The Size of the Dog

In the hazy light of retrospect I can still see her lying there on the hospital bed scowling at me. She was clutching her baby as if she’d won it in a game in which she’d cheated. In fact, I suppose she had… But I’m getting ahead of myself. Way ahead.

I’d first met Mary a few years before when I was on call at the hospital. She was pregnant for the first time and was not progressing in her labour. A short woman -she was less than 5 feet- with a tall and heavy husband, she looked almost out of place beside him in the room. They both looked at each other as I walked in; clearly a consultation with an obstetrician was not what they had anticipated. They’d been followed throughout the pregnancy by a midwife, and had only come to the hospital under duress. They both desperately wanted a normal delivery and despite the reassurances of their caregiver that she was just being safe, they suspected the worst.

Mary confronted me with her eyes before I could even approach her bed. “I don’t want an epidural,” she said and metaphorically crossed her arms to ward me off.

“Good, ” I said, “because I’m not the anaethesiologist.”

“That’s not what I meant, and you know it…” her face was hard and then suddenly her forehead wrinkled so much I’m surprised she could even see me. “And I don’t want a Caesarian Section either!” Then she seemed to pout. “Babies do better after vaginal birth..!” She thought about it for a moment. “And so do mothers!”

I could hear the exclamation marks from across the room so I put on my best smile and walked towards the bed.  I glanced at the midwife.  “Susan tells me you’ve been contracting now for almost twelve hours at home….”

“Yes, but they weren’t very strong.”  She noticed Susan staring at her. “Well,  I mean they weren’t all that close together…” She glanced at Susan to see if she agreed.  Susan just blinked -a tired kind of boarding up of both her eyes. I think she could have fallen asleep if the room lights had been dimmer.

“And she says you’re still about four centimeters dilated.” Susan nodded, apparently wide awake again.

This seemed to deflate Mary, and she reached over and squeezed her husband’s hand. I could see a tear rolling slowly down one cheek. “Sometimes labour takes a while, doctor. I know I can do it,”  she said, and yet I could hear doubt mixed with fatigue in her voice. But her face was softer now. Gentler. She was not an unkind woman, but disappointment had robbed her of any dignity.

“I suspect you’re absolutely right about that, Mary.” I walked closer to the bed and stood beside her.  “But I think we’re going to have to do something to make those contractions more efficient.” Now that I was near, I could see the size of the baby distending her abdomen. It seemed huge.

Susan smiled at my expression. “I did an ultrasound last week and the estimated weight is over four kilograms.”

I took a slow, deep breath, but carefully preserved my smile for Mary. “It’s not the size of the dog in the fight; it’s the size of the fight in the dog…”

“I don’t…”

“It’s something my father used to say.”

One of Mary’s eyebrows elbowed its way past a brow furrow and for the first time she appeared amused… Well, anyway, not angry at me. “So you think maybe if you can make the contractions stronger..?” It was a question disguised as a clarification, hiding a deep sense of failure.

I tried to warm my expression. “Well, we can try…”

She studied me for a moment, knowing what I really meant. “But it’s an awfully big baby, you mean?”

I nodded slowly. Carefully. “But you know, sometimes the body is full of surprises,” I said, mindful of the pun.  “In medical school we were always taught that the the secret to a successful labour depends on the combination of Power, Passageway, and Passenger.” I hesitated for a moment. “But sometimes, no matter what we want, and no matter what we do, there is no choice…”

“What do you mean?” her husband said, genuinely puzzled. But fearful. His eyes darted between Susan and Mary like little birds looking for a branch.

Mary sighed and squeezed his hand again. “He never guesses the murderer on the Mystery Channel either, doctor.” Her expression softened as she looked up at him; he seemed so worried for her. “The doctor just means if we can make the contractions stronger, they may be able to push the baby out.” She glanced at me to see if she’d got it right. There was a wisp of a smile lurking just out of sight on her face. I think she was actually looking forward to the challenge.

I ordered an intravenous infusion of oxytocin to augment the contractions, but despite that, after another three or four hours of gradually increasing the dose, even with the stronger and more frequent contractions she hadn’t progressed at all.  Sometimes you just have to admit defeat -or at least claim your victory on a different field.

When I walked in to tell her she would require a Caesarian Section, she wasn’t as tearful as I had anticipated. She was tired -exhausted, in fact- but cheerful. “Sometimes the first labour is a dress rehearsal, isn’t it doctor? You work out all the bugs, so when you try it again, you get it right…”

I nodded reassuringly. I had expected tears.

“So I can try for a vaginal birth for my next one, eh?” It was not so much a question as an entreaty.  And when I nodded my approval -Susan had probably told her I was usually in favour of trials of labour after Caesarians- she smiled. “I think my poor uterus was floundering this time. Probably hadn’t even read the instructions…”

And confident of her future triumphs, she chuckled all the way to the OR and presented me with a healthy, screaming eight and a half pound baby through her abdomen. Her smile spread through the OR like a virus. Some things, some people, are just contagious.

