I'm writing about my childbirth philosophy in a series of posts. Like many doctors and some midwives, my experience attending births began in large teaching hospitals, in my case during third- and fourth-year obstetric rotations. In this post, I'm going to describe these experiences and what they taught me, and examine the implications of these early experiences on a learner's later beliefs about childbirth practices.
By the time I finished medical school I'd done four rotations involving pregnancy and childbirth:
- Core third-year OB/GYN clerkship at a large university hospital which served as a tertiary care referral center
- Sub-internship in OB/GYN at a community medical center serving a metropolitan community and outlying rural areas
- Rural family practice elective in a very small (25 bed) hospital and affiliated clinic
- Rural family practice elective in a medium-sized (165) community hospital serving a large agriculturally-based population
This list demonstrates the breadth of possible locations and settings in which a doctor or hospital-based midwife might practice. I believe it is a good idea to pursue broad training in any area of interest, to see the range of possibilities for practice. Here are some of the experiences I encountered:
1. Metropolitan Tertiary-Care Labor & Delivery
- Staff: OB/GYN interns and residents, Certified Nurse Midwives (CNMs), attending physicians
- Patient population: low-income urban residents (prenatal care in resident's clinics), middle- and upper-class insured patients (prenatal care in faculty clinics)
- Acuity of inpatients: High. Many women referred from rural communities with complications of pregnancy.
- Number of vaginal deliveries daily: Few. Days went by without any vaginal births.
- Number of C-sections: Higher than average, a reflection of high-risk population including conditions for which C-section is absolutely indicated (i.e. placenta previa)
- Anesthesia: Dedicated in-house OB anesthesia. Access to epidurals readily available and liberally used.
This was my first rotation, and strangely enough, where I became completely obsessed with pregnancy and birth. I say it is strange because I saw relatively little birth at this hospital. In fact, I can only remember witnessing one vaginal delivery, even though I think a few others occurred while I was on rotation. Instead, I saw a lot of epiduralized labor preceding C-section, and learned a heck of a lot about complicated pregnancies such as high-level multiple gestations, thromboembolic disease, preterm premature rupture of membranes, preterm labor, placenta previa, etc. The residents I worked with were mostly women and were, as a group, intense and driven Some were great, some were awful, but all were meticulous, evidence-driven, and certain they were providing the best care they could by recommending technologically-driven, interventionist obstetric care.
What I learned from Hospital #1 was how infinitely complex and unpredictable the processes of pregnancy and birth can be, not only because of the nature of medical interventions used in modern obstetrics but also because of the physiologic events of pregnancy itself. If this had been my only experience of childbirth care, I might have come to believe birth was inherently dangerous and required continuous medical supervision, because I would not have had the chance to witness birth within a different setting. The OB/GYN residents probably never got to experience birth outside the modern obstetric model, and I suspect this is why young OB/GYNs are so interventionist in their practice style.
2. Metropolitan Community Hospital
- Staff: OB/GYN and Family Practice interns, OB/GYN residents, CNMs, attending physicians
- Patient population: predominantly low-income women from host city and outlying areas. Prenatal care at resident's clinics
- Acuity of inpatients: Low/Moderate. Relatively few women admitted with high-risk conditions; women with identified complications were stabilized and transferred to the hospital in #1
- Number of vaginal deliveries daily: 1-6, approximately. Most days at least one baby was born on the unit
- Number of C-sections: average
- Anesthesia: In-house anesthesia but none dedicated to OB patients. Epidural available but dependent upon anesthesia availability and willingness. Epidurals not widely used.
I chose a smaller metropolitan hospital for a sub-internship in OB at the beginning of my fourth year, mainly because I didn't get to deliver any babies during my core rotation. That's right, none. Hospital #1 had so few births and so many interns there were no opportunities for me to experience birth hands-on. In fact, the residents at Hospital #1 didn't even permit their sub-interns to perform exams for cervical dilation. ("Have you seen a delivery?" One chief resident asked a sub-intern at #1. "Because doing one is about the same.")
At Hospital #2, I spent most of my time on Labor & Delivery. There were fewer residents and although some of them were hard-edged, they were a lot more approachable than the residents at Hospital #1. There were more men in the residency program, and they were especially nice to the students. The residents supervised my work, but so did a CNM who--in terms of practice style--was very much like the OBs she worked with.
