Why do some patients think that they are so special or unique, while those that are just go with the flow. My least favourite consult is when a patient is 42 weeks, previous C-section and may or may not be ruptured for 24 hours. They want to talk to me about their options, but in reality, I think they want be to endorse their ideas that they are set upon already.
In this scenario, there are not really many medically sound options. One is to wait until something is actually pathological – fetal tachycardia, bleeding, maternal infection; and then intervene emergently. I don’t particularly endorse this plan, but is seems to be a popular choice around here. The second is to accept the risks and benefits of an induction, including a small increase in the risk of uterine rupture. Let me admit you, (likely treat the GBS which they may or may not have been tested for), and start some oxytocin. At some point, I will have to bite the bullet and examine your cervix, maybe there are fore-waters that are slowing things down. But if I tried to induce you, and we manage to get regular contraction, I won’t continue to the process for hours and hours without progress. I will help you try to attempted a vaginal delivery, but I am in no way obligated to help you have a vaginal delivery at all cost. The final option is to just go straight to c-section. Some women will choose this options because they have such a fear of oxytocin, that they would just skip the induction all together. Honestly, at 42 weeks with no sign of labour, you probably have a nearly 50% chance of an intrapartum C-section anyways, it may not be a bad choice, particularly if the baby is measuring large.
But that is it. There are not other options that I would recommend or assist with. Patients may have ideas of their own. They may have thoughts that they are special and warrant more individualized treatment. However, after years of practice, I have come to realize that although they may be special snowflakes, at the end of the day, they all melt and look the same. Yes, moms and babies are unique, but for the most part, the process of getting them out should follow a common pattern.
What I find the most frustrating is the amount of time these patients consume. This recent patient had already had two separate obstetrical consults, I was number three. Did they really expect to hear something different? I couldn’t come see them right away, I had more urgent matters to deal with, including a postpartum lady getting transferred to ICU for an acute fatty liver picture, with worsening renal function and a family who was losing a very wanted pregnancy at twenty-five weeks, but the baby was so profoundly IUGR, there was nothing that could be don’t to save the baby. These are special patients where my expertise is needed. This 42 weeker was not special. She had waited more than 24 hours to report her ruptured membranes, she could wait to see me too.
I overhead her complaining to the nurse. Apparently, I work for this patient, and should be making her my priority that day. When the nurse explained that she had already discussed her options, the patient replied that she had brought some research (likely from the internet) that she wanted to discuss with me. She wanted to test my knowledge, and find some magical loop-hole that would make her more knowledgeable. She told the nurse that it didn’t really matter that we were busy in labour and delivery because she was only here to discuss things, not to “do” anything. At that point, I wondered why I was supposed to see her at all.
I would like to clarify. I do not work in the USA, and I do not view medicine as a commercial enterprise. I do not work for you any more than I work for the hospital. I am a consultant who is there to provide medical advice and make medical recommendations. I cannot force a patient to do anything, but I am definitely not obligated to anything they ask of me. It is not my job to spend an hour explaining why blogs don’t equal medical research, to teach patients the difference between case-control studies, cohort studies and randomized studied (and no, randomize studies don’t mean you pick people randomly to your cases). However, I end up doing this more and more frequently. I really don’t care at the end of the day how special you think you are, my job is to protect you and your baby from your bad decisions. I don’t work for you, but you might just want to listen to my advise, its actually not all that bad. I want you to have a healthy baby, and I really am quite flexible on how we reach that point. I just won’t put your baby at risk to make you feel special.