Rural Doctoring

This is Hard to Say

Of all the recent professional upheavals I've survived recently, there is one which has posed a particular barrier to writing this blog: my departure from childbirth services. You heard that correctly--I'm no longer attending births. Doing so has been such a huge part of my professional identity, and my identity as the writer of this blog, that it has been really difficult for me to talk about the change without succumbing to despair. Today I feel ready to blurt out the truth, and I hope this will release some of the inhibition I've experienced in my writing.

Childbirth Philosophy 6: The Role of the Family Doctor

As I've been keeping up with this blog and establishing productive dialogues with natural childbirth and alternative birth practice advocates, I've been struck by the recurring statement women often make of me and the birth center where I work:  "I wish we had doctors who practice like you/hospitalist like yours where I live."  This is both flattering and alarming, because it reminds me most women don't live in areas where providers and hospitals support minimally interventions during labor and birth.  

One reason why my hospital continues to provide opportunities for natural/alternative childbirth practices is because the majority of the births are attended by midwives (two CNMs and one licensed midwife) and family doctors.  Other blogs already provide excellent advocacy for midwifery-directed childbirth care, so I'm choosing to focus on those aspects of my family practice training which have influenced my own childbirth philosophy.

What Counts as Experience?

According to my birth log, a notebook I have updated since 2000, I have attended 476 deliveries.  For almost all of those 476 births I have recorded the mother's name and--variably, depending on my memory and state of exhaustion--her age and parity, the date and time of the birth, sex and weight of the baby, and whether I attended the birth while on call, on night float, or because I was there to "special" the woman on a day off.  As time has progressed, the entries into this book have occasionally expanded to include detailed notes about unusual labor patterns, unexpected rotational dynamics of the baby, psychosocial drama occurring in the birth room, my own exasperations, and the redemption of hope when--despite all of the above--a woman gives birth and holds her newborn baby in her arms for the first time. 

Childbirth Philosophy 5: Our Birth Community

I've witnessed childbirth in a number of U.S. settings, as I described in Part Two and Part Three.  Here in Rural, I'm lucky to attend births in a unique community of expectant women, tolerant childbirth and pediatric providers, and very special Labor and Delivery unit at our small community hospital.  Unfortunately, this unique community is not available to all women; most of the U.S. does not offer the possibilities for tolerant childbirth alternatives we have in Rural.  Let me describe our local system.

Childbirth 4: On Being a Childless Childbirth Attendant

Women often ask me how many children I have.  "None," I say.  "I have cats."  This is the truth; I have four cats, one dog, and no children, and yet my professional life is very much tied up with issues relating to pregnancy, childbirth, child development, women's health during the reproductive years, and the social/caregiving responsibilities of families.  People are often surprised that I have no children:  "None? Really?" they say, and I reassure them of my certainty on the issue.  The conversational awkwardness soon blows over, but I am left with the insecurity of the original question and its underlying accusation:  You have never had children.  You have nothing to offer to women who want children.

Childbirth Philosophy, Part 3: Lessons from Residency

By the time I entered my intern year, I thought I'd had a lot of exposure to OB and childbirth care. After all, I'd done four rotations and delivered ten babies, a good record for a mere medical student. I had a few moments of pure hubris in thinking I'd seen enough to be ready for the large number of deliveries I was looking forward to doing at my program's hospital. In this post, I'll discuss what I learned about childbirth and maternity care in during my three-year family practice residency.

Childbirth Philosophy, Part 2

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.

Childbirth Philosophy, Part 1: Introduction

As you know, I’ve been writing Birth Stories regularly on this blog because I treasure these stories and writing them reinforces the love I have for attending births. Anything I can do to reinforce this love is a good thing, because it is physically arduous and mentally exhausting to accompany women through labor and delivery. As the Birth Stories have gained readership, a number of midwives, home birth advocates and doulas have read this blog and left their comments. They join an audience of doctors, medical students, nurses, and laypeople who share a fascination for the experience of birth.

