Follow-Up: Birth Story #478

A reader of this blog who was extremely helpful during my recent foray into high-tech library research has alerted me to a discussion about Birth Story #478 currently taking place in the comments of another blog. I have too much on my plate to respond to discussions taking place outside of this blog--heck, I can't even keep up with the comments here--so I will confine my remarks to the following:

1. My Birth Stories are fictionalized synopses of births I've attended. As such, they do not contain every word recorded about the patient upon whose case an individual story is based. Many of the concerns expressed in the comments on the other blog are derived from conjectures about the care I and my colleagues provided for Nola, including the following incorrect assumptions:

a. Nola "wanted a C-section," and we persuaded her to have another trial of labor. During prenatal care, Nola asked if a C-section was a good idea, given her first birth experience, and we discussed the risks and benefits of a C-section with her over several prenatal visits. We were open to referring her to an OB for elective C-section if she'd decided to pursue this path, but ultimately Nola herself preferred to attempt a vaginal delivery because she didn't want to have surgery unless it were necessary.

b. The prenatal team used bad judgement in not consulting with an obstetrician. Actually, we discuss all our higher-risk patients with the OBs who back us up. One of them sees patients at our clinic and is aware of all issues arising during prenatal care. Neither of our OBs felt an elective C-section was warranted. When Nola was in labor, a midwife colleague and myself consulted with the OB on call and he was completely supportive of the plan to induce with Pitocin and attempt a trial of labor. I don't mind being the subject of criticism but I will not have my team called incompetent because of what I write on this blog.

c. A certain hypocrisy prevailed in the decision to induce Nola at 39 weeks, given the recommendation against elective C-section. I can't really argue the decision to induce was based upon evidence, because it wasn't. Here, the team decided to proceed with induction as Nola wanted, after much discussion with her and with the backup OBs. This decision was very much directed by Nola's preference as well as local standard of care. Because we live hundreds of miles away from a Level 3 NICU, doctors will often recommend an intervention if they think it will avoid an outcome requiring neonatal transfer, especially if the intervention is relatively low risk. I think our OBs agreed with induction at 39 weeks, but I wasn't present during the discussion.

2. Some of the commenters implied I am against C-sections and "overly value vaginal birth," regardless of the risk to maternal or fetal outcome. Actually, I am not opposed to C-sections when they are needed. If I think a woman would be best served by a C-section, I will recommend one. There are many worse things that can happen to a woman than a timely C-section when labor is stalled or the fetus in true distress. There is so much polarization of debate between interventional and non-interventional schools of thought in childbirth, I've gone out of my way not to fan the flames. I am not, of course, a supporter of elective C-section without medical indication (see #4), although I acknowledge women's autonomy in deciding to proceed with elective C-section after extensive discussion of risks and benefits. If I seem to favor vaginal births, it is because most of my Birth Stories are about vaginal deliveries, not C-sections. I plan to even out this representational bias with my Labor Files stories, which will include C-sections and other adventures.

3. In discussions such as these, the risk of elective C-section is rarely discussed in detail, and I think this is a serious oversight. A C-section is not merely an alternative method of delivery, but it is a major abdominal surgery, with all of the attendant risks attached: infection, bleeding, accidental injury to contiguous structures, post-operative morbidity (DVTs, pneumonia) and future morbidity due to post-surgical adhesions. There are a number of potential complications unique to Cesarean delivery, such as respiratory distress in newborns born without labor, and a higher risk of placenta previa and accreta in future pregnancies. Furthermore, in the current obstetrical climate, an elective C-section will inevitably limit a woman's options for future births. I encourage everyone to keep this very real risks in mind when they participate in any debate about Cesarean delivery.

4. Regarding medical indications for C-section, it should be noted that these do not include prior shoulder dystocia. Some obstetricians will offer a woman an elective C-section after shoulder dystocia if the prior delivery resulted in significant maternal or neonatal injury, but this is based upon individual practice preferences rather than evidence. 

5. One commenter believes Nola should have been delivered by an obstetrician instead of an "inexperienced family doctor." In some communities, Nola might have been referred to an OB because of her first birth experience, and it is possible she might have been well-served by having a provider with a different set of skills than my own. However, in Rural we have only two overworked OBs who provide services at our hospital and we only refer truly high-risk pregnancies (multiple gestations, breeches, severe pre-gestational hypertension, Type I diabetic mothers) to them for ongoing care. Nola's situation fell within a grey area of undefined moderate risk, and if I were to refer all such women to our OBs for delivery, there would be no way the OBs could cover the load.

