The obstacles preventing natural birth practices from becoming part of the routine options presented to women are numerous and complex, but they are important to understand, both for medical providers working with patients who desire a natural birth and for women themselves who may be meeting resistance toward their natural birth plan. One of the harder to define barriers is the general culture of labor and delivery units that often stands in opposition to the natural birth plan. That culture can be a product of the stressful, dynamic, and fast-paced working environment nurses and doctors find themselves within, but it is also a result of the way in which nurses and resident doctors are trained and their own life experiences. An obstetrical residency is one of the most challenging and often demoralizing residencies a physician may undergo and this impacts both their relationship with patients and their approach to labor management. Obstetrical residencies also rarely include formal training in low-intervention techniques. This is because most training tends to occur within busy, high-risk centers which provide the opportunity for residents to be exposed to a large volume of delivery and surgical experiences, as well as a wide range of complications and unusual pathology, but little time for the actual one-on-one work with laboring women that really promotes understanding of the labor process.
Much of the other impediments to the natural birth approach are, unattractively, all business. Birthing babies takes considerable time and our medical system is based mainly on procedural reimbursements, meaning obstetricians earn the same amount of money for a procedure, or delivery, that takes 10 minutes as one that takes 10 hours. The risk of litigation for performing that procedure also continues to rise, with physicians assuming large costs for malpractice and living under the constant threat of a lawsuit that would increase those costs further or even threaten their personal property and their ability to continue to practice medicine in their specialty. It is a complicated set of challenges that often pit the interests of physicians against the interests of their own patients.
An Obstetrics and Gynecology residency is an intense four year training program that competes only with surgical residencies in terms of its reputation of suffering among the residents completing it. While all residents work hard, it is only in OB/GYN that a resident can go an entire twenty-four hour shift without sitting down or eating. In my hospital, there was always a patient in need and it was always urgent. We divided our time between delivering babies and triaging pregnant patients on labor and delivery, learning to perform gynecologic surgery with up to fourteen hour stints in the operating room, managing all the postpartum and postoperative patients recovering on the hospital floors, caring for patients with gynecologic issues in the emergency room, and seeing patients in the hospital’s outpatient clinic. A normal week consisted of eighty hours of physically, mentally, and emotionally draining work. In recent years, more attention has been given to the plight of doctors in training and the dangers of sleep deprived physicians delivering care. Several new regulations have been implemented which have improved residency hours, however when I started my residency several of those regulations were not in place and the ones that were in place were often intentionally ignored. Residents frequently lied about their hours under the threat of their program being put on probation or because they were convinced their life would actually be worse with some different system.
I began my residency with a q3 call schedule. This meant I worked two back-to-back twelve to fourteen hour days followed by a third day and night, over twenty-four consecutive hours, in the hospital, where I literally never saw my call room bed. I only had four consecutive twenty-four hour periods off each month and that could include a post-call day, where a large part of the time was spent in bed recovering from the day and night before. As we moved up in the hierarchy, we transitioned into a night float system, which was significantly better and meant we only had to work overnight every other weekend. Still, that equated to working two weeks straight, with one twenty-four hour stint in the middle, to get two days off. In exchange for this “better” working schedule, we gave up two months of our lives to work the vampire shift of fifteen hours, overnight, five days in a row, trying to fit in a few hours of sleep during the day. Our weekends were free until Sunday night, but again much of that free time was spent in bed recovering. The demands of the night float shift were so intense that most people were physically sick for a large portion of it. The level of exhaustion I experienced literally made me nauseous to the point that I would often vomit if I tried to eat after long shifts.
Beyond the physical and mental demands of this level of training, residency also took a tremendous toll on all our personal relationships. Of the residents I trained with, four marriages dissolved during residency and three nearly did. One of the most common complaints from all of our partners was that no matter how bad their day had been, ours was always worse. They could never be the one that needed taken care of. They could never be tired. They could never be sick. In the battle of who had it worst, we always won and that can be very difficult to live with, especially if there are kids involved. There was also the problem that the further into the medical world we got, the farther away from the real world we went and the journey back into everyday life was often difficult if not impossible to make. Slowly, people began to feel closer to the people in the medical world than their own spouses. Infidelity was and remains common in our program.
I started my residency with an eleven month old baby girl. She had been born during my fourth year of medical school, which had granted much flexibility in terms of her care, as the last year of medical school tends to be filled with elective rotations and light schedules. She was a happy, chubby little baby with a mess of dark curls and deep black eyes that would search my soul in the quiet nighttime hours when we would walk the halls alone. I was as in love with her as I was naive in my belief that my training would not take me from her for too much. I had not even weaned her before I started. Somehow that thought did not even occur to me. I assumed I would find time to pump at the hospital, that somehow doctors in training to deliver children and care for women would be sympathetic to my situation and supportive. I was mistaken.
