Labor and Delivery Care E-Book

Wayne R. Cohen

• Herausgeber: John Wiley & Sons
• Kategorie: Fachliteratur
• Sprache: Englisch

Seitenzahl: 683

Veröffentlichungsjahr: 2011

Beschreibung

Labor and Delivery Care: A Practical Guide supports and reinforces the acquisition of the practical obstetric skills needed for aiding a successful birth.

Beginning with the most important element of successful labor care, communicating with the patient, the authors guide you through normal delivery routines and examination techniques. They then address the best approaches to the full range of challenges that can arise during labor and delivery. Throughout, the 15 chapters provide concise practical guidance with:

• algorithmic decision trees
• clinical management tips
• detailed drawings

Labor and Delivery Care: A Practical Guide provides a thorough tour-de-force of the practical obstetric skills needed for best and safest practice based on clinical experience and evidence.

Leseprobe

Contents

Preface

How to Use This Book

Chapter 1: Communicating Effectively With Your Patient

Special aspects of parturition

Communication skills

Continuity of care

Ethics and maternal–fetal conflict

Violence

Boundaries

Does gender matter?

Goals

Further Reading

Chapter 2: Examining Your Patient

General principles

General examination

Abdominal examination

The pelvic examination

Documentation

Further Reading

Chapter 3: Normal Labor and Delivery

Terminology

Uterine contractility

Clinical course of labor

Graphic analysis of labor

Further Reading

Chapter 4: Evaluating the Pelvis

Clinical anatomy of the bony pelvis

Changes in the fetal head

Method of clinical cephalopelvimetry

Significance of pelvimetric findings

Anterior asynclitism

Posterior asynclitism

Further Reading

Chapter 5: Diagnosing and Treating Dysfunctional Labor

Cephalopelvic relationships

Identifying dysfunctional labor

Oxytocin and uterine activity

Second stage problems

Duration

Pain management during labor

Further Reading

Chapter 6: Managing the Third Stage

Normal limits

Clinical signs of separation

Management of the third stage

Retained placenta

Further Reading

Chapter 7: Dealing with Malpositions and Deflexed Attitudes

Occiput posterior

Deflexion attitudes

Further Reading

Chapter 8: Managing Breech Presentation and Transverse Lie

Breech presentation

Transverse lie

Further Reading

Chapter 9: Avoiding and Managing Birth Canal Trauma

Vulvar lacerations

Perineal lacerations

Vaginal lacerations

Lacerations of pelvic fascia

Hematomas of vulva and vagina

Cervical lacerations

Uterine rupture

Fistulas

Injuries to the bony pelvis

Further Reading

Chapter 10: Inducing Labor

Indications

Contraindications

Risks

Prerequisites

Bishop score

Management

Decision-making issues

Further Reading

Chapter 11: Cesarean Delivery

Indications for cesarean delivery

Types of cesarean delivery

Surgical techniques

The patient with a prior cesarean delivery

Patient-request cesarean delivery

Key points

Further Reading

Chapter 12: Delivering Twins

Maternal considerations

Fetal considerations

Managing the labor and delivery

Key points

Further Reading

Chapter 13: Managing Shoulder Dystocia

Etiology

Normal shoulder mechanism

Predisposing factors

Prediction

Clinical management

Special situations

Documentation

Shared responsibilities

Key points

Further Reading

Chapter 14: Using Forceps and the Vacuum Extractor

Obstetric forceps

Vacuum extractor

Trial of instrumental delivery

Key points

Further Reading

Chapter 15: Obstetric Case Studies

Case 1

Case 2

Case 3

Case 4

Case 5

Case 6

Case 7

Case 8

Case 9

Case 10

Case 11

Case 12

Case 13

Case 14

Case 15

Case 16

Case 17

Case 18

Case 19

Case 20

Case 21

Case 22

Case 23

Case 24

Case 25

Case 26

Case 27

Case 28

Case 29

Case 30

Answers to Obstetric Case Studies

Glossary

Index

To pregnant women, with admiration and wonder and To Sharon and Judy

This edition first published 2011, © 2011 by John Wiley & Sons, Ltd

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Library of Congress Cataloging-in-Publication Data

Cohen, Wayne R.

