Obstetric Gynecology Is No Science- A Reminder to both doctors and doulas

One of the qualities of science is that it is predictable.  When creating a scientific experiment you are making an assumption regarding the result.  When the findings are in line with the assumption time after time, it becomes a prediction you can rely on. If obstetric gynecology was a science, doctors would have been able to manage birth. However, the body has a mind of its own, and we can never fully predict the result of any medical intervention by 100 percent.  This is a lesson which both doctors and doulas should be reminded.  Why doulas? Since part of the doula role is to advise her clients to avoid a medical intervention suggested by the doctors, if she thinks it is not evidence –based care and has high potential to take her client to a cesarean.

At a recent birth which I have attended, the doctor decided to induce my client 3 days before her due date. The client had hypertension for the last two months of her pregnancy; she was swollen and suffered severe headaches, which in a way increased her chances to be induced. However, my client was told by her doctor that the reason for the induction is a reduction of amniotic fluids, which her associated with the hypertension.  My client was never told how much of a decrease there was, and the truth is there is always decrease of fluids as mother is nearing the birth. 

My client was admitted to the hospital on Tuesday at 1pm with a firm, long and closed cervix, and a baby in station (-4), meaning- baby was not engaged in pelvis. The disengagement of the baby 3 days before the mother’s estimated due date is a concern which should not be ignored, Why is the baby so high? Something must be In the way of this baby to come down to the -3 or

-2 position , which is common around due date. Looking at the client’s belly, and investigating about where she feels the kicking and wiggly sensations coming from the baby, I suggested that the baby is posterior.

Upon admission, at 1pm, my client received 12 hour doze of Cervidil., which took her  to ½ cm dilation. The doctor wanted to proceed to Amniotomy- rupturing membranes. When she consulted with me over the phone, I told her that to the best of my knowledge it’s a no-no. Here is what Henci Goer wrote about it in her book: “The Thinking Women Guide to a better Birth” : “Studies suggest that early amniotomy may not benefit slowly progressing labor….If the baby is posterior…labor often progresses slowly until the baby turns into the anterior position. With membrane rupture, the head may surge downward into the pelvis and get stuck. …releasing an amniotic fluid adds to the baby’s stress by exposing the umbilical cord to compression during contraction. In addition, one potential cause of fetal distress is that the umbilical cord has slipped between the head and the cervix. Rupturing membranes could then cause prolapse”.

Relying on my experience and my knowledge, I advised her to ask for low dose Pitocin. And so she did.  Pit was started at 9 am, and around 1pm I joined her. She had contractions every 3 minutes for a minute long for a while, but she was not progressing still. At 5 pm I decided to talk to the nurse and see what the plan was. They decided to stop the Pitocin and let my client eat and rest. I went back home and talked to my client at 9pm again, when she told me the doctor decided to try Cervidil again.  At that point I asked her for her blood pressure, and when she reassured me it was on the lower side, I raised the question- why not going home? The client can go home, have a good night rest and come back tomorrow morning to the clinic to be monitored. 

The couple decided to stay at the hospital, and proceed with induction.  To make a long story short, after 12 more hours of Pitocin, the doctor did operate and amniotomy, when the baby was still at -4 and the cervix at 1.5 cm.  As her doula, I shared my opinion and knowledge with my client – that was not evidence based care, extremely invasive, and has high potential to end up with prolapse, deceleration of baby’s heart rate and cesarean. 

However, breaking the water got my client to 4 cm in 3 hours. After 2 more hours she was in 6 cm. Pitocin had to be increased again and again, but the baby was just strong.  Around 8:30 pm she was stuck again at 8.5 cm, and the doctor came to diagnose a posterior baby (Told you J) , He was kind to agree to collaborate with all my requests for position change, even thought my client was already on Epidural. We managed to bring the baby to an anterior position after 6 hours, started pushing at 11:30pm, and the baby was born vaginally at 3:38 am on Friday.

Although it was quite a triumph- a long induced birth which ended vaginally, I can’t tell you I felt good. I was haunted by the thought that we could have agreed to amniotomy when the doctor first suggested it , at ½ cm, and maybe save the mother many hours, since after all  things did start to progress with the amniotomy.  But I have no proof that we wouldn’t end up at the operation room as well. The doctor took a huge risk breaking the water with such high baby, but this time it worked just fine. There is really no way to fully predict the result of medical interventions in birth, we can only rely on our best knowledge and our experience, and hope for the best.  I had to remind myself of this concept of unpredictability of OBGYN, and believe in my contribution as a doula  -  the comfort measures I applied, such as relaxation and visualization techniques and breathing techniques, and the positions we changed in order to bring the baby to the anterior position.  Who knows if we wouldn’t end up with a cesarean without these positions?