on birth

I suppose it's not really all that surprising that I've been thinking about birth more and more lately, seeing as I've hit the eight-months-pregnant mark and all. It's interesting to see how many people think they have the right to impose their views on a pregnant woman when it comes to labour and delivery choices (of course, that's after they've also felt free to rub her belly and express their thoughts about her pregnancy, but before they'll tell her how to raise her kids). I mean, it's one thing for close friends and family to tell you what they think -- in a lot of ways, we rely on that -- but it's something else entirely when random people on the street or internet try to tell you what you "need" to do.

I have been involved with something like eighty or ninety births, and it's an interesting exercise to think about the process from different perspectives.

When I was pregnant with Robin, I had a few different feelings as the birth drew nearer. First, I was looking forward to being not-pregnant again. Being nine months pregnant is not a particularly comfortable state. Second, and more importantly, I was looking forward to meeting this little person and getting to interact more meaningfully than just feeling kicks and hiccups. Although I was somewhat nervous about the delivery, I fully accepted it as a necessary step and was looking forward to getting through it and starting this parenthood gig. Not that Andy and I particularly felt that we knew what we were getting into, but I was pretty sure we'd be able to figure things out as we went along.

I didn't really have any "expectations" for the birth other than having a safe delivery with a healthy baby at the end. Of course I was fully aware that there are no guarantees in L&D (or the rest of life, for that matter), but it is the norm in this day and age in a developed country. It's very easy to take for granted, and I did.

I definitely didn't have any pre-set ideas about what I was going to choose in labour. I'd considered things like labour positions and pain-control methods, and knew what the options were, but I was pretty sure that these would be game-time decisions -- that I'd have to see how things went and decide what was going to work best at the time. My birth plan was (a) call my parents to look after the dog and (b) go to the hospital. Everything after that I considered up in the air.

But as a birth attendant (and by this I mean a doctor, nurse, midwife or other person trained to oversee the process of L&D -- as opposed to a support person, like a spouse or doula), I thought of things very differently. My goal for each birth was the same as when it was my own: a safe delivery with a healthy baby and mom at the end of it. But my job was to do everything possible to make sure that happened, not to simply hope for the best and assume that things would work out as I did when it was my own delivery.

I had spent years learning about L&D, but most of this time was spent learning about all the things that can go wrong -- and that's a LONG list. Sure, most of the time things go more-or-less well, and in those cases the delivery is, from the attendant's point of view, "easy." Obviously I recognized that the mom usually wouldn't agree -- it's called labour for a reason -- but in these cases she didn't need a whole lot from me (although even in the most straight-forward situations, there was almost always something that I was needed to do).

The thing is, the whole point of having a birth attendant is not really to manage "normal" birth -- it's to have someone who can identify problems and take action if things take a turn for the worse. Things can go wrong, slowly or suddenly, in a minor way or catastrophically. And it's not always predictable -- they can go wrong even when everything has been perfectly normal up to that point. Catastrophe is not all that common but it can happen, and that's why throughout history (and even now in developing countries) maternal and infant mortality have been serious problems. Lots of people minimize the risks of childbirth by saying something to the effect of, "Women in Africa have babies all the time without doctors," and that's true -- but far more of them die, or their babies do, than women and babies who have access to good care. Want to know how much this actually matters? The WHO estimates that in Canada, maternal mortality in 2003 was 7 per 100 000 live births, whereas in Rwanda in 2005 it was 1300 per 100 000 live births.

That's right, in a country where access to perinatal care is limited, maternal mortality is almost 200 times higher than in a country where high-quality perinatal care is the norm.

So as a birth attendant, I felt a tremendous responsibility to make sure that I knew how to identify very quickly things that were starting to go badly, and to know how to react to reduce the risk as much as possible. That was my job, and I was too focused on that to worry very much about the smaller details, the "niceties" that some of my patients were focused on. Perhaps it was callous, but things like nice wallpaper and the ambient music were not helping me accomplish the "healthy mom and baby" goal. It was fine if someone else wanted to worry about those things, but it was not my role; I had other things to think about.

Virtually every birth I was involved in (and I was only an active participant in low-risk births; I was involved in some high-risk births but didn't do much more than observe) had at least one "uh oh" moment, where I wondered if things were starting to go sour. That's just the nature of birth -- even when things are completely normal, it's one of those extreme events, when both mom and baby really are on the edge. These "uh oh" moments were almost always relatively brief and sorted themselves out, but sometimes they didn't. Even in the cases where I had to take some kind of action, it was usually a simple maneuver that often the mom didn't really notice at the time.

