REAP WHAT WE SOW | Janice Anderson
Amid flowers and the smell of fresh dirt in Lowes’ garden department, my pager vibrates: a stat call from the labor room. Pat and I had been picking annuals for our yard; with its partial sun and dense shade Impatiens grow best. I’m partial to multicolored, but this year it’s her turn to pick and she’s opted for solid red. As she loads the crimson flats onto our cart, I step a few feet away to call Wafia, my family medicine resident. She trips over her words trying to tell me everything at once. A fifteen-year-old pregnant patient, let’s call her Casey, has broken her water and come to the hospital in active labor and… I don’t need Wafia to say much more, because I hear the nurse yell in the background, “Heart tones down in the 60’s. Get in here!”
I signal Pat we have to go with a sideways jerk of my head. She quickly slides the young plants back onto the shelf. Wafia tells me Dr. Dillon is the obstetrician on back-up call, and the nurse is paging him now. He lives close to the hospital and I’m half-hour away. “Great,” I say. “I’ll get there as soon as I can.”
After thirty years of call, it’s still difficult for me to transition from buying plants on a quiet Saturday morning to a stat call about a woman in labor. Stat means don’t finish your meal, your movie, or your shower. It means a fear-based surge of adrenaline, followed by please let this be a false alarm, and then, when I remember not to ask for things to be different from what they are, please let me be up to the task.
Fortunately, when the call is about abnormal fetal heart tones, it’s often a false alarm. For over forty years, laboring women across the country have had two transducers strapped onto their abdomen: one for contractions and the other for the fetal heart rate. It takes time, skill, and frankly a little nerve to interpret fetal heart rate patterns. Drops, or decelerations can mean anything from a simple squeeze of the umbilical cord to a heart about to give up. The squeeze-type deceleration usually come back to normal quickly and causes no harm. But the heart-about-to-give-up kind of deceleration can mean the baby’s not getting enough blood to his or her brain. In that case, acid builds up and can lead to asphyxia, brain damage, or even death.
The use of continuous fetal monitoring has skyrocketed since its development in the 1960’s. No one waited for proof. We hoped it would stop babies from dying or reduce cases of brain damage. We assumed delivering a stressed fetus by cesarean section would prevent problems like cerebral palsy. However, despite almost universal use, the rates of Cerebral Palsy have not changed a lick. Instead, there’s been an astronomical rise in the cesarean section rates; over a third of deliveries now happen through a surgical slash across a woman’s abdomen.
I picture Dan Dillon jumping on his motorcycle, that’s what he drives to work three seasons a year. Back in the 1970’s, he bucked the obstetric trends of the generation before him, rejecting, for example, the move to the operating room for all deliveries. He’s five minutes from the hospital, which makes him everyone’s go-to-guy for emergencies, even when he’s not on call. Our nurses love him or hate him, depending on which way his mood swings. I’m reassured he’s on his way, but not enough to stop my heart from racing. I guess it’s contagious, because Pat rolls through stop signs and lays hard on the accelerator.
When I’m closer to the hospital, I call again. The unit secretary tells me the heart tones came back up after ten minutes.
“Dr. Dillon’s in Casey’s room now,” she says. “And he’s going all Darth Vader on them.”
“Oh dear,” I say, “Thanks. I’m almost there.”
When I get to Casey’s room, I see she’s out of control. At fifteen, she’s scared and in pain. Her light brown ponytail has long since loosened up, and strands of hair stick to her moist face. Between thrashing and screaming for her epidural, she’s unable to focus.
Dan Dillon tries to out-yell her. “We can’t do anything until you settle down! We need to get your baby out.”
Casey’s mother, flushed and teary, stands next to Casey with her hands over her mouth. Her eyes track from person to person, depending on who is speaking. Wafia stands wide-eyed but silent at the base of the bed.
The nurse moves the dislodged oxygen mask back over Casey’s nose and mouth. “You need to keep this on, Casey. It’s for the baby.”
“I can’t!” Casey yells as she yanks the mask off again. “Mommy, make them stop!” She rolls over, and sobs, “I can’t; I can’t.”
I step into the fray. “Hi Casey. I’m Dr. Anderson, Dr. Sarwar’s teaching attending.” I look from Casey to her mother, my voice self-assured, but not loud. “Do you understand what’s going on?”
Her mother shakes her head, no.
“I’m not doing this!” Casey shrieks as she kicks at her blanket. “I want my epidural!”
Experience has taught me that if a patient understands what’s happening, if she’s given some sense of control or choice, she’ll have less fear. Feeling powerless is a risk factor for postpartum stress symptoms. Sometimes the only control that can be offered in a critical situation is the choice to trust us. So, that’s what I go after.
I touch Casey’s arm firmly, “Soon. In just a minute.” I lean in so our faces are just inches apart.
“Look at me,” I say, and then pause. “Casey. Can you look at me?” I wait until her eyes find mine. Then I nod and say, “Good. You’re okay. We’re going to take care of your pain soon, but your baby could be in trouble. You need to listen to Dr. Dillon here. Can you do that? It’s almost over.”
