The Saddest Thing

22 02 2012

I recently witnessed what was probably the most truly upsetting event in medicine that I’ve seen yet.  Some of you may have heard me ranting about it, and I subsequently decided to write about it here with every possible identifying detail removed.  (This, admittedly, makes the story much less dramatic, but I’d really like to prevent my butt from being tossed out of med school for a HIPAA violation)

So here’s what happened.

A couple came into the triage area (kind of the ER of the maternity ward) while I was on call. They seemed like relatively normal people who had come into the hospital at the insistence of the midwife who had been supervising the woman’s labor. The couple arrived and said something about her having “a lot of meconium (baby poop),” and it was clear they didn’t want to be there to the extreme.

The mother refused to be touched by the doctors and nurses, refused all of the basic things that are standard of care for women in labor. The reason for the refusal was simple: she wanted a natural birth. She thought if she allowed one medical intervention, it would lead to another, and another, and another (which, given her condition, was accurate). She and her husband wanted to do everything in their power to have that experience. Everything.

First of all, I have absolutely nothing against nurse midwives. I love them. For the most part, they are smart enough and well-trained enough to not only deliver a baby (and, let’s be honest, babies can almost deliver themselves), but more importantly to know when the complications that arise are beyond their abilities and when they need to call a doctor. A lot of them even do deliveries in freestanding birth centers, and almost all of them have formal physician backup. Lay midwives are the other kind. They are not medically trained, but “apprenticed” and while experience is good, there’s a lot to be said for book knowledge when it comes to high-stakes decision-making. They focus on “completely natural” deliveries (you know, like they did back in the day when overall maternal mortality was like 5-10%). They usually do more home births, avoiding hospitals, and usually don’t have physician backup. Not surprisingly—to me, at least—they are illegal in some states.

So recapping there are 3 levels of care here: Ob/Gyn > nurse midwife > lay midwife (in order of education and training). The couple in the story here wanted a midwife, so they tried to get cleared for the birthing center near the hospital (they’d have a nurse midwife). Unfortunately for them, the mom was turned down, deemed too complicated, and rightfully so. She had conditions can still have a normal birth with no epidural, but their deliveries should be in the maternity ward with lots of supervision. She and her husband were ticked that they were turned down, so they said, “Forget this, we want to do this our way.”  And so they went against all medical advice, hired a lay midwife, and prepared for a home birth.

One of the residents here explained to me that when they talk to “clients” about developing their birth plans, they often ask this question: Is it more important for you to have the full natural home birth experience, or is it more important to have a healthy baby? Because regardless of all of the granola moms out there, the two don’t always go hand-in-hand. This might sound like coercion to you, but it is the truth.

The experience is nice, but what does it matter in the long run as long as you have a healthy baby?

When the couple in triage finally allowed a fetal heart monitor to be strapped to the woman’s belly, everyone freaked out. The heart rate was in the 90s. Normal fetal heart rate should always be over 120, under 110 is cause for alarm. The nurses told the couple that the heart rate was too low and the baby wasn’t getting oxygen, and they tried help. But she would not let them touch her.  Then the heart rate fell again. The senior resident was called in a panic.

This heart rate is bad, bad, bad; the baby isn’t getting enough oxygen and it is dying inside of the mother’s womb. Let the baby sit with that oxygen level, and the best case scenario is that it winds up with cerebral palsy if not brain dead or actually dead. This was explained to the parents, multiple times, by every single person who tried to care for them. Yet, still insistent on that natural birth, they kept resisting care even after the attending showed up and tried to convince them otherwise.

Because the baby’s heart rate kept dropping—and nobody knew how long the heart rate had been down to begin with—she went straight to the OR to get the baby out. And yet, both of them continued to refuse. As the heart rate dipped into the 70s, the mother refused to get onto the OR table.  Eventually, after much forcing the fact that this baby’s life was in danger and it was almost 100% surely brain damaged already, they consented.

The baby came out more blue than most (or so I am told, I was not in the OR for the delivery). It’s first APGARs were close to zero (normal babies come out at 8 or 9 out of a possible 10). The poor thing required chest compressions and later had a seizure.

