What is it like to be a…?

I should have known not to answer her question like that. I should have seen the book she was reading; I should have seen how heavy her briefcase was… But I’m getting ahead of myself.

I’m a doctor now -an obstetrician/gynaecologist- but in the beginning I wanted to head in an an entirely different direction: philosophy. And it has remained in the background, nagging at me from time to time -always superficially, of course. My adventures were often confined to a simplistic skimming of the surface of the words, with their all too frequent academic double entendres escaping me completely. But nothing ventured, nothing gained, eh? And I did learn a lot of new phrases that I found I could sometimes slip into my consultations…

Usually I would get away with the occasional philosophical nuance, but I could also be careless at times. One has to be cautious with new patients; there are signs that should be read. For example, it is common sense never to wax philosophical with anyone carrying a heavy book and wearing unstylish, heavy glasses until you know them better. To ignore this maxim is to court embarrassment –or worse, acknowledgment that a boundary has been crossed.

Sandra exhibited all of the danger signs as she sat engrossed in a tome sufficiently heavy to require both knees to support it. A young looking woman with short brown hair and a blue skirt and blouse, she looked as if she were deeply concerned about the meaning of something on the page and as I watched from behind the front desk, she both underlined it and then wrote something in the margin. Even at that distance, I could see she was deadly serious about it. I debated for a moment whether or not to give her additional time to finish her deliberations and see another patient first, but just at that moment she spotted me and smiled.

“Sandra,” I said, walking over to her and wondering how she was going to manage to shake my hand and keep the weighty book safe from the floor.

But she managed it with the skill I would have thought only an older and more experienced scholar could aspire to. And then with a quick, practiced sweep of her other hand, she realigned her glasses further up on her nose, without dropping either the book or her smile in the process.

After that, she, the book and her briefcase followed me to my office and all three of them found a space across from my desk. Once settled, she scanned the room with curious eyes which flitted about like a pair of barn swallows but finally came to rest on a little carved wooden effigy of an African woman holding a baby in her arms.

“What’s it like to be an obstetrician,” she said after examining the woman for a moment.

Although the question seemed simple, it caught me off guard, for some reason and I was suddenly struck with the difficulty of answering something that really had to be experienced to be conveyed, let alone understood. It was almost like trying to describe what its like balancing on a bicycle, or what it would be like to be a police officer walking in a dangerous neighbourhood. It’s a subjective thing that can not accurately be described from the outside.

I’d recently been reading the famous 1974 paper by Thomas Nagel entitled ‘What is it like to be a bat?’ in which he confronts those who would attempt to answer the question by resorting to either physicalism (the idea that everything can be explained by some sort of physical process) or reductionism (by and large that the whole is equal to the sum of its parts): http://organizations.utep.edu/portals/1475/nagel_bat.pdf

I have to admit that I succumbed to the temptation of pretending I understood more of what he wrote than I did. “What is it like to be a bat?” I said -it just slipped out before I could stop it. I suppose that somewhere inside I was thinking I was being clever and that I could then throw out a loose reference to Nagel’s paper –something like his ‘To the extent that I could look and behave like a wasp or a bat without changing my fundamental structure, my experiences would not be anything like the experiences of those animals.’ And so, their experiences being totally alien to me, I would not be able to describe them in words.

But as soon as I said it, I could see by her expression that I had inadvertently crossed a border into the country where she lived. A country where I, perforce, had become a bat. Her bat.

Her eyes immediately hummed with interest. “Fascinating you should ask that,” she said, choosing her words almost as if she were trying to keep them simple –much as we might when speaking to someone from another country. Another culture. “It’s difficult enough to describe what we do to someone in a different field, but an order of magnitude more difficult to describe what it is like to do it…” She smiled disarmingly and then continued. “As Nagel said,” and here she reached down and picked a somewhat lighter book from her briefcase and thumbed through it- ‘Our own experience provides the basic material for our imagination, whose range is therefore limited.’ He picked bats instead of wasps or flounders, he says, ‘because if one travels too far down the phylogenetic tree, people gradually shed their faith that there is experience there at all.’ I suppose he could have chosen dolphins or orcas but… whatever.”

