A family doctor who does low-risk obstetrics agrees. “Birth is normal, natural and healthy, and it’s all just beautiful in a dark room with all of us humming ‘Kumbaya’—until something goes terribly wrong,” he says.
At the same time, Moola recognizes that problems like a breech baby or a prolapsed uterus are the exception rather than the norm. “I think it’s rare that things go from normal to absolute chaos,” he says.
It’s the medical model’s attachment to rare complications that makes some OBGYNs uncomfortable. “We’re looking for problems,” Marjorie Greenfield says. “There’s almost this internal logic that leads you down a road where you do a lot of interventions that lead to a lot more interventions that lead to a lot more interventions that lead to a C-section and then everybody thinks, ‘Oh, well, you know, boy, good thing she didn’t deliver at home because she needed a Caesarean.’”
The derivation of the term Caesarean section itself is fascinating. According to Cesarean Section—A Brief History (published by the U.S. National Library of Medicine), the term derives from Roman law under Caesar, which decreed that all women who died during childbirth were to be cut open in an attempt to save the child “for a state wishing to increase its population.” The notion that the term is derived from the surgical birth of Julius Caesar has been dismissed, because Caesar’s mother Aurelia is believed to have lived long enough “to hear of her son’s invasion of Britain.”
Ironically, Greenfield says, the slang C-section technician—the term that that made the OBGYN yell at the family doctor—may be deserved. “I think what we do is, often—we manage the labour in such a way that we paint ourselves into a corner and then we have to cut ourselves out of it.”
In addition to slang, adages are being coined to describe the phenomenon of too much intervention. “They say that the most dangerous place for a woman in early labour is Labour and Delivery,” an OBGYN resident says.
The belief that interventions are necessary promotes a culture of fear, another aspect of modern maternal care that has many up in arms. “I think we terrify our mothers from the first prenatal visit,” says a family doctor. “And we keep them scared until it’s all over and [then we say], ‘Oh, you’ve got a beautiful, healthy baby. Aren’t you the happiest lady in the world?’”
Perinatal nurse Nancy Hewer says malpractice lawsuits contribute to this culture of fear. The threat “would obviously influence anybody’s practice,” she says.
A doctor who practises in the U.S. was faced with exactly the kind of situation Hewer is talking about. It began with a prolonged labour, or a patient’s “failure to progress.”
In these scenarios it’s become common practice to induce labour after twenty-four hours of waiting. One reason for doing so is to avoid an infection called chorioamnionitis, which occurs when bacteria from the vagina enter the womb. It can lead to serious complications for both mother and child, including the death of the baby.
The doctor chose to wait for labour to come naturally. The mother showed no signs of infection and when eventually they decided to induce her labour, all seemed to still be going according to plan. It wasn’t until an hour before her delivery that the signs of infection showed up. The doctor delivered a baby who was acutely infected, severely ill and eventually brain damaged.
Situations like these are a doctor’s worst nightmare. Not only do doctors grieve the loss of the patient, but they can be tied up in litigation for years. OBGYNs have learned that it’s better to deliver a healthy baby by whatever means available than to open the door to disaster.
* * *
There’s tension between health professionals and the views of birth they hold to be true. Then again, there’s tension between doctors and moms to be—which is revealed by some telling slang.
Not infrequently, Dr. Moola says he is summoned to repair an unassisted home delivery gone wrong. He told me about a woman who had fired her midwives because they weren’t passionate about her birth plan—which was to deliver at home in a location that didn’t have road access.
The birth didn’t go as planned. When the mother called the hospital for help, Moola persuaded her to come to the hospital and she ended up having a vaginal delivery, but her waters had been ruptured for a few days and she ended up with an infected uterus and a postpartum hemorrhage. “I put my hand inside to remove her placenta and by this point she’d already lost a litre of blood,” says Moola. “And as I removed her placenta—one keeps their hand on the uterus to get it to contract—I just feel the uterus essentially just give up.”
Moola says they rushed the woman to the OR, where they worked furiously to try to stop the bleeding. In the end, they had to remove her uterus in order to save her life.
As heartbreaking as situations like these are, the frustration of doctors at having to manage catastrophes that could have been avoided leads to slang. Scenarios like these sometimes get labelled as natural selection at work, free-to-die births or bleed-to-death births.
“The decision to have an unassisted home delivery is akin to landing an airplane by reading about it. You know you’ll get on the ground, but you’ll probably end up in pieces,” Moola says. He notes that one of the greatest factors contributing to maternal mortality around the world is the lack of a skilled birth attendant.
On the other side of the spectrum are whiney primeys or divas. A whiney primey is a woman in her first pregnancy and in an early phase of labour who comes to the hospital day after day, believing she’s ready to have her baby when she isn’t. The former resident in OBGYN said she saw patients like that all the time. She says she felt sorry for them. “In my head I’d be thinking ‘You think this hurts? Just you wait until labour happens.’”