Part of the shocker for me (because I’m not quite so jaded yet) was the flurry of activity that followed the C-section.  When everything was settled with the mom from an OB standpoint, and the baby was (safely?) in the care of the NICU team, the doctors and nurses began rushing to document everything exactly as it had happened from the beginning of the encounter to the end of the delivery. They teach us over and over again in the first 2 years of medical school that it’s important to write good notes, but when I asked one of the residents why, he turned to me and said, “because these are the kind of people who will try to sue.” I thought that sounded ridiculous.

But sure enough, he was right.

A few hours later, the nurses reported that the mother was starting to get emotional and upset that she wouldn’t be able to take her baby home in a couple of days.  Then she and her husband both started to insist that nobody had told them the gravity of their baby’s condition.

Yeah. I know.

That’s why the documentation. And even though what was happening and the seriousness of the situation were explained over and over, these people are going to continue to insist that the outcome isn’t their fault. Even if they know that it is entirely their fault, they are never going to tell their family or friends that. I wouldn’t want too, either. It’s a really daunting thing to carry that weight around—to know that you personally killed or disabled your child because you refused care that people smarter than you said was necessary—for the rest of your own life, much less face coming clean to the friends and family who have watched you carry a healthy baby for 9 months.

So what will most likely happen? The parents will blame the OB staff because they don’t want to admit to their loved ones what really happen. Then they will try to sue. Hopefully, they will lose, but that’s not what’s important here.

The most important part of the story is, as of yet, unknown. Their baby has made it longer than the NICU pediatricians were expecting, but my understanding is, the baby’s not really improving. The most daunting part of this is that if it goes home at all, it will be months, if not years, before anybody knows the true extent of the damage done.

After this first happened, I was so angry at these parents that I was almost physically sick, and I actually did shed a few tears (I am not a super emotional person). I cannot even begin to fathom how any parents can choose to sacrifice the health—and very possibly the life—of their own child just to have a natural birth experience. Is the desire to have that one temporary experience really worth knowingly allowing your baby to suffocate to the point Death’s doorstep and even beyond? Absolutely NOT. Even the most anti-Ob/Gyn moms I know would opt for a C-section to give their child the best possible chances for a healthy life. And even now this situation, that the parents chose to ignore the health of their own child and now they want to pin the blame on the people who were trying so desperately to help them when they wouldn’t listen ticks me off.

This is the first time in medicine that I ever felt hatred toward a patient.

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21 responses

23 02 2012
Anj

This is for all the non medical people:

When the HCPs (health care professionals) who have been in the business for years or decades “freak out”, you should pay very close attention to what they are telling you. These are people who do not lose their cool over trivial concerns. Something is seriously wrong.

Minor objection: HCPs are not necessarily “smarter” than lay people. More educated and more experienced, yes. People can be very smart while being dangerously ignorant, especially if they are willfully ignorant. People whose beliefs do not include the idea that “Birth is dangerous and can result to damage or death to mother and child.” can be resistant to education, especially when time is short.

23 02 2012
Pretty Babies

I am really sorry you went through that. It’s just sickening. That poor, poor baby.

23 02 2012
Amy (T)

this is really sad. I want to give you a heads up that the hardcore homebirth advocates will probably be cascading in here to comment soon enough, as Dr. Amy at The Skeptical OB linked to your very sad and touching post. They’ll have plenty of gems of wisdom for you, I’m sure . . . sometimes it takes them a few hours to a few days, but they usually can’t help but “educate” all the poor science based folks. (as an aside, do you read science based medicine blog?)

23 02 2012
Heather

What an awful, awful story. You know who is really to blame for this? Natural childbirth advocates like their midwife who spend more time vilifying real health care providers than they spend learning how to deliver babies. The people that told her all about the “cascade of interventions” and how OBs just want want to give them a csection so they can play golf. Or offer epidurals to women in excruciating pain because they’re evil. This story makes me sick.

23 02 2012
Charlotte

What a horrible, traumatic, tragic event. I would have given anything to have had a healthy baby (I had severe early preeclampsia and HELLP syndrome and my tiny preemie spent many weeks in the NICU) and to think that there are people who would carelessly endanger or kill their child like that is unfathomable. I had an emergency c-section and it wasn’t that bad, and it was absolutely worth it to save my baby’s life. I just can’t get over what this woman did. If you can, please update us on the condition of the baby.