I keep my hand on her arm and turn it back to him. His voice and demeanor have come down a notch. He addresses Casey, but she doesn’t look at him. “The baby’s heartbeat was bad and could go down again. Your baby could be in danger.” He turns to her mother. “We have to take her, right now, for a cesarean section.”
I chafe at the way he uses his authority to tell, rather than ask. It is a small example of a much bigger problem. Doctors, not women, make the decisions. Birth has become a procedure instead of a natural process. I have seen how powerful natural birth can be, and I mourn the loss of its popularity. If a woman is prepared and supported, if she trusts her body, she’ll come out of the experience empowered. On the other side of the spectrum, and it is a spectrum, when women lack understanding or control or support, the likelihood of emotional harm goes way up, and with it rates of depression and PTSD.
Even the babies know the difference. After unmedicated births, newborns placed belly-down on their mother’s chests will push their feet against the top of the uterus and bob their heads up and down in search of the areola and nipple—conveniently darkened by pregnancy. Unassisted, most newborns find and latch on to the nipple within ten minutes. The nipple stimulation, which releases oxytocin, and the kneading motion of the feet on the womb, help the uterine muscle contract. These contractions, or after-pains, pinch off blood vessels in the uterus to minimize bleeding. This doesn’t happen after an epidural or a cesarean section. Medications change something—maybe it’s an unfamiliar smell or a change in the natural oxytocin. Don’t get me wrong; I’m grateful for epidurals for my patients when they need them; just as I appreciate the commitment and availability of our obstetricians in high-risk situations. Casey, in fact, is a perfect example. She needs this epidural, and probably, this stat cesarean.
As I step out of Casey’s room, I see Dan looking through her prenatal record in the nurses’ station. A far cry from the earthy smells and spring colors of Lowes’s garden department, the nurses’ station has no seasons; under its artificial light, everything is overwhelmingly beige. Every three feet, monitors display the heart rate and contraction patterns of each laboring woman on the unit. Reviewing Casey’s pattern, I see the rhythm has been fine since that first deceleration. So I wonder, what’s the fuss all about?
Admittedly, I’m hesitant to challenge Dan Dillon about his plan. As a general rule, OBs don’t want their thinking questioned, especially when they are in a high adrenaline state. But I can’t help myself. After I thank him for coming in, I ask his rationale.
“The heart tones are okay now, Dan,” I say, “What’s up?”
“Look,” he practically bellows, “she’s only eight centimeters, the baby might not stand the stress of pushing.”
“But it’s possible. She could birth vaginally, right? Can’t we give her a chance? We’re all here now, if something happens we can take her back for a section then.”
“You consulted me. It’s my call,” Dan says, clearly irritated. “If it were me, or my wife, I’d want that baby out of there.”
I see he’s made up his mind, and while this is not a collaborative decision, he beat me there, he’s the surgeon, and he’s right—we consulted him. Whether I like it or not obstetricians are above family doctors in the labor unit pecking order. Still, I feel disrespected, and wonder if it’s my own deference that bothers me.
In the Operating Room, the anesthesiologist numbs Casey’s pain with medicines inserted near her spinal cord. A thick leather belt is slung over her legs, and her arms are strapped to arm boards at right angles to the OR table, like she’s on a cross. Under bright lights, her hospital gown is lifted to her shoulders. Dr. Dillon swabs a cold iodine solution from her nipples to her pubic bone. After what might feel like an eternity to Casey, he covers her with blue paper drapes. Only her head and a twelve-inch square on her lower belly remain exposed. Dr. Dillon places his knife in the middle of this square and cuts his way through skin, fat, and fascia to the uterus, cauterizing blood vessels along the way. This creates an acrid and nasty smell, not unlike burned hair, one that Casey and her mother are apt to forever associate with this day. When he reaches uterine muscle, he slows down and slices fiber-by-fiber, careful not to injure the baby’s head or face, which fill the uterus under his knife. The small incision is then expended to the left and right until the top of the baby’s head is exposed.
Despite pushing on the top of the uterus, Wafia cannot eke the baby’s head out of the incision. Dr. Dillon asks for a set of forceps. He carefully slips two shoehorn shaped blades between the baby’s head and Casey’s uterus as everyone watches silently. He then clamps them together and pulls. Almost suddenly the baby’s head pops out. He removes the blades. Wafia pushes once more and the baby plops onto the blue drapes: wet and still and breathless. As he cuts the cord, Dr. Dillon says, “It’s a boy” without joy or alarm, and hands him to the waiting nurse. The pediatric team stimulates the stunned newborn, and within minutes he pinks up and appears healthy. Once the baby breathes easily, so does everyone else.
While fetal heart tones are a poor predictor of fetal distress before birth, we do have an acid-level test of cord blood that reveals whether a baby had been distressed before birth, and if so, how seriously. In Casey’s case, the test showed the baby wasn’t under stress for very long. Instead of a heart-about-to give-up kind of deceleration, we had a squeezing-the-cord kind of deceleration, one that we could’ve watched for further problems. But Dr. Dillon doesn’t see it the say way.
“That cord would’ve prolapsed and caused problems,” he says.
“Thanks, Dan,” I say before walking out of the Operating Room. “Thanks especially for being so easily available. Really appreciate it.”
