Why Home Birth?

I mean, seriously! I'm the first one to admit that my experience in labour and delivery has been biased by the fact that both of my obs/gyn rotations have taken place in tertiary care centres, where all high-risk patients end up. Not to say that we don't see run of the mill deliveries as well, but we definitely see more than our fair share of complicated ones.

In the past two months, I've seen some scary shit. I've seen a maternal death secondary to chorioamnionitis (infection of the uterine contents) which also caused baby to be delivered stillborn at 20 weeks. I've seen a uterine rupture when a woman was VBAC (attempting to have a vaginal birth after a previous caesarian section)-- baby ended up with brain damage from sitting in the abdomen for 6 minutes between the time of rupture and the time they were able to get her out of the abdomen. Mom, amazingly, didn't only survive but was able to keep her uterus. I've seen more post-partum hemorrhages than I can count. I've seen the heart rate of full term babies inexplicably plummet during labour, requiring a crash c-section. When things can go SO badly SO quickly, how can you possibly justify giving birth at home? Regardless of how close you live to the hospital, any amount of time is too much when you're talking about a prolapsed umbilical cord or anything else compromising blood supply to the fetus.

Proponents of home birth often talk about stuff like 'feeling more comfortable at home' and 'not wanting to be exposed to germs in the hospital'. Personally, that's crap. So you don't feel comfortable in the hospital? How comfortable will you feel if something goes wrong that hurts your baby... and you have to live with knowing that the outcome could have been different had you compromised your 'comfort' for the sake of the baby? And germs? Please. First of all, we're not sticking women in labour in the middle of the infectious disease ward. Second, I'm sure if you had a microbiologist over to take samples and swabs from your counters, sinks and carpets, you'd be horrified at what's living in your 'clean' house.

Although I don't agree with it (obviously), I can still respect someone who decides to give birth at home if it's not your first baby (so you've proven that your anatomy can handle vaginal birth) and there is no reason to think that you're at risk of any complications. But no one is there to draw the line. Some midwives will allow you to home birth as a VBAC, for God's sake! I know a girl who decided to have a home birth in her parents living room in a hot tub. She's a good 250lbs. As I've learned recently, being obese puts you at much higher risk for a number of complications in childbirth... your risk of needing an emergency c-section is much higher, as is your risk of shoulder dystocia (baby getting stuck after the head is out) and macrosomic (really big) babies. Why would you risk a home birth in that circumstance?

Okay, rant over. For now.

Medical Errors

We all know they happen. Hell, we hear enough statistics on the subject. But actually seeing one is a completely different story. I'm doing obstetrics and gynecology right now. One day, I was assisting a surgeon who had been on call the night before. When you're a big, important attending physician, 'on call' usually means that you get to sit at home and when something happens the senior residents phones you and tells you about it. Unfortunately for him (and later, for his patients, as I'm getting to) he had been called into the hospital to actually perform a surgery. A woman had shown up in emerg with ovarian torsion-- basically, the ovary had twisted back onto itself and choked off it's own blood supply. If it's not corrected very fast, not only will the ovary die but the dead tissue can make you go into shock. So it was a real emergency. The surgery took nearly three hours, so this surgeon didn't get to go back to sleep. And he had a full OR list (the list of people scheduled for surgery) for the following day. So I was assisting an exhausted surgeon. Luckily, the surgeries scheduled were pretty routine.

Or so I thought. The first case bled... a lot. Now, I'm no gynecologist, but the surgeon seemed to be having an awful lot of trouble stopping the bleeding. The surgery ended well, but took considerably longer than expected. We went to the lounge while the staff cleaned the room and set up for the next patient. The surgeon fell asleep. Like, dead asleep. He was obviously wiped. I don't think he was used to the feeling of being "post-call"... that state of terminal sleep deprivation that most residents are well familiar with. At that point, it hadn't even occured to me that the bleeding in the first case might have been due to physician error. Until the second case.

