Thursday, July 16, 2009

A bit more Pit ("to distress")

The phrase that's been shaking up the birthin' blog zeitgeist continues to reverberate. When I shared the link on Facebook, a bewildered friend of mine asked why, WHY would they deliberately do this when it's clear that c-sections are so much riskier for both mom and baby? "What do they get out of it? Is it just a money thing or what?"

I think it's several things. I agree that it does have to do with money, but it also has a lot to do with - dun dun DUNN - fear of litigation. OB's malpractice insurance is through the roof, and the prevailing mindset among OB's is that "you don't get sued for the c-section you do, you get sued for the c-section you didn't do." Remember in Business of Being Born, when one OB was recalling her teacher saying, "Section 'em! Just section 'em! They can never fault you if you section 'em." This an enormous part of why it has spiraled so out of control.

As a result, many, many doctors are 'practicing defensively'. They speak of this openly, too. It makes me pretty near apoplectic with rage - it is essentially admitting that they are putting their own self-interest before the well-bring of their patients. And now that it's out that many OBs are INTENTIONALLY endangering mothers and babies? As far as I'm concerned, "pit to distress" throws the entire Hippocratic oath right out the freaking window. It's not "First cover thy ass . . . and then maybe do no harm as long as I'M comfortable."

There are still other aspects to it besides money and fear of litigation. There's also, frankly, convenience. We often joke about OBs doing c-sections in order to get home for dinner or get to their tee time, and it sounds exaggerated, but I have read so many first hand accounts of doctors saying right out loud, with NO SHAME! Nursing Birth corroborated this - she hears it all the time. Not from every OB, of course, but it literally does happen. Remember, again in Business of Being Born, an OB talking about how studies of c-section rates spike around 5 pm, and then again around 10 pm. He said the first is "I want to get home for dinner," and the second is "I don't want to be up all night." Right from the horse's mouth, people.

A fourth factor is harder to quantify, but has to do with their entire philosophy. They often seem to reach a point in labor when they're just tired of putting up a pretense of letting nature take its course, or, as they often patronizingly refer to it, "letting her try" for a normal birth - which is not what they're really, truly trained to do - they're trained in active management of labor, meaning their belief system revolves around the idea that THEY are in control of labor, that THEY are the active verbs in the sentence,"delivering" babies, rather than women birthing them. So why should they sit around and wait for a woman to find her own way through the labyrinth, when they can hook her up to machines and churn the baby out - and take credit - one way or another.

This IS a huge problem, and solving it is complex, but I really take issue with all of the above. (In case you can't tell.) What's the answer? The litigation problem is very real. How do we solve that? I cannot and WILL NOT ACCEPT that the answer is to increase the c-section rate even further. We're already at an abhorrent national average of 30%, and in some areas it;s even higher. Florida recently made it to a whopping 50% -with some counties near 70%. SEVENTY!

Part of me wants to say that women need to change what they're suing for, and start suing FOR unnecessary c-sections, and for other horrific experiences, like the recent case of Catherine Skol (read that only if you really want to shoot your blood pressure up - and I wouldn't advise any pregnant women to even look). But that's just me feeling spiteful, really; I don't seriously believe that even more lawsuits are the answer, in an eye-for-an-eye payback payback kind of way (though I definitely support Ms. Skol). That won't solve anything. But I do fully believe that part of the solution to the litigation crisis is for maternity care itself to change, fundamentally.

What has to change, I feel, is the entire active management philosophy - the mindset that many hospital maternity care providers maintain (as a whole - there are notable exceptions, of course). A perfect example of this occurs in Business of Being Born, when touring a L&D department; a nurse gestures to an IV bag and says "And this is Pitocin, which is the medication given through the IV that causes contractions." That struck me from the very first time I saw it - the way she phrases it, it really seems as though she BELIEVES that Contractions Are Caused by Pitocin. Not that it's a facsimile of the real thing, not that it's a synthetic substitute, not that it's an artificial means we occasionally have to use in certain circumstances when extra help is needed. No, IT causes contractions.

Very revealing, n'est-ce pas?


I wanted to share a few other great posts on the topic. I was interested to see that even what I'd consider a more mainstream source,, has weighed in. It's currently at the top of the list when you Google "pit to distress", in fact. I was a tad worried that it might downplay the whole thing, but I was totally wrong. While the initial post basically explains the concept and then recounts the chain of outrage from Keyboard Revolutionary to Unnecessarean to NursingBirth ( the three most influential posts, I'd say), at least the information and the links are out there to a wide audience! There are a few good comments, too.

I also really liked Your Birth Right's thoughts. As another L&D nurse and midwife, she, too has some practical advice on avoiding this if you're in a hospital, gives good quotage, and uses this apt metaphor on navigating a hospital birth that gave me warm fuzzies, being a former dancer:

Pregnancy, labor, delivery, induction and the like, especially when you make the decision to have a hospital birth becomes a fine balancing act. It’s almost like doing a dance where the choreography is completely spontaneous. Nurses have to spin around policies and procedures, leap over doctor’s orders, plie’ to patients wishes and occasionally do an arabesque just to keep her sanity. There are many nurses who have learned to do the dance and these nurses are able create a waltz, a jitterbug, or a fine ballet, whatever is necessary to help their patients achieve the birth they desire. Many others however, either don’t care or don’t have the skill set and never catch the rhythm to make that happen.

Maybe it's a bit more like extreme contact improv, actually. Or possibly a workshop with Elizabeth Streb's SLAM.* But anyway . . .

*Shout-out to any dancers out there.

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