Wednesday, September 26, 2007

If you believe in intuition, how can you ignore the doctor's intuition?

One of the main topics discussed in the extensive comments in response to the breech tragedy in Oregon is whether patients have the right to the type of delivery of their choice, against the advice of an obstetrician.

I have written (scathingly) about intuition in the past, but let's for a moment assume that such a thing exists. I have a great deal of experience deliving babies, I am a woman, I have given birth to four children of my own. So if anyone should have intuition, I should, right? If homebirth advocates believe that intuition is a form of knowledge and if they believe that midwives should use intuition as a basis for clinical decision making, how can they blithely ignore the obstetrician's intuition?

I can tell you that the only real regrets I have had during the years that I practiced were the few times that I allowed myself to be persuaded (by a more senior doctor, by a midwife, or by a patient) to do something other than what I thought was the right thing.

Early in my career I had a patient with a persistent transverse lie. We (the patient and I) had decided to attempt a version. If the version worked we would proceed to immediate induction. If the version did not work, we would proceed that day to C-section. The version did not work, or rather it did, but the baby immediately turned back to transverse.

A much more senior colleague was on the labor floor at that time. He asked me what I had going on and I explained. He advised me to let the patient go home and check the position when she came back in spontanous labor. "Don't worry," he said, "the baby will be vertex when labor starts." I was dubious, but he had about 20 more years of experience than me, and was an excellent clinician.

So I ignored my own plan, and sent the patient home. When she came back in labor 2 weeks later, the baby was vertex, just as he said it would be. Unfortunately, the baby was also dead. It had died of a knot in the cord that had probably pulled tight when the baby was switching from transverse to vertex.

Years later a midwife persuaded me to apply a vacuum on a baby stuck in the second stage rather than perform a C-section. She had pushed for several hours and the head had come down somewhat. The midwife had called me specifically to put on the vacuum. She felt there was adequate room. After examining the patient, I was going to recommend a C-section, but the midwife really felt that the baby would fit. It was her patient; she was a very experienced midwife and I respected her judgment.

I applied the vacuum. The head came down without difficulty, and was born. Then, of course, the shoulders were stuck, a true shoulder dystocia. I proceeded through the various maneuvers for shoulder dystocia without any success. Ultimately, I broke the baby's collar bone (accidentally) and the baby was born. The neonatologist was on hand and easily resuscitated the baby. The collarbone healed over the next several weeks and the baby had no lasting effects, but I never forgot how close we had come to losing that baby.

So here's my question for those who claim that a doctor should honor a patients wishes for a vaginal delivery no matter the risks and applaud midwives who are willing to undertake vaginal delivery no matter the risks, and for those who believe that intuition is a form of knowledge: Why should you or I ignore my intuition?

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