Randy Stopped Delivering Babies
When asked in the middle of my third year of medical school, which specialty I was likely to choose, my answer was not given firmly, other than to confide that I was sure that it would not be Psychiatry. At one point in my graduate years, I thought I could be a student forever but in fact, a need to move on was growing and with it, a decision had to be made. I chose to be a generalist, a family physician. An important personal variable in that decision was that I wanted to do procedures in my work. Internists are generalists, but they do not do many procedures. This was an almost intuitive need as I had little experience with them as a student. Specific to Obstetrics, my three weeks was at UCLA and was mostly an education on how not to practice the specialty. The technical aspects of the education was fine, but the artful work of healers, clearly lacking. The head resident was an awful man and half the residents no better. The other half were superhuman but my exposure to them was mostly the three weeks working the GYN side of the six week rotation.
I entered my residency having “caught” perhaps two babies as a student, and with little practical hands-on knowledge of how to manage labor. As I worked in a county hospital in rural California, my work was cut out for me as this was a core function of the hospital. Within months, I was assessing and learning how to do the work with a very capable set of teachers which included the nursing staff. Delivering babies became the thing that when on call, was worth the fatigue and stress that were part of the job of being a resident on call. At the end of my first year of residency, I was, with that experience, considering the specialty of obstetrics in a way never previously considered. I verbalized this thought with Kernie, now married to me for a year.
“That’s a very interesting idea, Randy. You can do that with your next wife.”
While that is not phrased as advice, it turned out to be very good advice —which happily, I took. My passion for obstetrics was subsumed into a family practice where I would hunt for interesting cases at the county hospital to generate more experience. My enthusiasm was rewarded with my being supervised to do a C-section in my first year of residency—that enthusiasm would find me nicknamed, “the slasher” which was an embarrassment — and I recovered with time to be reliable and efficient in this field.
The choice to come to Olympia was in part because of the structure of working for Group Health Cooperative, and for the fact that family doctors did a significant number of the deliveries. I sought and received C-section privileges which was a nod to my experience but the reality soon set in that operative obstetrics requires a volume of cases to maintain skill, and I was not going to be able to do that. I relinquished any claim to such privileges after my first year of work there. I did command some respect with my specialty colleagues. If I called with a problem, they gave me some rope and came when requested. I built rapport with the nursing staff and did my best to be the face of why a woman would want to choose a family doctor rather than an obstetrician for her delivery; I pretty much promised that if I was in the state, I would stop what I was doing to come in and personally do the delivery.
In this setting, I got an education on how medicine was changing. The majority of family doctors in our clinic were male, something that would flip during my career. I worked for a consumer owned medical cooperative. The local consumer group had asked that our clinic hire midwives. The Family Doctors, hearing this, felt threatened, and actively resisted. The consumers won that battle and a small staff of midwives were hired. Within a year or so, it was clear to me that all other things equal, a woman who was pregnant would prefer a female to deliver her if it could safely be arranged. And it was. Over the next decade, I saw my number of deliveries a year change from almost 40 to less than 20. Decision that used to come easy and without hesitation required some soul searching and second guessing. My number of calls to Obstetricians for advice went up. The patients who came to me were getting older ie more complicated or they were very young.
A sense that maybe my infatuation with Obstetrics was fading came when at 6:30 in the morning, I presented to discuss breast feeding with one of my younger patients who had come for care in the second half of her pregnancy. She seemed really young— younger than her 20 years. My moment came when as I reviewed lactation consultations and things we could do to enhance her success breast feeding, I saw that she was looking over my shoulder and she gave a laugh. I turned. Scooby Doo was on the TV. Maybe, just maybe, my temperament and interests despite my historical attachment to this specialty was coming to an end.
I had a mid afternoon call to come quickly for a delivery. Racing through town, pushing the speed limit and going through traffic lights late, I got to the hospital in time to watch the mother cradling her baby just delivered by……….the OB nurse. The joy I associated with fitting deliveries into a busy schedule was fading and fading fast.
My last delivery—the one that convinced me it was time to stop doing OB as a hobby —and not a foundational piece of my practice —reminded me of something every OB resident faces before graduating. That was Brenda’s delivery.
