The Secret Language of Doctors
Page 14
Who does what during a delivery has a profound effect on how it’s done and what language is used to describe the process. “There’s a fundamental philosophical difference in approach to obstetrics between obstetricians and family docs [and other] low-risk obstetrics people, whether that’s midwives or whoever,” Prince says.
And there are political differences.
A family doctor who does low-risk obstetrics at an urban hospital learned all about such differences a few years ago. At the hospital where the family doctor works, one of his patients—a healthy woman with no medical complications—was booked for a C-section. During morning rounds, the family doctor leaned over to the OBGYN scheduled to do the operation and said, “My patient is the 10 o’clock Caesarean. I just want you to know that she’s normal and healthy.”
The OBGYN became visibly upset for several reasons. Having been trained to expect complications, he wasn’t about to buy the family doctor’s assertion that all was well with the mother-to-be and the baby. More important, by informing him at the last possible moment, the family doctor was telegraphing to the OBGYN that he didn’t need his opinion as to the situation. In effect, the family doctor was calling upon the OBGYN to just do the C-section, turning the OBGYN into what’s known in the business as a C-section technician. And that really makes OBGYNs bristle.
“Why am I hearing about this now? Why didn’t I get a referral a week ago?” The OBGYN screamed at the family doctor.
The family doctor was taken aback. “This is very routine surgery,” he thought to himself. “You could do it in five minutes if you had to.”
The OBGYN’s chief, the family doctor’s chief and the two physicians had to sit down to sort out the incident. They patched things up, but not before the family doc learned an important lesson about how OBGYNs feel about the work they do.
“Surgeons do not want to be seen as Caesarean section technicians. They do not want to be seen as residents in house for the family doctors in the office,” the family doctor says, “and managing that relationship is a serious challenge.”
In telling me this story, the doctor revealed an important bit of slang for OBGYNs: C-section technicians. They’re also called baby catchers. These terms are hated by OBGYNs because they diminish the scope of what they are capable of and provide insight into why relationships between those who provide maternity care are at times strained. Family doctors tend to be less interventionist than OBGYNs. More than that, both are fighting to hold territory in the labour and delivery ward.
Part of this battle for territory includes “privileging,” a formal process in both Canada and the U.S. through which family doctors apply to hospitals to be allowed to do uncomplicated obstetrics. These seemingly polite requests for permission are often laced with the underpinnings of a high-stakes political turf war: the more procedures doctors can do, the more money they make.
Another primary-care doctor who does low-risk obstetrics has also had his share of turf battles. Previously, he had been used to a routine of family doctors granting privileges to their peers. But the region where he worked was amalgamated with another and the new region did it differently. There, the department of obstetrics decided who got to do what, and its selection process proved more contentious. The GP remembers asking the chief of the obstetrical department if family doctors could have the right to manually remove placentas—a life-saving procedure in certain instances. In a perfect world, after the mother gives birth to the baby, she pushes out the placenta and the uterus contracts to close off all the blood vessels inside. If, however, the placenta stays put, the vessels will continue to bleed and the woman is at risk of a postpartum hemorrhage. Manually removing a stubborn placenta—called a retained placenta—is one way of avoiding such a scenario.
“No, I don’t think family docs should be able to do that,” the chief said. “I don’t think they do it safely.”
“I have people who have been [removing placentas] for twenty years and you’re telling me that you wouldn’t privilege them?” the family doctor asked.
“I just don’t think they should,” was the reply.
“So if I’ve got a woman who’s delivered and is bleeding and needs a manual removal, and I can perform that service, I should let her bleed and call the obstetrician and wait for them to come in the middle of the night?”
“Yes,” the chief said, “you should wait. If the patient bleeds to death, it’s not your fault. You didn’t have privileges.”
I find that shocking: Putting patients at risk because you’re unwilling to share responsibilities with a colleague is unconscionable.
Family doctors aren’t the only ones likely to call obstetricians butchers or C-section technicians; midwives also wage war with OBGYNs.
“I remember it was often like having to get over the perceived hostility that the OBGYN is being called in, and that leads to a C-section,” says a GP who completed a four-year residency in obstetrics and gynecology before switching to family medicine. “There was a kind of a sense [coming from midwives and their patients] that all the OBGYNs want to do is cut, that we didn’t really care about patients. We didn’t really care about the moms or the babies, and that we didn’t get that birth is a natural process. The message we got from them is that the midwife really cared and really wanted the mom to have a natural delivery and that the OBGYNs were kind of the enemy to that.”
The former OBGYN resident remembers one instance in which the patient (of a midwife) was in early labour that was not progressing well. The woman’s contractions began to peter out. The baby’s fetal heart rate showed a pattern known as late decelerations—which means the heart rate went down late during a contraction and stayed down after the contraction ended—a sign that the baby was in distress and at risk of asphyxia.
“I’m consulted to come and talk about starting oxytocin to increase the contractions of the woman’s uterus and to speed up the labour,” the former OBGYN recalls. “The woman is very hostile to that idea because she wants to have a natural delivery and not a C-section.”