I felt encouraged at her use of ‘whatever’. I thought maybe I could change the subject, but she immediately launched into a description of her position on his argument.

“Me,” she said as if we were sitting in a university lounge discussing the issue over a coffee, “I subscribe to a more intermediate position between reductionism and pure physicalism. I would put myself somewhere in the epiphenomenalist camp.” She looked up from the book and sent her eyes on a brief mission to study my face. The report was evidently not encouraging, so she decided to explain. “Epiphenomenalists posit that mental states are byproducts of physical processes –much as energy and its ability to do work are a product of, say, a steam engine boiling water.”

She carefully replaced the book in its briefcase-vault and stared at me again. Then she shrugged and a mischievous expression gradually conquered the previously academic one. “I think I will rephrase my original question and let you get on with your job. Do you enjoy being an obstetrician?”

“It’s sometimes Hydra-headed,” I said without thinking, and then quickly hid behind the computer screen when I saw her eyes light up once again.

The Doula

For some reason, there are opposing sides in this issue and it’s hard even to approach the topic without raising the eyebrows of one side or the other. It’s not at all clear to me why there should have to be this division, but I’ll attempt a dispassionate consideration of the concept and then venture an opinion for what it’s worth…

First, a definition of sorts: a Doula is basically a labour coach -hopefully one with experience and knowledge that she can draw upon. I suspect the Doula originated in the mists of time because of the needs of women, usually in their first labour, who were beset by a bewildering number of myths, stories, and expectations all encased in a smothering blanket of pain. With no guide but the previously instilled rumours of hours of agony followed by horrid disfigurement if the baby was able to successfully negotiate the birth canal, the idea of a calming presence who could offer guidance and reassurance throughout the travail was appealing. Originally, no doubt, this would have been an older woman in the village who had some experience with labour, probably with a child or two of her own. She would therefore be able to approach childbirth with both compassion and empathy, her very presence reassuring, and her experience proof that there was not only and end to the process, but that a successful conclusion was possible. That the pain was worth it.

It’s still the same process, of course: hours of painful uterine contractions trying to force the baby down a previously untried birth canal; it still takes time for dilatation of the cervix, and descent of the presenting part -the usual definition of progress in labour; it still can go awry. And it’s all of these things but especially the last, that jeopardize the ability of even the bravest to cope.

Some things have changed, though. Effective pain relief is usually available if requested; monitoring of the labour and the baby’s heart rate help to determine if and when interference is warranted; intervention skills and techniques have improved. In most settings both mother and baby are probably safer now than they have ever been. Also, education about pregnancy and labour are widely available: there are prenatal classes, books and magazines full of helpful advice -albeit of sometimes dubious quality, and of course the ubiquitous internet with its plethora of opinions.

The point is, few women approach their delivery entirely ignorant of expectations and fears. I would submit that there is no tabula rasa for labour: everybody, even in direst poverty, has heard something about it; the Doula, if employed, should put those things into context for her client, dispel the harmful myths, provide reassurance and compassion. A friend might provide a similar service. Or a midwife. Or a nurse… We all need a hand to hold.

Why not just have the partner in there providing sustenance and support? That’s ideal if he (or she) can, but let’s face it, the partner is often just as excited and in turn dismayed and frustrated as the one in labour. They are, by and large, a unit with the same expectations and concerns. A knowledgeable outsider is probably better positioned to provide reassurance especially if the labour is long and difficult. A Doula should be a welcome addition to the team.

If I sound like I have reservations, it is because I do. The concept is great. Who would argue with support? A calm and reassured woman is likely to tolerate the problems of labour better than one who is beyond herself with worry and concern over various aspects of it that she cannot process or even understand in the circumstances. Pain and fatigue rarely dispose one to rational analyses. But it’s the experiential component that is often missing in the support -the objective assessment of the situation and the ability to change expectations accordingly. I have heard Doulas vociferously regurgitating their pre-labour instructions not to allow their client to ‘give in’ to the pain, despite its possible role in slowing the progress or tolerability of labour. I suspect that a more experienced coach might better understand that earlier, more naive instructions are not always sustainable in the light of changing circumstances. Many Doulas are sensitive to this and act accordingly -most Doulas, perhaps. But they are not nurses and shouldn’t try to function as such. They are there for support, not to interpret symptoms or read fetal heart rate monitors. They are not there to interfere with their client’s management.

