Yes, Virginia, crappy OBs really do exist

I read and enjoy several blogs by physicians including OBs. One theme I hear frequently repeated by those doctors is (if I may paraphrase) "the natural birth community (particularly online) paints all OBs as evil/uncaring/c-section happy/in a rush to get to our golf game. I am not like that" - sometimes then there is a chorus of "well YOU are very rare and special" from the commenters - "and my colleagues are not like that. They are wonderful people who care about their patients."

I believe that there are caring, dedicated OBs out there and I believe they are in the majority. Keep in mind that this doesn't mean I believe their caring and dedication play out in ways that are always mother-friendly. I also believe there are OBs who routinely practice in a way that is based on informed consent, patient choice, and respectful communication even when the patient disagrees with them or wants to diverge from their standard practice; I sometimes have difficulty believing they're in the majority, but I don't believe they're rare, special pearls.

However, I do think that the proportion of non-evidence based, aggressive, and/or insensitive OBs is higher than the other OBs realize. They just don't routinely see each other in practice. In a teaching hospital where there are residents, fellows, attendings, etc. all working together this is less true, but once OBs are out in the community in their own practices, they're not following each other around to see what goes on inside the exam room or in L&D. So behavior like this happens to women, is reported by those women or by observers, and is disregarded by OBs as "My colleagues are good people. They're not like that." You can be a nice, caring person and still be like this:

Well, the OB feels this need to check her cervix again. After I just did the same thing less than 2 minutes before. I even said - "hey, I just checked her. She's still only 7-8 cm. But she's hurting bad in that one spot, so anesthesia is coming up to re-dose her."

"You think I can stretch her to 10cm?" he asks.

"No way. Cervix is too thick all the way around." I tell him as I cringe at the thought of manually opening her cervix when she is in such excruciating pain to begin with.

The OB insists on checking her again. And forces her cervix open another 1-2 cm. The woman is screaming at the top of her lungs through all of this. I'm giving the doc the evil eye, and telling him again - "anesthesia is coming up. This woman deserves some better pain relief!"

The OB is telling the woman to push through it.

Fucker.

I look at the woman and mouth "I'm so sorry" to her.

From labor nurse At Your Cervix.

I doubt that this doctor walks around with horns sprouting out of his head, or telling OB colleagues how much he hates his patients. He may even be lovely to some of his patients, or lovely in certain situations. But I think it's OK to admit that not everyone knows what goes on behind closed doors, and that when women tell their stories of inappropriate treatment, we should validate and honor those stories. The kneejerk response should not be "No one I know would do that - we are good people" (and neither should it be "All OBs are EVIIIIIL"). Because clearly, someone IS doing that - and why couldn't it be someone you know?

Physiologic birth and breastfeeding

I went to a very fast birth recently! Mom called me to tell me she was in labor, an hour later to say they were going to the hospital. I didn't believe from the tone of her voice that she was really so far along (although I just said, "Sounds good, see you there.")

I arrived at the hospital thinking she might be 4-5 cms, max. But when I walked into her room they said "You're just in time!" I said, "Just in time for what?" "For her to have the baby!" Yep, she walked in at 10 centimeters and pushed the baby out about 45 minutes later. Until she was checked she fooled just about everybody about how far along she was, including her husband and the midwife - everyone was shocked by how far along she was. Fortunately mom tuned into her own body and ignored the rest of us!

Because she walked in ready to go, and didn't want drugs anyway, mom really got absolutely nothing - no IV, no injections, nada. She just sat down on the bed and pushed her baby out. And after days of rounding with the LCs on a floor full of post-epidural babies, it was so striking to see a baby from a totally unmedicated labor! This baby was so alert from the beginning - eyes open, looking around - and latched on and nursed beautifully within half an hour. When I went in the next day it was the same story - awake, perfect latch, nursing frequently and effectively. This on a floor full of babies with bad latches, breast refusal, ineffective suck.

Birth practices affect breastfeeding. It just gets brought home to me over and over. The LCs all know it. They dislike epidurals and other interventions not in any holier-than-thou, you're-a-worse-mom way. One LC needed to have all her babies by c-section. But just like the others, she sighs in frustration over how all those meds are affecting the babies that she's trying to get onto the breast.

We so rarely see a baby who has experienced a physiologic birth, we forget what it looks like. This mom went into labor on her own, got zero meds, followed her body's urges to push (very minimal coaching), and when baby emerged it went straight to mom. Her placenta came out quickly, her uterus firmed up nicely, she began nursing, the end. Nobody did anything to speed her up or slow her down, and she moved and positioned herself however she wanted. Her body just did its thing. That's a physiologic birth! As a doula, I'm fortunate to attend more than my share. As an LC-in-training, I'm lucky to see them at all. All these nursing problems begin to seem normal...but they're not, or at least they don't have to be.

I don't want to sound all super crunchy, "Sure you can have your precious epidural...IF YOU NEVER WANT YOUR BABY TO BREASTFEED." Can you have an epidural and breastfeed successfully? OF COURSE! Can you have an physiologic birth and have feeding issues? Sadly, yes! I'm not talking here about individual choices - many birth-related feeding problems are transient and a determined mom can easily surmount them. But I'm speaking here from a public health standpoint. Not all moms are determined, or have the resources to draw on to overcome those problems. By messing with breastfeeding in any way, we tip more and more of those moms-on-the-edge right over it. And we're messing with breastfeeding big time via birth. Too many women see the fussy sleepy baby and/or the latch issues, and they just decide "This is not for me". Either we have to do something about how we provide pain relief for those who want it, or how we prepare and support moms who have high-intervention births.