The former resident says she’d often feel the tension as soon as she walked into a patient’s room.
“There’s a body language of a barrier—like a defence—starting,” she recalls. “I would see the frown. I’d see them almost squaring for battle like they’re thinking they have to protect their baby and protect their vaginal delivery—like I was this person who was going to try and take it away from them—and turn it into a C-section.”
Nancy Hewer, a perinatal nurse in British Columbia, explains why the relationship between an OBGYN and a midwife might be adversarial: “You see very different styles of practice between an obstetrician and a midwife. A midwife is more . . . encouraging of the woman. [She allows] the woman lots of time to get through the process, whereas obstetricians—lots of nurses, as well—just sort of say, ‘Well, we’ve got to make this much progress in this amount of time.’ I think there are system pressures in terms of budget-centred care instead of patient-centred care.” In budget-centred care, Hewer explains, the focus is on moving the new mother out of the hospital as fast as possible so that someone else can take her spot.
Sometimes, the lines between these models of maternal care aren’t so clear-cut. “In reality, you can find family-practice physicians, especially, who really want to practise like a midwife,” says Rosanne Gephart, the certified nurse-midwife. “And you can find midwives who practise like physicians.”
Gephart’s comment reminds me of another slang term: medwife, or a midwife whose practice aligns more with the medical model than it does with that of her midwife colleagues. Among midwives, it’s used pejoratively as a way of saying the midwife has abandoned her roots for the medical model. When OBGYNs use it, however, they’re implying the midwife is infringing on their territory.
OBGYN Shiraz Moola says, “These are midwives who think they know better than the OBGYN about when to del
iver or how to deliver a patient.” He says that midwives are sometimes referred to as frustrated obstetricians.
Gephart says that, for some midwives, practising within the medical model is more a matter of necessity than it is choice: “If you’ve got six patients in labour, and your job is to prove to the obstetrician who’s on call that each one of these people is making progress and going to have their baby and not need surgery, then you manage them in a very medical fashion,” she says. “You’re still a midwife, but you are performing obstetrics. When you’re putting on internal monitors, when 90 percent [of your patients] have epidurals, can you really still call yourself a midwife? You can. You’re just a different kind of midwife.”
Midwives working within a hospital and abiding by hospital rules might threaten OBGYNs if they feel their role is being usurped and their skill set relegated to the confines of the operating room. Midwives who avoid hospitals altogether, however, can pose a different kind of frustration.
“I probably bear them less goodwill,” Moola says. “We’ve sort of made attempts to bring them in from the cold and try and engage these individuals. I’ve seen moms come in here with their placenta hanging out between their legs, and oftentimes they’ve been abandoned by those same individuals who were helping guide them through their pregnancy. Part of it is because [the midwives] recognize if they walked into the hospital they may be facing sanction or legal summons.”
* * *
The history of birth gives rise to obstetrical slang as well as to the medical jargon heard every day in delivery rooms—much of which irks health-care providers, especially midwives. I’m talking about words and phrases that at first glance might seem benign—to doctors. Delivery, incompetent cervix and unproven pelvis are a few examples.
When birth moved from the home to the hospital, having a baby became more about the doctors overseeing the process than about the labouring mother. Rather than the mother giving birth, the obstetrician was delivering her baby. The two phrases describe two profoundly different experiences.
The family doctor I spoke to who is currently the deputy head of family medicine at a major urban hospital in Toronto says he remembers the first time he witnessed a child being born. “I donned a ‘space suit,’ or full surgical greens, including mask and cap,” he recalls. Like her doctors, the soon-to-be mother was also covered up. She was fully draped with a surgical cloth. “All you saw was surgical drape [with a] little hole in the middle,” he recalls.
Wide-eyed, he watched as a tiny head emerged from the “little hole in the middle” of the draped cloth. “There’s no woman. There’s no patient. There’s no father. [And there’s] probably epidural anesthesia, so no sound,” he says, thinking back. You can see how in this scenario, delivery is the only word that makes sense.
As more and more births took place in hospitals, the birth-is-risky-business attitude took hold. With it came language. Unproven pelvis is an example of a phrase that was probably not thrown around much in farmhouse bedrooms, but nowadays is frequently heard in hospital hallways.
“[It’s] coming from that risk perspective,” says perinatal nurse Nancy Hewer. “‘We just don’t know if this baby’s going to fit through that pelvis. We just don’t know until we give it a try,’” she says, mocking those who use the term.
Incompetent cervix is another term often attributed to the rise in hospital births. When a woman’s cervix starts dilating prematurely and she’s unable to carry the pregnancy to term, she’s said to have an incompetent cervix, a phrase that makes many in maternity care recoil. “I think it’s a loaded [phrase] just in terms of the woman,” says Hewer. “She hears, ‘Okay, so you’ve lost your baby. You have an incompetent cervix.’ The issue around the language for me is: Just how is it taken in by the woman? And how is she then perceived? And how does she perceive her body?”
