Saturday, January 20, 2007

An obstetrical memory

I don't know when I first recognized it, but I like jargon, the peculiar set of words that grow up to shroud or nourish a particular field. Hence, in college, I would laugh along with the engineers' obscure cracks about heat transfer, and the hackers making obscure puns on the distinctions between grep and grok, peppering their conversation with quotes from the immortal tomes of Douglas Adams, all the while meandering towards my own degree in an unrelated field.

Perhaps this explains why I find blogs about the humor in child raising funny, though I have no children of my own. (Not likely to soon either, but that's another story, boiling down to "got to find the girl." I digress.) I also found this article in Slate hilarious and intriguing, despite only ever having been on the other side of it. I'd like to think the hilarity is just the author's style, but the intrigue is in the point of view I didn't get in my time on OB/Gyn.

He discusses the doctor-doctor interaction, handing off the patient who is his wife with this wonderful passage:"Tabitha's doctor collected information from the doctor on call, in the way doctors do. They spoke for maybe two minutes, in English as intelligible as their handwriting."

And then, in a paragraph I like because it reflects a lot of my own feelings on medicine:

Tabitha's doctor is maybe the least likely obstetrician in Berkeley, Calif. He doesn't believe, for example, in the sanctity of his patients' whims. He has no time for superstition; he is unapologetic about his belief in the power of modern science; he believes that the best way to endure childbirth is not out in the woods surrounded by hooting midwives but in a hospital bed, numb from the waist down. He is, in short, my kind of guy.

As a resident of mine on my obstetrics rotation put it, "there's nothing wonderful about 'natural childbirth.' People died in natural childbirth, that's why there are doctors." I do know more than a few people who are fans of natural childbirth, but while (being bound for internal medicine) I'm a little more understanding of the sometimes inscrutable whims of patients, this is one I don't think I endorse. Life is painful enough sometimes.

The passage I quoted above reminded me of a patient I saw on my obstetrics rotation, who is the reason I don't like doulas. She was pregnant with twins, and had a history of several prior births that had not gone well. Her children had all been born drastically prematurely, and as a result suffered from a variety of congenital ailments. Because of her history, she had a cerclage placed, though when I first saw her, she had finally reached term, and had that particular apparatus taken out. Here is where it got complicated. She had been discussing her situation with a doula, and this non-medically trained individual convinced her it would be a good idea to give birth at home, despite her history of tragic pregnancies, and the fact that she was carrying twins. And to complicate the matter further, the final ultrasound I saw her get showed the twin closest to the cervix was smaller, and the second was breech.

When a woman gives birth to twins of different sizes, the order in which they come out has a powerful influence on the ease of the birth. If the larger twin comes out first, the second delivery is relatively easy, as the cervix and canal have stretched already. If the smaller one comes out first, the second will involve more laboring, and chances for things to go wrong, such as prolapse of the umbilical cord with concomitant asphyxiation of the newborn. This patient was set up for failure.

The next weeks were tense, as every night the patient's story was related, "just in case" she changed her mind, or showed up on the ER door with a kid halfway out of her and in extremis. And about a week and a half later, she did show up, doula in tow.

She had tried to give birth at home, and finally her screaming had gotten to be too much for everyone involved, who dragged her onto the labor and delivery deck at about 2am, probably waking the entire population of the hospital. As I went into the triage room, I was genuinely concerned someone was dying, because of all the noise. My resident was right behind me and it took a total of about 2 seconds to decide to take her to the OR.

We did manage, in the OR, to start an epidural, and then we tried to deliver the kids vaginally while waiting for the staff doc. He arrived minutes later, and began to prep for a C-section, just in case. Through the whole delivery, I heard absolutely the most foul language imaginable coming from the doula and her charge, our patient. Evidently the epidural didn't have time to kick in before the kids were coming. It was positively distracting, and my resident reflected later that it was a pity the first word the kids heard was a vulgar reference to their conception. The second child had to be delivered with forceps, and that wasn't pretty either.

The whole team came out of the delivery pretty exhausted. The doula had disappeared. My attending turned slowly to me and intoned "well I hope you've learned why natural childbirth is overrated."

Oh I have. I most definitely have.


zhoen said...

There is a difference between this extreme case of risk and stupidity, and a healthy woman with a normal birth, with an experienced and well trained midwife, in a facility in or beside a hospital. And it is the history of male GPs, taking over, fighting against birth control, and abortions, mix in some purpural fever, that still tinges this rift.