Twenty hours into my first shift, I had not eaten or emptied my bladder and my swollen breasts were leaking through my last set of breast pads. I quickly realized that having a child was not a strength in the eyes of those who were training me. It was a weakness. It also, above all, was not a permitted excuse. Others could use personal situations as cause for needing some special request met, but whether it was scheduling calls and holidays or getting out of the hospital on time, having a child was unmentionable. It could never be the reason. It was a liability. There was no empathy because for someone to have empathy meant they had to do more work. By the time my residency was done, I realized I could not even remember what my daughter was like between the ages of one and three. At least my husband took a lot of videos.
For whatever reason, the intolerance was worse between women in the department. All too often, as one of my male senior residents with a thick Southern accent so memorably put it, it was “girl on girl action,” and girls are not just mean, they are ruthless. Whether it was the nurses or female attendings relating to the female residents or interactions between the female residents themselves, there was little kindness. My first morning presenting “The Board,” complete exhaustion won out and my mind became a blank slate. I was simply unable to remember the details of the patients who I was supposed to be passing off to the next team. Instead of coming to my aid, the upper year residents who had worked with me overnight, who were in charge of teaching me and guiding me, smelled the blood in the water and began circling for the kill. Each bit of information I forgot, they were there, nipping, until the point that I had lost all composure and any chance of performing my job. After the sign out was done, the resident who had been doing most of the shaming, came to me laughing, saying she had “been there too” and that some day it would be funny for me as well. It never was and, to this day, I feel humiliated when I recount the experience. However, it was by no means the last time such a thing happened to me during my training. Each mistake made in residency opened the door for someone to yell at you, belittle you, or, the most dreaded consequence of all, pile on even more work when all you wanted in the entire world was to just go home. When my classmates reached the top of the totem pole, they even tried to implement a demerit system which would force people to work in the triage unit after their shift was complete if they stepped out of line.
This process hardens most people and they usually end up repeating the cycle. Upper year residents and attending doctors would recount their stories of residency abuse with certain pride. Most considered it a necessary part of the training of young obstetricians. Unfortunately, that hardness often carried over into their relationships with their patients. Poor bedside manner is a one of the most frequent criticisms of doctors in a field where one should expect nothing but patience and sensitivity. However, it is difficult to have sympathy for uncomfortable pregnant women when you have been emotionally battered and sleep deprived for years, especially if you spent any of that time pregnant yourself.
One evening call, I was paged to evaluate a patient in the triage unit. She was contracting frequently but was not dilating and was not yet even term. This was the fourth or fifth time she had come to the hospital with these complaints and was very tired and frustrated. I was thirty five weeks pregnant with my second child at the time and had just spent ten hours on my feet in the operating room before heading up to labor and delivery to take over the night call. As I explained to her that she was to go home, a terrible rant ensued. How was she supposed to go on like this? Did I just expect her to live with these contractions? Her other baby had been born early and been fine. She insisted that this baby be delivered early or, at the very least, that I would take her out of work, though I had no power to do that as a resident. As she carried on and on, the annoyance boiled up within me and my own belly tightened into one of the many contractions I had been having since twenty-eight weeks. I simply walked out of the room. Poor bedside manner indeed.
The principle of soldiering on is ingrained in us from the very beginning of our training. The first day of our orientation, we sat in a nice conference room and were informed of how many sick days we had in our contract. We were then informed that, while it did not say so in the contract, the only sick day you were permitted was when you were either in the ER or dead. I spent many days vomiting or having diarrhea between my surgical cases. When it became really bad, we would have an IV placed by one of the nurses, get some fluids and anti-nausea medication, and go see the next patient. A cold did not even get you sympathy. Pregnant residents kept the same schedule as everyone else, often working more calls to make up for the call they would miss during their four weeks of maternity leave, which was taken out of their vacation time. Pregnant residents literally worked until their water broke or they were dilated enough to be admitted themselves. I wrote up my own history and physical on the day I delivered my son and would have put in my own orders if my water had not have been broken.
While the necessity of this method of training could and should be debated, its effectiveness cannot. Our training program had amazingly consistent results in terms of clinical knowledge and surgical expertise. Residency makes you into a machine. You develop a sequence of movements to complete each task before you as quickly and efficiently as possible, while simultaneously being distracted by the next page, the next patient. You become fast. You become good. In the operating room, your hands begin to move with a fluid, dance-like motion and by the end of your third year, you walk with a swagger of purpose and confidence. When the emergency presents itself, your muscle memory kicks in and you tackle the situation with complete calm because you know you can handle it, just as you have done it or seen it done so many times before. When the bad, scary moments come, the machine is reliable. The machine is consistent. The machine saves a life. The machine gets it done. And if you are a patient, finding yourself on the receiving end of that emergency, you want the machine.
