Push!

I have a patient laboring right now, which is the calm before the storm around here. Anybody who has had a baby knows that pregnancy is one big waiting game.  First, you wait nine months for the baby to grow. After about eight and a half months, the baby is generally safe to come out. But most women will have to wait another two or three weeks for their body to say that it's time. And for a lot of pregnant women, waiting two weeks with an eight-pound, heartburn-causing, bladder-squishing weight hanging off of your chest feels about as long as the 37 weeks leading up to it.

Then the contractions start getting more painful, and maybe your water breaks, so you come into the hospital expecting to have a baby. No, no, my friend. You still have to wait for your cervix to dilate 10 centimeters to make room for the baby. For a first time-mom (like the one laboring today), it can take hours. And in at least one occasion, it has taken 24 hours, as I'm often reminded by my mother.

This last stage of the pregnancy can be wildly different from one woman to another. Most deliveries in the US occur in a hospital, but not all of them. Other options include births at home, births in a birthing center, and of course births in the ambulance on the way in. Two of those options are not ideal, but birthing centers are an under-appreciated option for most women. They're generally run by midwives, and have a much more comfortable approach. Couches, bathtubs, and giant exercise balls replace the stirrups, sterile drapes, and face masks of a hospital birth.

But that's not to say that giving birth in a hospital is an unpleasant experience. Many hospitals have taken big strides to make the process of giving birth feel less like the process of giving a kidney. Rooms are getting bigger and more comfortable, and the standard of care has changed a lot over the past 20 years.

The studies that defined how long labor should take were first done in the 1950s, and that set the tone for hospital births. If you were taking longer than the labor curve said you should take, you were given medicine to speed up the process. If you were taking a lot longer, you got a C-section. Period. But several of the more recent studies have shown that labor can safely take a lot longer than we initially thought.

But with all the progress made in de-escalating hospital births, there is still one pervasive element that we can't quite kick: fear. Fear of bad outcomes, fear of upset patients, and unfortunately, fear of lawsuits. Thankfully, all three of these occur incredibly rarely, but it's the fear of them (especially the last one) that sets the tone of what's done in a hospital.

This fear leads to a lot of hyper-vigilance. To keep an extra close eye on the baby, many hospitals strap a fetal heart rate monitor to each mom's belly. It's a pretty nifty device that uses ultrasound to monitor the baby's heart rate in realtime. It was heralded as a lifesaver when it came out in the 1960s, since we can tell a lot from the baby's heart rate. If the rate is too slow or too fast, we can assume that the baby is struggling and needs to come out.

That seems pretty reasonable right? But in the fifty years since continuous fetal heart monitoring has been around, we haven't seen any real decreases in most bad outcomes. This is probably because truly bad outcomes are rare, and many, many, many babies are going to show concerning heart rates without any serious underlying disease. But we can't tell which babies are truly under stress, and which ones are just getting excited about coming out. So we get extra aggressive with labor induction and C-sections, which of course, have their own risks associated with them.

One of the maternal/newborn nurses here used to be a doula (birthing aide), and says that it's just a difference of approach. Doulas assist mothers in both birthing centers and hospital births, so this nurse has seen a lot. Her take is that birthing centers are slightly more comfortable with a relaxed approach, since most babies will be born without any major issues. The birth centers send their high-risk patients to the hospital, and don't place the remaining ones on continuous fetal monitoring. The outcomes aren't any different, and a falsely concerning monitor strip won't result in a rushed labor or emergency C-section.

Obstetricians have one more tool available to them: the C-section. Their approach is that if there is any risk at all to mother or baby, they will both benefit from a rapid birth to get through the most dangerous phase quickly. C-sections are often derided, but they have phenomenally good outcomes. Yes, it's a scar on mom and a non-typical birthing process for baby, but both generally do great afterwards. Of course, there's no way to know if they would have been fine without the surgery, but obstetricians don't want to take the chance.

To their credit, obstetricians are the people you want taking care of high-risk pregnancies. They have tools, procedures, and medicines available to them that other birthing professionals do not. But after you've seen enough scary pregnancies, it's hard to remember that most women will be just fine. I get that.

For example, I took care of eight laboring patients in the last 48 hours. Three or four had concerning fetal monitoring strips, and one of them was scary enough that we gave the mom some medicines to speed up the labor. Of the eight, seven patients gave birth to seven very healthy babies, even the ones with scary monitoring strips. But the eighth women had an entirely different outcome. She had some health problems that complicated the pregnancy, and even though she was fine a few days ago, the fetus had died before the patient even got to the hospital. So at 3am, I had to tell a mother that was excited about having another child that it was not going to happen with this pregnancy.

That was a heartbreaking conversation, and one that I don't want to repeat any time soon. So maybe that will be on my mind when I decide whether or not to monitor the next mom's fetal heart rate or consider induction. But I hope it isn't.

I think that my training as a Family Physician is a good balance between the two approaches. We're often thought of as General Practitioners, but we're a completely different specialty. GPs get one year of training after medical school and take care of mostly adults in an outpatient (clinic) setting. FPs, like me, go through three years of training after medical school (the same as internists and pediatricians) and are qualified to deliver babies, take care of kids, and treat people in a variety of settings. We're equally comfortable in the birthing center and the hospital, and although we have access to many of the same tools and medicines as obstetricians, we're a little less likely to use them. We know that most laboring women will be just fine, and we're willing to spend a bit more time before going to the OR.

So if you have underlying medical issues or a more serious pregnancy complication, you should deliver under the care of an obstetrician. If you already have a Family Physician that you know and trust, that's who should deliver your baby and take care of him or her after the birth. Most other women should see if a birth center is right for them.

But I've spent far longer talking about this than I thought I would. I should go check on my laboring patient, although she really doesn't need it. She will probably deliver a perfectly healthy baby without much intervention on my part.

Update: She did.