5b. For the record, I am not an inexperienced family doctor. I am an experienced family doctor. Does that mean I have the same skill set as an experienced obstetrician? Of course not. It means I have mastery over the skill set of a family doctor who provides obstetrical care, and this is not a skill set to be summarily dismissed. I take exception to the assumption that the obstetrical or medical care provided by family doctors is automatically inferior to the same care delivered by obstetricians or internists. Depending upon the skill and experience of the family doctor, it can be equal or superior to the care of these specialists. The assumption that such specialists are superior, or even easily available, is a particularly urban bias which ignores some of the excellent and extremely difficult work we rural family doctors provide in this country.

6. Another commenter suggested I had issues I needed to work through after Nola's first birth. Damn straight I did! Any doctor who denies emotional turmoil after such an event is a liar. Like any emotional turmoil, you've got to work through it, and you might bring it with you to the next birth you attend. It's the gorilla in the living room, and it's time to be honest about it. I believe my "issues" with Nola's first birth helped me be more prepared and adaptable when I attended her second birth.

7. The commenter I referred to in #5 said "Rural Doc...gives the impression of not knowing what she is doing sometimes." Actually, I do know what I'm doing. Whenever I don't know what to do, I find someone who does. You won't find me, for example, floating a Swan-Ganz catheter in the ICU or laparoscopically removing an ectopic pregnancy--I get specialists on the case if these interventions are needed. If I sound uncertain at time, it is because medicine is, at best, an uncertain art. What I share with readers of this blog is my thought process, in which I weigh options and decide yea or nay based upon a patient's individual situation and the data at hand. This is not a process based upon 100% certainty. There are no flashing lights when you get the answer right, and for people who like things black and white, it is a damned uncomfortable profession to be in. Any doctor who says she knows what she's doing all the time is a liar, and I'm only sorry the acknowledgement of uncertainty should be misunderstood as professional insecurity on my part.  

I'm quite fascinated by the debate Nola's birth stories have provoked, even though I have been roundly criticized by people on both sides of the interventional/non-interventional fence. I believe in open discussion and I hope the dialogue about shoulder dystocia will be helpful to people who read this blog. I want to conclude this post by re-iterating the fact that I am attempting to share a range of birth experiences and practices, from the most interventional to the least. It is remarkable how much commentary the interventional birth stories inspire, compared to the more straightforward ones. No one ever writes, "How dare you let that woman labor for seven hours with intact membranes? Didn't you think rupturing them might have brought her labor to an end faster and saved her physical suffering?" The temptation to write about nothing but perfect, wonderful, uncomplicated births is compelling, but if you want to hear nothing but happy outcomes, you can watch the Learning Channel or Discovery Health. Here, you're going to get the entire spectrum. 

Comments

[MinorityView]

Great couple of blogs! Thanks for telling the story of Nola's birth. I definitely lean towards the non-interventionist side, but I know a lot of women do need medical support and it is good to hear from someone who can give that support sans arrogance.

Keep it up! And don't let the creeps on either side of the argument shut down your voice.

[TracyKM]

My first birth was with a family doctor (not my own, he was on call). Several things happened that I think should have been avoided, and I ended up with a very sudden vaginal birth with my son pulled out by his ears. The doctor seemed a bit in shock. Years later, I find out that before the OBs moved to town, he was the 'difficult birth specialist'. I don't know if he was out of practice, but I was really disappointed that things went the way they did. I was hoping for a birth like you describe in your stories. I'm totally for family doctors doing deliveries though!!! However, my family doc. died very young from a rare cancer and I did end up going to an OB for the next two births...which ended up being more like the ones you attend! LOL. I'm really enjoying reading your perspective. It's a fresh change from the many 'keep your hands off' birth blogs. Keep it up!!!

[Yehudit]

"leaning into the wind" (as expectant management is commonly described over there)

++++++++++++

Well, that is basically the problem. Either intervention or non-intervention can characterized as "leaning into the wind" or "taking a chance." Birth is only normal in retrospect, but intervention is only routine in retrospect. And the default (from an evidence-based practice point of view) should be that the intervention must show benefit over non-intervention, not the other way round.

What I'd do for a retrospectoscope!