Labor and delivery care : a practical guide / Wayne R. Cohen, Emanuel A. Friedman.

p.; cm.

Includes bibliographical references and index.

ISBN 978-0-470-65459-0 (pbk. : alk. paper) 1. Labor (Obstetrics) 2. Delivery (Obstetrics) 3. Childbirth. I. Friedman, Emanuel A., 1926– II. Title.

[DNLM: 1. Labor, Obstetric. 2. Birth Injuries—prevention & control. 3. Delivery, Obstetric—methods. 4. Obstetric Labor Complications—prevention & control. WQ 300]

RG652.C63 2011

618.4—dc23

2011020592

A catalogue record for this book is available from the British Library.

This book is published in the following electronic formats: ePDF 9781119971535; Wiley Online Library 9781119971566; ePub 9781119971542; mobi 9781119971559

Preface

The impetus for this book was born of satisfaction and lamentation. We celebrate the remarkable advances in obstetric care that have occurred over the span of our careers (encompassing 50 years). We are nevertheless troubled by the fact that the burgeoning medical technocracy has diverted attention from fundamental medical care skills in our specialty, and no doubt in others. The fall in maternal and fetal mortality and morbidity over the last half-century reflects in large measure gratifying advances in obstetric and neonatal technology. Surely the advent and increasing sophistication of ultrasonography, electronic fetal monitoring, prenatal diagnosis, antimicrobial therapy, molecular medicine, and advances in epidemiology have, among others, shaped the form and substance of obstetric care in ways that have done much to improve outcomes. Residents are now well versed in the complexities and subtleties of ultrasonography, molecular genetic diagnosis, and immunology; nevertheless, relatively few have mastered the essentials of clinical examination and decision making that can make obstetrics so satisfying to its practitioners and so much safer for its patients. The training of midwives and physician’s assistants has in its way likewise tended away from the complexities of clinical assessment.

The recently awakened emphasis on patient safety initiatives in obstetrics puts this trend in high relief, as much of the focus of these performance improvement activities has been on improving basic clinical skills. Moreover, the majority of medical negligence litigation that has pestered our specialty for decades, reducing the happiness of its practitioners and its appeal to students, relates to alleged failures in application of fundamental clinical doctrine. So there is ample justification for a text that emphasizes our bedrock principles. Within them lie the solutions to many of our contemporary challenges.

Someday our medical heirs will use anatomic and functional imaging techniques and laboratory analyses now barely imaginable to evaluate and diagnose. Skillful physical examination and probing medical history may no longer be needed or taught. We have not yet, however, reached the crossroads leading to that brave new medical vale; rather we exist in a period of transition that requires attention to advanced technologic approaches as well as to traditional techniques of diagnosis and problem solving. It is with reverence for the latter that we have directed this volume.

Obstetrics, particularly the management of labor and delivery, has always been a discipline that requires skilled physical diagnosis in order to make the most refined diagnostic judgments. It demands the synthesis of several simultaneously acquired lines of diagnostic evidence into a cohesive probability matrix in order to balance the risks of intervention and watchful expectancy. During labor, fetal information (e.g., state of oxygenation, lie, position, attitude, molding) must be integrated step by step with facts about the mother (e.g., vital signs, medical condition, uterine contractility, pelvic architecture) to determine changes in the probability that a normal vaginal delivery will ensue or that some pharmacologic or surgical intervention will be necessary to optimize safety. Decisions based on these changing probabilities obviously require accurate and complete clinical information to make them reliable. Ideally, that information should have been demonstrated to be meaningful in appropriate investigative studies.

