:: to the teeth ::    thoughts on social justice, medicine, race, hope and beats

"Another world is not only possible, she is on her way.
On a quiet day, I can hear her breathing." :: Arundhati Roy ::

"The most common way people give up their power is by thinking they don't have any." :: Alice Walker ::
Saturday, July 15, 2006  

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.


posted by andru | 7/15/2006 01:06:00 PM | |


i understand your frustration, but you also have to put yourself in her shoes - whether or not she got just what she expected - delivering a baby is damn painful. When the epidural wears off, that is still a painful experience and somehow if only you can experience such an event first hand, refrain from the temptation to judge from outside the faulty system of healthcare.

it is not karmic justice for her to see only the pain in her experience and thus relay only that aspect of her experience to you.

the reality that you expect is not her reality. you see only the beauty of a newborn and not the painful experience one can go through begetting such beauty. do give her the permission of seeing and experiencing the pain she felt, and keep the judgement of her karmic justice (that is not for you to dictate, but only human to expect) to yourself. there could have been so many other factors to consider - not just the factors from the healthcare point of view - but from her own personal experiences and situation. I am sure she sees a beautiful baby and is grateful for a healthy and lovely gift - but pain is still pain, and sometimes people forget to come out of that experience sooner than we'd like them to - it's their journey, and our journey to honor their paths to healing.

# posted by Anonymous Anonymous : 7/17/2006 3:05 PM  

Dear comment poster above:
Um.....No. Delivering a baby does not have to be that painful if the practitioners who assisted her knew what they were doing, and also, delivering a child in a squatting position and allowing gravity to assist with the childbirth, as so many other cultures practice, helps with a less painful delivery.
Of course, so do water-birth and other alternative methods such as that.

# posted by Anonymous Anonymous : 7/17/2006 9:47 PM  

I do understand that there are many other ways that delivery can be less painful, however based on andru's post above, it wasn't exactly on the menu for this woman to choose. and even if she could choose, her fear would probably have overriden any other choice possible - as there were other factors mentioned, like the anxiety in her relationship with the father/husband, the financial stress accompanying a hospital delivery, etc.

my comment was about honoring her decision to be in her fears, her reality, and giving her the permission to be in that reality - whether it was fear-based or not, but not necessarily putting the blame as if 'she got what she wanted' kind of thinking. there are still so many people out there who just aren't as enlightened about their many choices as we'd like them to be, but we have to honor their path just as much as they hopefully honor ours.

# posted by Anonymous Anonymous : 7/18/2006 12:07 AM  

i appreciate the dialog. i actually agree with you about honoring her to be in her fear or pain, or reality. i didn't have judgement about her needing or using an epidural. i walk the path with people almost anywhere they choose to go.

it was her wish to have a "relatively" natural birth without those pain relieveing tools. when relating the hospital experience, you could feel her pride in the story of her birth until her bag of water was broken without her consent and her pain increased and became the center of her story.

my comments about karma are not meant to imply judgement, actually acceptance of what happened. i'm not a monk and have very little real understanding of the concept of karma.

the breaking of her bag of water happened to reduce the overall time of her labor. we are taught that it speeds things up by about 20 minutes. maybe if she wasn't ruptured she would have wound up with a c-section... no way to know. but likely, as these things go, she would have progressed slowly to complete and pushed the baby out in another few hours.

this is a soft call on my part, i'm not second geussing her hospital course, i wasn't there. but on the surface of it, there were perhaps other decisions that could have been followed.


# posted by Blogger andru : 7/22/2006 2:12 PM  

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