Most of us, when in a position of responsibility and faced with something that we think might be going sour, feel an overpowering need to take action, to do something, rather than simply wait and see. Obstetrics is no different. Like other areas of medicine, OB is becoming more evidence-based (ie. more and more things are being properly studied to see if they are actually helpful or not), which is a tremendously good thing. But there's still a lot of things that just haven't been studied yet -- sometimes because it's so rare that it's hard to find enough cases to study, sometimes because nobody's thought to do the study yet, sometimes because it's very difficult or impossible to study accurately or ethically. So in these cases people just have to do the best they can with what they've got. It's not a perfect world; we just have to muddle through.

reducing dangerous plays in hockey

Every so often, some NHL player does something unbelievably stupid and seriously injures another player. These dirty shots are often just sickening to watch -- for example, Marty McSorley clubbing Donald Brashear in the head in 2000, or Todd Bertuzzi sucker-punching Steve Moore in 2004. The world is shocked, hockey gets on the front page for all the wrong reasons for a few days and the player who delivered the shot expresses his profound regret. Usually, though, it's not much more than a blip in the career of the injurer, but the injuree often has to live with the consequences indefinitely.

Hockey has become much more cognizant of the long-term effects that head injuries can have, which is a good thing. They are currently working on a plan to discourage headshots in particular, though frankly I was underwhelmed by the plan recently announced: they can call penalties. Holy moly. That'll learn 'em!

May I present my suggestion: the You-Don't-Play-Till-He-Plays Rule.

It's pretty straight-forward: a player who is deemed to have committed a wantonly reckless act that was clearly intended to injure another player and results in a career-threatening (or worse) injury, is suspended until the injured player is also able to return to the game. Yup, that means that if you end a guy's career with a a$$*@&# play that if committed anywhere else would result in jail time, you'd end your own career too.

Sure, there are definitely some areas open to debate here. First and foremost, nobody can prove beyond a doubt what a player's intent was; that would have to be left to the league's discretion. But that's already the case anyway -- nothing new here. And there would have to be an appeal process, since we're talking about a very, very serious punishment -- but again that's nothing new. And I'm not talking about incidents where the contact was accidental, or a nasty-but-routine play that happens to result in serious injury -- I'm talking about the incidents where the action taken can result in nothing other than serious injury, like the incidents mentioned above.

Why? Because I think that if you're willing to end another player's career, you are forfeiting your own privilege to play.

This rule would create a very strong disincentive for players to let their emotions run away with them during the game. Sure, there may have been a long history of animosity between Bertuzzi and Moore, but in the real world, you can't break someone's neck just because they've been harassing you for a while.

This would also create an incentive for the injured player to stay out of the lineup longer if the other player is a bigger asset to the team than the injured player. But would this really be a big deal?

• Most players want to get back into the game sooner rather than later as it's not good for their careers to stay out longer than necessary. As the saying goes, you can't make the club sitting in the tub. Of course, it's possible that management could take the decision out of the hands of the injured player, but most clubs aren't eager to pay guys to sit on the bench unnecessarily either, at least not for long. Historically, management has been far more likely to rush players back into the lineup before they were ready than to keep them out too long. Particularly if the injury is a concussion, this might actually be to the injured player's long-term benefit.
  
• It's unusual for a "skill" player (eg. Gretzky, Crosby) to injure a goon, but they are much more likely to be a goon's target. In other words, it's the skill players who need the league's protection more, and it's also in the league's interest to protect them, as they're the ones people pay to see. So the issue is more important when one goon hurts another and there's a significant difference in their importance to their respective teams.
• This is also more important when the teams involved are in the same conference or division and are competing for the same playoff spots. And these teams play each other more often, so they are more likely to be involved in these sorts of incidents. However, these factors are nothing new -- they're already reasons for a player to be more likely to injure someone in his own conference.

Under the current system, the player who commits an act like this is given a suspension and usually some kind of economic penalty as well. And sure, that probably hurts after the fact. But in the heat of the moment, competitive juices probably overwhelm economic considerations, so in the instant where the player is deciding to swing the stick or deliver the elbow to the head, a financial penalty is probably not as much of a deterrent as the knowledge that they might be ending their own career (which would be a bigger financial penalty in any case).

The biggest stumbling block to this rule would likely be the NHLPA, the players' union. It has a mandate to protect its members from unfair discipline, because historically sports leagues do not exactly have a great track record for looking out for the players. (Of course, the NHLPA has not always been great for its members either.) And I can see the union not liking the idea of indefinite suspensions, even though it's been done before.

But shouldn't the NHLPA it have a mandate to try and protect its members from each other as well? How can they justify standing behind, say, Bertuzzi (other than to make sure he gets his due process with the league) when Moore, who's just as much a member as Bertuzzi, has suffered a catastrophic injury at his hands?

I'm not saying this rule would eliminate career-ending injuries in hockey. It's a rough game and accidents happen. But it might reduce the non-accidental injuries, and would demonstrate the NHL's desire to foster some degree of respect between players, which is one of the reasons we want our kids to play sports in the first place.