Wednesday, October 14, 2009

A (Homebirth) Baby Story

After I took obstetrics class the second quarter of my third year, I was eligible to sign up for a birth rotation. I put my name in the hat and got a call in May that I was assigned to a 26 year old pediatric nurse expecting her first child. Her due date was October 7th which seemed to be forever in the future. Leading up to her labor, I would attend all of her appointments at the naturopathic obstetrician’s office and be ready to drop my life when the time came to help deliver the baby. That time came at 3:30 in the morning on Friday October 9th.

24 hours after the initial call, still no baby and little progression. We took mom to OB triage at the local hospital thinking an augmentation with Pitocin would be best to help make progress. The ER doc believed that she was simply having a prolonged latent phase of labor and thought that starting Pitocin would actually be more like an induction rather than augmentation. They decided to give an injection of morphine to ease her pain and send her home to hopefully get some rest. Saturday morning her contractions became more intense and lasted longer. This meant that she was actually in active labor. By the time we arrived at her home, she was 7 cm dilated. After that, the labor was textbook. Around three o’clock, she was exhausted and stated that “she couldn’t do it any longer.” Those words usually mean it’s time to push. We had her sit on the birth stool which helps open the pelvis and puts the mother in an ideal vertical position to deliver. She pushed for a total of 11 minutes and a beautiful baby girl (Surprise! Nobody knew the sex!) was brought into the world. Immediately we put the baby into mom’s arms, she let out a healthy cry and the room full of family and friends burst into tears as well. 44 hours of total labor time had culminated in the gift of life.

I learned from this experience that freedom of choice and safety are top priorities when deciding where to deliver a baby. According to a 2000 Cochrane Library study, “There is no strong evidence to favor either home or hospital birth for selected, low risk pregnant women. In countries and areas where it is possible to establish a home birth backed up by modern hospital system, all low risk pregnant women should be offered the possibility of considering a planned home birth and should be informed about the quality of the available evidence to guide their choice.” Mom was able to lay, walk, eat, and sleep in her home. She was comfortable and had the freedom to labor however she felt.

The lithotomy position has been shown to be an ineffective position to labor and push, actually works against gravity and can lead to complications like episiotomy and perceived dystocia. My Family Practice Obstetrics text states that, “Four of seven randomized controlled trials and several case study series have shown shorter labor duration and greater uterine contraction intensity in vertical positions.” Horizontal supine positions are really most convenient for doctors and procedures and do not provide much benefit to the mother.

After the birth, mom was immediately able to hold the baby; an important event that often is interrupted by hospital procedures. She also declined erythromycin eye ointment, a legal requirement in most hospitals, because she did not have gonorrhea or chlamydia, the reason ointment is applied in the first place. Recently there has been a shortage of erythromycin ophthalmic. The CDC’s website provides a substantial list of alternative ointments and culminates the discussion by adding, “STD guidelines outline recommended prophylactic treatment for infants whose mothers have gonococcal infection and for management of infants born to mothers who have untreated chlamydia. Empiric treatment is recommended for infants exposed to gonorrhea, while monitoring for development of symptoms prior to initiating treatment is recommended for infants exposed to chlamydia. Screening mothers will allow providers to identify infants with known exposure.” In essence, if you don’t have gonorrhea or chlamydia, it may be an unnecessary procedure.

Baby received oral vitamin K drops, Apgar scores of 9 and 10, and was surrounded by the love of her mother, father, family and friends. The baby must have felt incredible energy and love when she entered the world. This was a safe decision because the mother was a low risk patient, had proper prenatal care, and had an uncomplicated pregnancy. I believe that birth does not have to be an overly medical event. In this case, we were lucky to have a hospital nearby to take over for a perceived complication and valuable second opinion. I would urge any expecting mothers to consider birth at home, in a birthing center, or by a midwife as a top choice depending on risk factors. My experience exemplified an ideal birthing situation and even more fun story to tell.

Thursday, October 1, 2009

When I Grow Up...

“Something mystical happens when we stop forcing our way through life and surrender to each moment.”

I had a great conversation with an old friend tonight. She just headed back to school for the first time in years, works a full time job, and still ponders the age old question, “What do I want to be when I grow up?” I often consult Google with difficult questions such as these, so I searched, "what do I want to be when I grow up?" and  got 54.6 MILLION results, which included one inspiring song.

Our conversation reminded me of an interesting, and somewhat uncomfortable, experience with a patient this week. His chief concern was hypertenstion, hyperlipidemia and weight gain. I was observing the interaction between him and the supervising physician as she explained what he needed to do in order to make the necessary lifestyle and nutritional changes to successfully address the problem. His resistance and anger was evident throughout the visit (especially when he yelled at the doctor!) and no matter how the treatment plan was described-- the message just was not getting through. We later learned that his father was dying of cancer, work is slow and he is not making much money, and he hates his job. He stated that he didn’t know how he got to this place; it was not what he planned for and now felt trapped by his life. As a listener, it was easy to see a change he could make to start with-- he needed a new job or to change his job somehow so that it was enjoyable for him. He clearly didn’t know what he wanted to be when he grew up, or somehow his current situation wasn’t fitting his vision for life.

This man could not see the dots. He just saw himself frustrated and alone with his problems. People, places, circumstances, and things are put into our lives often for unknown reasons until we can look back and see the dots connecting. At some point, the dots line up and we realize we have what we wanted. Did it take growing up? Did it take trying on different hats to find out what to "be"? Showing up and being present for life? In the case of my frustrated patient, his limiting thoughts and anger made it hard for him to be present to deal with this difficult time and constructively make change.

This experience exemplified my belief that the doctor must always meet the patient where they are. For this man, no amount of diet and exercise counseling was going to make a difference at this visit and frankly, it wasn't important. What he needed was to vent his frustration. He needed to shed a tear, get angry, argue and resist any suggestions we offered. He needed to be in a place where he would be listened to, not judged, and be given empathy. When I grow up and am officially a doctor, I will remember that a listening ear is often the best and only therapy a patient needs; because to truly be heard is something that is often complicated and difficult to find.