The Business of Being Born

Celebrity actress/host Ricki Lake's new movie, "The Business of Being Born" points out that some of the most traditional practices of contemporary obstetrics have everything to do with the convenience of the physician, but can actually make delivery more difficult for the mother.

The Next Inconvenient Truth?

"Birth is miraculous, a natural process. But birth is also big business and this movie will change your mind about everything you think you know about it," said Sabrina McIntyre, a Fairfax County mom and former flight attendant who delivered one daughter by Cesarean section (c-section) and another at home by midwife.

To most people, the idea of giving birth outside of a hospital seems foolish and even dangerous: why would any parent limit their newborn's access to technology in the event of an emergency? Why would any couple put their child's life in the hands of a midwife instead of an obstetrician? "When my friend Ricki (Lake) approached me about making this film, I admitted to her that I was afraid to even witness a woman giving birth, let alone film one," said Abby Epstein, the Emmy-winning director of "The Business of Being Born." "I discovered that the business of being born is another infuriating way medical traditions and institutions -- hospitals and insurance companies -- actually discourage choice," said Epstein.

"The point here," observed Dr. Marsden Wagner, former Director of Women's and Children's Health, World Health Organization, "is there's not a good history in obstetric practice of careful study of the long term effects of all these interventions. This is why; if you really want a humanized birth, the best thing to do is get the hell out of the hospital."

A Movement Underway?

Arlington-based midwife, Tammi McKinley, said her practice has "boomed" with the number of women questioning high-tech birth. "Women are really starting to understand that all those gadgets don't always mean a safer birth, and women are looking to replace high-tech birth with high-touch birth," said McKinley, who delivered one child by c-section and her second at home by midwife.

Statistically, the use of c-section, a major surgery, is being widely employed, more as a measure of convenience for both doctor and patient instead of a last resort in the event of an emergency. Dr. Michael Brodman, Chief OB/GYN at New York's Mount Sinai Hospital, cites a study that reveals the peak hours for c-section procedures are 4:00pm and 10:00pm. Brodman interprets the data from the perspective of the hospital-based physician:

"It's obvious," he says, "that four in the afternoon is 'It's late in the day, I don't know what's going on here, I want to get out of here and the ten o'clock at night is, 'I don't want to be up all night.'"

FAST FACTS:
-- In America, midwives attend less than 8% of all births and less than 1% of those that occur outside a hospital. At the same time, the US has the second worst newborn death rate in the developed world. Lake and Epstein ask, "Why do less than 8% of Americans take advantage of the benefits of midwifery, which is statistically safer and cheaper than physician-attended birth?"

-- The five countries with the lowest infant mortality rates in the March of Dimes report -- Japan, Singapore, Sweden, Finland and Norway -- midwives were used as their main source of care for 70 percent of the birthing mothers.

-- C-section is the most commonly performed surgery in the US, at a cost of $14 billion per year. Cesarean-delivery rates are now at an all time high in the United States, standing at 1.2 million, or 29.1 percent of live births in 2004. The increase represents a 40 percent increase in the past 10 years.

-- In one 1999 survey, 82% of physicians said they performed a C-section to avoid a negligence claim.

Jennifer Block, author of "Pushed: The Painful Truth About Childbirth and Modern Maternity Care," writes, "Too many Caesareans are literally medical overkill. Yet some US hospitals are now delivering half of all babies surgically. Across the nation, one in four low-risk first-time mothers will give birth via Caesarean, and if they have more children, 95 percent will be born by repeat surgery. In many cases, women have no choice in the matter. Though vaginal birth after Caesarean is a low-risk event, hundreds of institutions have banned it, and many doctors will no longer attend it because of malpractice liability."

She adds, "We've become dangerously cavalier...the Caesarean rate should be a major public health concern."

Natural Solutions to a "Medical" Problem
Midwives are definitely a viable solution; however, many find it difficult to assist with birthing because of the impossibility of obtaining malpractice insurance. Peggy Vincent, a midwife in California, writes candidly about her life as a midwife and the barriers she encountered with regulations and insurance in her book, "Baby Catcher: Chronicles of a Modern Midwife."

