Delivering another message around OB...

We've been caring for pregnant women at the office who fall thru the chasms in the system and have no affordable place to go. Most recently I cared for a woman who got caught in a crossfire between Medicaid and the Public Hospital. She was uninsured, working, earning too much to qualify for Medicaid, too little to pay for private insurance. By the time she registered at the public hospital she was no longer working so they told her to apply for Medicaid again before they would put her on their payment plan. No resolution yet and she's already had her baby...

finances aside, i had the opportunity to follow this patients progress while in the hospital. I have a few thoughts to share. i had worked for 6 months helping this woman face her fears around pain, her underlying depression and fear around becoming a mom, the tensions of her relationship with her husband, her stress and anxiety around the hospital bills. Towards the end of the pregnancy she was particularly ancy about having the baby as soon as possible, ready to get the whole experience over with. we did some counseling and some therapies to help her relax, accept the pace her baby and her body were setting and find some joy and peace in her pregnant condition. and she was shifting, relaxing, enjoying.

when her contractions started, 5 minutes apart, she went in. she was 4cm so they admitted her. She entered the hospital with a smile, ready to birth as naturally as possible. her progress was slow so after a few hours they augmented her labor with pitocin which made it more painful for her. at 7cm they ruptured her membranes in an effort to speed things up. up till that point she was laboring without pain meds but once the membranes were ruptured her pain increased significantly (a well known reality is that the intact bag makes laboring more comfortable, a cusion effect for the mom). after an hour she needed an epidural for the pain, it slowed her progress down, she almost needed a c-section and in the end, the epidural wore off before the baby birthed so she wound up feeling most of the final labor.

her first words to me back in the clinic with a 3 day old baby were - "it was so painful." not, "it was so beautiful, look at my baby, what joy i'm feeling." this is a problem. more easily visible from outside the hospital than inside. the focus on rushing, on controlling every variable, and the ignorance of the subtle and deep personal issues of each case are a bad combination of factors that lead to excess intervention, dehumanized experiences, a focus on pain and suffering instead of enjoyment to achieve what we euphamistically call a "good outcome." the baby didn't die, the the mom had no physical complications, and she didn't sue.

there's no reason why a few different pathways couldn't have been activated successfully. she could have been sent home until her contractions were closer together but we use 4cm as the magic number for admission for everyone. there is no reason why she couldn't have walked and walked and walked inside the hospital until she was in true active labor. there is no reason why they had to rupture her membranes. babies can be born with the membranes intact and removed after birth. in some Native American cultures that is considered a very special, powerful omen for the person's life.

no doubt this patient was anxious, scared and eager to make the process happen faster. in a "karmic" sense, she got exactly what she wanted so this isn't so much a complaint against the system as an expression of frustration. the patient could have chosen to stay home longer, until her contractions were closer together. (i know many women who stay home until they can no longer tolerate it. they show up to deliver their babies fully dilated. it frustrates the heck out of nurses and doctors because they aren't then in control of every aspect of the labor but it means less interventions for the woman, which some prefer.) at the same time, docs and nurses in these big institutions could make sure that the patient is fully informed before each intervention. they never told her they were going to rupture her membranes. it was an ASSUMED decision by the doctor, not chosen by the patient. i remember when i was a resident that i would have been frustrated if someone told me that rupturing the membranes required informed consent, it seems like such a small detail in the BIGGER picture of hospital care, but when the bigger picture is patient comfort, patient-centered care, quality of care, it is front and center.

andru