesting viewpoint.

At the end of all this rambling, I've reached some temporary conclusions about the way I want to labor. Home birth scares me, because of my innate fear of something going wrong emergently, STAT, that requires medical intervention. Fully medical birth is distasteful to me. I think if I were to have a baby tomorrow, I'd probably try to find a doula to assist me in labor at a hospital. I'd like to try to do without the epidural, or at least put it off for a while. If my labor is progressing well, I'd like to avoid pitocin and artificial rupture of membranes. I'd like to get up, walk around, use a birthing ball, use the restroom without help, etc.

However, out of cowardice, I'm hedging my bets. Instead of fully trusting my birth to a midwife, at home, I'm trying to have my cake and eat it too. I'm also leaving myself plenty of room to eventually change my mind in either way as I get more information--hence "Part III" instead of "Conclusion". And, like the lady in Better, who ended up having a c-section after extremely protracted labor and arrested descent, I'll get over it if I can't have everything I want, so long as I'm home with my baby eventually.

No, I'm not pregnant. No, I'm not planning on becoming pregnant any time soon.


frectis said...

However, out of cowardice, I'm hedging my bets. Instead of fully trusting my birth to a midwife, at home, I'm trying to have my cake and eat it too.

I wish you wouldn't have said that. I don't think for a second that there is any one way of giving birth over another and certainly don't think that whatever you envision for your future baby's birth in a hospital is at all a cowardice act of hedging your bets.

The main reason I want to continue my education and become a CNM, aside from the fact I'm too old and math challenged for med school, is I can provide assistance for births in all three settings. I can order up an epidural in the hospital or catch a water baby at home. I don't think it has to be one way or the other. Hospitals don't suck, it's the administration that does. I have not been "raised" in midwifery to believe that it's "us versus them" like so many have.

FWIW the old geezer who lectured "you ladies" is nice to blame the women on the desire for elective inductions. It's great he gets to attend 90% of births but what does that mean? Are they getting any more attention from him than when they spontaneously give birth at 3am? Probably not.

I can personally attest to the importance of being good at forceps: I have a nice gash in my cheek bone from birth. My dad told me the doc said it would fill out over time.

Tiny Surgeon said...

He was quite the old codger, indeed.

I just wish the whole issue weren't so apples versus oranges. I wish more OB's were like MWWAK and more midwives were like you, Frectis. And so long as old codgers like this guy hold forth, compromise is going to be long in coming.

Midwife with a Knife said...

If I ever get pregnant. If I don't develop some terrible high-risk complication, I want to have a midwife managed pregnancy/delivery at a hospital where I can have the option to have an epidural, and have interventions limited to ones that are really necessary for me and my baby (or ones that I really really want!). I want intermittant monitoring. I want to walk/bathe/shower/eat (ok, most people don't really eat.. but being npo in labor is ridiculous) during labor. I don't want to deliver in stirrups unless I need forceps. I want to hold my baby immediately after birth. Skin to skin. No pediatricians unless there's a problem. I want the cord clamping delayed for ~30 seconds to give the baby more of the blood volume it probably needs.

Mostly, I just want a healthy baby. But I think that all of those things above help with this.

frectis said...

but being npo in labor is ridiculous) during labor

The docs at OB/GYN.net are loosely discussing this. The majority of those speaking up are in favor of NPO "in case" of GA for a c/s. There is an anti-homebirth blog (I'm not linking her karma to your blog; google her for curiousity) doctor who insists there is no harm in NPO and no benefit to allowing food/drink. She mostly thinks it's selfish of women to want to eat and drink in labor at the risk of their babies "in case" they need a section. And that insisting on eating/drinking is a classic act of defiance against medical advice and science.

FTR I don't restrict it but find women naturally restrict themselves as labor gets underway.

Tiny Surgeon said...

Can't they do rapid induction of anesthesia in case of a stat c-section if the mother ate? I hardly see how it is selfish of the mother to eat to sustain herself (and the baby!), especially if her labor is early enough that she still wants to eat.

I just wish a) there was more overlap at the hospital I was at and b) more women were better informed about their choices.