We live in an era of the deification of “evidence-based” medicine. In fact, evidence-based practice is not new. Good physicians have always functioned by incorporating the best available scientific evidence into their practice. They have, however, tempered the application of evidence with sound clinical judgment and the wisdom born of experience and sapient observation. We ourselves have always emphasized the importance of requiring objective proof whenever possible to justify clinical interventions. We are, nevertheless, mindful of the fact that not everything can be studied with a randomized clinical trial. It is too often unacknowledged that most of what we do and think is right in medicine has never been subjected to such investigation. This fact emphasizes the great value of developing good clinical skills and an in-depth understanding of the labor and delivery process. From those skills and understanding derive the obstetric acumen and good clinical instincts that characterize the best practitioners.

In this volume we have attempted to integrate science and clinical evaluative arts. We have deemphasized issues related to the application of electronic technology, such as ultrasound and electronic monitoring, and focused on the application of good clinical skills and their interpretation. That is not to downplay the value of technology, which is of vital importance to us; rather, it is done in the service of helping practitioners establish first-rate clinical skills. We hope the result will prove useful to anyone privileged to assist women in childbirth.

We are aware of the gender and other biases that tend to populate textbook writing, and equally conscious of (and appalled by) the solecisms, awkward syntax, and grammatical gymnastics often employed to avoid them. Throughout this book we have chosen certain default pronouns and nouns to promote easy reading and ensure uniformity of style. Thus, we use “she” and “her” when referring to the obstetric practitioner, and “attendant,” “practitioner” or “provider” for any professional involved in patient care during labor. Similarly, we use masculine pronouns to refer to the parturient’s partner in the birth process. Neither these choices nor the inevitable places in which we have strayed from our best intentions in this regard are meant to offend.

We are grateful to Martin Sugden and Michael Bevan, our editors at John Wiley & Sons and their team. Their professionalism, guidance, and confidence in the virtues of this project have been immeasurably helpful.

Wayne R. Cohen and Emanuel A. Friedman

New York and Boston

How to Use This Book

True obstetrics is a great art, and because it is a difficult art, it is easier to be a good “Caesarist” than a good obstetrician (Archiv Gynäk 1955;186:41).

The sentiment conveyed by the eminent Austrian obstetrician Hans Zacherl in 1955 could very well have been expressed yesterday. While it is entirely appropriate that today’s cesarean rate is considerably higher than in the 1950s, the frequency of cesarean delivery has reached alarming levels in many countries. This has occurred in part because many well-intentioned obstetricians believe that cesarean delivery usually serves the best interests of mother and fetus, a view that for the most part is not supported by available evidence. The cesarean delivery trend has also been nourished by the failure of our training system to teach the skills necessary for obstetric practitioners to make the complex clinical evaluations and judgments needed to identify and to manage cases in which vaginal delivery would be the safest alternative. This volume is devoted to helping you learn those skills. It will serve both the experienced clinician wishing to refresh her knowledge on a topic, and the novice.

The book consists of 15 chapters. A few readers will try to absorb it from cover to cover. That strategy will work for some, but may prove less profitable (if not soporific) for most. A piecemeal approach will work better.

The first five chapters cover basic principles, and set the stage for the ensuing chapters, which address specific obstetric issues. The last chapter provides a series of case studies with brief analyses that emphasize the principles advanced in the text. These cases can be used for self-study or as the basis for small group learning in a training program.

A glossary is provided for quick access to terms with which you may not be familiar.

You will best profit from the book by reading chapters in the context of your clinical experience. For example, if you read about face presentation right after you have seen one (or, better, while you are involved in the care of one during labor) it will do much to reinforce and expand your knowledge. Reviewing the chapter on evaluation of the pelvis before or during a tour on the labor floor will help you hone your examination skills. We hope you will use this as a handbook, and consult it frequently during your work with women in labor.

We have alluded only infrequently to ultrasonography, despite the fact that it has become part of daily obstetric practice for most of us. Imaging is a wonderful tool, but it is a mistake to use it in place of your hands, eyes, and ears. Rather, it should complement those senses. In fact, if you are a good sonographer, you can use those skills to reinforce your learning of physical examination skills. Verify with sonography, for example, your clinical determination of fetal presentation or position. With experience, you will find you will no longer need imaging very often. Clinical examination is faster, more efficient, less expensive, and available to everyone.