24 02 2012
Glia414

Charlotte, thank you for reading. I am sorry to hear about your HELLP and I hope you and your child are okay. Unfortunately, the baby did not fare so well, and after 4 days of struggling she passed away in the NICU.

23 02 2012
Rain

Please don’t feel hate for these parents. They believed they were doing the right thing. They had been told all doctors and nurses are just out to make money and cut their baby out. They have been told meconium means nothing and isn’t a sign of anything bad. They were told heart rate monitors are ineffective and all they do is lead to unnecessary csections. Please read writing from Gloria Lemay, Lisa Barrett and Ina May Gaskin to understand how these parents were brainwashed to believe anything said to them by a doctor is a lie. Do not hate these parents. Feel compassion for them and try to understand how this happened to them and their innocent little baby. It’s such a horrible story and there are many more like them out there. It’s scary the damage the natural birth extremist are doing. Perhaps if you learn where parents are coming from when they behave this way you can be there to help them understand their baby really is in trouble! Maybe you can save the next baby from this same fate? If you learn there language and there ideas and why they think the way they do, maybe just maybe, you can get through to the next couple. The Natural Childbirth extremist are like a cult. These parents were heavily indoctrinated into the cult.

24 02 2012
Pat

I’m an OBGYN and I have never hated a patient, not even after many years of practice. Patients chose things that I would never chose, for reasons that I can’t fathom because I am not them. I have not been in their place. I know it’s the hardest thing to do sometimes, but it is possible to understand. My hope for you is that you will find that place of understanding, or at least, come to believe that it exists.

25 02 2012
whencanihaveanap

Wow this was chilling to read. Sorry that you had to experience the utter stupidity of these parents, and I hope hope hope that the little baby will turn out to be okay. However, I think parents that are that careless with their child’s life are selfish to the extreme. I wish that there could be some way to legally take action under ‘child endangerment’ however, abortion laws being what they are make that impossible. (Think of story of mom that killed her newborn child but could not be charged with murder as the child was still attached to the placenta inside of her…)

29 02 2012
Med School Odyssey

Just found your blog via Dr. Tuteur and I’m looking forward to reading some of your other posts. Thanks for taking the time to write about this and share your thoughts with the rest of us.

29 02 2012
A Med Student’s Blog to Read « A Med School Odyssey

[…] student blogger I ran across this evening.  If you have some time, check her out.  Try reading this post first. Share this:ShareEmailFacebookTwitterLike this:LikeBe the first to like this […]

1 03 2012
Ad2b

This makes me really angry… really angry. It is bad enough that the parents refused care but IF their child goes home, I have to wonder how well the parents will take care of it.

So many, most actually, parents would give their lives for their child.

As the mother of a dead child (SIDS), I am one of them… I’d have done anything to have him live and take his place.

I do not, and will not try, to understand people like this and thank God, if accepted into med school, I will NEVER be an obgyn (bless you to those that are!)

1 03 2012
S.A.B.

Tragic story, thank you for sharing though.

21 03 2012
Charlene Connell

I find this a very sad story. I do not understand the parents. I am a natural birth advocate, but I know no one who advocates it at all costs. If this were my labor, I would want to monitor baby’s heart rate because of the risk with meconium. I also would have accepted an IV in case C-section became necessary. I would seek remedy immediately as soon as baby’s heart rate was boarder line, and go for invasive remedies as soon as it was poor. I know this to be true of myself, my friends, and my home birth midwife (who would have been there with me telling me the baby needed to come out NOW.)

There are bad midwives and stupid ppl, But using this case to push against natural birth-or even home birth-is like using the case of the mom on meth whose baby apparently died from the meth in her breast milk to argue against breast feeding. Clearly, there are times when breast feeding is not indicated, and that is also true of natural birth.

