The Way We Give Birth, Part II

As promised, I want to talk about the (very little) I know about midwives and/or alternatives to the accepted medical standard of birth. My first thought is that there is very little consensus to the standard of birth and/or labor anyway. At my hospital, we do epidurals, pitocin, cut the cord immediately, term inductions, etc. At [county hospital], they get pitocin, but most of the ladies come in during the active phase of labor, if not delivering the baby on the stretcher, so there is much less "active management". At [froofroo private hospital], the third place students rotate, I think it's probably more common to induce electively; they probably do some elective c-sections, etc.

So if there's so much variation in the medical community, what is so different in a midwife birth? The following list comes from limited internet research, discussions with "the other med student on OB", and reading about midwives I've done over time. It is by no means all-inclusive, and I could be wrong on any point--I'm no expert.

• Likely to be at home or in a birth center. Some midwives do have hospital privileges, and many (most?) will accompany a patient to the hospital if a home birth fails. Doulas may assist a laboring mother in a hospital setting or at home, with or without a midwife. If you give birth at home, you're surrounded by your own furniture and family. Birth centers tend to be better-decorated than hospital rooms (at least the ones in my hospital).
• Depending on the midwife, there may be more focus on nutrition and/or herbs in prenatal care. Some, but not all, practice homeopathy.
• Many midwives encourage water birth. Since the baby is still attached to the umbilical cord, they won't drown. From what I understand, the warm water relieves pain quite well.
• There is a greater focus on immediate breast-feeding, mom/baby bonding, and father bonding with midwife-tended birth. There's no whisking the baby off to the nursery; instead, any labs to draw on mom and baby take second place to breast-feeding and bonding.
• Many midwives believe in delaying the cutting of the umbilical cord. As Midwife With a Knife said in a comment, some neonatologists believe in the same thing, as the baby is still receiving precious oxygen via the umbilical cord until the placenta detaches from the uterus.
• Most of the midwives I've checked out locally offer a full one hour initial visit, with as many prenatal visits as necessary. They're definitely more thorough than the 5-10 minute prenatal visit that is the medical standard.
• Midwives aren't very likely to rupture a woman's membranes to "hurry the process along". Many of the stories I'm reading on midwife websites talk about the water breaking immediately before birth.
• In our hospital, we constantly monitor all laboring mothers with a tocometer for contractions and an external fetal heart rate monitor for the baby. The monitors are held on the belly with tight elastic bands that aren't extremely comfortable; the only time they're off of most moms is if they're in the bathroom. Many midwives only monitor babies intermittently, especially if the pregnancy is low-risk, helping mother's comfort.
• After a mom has an epidural, she can't really get up to go to the bathroom easily, so she either has to use a bedpan or have a straight catheter drain her bladder. If you have no epidural, you can walk around to go to the bathroom in privacy.
• No ugly hospital gowns in a home or birth-center birth.
• More focus on mom pushing on her side, propped on her back, in a bathtub, or even squatting, which should help with pain control and *help* prevent back labor. Pushing with gravity should help pushing be more efficient and take baby's weight off the back, rectum, and perineum.
• Midwives and/or doulas stay with mom for longer during the labor process. In our hospital, the ob's check on laboring moms every 2 hours unless there's a reason to check on them. After the delivery, we leave shortly after everything is over. The midwife or doula is much more involved with labor than we are, and they stick around longer to help get everything squared away. Fortunately, we do have excellent L&D nurses at our hospital who kind of take on this role, but even they have multiple laboring patients at a time and other duties to attend, and cannot stay at a woman's bedside for long periods of time.
  

So, why doesn't everyone have a midwife birth? Why don't we all give birth in our hot tubs, surrounded by family, unhindered by medication, flowers in our hair, connecting with our instinctive inner mother? I will discuss my own pro and con list in Part III, coming soon. Keep the comments coming--I love hearing the different opinions! Also, if anyone could explain the difference between lay midwife and nurse midwife to me, I'd be grateful!

