Wednesday, April 11, 2007

The Way We Give Birth, Part I

Currently, on my L&D rotation, I’m watching some of the best of medical obstetrics. Patients are actively managed throughout labor; OB’s break their water, start pitocin, consult anesthesia for epidurals, examine their cervixes every 2 hours, monitor the baby and contractions, and deliver the baby, repairing any lacerations that occurred along the way. I’ve seen a vacuum extraction and at least two forceps deliveries, as well as a cesarean delivery. We routinely induce labor in up to four patients per day, placing cervical ripening agents to make an unchanged cervix respond.

We deliver babies in head to toe sterile blue gowns, sometimes with face shields and booties. We drape the mother in sterile blankets, break the bed down, put her feet in stirrups, and place a plastic bag under her bottom to catch the mess. After the baby is born, we stand to deliver the placenta into a plastic bucket and repair any lacerations while the pediatricians examine and wipe down the baby. Often, mom is holding conversations with family members while we are trying to repair her perineum. Fortunately, most (all?) of these women have had epidurals, so they can’t really feel us stitching. Eventually, baby comes back to mom, we finish stitching, and someone wipes all the mess off, dries her off, puts the bed back together, and covers her back up.

It’s an entirely medical, sterile process, until mom starts to push. When she grabs her thighs, puts her chin down, and really pushes, I’m reminded of what an ancient process this really is. Then, I start to ask questions. How much of our “active management of labor” is really meddling with a natural process? How much are we really helping? Do we help more than we hinder, or vice versa?

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Most of my mothers labor flat on their backs. Gravity isn’t allowed to assist them; at best, their bed is tilted slightly above horizontal. The bed is often raised 3+ feet off the ground, to make the angle better for the OB. So why can’t we change the angle for the mother? Women for centuries gave birth standing in a squat—it seems the least we could do is give these ladies some gravitational force.

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I have not yet attended a labor without an epidural. I have nothing against epidurals; I’m seriously considering one when I have babies. I’ve seen many mothers say “Wow, I could really push—I wasn’t tired at all!” I also have not seen any latching problems that I could say were directly related to the epidural; I would venture to say that we do not encourage immediate breast-feeding enough, which probably has a large impact. The babies I’ve seen have all been quite alert. (I know I haven’t seen all that much; I’m only commenting on my experience.)

My only problem with our use of epidurals is that everyone has one. We have talked several women into epidurals who really didn’t want one. Sometimes, it’s medically indicated, but often it is not. I’ve seen several moms who really didn’t seem to need one, at least not early. Also, epidurals can cause complications (like everything else), and I'm not sure how well we really counsel patients as to the risks and benefits. But, I've never really seen a mom say "Man, I really wish I hadn't gotten that epidural," so maybe it's all worth it.

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As I briefly mentioned above, we do not seem to encourage immediate breast-feeding. Even in moms who say they wish to breastfeed, no one has returned a baby (after weights and Apgars) and suggested that she attempt to feed. It’s not a huge deal, I guess, but it seems logical that many breast-feeding problems may be avoided, or at least caught sooner, the sooner one starts to breast-feed.

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Almost every mother I’ve watched has had her labor “augmented” with pitocin. It’s an automatic reflex for the residents and attendings. “Start her on pit—I want to get her delivered before 5 so I can go to my meeting” is not an uncommon sentiment. Ladies on pit contract harder, so they have more pain, so they all have epidurals. Then, sometimes pit induces uterine hyperstimulation and fetal bradycardia, so they’re given terbutaline. I remember on internal medicine that someone told me you should try not to give a medicine to treat a side effect of another medicine, unless for some reason the medicine is absolutely necessary. Is all this pit necessary?

I guess I wouldn’t find it so problematic if the women were saying “I want pit—let’s hurry this up.” Instead, it’s usually the OB’s who are saying “let’s hurry this up.” There’s very little choice involved on the part of the mothers; I’d venture to say that most of them don’t realize they HAVE a choice.

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I guess my biggest problem is the attitude of the obstetricians. Most of the residents are fairly passionate; they enjoy delivering babies. When they’re on L&D, they have no other responsibilities—no clinic, no meetings. The attendings, however, are super, super busy. They’re lucky to make it to the deliveries of their patients, and they’re usually impatient. They come in when she’s pushing and they leave after the lacerations are repaired. The majority don’t seem too excited to be there; they’re usually in a hurry to leave.

I’m sure that childbirth can lose its excitement after a while. I understand that. It’s more the impatience that bothers me, this attitude that we should induce this lady or increase the pit in order to suit OUR schedules, not hers. I would venture a guess that the real problem, though, is simply the extreme busy-ness of the attendings. If they were less busy, there might be more time to come in and deliver, or they might be able to enjoy it more.

