OBGYNDoc
Minneapolis, MN
Female, 36
I am a practicing Obstetrician and Gynecologist, providing care for women in all stages of life. Approximately half of my practice consists of pregnancy-related care, including routine prenatal care, high risk obstetrics, and delivering babies at all hours of the day. The other half consists of gynecologic care, which ranges from routine annual check-ups to contraception and menopause. I perform many surgeries, including laparoscopies and hysterectomies.
The cesarean section rate is at an all time high right now, and while cesarean section is usually a very safe surgery, there are risks to performing any major surgery. Having a vaginal birth after cesarean section (VBAC) is one way to reduce the cesarean section rate. Benefits to having a VBAC include less bleeding, a shorter and less painful recovery, and lower overall cost. However VBACs also come with significant risk. The uterine scar, through which the baby was delivered at the time of cesarean section, may be weak, and may not tolerate the stress of repetitive uterine contractions. If this is the case, the scar could open up, or rupture. Although rare, uterine rupture can potentially result in hemorrhage, loss of blood flow to the fetus, and ultimately fetal and/or maternal death. When we discuss the possibility of VBAC, we want to make sure that the patient is a good candidate for a successful VBAC- we aren't willing to take this risk unless there is a high likelihood of success. Therefore, patients who had their cesarean sections performed for poor labor progression or because the size of her pelvis was too small for the baby to pass through may not be ideal candidates. If you are considering VBAC, you need to have a discussion with your physician to see if you are a good candidate. If you decide to attempt VBAC, you will be monitored very closely during your labor, and if anything out of the norm occurs, your doctor will likely recommend a cesarean section. It's very important that you understand that at any time during the labor, if there are worrisome signs for uterine rupture or the baby not tolerating contractions, you will likely undergo a cesarean section.
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Approximately half of c-sections are scheduled, mainly for indictions such as a previous cesarean section or breech presentation. The other half consist of unscheduled cesarean sections, for protracted labor, fetal intolerance to labor (fetal distress) or other unpredictable circumstances. So much about labor and delivery is unpredictable, and therefore the mode of delivery is often decided upon after a trial of labor that can last for minutes to hours to days. Because there is often an emergent nature to cesarean sections, I am very thankful for the advances in modern medicine that allow us to perform these lifesaving procedures immediately and safely.
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Of women who know they are pregnant, the miscarriage rate is approximately 20%. However, miscarriages can also occur so early that a woman might not even know she was pregnant. Thus, we believe that the overall miscarriage rate may actually be closer to 25-33%. Sadly, miscarriages are very common, but that certainly does not make it easier to come to terms with. I find the best way to approach this is by being direct and honest. I always try to be empathetic and express my sympathy for their loss. Many women have already emotionally and spiritually formed a relationship with the fetus they are carrying, and will experience grief and mourning with the loss of their potential child. Some women will even experience depression after their loss and may require counseling. Everyone responds differently to the news, but my job is to remain empathetic and available for questions and support.
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I believe the ratio is probably similar to the general population. Whether we consider them to be ethical, religious or personal beliefs, we all come into this profession with our own beliefs, and one's area of medical expertise doesn't tend to change those.
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Trained midwives are skilled clinicians who are fully capable of providing care throughout an uncomplicated pregnancy and delivery. I have worked with some outstanding midwives, and I do think they can offer a different approach to pregnancies for patients who desire a more non-interventional approach. When choosing a midwife, be sure that he or she is a Certified Nurse Midwife (in some cultures, the term 'midwife' is applied to a lay person who participates in deliveries but who may not have official training and certification). I would always be sure that your midwife has an affiliation with a physician who will provide emergency coverage in the event that things do not go as expected. For a healthy woman without any major complications during the pregnancy, labor and delivery, a midwife is absolutely capable of providing prenatal care, performing deliveries, and caring for you in your postpartum period. If there are concerns for preterm labor, gestational diabetes, hypertension, multiple gestation or other complicating factors, I would recommend consulting with, and perhaps transferring care to, a physician. Finally, I would always recommend delivering your baby in a hospital or birthing center affiliated with a hospital. I do not support the concept of home births with a midwife.
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During my training, I often worked for 48 hour shifts without sleep between, only to return 12 hours later for another shift. This was the traditional way of training residents. Nowadays, there a strict rules in place that limit the number of hours one can work at a time. In real practice however, we continue to work 24-36 hour shifts simply because we don't have the person-power to take shorter shifts. In addition, in our field, there is a need to keep continuity of care- we prefer to follow a patient in labor through delivery, and shorter shifts would mean more frequent turnovers in patient care. If I feel I am ever overtired or impaired, I would certainly call on my colleagues for help.
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The studies on alcohol consumption in pregnancy are unequivocal- drinking alcohol while pregnant can result in many complications ranging from birth defects to growth restriction, mental retardation and stillbirth. There is a clear dose response relationship between alcohol and poor outcomes, which means that as higher quantities of alcohol are consumed, the risk of complications is higher. However, because every individual metabolizes alcohol differently, there is no "safe" amount of alcohol that can be consumed in pregnancy. Bottom line, I recommend abstaining from all alcohol while pregnant. The critical developmental period for vital organs (such as the brain) occurs in the first trimester. Therefore, it makes sense that most of the birth defects are related to drinking in the early part of pregnancy. However, drinking later in pregnancy can result in cognitive and developmental delays. Of course, if there is a special occasion or celebration, I tell my patients it's acceptable to have a rare glass of wine. But my overwhelming opinion is that drinking in pregnancy should be avoided- why take the risk?
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