The second case should also have been routine. It was a healthy young woman who had come in for laproscopic investigation of infertility. Basically, she wasn't able to get pregnant, so the surgeon looks around her pelvis with a scope inserted through small incisions in her abdomen. The surgeon placed the first scope, the camera with the light attached, through the incision in her belly button. Then he cut a second small incision through the left side of her belly... in the previous laproscopic surgeries I'd seen, the surgeon uses the light in the abdomen to try to 'see' the blood vessels in the abdominal wall so that he knows where they are and can avoid them. He didn't. Whatever, I just figured it was a different technique. Until he hit the artery. Instantly, we could see the hematoma (collection of blood) spreading through the abdominal wall. The blood started spilling into her abdomen. There was so much of it, it was obscuring the scope... we couldn't see a damn thing. The surgeon tried for what seemed like forever to stop the bleed... he tried putting a stitch through it, cauterizing it, putting pressure on it... the damn thing just kept on pumping. In the end, he had to abort the procedure and just focus on damage control. What was supposed to be a day surgery ended up a week-long stay with an infected hematoma and several blood transfusions. The poor woman just wanted to know why she couldn't get pregnant, and she ended up very, very sick. Although it would be hard to determine how much of what happened was fluke and how much was surgeon error, I've already been told that there will likely be a lawsuit. Will it change the system? Doubtful. Doctors have always worked crazy hours, and been expected to perform perfectly with little to no sleep... sometimes to the detriment of their patients.

Hmm.

Match Day Results... The Anticlimax

So, it was match day. I figured that checking my match would be a formality. Until I found out that I matched to my fourth choice. Holy crap. The good program in the town I didn't like. I was devastated.

My first instinct was to confront the program director and ask what the hell happened... how could he stab me in the back this way after being my mentor for two years? But as much as I hate to admit it, I was unable to even talk about the match without feeling myself come dangerously close to tears. There was no way in HELL I'd approach him only to break down. There is no crying in medicine (which is a rule that likely warrents it's own entry). I never did get any closure on that one. I only saw him one more time before school was over. I was doing a consult in emerg on behalf of internal medicine (my last rotation) and he was the attending on that night. He came up behind me and said in a high pitched whine... "so what HAAA-pened?". What the fuck do you mean, what happened? Grr. I very calmly said that I had ranked his program first, as I had been very clear about since the beginning. His pathetic attempt at a response?

"Hmm. I wonder what happened, then? Cause we ranked you REALLY high."

Um, sure you did, buddy. So why is it that one of the three people that ended up matching to your program I know for a FACT ranked another program higher? Bottom line... there were three spots, and they went to three people that the program had ranked higher than me. And I was leaving.

Now I could go into the betrayal I felt by being left out in the cold by my home program after being assured that they wanted to keep me there. I could go into the dread I felt at having to move to a city that I had lived in before (albeit during a not-very-happy phase of my life) and hated with a passion. I could talk about leaving my friends, my gym, my sweet apartment and the first town I had felt a real connection with to move to a new place that might have well been on the moon for how easy it became to visit my family... but I won't. Cause that would take me forever.

I gave myself all of 24 hours to feel sorry for myself, then I picked up my significant other and our dog and headed to our new digs. Ever try finding a decent place to rent when you have a dog? Yeesh. It was NOT a fun experience. It seems that my new town, although it had a lot of rentals available, didn't have all that much that was... um... livable. In fact, trying to find a place in my new city was a disaster that I'd rather not dwell on. Obviously, this was NOT a fun time.

So that brings us close enough to today. I'm now a first year resident in emergency medicine. For you newbies to the world of medical education, a resident is a junior doctor. I have graduated from medical school, and there is a "Dr." in front of my name, I'm allowed to perscribe drugs, but I'm very closely supervised and have very little autonomy. Oh, and I make all of $44K (Canadian) a year, which works out to all of about $10 an hour if you divide it by the number of hours I actually work in a week.

Now, on to the interesting stuff. Well, interesting to me, anyway.