Thursday, August 12, 2010

The Great OB

Yes, they do exist!

The Midwife who writes at Birth Sense published a post called "Can We Clone This Guy?" where a real-life Obstetrician answered the questions she suggests every woman ask their pregnancy/birth care provider in a manner that respects natural birth and the patient's autonomy:

I was delighted to receive the following comment from a reader, Dr. Henry Dorn, who answered the questions I suggested asking a physician when you are searching for the right doctor.  Dr. Dorn’s responses were so close to my ideal that I wanted to share them with all of you.  If all of us printed off this response and passed it on to our own doctors, perhaps other physicians would begin to see that modern obstetrics can (and should) include practices that support normal birth.  Thank you,  Dr. Dorn.  I wish there were more OBs like you out there:

I will preface my comments by saying that Pam asked me to answer the 11 questions here, so it’s her fault if I take up too much space! I also have avoided reading the right and wrong answers she included, in order that my answers be more candid. Hopefully I get a few right!
1.  What is your philosophy of pregnancy and birth?
I believe that we should attempt to allow the natural processes to occur as much as possible, since this is how the system seems to work best for most healthy moms. This includes a really healthy diet of whole foods, lots of activity and a safe home environment. If mom and baby are doing well (normal fetal growth, maternal weight gain, fetal movement, etc) then labor should be allowed to progress naturally & spontaneously. Our job as caregivers is to support the normal processes and to identify the outliers, who need medical care for optimal outcome.

2.  How do you define “normal birth”?
Normal birth should include spontaneous labor, uninhibited maternal activity, no medical analgesia, spontaneous pushing, immediate maternal/neonatal contact, cord clamping after pulsation, etc. This should ideally occur in a quiet, safe environment.

3.  Can you give me an example how you typically manage  a normal birth?
As above! After confirming fetal well being, mothers should be encouraged to move and find the positions which feel best to them, have caloric intake, and as little intervention as possible, provided that there are no indications of maternal or fetal distress.

4.  How would you feel if I disagreed with you about a procedure you recommended during labor or birth?
I would explain in detail my position and rationale, but ultimately allow the mother/family to decide what they feel is right for them, as long as neither she nor the baby were in imminent danger, which is rare.

5.  How long will you “allow me” to wait if I go overdue?
That depends on a lot of factors, but assuming all indications show a healthy mom and baby, and the mother and family clearly understand the risks of post term pregnancy, as well as the range of options, there is no absolute limit.
As an example, my wife was not excited about being induced after hearing all of my tales, and went over 43 weeks with our first.
I do recommend close monitoring after 42 weeks however, to determine which babies are continuing to thrive inside mom and which may benefit from delivery.
There is also some evidence that induction of labor after 41 weeks may lower the C Section rate, which I make mother’s aware of, and offer as an option.

6.  What position(s) will you allow me to use when giving birth?
Anything goes. All fours, squatting, on the side… Perhaps there should be a “Mama Sutra”, diagraming all the options! Just don’t ask me to get in a tub.

7.  How do you feel about IVs and continuous fetal monitoring?
I recommend IV access (saline lock) as it allows rapid response to emergencies, which is why women deliver in a hospital in the first place. Trying to start an IV in someone with heavy bleeding and low blood pressure can be very challenging and delay treatment. Healthy moms don’t need to be tied to an IV pole however and can hydrate themselves.
I am not a big fan of continuous fetal monitoring for low risk moms, as it offers limited benefit in terms of improved outcomes, according most studies. Its primary use is to allow nurses to care for more than one patient simultaneously, which is often the case in todays maternity wards.
8.  How do you feel about a woman eating and drinking in labor?
As long as there is no evidence pointing to likely C Section, I think a woman benefits from nutrition in labor, especially when prolonged. The risk of aspiration in an emergency C Section under general anesthesia is fortunately low nowadays, and I explain to moms that this is the chief rationale for restricted intake and let them decide.

9.  What do you recommend a woman do during labor?
Move around, get a massage, listen to soothing music – whatever she feels is most relaxing, as I agree strongly with Ina May Gaskin about the Sphincter Theory of childbirth, which asserts that a woman must be relaxed to let her baby come down most efficiently.

10.  What are your thoughts on pain relief in labor?
It is wholly up to the mom and I do not deny it to anyone, however I explain to moms that epidurals increase the C Section rate, likely by limiting maternal movement, which would normally help a baby move into the best positions for passage thru the pelvis and birth canal. Also, narcotics may be in the baby’s system at birth and interfere with normal functions after birth, including breathing, bonding and feeding.
I have however seen some very anxious women with arrested labor relax following analgesia/anesthesia and delivery shortly thereafter.
As stated earlier, I believe in most cases, the best outcomes occur when we leave things alone, but patient autonomy rules here as well.

11.  How do you feel about cesarean birth?
 A C Section generally takes less time and pays more than vaginal birth and carries far less legal risk. Therefore it is a no-brainer as a business decision. ;-)
However for the mother’s sake and good medicine, it should be reserved for the few women who truly have issues which preclude a vaginal delivery, or in true emergencies. The rate should be well under 10%, and far less for truly healthy women.
That being said, since I support a patient’s autonomy, I would not refuse to do an elective primary C Section if the patient was well informed and rational. There are real risks exclusive to vaginal delivery and these should be included when considering risks, benefits and alternatives.
Just my 2 cents. Hope it’s helpful.
Henry Dorn MD
High Point NC 

1 comment:

  1. Great info! I found your blog by looking up some info for a client (I googled "Doula questions for OB"), and this post was so good I posted it on my facebook page. :) I agree... I wish there were more OBs like this out there!


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