Dr. Marjorie Greenfield is a veteran obstetrician-gynecologist with more than twenty years of experience. She’s a professor at Case Western Reserve University School of Medicine and at MacDonald Women’s Hospital of University Hospitals Case Medical Center in Cleveland, Ohio. “The term ‘incompetent cervix’ always was to me the worst,” she says. “I think the new term is ‘cervical insufficiency.’ Whether that’s much better, I don’t know.”
Not everyone thinks this area of obstetrical jargon is worth dwelling on. “Call a rose whatever you want to call it, just stick to whatever it is,” Gerry Prince says. “If we would spend more time on being able to roll with things and not be offended by every little nuance of whatever language we’re using, then all of us would be a lot better off.”
For Greenfield, it’s the attitude behind the language that needs addressing. “Fixing the language without talking about the attitude isn’t going to do anything. Then you’re just changing the language in order to be politically correct,” she says.
Not that the language is changing all the quickly or all that much. If you want proof, look no further than the birth announcement of His Royal Highness Prince George of Cambridge, first-born son of Prince William and Catherine, Duchess of Cambridge, on June 22, 2013: “Her Royal Highness The Duchess of Cambridge was safely delivered of a son at 4:24 p.m.”
When it comes to the British monarchy, it’s hard to argue with tradition, no matter how outdated the language seems to be.
* * *
Midwives and doctors alike will tell you that the great tension between them is largely about how they view birth itself. Midwives say it’s a normal process; doctors say it’s risky business.
“Up until the moment the baby is out, you never really know if things are going to go sideways,” Shiraz Moola says.
During moments like these, slang is invented on the spot. Moola was once called to a delivery room where a mother was giving birth to a breech baby, an infant who is entering the world bum first as opposed to head first. Optimally, the head—which is the widest part of the baby’s body—comes out first to widen the birth canal. Having the head come out last increases the risk it will become trapped, and the baby will asphyxiate. Fortunately, breech babies occur in only 3 or 4 percent of all deliveries. While most breech babies are delivered through Caesarean section, in the right hands a vaginal birth can be just as safe.
Normally, during a breech delivery the baby’s buttocks will appear first, with the baby’s back lined up against the mother’s pubic bone. In the case Moola was dealing with, the breech was turned sideways.
It was not a position Moola had encountered before, but it was too late for a Caesarean section. Moola delivered the baby’s feet and moved the baby so that its spine was in the proper position. Then came the next challenge: one of the baby’s arms was stuck. Normally, the arms fall down; in this case, he had to rotate the baby 180 degrees to allow for both arms to come out.
“But then I couldn’t get the head out,” Moola says. “And that oftentimes is the one moment that scares the pants off OBGYNs. Because literally you have minutes in which to deliver the child or it will suffer a lack of oxygen to the brain. So I lengthened the [umbilical] cord a little bit and I could feel that the pulse was fairly weak, but again what happened is the baby’s head turned sideways. And I didn’t know any manoeuvre for that.”
At this point the mother was screaming so loudly the anesthesiologist could barely hear Moola when he asked him to give the patient nitrogylcerin, a medication used to relax the uterus.
“No doubt my heart was going at 180 beats a minute,” Moola says. The drug worked and the OBGYN was able to turn the baby’s head so that it lined up with the rest of the body. The baby was born alive and without having suffered any damage. Moola now calls that one last turn of the baby’s head a Hail Mary manoeuvre.
It’s moments like these that make many believe that birth is dangerous. You never know what could happen and you best be prepared. “That’s the very reason a lot of physicians won’t go into obstetrics,” Prince says.
Moola remembers walking in on a colleague’s particularly bloody Matrix moment.
Moola arrived at a hospital to begin his shift. The maternity ward is normally a zoo, with nurses and doctors bustling from one room to the next. But that night, it was completely deserted. Standing at the main desk, Moola spied a trail of blood starting at the doorway of a patient’s room and leading all the way to the OR. “It looked like someone had taken a body and dragged [it] down the hallway,” he says.
Moola followed the trail to the operating room, where he opened the door and looked inside. What he saw looked like “some kind of tableau that you might see in a Renaissance painting of something out of Dante’s Inferno,” he says.
“There was essentially the entire staff—a whole bunch of nurses, a whole bunch of obstetricians and doctors—surrounding this mom, and it looked like a bomb had exploded in the room.” The mother was suffering a prolapsed uterus, meaning her womb had fallen from its normal position into her vaginal area. It “can be a catastrophic complication,” explains Moola. “The mom suddenly goes into shock and then begins to bleed like stink.”
The obstetrician had his hand up to his forearm inside the woman’s body in an effort to help massage her uterus back to its proper size and muscle tone. The staff stood frozen around him, waiting to see if his efforts would work. They did, and the woman was saved from bleeding to death.
“That to me would be a very vivid memory of the amazing things that can happen in terms of the risks of childbirth,” Moola says.