Monthly Archives: March 2009

Hoo-ha doctor

female-parts Ha ha ha ha! I used to use the term hoo-ha for vagina all the time. I always said I would have to stop saying hoo-ha by the time I was in practice, or no one would take me seriously.

Hmm, maybe I should update my avatar with this image.

Courtesy of “Hoo-ha doctor wins the Nobel Prize”, from the Onion.

(H/t to Rachel. By the way, Rachel, we are Soup fans here, too.)

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Boy’s birthday reproductive rights round-up

abortion-poll

On my older son’s birthday, I feel like it is only appropriate to post a link round-up with items of reproductive rights interest. Why? Well, when I think of reproductive rights, I think of what a fierce dedication and sense of wonder I have toward being a parent. I don’t want anyone to parent a sacred, important human being unless they really, really are up to the challenge. I don’t even want anyone to babysit if they are forced or pressured to.

So, in honor of parenting by choice, here are some links and stuff for your reading and viewing pleasure:
According to this poll, the vast majority of people in our country and most others do not think abortion should become illegal, or even legally restricted. So, why is this considered to be such a third rail, controversial topic? Only 8% of Americans think abortion should be discouraged by punitive methods. Let’s move the dialogue on past these extremists, finally, please!

From Sociological Images: Seeing is Believing.

Here is a great spot about why the fertilized egg = human argument hurts all pregnant women, not just women who want an abortion. Reproductive rights are intertwined, indeed.

And finally, the New England Journal of Medicine has a wonderful opinion piece up about the recent conscience clause rule and its proposed rescission. It ties in well with my discussions with Jill on the patient as customer and refusal of care.

(H/t to Our Bodies, Our Blog)

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The big one – oh!

after haircut

My older son is ten years old today.

I have been a mother for a decade. Wow. It seems like it’s been forever, even though I don’t feel like he should be that old.

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Reply turned post, three way mirror style

This was a reply to Jill from the Unnecesarean’s thoughtful comment on my already-a-reply-turned-post about requests for cesareans for moms who were tired of pushing. (See why I called it “three way mirror style”? It is a post of replies reflecting upon replies…)

That is a really good point. I have discussed this with my faculty adviser at school. He thinks elective cesarean section is a valid choice in the patient choice spectrum, and is an integral part of reproductive rights and patient autonomy. I sometimes wonder if I am rigid in my ignorance of what the “real world” is like in practice, and if I would consider doing some elective cesareans in the future.

Even when I was writing this post, I paused at the last paragraph and thought a lot about my language. I will tell people that I don’t think cesareans are medically justified in many situations, and that I would advise against them in situations that are medically normal (like a not-even-prolonged 2nd stage) when the risks outweigh the benefits.

The only person I know well who opted for a true maternal request elective cesarean had a family history of complications in labor and delivery. From what I have heard, none of these would indicate that she would have similar issues (I think one was a severe shoulder dystocia with a poor outcome), but I can clearly see her fear of vaginal delivery. I have strong faith in genetic issues with labor and delivery. Women deliver like their mothers and sisters, and I take do not take these concerns lightly.

I think this is a fine line that needs a lot of cooperation between patient and doctor, and an acknowledgment that this is a gray area. (OK, I have a feeling this is turning into a reply-turned-post). I know many people want a strong balance of maternal rights with practitioner or government legislation. Limiting women’s choices for elective cesarean might also limit her access to homebirth. Or VBAC. Or selective reduction. Or abortion.

I think this is a topic that needs to be discussed with a lot of nuance (der) and there is room for a balance between evidence based medicine, patient autonomy, informed consent, and yes, sigh, provider conscience. I am strongly in favor of all of these thing with a passion that sometimes makes ethical hypotheticals (as of now, who knows what I will be facing in the next few years?) very challenging.

I strongly support the right of refusal of care. I am not as fervent about the right to interventions that are not evidence based. That is one of the ways I base my ethical decision making. I am much more willing to listen to an argument against intervening rather than for intervening, for the most part. This consideration seems more likely to prevent an overzealous practitioner from pressuring someone into an unwarranted procedure or medication. Or, an uneducated or emotional patient or guardian insisting on an invasive procedure that is either elective or not indicated, that has inherent risks over any potential health benefits. Or, less likely to favor patients who insist on the latest advertised medication for PMDD or the latest compounded hormone recommended on Oprah. Most favorable health outcomes based on available literature is also a large factor for me. Luckily, for obstetrics, these two things tend to go hand in hand.

As of right now, this is how I think I will handle maternal request for elective cesarean. I will inform them of the risks versus the benefits of all of their options. If they seem to understand that cesarean section on a healthy mother and fetus with no medical indications for surgery has more risk than benefit to the mother and fetus (according to current literature), and still want a cesarean, I think I will politely refer them to one of my peers who I think is an excellent surgeon and wish them the best.

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Reply turned post, tired-of-pushing style

Pinky has a great post up about women who can’t push adequately because of their epidural who then ask for cesareans. (And, may I add, they may have an unrealistic idea of what the normal pushing a.k.a. 2nd stage of labor should take, which is, on average, 48 minutes or so for a first time mom. Up to 2 hours is definitely normal and safe if the fetus does not appear to be in distress. If they’re asking for cesareans after 30 minutes, there is a misconception there that needs to be corrected.)

Here is my reply-turned post:

I do not believe in the patient-as-customer paradigm in which a patient can request a non medically justified intervention, like a cesarean section in a slow but within-normal-range 2nd stage (or as an elective section without labor, for that matter.)

I am going to try to refuse to attend these kinds of deliveries when I get to make the calls. I have a feeling as a student on rotations and as an intern I will probably have to participate in many procedures like unwarranted inductions with poor Bishop’s scores and good biophysicals.

But, when I call the shots, I will tell the patient the pros and cons of all of their options. I will make it clear from early on in their pregnancy that I do not choose to perform cesarean sections (or any other medical interventions, for that matter) that do not have good evidence of improved health outcomes.

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Prostelytizing at the health fair

I was volunteering today at a health fair, distributing condoms and passing out literature on teen pregnancy, HIV, STDs, fertility awareness and birth control options.

A woman told me “Only two things work: abstinence and then marriage.” I said “That may work for 2%, but the 98% of us want information about birth control.”

She came back and brought me a card that said “Jesus Christ Loves You”.

I’m sure he does.

Seriously, even people who marry as virgins may want to limit their childbearing. I knew a couple who say they were abstinent until marriage. They have two lovely daughters, and the mom takes the birth control pill continuously now and works quite happily. And, the vast majority of us do want to have non procreative sex. I have heard 98% of women practice some form of birth control at some point in their reproductive years.

I was really happy about how many parents of teenagers took information and condoms.

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She’s in labor!

Some of my closest friends are having a baby. Her water broke at 5:30 this morning. I will be headed to the hospital soon.

Good vibes, please!

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