A recent study showed that 1 in 6 people who had babies in the United States believed they were mistreated during labor and delivery (https://reproductive-health-journal.biomedcentral.com/articles/10.1186/s12978-019-0729-2). That's almost twice the incidence of diabetes in this country, to put that into perspective. Since I follow a lot of reproductive healthcare providers, organizations, and news sources on Twitter, this study and articles referencing it have been on my radar all week (https://www.scarymommy.com/gop-rep-michael-burgess-migrant-kids-can-leave/). My initial reaction to this (and to the many research studies and news pieces that have been published recently regarding problems in OB/Gyn healthcare) is to be defensive. It's natural for any of us to feel this way when something about who were are or what we do comes under scrutiny. Once past this gut instinct of anger, however, all of us in the OB/Gyn community have to reflect on the care we give so that we can improve this clearly problematic landscape of maternity care.
Something I have been considering a lot lately is how my patients and I communicate with each other. I've been trying to be better in explaining all of what I do and understanding my patients' views and desires. I think there can be a big impression when people go to the doctor in general that things are being done TO them. I want there to be more of a sense that things are being done FOR them. If someone as a medical provider can't provide a concise reason for doing a portion of a physical exam, ordering a lab test, or obtaining imaging, there's a good chance it's not necessary. This can translate to any action I take as a doctor - in the office, the operating room, or on labor and delivery. If you ask my surgical assistant or anyone who has been in the operating room with me, for instance, I pretty much always start mumbling a conversation with myself/everyone/no one about what I'm encountering and what I should do as I try to figure out what's best to do in a case that's tricky or not clear-cut in some way. This helps to keep me in check to ensure that I accomplish not only what I feel is best for the patient but also whatever the patient's goals were in undergoing surgery.
I think communication and rationalization has changed for me a lot in transitioning from residency to being in private practice. Often in training, we do things because of what's expected by someone else. For example, I remember often stressing about making sure to check the cervix of every laboring patient and make sure any interventions were performed by the time of signout, when we discussed each patient in order to transfer care to the next shift. There was a lot of pressure to do things simply for the sake of having the information and feeling like I had done everything possible for signout. There was an impending sense of a clock of doom on every patient's course. Is "it's almost time for signout" a good reason for an action? Not always.
I still care about guidelines, and I haven't completely thrown my training out the window in the two years since graduation. However, I do think that I am better at critically considering all interventions (including simply performing a cervix check) and ensuring the patient has full understanding and autonomy in all decisions made. I have the opportunity to be much more stubborn in trying to help achieve a vaginal delivery for someone who highly desires one (in cases where this is safe for the patient and the fetus) before deciding on a C-section, for example. It's not always successful, but I leave the situation knowing that I did everything I could to provide the best possible birth experience for the patient. This can be a major challenge, however, in very busy maternity hospitals. Many hospitals in urban and suburban settings are becoming busier and busier as rural hospitals stop providing maternity services. This needs to be addressed.
Another change from training to "the real world" has been in my relationship with patients. Often as a resident, I was caring for patients on labor and delivery that I had never met before. I had their medical charts available in order to know their relevant histories, but I didn't know them. Now, I have an established relationship with many of the people whose babies I deliver. I know what outside non-medical factors they are carrying. I know what pieces of their whole selves I need to consider to provide appropriate, individualized care. This is a huge challenge in places and in circumstances where people cannot access consistent prenatal care, which is becoming more and more of a problem in our country. We need to ensure quality prenatal care access to all.
Unfortunately in the world of OB/Gyn, the rationale that many providers have for many actions is related to their own convenience, including "to not get sued". It's faster to just go to a C-section than try other measures. It gets an OB/Gyn back to bed quicker to do an operative vaginal delivery after pushing for a while at 3:00 am than to simply have the patient continue pushing. Medical litigation is scary, and malpractice suits are common in the OB/Gyn world. We need to do a better job of establishing relationships of trust built on open communication lines and thorough education so that the fear of being sued won't even have to exist. I think for a lot of physicians, stress, scheduling, lack of sleep, and other personal issues place a barrier on that and change the role of caregiver into something different, something negative, something reactionary. We need to consider how we can improve these factors.
I hope that I and every OB/Gyn physician can take the findings of this study and use it to improve the care we provide. In a broader sense, I hope our healthcare systems can find solutions to provide appropriate pregnancy care to everyone who needs it. Though circumstances arise in labor and delivery and sometimes the desired course needs to change, we need to create an environment where this can be accomplished without inflicting trauma.