My grandmother told me once that she thought her OB had given her pain medication to delay the birth of my father so that he could go home. I actually don’t doubt her story, or at least that it happens.

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Is there an alternative to all this? There is: the midwife. In my next post, I’ll address what little I know about alternatives to medical birth (which, I'm sure, is not much, as I have not seen a single midwife or doula in my time in L&D).

6 comments:

frectis said...

:: sigh ::

That was as depressing a read for me as the urology news must've been for you. But I have to say it's not surprising from what I've experienced at the university hospital near me. The students/residents/attendings are always awesome but they are juggling so many things that routine makes it all easier.

FWIW I don't think urology is the easy way out especially if its something you are led to not just for the hours or money or whatever. I can't figure out what a man would dig about OB/GYN. I never saw a male OB/GYN who could look me in the eye, that's my turn off. Maybe I'm just too hot ;) LOL But the females have always focused in a different way. Sisterhood of the Vag and all ;)

Midwife with a Knife said...

That is sadly the state of birth in many places. I've really become a nag to the residents here. "Is she making progress in labor? Oh, you don't know yet? So, why'd you start the oxytocin, then?", and I try to tell them over and over again that every intervention, every medicine, and every procedure (including internal monitors) has some sort of risk associated with it; so you need to have an indication.

I was trained, at least partly, by midwives. I just loved the birth with the crying baby on the mom's chest, the father with the tears in his eyes.

We can't even do skin-to-skin here with the baby until after peds gets the baby. Which means that the cord gets clamped immediately (I'm actually a proponent of delayed cord clamping, too. A newborn needs a higher volume than a fetus because it has to perfuse the lungs, so if you can wait a few seconds to let some of the blood from the placenta flow back into the baby, it's probably a good thing).

Anyway, I totally agree with you. I'm all about pain control if people need it, and moms with epidurals can't move well and usually can't squat, but even a lot of them are more comfortable pushing on their side, or leaning over the head of the bed.

Sorry about that little tirade there. :)

the other med student on OB said...

i was actually waiting to see what you had to say about this midwife. tiny surgeon and i have spent much of the past 2 weeks discussing our distaste with 'active managment of labor' and how medical (not natural) the process of birth has become.

Chemgirl1681 said...

From personal experience I agree with your judgements about the state of births having experienced an augmented one a year ago at a "cushy" hospital. I was scared into the induction because the doctor said my pelvis was very small and at term she was guessing he'd be 8+ lbs and probably wouldn't fit. Then after telling me that asked what I wanted to do. Then with the induction I didn't feel like I had a choice when they broke my water (I had only dialated <1 cm after about 11 hr cervical ripening and around 5 hrs pit- and might I insert here that Pitocin is Hell on Earth!!!!!!). Then several hours after that my contraction we come on top of one another, Aidan's heartrate was dropping with the contractions, and I had INTENSE backlabor - oh and the epidural lasted all of 45 min! Then again I was asked what I wanted to do as I had not dialated any more.... I felt my options were to go insane from pain (I couldn't even focus to do breathing) or to have the c-section. Needless to say from this little rant I felt pretty helpless but atleast I have my beautiful boy!

dr. whoo? said...

As a resident, you are also at the mercy of your attendings' desires. I had one attending who had the largest volume of patients (he rarely saw them in pre-natal care, he had several NPs doing that) who wanted in by 7 and out no later than 6 so he could go home/party. If all of his inductions (usually at least 3 or more a day) were not ruptured and internalized (IUPC and FSE) before 7 am rounds, you got your ass blasted. By the end of residency, artifical labor, AROM, internals, and pit seemed like the "norm" instead of the exception. We were merely his bots.

It took some time to get out of that mindset, but now that I get to manage my own patients, my interventions (and inductions) have gone way down. I still have to race between office and OR and L&D, that's just reality. If I have inductions, I try to do them on my OR days when I am present in the hospital all day long. Funny thing though, labor seems to happen on its very own time schedule sometimes.

It saddens me to read your series of posts on this matter. Not all OB docs are trying to punch a clock and set an assembly line, and many advocate for their patients in labor as much as any midwife. The difference is the volume of patients that we need to see to cover skyrocketing malpractice and balancing it with some semblance of a normal life to maintain sanity. Midwives have the luxury of taking on no more than 1-3 patients per month if they wish (and they get to pick and choose who they like!) In solo practice, I need to have about 15-20 deliveries a month just to cover malpractice (more than 9K/month), office staff, supplies, salaries, etc. That makes a big difference in the monthly time crunch. Sigh.

Sorry for the long comments, just wanted to advocate for some of the "less evil" OBs out there in the world.

Magpie said...

Fascinating - both your post and the comments.