I am still bitter about my birthing experiences at San Diego Naval Medical Center. As an active duty sailor, I was not permitted to have a midwife assist with my labors nor was I permitted to have a homebirth. Consequently, I got the physician only on-call when I went labor and that resulted in a an emergency room physician (not even someone doing their residency) catching my baby for only the second time in his life. I suffered a fourth degree laceration (extending through the rectal mucosa to expose the lumen of the rectum) with an infant that weighed only 5 pounds, 13 ounces. At least, I didn't have a Caesarean, although they threatened me with that.

Addendum
ABC News published a story on unassisted home births. You can view the story and comments here:
DIY Deliveries: More Women Go It Alone

Here's an additional resource on the history of childbirth. As someone who studied medical sociology, this book should add depth to the rise of the American Medical Association:
http://www.mcfarlandpub.com/book-2.php?id=978-0-7864-3362-9

Mary K & and Terrible, Horrible, No Good, Very Bad Day

We made bedside rounds that morning and one of the patients TOW'd from the ICU two days earlier was reporting a headache. Since that's one of my specialties, I asked, "Is this headache like headaches you've had before?" She said yes, and she treated it with Tylenol. We promised to get her relief. The plan was to discharge her home the next day.

Subconsciously we knew she just wasn't right, because everyone checked on her frequently. She started vomiting and told us it was related to the headache. Her only PRN medication besides Tylenol was MOM. She refused offers for us to get Zofran or phenergan. The doctor had ordered a doubling of her lisinopril dose and I reviewed the side effects. I went back to her room.

"Have you been taking lisinopril long? Did your headaches start with the addition of lisinopril?" She considered the question, and said no, the headaches started long after that. She was sitting in the chair, leaning her head against her hand, resting her elbow on the rolling table. "How bad is the pain?" She replied, "It's a 2." I went back to the med room and saw that I could at least give her another dose of Tylenol.

She never got it. When I returned to her room, the ward clerk was holding her hand and calling her name. She was splayed out in her chair, with her head at an odd angle. She was on telemetry so I ran for the bat phone to the ICU and told the listener on the other end to start recording strips. The LPN called for a code. The corpsman and I raced the crash cart down the hallway. We dragged her chair over to the bed where we lifted her up and laid her flat, her eyes open wide and drool running from the left side of her mouth. We opened the crash cart as the code team came up the back ladderwell from the ER. The other floor nurse was assisting with the efforts, so I stayed outside the room and managed the rest of the floor.

Another patient's oxygen saturation levels were dropping to the low 70's. His ABG's showed severe acidosis and the hospitalist went in to deliver the bad news to the patient and his wife. My patient had a final request so I had the legal officer get a lawyer from Big Navy to come and do a deathbed will. I witnessed his signatures on all the forms and when we were done, they had already taken the other patient away.

Without the bed, the room was cavernous. Crumpled 4x4 gauze and blood smeared the floor where they started an EJ instead of wasting time searching her non-existent antecubital veins. A freshly spiked and primed infusion set dangled on the edge of the trash can, unused. The chair had been shoved into the corner. It was a rave gone bad.

Back when I first started nursing, one of my intern friends coined a term: the Grillo sign. Practically everything in healthcare is objectively measured or assessed and identified by signs---Obturator or Psoas Signs, drawer sign, or Homan's Sign. For Dr. Grillo, this meant the radiologist didn't have to point out the abnormality on the films; the defect or problem was readily apparent, often at some distance from the viewer.

This patient stroked out. The signs were there. She'd reported nausea over the past few days and other non-specific or vague symptoms. Only a few tools exist for treating stroke on Guam: medications like mannitol to reduce brain swelling and vasoactives to control blood pressure, drilling holes in the skull to relieve swelling (a very bad sign), and prayer. These patients are not stable enough to medevac to Hawaii or Japan. And rehab is extremely limited for those who survive.