The Depths of Despair

The title of this post comes from the movie the picture comes from. I'm not actually in the depths of despair, but I am somewhat frustrated with life in general and medicine in particular. Sometimes, I feel like I've gone into the wrong profession. There have been shining high moments while I've been a medical student, where I feel like everything is worthwhile, but right now, I feel like those moments are few and far between. There seem to be many more moments where I'm frustrated with a resident's callousness toward a patient, or an attending's casualness with time, or a patient's refusal to take responsibility for their own care, or the system's inability to provide even basic care to those who really need it, or any of the other million things that frustrate me.

My decision to go into urology has seemed somewhat ridiculous here lately. Several guys I've discussed this with have told me they wouldn't see a female urologist, as if women never see a urologist or as if all men have such a preference. Should we tell men not to become ob/gyns, since some women have a strong preference for female ob/gyns?

I met with a urologist today to discuss research options. After scheduling an appointment via email, I walked over to the clinic, hopeful and excited. As I went to meet the doctor, he said, "Ah, you think you like urology, right? I want you to meet with my resident here, she's the best resident I have, and she is quitting urology here soon. Oh, yes, research. I have some basic research starting soon, leave your contact information with my secretary and I'll get in touch with you when it begins." For this, I walked about a quarter of a mile, and had to get special permission from the attending and chief resident to leave L&D. Was he deliberately trying to discourage me? Why else would he want me to meet a resident who is quitting? Or did less thought go into this than that?

I had been doing so well for a while. I can't tell if I'm getting more upset because I should be, or because I'm getting depressed. I do feel somewhat hopeless, like what the fuck am I doing? Am I going into the right field? Am I taking the "easy" route by not doing family practice or internal medicine or OB? How interested am I in this field? Am I picking it by default, because nothing else was interesting at all? The questions just keep coming, and I can't quite answer them right now. I'm sure this will pass--after all, I've been very excited about urology. I just dislike feeling so helpless.

At least I got to deliver my second baby today. I also sutured a perineal lac, which scared me to death--I hadn't sutured anybody since surgery in August, for pete's sake. And I still haven't dropped a baby, thank god.

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).

Brings Out the Bitch in Me

Theorem One: OB/Gyns can be bitches.

There, I said it.

I do not think that all OB/Gyns are bitches. I think there is something about being around all that estrogen ALL THE TIME that encourages the bitchiness. There's estrogen from the patients, of course, and also from the doctors themselves, probably 90% of whom are female.

I will back up my theorem with proofs:

1. In the resident's lounge, one wall is covered with pictures of the residents hanging out, cooking together, getting drunk together (a frequent occurrence); pictures of their babies, baby pictures of themselves, etc. In front of this backdrop, there is gossip going on. Constant, nonstop gossip. Every resident knows every other resident's business, and they talk about it incessantly.
2. The male intern I have worked with the past week practically owns his own pair of ovaries. He drinks Diet Coke, he gossips about the attendings, he gets his feelings hurt, and he picks up on subtle digs that one attending makes about female residents. Last week, he said "Guys, guess what? I managed to hold a phone conversation AND answer a page AT THE SAME TIME! I can multitask now!" He's actually married with children, so it's not that he's gay (I assume).
3. I am becoming bitchier by the day. It could be the lack of scheduled food and/or snacks (big girl's gotta eat, ya know), or it could be the SEA OF ESTROGEN.

A fable, if you will, to reinforce the point:

This morning, the other student and I spent a fair amount of time talking with a laboring patient. She was very sweet and friendly, telling us over and over that "I don't mind students, I'm just so glad you two are female!" It was her third baby, and she was well-used to the entire process.

Right after grabbing pizza for the residents (and sneaking a piece for myself), I returned to the lounge to the news that the patient was completely dilated. Since the other student had seen a delivery today and I had not, I ran behind the resident to the room, tucking my hair into my fashionable pony scrub cap on the way. We got there and indeed, the patient was ready to push. Her attending was on the way, so we waited outside until she arrived.

