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Denise Punger MD FAAFP IBCLC
Reflections of My Obstetrical Training

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Reflections of

My Obstetrical

Training

By Denise Punger MD IBCLC

 

By sharing my birth story with Mother to Mother over two years ago, it gave me the opportunity to learn far more about birth than I thought possible after completing residency. Telling my story made me listen to other mother's stories in greater detail. I mean, really listen, not just "take a medical history." I have reflected on my previous training in managing labor. My respect for pregnancy and birth has been increased. I am thoroughly convinced that birth forever changes everything about a woman. An empowering experience will improve emotional and physical health. On the other hand, undermining a woman's ability to birth will adversely affect health. The result can have a profound impact on the way the woman raises her children, relates to her partner, relatives and friends.

I am amazed, but not all surprised, that this simple concept is overlooked by our culture. Even my expectant patients, whom I inform, will often put more thought into their nursery theme than their birth plans. I have heard a lot of excuses why birth is minimized. For some it may be valuing material goods over experiences. Some women just don't believe they can have a bad experience with birth. Some are under the false impression that you don't remember any of it. Even some feel that getting an epidural or having a scheduled c-section negates the need for having a birth plan. Woman planning surgery or intervention need even more support because they are at greater risk for complications. They should not ignore the information and help available. Getting the right information may even help prevent the c-section.

My previous obstetrical exposure included a high school job working in the newborn nursery at a community hospital. From the nursery I cringed when I heard all the laboring women suffer. My empathy was suppressed because I was repeatedly told, "You forget it all anyway." Once the baby was born, an L&D nurse carried the bundle to the nursery to put under the warming lights. In about four hours we asked the mothers if they wanted to feed the babies or should we feed them in the nursery. I was young. I never gave it a second thought. It was just a routine. I did not question authority.

I did not question my earlier OB rotations much either. The rotations met my expectations: to teach protocols and procedures. Residents love to do procedures. It is almost a contest to see whose laboring patient will "go first," who can do an amniotomy (rupture membranes) at only 2cm dilation, and who can get the minimum number of c-sections and instrumental deliveries in order to get hospital privileges. I continued to watched hundreds of women get separated from their babies and family, and share labor rooms and postpartum rooms with strangers so that we could carry out our work.

The Family Medicine department I trained with taught me to start questioning the routine. Possibly because the women who came to the Family Physicians (FPs) were low risk compared to the high-risk ladies that had been referred to Maternal-Fetal. Often these high-risk women had a combination of risk factors. They may have had known maternal medical problems requiring medications during labor or fetal problems necessitating a team of specialists to be available at birth. HIV and/or addiction complications were also common at a teaching hospital. Subsequently, OB rotations prepare a physician to handle the most difficult births. The FPs got to see the healthier patients and did not need to rely as much on surgical skills or routines. They introduced me to the idea that all these interventions were not necessary for all patients. While my department recognized birth as a significant event in a woman's life, I still only walked away with the message that having a decorated birth room, playing music, and avoiding the shave and enema met these needs.

It is hard to change a mind-set you have carried all your life. Alternatives to hospital birth were not addressed well. I thought concepts such as "birth centers" and "midwifery" were for progressive (California) types. The doula profession was just barely emerging. I don't remember ever discussing home birth except if it was derogatory precipitous and unplanned, or someone we judged too stupid to know they were even pregnant. This close-minded approach is typical of physician training and is unfortunate for the majority of expectant mothers.


One of my very last OB patients during residency was exceptional. Jayne was a single lawyer who had a birth plan, unlike other teaching hospital patients. She advocated her need to have a natural delivery. My first thought was "An attorney! I should refer her to the OBs who know a lot more about obstetrics than me." But, I was curious and open to her views. I didn't think her needs could be met in our hospital. Could I, as a third year family medicine resident, protect her birth plan?

I looked forward to Jaynes appointments. I learned so much. She came to her prenatal appointments with tons of questions stemming from parenting books. Questions that I could not answer, but sure raised my curiosity. Up to this point in time, I had read much of the standard obstetric texts. What could a lay book add that I didn't read about in a medical text? It wasn't till years later when I read these books as a parent that I saw their value. Parenting books give quite a different perspective. People who are passionate about a special topic write them. They often present research that has been ignored because there was no financial interest or theories not yet researched, where as, text emphasizes proven research and protocols. Texts are often outdated by the time they get published. Now I have a list of recommended reading for families.