FYI, my birth history is 2 midwife in clinic births, 3 hospital births, and then 1 supposed to be home birth where my midwife sent me to my OB because of bad tests (I had seen him through 6 mo and a lvl 2 u/s) only to have my OB refuse to see me because, despite claims that if I needed anything he was here, once I told him I was birthing at home, he cleared me out of his system in 40 days or less. I ended up sectioned at 29 wks by another OB I’d never met until the day before, and baby spent 5 wks in NICU. To be clear, this was my outcome, and I’m not blaming anyone. (I saw my doctor from about 7 weeks to 6 mo-my midwife from about 4 mo to 7 mo along–there was overlap. The comment about him being unwilling to see me was presented only to show why trust between those who want a different birth experience and OBs can be so tough from our perspective, since you have shared so well why it might be difficult from the hospital’s perspective.) I was sectioned after spending 2 nights in the hospital. My midwife started the chain that saved my life by recognizing when to refer me to higher risk care givers. My OB saved my baby from a brain bleed by doing an amazing job with my C-section. I am thankful for both of them. It worked just like it is supposed to.

(Don’t go for a home birth, or any kind of birth, out of fear. Be educated, and if you chose home birth especially, be ready to make life and death decisions based on fact and then take responsibility for them!)

3 05 2012
Anonymous

I have just been re-reading these comments, and have one thing to add in response to home birth advocates, and to Charlene. Regarding an OB who discharged you as a patient because of planned home birth, that is entirely appropriate. OB’s are paid for delivering babies. You were asking your doctor to follow your pregnancy for little compensation, then to turn you over to the care of a non-medically trained individual who would then decide whether to send you back once you or your baby’s life were deemed to be at risk. Can you see how unfair this is to the doctor? Home births rely heavily upon the fact that there is a doctor who is legally obligated to bail you out if things get dicey, while in a hospital setting the risky situation could have been more safely monitored and controlled.
I’m tired of seeing my OB/GYN colleagues taken advantage of in this way. Not to mention the very sad fact that bad birth outcomes also often end in lawsuits and these doctors unfairly have to take on the expense of defense for a situation that they did not cause.

22 03 2012
K

This story brought tears to my eyes. So sad.

26 03 2012
thebabydoc

thank you for sharing. I am a pediatrician, and did three years of hospital-based neonatal work, so I have felt the same feelings of helplessness and frustration, and anger. I appreciate your willingness to work through the emotional experience of your training in this way, and look forward to following your blog.
To other readers… I agree completely with Rain, and once Scrubbed In is over the initial grief and anger of what he experienced, I suspect that he will get to a point of compassion for these parents. I appreciate his honesty about his feelings of hatred. It’s okay, give him a break. It’s part of the process. Feeling hate and continuing to hate are different things. I see a young physician who is honestly exploring his emotional reaction to a horrendous experience, and there is no other journey to compassion that I know of.

1 05 2012
Carolyn

Thank you for sharing your experience. My sister is a med student and wants to be an OB. She was interested in paediatrics but after 3 years of med school, she says she “doesn’t have the strength to deal with the frustration of working with parents”. I only hope that she never faces the same type of situation as you did in the Maternity ward.
Being a new mom myself I am floored by how militant “natural birth advocates” can be. I have even lost a close friend over it. Even though I had a natural birth, it was in a hospital. I eventually could not take the constant judgement and criticism for having a doctor in a hospital vice a midwife and home birth, so we haven’t talked in a quarter of my son’s life.
Hang in there, don’t be ashamed of your feelings of frustration and helplessness. You will learn from painful experiences and it can make you a better doctor. Just don’t let it jade you or cause you to lose the compassion for patience as a result.

27 02 2013
Katie

There is way too much emphasis on Natural Childbirth. It comes from everyone, including the classes that you take. Breastfeeding is overemphasized too. This attitude puts women under so much pressure to perform perfectly, and anyone who has a C section, or formula feeds her baby is a failure. That is not fair at all especially to the baby. We have got to educate people properly. There needs to be laws against practicing medicine with out the proper training. And, no vitamins do not cure cancer. Too much bad information out there.
I had 2 C/S and formula fed both of my beautiful children,
There is NO shame in that, get over it already….

13 04 2013
Christy's Houseful of Chaos » Blog Archive » sad stories and questions arising from them

[…] story… I read this story https://scrubbedin.wordpress.com/2012/02/22/the-saddest-thing/ about a couple that were so scared of the “cascade of intervention” that they refused […]

30 07 2013
medgirl16

Thank you for sharing this. I really appreciate hearing your true feelings, not the ones that are considered politically correct or what is the right thing to say. I love being able to hear your actual feelings and insight on this and I can’t imagine seeing something like this happen and not feeling the same way.

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