She came clumping down the hall in the loudest pair of clogs I've ever heard, talking a mile a minute with the chief. At the door, she turned to me and said "Oh no, honey, no students on this one, this patient's kinda funny about that, ya know? No students, sorry, she's just kinda funny," and walked on in.

There was nothing for me to do but say "Okay" and walk back to the lounge. The residents inside asked me why I was back so soon--did I get kicked out? I confirmed. They asked why, and I said briefly that she said the patient didn't want students. The other student gaped at me--she'd heard the same message from the patient I had. The residents began to abuse the attending a bit, saying it wasn't fair, she was kinda weird, etc. I kept quiet--I'm well aware that the lounge's walls have ears. When the attending came in after the delivery, everyone said "Oh, hi, Dr.! How did it go?" as if they hadn't just been speaking unkindly.

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It's not that I'm not a gossip, it's not that I can't be mean or talk about people behind their backs. It's just that it's every day, all the time, and I'm fairly sure that no one is safe from the razor tongues (with the possible exception of the students--said male intern can't remember my name, and I wear a name tag every day). And I dislike talking badly about my friends behind their backs about subjects I wouldn't bring up to their faces--I'm sure I've done it, more than once, but it makes me feel slimy. It's just so freaking prevalent here! It's a corrosive environment!

I'm actually kind of glad that urology is more male-dominated. I get along better as one of the guys than one of the girls.

Feast or Famine

So far, I'm on "OB Days", or 0500-1700 shifts on L&D. Friday morning, the chief resident entered the lounge, looked at all of us (resident, intern, 2 students) sitting around groggy-eyed and said "Man, you guys look like the first week of days."

Friday night, I came home, watched "What Not to Wear", and fell asleep by 9 pm. And didn't wake up until noon Saturday.The only reason I didn't wear pajamas out to study on Saturday was because I'd watched WNTW on Friday, to be honest.

Tuesday, Thursday, and Friday were non-stop exhausting days. Babies were being born all over the place, both in L&D and in the OR. Women were coming into triage, either in labor or with BV or in preterm labor or vomiting or... or... or...

Wednesday, we sat around and did nothing for hours. I went to get my urology advisor to sign my paperwork, and my one patient in labor delivered in the 15 minutes I was gone. I did practice delivering a doll through a plastic pelvis, and I stitched an "episiotomy" on a piece of foam. Sunday, on call from 0800 to 2200, I watched "Old School," "Dodgeball," and "Van Wilder."

TODAY I DELIVERED MY FIRST BABY! AND I DIDN'T DROP IT! AND I WASN'T THE JERK ON THE CORD!

*ahem*

I've been so freaking busy on this rotation that every time I think of great stuff to write about, I don't get to write it until it's too late. I want to write about the residents, and the gossip, and some of the funny stories, but I'm not sure I can remember enough stuff to write at this point.

I'll share one anecdote before I forget it. Eighteen year old girl was in labor Sunday morning. Her husband/boyfriend/baby daddy kept joking about everything, so while she was trying to deliver, she kept laughing and saying "Oh, quit making me laugh, it puts more pressure on!" Every time she laughed, the baby's head would crown a little more. Her baby daddy started cheering her on: "Come on, honey, laugh the baby out! You can do it, just laugh a little more and laugh it out! Seriously, baby, every time you laugh it pushes more than when you push!" This, of course, made her laugh harder, which made the baby come out faster. Unfortunately, she then had a contraction, and pushed the baby out the conventional way. Her baby daddy told her he was proud anyway.

