Archive for the ‘Obstetrics’ Category

Ending obstetrics

May 2, 2010

I sing and I dance like a bunny

I laugh and I think that it’s funny

     I caught my last baby

    I don’t mean maybe

And I’ll take a great trip with my honey.

Thirty years ago, on a fine spring day in Casper, Wyoming, I talked with one of the Family Practitioners in town while making hospital rounds.

“You sure look happy,” I said.

“I stopped obstetrics,” he said.  “They say you retire twice, once when you stop OB and once when you retire for good.  I feel like I retired.”

At the time I thought he was copping out or caving in.

In the ensuing years FP’s presence in the delivery suite has steadily eroded.  Most don’t do OB any more.  In 1987, I said at a partners’ meeting, “If we’re in OB we’re dinosaurs. There’s no way we’re going to be delivering babies in ten years.”  They all agreed with me. 

Time proved me wrong.

In our practice, the doctor who does the prenatal care is the one called for the delivery.  Exceptions include vacations, weekends (sometimes), or the doctor’s day off.  The continuity of care gives a competitive advantage against those practices which do deliveries by rotation.  For the last twenty-three years, I’ve carried a beeper because I’m the only doc in town who delivers babies and speaks Spanish.  The Labor and Delivery units have been under instructions to call me first if the patient doesn’t speak English, even on weekends and my days off.

My patient’s due date was April 24, and we haven’t seen her since March.  When she missed an appointment at 37 weeks, we called her and she scheduled her 38 week appointment but she didn’t show for it.  I’ve had the most capable staffers trying to find her, but the cell phone number we have for her doesn’t work and we kept getting an answering machine at her home phone number.

A normal pregnancy lasts more or less 40 weeks.  First pregnancies go an average of 5 days longer than the other pregnancies.  Women who have sex throughout their pregnancy generally deliver, on average, 5 days before women who don’t.  Smokers have shorter pregnancies on average because they have so many preterm births.  Races vary by one or two days.

The placenta, which nourishes the baby, starts to degrade at 40 weeks.  A few quit working before 40 weeks; after that the decay function has a steep drop off at 41 ½ weeks.  If the placenta wears out before the baby is born the baby dies.

Most babies are ready to be born at 37 weeks, a few aren’t. 

Thus there is a tradeoff; does one wait for one’s patient to go into labor and risk a still birth, or does one induce labor and risk having to put the child in the Neonatal Intensive Care Unit for several days?

National research suggests that induction of labor before 39 weeks causes more problems than it solves, and both hospitals have protocols; we have to arrange for a consultation with a specialist if we want to induce labor.

Most of the patients I’ve delivered in the last six months have had their labors electively induced after 39 weeks.  One patient, who very much enjoyed being pregnant, refused induction till I insisted at 41 weeks (everything came out fine). 

I have been worrying about my last OB patient for the last three weeks, and the worry has grown with every day, borne not only from scientific research but from the first hand emotional trauma of being involved in OB cases that did not go well.  I fretted so much that I stopped delegating the calls to try to reach the patient and I started doing them myself last week.

Friday afternoon I finally reached a live person.  With sick relatives in another state, I was told, the patient left town weeks ago, and has since had the baby.

I set the phone receiver in its cradle and I looked out my office window, saw the fine green grass and the clear blue sky with billowing white cumulus clouds. Waves of endorphins washed over me.  I danced down the hallway even though people were watching and announced the news to a med student and two of my partners, one of whom stopped OB a month ago.

Then I danced down the hallway again.  I didn’t care who saw me.

It was the same kind of feeling that I had when I bicycled into San Diego from Colorado, but more so.  It was an accomplishment twenty three years in the making.  I’ve been riding a roller coaster without a grab bar for more than two decades and I just got off.