[Leelee]

Lurker and participant on "that other" blog, delurking to say I'm very glad you addressed the comments. Things over at the other site get a bit heated, as that's the nature of that site, and a few of the longtimers have (justifiable, given their own birth experiences) preferences that lean toward c-section rather than "leaning into the wind" (as expectant management is commonly described over there). I'm not a medical professional, just a mom who had an unexpected primary c-section over which I had a lot of doubt for a while, and it sent me into the blogosphere and voluntarism. I've since come to a more nuanced view (and ironically, come to conclude that my c-section was a justifiable call if not a universally-recognizable ironclad necessity). But am always fascinated by the shifting, nebulous line between interventive/non-interventive care, and the people who have to make that call every day, and the whole thing's relationship to cost-effectiveness and best practice. At my white collar office in a big urban hub, it seems telling that nearly 50% of the professional women I know have had c-sections at one of the private hospitals, while at the same time an African-American woman I know who grew up in the city, had a stillbirth a few years back due to caregivers forgetting (or never communicating with her prior caregivers) that she needed Rhogam. No matter which side of the debate one falls on, I think we can all agree that there is something wrong with the allocation of resources, and it does goad me to see the stance defended that every single woman needs high-risk obstetrics when that is neither economically nor geographically feasible for many (or even supported by current ACOG guidelines!). OKee- back to lurkdom.

[drk]

I also am a family doc who does OB. I think you are asking and thinking about all the right issues. I also think virtually every doc (OB and family) and midwife in our major academic medical center would support the decisions you and your colleagues made because they reflect the current knowledge and evidence of the profession. These are not black-and-white decisions and anyone who thinks they "know" the right answer hasn't been to enough births to understand the nuances, outcomes, and experience of labor and delivery AND hasn't read the state of the science (admittedly sparse). You do outstanding work. Appreciate your willingness to reflect on your decisions and discuss publicly, but from a medical perspective, I think they are absolutely solid.

[transplanted]

I thoroughly enjoy your blog and appreciate your reasoned approach to medical care. As nursing student, I could only hope to work with more doctors like you. You have shown yourself to be committed to respecting women's voices while remaining true to your convictions. Bravo, you.

[liz4cps]

I'm very glad you blog; I've learned a lot, and I enjoy your writing style.

There's always people who will disagree and who will be angry about things, no matter what you say. That was even true way back in the days of Usenet, before the web. The net gives us the ability to make connections w/ people we would not otherwise have which is mostly a good thing...

[Rachel]

Excellent post, and thank you for sharing these birth stories with us.

[Beach Bum]

Great post! I enjoy reading this post, and your birth stories in particular. I'm currently finished my second year of meds and am thinking very seriously of rural family. Thanks for the perspectives!

[Rebecca]

I really enjoy your stories (birth in particular, but all of them in general!) and I hope the debates elsewhere don't keep you from continuing to post. I read that blog occasionally but it is so disheartening and depressing to see how people treat each other, when there are real issues that could be discussed. I was very surprised at the implication that a doctor should always know exactly what she/he is doing...my parents are doctors and I grew up understanding medical fallibility - after all, they couldn't always diagnose my sore throat! And they also came home and discussed situations where they had doubted their decisions, or felt unsure, despite decades of practice. The older I am, the more I understand how many gray areas medicine covers. I think you do a nice job of acknowledging them, without fanning the flames. (And for what it's worth, my parents are primary care doctors as well and I admire you for going into a field that seems very thankless at the moment.)

[Squillo]

Rural Doc:

Thanks for your response. As you probably guessed, it's a topic that needles me a bit because I feel a bit as if I didn't have all the relevant facts with which to make my own decisions the second time around.

I'm glad all turned out well for your patient, and thanks again for responding to the Monday-morning quarterbacking.

[Lisa Clark]

I almost commented on your first post this week about Nola's birth and didn't. But after reading this one I have to post. I am very firmly on the side of natural/non-interventive birth, but I completely understand how belligerent some of us can come off sounding when talking about our personal passions or pet peeves. A very wise midwife once said that none of us has any business passing judgement on a birth we were not in attendance at. I have made that a habit ever since and I hope you know that, for all the negative comments out there, I'm sure there are a dozen like me who are just quietly taking in your insights. I want to say how very much I appreciate your blog and all the stories you share, even though it was your birth stories that first brought me here. Your community is blessed to have you and your tremendous experience.