Dr. Gerry Prince invented his own slang to describe whiney primeys. He calls them “perineophobes,” derived in part from perineum, the part of the body between the pubic bone in front and the tailbone in the back, where a vaginal delivery takes place. The neo part of perineophobe means it’s the woman’s first time in labour, while the suffix –phobe refers to a phobia or persistent fear of an object or situation.
“I use this to refer to women who are so sensitive to any touch or pressure in the vaginal area that it can actually prevent or delay a vaginal delivery,” says Prince. “The first clue in the delivery room is that when you do the first examination on a woman who thinks she’s in labour, you can barely complete a vaginal examination without her crawling off the bed!”
Prince says that for most women the urge to push during the second stage of labour is enough for them to overcome whatever discomfort or apprehension about discomfort they possess. Perineophobes are different. “They just can’t do it,” says Prince. “They will make all sorts of noise, turn all shades of red and purple, tense all sorts of other muscles to satisfy nurses, doctors and family members that they are trying. But every time the baby’s head descends a little, they back off. It is worse, of course, without an epidural. Most women you can coach through it, but sometimes you just can’t! Sometimes, they pretend to push until they are exhausted and end up a going for a C-section.”
That’s assuming they reach the second stage of labour still determined to have a vaginal delivery. After three or four visits to hospital, many such women want the pregnancy over and done with.
“They say, ‘This is too much. I just want to have a section,’” says the former obstetrics resident. “It can be a long, drawn-out process, especially for the poor women who have that niggling really early labour for days, which can exhaust anyone. I had a lot of empathy for those women,” she adds.
To section or not to section is a major source of tension in labour and delivery wards these days. In 2010, the Caesarean delivery rate in the U.S. was 32.8 percent of all births, according to the National Center for Health Statistics. While this percentage is high, it actually represents the first decline since 1996. From 1996 to 2009, the C-section rate rose near
ly 60 percent.
No OBGYN I spoke to says he or she does C-sections on demand. Most see the high rate as the natural extension of the argument in favour of managing risk. But not everyone agrees.
“Maternal mortality in the United States is going up. And I think there are two explanations for it,” says Marjorie Greenfield. “I don’t think that our care has changed tremendously. I think the explanations are that obesity increases your chance of maternal mortality, and having had a previous Caesarean increases your chance of mortality.”
There’s wanting a C-section and there’s dictating the terms under which the operation—and all the other procedures that often go with it—take place. Not surprisingly, there’s a slang term for that.
“A princess is a woman who wants her epidural the minute she enters the hospital,” says the former resident in obstetrics. “A princess phones ahead and says ‘I’m coming. Have the anesthetist on standby for my epidural.’ There’s no question that they love their baby, but on top of their brain is the cosmetics of the situation. When they have a C-section, they dictate how many centimetres they want the incision to be.”
The upside of a smaller incision is a smaller surgical scar. Unfortunately, the downside of a smaller incision is that there’s less room to get the baby out. Sometimes, the incision is so small that the baby’s head can get stuck, a condition known as skin dystocia.
“Several times [during residency], I saw that there wasn’t room to bring the baby’s head up through the incision,” say the former OBGYN resident. “Mid C-section, we’d have to negotiate with the woman to extend the incision.”
Closely related to a princess is a diva. “My favourite was one of my patients who literally almost had her baby in the parking lot because she had to get her makeup on,” Gephart says.
* * *
Medical birth professionals of all stripes agree on one thing: their mutual disdain for birth plans. A birth plan is a document written by a woman to describe how she would like her labour to go. Some of them run several pages long.
Moola and colleagues call a multi-page birth plan by the slang term Caesarean section consent form. Recognize the sarcasm here: For whatever reason, be it scientific or chance, women who show up with birth plans tend to have labours that go anything but according to plan. If it says “no C-section,” they’ll probably end up needing one. If it says “I don’t want an epidural,” they’ll probably end up begging for one in a moment of intense pain. If it says “I want my husband to cut the umbilical cord,” he’ll probably end up stuck in traffic when the moment comes—or passed out on the floor of the birthing suite.
Almost everyone I interviewed for this chapter confirmed the irony. “I usually tell them, don’t bring a birth plan because it’s like the kiss of death,” Prince says. “Anything you put on there that you don’t want to happen is going to happen, so just don’t make a birth plan.”
More than that, Moola says, women who come in with detailed plans often end up getting what he calls the “full-meal deal,” or the whole obstetrics package—epidurals for long periods of time, induced labour and forceps included. Oh, and they get the worst complications.
Greenfield thinks there may be a scientific explanation for the positive correlation between birth plans and complications. “I think there’s a kernel of truth in that the more anxious someone is, the more they try to control their experience in the hospital by making a birth plan as if it were a contract. And the more anxious you are, the less well labour goes,” she says.
Birth plans can contain items that some would think of as esoteric—for instance, to have a favourite song played over and over again during labour.
“I can think of one woman wanting to labour while on her hands and knees with chanting music in the background,” the former obstetrics resident recalls. “The only pain control was to be deep [Lamaze] breathing, with absolutely everybody in the room taking part in the breathing: the nurse, the midwife, the doula and the resident.”