But what I’m really thinking is, was this yet another unnecessary cesarean section? This is not an unfamiliar feeling. I often have to say one thing to our back-up obstetricians, when I mean another. I try not to be argumentative, try not to dent their egos. But that sometimes leaves me feeling guilty for my part in physically or emotionally traumatizing a patient or her family. I struggle to give patients a healthy outcome and a good experience. Today, I’m only 50-50. We have a healthy baby, but instead of reviewing an empowering experience with Casey and her mother—and Wafia, for that matter—I have to teach Wafia the signs of emotional trauma. She’ll need to look for these signs when she sees Casey over the next few weeks: depression, poor bonding, intrusive thoughts, or avoidance of anything that reminds her of this birth.
On our drive home, I debrief with Pat. Thankfully, she’s born plenty of my stories over the years. I go over all the ways the experience could’ve gone better for each person involved. I start, as is necessary I suppose, with my own hurt feelings, rational or not.
“How can I not have anything to say about how things are handled? They treat my patients like they have no feelings, give them no control over their own bodies.”
“Another hard one, huh?” Pat asks as she reaches to turn off the radio. I smell fresh soil from plants in the back of the car and realize she’s gone back to Lowes while I was in the hospital.
“It was terrible.” I continue. “The deceleration that started the whole thing never returned. It was a long one, I grant you, lasted almost ten minutes. But we see that sometimes. I tried to talk Dan out of a section, but he wouldn’t hear of it.”
Pat makes a complete stop at the hospital exit.
“Now, the poor patient doesn’t know what hit her. And her mom’s a mess. She cried before I left. Told me she thought both her daughter and the baby were going to die.” I roll down my window to a rush of warm June air. “It’s bad,” I go on, “both of them are set up for emotional trauma: one helpless, the other horrified. And neither had any control. Perfect risk factors for PTSD… I should have protected them better.”
Pat listens generously the rest of the way home.
It’s a joke on the labor unit that Dan Dillon has mood swings. Hence the Darth Vader comment. But in truth, we all have our moods. Did the unit secretary’s comment prime me to react unfairly against him? And what about Dan, the man behind the Vader front? Like most obstetricians, Dan’s been sued. Does every near emergency bring to mind that subpoena-holding-sheriff at his door? Plus, I’m sure he’s felt responsible for bad outcomes, as have I, and it’s a horrible feeling. Maybe he saved the baby’s life, and my unrest is my own discomfort with collateral damage. Or was it all simply a ding to my professional ego?
I don’t know the answers, but these questions will haunt my nights for a while. My relationship with Dan Dillon and his partners has been rough for many years: the crash of egos, polarized perspectives, and the fight for locus of control. Much like planting a garden, you have to know the yard. It lacks sun here, it’s gravelly over there, and all of it needs to be weeded and watered regularly. I’ll continue to tend to these relationships. I’ll meet with the chair of OB to discuss how our departments can better handle cases such as this, because I know that birth is more than the delivery of a baby: it’s the birth of a brand new mom, a new family. How birth happens matters.
When Pat and I get home, I try to recapture my Saturday. As we unload the car, I’m tickled to see that she has bought flats of multi-colored impatiens, my favorite. We spend the rest of the afternoon in our yard, planting. I find it reassuring to gently push the impatiens’ root-ball out of its little plastic container. One at a time, I place each seedling into its hole and cover it with rich soil. Some will take, I know, and some won’t—especially the ones in the dense shade, but it feels good somehow to give each one a fighting chance.
I sent this writing to Dan Dillon (not his real name) and he agreed to meet with me. He was gracious and generous in his response. He focused on seeing that “subpoena-holding sheriff” at his door early in his career. The case settled, “but stays with me,” he said. I asked him why he keeps at it. “I like it, but I look for trouble. Just like when I drive my motorcycle, we’re taught to look 4 seconds and 12 seconds ahead. You’ll be able to react to, or avoid a situation. So I’m always around, always available. I’m aware of what’s going on with your cases, even if I’m not consulted.”
He told me the writing allowed him to see himself in the mirror I held up. He saw some truth in his reactivity and realized this led to my being “collegially diminished.” This is something years of meetings to discuss similar issues hadn’t accomplished. Our conversation enriched our relationship. His manner toward my colleagues and me improved, and we in turn have modified ours toward him. Narrative Medicine at its best.
Janice M. Anderson, M.D. is the Associate Director for Forbes Family Medicine Residency Program, where she has coordinated the obstetric and gynecology curriculum for 25 years. She is also the Medical Director of a freestanding birth center, the Midwife Center for Birth and Women's Health, located in downtown Pittsburgh. In addition, she tends to the medical needs of incarcerated pregnant women at the Allegheny County Jail. In 2013, she earned an MFA in Creative Writing from Chatham University where her focus was on emotional trauma. She has also written How to Move in One Direction While Flying in Another, published in Hippocampus Magazine and nominated for Pushcart Prize: http://www.hippocampusmagazine.com/2012/11/how-to-move-in-one-direction-while-flying-in-another-by-janice-anderson/#disqus_thread.