*

I never really forgot the incident, and for years I used her positive attitude as an example to others who required an unexpected and unwanted Caesarian. Like that dog my father had been so fond of mentioning, Mary was one of those who seemed to destined to snatch victory from the jaws of defeat. But, as years and patients slipped past with increasing speed, I realized I would probably never see her again. She became another nameless legend. Another in a long line of inspirational examples to be trotted out when the occasion demanded.

And then, one day there she was: the unforgettable short woman with the engaging, toothy smile. A little plumper than I remembered, and with little strands of grey in the weft of her short, brown hair, but Mary, nonetheless. And she seemed happy to see me.

“I finally decided to move on from the dress rehearsal, doctor,” she said, her eyes bright and twinkling, and her words somehow able to emerge intact through a grin that split her face in half. “I’ve always wondered which dog wins that fight…”

I checked the referral letter on the chart. She was only a month from her due date. I blushed inwardly; that accounted for the plumpness, for sure… “So congratulations, Mary,” I said with enthusiasm. “I hope things work out better for you this time.”

“Things worked out just fine last time, too, doctor.”

“Yes they did. Sorry we had to do the Caesarian, but sometimes there is no choice.”

“Unlike this time, I guess.” Her expression changed subtly, and then the smile returned. “I mean I do have a choice, right?”

I put my pen down and sat back in my chair. Her expression had shifted again. “Of course you do, Mary. Your pregnancy has been normal so far; there seems no necessity for a repeat Caesarian…” I stopped when I felt her eyes focussed on my face.

“But I want a Caesarian Section again, doctor.”

I have to admit my mouth fell open, and I became conscious of the need to close it.

“I was so young and naïve in my last pregnancy. So influenced by my friends…” She sighed and tried unsuccessfully to recapture her smile. “I don’t want a repeat of last time. There’s no need; I have nothing to prove.”

I put on my best doctor voice. “It may not turn out like the last time, Mary. Second labours are different. The body learns…” I could see my words bouncing off her cheeks. “I often tell my patients there should be a different name for second labours, so it wouldn’t engender the same expectations as the first.” Her head was still pointing at me, but I could tell her eyes were not listening. “You know, like the Inuit with their twenty-something different expressions for snow…”

“Whatever. I want a repeat Caesarian, doctor. I don’t want to take a chance on the snow.”

I shrugged my well-intentioned-defeat-shrug and told her I’d try to arrange an OR date for around the time she was due. “But,” I cautioned, “You may go into labour before that date -I mean how do we know?” I smiled as I got her to sign the operative consent forms. “And then you have a choice again.”

One eyebrow explored her forehead for a time. “What do you mean?” she said suspiciously.

“I mean that if you do show up in labour, you have a choice to opt for an emergency Caesarian -no one would bat an eye over that. Or… if you were dilating quickly, you could decide to see if the labour progressed. Our threshold for intervention is really quite low for a trial of labour. You wouldn’t have to worry that we’d try to force stronger contractions, or anything…” I suddenly realized it was me that was bargaining this time. Begging.

Her whole body stiffened. “Perhaps you don’t understand, doctor; I’ve already made up my mind. I do not want to go through another labour! I have made my choice.”

It sounded sufficiently litigious that I quickly nodded my understanding. It seemed the only wise thing to do.

*

As things happen, I was on call a few days before the scheduled OR date for her Caesarian. And, of course, she arrived in the Delivery Suite in heavy labour. She’d arrived by ambulance she was so worried and we rushed her into the assessment room to examine her. Her cervix was already almost fully dilated, and her contractions were coming fast and furiously.  I smiled to reassure her and ran out to book her for an emergency Caesarian. A stat section means right away and as luck would have it, the OR had just finished a case and had not yet sent for the next patient. They assured me they’d be ready for us if we wheeled the stretcher to the OR ourselves.

Just as I was hanging up the phone, however, I heard the nurse yelling for me to come, so I sprinted to the assessment room only to find the nurse trying to manage the baby’s head as it emerged through the vaginal opening. I grabbed a pair of gloves and took over the delivery of a large, healthy, crying baby girl. A precipitous labour and delivery. Who could have guessed?

After delivering the placenta, I inspected Mary for the expected trauma, but… nothing! The skin was intact; there was almost no bruising. Nothing to suture. Nothing to do really, except congratulate her on her new little girl.

But instead of a “Thank you so much!” or an “Am I every happy you were on call tonight!” it was a scowl that greeted me. A pair of furious eyes that followed me around the room as I cleaned things up.

“You lied to me, doctor!” she said through tense lips that barely moved. “You said I could have a Caesarian Section -that I didn’t need to go through another labour!”