Some birth plans require that health-care professionals obtain the approval of the patient’s clergy before intervening. In some cases, it’s not a spiritual leader but a doula who the woman in labour grants the right of refusal.
A doula is a non-medical person trained to assist and support a woman, her partner and her family during pregnancy and childbirth. Although there are many training programs for doulas, they tend to be as brief as one or two weekends. There may be little if any professional oversight of the work they do.
The former resident says that on several occasions, the birth plan stipulated that the woman’s doula was to be consulted before any obstetrical intervention. One time stands out in her mind. The woman was in the late stages of labour when the baby’s heart rate showed signs of fetal distress. As a consequence, the woman’s midwife called in the obstetrical team to assess the situation.
“There were problems with the fetal heart rate,” the former OBGYN resident recalls. “There’s a predictable pattern of fetal distress and a predictable course that if you let that go long on enough, the baby’s most likely going to die.”
Both the attending and resident in obstetrics concluded that an emergency C-section was needed to get the baby out before oxygen deprivation led to irreversible brain damage. They explained things to the mother-to-be, but she said to clear it with the doula.
“Mom was saying, ‘Oh, I don’t know,’ and the doula said, ‘No, the baby’s fine. Keep with on with the labour,’” the former resident recalls.
As time went on, the fetal heart rate kept dropping—an ominous sign. The former resident says she and her attending kept suggesting a C-section with ever-increasing urgency. “The mom kept turning to the doula and saying, ‘What should I do?’ And the doula’s saying, ‘No. You can still hear the heartbeat,’” the former resident recalls. “Then it was 100 and then it was 80, then 60. I still get tingles thinking of this. We’re just standing in front of the mom saying, ‘We are losing this baby and we have to go.’ Then, the heart rate was 40, and then 20. Finally, the doula just kind of nods. We race down the hall and do the C-section to get the baby out.
“I always wonder how that baby did in the end” she says. “I can’t help but think that there’s brain damage of some sort because of waiting all that time.”
The former resident is almost shaking as she tells the story. “I’m angry for the mom, for the baby and angry for the system,” she says. “I don’t know what led to that mom to not trust the medical advice and [instead] trust this person who had a weekend training course about supporting moms.”
Some women put a lotus birth on the birth plan. A lotus birth is a practice in which the umbilical cord is left uncut following the birth—leaving the baby attached to the placenta until the cord separates at the baby’s umbilicus several days later. The practice is common in some parts of the world. Until fairly recently, it was all but unheard of in North America—but has become quite trendy of late. The placenta may be placed in a bag with pine cones and herbs and spices—and even diamonds—to reduce the smell as the placenta tissue decays.
“The placenta is to be kept, and there’s a spiritual ceremony said over the placenta,” says the resident. “And then they take the placenta home and plant it under a tree.”
There are no obvious health benefits to leaving the newborn attached to the placenta for the up to ten days needed for the umbilical cord to detach. In 2008, the Royal College of Obstetricians and Gynecologists (RCOG) noted that if left for a period of time after the birth, “there is a risk of infection in the placenta which can consequently spread to the baby. The placenta is particularly prone to infection, as it contains blood. Within a short time after birth, once the umbilical cord has stopped pulsating, the placenta has no circulation and is essentially dead tissue.” The RCOG strongly recommended that babies whose mothers opt for a lotus birth be monitored carefully for any signs of infection.
Gephart isn’t alone in thinking women with birth plans are unappreciative. “Part of being an obstetrician is the belief that you know what’s best for this person in this particular moment,” Moola says. “And that’s sometimes hard to juxtapose with a mom who may honestly feel that there’s something else that needs to happen.”
Oftentimes, a birth plan is unnecessary because it forbids procedures such as enemas and shaving of the pubic hair—things that fell out of favour years ago and are no longer done.
Some doctors and midwives are fighting back. Greenfield told me about one obstetrics department in Cleveland that doesn’t allow birth plans. They tell potential patients, “You have to trust us. If you don’t, go find another doctor.”
OBs think of birth as a medical procedure—something proposed and formulated only by doctors and other health professionals. It’s unheard of, for example, to come into the hospital with a plan for how you’d like your appendectomy to go. In an OB’s mind, the same goes for birth.
Greenfield says a birth plan is a list of preferences, not a contract: “You can’t really have a birth plan because you don’t know what’s going to happen.”
One family doctor says he tells expectant women that “no part of this is plannable or knowable. You have wishes that I could try to respect. We’ll call those birth wishes. I dissuade my patients from being invested in [birth wishes], because I’m not loving the disappointment after.”
Sometimes, birth plans evoke even stronger reactions among health professionals.
“I’ve seen a nurse rip one up,” perinatal nurse Nancy Hewer says, adding that she thought the nurse was being disrespectful. She tries to reframe the discussion. “To me it says, ‘Okay, this is somebody that I really need to spend some time with to establish trust and really let her know that I’m listening to her.’”
The Secret Language of Doctors Page 15