In my center, there is a trained obstetrical nurse assigned on a one to one basis for each labouring patient. They can and do provide support and professional advice as part of their function. They are objective and compassionate, experienced and empathetic. And they are definitely patient advocates, making sure that any management decisions are in their patients’ best interests. Maybe their multiple roles should be more widely advertised. Maybe they are the best Doulas.

I realize that I am coming from a Western medical model, and that as a man, I am someone who could never truly understand what a woman experiences in labour, the support she needs, the encouragement that will help her achieve her goal. My views are biased by my own expectations, my model, my gender it’s true. I can’t escape them.

But I can advocate for safe and compassionate care that helps to ensure the well-being of both mother and baby. That minimizes unnecessary suffering. That strives for a rewarding experience free of fear or untimely intervention.

And so can the nurse… But wait, isn’t that what the Doula was hired to do?

Antenatal Genetic Testing

When I bring up the subject of antenatal genetic testing, most of my patients don’t even bat an eye: it’s just what you do nowadays. Of course you want to know as much about your unborn and developing baby as possible! But there are some -just a few- who look at me suspiciously, searching for a reason I suggested it on their first visit. Do I suspect something is not quite right? Are they high risk? I can see the questions on their faces before they answer. The woman will look at her husband with a worried expression, and he will stare down at his shoes. The real question they are struggling with is: What will we do if the test comes out abnormal? Will we terminate the pregnancy -or perhaps even more troubling- will we have to?

No, I don’t think they fear some legal or medical attempt at coercion for termination. I suspect some of them had not even  considered the possibility of an abnormal fetus. Why would they? After all, does one consider the possibility of an accident every time one gets in a car? Or crosses the street..? It is, in other words, a surprise that anyone would confront them with the risks. It’s supposed to be a happy time, a new life, a new journey. I think that what many of them fear is the unspoken assumption that if there is an abnormality, they will want to terminate: an expectation, not a requirement.

Societal expectations are stronger than we realize. It’s often only when we dare to run contrary to them that we feel the strength of the current. Try shopping in a grocery store with a wheelbarrow rather than the supplied shopping cart, or maybe less fancifully, showing up at an expensive restaurant wearing a tee-shirt. You can do either of these things without getting arrested, but would you? Would you whistle at the symphony? Society’s pressures may be subtle, but they are compelling; we are supposed to know what to do and then do it.

There are other pressures to conform that are sometimes even more difficult to spot. A recent study in one of my medical journals looked at how information for patients with abnormal genetic screening (blood tests, ultrasounds, or amniocentesis) was presented. Discussions about Down Syndrome in literature handed out to patients undergoing genetic screening, for example, were purportedly neutral to allow for untainted management choice options. But the information stressed the problems the Down syndrome child would encounter and the problems the parents would confront rather than -and not balanced by, say, the joys any parent might expect raising such a child -any child. At first glance, this seems beyond reproach: the parents need to know what to expect. And yet, if you read a pamphlet on a car you were considering purchasing, and it merely talked of its problems, what’s the chance you’d turn it down and look elsewhere?

Objectively considered, antenatal testing for all of its advantages, could be seen as a type of Eugenics process. Don’t get me wrong, I’m totally Pro Choice: the couple -the woman– should have the right of choice and no one else! And yet I’m struck by the attitude of many in the profession who seem to assume that antenatal screening is there to assure the parents of a good product. And if what it finds is something different -note the word different, as opposed to substandard, or even defective- well then… We are doctors and by definition we deal with health problems -illness, pain, suffering- and we see the world in those terms. It is hard to put that prejudice aside in counselling as much as we might wish. We, too, are affected by the societal currents. Just look at the difficulty we have -we all have- in dealing with expectations or even medical practice models in other cultures less like our own.

And it is difficult to transcend these, try as we might. We are the creations of our own society and its customs and expectations. We are what we have been accustomed to believe, and non-believers often seem odd, even alien. More often, however, we see them as simply being wrong and assume they need to be corrected. Or we convey in our words or expressions that it is their values that are at fault. And yet all choices are value-laden -even ours.