I was speechless for a moment, and the room fell silent. The two nurses in the little alcove with me turned and stared at her, then thought better of it and left the area. My mouth opened, but no sounds came through it. I felt paralysed.

Suddenly her eyes relaxed and her face dissolved into laughter. It was the Mary of legend returned from the wilderness. “Had you there for a minute, didn’t I? Sometimes there is no choice… Didn’t you once tell me that, doctor?”

 

 

 

 

 

 

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Midwifery… Deja vu all over again?

Well, I see that midwifery is back in the news again, so I thought I’d revisit the issue -my last look at it  was in November, 2012. Its not that I’ve changed my opinions -I haven’t; nor that I have since discovered something new and compelling about the role of midwives in pregnancy -I continue to support them as I always have. Its more that I am surprised that there should still be any lingering doubt as to their value; that we should still be treating midwifery as if it were an Alternative Medicine -you know, like Huckleberry leaves for indigestion, or something. Midwives have proven their worth over millennia; their extensive and practical experience has helped countless women over the centuries -especially those who couldn’t afford, or even access doctors with their often unhelpful and sometimes misguided medical beliefs and practices -some dating back to Aristotle… It occurs to me that perhaps I am  being too harsh, too revisionist -too reductive- in my recollection of Medical History, but until quite recently there didn’t seem to be much advantage accruing to the involvement of a doctor in the care of a woman in labour.

A predictably Canadian stimulus -the CBC News- got me thinking about midwives again. They reported on a recent issue of the Cochrane Database of Systemic Reviews which looked at 13 studies that included more than 16,000 women comparing various models of obstetrical care with midwife-led care. This model is different from what has traditionally been known as the Medical Model in which a doctor is in charge and a midwife is (maybe) part of the team, but not the leader. In it, she was a useful accessory perhaps, but really just a doctor’s helper: someone who could see the simple and uncomplicated cases and therefore ease the doctor’s burden. I almost said ‘was allowed to see’ these, but I caught myself.

So the meta-analysis tried to put midwife-led care into perspective: was it as good as doctor-led care? Was it merely a niche product serving women with unusual needs and attitudes, or more mainstream in its goals and aspirations? Were they just two Majesteria staring at each other from afar, as incapable of comparison as the proverbial apple and orange?  Well it turns out that one can compare them, and after allowing for the more complex and sicker women that are more likely to find themselves assigned to the medical camp, it seems that there are definite benefits to seeing a midwife… Surprise!

Of course one could argue about some of the touted advantages of midwife-led care mentioned in the article: the use of fewer epidurals for pain relief in labour, for example. I’m not sure I understand why a procedure that truly does relieve pain -and which, if used in a timely and appropriate fashion, has minimal effects on the outcome of labour – can not be judged to have a positive effect on the experience. Labour doesn’t need to equate to running a gauntlet; there are no prizes for enduring the most punishment; no moral or societal penalties for actually enjoying it -in other words, being open to pain relief without a sense of guilt or failure. Or at least cherishing the opportunity to choose. Epidurals aren’t for everyone, but its nice when they’re available. Options are good. Maybe its the man in me wondering what all the fuss is about natural labours; can any labour that results in the birth of a baby -perhaps apart from circumventing it entirely with a Caesarian Section- really be unnatural? Unplanned, maybe; not living up to expectations or desires, perhaps; requiring interventions one would rather have avoided, possibly -things happen… All of us -doctors included- would like to see events unfurling as the mother had hoped, and honestly try our best to achieve this. But above all, we want a satisfying, but safe delivery of a healthy infant.

Fewer episiotomies is another benefit to midwife-led care apparently… Uhmm, I’m trying to remember the last time I -or my colleagues- had to resort to one of these! But I understand the point: there are some things doctors may do that could be construed as unnecessary intervention.  I take exception to a comment the CBC reported from a Guelph, Ontario midwife, though. She apparently felt that the fewer midwife interventions noted in the studies made sense “given how midwives view birth as normal.”  [italics are mine]. However, she does go on to say that “There’s more time in the visit to really address their concerns, so my expectation is we would really care for the whole person, address problems early, refer problems early and that allows women to be healthy.”  No Us and Them in that follow-up statement;  no aspersions cast there. Indeed, she’s managed to encapsulate just why I feel so comfortable with midwives. But I would like to suggest that even doctors are capable of considering the whole continuum of conception-pregnancy-birth as normal, too.

Choice in pregnancy care is the important issue, I think. Midwives, like general practitioners, refer to specialists when there is a need. Some pregnancies are known to be at higher risk than others right from the start -an older woman with hypertension, or diabetes, for example- but even there, as long as the midwife, mother, and specialist are comfortable with each other and with the probability of more intensive and perhaps more frequent testing, shared care between them is still an option if the patient wishes to continue with the midwife. Its a beautiful compromise that dips a toe in both rivers without being swept away by either.