Would identifying her problem earlier have made a difference? I repeated this story so many times that day, to myself and to others who patiently listened, who must have been reminded of "what ifs" in their own careers as healthcare professionals. As others reassured me, everything had already been set in motion long before I assumed her care that day.

Ultimately, the long slow bleed filled the right ventricle of her brain. And now, it is a waiting game, as it is for the patient with lung cancer, while we wait for the next terrible, horrible, no good, very bad day.

Disruptive Physician Behaviors

My patient was convinced he was on a regular diet. "I can't eat jello and broth for breakfast," he said. "The doctor said I could eat real food today."

His diet orders were written"clear liquids." I paged the surgeon, a difficult task to do at 0900 on Sunday morning. He didn't return my page. I paged again and finally left a message on his cell phone at 0945. Good thing it wasn't an emergency.

He finally returned my call at 1015.
"I need orders for a regular diet," I said.
"He has orders. I ordered it when he was transferred from the ICU."
"No, sir, he doesn't. The only orders are for a clear liquid."
"Fine, give him a regular diet." Slam.

I went ahead and ordered a 2000 ADA diet (which should really be "carbohydrate-consistent" but just try re-writing deeply ingrained institutional habits) instead of a regular diet and didn't page him back to request a correction because he'd just slam the phone down again. We both knew what he meant.

Unfortunately, I had to page him later, this time for a patient experiencing bladder spasms. I have learned to be concise with the surgeon because he becomes impatient. I explained the patient was feeling the urge to bear down and urinate and was telling himself not to do it.

"He already has Ditropan ordered," he said.
"No, sir, he doesn't."
"Well, the urologist ordered it yesterday."
"No, sir, he didn't. When he came to examine the patient, the symptoms were not consistent with bladder spasms and he consulted YOU for input to give a one-time order for morphine and start around-the-clock Toradol."
"Fine. Ditropan 5 mg po TID." Slam.

Barely time to do a read-back and verification. Good thing I have a thick skin and lots of experience with surgeons. I never take anything personally because they're just operating (ha-ha) on a higher plane.

Unfortunately, I have a lot of junior nurses who don't have this experience and they are terrified to call for assistance, to request clarification, to ask for guidance, because the surgeon will condescend, belittle, and in some cases, yell at them. This surgeon is going on leave for two weeks in May. Maybe he'll come back a little less stressed, a little more rested. Then again, surgeons are a different breed from the rest of us---highly driven and deeply superstitious but skeptical perfectionists with poor bedside manners.

In the nurses' station, I laughed and repeated a comment made by the infectious diseases specialist regarding one of my patients whose oxygenation levels hover around 66%: "He's a
facultative anaerobe."

This surgeon overheard me and said, "That's mean. Even if it's the Department Head for Medicine, you shouldn't repeat things like that. That's just mean."

I don't think he grasps the irony.

Disruptive Physician Behaviors

Disruptive Physician Behaviors - Rhode Island

Practicing Excellence

"A healthy physician-nurse relationship is not just a nice thing to have; it is a competitive advantage driving clinical outcomes, patient safety, and staff retention. Interviews of nurses demonstrate that when physicians intimidate and behave disruptively, clinical care is impacted. Ninety-two percent of hospital-based nursing staff have witnessed disruptive physician behaviors and report a compromise in communication, collaboration, and information transfer. Nurses also reported disruptive physicians increase frustration, stress, and the quality of workplace relationships. When respectful, collaborative physician-nurse communication is in place, and nurses are encouraged to speak up in the face of patient danger, errors are reduced and care for patients improves.

“The physician’s role in workplace operations and performance is critical,” says Beeson. “Physicians are in a leadership position and will influence the perception, attitudes, and behaviors of others. A vested physician committed to reward and recognition, who clearly articulates expectations, who gets to know and takes care of staff, and models the behaviors consistent with their organizational mission, will create a high-performing unit.”