I'd Hammer All Day

Yesterday I went to the doctor to check on Miss Olga's position.

She was oblique, with her head at 5:00 and her bottom at 11:00. Discussion ensued. He cautioned me repeatedly that if my water broke, I'd need to get to the hospital right away. I'm totally on board with that. I'm not going to mess around with a possible cord prolapse.

Then he said something that still has me boggled. He said if she flipped to transverse or breech they could offer me an external version, but that immediately afterward they'd want to induce my labor by breaking my water.

Now I can kind of understand where he's coming from with the induction idea. I'm not going to consent to that without a much, much clearer indication that it's warranted, but I get it. It doesn't make a lot of sense to expose a baby to the risks of a version if she's just going to do another Korbut Flip right afterward. But it makes no sense to me -- none, zero, comes from another GALAXY far far away from my idea of sensible -- to spend ten minutes telling me about the hazards of cord prolapse and then offer me my very own iatrogenic cord prolapse.

He can get that little head down, probably, but he can't engage it in my pelvis. And if he breaks my water when the head is not engaged, how on earth does he know the head's going to beat the cord to the exit? One of the deaths in the Johnson & Daviss homebirth study happened in just that way: midwife recommended a transfer, doctor at the hospital broke the woman's water, baby's cord prolapsed and they couldn't get him out in time. That story haunts me.

He quit talking about induction after he checked my cervix. He said, sounding a little surprised, that it's completely unfavorable. I could have told him that with my pants on. I bet I can judge the state of my cervix fairly reliably by the state of my kitchen floor. When I can invite you to eat from it? Ready to go. Today it's clean but not sparkling, and if I have a baby before I enter my 41st week, I'll eat my placenta. Tartare, baby.

He doesn't think I'm going to make it to 41 weeks. I did not remind him that he had confidently predicted I wouldn't make it to 40.

I have been thinking a lot this time around about the differences between the midwifery model of care and the obstetric approach. I suppose it's a little odd that I've had this many babies without ever seeing an OB for prenatal care before, and maybe that's left me biased. But it astonishes me, now that I am comparing the care I've received from midwives, family practitioners, and OBs, that OBs are providing the lion's share of routine prenatal care in this country.

Yesterday an analogy occurred to me -- an imperfect analogy but I'll throw it out there anyway. If pregnant women are like nuts, the OB model is the sledgehammer approach to shell removal. BAM! BAM! BAM! Lots of oomph, not so much with the patience. Sure, they get the shell off, but there can be some collateral damage. They look at the piled-up splinters of shell and say, "See, birth is fragile." They look at the homebirth midwives wielding little nutcrackers and say, "I would never attend a birth without more firepower at my disposal." And you know, sometimes you can't get the nut out of the shell intact with a little nutcracker. But does that really mean that every woman would do better with a sledgehammer?

It seems so obvious to say that every intervention is associated with risks as well as benefits, but I'm feeling like my OB's default is to intervene. It perplexes me. SROM = grave danger, but AROM = high-quality care. Elective opiate use in pregnancy is (reasonably) viewed as unconscionable, but elective opiate use in labor is perfectly normal. Recommended, even.

I wish I could say to him, "I am not crazy. I am not reckless." Going to the hospital in labor is also associated with risks as well as benefits. I have observed the enormous differences in my own labors at home and in the hospital. I am certain that I could not take the joy and the yieldedness and the flow of my labors at home into the hospital with me. There was a profound rightness to bringing forth those babies in their own homes.* If I need to go to the hospital, I'll be there in a shot. I don't assume I need to be there, any more than I assume I need a sledgehammer for the bowl of walnuts on my dining room table.

[Standard disclaimer: my experience of rightness does not imply the wrongness of other experiences.]

Miss Olga (head down since last night!) is waking up and jabbing me gently, which prompts me to share one other observation before I wrap up this overlong post. My OB tells me that my baby should move ten times in every single hour, and that not doing so is cause for concern. As she is maturing, though, she has distinct stretches of sleep and wakefulness. She moves vigorously when she's awake, but she's a quiet little sleeper. I refuse to conclude that a pattern consistent with normal neurological development is indicative of pathology. I am going with my midwife's worry threshold instead. Nutcracker over sledgehammer, once again.

Comments

[Rebecca]

You are so smart! Wonderful. May you have a blessed birth.

[Sarabeth]

"Elective opiate use in pregnancy is (reasonably) viewed as unconscionable, but elective opiate use in labor is perfectly normal. Recommended, even."

Completely different, CJ, and I suspect you know this. Opiates used for epidurals and even IM do not cross the placenta, causing no harm to the baby.

I would also like to clarify that going into labor, being pregnant, has inherent risks, no matter where you are.

I am quite glad to hear that she is head down.

[Maria Wood]

Your analogy is apt and wise.

[CJ]

Hm, Sarabeth, I'm happy to agree that pregnancy and labor pose inherent risks, and happy to agree that there are important benefits to labor anesthesia and analgesia. But I do think that opiates cross the placenta, whether they are delivered as part of an epidural or as an IM analgesic.

[Kristin]

I love your sledgehammer/nutcracker analogy! It seems like a kid with a full box of toys - gotta use 'em all - EFM, AROM, Pitocin, etc...

I'm currently 39 weeks, 5 days. I'm using an OB for this, my 3rd birth because it's my husband's first child and insurance requires an OB. I've got a whole set of risk factors for this one, too.

But, my main point was that I've heard the same 10 in an hour for movement, but that's just odd. Babies in utero have to sleep sometimes, don't they?

Blessings,
Kristin

[Sarah in Ottawa]

I love your entries -- they always make me reflect and are incredibly informative!

That said, I am so, so glad to live in the province of Ontario, where midwifery is fully covered by our heatlh care plan. There are waiting lists because the demand is higher than the supply, but I am so happy to have been able to enter midwife care. I started out with an OB who seemed very nice but who viewed me as some distant audience member in the play that would be delivery. The midwives are just amazing, and have a much more gentle, nutcracker-wielding approach.

Good luck as you go through the next few weeks. My thoughts and prayers will be with you.

[Erin]

Very interesting post. I thought it was quite natural, especially in second pregnancies and beyond, for the baby not to engage in the pelvis until labor is imminent. I bet she'll know what to do!

[CJ]

Oh, it is very natural for babies to engage late in the game in later pregnancies. It's not so common for them to be turning transverse at this point, and that's what has me a little worried. But she's been in the right position since Tuesday night, so I'm feeling less concerned. :-)

[Amma Always]

As a former OB nurse, I am hesitant to admit that there are ever "important benefits to labor anesthesia and analgesia" for a normal delivery. Of course women have a right to pain meds and epidurals if they wish to have them. But they also have a right to the truth. I have seen more complications caused by medical interference than by attentive, natural birth. Life is full of risks - and medical interference in a natural birth only increase those risks. (I am struggling very hard to not launch into a long lecture on the subject, so I will stop here.)

You go, CJ. Tell the truth and have a beautiful little girl when she and you are ready.