Were I to give birth, I would want a birthing center in a hospital, accepting exactly as much intervention as is needed. Not deciding beforehand on everything or nothing. Nor would I want an OB who considered me over emotional, just because I was female.

Thainamu said...

A birthing center in a hospital is a great option. My two sons were born in such a facility when those facilities where pretty new. I had friends and family there, took lots of photos, no medication, and had a grand old time. But the hospital was right next door if there had been any last-minute complications.

Nathan said...

zhoen - you're right, this is an extreme case. And I'm probably over-reacting to it. I do think your last paragraph is right on, and the attitude I would hope to have as an OB, were I to be one. I do generally hold to the idea that modern medicine is superior to the natural way, and though I don't think pregnancy and childbirth should be treated as a disease, I also think that pain control and the availability of more technical interventions are gifts from heaven.

And Semmelweiss was definitely more modern than his puerperal fever inducing contemporaries.

And as a last note, I hope I didn't imply I was considering anyone overly emotional on the basis of their gender. This patient was completely out of control, and other than the fact that you must be female to pregant, her sex had nothing to do with it.

thainamu - I'm glad it worked out for you. I'm also glad you did not elect to reject modern medicine entirely.

Judy said...

I'm glad things turned out well for the babies, and I don't believe most doulas would have been so stupid as to recommend a home birth in this situation.

Ibid said...

I was also born in a birthing center in a hospital. It went so smoothly my mother had the four remaining children (one at a time) at home. But she had sound medical advice present.

Nathan said...

judy - probably not. I would certainly hope not. But I've seen a few running around the hospital since, and I haven't been impressed, unfortunately.

ibid - in your family, one would think to find sound medical advice almost omnipresent.

Overall, the responses here are demonstrating why it's probably best I didn't pick OB/Gyn. I am much more tempermentally inclined to consider disease, not natural conditions which unfortunately are occasionally cast as disease.

Alaska Steve said...

II was surprised, after reading the words at the top of your blog

Without faith, without poetry, without music, medicine is pointless, for why save a life which is not special, and why dedicate so much effort to a cosmic accident? It would be worse than pointless, it would be cruel.

That you could write in this post,

he is unapologetic about his belief in the power of modern science; he believes that the best way to endure childbirth is not out in the woods surrounded by hooting midwives but in a hospital bed, numb from the waist down. He is, in short, my kind of guy.

And I was pleased to see that the comments all reflected that it isn't either/or - either ideological crazies or mechanical medicine. There are times when modern, scientific medicine is great (for all those clearly technical breakdowns - broken parts that are immediately life threatening). There are times when traditional practices make sense - like getting the whole body in balance so that those breakdowns are less likely to happen at all.

For the record, both our children were Lamaze babies. It was the ideal, but if my wife had changed her mind at any point, we'd have gone for pain killers, no judgments made. As it was, my wife brought home a nasty staph infection from the hospital as well as the first baby.

Nathan said...

Alaska Steve - thanks for the comment. That passage you quoted (the second one) is a quote from the article I linked, and not my own words. I found them, and the rest of that article, rather humorous, which may have skewed my judgment of their underpinnings. The first passage "without faith, etc." is my words and I do not see the inconsistency in using God-given reason to develop technology to make our lives easier or less painful.

I have met women on both sides of the spectrum, from the ones who enjoy the pain, in a retroactive sense, to ones who say "that taught me two words: epidural and adoption."

There is, of course, no either/or dichotomy and it is possible to use medicine in a way that complements, but does not deny, our humanity. I certainly hope to practice in such a way. But I do not have rosy ideas about pain, I have seen the extremes that childbirth causes, and I would not hesistate to recommend modern medical pain control to save that life "which is not pointless." To do any less would be cruel.

Diana Moses Botkin said...

Hi Nathan, I discovered your blog this evening while reading my daughter's mind. Not only did I waste a perfectly good half-hour reading your thoughts, but I enjoyed the time immensely. And yes, natural childbirth can be a good thing. I gave birth the first time at a birthing center and our other 4 were born at home. I loved not having to go somewhere in the middle of labor. Although home birth is not for everyone, I highly recommend it for women who have low risks and like the idea. Birth is a natural process and women have been doing it for thousands of years without doctors or hospitals. 'nuff said. If you ever get up to the edge of the earth, our door's open. We'd enjoy meeting you.

Nathan said...

Diana - I am quite pleased to have entertained. Thanks for the input, and I appreciate the offer. I'm certain I would enjoy meeting you all as well.