Friday, September 01, 2006

Same due dates, different philosophies

It never ceases to amaze me, the range and experience of each individual woman's pregnancy and delivery. I know that it is a tired expression, but every delivery truly is unique. Since I am contemplating pregnancy number two, I feel hyper-aware of my patient population and everything that they experience. OlderMom and YoungerMom were due on the same day, but that is where the similarities ended. OlderMom was having baby #4, YoungerMom was having baby #2. OlderMom had a history of large babies and gestational diabetes. YoungerMom's pregnancy was complicated by first trimester bleeding and poor weight gain. YoungerMom wavered between VBAC and Repeat C-Section. OlderMom almost got forced into C-section by my unwitting partner. I delivered both this week, in very different ways.

I returned home to a frantic phone call from one of the L&D nurses. "Thank goodness, you're back!" she exclaimed. When I left, we knew that OlderMom's infant was measuring large for gestational age, a common complication with gestational diabetes. She had attempted to undergo amniocentesis for diagnosis of fetal lung maturity, but backed out at the last minute (fear of needles). The plan when I left was to induce her labor at 39 weeks, upon my return from vacation. While I was away, OlderMom saw OtherDoc for a prenatal visit. He ordered an ultrasound which showed fetal macrosomia (surprise) but he decided to schedule my patient for a PRIMARY C-SECTION the day I returned from vacation. My patient had 3 previously successful vaginal deliveries. Her largest baby was nearly 9 pounds. She had a very proven pelvis, and I was shocked that my partner would make such a decision in my absence. Luckily, the nurse that was doing her surgery intake realized my patient's reluctance to have a primary section and called me. I spoke with the patient, and she very much desired a vaginal delivery (of course?) so we settled on induction of labor. It turns out that induction really wasn't necessary, she was 4 cm dilated and contracting fairly well on her own. I observed her overnight, and once she was comfortable with her epidural early in the morning, we started a small amount of pitocin to increase the frequency of her contractions. She progressed from 4 cm to 10 cm in about 4 hours. They called me in from the office for delivery around lunchtime. OlderMom's poise amazed me as she sat upright in the bed, barely hurting and serene, with the baby's crown visible as I sprinted into the delivery room. I dressed and gloved for the delivery with my new 3rd year med student in tow. It was a textbook delivery. She should have been the Lamaze birthing video model! As soon as I was dressed and ready, OlderMom began to push. She pushed exactly one time and the head slowly delivered, crowning and controlled. The second push yielded a very large anterior shoulder (and an internal sigh of relief from me) followed by the posterior shoulder. The infant's body was delivered, as if in slow motion, and the cord clamped and cut by a tearful father. The nearly 9 pound baby was placed on OlderMom's bare belly, his cries heralding his arrival to the world. It was one of the smoothest deliveries I have done. She had but a small perineal laceration that required no stitches. A triumphant failed C-section, and I was so happy to have arrived back in town when I did.

YoungerMom sat in my examining room on the self-same day that OlderMom delivered, debating her course of delivery. Her first pregnancy was delivered as an emergent cesarean section for prolonged second stage and fetal distress. She was asleep for the birth of her first baby, and didn't get to hold the baby for 5 hours after the surgery. This was an experience she was not anxious to repeat. As I have mentioned before, I am one of the few docs around here that will staff an attempted VBAC. I have fairly strict guidelines to which I adhere, in order to have the best possible outcome. One of these guidelines is that I do everything I can *not* to induce women desiring VBAC. Not only do induction agents increase certain risks associated with VBAC such as uterine rupture, I truly feel that a natural onset of labor is one of the best case scenarios for a successful VBAC. This logic boggled YoungerMom's mind. She wanted a baby before her due date, because her older child was starting school. She wanted to VBAC, but on her own schedule. I was firm in not allowing an induction at her current dilation and desire for VBAC, so she settled on the predictable choice, repeat cesarean section. This struck me as an oddity, because women who are committed to VBAC will usually do anything to enhance their chances of a vaginal delivery. We proceeded to a repeat cesarean section. The surgery was easy. The infant cried even before the body was delivered. Mom was able to see the baby as soon as she was delivered from the womb. The baby scored a perfect 10 on the APGAR (a rarity in this hospital). Unfortunately, she developed a fever and was kept under strict supervision for the next few days. YoungerMom (another patient with the grating habit of calling me by my first name) said repeatedly as the surgery concluded, "That was so much easier than my last C-section! All I wanted was to see the baby when she was born."

Different delivery outcomes, different delivery methods, different women altogether, tied together by the common bond of motherhood. As different as these two deliveries were, I saw them as the same. Two mothers, wanting to glimpse their child's first breath of the world, to share in the wonder that is birth. I am so lucky and blessed that I get to help these women share these moments, however they are attained, with their newborn children, and I hope that I never become too bitter or overworked to remember why I chose this profession.


Anonymous said...

Older mom is lucky you are her doc. How scary how close she came to an unneccessary section. Glad both babies are healthy, that is the important thing--obviously.

dr. whoo? said...

I am so glad that OtherDoc didn't operate while I was away. He usually isn't so blade-happy, I'm not sure what was happening there! Yes, both babies are doing great and home with their respective families, thank goodness.

Anonymous said...

I call my ob/gyn "Dr X", but I feel weird about this because she's younger than me and I have as high a level of education as she does (but my degrees are not in medicine). I call work colleagues by their first names and I call personal friends who are MDs by their first named. Why does this bother you? Do you call your doctors "Dr x"?