I don’t know that we can ever shed our cultural -our societal- heritage nor that we should even consider this necessary. But a heritage is a wealth of accumulated -and accumulating- customs, values and opinions. It is an ever-expanding, ever-changing treasure that defines who we are and what we think. It is never static, never ossified; and like a parent, should be open-armed, forgiving, and all-encompassing. It is how I would like to counsel those parents before they even receive their results -before they even decide whether or not to be tested.

In a way, it is me that is being tested.

Forceps

Forceps seem to be controversial in some quarters. To be clear, I don’t find them at all controversial nor do my patients by and large. But I realize that for some, forceps are the standard bearers for all that is intrusive and perhaps malevolent in obstetrics. Everybody seems to have an aunt or second cousin somewhere that has had a bad experience with them, so I have had several requests from readers to comment on the use and abuse of forceps. I speak only from my own experience, naturally, and am not suggesting that everybody would agree with me. Speak to your own doctor if you are confused.

First of all, a little background. When labour has been hard and perhaps slow, and the baby’s head has not descended along the vagina despite a completely dilated cervix, prolonged pushing, and the passage of time, decisions have to be made. There are several options -there are always options… First, one could continue to observe and see whether progress occurs. There might be problems with this approach of course: maternal fatigue, increased swelling of the tissues around the opening of the vagina that would be more likely to tear as the head and body of the baby pass through, and the fact that the mother has likely been pushing for a considerable time already with no progress. But, as long as there are no other contraindications to waiting -like an abnormal fetal heart rate pattern, or maternal fever, to name but two- it is still an option the couple may wish to choose.

A second option is to do a Caesarian section. There is nothing wrong with this option of course, but for many people surgery is something they would rather avoid unless absolutely necessary. If the baby is in trouble, few would argue -including me. But often things are not so clear-cut: the baby ‘s heart pattern on the monitor is normal, the woman is exhausted, but not ill, and she is frustrated at the lack of progress. She wants her baby -ideally with minimal fuss, and soon.

A third option presents itself: helping the baby to come out, but vaginally. This assumes that the baby’s head is low enough and likely to fit through the vagina of course -in other words, deliverable but not so far. And there are two choices for this: vacuum and forceps. Vacuum first. There are several types of vacuum currently available and all work on the principle of a suction cup on the baby’s scalp. Common sense suggests the method is only applicable to situations where the head is so low that pulling on the skin of the head would be likely to make a difference. To be honest, I do not like the method, but I concede that  in untrained hands, it is probably the safer of the two choices because the vacuum usually is not strong enough to do much damage -i.e. the suction cup comes off if you pull too hard.

But if the head is a little further up inside the vaginal canal, and the mother has been unable to push it further using both the contractions and her own expulsive efforts, vacuum isn’t likely going to work either. Here’s where forceps might be useful.

A word about forceps. No, they are not like salad tongs that work by squeezing to gain their traction, and certainly not like vice-grips. Properly applied and skillfully employed, they work more like a helmet that forms a dilating wedge in front of the head to help it to travel along the vaginal canal. Yes, they make contact with the head -so does a helmet- and yes, traction is applied by the obstetrician, but only in conjunction with a uterine contraction and active pushing by the mother. A dilating wedge requires traction to open the way for the head and the head has to follow in close proximity to the wedge…

But there are many different types, shapes and sizes of forceps. Without getting into the names and the multiple conditions for each type, let me say that there are several basic requirements that need to be considered before, during and after the use of forceps. First of all, the head has to be low enough in the vagina to apply the forceps; secondly the blades of the forceps should be thin -after all they have to fit between the head and the skin of the vagina without injury; and thirdly, the shank of the forceps should be narrow so that undo pressure is not exerted on the vaginal opening until the head actually reaches it.

At that point -when the head is ‘crowning’- the forceps can be removed and the woman deliver the baby on her own. The dilating wedge has succeeded; the head is where the woman was trying to get it in the first place with all her pushing. There are many techniques, of course, but I do not do an episiotomy with forceps -or any time, for that matter (unless there is a dire emergency). By taking off the forceps in a timely fashion, damage to the area is minimized and likely equivalent to what the head would cause had the mother been able to deliver it on her own and without help. Even without the episiotomy, patience and allowing the tissues to stretch as the head begins to emerge from the vagina allows for deliveries that are well tolerated by both mom and baby -often without stitches, often without tears.