But somewhere the people get lost. You get lost. Most people do not even know it has happened. I was fortunate enough to have a cabinet door fall on my head and let me know it had happened to me. Our labor and delivery unit was in desperate need of a makeover. Lovely pink and teal adorned the walls and the cheap cabinets hung loosely from their hinges and creaked each time they were opened and closed. One evening, at the start of a night shift, I was called to check “Room 9.” I had yet to meet her but my focus was absolute.
Task: Check patient
Step 1: Get glove
Step 2: Check fetal heart rate monitor
Step 3: Inform patient you are going to check her while putting glove on. Do not ask.
Step 4: Check patient
Step 5: Update labor board
Step 6: Write note
Step 7: Call attending.
Somewhere between step one and two, I felt a very sharp thud land on my skull, as the cabinet door I had just opened to retrieve my glove came crashing to the floor. I immediately felt tears come to my eyes and a gash in my head. The surprise of the patient took my attention to her for the first time since I had come in and, as I looked into her eyes, I realized I had entered the room not knowing her name, not informing her of who I was, and had not even looked at her. I could not believe that I had become “that doctor”; I could not believe I had become that person.
The first time I thought I might want to be an obstetrician, I was actually still in high school. I participated in an amazing program where, at age fifteen, I was able to shadow doctors in different fields for an entire summer. I witnessed surgeries, tagged along during oncology rounds, and held tiny babies in the Neonatal Intensive Care Unit, but the most vivid and powerful memory I have of that entire experience was spending an afternoon with an obstetrician. He was doing an external cephalic version on a patient with a breech baby. During an external cephalic version, the doctor pushes on the woman’s belly, directing the baby’s head from her ribs to her pelvis. It is a fast procedure and often helps a woman avoid a cesarean delivery for an upside down baby. After the procedure was done and the doctor was filling out his paperwork, he explained to me why he loved his specialty, “It is a hard job and I work long hours, but every day I get to be there for the most important moment in someone’s life. There is no better job.”
In the grueling day to day experience of residency, that simple truth is forgotten by young doctors in training. It is also forgotten by nurses, anesthesiologists, and the attending doctors who take care of these women throughout their entire pregnancy. To the medical staff, the most special and intimate day in a woman’s life is just another delivery, section, epi, or cervix to check. We talk of television shows as women are pushing their babies out. We call patients “hun” and their partners “dad” because we cannot be bothered to learn their names. We take their babies the second they are born to suction, stamp, and weigh so the right boxes can be filled out in enough time to accept the next patient. There is nothing sacred. It is just business as usual. Is it any wonder we don’t take the time to care about their birth plan?
All residencies are characterized with militaristic terminology, but obstetrics residencies, similar to other surgical training programs, truly function like boot camp. Residents are organized in a hierarchical fashion, usually in teams composed of a member of each resident year, with the more senior team members supervising the lower year residents. Little to no management or teaching training is provided for the senior team members, yet they are held responsible for their team’s performance, as well as their patients’ well-being. Senior team members care for the higher risk pregnant patients and perform the more complicated surgical procedures, while the junior residents are handed the volume tasks of performing all low-risk deliveries, triaging incoming patients, and managing all postpartum and postsurgical patients on the hospital floors. This creates a stressful dynamic where upper-year residents are being challenged with the sickest patients and most difficult surgeries while attempting to supervise the lower-year residents, with the least knowledge, who are juggling the greatest number of tasks. Mistakes are inevitable and even considered a necessary part of the training process. As one attending put it, “Residents need enough rope to hang themselves, just not enough to hang the patient.”1
Junior residents report being frequently yelled at by their upper-year residents, while upper-year residents are frequently yelled at by their attending doctors. Sign outs from one shift to another, intended to ensure patient safety by communicating relevant updates on patient status instead often resemble a courtroom, where the outgoing team is adjudicated on each decision they made during their shift. As residents move forward in the program, autonomy and respect increase with experience, but responsibilities and expectations do as well. Fear of making a mistake is pervasive across all training levels.
Sign outs are also a time where residents are frequently “pimped,” a method of teaching where the patient being discussed is used as a springboard from which the presenting resident can be grilled on related medical knowledge, with the goal of reaching the point at which the presenting resident no longer has the knowledge base to answer. The pimper then moves on in a sequential fashion to each more senior pimpee. A successful pimping session leaves the entire team demoralized, with each team member having reached the point where their ignorance was displayed for all in attendance.
