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Reflections Of My Obstetrical Training

by Denise Punger, MD IBCLC

This article first appeared in Mother to Mother, October 2002.

My first obstetrical exposure was a high school job working in the newborn nursery at a community hospital. From the nursery, I could hear all the laboring women suffer and I would cringe. Eventually, my empathy was suppressed because I was repeatedly told, "You forget it all anyway." Once a baby was born a labor and delivery nurse carried the bundle to the nursery to put it under the warming lights. In about four hours we asked the mothers if they wanted to feed their babies or if we should feed them in the nursery. I was young and never gave it a second thought. It was just a routine. I did not question authority.

I did not question my early OB/GYN 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 cesarean sections and instrumental deliveries in order to get hospital privileges. I watched hundreds of women get separated from their babies and families and share labor 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. Consequently, OB/GYN rotations prepared 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. My department recognized birth as a significant event in women's lives; yet, I still only walked away with the message that having a decorated birth room, playing music and avoiding the shave and enema met most womens 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 homebirth, except if it was in a derogatory way: precipitous and unplanned, or someone we judged too stupid to know they were 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/GYN patients during residency opened my eyes. She 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 OB/GYNs who know a lot more about obstetrics than I do." 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 with tons of questions, stemming from parenting books. Questions that I couldnt answer but that sure raised my curiosity. Up to this point, I had read many of the standard obstetric texts. What could a lay book add that I didn't read about in a medical text? It wasn't until 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 published, whereas medical texts emphasize proven research and protocols. Texts are often outdated by the time they get to print. Now I have a list of recommended reading for families.

I remember one early prenatal appointment that offers a good example of how I learned to allow patients to make choices. I was scheduling an amniocentesis for Jayne, who was barely over 36. You don't have to have special training to know the equation, "age > 35 = amniocentesis." My questioning faculty attending 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 risks? Did I ask her if it mattered to her to know the results? He reminded me that not all women wanted to know. Even if a genetic defect is discovered, many want to love and cherish their babies no matter what. So, after informed discussion, Jayne chose to pass on the amniocentesis. It was great to have an FP instructor with a perspective different from the OB/GYN view.

At another appointment, Jayne announced that she would have a female companion to support her throughout labor. I thought it was a good idea because she had no family in the area; na´ve, I couldnt know the impact it would eventually have on me. As her due date came closer, I became anxious about her delivery. I wanted to be certain that I would be there. Finally she called, saying she was having strong, regular contractions. At that point in residency, I always encouraged my patients to stay at home as long as possible. The longer you stay 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. This was the first time I had ever seen anything like it. It was a strong contrast to the awkward, inadequate feelings I had in the labor room, where I didnt know how to comfort laboring women. I could catch babies, cut and stitch, but, honestly, I don't think Jayne even needed me.

This woman was going to make my job as physician easier. Jaynes labor was one of the quickest. (Years later, my father-in-law, a retired OB/GYN, admitted that a doulas presence made it much easier for him.) No one had ever explained to me 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 a priority. All our OB/GYNs had epidurals and/or injectable pain medications. The only way I knew to deal with pain was to cover it up or speed up.

As I approached the elevator, I called out, "Hold the door! Im her doctor." Its unfortunate that Jayne didn't deliver in the elevator. By the time she got to her room, nurses were ready to start an IV and strap the monitor around her, even though the baby's head was crowning. She was a primigravida 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 would take care of the pain. They passed me the betadine and razor, which I didnt want to use. They argued with me, "What if she tears?" I said, "I'll worry about it then." I did repair a tear and did not need to trim away any hair. Her coach was still providing comfort and reassurance, something I couldnt do while stitching. It came naturally to me 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 were. I realized that this validation from me would help bonding and perhaps compensate for the hospitals inadequacies.

As far as I can remember, Jayne was the first patient I ever had who wanted to breastfeed for at least a year. She actually looked forward to breastfeeding. How intimidating to me! The only thing I had learned about breastfeeding all those years was from a poster in the Tri-county Health Clinic aimed at low-literacy clients. "Breastmilk: healthier, neater, cheaper and smarter." Thankfully, Jayne had no problems, because I had no skills to deal with breastfeeding complications. It wasn't until becoming a parent myself, that I realized medical education didnt 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 we ever requested hospital OB privileges, we could demonstrate that we had the experience. I logged Jayne in, even though I didnt do much for her, but learned the most from her.

In the years since, I have had two children. Sharing my birth stories has 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 increased and 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 she raises her children and relates to her partner, family and friends.
I am amazed, but not surprised, that this simple concept is overlooked by our culture. My expectant patients will often put more thought into their nursery theme
than their birth plans. I have heard a lot of excuses about why birth is minimized. For some, it may be about 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 they won't remember any of it. Some even think that getting an epidural or having a scheduled cesarean section negates the need for a birth plan. Yet, women 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 cesarean section.

I am often asked why I didn't go into obstetrics. Originally, I eliminated OB/ GYN as a specialty because although delivering babies was a happy event, the emphasis was on the challenges 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 practice obstetrics, I strive to do more for expectant families by providing anticipatory education.


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Denise Punger MD FAAFP IBCLC
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Copyright 2005