I got to deliver eight babies at Hospital #2. I remember the first as if it happened yesterday. I remember the vitality of the baby's first cry. I remember feeling high for an hour after the birth. What I learned at Hospital #2: I really did love pregnancy and birth, and I could do the work. I needed to have the hands-on experience of the rotation at Hospital #2 to arrive at this conclusion. You have to participate in labor and birth to learn to respect the process.
3. Small Rural Community Hospital
- Staff: Family Practice interns and residents, Family Practice attending physicians, including some with C-section privileges
- Patient population: almost 100% low-income, Spanish-speaking women from migrant farmworking families
- Acuity of inpatients: Low
- Number of vaginal deliveries daily: Less than one--about 20 births/month
- Number of C-sections: average/below-average
- Anesthesia: no in-house anesthesia, no epidurals available
Immediately after my sub-internship at Hospital #2, I started a family practice rotation at a tiny community hospital about 40 miles away. The hospital was run by the same residents and family doctors who staffed the clinic only a few steps away. The residents took call for the entire 25-bed hospital after-hours, doing the kind of job I do now: admitting inpatients, making rounds, delivering babies. I spent a month running back and forth with them, seeing prenatal patients, making rounds, following laboring women. One of the family docs had C-section privileges and another did postpartum tubal ligations--I assisted them in the OR.
What I learned at Hospital #3: maternity care exists as a part of family care, and I liked the whole package. Family doctors were providing the kind of full-spectrum care I believed in, and there were plenty of places in the world who needed that care. Hospital #3 gave me a glimpse of my future.
4. Medium-Sized Rural Community Hospital
- Staff: Family Practice interns and residents, OB and Family Practice attending physicians
- Patient population: 100% low-income, 85% Spanish-speaking women from farmworking families
- Acuity of inpatients: Moderate/high. Full range of complicated pregnancies represented. Preterm patients (less than 32 weeks gestation) transferred if stable, otherwise most high-risk kept at home hospital.
- Number of vaginal deliveries daily: 8-9 births/day
- Number of C-sections: average or slightly higher. Increased after VBAC option eliminated during my R2 year.
- Anesthesia: in-house anesthesia but none dedicated to OB patients. Epidurals not available. Residents trained to do intrathecal analgesia, which was widely used.
A few months after Hospital #3, I traveled to a different community hospital. It was host to a larger family practice residency than #3 and I was interested in matching there, but I'd heard mixed opinions about how busy the residents were and the "cowboy" reputation of the place--i.e. residents doing difficult procedures without adequate supervision. I've always been suspicious of rumors, especially if the truth of them is important to my decision-making.
So I spent a month at Hospital #4. I followed the residents all around the hospital, from rounds to call, which began on Labor & Delivery each evening because the activity on L&D was the heart of the hospital. The residents delivered the vast majority of 3000 babies a year at Hospital #4, at the same time as they admitted twice that number of adult and pediatric inpatients. The pace was fast and often stressful but I saw the residents were smart and well-trained, and they were going on to practice the kind of family medicine that was my new professional goal. Not "cowboy" medicine, but solidly-grounded, hands-on family practice.
What I learned from Hospital #4 was the importance of attaining adequate volume of experience in the area of medicine you plan to practice, especially obstetrics. Although the residents' OB training was fairly interventionist, they did experience a lot of unmedicated routine births and gained some faith in the processes of birth even if all the births they saw took place in the hospital. The volume of their experience made them less fearful of participating in childbirth.
These were my earliest training experiences in labor and childbirth. As you can see, all of them took place in different hospital based settings; I have never had the opportunity to learn or practice in a freestanding birth center, and I have never attended a birth in a private home. Certainly my approach to providing maternity and childbirth care is colored by these training experiences, but--as I'll cover in later posts--also by experiences during my residency and the four years I've been in practice, which have been transformative of my childbirth philosophy.
One theme that keeps coming back to me again and again as I investigate my beliefs about childbirth: belief systems are constantly in the process of change. One experience builds upon another and adds richness to what might have begun as a relatively simple set of rules and guidelines. As I mentioned above, I suspect many of the young OB/GYN residents I've worked with have not gotten the chance to broaden their experience of childbirth practices, which I suspect is why I've encountered a certain uniformity in practice among younger OBs, and perhaps why ACOG's positions on "alternative" birth practices, including homebirth, have been so rigid. I plan to expand upon this theme as this series unfolds, but I am interested to know your opinions on the effect of training on the development of practice style.