Monday, June 11, 2012

Ask an OB: Crystal ball

"Ask an OB" is a weekly series with Dr. Maude "Molly" Guerin, MC, FACOG. If you have a question for her, please share it with us here. 

How can you make sure you are on the same page, specifically regarding risk, with your midwife/OB? For example, is it appropriate to say, "I would like to do my best to birth this child naturally but if you can tell that the baby may not make it, or I am to blow out my body, that is where I draw the line." How do you draw lines with them? Is this a conversation you should initiate during prenatal classes? Should you say, "I am all for candles and bathtubs, but ultimately I am here for the outcome (i.e., healthy mother and baby) and am willing to sacrifice the process (i.e., uninterrupted birth) to get there. I need you to help me identify when our health is at risk." - Okemos Mom
I badly need a crystal ball. When they invent them, I get it first! If I could peer into it and see a 30 hour labor, 4 hours of pushing, a C section, a stay in the Neonatal Intensive Care Unit for the baby and a blood transfusion for you . . . I would do a C section before labor and skip all that! If I could see a baby that comes out and doesn’t breathe, has Apgars of 1 and 4 . . .  I would labor you in the hospital, on continuous monitoring, and do a C section if things looked bad. And you would gladly forgo the “candles and bathtubs,” I’m sure!  If I was worried a VBAC would rupture your uterus with a trial of labor, but could use my crystal ball to see a 3 hour labor, 2 pushes and a happy baby and mom, we wouldn’t even talk about all the bad things that can happen! Unfortunately we don’t have that crystal ball. Therefore you DO NEED to have that conversation with your partner before you decide where to have your baby. Then you need to be explicit with your provider. Here are some examples of ways that you can set clear expectations:

• “We are committed to a natural labor and delivery at almost all costs. We accept some increased risk for low Apgar scores, neonatal seizures, and a long labor – in hopes of reducing our risk of a C section. Unless you have clear incontrovertible evidence that my baby or I WILL have irreversible damage, I want to continue with no intervention and accept the outcome.”

• “We sincerely hope for a low tech, ‘hands-off’ labor and an unassisted vaginal delivery. Please stand by and let us know if you see warning signs of trouble for mom or baby…we would like to discuss options for intervention in that situation, and have a time line for decisions.”

• “We want as close to a 100% guarantee as you can give us that our baby will be under absolutely no stress during labor and delivery. If things aren’t going perfectly we want a C section immediately.” 

Writing your feelings down is always good, too. I would much rather see an essay on your risk tolerance and the strength of your desire for no intervention than the list of “do’s and don’ts” that make up most birth plans. So my advice is yes – please talk talk talk to your provider about risk and how you want to handle certain situations. If your provider has her/his own agenda about these things, you need to know that up front and decide if you can live with that. 

Finally, I find the last sentence of your question critical. “I need you to help me identify when our health is at risk.” Honestly, this is not your job, it is our job. Your job is to be strong, to be thoughtful, to climb the big mountain that is labor. Our job is to be nearby spotting you. When you veer off the safe path, we notice, we shepherd you back. Sometimes we yank you back! “Hey your baby is in trouble – get into the O.R. RIGHT NOW!!”  You shouldn’t have to worry about identifying when your health is at risk, you have a huge job to do just getting through this (it’s called “labor” for a reason!). If you are second guessing your provider and don’t trust that they will be able to “identify when your health is at risk”, you are in the wrong place for care.

You can read more about Dr. Maude "Molly" Guerin, MD, FACOG, right here.

1 comment:

  1. This is great, and what I think is missing from many misled parents-to-be, who believe that L&D is a low-risk part of life. I had a great OB, Dr. Lester Voutsos, at Providence Southfield, who told me as I was preparing to have our first child, "Attending a L&D is a lot like herding cats. You have a general idea of where they need to go and how to get there, but it's messy and unpredictable." I presented in labor at 40 wks 4 days, already 5 cm after laboring at home a good 18 hrs. The epidural was too-little-too-late, the baby came fast. Literally arrived, got changed and checked by the resident, which broke my water. Was wheeled into a delivery room and Dr V was paged. He arrived within an hour and stuck close, as my baby was having some wonky heart rate issues. I had an internal monitor put in and was asked what I wanted to do. My only concern: Healthy Mom, Healthy Baby. We talked C/S, and knew that if things dipped below whatever his reasonable threshold was, we'd pull the baby. He started descending with his cord around his neck. My doc reached up and pulled it away, encouraged the baby to keep spinning the right way, and I had all 8 lb 12 oz of him with a weird epi (numb above the navel), retching in a bucket and shivering the whole way. There was meconium present, and grunting, and the baby was taken to the NICU for a few hours of monitoring. He perked right up and was brought in to me a half day later.
    I realize that anything could've gone either way. The heart rate could've gotten wonkier. He could've spun the wrong way, tightening his cord around his neck, meconium could have been seriously aspirated. None of these things I trust could have been handled properly with a midwife at a home/birth center. Instead of having a thriving 5 year old, I could have been mourning him. Needless to say, his baby brother was also an OB-attended, hospital birth. Another good choice, as this weenie turned transverse at 38 weeks. As I was being prepped and rolled into surgery at 39.5, the OB (this time, at Cedars in Los Angeles) wanted one last ultrasound to note his position. She was already scrubbed in and waiting for me. He had turned again, engaged, and was ready to go. I was offered a binder and Pitocin/Cervadil, which I happily accepted and had him vaginally (this time with an amazing epidural- I smiled and enjoyed every minute of L&D) 12 hrs later. Again, how could a home/birth center midwife dealt with a late- transverse baby? As I've read, unfortunately not very well. Thanks for your writing- you are educating the uninformed. Baby birthing is serious work!