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.