[Theresa Chan]

Hi Squillo, I don't stand for much drubbing on my own blog so I wouldn't worry too much about that :-)

As for the rationale for induction, the idea is that the fetus gains about 25g per day in the late third trimester, or about a pound every two weeks, so by inducing labor at 39 weeks you're avoiding the risk of interval weight gain between 39-41 weeks. At 41 weeks, we offer induction to all women, although most women prefer not to be induced if their antenatal testing is favorable.

The idea isn't grounded in evidence but playing the odds of dystocia associated with macrosomia. I don't disagree with the decision in Nola's case but I'm not going to try to defend it as the absolute right thing to do either. The big problem I have with everyone throwing around absolute statements is this ignores such nuances as woman's preference, local standard of care, capabilities of the hospital, etc. etc. In this case, Nola wanted to be induced so there was no controversy within our group over the decision. The 39-week fetus of a non-diabetic mother is usually mature enough for delivery, and common wisdom supports the idea that induction is pretty easy in a woman who has had a vaginal birth in the past--these are the kinds of considerations underlying my group's decision.

Thanks for checking in.

[Squillo]

Rural Doc:

Thanks for your thoughtful commentary on the questions "they" (we) have brought up on the other blog. I, for one, appreciate it, although you were obviously under no obligation to do so.

I'm not a physician, but am interested in this story since my first birth involved a shoulder dystocia (good outcome). At no time did the OB for my second birth discuss the option of an elective c/s (nor did I raise it, being largely unaware of the risk of recurrence.) She did recommend an induction at 40 weeks, as my previous baby was a 42-weeker, but was just shy of the 4500 g mark. I have since had occasion to wonder why, given that all the literature I have since read suggests no benefit to early induction in preventing shoulder dystocia. (Birth #2 was smooth as silk, so my subsequent interest in the decision-making process is merely academic.) This is why I wondered about the rationale behind inducing your patient. From your follow-up, I now understand that this was not specifically your recommendation, but was agreed upon by the team in accordance with the patient's wishes. Again, I appreciate the clarification, but I am still wondering about the rationale. What was the intended benefit of the induction?

I'm sure I'll take a drubbing here, but my feeling is, if you can't take the flames, get off the internet. ; )

[Sheridan]

I love your stories and think you are a very balanced care provider. I wish more moms had a care provider like you! :)

[mommy michael]

sorry, meant to type "you're a" and "her baby"

been a very long day.

and for what it's worth. I love reading your blog.
you working during the holidays reminds me of my dad. He was a paramedic for 27 years and pretty much always volunteered to work the holidays if they needed him. We got pretty used to celebrating it either at the station, or a day later. =)

[mommy michael]

Don't worry, you're not the only blog "They" like to attack. It's pathetic really that women can be so shameless when commenting on the internet, so rude.

Doesn't matter if your a mother who lost their baby during labor, or the caregiver who attended it.. you'll be to blame, and they'll be righteously in the know of how wrong you were and what mistakes you did.

give them enough rope, they'll hang themselves. eventually...

[DrCris]

It is an amazing "payment" for your choice to be open and discuss difficult cases and decisions. I think you are great for sharing these stories, as there is a worrying public opinion that doctors should be infallible, and that all decisions are black and white.

I have no close knowledge of obstetrics, so I wouldn't dream of commenting on the validity of your decisions, but it seems similar in some ways to surgery where there are often no absolutes. Furthermore, both specialties provide vital information at the end of the process - that is, it is much easier to make decisions after the fact, rather than when you need to.

I actually think it is cool that people discuss this stuff on their own time, but definitely uncool that make any comment on your aptitude. Hopefully, sharing times of indecision and poor outcome might improve the unhelpful and ridiculous ideas people have about what goes on between a doctor and a patient when times get tough.

But it must be encouraging that there are people defending you behind your back, too. ;)

[dj]

Those people are being ridiculous. Your birth stories are very interesting and wonderfully written. And any doctor that thinks they know what they're doing all the time is truly scary.

[Peggikaye]

I'm so sorry this is going on. They've got no business discussing your blog stories on their blog ...or disecting your medical practices.

They weren't there ... they're not the patient ... if they want to discuss it, they should be commenting here.

It is a shame people do this to other people. Something about this internet allows us to dehumanize people in this way that we'd never do to people we see day to day.