I’ve only scratched the surface of the topic of forceps I realize; I just wanted to introduce the idea and perhaps clarify it a little for further and hopefully less passionate discussion. The use of forceps, like much of medicine, requires practice and skill, not to mention judgement and knowledgeable consent from patient and partner. They are only one tool in a box of many tools, but one that is extremely useful and also safe -in the right hands.

Pain

I don’t want the title to imply that I am some sort of expert on pain; I am, like most people, pain averse. I do not necessarily understand pain; I see it in others and assume it has similar characteristics in common with what I experience and so I avoid it whenever feasible. I understand when others have a similar response. Some less charitable souls might characterize this as cowardice, but I suspect pain is something that the majority of us would not willingly endure if at all possible.

I would like to separate the concepts of pain and suffering, however. They are not at all the same. Cassell in his 1991 book The Nature of  Suffering, talks of people reporting ‘suffering from pain when they feel out of control, when the pain is overwhelming, when the source of the pain is unknown, when the meaning of pain is dire, or when the pain is apparently without end.’ He goes on to suggest that ‘In these situations [that is, when they suffer] persons perceive pain as a threat to their continued existence -not merely to their lives but their integrity as persons.’  Further, that ‘suffering has a temporal element. For a situation to be a source of suffering, it must influence the person’s perception of future events.’ And so, ‘suffering would not exist in the absence of the future.’ Yes it is still pain of course, but it has different meanings, different attributes, in different situations and those in turn are influenced by what the person may have experienced in the past. Expectations rule.

And as a physician these expectations that are engendered by past experiences are important. Not only do they influence how I interact with my patients, they often dictate how those interactions are interpreted: the meaning they assign to the pain, and that I assign to the pain. Take the pain of labour as an example. It is very likely one of the most severe pains the average woman will endure in her lifetime. It comes wrapped in culture, past experiences of other pains -or past labours for that matter- expectations, and even self-image. As Cassell again observes, ‘Events of the present can be checked against the past, and events of the past contribute to the meanings assigned to present happenings.’ As a physician -as another person- I can only guess how the experience might be construed in the situation. And that guess is often based on such things as body language, stated preferences, previously expressed preferences and so on. My interpretation, of course.

So should I -or the nurse, the midwife or the doula- assume suffering and act on what is externally presented? And even if there is no suffering, should that alter the decision? Should we, that is, assume we are somehow able to read the internal mental status of the woman and yet act objectively enough to react to her anguish in a thoughtful and appropriate fashion? Should all pain be eliminated regardless of its meaning to the person? Regardless of the possible effects on the labour, the woman, or the context in which she finds herself inextricably embedded? Or is even thinking like this merely subterfuge: insensitivity to the situation, the woman, the need? Am I, who could not possibly be immersed in the same intensity of experience, projecting my prejudice, my reading of cultural demands, -my male viewpoint- on her? My meaning?

It is something I have struggled with -and indeed all others interacting with those in labour have encountered- all my professional life. I do not live in another’s body, nor am I privy to her past and lived experiences. I cannot presume to know the answers. Indeed the answers are more like contextually based questions that are impossible to phrase. I suppose an important guiding principle is contained in our Hippocratic oath: Primum non nocere -most importantly, do no harm. And even this is simplistic: how do I know it is not harming the situation? Simply that I don’t injure her or the baby? If I somehow caused the need for a Caesarian Section because of, say, an inappropriate timing or type of analgesia, is that non nocere? Or if I convinced her that she would indeed benefit from an epidural for her pain, and so took away her feeling of self-control, or the image that she had set for herself -that her mother had set for herself, maybe- would that  constitute non nocere even though both mom and baby got through the labour relatively unscathed?

I suspect I would have thought I knew the answer when I was younger, when I at last escaped from medical school and my interminable residency program, when I first started in practice as an academically sound, yet experientially naive individual. I knew an answer, of course. Now I am no longer certain I ever knew anything other than what I was taught. But the answer? I don’t think so. I’m not sure I ever will.