The "Art" of Obstetrics

As a resident constantly striving to do right by my patients as I learn the practice of medicine, I've recently become keenly aware of a major source of frustration in my training-- there is something so maddening about constantly being told different ways of practice. Never has this become more self-evident to me than on OB.

Now don't get me wrong, I absolutely love delivering babies. The joy! The beauty! The pride and excitement on parent's faces! I wouldn't trade it for the world. But with the good comes the bad. And working at a county hospital where extremely high-risk patients come through the doors every day, OB's learn to anticipate the absolute worst. And of course, that influences our practice.

Here's a little taste of the ping-pong of different approaches that I am confronted with every day...

• We're not getting a good tracing on the fetal monitor - put in an Intrauterine Pressure Catheter and Fetal Scalp Electrode.  //  Are you crazy? Don't internalize her and increase the risk of infection! 
• Pit* her! Her labor's taking too long.  //  Relax, give her body a chance to make change on her own.
• Get in there and stretch that perineum, I want that baby out by 5pm!  //  Let her "labor down", don't make her push too early.  
• Massage the uterus and get that placenta out--it doesn't matter if it's uncomfortable for the mother.  //  There is no rush - just apply gentle but firm pressure and give the placenta time to spontaneously detach.

I suppose this is the "art" of medicine.. in my opinion, what is often used as a euphemism for the fudge factor in medicine when we have no clear answers for the best way to do things, and it ends up coming down to personal style. Evidence-based medicine clearly faces major limitations in obstetrics (you can't exactly do randomized controlled trials on fetuses). This can be especially horrifying to someone who comes from the traditional medical perspective where we are always expected to show the highest level of evidence behind our clinical decision-making. So a lot of what we do in OB is based on "expert opinion", experience, and what those who came before us have taught us - we do the best we can to maximize positive outcomes for moms and babies with the limited data that we have.

Of course, as in many areas of medicine, many of the decisions we make in OB are quite patient-dependent.  For example, as a family doc following a low-risk delivery, I may be more prone to let mamas labor down or defer extra interventions. Whereas an OB following a pre-eclamptic mother with a sketchy-looking fetal strip might be a little more trigger-happy, and for good reason, when it comes to intervening on her patients. If baby needs to come out, you gotta do what you gotta do, whether it's hastening labor, using forceps or a vacuum, or even C-section. Of course, one can't deny that our practice decisions are influenced by our average patient population - if an OB has taken care of several high-risk patients, she might be more prone to pursue more interventions (breaking bags of water, continuous fetal monitoring, etc.) even on her lower-risk patients because she is accustomed to that type of practice. So understandably, if you have a fairly low-risk pregnant woman, you might be told a plethora of different approaches to managing her care, depending on whether you talk to a perinatologist, obstetrician, family physician, or midwife.

Like with anything in this crazy residency journey, I've learned to take everything with a grain of salt. I'm starting to adapt the things I like, and pass on the things that don't suit me. I oblige when my attending tells me the "right" way to do this or that thing, and remember the way that they like things done so that I practice that way when I work with them, even if it's not my favorite approach. I am finally starting to accept that there may be a multitude of potentially "right" or acceptable ways to get the job done, even if I'm not a fan of all of them. And later on, when I'm out there on my own, I can style my own practice that is as evidence-based as possible, and ideally congruent with my values and my patient's wishes. And then I get to confuse future docs-in-training with my own ideas! The cycle continues...

*Pit= pitocin, the drug of choice to induce labor.