While attempting to cope with this stress-producing social structure, residents work exceptionally long hours with little to no rest for prolonged periods of time. All residents report extreme sleep deprivation, though it tends to be worse among lower-level residents. In one study, 84% of residents who were evaluated by the Epworth Sleepiness Scale scored at a level which would indicate a need for clinical intervention. Those residents reported significant impairment in their learning ability, job performance, professionalism with colleagues and patients, and personal life.2 Limitations on work hours meant to address some of these concerns have not had the intended effect, with residents reporting no change in overall fatigue level or frequency of fatigue-related errors after the implementation of the 80-hour work week restrictions.3 A review of 135 studies from 1980 to 2013 showed similar results, with no improvement in resident wellness, training quality, and patient outcomes with work hour restrictions.4 However, this is understandable, given that even after the work hour restrictions, residents are still working twice as much as the typical American work week.
The nature of the work itself also produces extreme emotional distress. Most choose the field because of its healthy patients and primarily happy outcomes, but when bad outcomes occur, they are particularly traumatizing because they occur in a young women and their babies, where death is as unexpected as it is incomprehensible. It is most often the resident in the triage unit who diagnoses an intrauterine demise, or stillbirth, and, without training in trauma or grief counseling, is the one that is tasked with informing the expectant mother that her baby is gone. Every resident can describe the very specific wail of grief, horror, and disbelief that fills the room at that moment and no one is emotionally prepared for it. Furthermore, very few receive any counseling to help them cope with the repeated times they will be exposed to this in their training. Residents are on the front lines when a placenta detaches or a fetal heart rate goes down and will not come back up, racing the woman to the operating room. They are the primary surgeons performing the needed crash cesarean, delivering the baby in under 1 minute. Residents are also the ones bedside pushing the antihypertensive medications preventing a severely preeclamptic patient from having a stroke and they are the doctors responsible for discovering, as quickly as possible, if a postsurgical patient on the gynecology ward with low-oxygen levels has a pulmonary embolism so that lifesaving blood thinners can be administered. At the end of a bad shift, labor and delivery feels like a war zone where doctors and nurses wage battle against the very real possibility of maternal and fetal death inherent in every birth.
This method of training does prepare resident obstetricians well for their future roles as attendings and most emerge from residency confident in their delivery and surgical skills. However, a deterioration of empathy is observed the further one advances in their medical training. This erosion of empathy begins in medical school, tragically upon entering third year, when medical students begin their clinical rotations and have first exposure to actual patient care.5 By the time their training is complete, 36% of obstetricians report high levels of emotional exhaustion and those with self-reported low levels of empathy are the most likely to report frequent conflicts with patients (65%).6 Ultimately, it is that difficult to maintain empathy that is so essential to the doctor-patient relationship, with perceived doctor empathy affecting patient satisfaction, their likelihood to adhere to physician-recommended treatment, and their likelihood to make a malpractice claim.7 Empathy is also essential in understanding a patient’s birth preferences and working with women through an unpredictable labor process to achieve a safe and satisfying outcome. Unfortunately, programs designed to decrease resident burnout and improve empathy toward patients, such as Balint training, which are widespread and efficacious in family medicine residency programs, have not demonstrated similar efficacy among obstetrical residents.8 Despite the recognition that process of residency is damaging both personally for those going through it and professionally in regards to the doctor-patient relationship, there are currently no good proposed solutions for problem. Women are left with highly skilled but emotionally battered physicians who have built up psychological walls to survive the rigors of their training.
Some even argue this emotional disconnect among obstetricians goes back to the origin of the specialty itself. For most of history, childbirth occurred in the home, attended by community midwives who had likely been known to the women they delivered for much of their lives. Friends and family members would also be present for the birth, providing emotional and physical support for the laboring mother, as well as maintaining her household while she was unable to do so. The first challenge to this tradition of female led, social childbirth, occurred in seventeenth-century England, with a family of apothecaries, the Chamberlens, who entered the midwifery business with a “secret instrument” unknown to the female midwives. Highly successful, this family of male midwives brought a new skill to delivery room and safely delivered infants in situations where often both mother and child were lost. They were said to operate in a clandestine fashion, entering the birthing room with their instrument hidden in an ornate box and working under a sheet. Peter Chamberlen attended the wives of both King James I and King Charles I and delivered King Charles II. Their secret instrument was the obstetrical forcep, which is credited with beginning the transition of birth from the home under the care of women to the hospital under the care of physicians and the subsequent professionalization of delivering babies.
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