A particular memory of an early prenatal appointment was a good example of allowing patients to make a choice. I was scheduling an amniocentesis. Jayne was barely over 36. You don't have to have special training to know the equation, "Age > 35 = amniocentesis." My questioning faculty noticed Jayne had a normal ultrasound and alpha fetal protein. Why was I scheduling this? Did I discuss it with her? Did I give her informed consent, i.e., let her know amniocentesis had risk? Did I even discuss with her if it mattered to her to know the results? He reminded me that not all women want to know. Even if they did know of a genetic defect, many want to love and cherish their babies no matter what. So, after informed discussion, Jayne chose to pass up the amniocentesis. It was great to have an FP instructor with a different perspective.

At another prenatal appointment, Jayne announced that she would have a female companion support her throughout labor. I thought it was a good idea since she had no family in the area, naive of the impact it would eventually have on me. As it got closer to her due date, I got anxious about her delivery. I wanted to be certain that I would be there. Finally, I get a call from her that she is having strong, regular contractions. At this point in residency, I always encouraged my patients to stay at home as long as possible. The longer you stayed at home, the less the hospital can do to you. But soon it was time for her to come in. Hoping to get there first, I approached the elevator and saw Jayne in there panting through a contraction with a support person who knew exactly what to do for her, like they were one. This was the first time I had ever seen anything like this. A strong contrast to the awkward, inadequate feelings I had in the labor room, not knowing how to console a laboring woman. I could catch babies, cut and stitch, etc.... But honestly, I don't think they even needed me. This woman was going to make my job as physician easier. Her labor was one of the quickest. (Years later, my father-in-law, a retired OB, admitted that a doulas presence made it much easier for him.) No one ever explained how to help a woman emotionally deal with the pain. Looking back, I don't know if anyone else knew how either. It wasn't priority anyway. All our OBs had epidurals and/or injectible pain meds. The only way I knew to deal with pain was to cover it up or speed it up.

Back to the story... As I approached the elevator, I call out, "Hold the door! I am her doctor." It is unfortunate that she didn't deliver in the elevator. The nurses were ready to start an IV and strap the monitor around her, even though the baby's head was crowning. She was a primagravida and couldn't push that baby out quick enough for the persistent staff to do their procedures. I told them to leave her alone. Pushing the baby out will take care of the pain. They passed me the betadine and razor, which I did not want to use. They argued with me, "What if she tears." "I'll worry about it then." Anyway, I did repair a tear and did not need to trim away any hair. Her coach was still providing comfort and reassurance, something I could not do while stitching. It came natural to acknowledge Jayne's effort and beautiful newborn. After that I made it a point to commend all my mothers on their labor. I also told them how beautiful their newborns are. I realized that this validation from me would help bonding and compensate for the hospital inadequacies.

Jayne was the first patient I ever had that I can remember wanting to breastfeed for at least a year. She made a big deal about it, too. She actually looked forward to breastfeeding. How intimidating to me. The only thing I learned about breastfeeding all these years was from a poster in the Tricounty Health Clinic aimed at low-literacy clients. "Breastmilk: healthier, neater, cheaper, and smarter." Thankfully, Jayne had no problems. I had no skills to help breastfeeding complications. It wasn't until becoming a parent myself, when breastfeeding came easy to me and not necessarily to others, did I realize medical education did not include breastfeeding. I began to notice how much physicians could do to undermine a mother's determination to breastfeed successfully.

As residents, we were encouraged to keep strict logs of procedures, so that if I ever requested hospital OB privileges, I could demonstrate that I had the experience. I logged Jayne in, even though I did not do much (but learned the most).

I am often asked why I didn't do OB. Most of the FP residents who continued to do obstetrics either stayed on as faculty or went to a rural setting. Coming to South Florida was not conducive to pursuing obstetrics as a Family Physician. I, originally, eliminated OB GYN as a specialty because the emphasis was on surgery with delivering babies, a happy event that coincided with the challenge of GYN surgery. My surgically inclined classmates readily admitted this. For them, birth was the end of a nine-month patient-physician relationship. To me birth was the beginning of a family unit. Family Medicine represented this. Despite my decision not to "do" OB, I will strive to do more for expectant families by anticipatory education. I am grateful that I have had the opportunity for the Gentle Spirit Doulas to intimately share their birth stories, particularly the out-of-hospital births, with me so I can continue learning far beyond formal training. Thank you doulas. You are wonderful role models.

Denise Punger MD IBCLC and her husband John Coquelet DO, both Family Physicians, recently moved from the Treasure Coast, Florida to NW Georgia with their two sons. She is involved with birth and breastfeeding organizations locally as well as nationally. Her personal Birth Story is on line at denisepunger.tripod.com. Comments to denisepunger@hotmail.com

(Written for Mother to Mother, Oct. 2002)