Plus ca Change?


You know if you wait long enough, what was old becomes new again. Old fashions become retro and are seriously nouveau. I don’t wear ties or cuffed pants, but I’m sure if I hunted around in the closet I could find something that would make a teenager’s eyes water.

Theories are sometimes like that, although when they return, they somehow look different: different words, different rationalizations, different paradigms into which they have been conveniently slotted. Sometimes they return because of the Law of Unexpected Consequences: the current wisdom has led to an undesirable product. And that’s totally acceptable and indeed what is admirable in science as I discussed in my last blog. It is appropriate that we continually monitor the results of thinking a certain way, re-evaluate even established wisdom when it seems to be leading us astray.

Our problem is that change is often slow. We adapt. We accept that which is only marginally different from what we have come to expect. It is only by stepping back from time to time that we realize how great that change has become and decide whether or not it still meets our needs. Whether, in other words, it is still acceptable.

Okay, plus ca change… There is an article in the March issue of Obstetrics and Gynecology that suggests that it is okay to let a woman labour longer. Not only that, but they should be allowed to push longer in the second stage as long as the baby is not showing any signs of distress. The lead author is a member of the American College of Obstetrics and Gynecology (ACOG) Committee on Obstetric Practice, so it’s imprimatur does carry some weight.

ACOG Guidelines Focus on Reducing Primary Cesarean Deliveries
http://www.jwatch.org/fw108498/2014/02/20/acog-guidelines-focus-reducing…

The impetus for this reassessment, dare I say, is the number of Caesarian Sections that are being done. In itself,  a surgical intervention would not seem to be a necessarily bad thing if it saves the life or the future health of a baby or its mother. There can be downstream consequences to Caesarian Sections that are seldom given much press, though. Caesarians are not a pancea, and not without complications –all surgeries carry their own risks. But in the case of obstetrics, it is often not simply a one-time risk. The mother may desire another pregnancy, and because of the problems she encountered in her first labour, may opt for yet another Caesarian. Or, complications from the first one such as infection or wound problems may necessitate a second Caesarian. The concern doesn’t just stop with the delivery of the first baby…

The question at issue, however, is whether it was actually necessary to intervene in the first place, or whether other factors were at play. Judgement, of course, is a multiverse, subject to all the biases of current wisdom, past experience, and not least, the way it was taught in medical school or the residency program. We seem to be creatures of the algorithm; we feel happiest when we can plot things on graphs. The Friedman curve of cervical dilatation was one of the basics we were taught as medical students: if progress begins to deviate from the nice sensible curve, then do something. All well and good: start some medication to enhance the mother’s contractions, maybe, and then observe. And reassess… The temptation, of course, is to set some arbitrary time limit to the observation and then intervene if progress has not occurred. The study is suggesting that we lengthen that time limit… or perhaps even question  the need for one at all. Patience can be a virtue.

But we need patterns to help us; it has no doubt been to the advantage of our species, to categorize: to identify the growl in the woods, then slot it into a judgment. A reaction. A pattern. So if we don’t immediately see a pattern, we look for one. Or we create one. Of course, the patterns are often arbitrary; we just feel better when one is there.

And we love to measure things in that search –measure and then analyse. But in a sense, we’ve again arbitrized a tiny section of the whole and generalized from it. Think of putting a grid over a window overlooking, say, a street –but only concentrating on one tiny section of it –ignoring the rest. In square 1C there is are 106 green things that look like leaves, and they sometimes move randomly. And since that’s all we can see, we conclude that we’re dealing with a forest, and that there might be an animal in the tree making it move. Or maybe wind… We convince ourselves we have discovered something profound. Well, maybe we have, but it seems to me that what would  be far more profound would be to take away the grid and realize we were only measuring a small segment of a far larger, far more diverse whole.

Sometimes we do that, but more often we get caught up in minutiae –especially if they fit into the current paradigm. Or we can make them fit. We need to step back every now and then. Clear our minds. Look at the whole… Why did we think we should set limits on labour? Why did we feel we should give up in the second stage after pushing for a certain length of time? Did this ever make sense if mom and baby were okay? Is this one of the reasons women are feeling more comfortable with midwives, or electing non-hospital births?

Even as an obstetrician with a rather lengthy career, I hesitate to say I told you so, but it’s the wide tie coming back into fashion again… or are they already back? The caveat for all of these recommendations is –of course- that there are no other impediments to continuing the labour, or the pushing. Mothers get exhausted. So do babies… So do doctors. And it’s this latter category that we have to be careful about. There may be no reason for intervention in the labour other than frustration.

Lack of progress is a highly charged observation in labour, and even more so after an hour or two of pushing without seeing much success. It can lead to decisions that, in less emotionally and physically exhausting circumstances, might be made differently. And that is where the nurse, midwife, or doctor has to step back from the drama. Has to try to divorce herself from the fray and consider what is truly in both the baby’s and mother’s best interest. Has to try not to succumb to the frustration thickening the air. A word of encouragement from a trusted caregiver goes a long way to diffusing tension. Sparking renewed determination. Inspiring hope…

But I thought we all knew this.

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