Blood, Guts, and Gore

My first day on OB:

• I arrived at 0500 and started prerounding. It took me the full 1.5 hours to see 2 whole patients. "Are you peeing and pooping? Aww, what a cute baby! How is your pain? Oh, the baby is so cute!"
• At 0630, the residents from night shift checked out to the day shift. By 0800, I had already seen several patients, but now it was time for attending rounds. I staggered into the residents' lounge carrying a stack of heavy plastic charts and prepared for the pimping. "Why do we give Rhogam? How much bleeding is allowed for postpartum bleeding, and how much for hemorrhage? What are the indications for IUD placement? What are the causes of postpartum fever?" etc, etc, etc. I love getting pimped on my first day of a rotation.
• By 1030, I had watched a delivery (OP, epidural, 2nd degree lac), examined another pregnant lady, broken her bag of water, and done other stuff I've already forgotten. I started thinking, man, I'm hungry, is it lunchtime yet? But I was deeply saddened that it was only 1030. My Cheerios had worn off hours earlier.
• At 1200, one of my residents sent me to the lunch "lecture" to swipe food. I came back with two pizzas (I had already eaten one piece) and a sack full of cold drinks. I felt like a huge sleaze, sneaking into a small room and walking out with half the remaining food.
• I saw another delivery (OA, epidural, easiest delivery EVER), watched a wound exploration (post-c/s infection), and then we were "allowed" to go to lecture.
• Lecture was actually for the residents, not the students, yet our attendance was required. We had a lecture at 1400, another at 1430, and then a 45 minute break, followed by another at 1600. *yawn*
• At 1700, we had to attend Grand Rounds. The topic: Avoiding the State Board of Medical Investigations. Some blowhard lawyer told lame anecdotes about physicians being reported to the state board for trivial complaints and how he miraculously saved them from loss of license, divorce, hell, etc. The attendings were fascinated, the residents gossiped, and all 5 of the med students had pulled out Case Files in the back row.

I got home at 1830, 13.5 hours after I left. It was a long damn day. I spent all day chasing residents back and forth from L&D to Triage, trying to figure out which patient was getting examined where and when my patients were delivering and when new patients had shown up in triage and WHAT THE HOLY HELL WAS GOING ON???!!!

Thought of the day: childbirth is an icky, icky process. Icky.

Getting Orientated

Today was the "first day" of OB/Gyn. I thank my lucky karma I was assigned to the "cush" hospital, where we work shifts instead of taking q4 call at [county hospital], aka the baby factory. We had some lectures this morning (mostly good), a long lunch, and then a VERY informal intro session with the course coordinator, who mostly has her act together (which is a pleasant change). Then, we walked over to the hospital for a quick tour of L&D. Once we found the residents' lounge, the course coordinator left us at the mercy of the residents sitting there. They seemed mostly benign, although little phrases stuck out:

"I don't really mind which order you see the patients in the morning, I won't yell at you, but some of the residents really prefer you to be on a different pod than the one they're on. But if I walked by Pod 3, and the student was there, I wouldn't yell at you for that, I would just go on to the next pod." (Well, gee, thanks!)

"We don't mind you following us around. If one of us gets up to leave, you should get up too--then, if we're just going to the bathroom or something, we'll say, Hey, it's cool, sit down. But otherwise, you should follow us."

Following a quick run-down, the Chief resident showed up. The mood shifted a bit, and she started her own orientation. She reminds me of my Chief from trauma surgery: they don't take crap from NOBODY, you understand? NOBODY. I don't think badly of her, but god forbid I cross her in some way. She let loose pearls like these:

"Don't let the attendings catch you sitting in this room, it looks bad."

"If you have a patient on the board, go by and check on her, because if suddenly her monitor quits showing up she may have gone straight to the OR and you need to be there. Don't come ask me where she is--no, ma'am--you need to be telling US where she is."

"Don't ask us if you can do stuff. We'll TELL you when you can do stuff."

All of it definitely made me shake in my boots a bit. The whole point of today seemed to be "Find stuff to do, and it better be the RIGHT stuff to do, but you'd better find it all on your own, or we'll be PISSED." Don't see the private patients, don't see the high-risk patients, do the triage H&P's in 15 minutes or less, write all your SOAP notes by the time the residents round, and DO NOT TOUCH a pretermer! Whew.

I do still have some apprehension about this rotation, since it used to be my chosen career path. What if I like it? What if I hate it? What if I drop a baby? What if I'm the jerk on the cord and invert some poor lady's uterus? GAH!

Time to go try to sleep this off, since I'll be leaving at 0440 tomorrow in order to preround.