Sunday, May 4, 2008

OBS up here

I was sitting at the nursing station one night while on obstetrics call chatting with the nurses and generally distracting them from their work. We were talking about the differences between obstetrics in the south, and in the north and having quite a laugh. Leanne, one of the best OBS nurses I know, was talking about visiting a friend in an L&D suite in a southern Canadian city; 'She was just laying in bed, there were tubes and wires everywhere. She was on a monitor, the baby was on a monitor, and I thought the $%*# must be hitting the fan!'. It turned out her friend was having a normal term delivery, but in a different style than we are used to here in Nunavut. We all had a chuckle and agreed that going back to working obstetrics in a southern environment would be difficult at best.

I've written previously about the type of obstetrics we do here in Iqaluit. It's low to medium risk, with careful export of known high risk patients to southern tertiary care centres. In practice that means managing labour and delivery of patients 35+ weeks, including patients with PIH/pre-eclampsia, VBACs, previas, and other higher risk situations. It also means managing the unavoidable complications of obstetrical practice; cord prolapse, abruptions, eclamptic seziures, hemmorhages, thick mec, flat babies, etc. At times it means managing high risk cases in consultation by phone with obstetricians in the south, in particular premature labour and it means medevacs of preterm labour from remote communities. Because of our remote location women from even more remote communities come down to Iqaluit at 36 weeks for 'confinement' until they deliver. This is often the most emotionally difficult part of obs up here, as they are often seperated from family and kids at home while they wait to deliver.

There are 6 docs who practice OBS. It's a nice group and we all have a similar philosophy. We have about 400 deliveries a year in our hospital, and we have good outcomes. Our C-section rate is 5%, and we do about 1 or 2 epidurals a year in total (there is no epidural on demand service). For uncomplicated labour the strategy is low-tech and dependent on the wishes of the labouring woman. Want to labour at home for a while? No problem. Want to stay in the hospital? No problem. Want to eat? The toaster is over there. Want to walk around? By all means. Want pain control? You're welcome to any or all of the options we have available. Monitoring is by intermittent auscultation unless there is a compelling reason for something more invasive.

There are probably lots of reasons why obstetrics is different here than it is in the south. There are cultural and historical reasons. The reason that is most striking however has to do with what patients expect around labour. Labour and delivery in the south (at least in the media) is often framed as an 'experience', in the same way that climbing a mountain or bungee jumping is an experience. It also seems (at least from what I read on various blogs/comments and forums) that there is at least some population of people who believe that doctors are willfully trying to take away from their labour experience.

When I talk with women about L&D at their prenatal appointments, I often ask what they expect will happen. Usually the person says something along the lines of 'I think it will probably hurt'. What do you think about that, I ask? They laugh and say, 'Well it's not optional'. Most people seem to view labour and delivery as a natural process, and my role (and the hospitals role) to intervene when required for the sake of safety. It's pleasant, it's happy, sometimes one women in early labour is in the room next door coaching another women who is pushing. People are walking around (yes, and going for a smoke), laughing, talking and feilding various relatives and visitors who are stopping by to see how things are going. It's a different world than down south. My role is a little more on the sidelines, there to spot and deal with any problems that may arise. Usually there are none, and all I need to do is hand a nice baby to a new Mom, whose first question is almost always 'So I can fly home tomorrow?'.


Inkling said...

Sounds like Nunavut is the place to give birth. When I first moved to BC, I was excited to hear that the government encouraged midwives. I had it in my head that I'd get to be like my sister-in-law, having the baby at home with all the low-tech freedom in the world. But then women around here told me that midwives are mostly found in hospitals, and from their experiences it sounded a lot more clinical (and scary) that I was hoping for. I'm afraid that if I go into the hospital here, I will end up with high levels of intervention, and that's not what I want. I'm also afraid that I will wimp out in a hospital and not allow my body to do the hard work, because I know all those interventions are so close. Having a baby isn't a disease; it's a natural (and painful) part of life. What I'm ultimately hoping will happen is that my friend will finish her Canadian certification in Ontario, and be able to be here for me. She's delivered over 1,000 babies in a primitive area of the Middle East as a midwife, and I'd trust her with my life. If that doesn't happen, well, I just hope I don't wimp out and that my doctor doesn't let me wimp out.

Jess said...

It sounds more relaxed than down here. Women are scared and often expect to be pain-free. Okay, people in general expect to be pain-free these days. When did that become the norm? And south of the border, I found the expectations even higher...and the patients less tolerant and definitely suffering from "acopia". Frustrating, to say the least.

The Lone Coyote said...

That was really interesting to read about the expectations for labors up there. It is a completely different universe from the "birthing suites" and epidural asap environment in hospitals here.

pennycakes said...

that sounds wonderful!
there was a post from Hoyden About Town ( - she's an obstetrician in Australia) about birth plans, or the lack thereof, that might interest you.