A good first start, from what I've seen, is to make sure moms get two full days in the hospital with lots of LC (or other trained staff) assistance - instead of the hospital hustling them out the door. It's hard to fix or even wait out birth-related breastfeeding problems in just 24-36 hours. Yet all these moms are being whisked out the door because hospitals get paid the same for your postpartum care, whether you stay 1 day or 2 days. And of course there aren't enough LCs to give the intensive support some moms need. Sigh.

IBCLC training update

This semester, it is busy. As usual, there are a million things I have sitting around waiting to be linked to. I haven't even talked about the Today show home birth ridiculousness yet! (But when so many other people have done it so well, now it seems repetitive).

Today is Wednesday, which is my lactation consultant observation day at the hospital, which is one of the things that is making me so busy: I'm there all day, and by the time I get home I am zapped and don't get a lot of schoolwork done (OK, any schoolwork done). If it wasn't for that I'd have the whole day free to do all the other things I have to do, which then get shoved into the precious open time in the rest of the week. But would I trade my LC observation days for more free time? Of course not. So, I am figuring out the semester as I go along. And I thought I would shake off my Wednesday evening sluggishness long enough to update a little on my LC observation so far:

The hospital I'm observing at is the same place I work as a volunteer doula, and in general I have found them to be a fairly mother- and baby-friendly hospital (they are actually working on getting their baby-friendly certification). The nurses and the pediatricians I have seen so far are very supportive of breastfeeding, even if they aren't always fully informed.

Lactation services is, unfortunately (maybe fortunately for me) not adequately staffed and in this era of budget cuts, unlikely to be increased any time soon. The LCs I work with are on their feet every minute of their workday, and usually can't even see everyone they're supposed to. Today the LC I worked with was supposed to see something like 11 patients, and made it to 6 - and that includes going to see all of those 6 multiple times - for some of them, we went to every feeding they did during the day. If you can't see everyone, this leads to some tough choices - prioritize the mom with inverted nipples, sleepy baby, and poor family support? Or see she doesn't seem that motivated, and think you should spend your time on someone who has a greater chance of succeeding? Much as these are unpleasant choices that shouldn't have to be made, they are real.

I say that the fact it's not adequately staffed is fortunate for me, only because I get to see so much in a day. There is zero downtime, unless you count when the LC dashes to the computer to chart, and I sit next to her trying to remember what I saw and record it in my observation notebook. I am getting to see so much - just a wide range of situations, anatomies, and medical conditions. I haven't done any days in the NICU yet, but I am really looking forward to my first experiences working with preterm babies & their moms.

One thing I've noticed is that my observation days seem to run in themes. For example, last week I was with an LC who was seeing a lot of outpatients, where overfeeding was the theme. This week, we were seeing all inpatients (most less than 24 hours) and the theme was sleepiness and breast refusal. I started to get a little leery as I saw the LC put on nipple shield after nipple shield. Was this her solution to everything? Then she told me, "I usually use one a week." She said she has been seeing more and more sleepy, fussy babies in the past few weeks and is getting concerned about it. Her concern is that they have apparently changed either the epidural dose and/or the medication; this being a typical American hospital, nearly everyone has had an epidural, and if it's seriously affecting the feeding behavior of the babies it's a big problem. I still don't know how I feel about the nipple shields for every problem she applied (heh) them to, but I am curious to know what she learns about the epidural meds.

In terms of the LCs I'm observing, I am learning a lot from observing different practice styles and different approaches. I try hard to check my judgment when I see something I don't want to emulate. It's so easy as an observer to think "I wouldn't do that" or "I wouldn't use that word the family probably doesn't understand" but I know how extremely hard it is to do in practice. And seeing how extremely rushed the LCs are, I can't entertain too many fantasies of long, empowering chats once my turn comes to do the consults. (Another good reason to find some LCs to shadow who are able to have a slower pace, for balance.) Still, I am trying to stay sensitive to places where I see overmedicalization, or creating dependence on the "expert". I am glad our class and professor give us space to discuss those issues.

So far, I love my LC observation days - I love working with families, having a new challenge every 20 minutes, keeping busy, and learning. And I love all those cute little babies! I know not every doula/midwife/other perinatal professional goes into the field from loving babies - sometimes they just love to work with women and don't find babies that interesting. But I have always loved babies, and I really love these tiny little newborns. It's amazing how they are simultaneously so dependent and helpless, and yet so capable. I haven't seen any true self-latching, but when a baby is hungry but not latching, the LCs will encourage the mom to put the baby upright between her breasts, skin-to-skin. The baby will right away start bobbing its head and throwing itself to the side, then move down her breast, and root for the nipple. And when they're done nursing, they'll just relax into a little pink ball on her skin and fall into the deepest sleep. It never fails to make me go "Awwww." So that's my mission these days: more empowered babies!

Don't count on your epidural

I used to work with a great midwife who gave a presentation of research on women's satisfaction with pain relief in labor. She said "If women are expecting pain relief and don't get it, they are not satisfied. If they are expecting unmedicated labor and end up with medications, they are not satisfied."

I thought of that when I read Reality Rounds' great post on expecting an epidural...and not getting one.

This is something I wish more women understood. Just because you expect to get pain relief in labor, you may not get it. You may never get it: you may have a fast labor, or show up too late, or have to wait too long for the anesthesiologist and by the time he shows up the baby is crowning. (If he ever shows up.) You also might have to wait for hours. When you get one, your epidural may not work, or only work partially. (My least favorite kinds of epidurals.) And most women do seem to feel a baby emerging from the vagina, regardless of the epidural.

I agree with RR: every woman should take a class that teaches them non-medical forms of pain relief. If your expectations for pain relief are met and you never needed those techniques - great. But if you need them, they could come in pretty handy. Above all, of course, keep your expectations flexible - then it's harder to be disappointed.