When a Woman Prefers a Woman Provider

My clinic sees a lot of prenatal patients, especially this year after another local prenatal clinic closed and most of their patients transferred care to us. The other practice was staffed with women providers, whereas our practice is staffed with both men and women (four FPs, 2 midwives). As I meet more of the expectant mothers from the other practice, I find myself being asked more often if one of the midwives or I can attend a birth, because the patient prefers to have a woman delivery her baby.

Book Review: Unassisted Childbirth

An unassisted birth is one at which only the pregnant woman and the people she chooses to be with her are present. Unassisted births take place, by definition, in a private home, and are not attended by anyone with experience in supervising childbirth. Before moving to Rural, I had never encountered this childbirth practice but have several times since then among the women who receiving prenatal care at our clinic, women who transfer to the hospital after attempting an unassisted birth, and women who planned a hospital birth but ended up giving birth at home. Now I understand that unassisted childbirth is a recognized movement in the home birth community, and the major spokeswoman for it is Laura Kaplan Shanley, whose book entitled Unassisted Childbirth is a commonly-cited reference on the practice. This post examines the merits of Ms. Shanley's book and touches upon the practice itself.

The Ambien Incident

I often take a sleep aid when I'm not on call.  If I don't, and I've been up a lot the preceding nights, I tend to wake up at 2 A.M. and stay awake. This doesn't do much for my bedside manner the next day. Taking a sleeper on non-call nights has always seemed like a safe thing to do, until recently. Here's the story:

Pondering Change: Healthcare Shortages in My Town

So far, 2008 has been a roller-coaster ride for the medical community in my neck of the woods. Some of the major events:

1. Three primary-care internists closed their practices at the beginning of the year. Their mostly geriatric patients are still in the process of finding new doctors.
2. A local prenatal care provider also closed her office. She practiced with two midwives, and between the three of them, delivered 25-30 babies every month. The majority of her clients have transferred their care to my clinic, where we have five prenatal care providers but are only used to 12-15 births per month. Now we are facing 35-40 babies per month through the summer months.
3. A family doctor who specialized in pain management also closed his practice. His pain patients, many of whom receive primary care at other offices but rarely saw their PCPs, are now re-establishing pain management contracts with these PCPs. Because the pain specialist practiced--shall we say--beyond the comfort level of the rest of the medical community here, the influx of his former patients has been causing a lot of distress among the rest of us.
4. Two hospitalists have resigned from my group, making it impossible for us to provide 24/7 coverage for our community hospital. Solutions are being proposed, but none of them look promising

Remember when you were a medical student and you thought your job was going to be showing up at the clinic or hospital and seeing patients? You thought the only sacrifices you were going to make were long hours, sleepless nights, and exposure to bodily fluids. Right? Wrong! The biggest sacrifice I've made recently is the investment in time/anxiety/energy/earning potential towards solving the shortages above, especially #2 and #4. I've spent more time attending meetings, rewriting contracts, generating call schedules, and preparing payroll than I have staying current with CME this year. Didn't get paid a dime for all that work, and I'm certainly no smarter.

I'll take bodily fluids any day. More anon.

Almost 500

I keep a book with the names of all the women whose births I've attended. It starts with the first baby boy I delivered as a fourth year medical student, and ends with the little boy I delivered last Friday. During my third year of residency, I mislaid the book for several months, so I missed at least 40 births during that year. I gave myself a low estimate of 293 births by the time I graduated; the actual number was probably higher.

While bringing the book up to date last weekend, I was amazed to discover that I have delivered 461 babies during my short time as a family doctor. That includes two sets of twins and a whole bunch of second babies for women whom I'd attended for their first birth. It does not include C-sections, which I never count. Along with date of the birth and the woman's name, I make notations about the circumstances of the birth: "I arrived to see someone else. She was on her hands and knees at the nurse's station, wailing."

Four hundred sixty-one births. That's almost 500, a number I associated with wise women and elders in a community. Me? Maybe I was wrong.

From time to time, I'll write about a memorable birth story. Glad I kept track all these years.