Brenda was unmarried and worked as a manager at the Evergreen State College (TESC). I met her significant other, a thin introvert who did not make eye contact easily. Brenda on the other hand had a piercing gaze and a tone that was unmistakeable. This was her first and likely only baby. She was happy to be pregnant, but not over the moon; she exhibited no sentimentality about being pregnant, the delivery she wanted, or about the baby itself. Her prenatal care was pretty normal and she seemed to be taking it all in stride. She worked until a month before her due date. She got an emotional edginess that last month and having experience, I wrote this off to a normal phase of a long nine months. She gained thirty-five pounds in the end, a little more than recommended at the time. She was tired.
She went into labor at term, and I got the call from the OB unit early one morning while I was still in bed to let me know she was having regular contractions and was effaced completely at two centimeters. We agreed I could see her on my way into work. As I was dressing for work, I got a call and the nurse was agitated. “Dr. Moeller, Brenda will not allow us to use the belt for continuous monitoring of the fetal heart tones. She is angry with us and we could really use a hand from you.” I had never encountered a hospitalized woman in labor refusing a fetal monitor before, especially for a first pregnancy. I was curious.
There were other firsts that day. When I walked into her labor room, she was pacing and crouching with each contraction. She did this stark naked. A nurse in scrubs followed her periodically using a hand held ultrasound unit to listen to the fetal heart beat. The father was not there and the tension between the patient and nurse was palpable. I greeted her, made good eye contact as we spoke and she allowed me to check her dilatation—all this passing like it was business as usual. She was close to complete and it felt good to giver her that news. I asked if while she was pushing, we could apply the fetal monitor as this is when sometimes distress became evident.
“I am having a natural childbirth,” she said, “I see no reason to have the contraption attached to me for a normal process.”
I made my points about nature not always being kind and that in fact, she was ultimately in control of her birth decisions and we labored on. She was strong and resolute and pushed hard for nearly two hours. The head crowned, she now accepted the help of the nursing staff and with great relief, the head cleared her perineum—-barely. It was a big head. As I suctioned the nose and mouth, I asked her to get ready for the final push.
“I am done!,” she said. The relief getting the head out was obvious.
“‘But the baby is not out. I need one more strong controlled push!” I was applying gentle traction on the head and getting a sense of immobility. I could not advance my fingers around the neck to see if I could feel the umbilical cord.
“NO, I am not pushing. I am DONE!” She said.
The contraction came; she panted through it despite our attempts to have her push. I tugged pretty hard—-no motion. The OB nurses got a nod from me as one applied pressure just above her pubic bone and the other moved her knees back attempting to wedge them up to her ears. I tried to feel the clavicle, but could not reach it. I tried to reach up for an arm, which if found could be pulled down ahead of the chest in an effort to make more room.
Nothing.
An aged OB on call, sitting by the nursing station put his head in the room and asked if everything was OK. I was in a panic, not having faced this before. I asked for his help and within two contractions, he had the baby out. The baby was a wimp at the first minute but perked up and seemed quite normal by five minutes post delivery. I checked for a broken clavicle and any damage to either arm. This nine and a half pound baby was just fine.
The mother gave me a “told you so look,” as I considered how I was not so fine. I repaired the episiotomy, made small talk, and left to have a debriefing from my new best friend, this OB who managed to deliver “the dystocia.”
“Shit happens,” he said, sagely. “I did not have to do any specific measures though trying to execute on them triggered a really good contraction and when she joined in, it was fine.”
He was being modest.
I felt anger towards this woman and her scripted delivery that could easily have ended with an impaired or dead child. That possibility seemed beyond her ability to conceive. I vented when I got home, I vented with my partners at work, but I was professional with her. I saw her at the six week mark after the delivery; happily, she had her clothes on. She healed well and my open ended questions about her recollection of the delivery remained unanswered. I did find out that she was going to raise the child as a single parent. She took her child to a pediatrician.
Three months later, I got a call from the medical director of our Medical Group which then numbered some eight hundred doctors. He, over the phone, awarded me a certificate that would be coming in the interoffice mail soon, celebrating, “exceptional skill and service.” I had been nominated by Brenda who wanted my abilities and skill rewarded. I had never heard of this award until that day.
I would come to a realization that the world of deliveries was changing in many ways. There was the old paternalistic model of delivering this care and I was in a new world where the patient’s preferences took precedence as in, really took preference. If the outcome intended was an experience but more importantly, a healthy mother and child, I realized my feet were in each camp as they were slipping apart, and that my weight was more firmly planted in the old. Along with having no liking of Scooby Doo, I had to accept that I was no longer a young doctor with fresh ideas and becoming temperamentally unfit for this work.
Ouch——Something I always associate with aging!
And Brenda helped me to make that decision just as she helped me age a little prematurely.
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