We hope that you will find this book to be a helpful companion. It is not easy to become a good obstetrician; but it is worth the effort.

CHAPTER 1

Communicating Effectively With Your Patient

Human labor and birth are remarkable events, imbued with wonder and beauty. They are, nevertheless, prone occasionally to challenges, infirmity, and even tragedy. Caring for women during these experiences is a remarkable privilege, often exhilarating, but not without its perils and trials. To meet the demands of this task as a labor attendant—whether obstetrician, family practitioner, midwife, or labor room nurse—you must be equipped with the necessary clinical skills, judgment, empathy, and emotional insight to deal with all possible events and outcomes. While many of the physiologic aspects of the birth process are familiar and predictable, each woman will experience them in her own way.

A woman’s emotional and physical response to her labor and delivery is conditioned by many factors. These include her cultural background, personality traits, religious beliefs, and other aspects of her personal psychosocial context and history. You may have little ability to influence these factors, but it is important for you to understand them and to recognize how they influence the patient’s expectations and coping mechanisms during times of stress. This insight should always inform the content and style of any communications you have with your patient.

Other influences on the parturient’s ability to contend with labor are under more direct control. These relate to her physical and emotional comfort during the process of labor and birth. In that respect, the approach of the obstetric team is of great importance and can make the difference between an experience marked by satisfaction and contentment (even if there have been complications) and one that leaves a residue of resentment, regret, unhappiness, and unanswered questions. Not every labor and delivery experience can be idyllic, comfortable, and unencumbered by complications or missteps. We should, nevertheless, always aspire to that goal. Patients do value our endeavor and attitude. They expect and deserve our best efforts, even when they occasionally do not succeed.

Special aspects of parturition

Labor and delivery can be extremely stressful for even the healthiest of women. It is a time when feelings of fragility, vulnerability, and defenselessness are common, as are apprehension and a sense of physical and emotional discomfort. The reasons for these feelings are obvious. Consider that the parturient is likely to be in unfamiliar surroundings. She is wearing a hospital garment that leaves her nearly naked. She is bombarded with attention, surrounded by strangers whom she has just met. This applies even if hospital personnel have properly introduced themselves, which is sometimes not the case. She may be besieged by nurses, students, residents, and laboratory technicians. All of them want things from her that she may be in no mood to provide. Labor, especially once contractions are strong and frequent, is physically and emotionally demanding. It is not, in short, the perfect context for thoughtful reflection and objective decision making.

Things happen unexpectedly during labor and may surprise even the best prepared patient. If you have not had the opportunity to get to know your patient during her prenatal course, your ability to address such events is especially challenged. This is becoming more of an issue as medicine moves to reduced work hours for physicians and the need for more frequent turnover of care to colleagues at personnel changes. It is a problem well recognized by nurses and other healthcare providers who have always worked in shifts, and one that requires the development of new skills to address well.

Much has changed in recent decades concerning the nature of the interaction between healthcare providers and patients. Previously, we (especially physicians) were considered omniscient leaders of the patient care team whose opinions and pronouncements were law, not to be questioned by professional subordinates nor, especially, by patients. That paternalism has given way to a more interactive collegiality that, ideally, values the feelings and opinions of all members of the healthcare team and of the patient. That approach has, in fact, been shown to improve patient safety. It certainly adds dignity and civility to the professional interactions that surround decision making during labor, and respects the needs and wishes of the parturient.

The value of prenatal care

One of the best places to begin to assuage anxiety provoked by labor is during your patient’s prenatal course. In addition to discussing what to expect during normal labor, it is important for you to talk to her about potential adversities, including cesarean or instrumental vaginal delivery or oxytocin administration, should the need arise. You should also address the possibility of shoulder dystocia as well as of postpartum hemorrhage. While some practitioners would prefer not to bring up such potential calamities because of their relative rarity, it is important for you to give your patient at least a general idea of what would be done if any of them should occur. With good communication skills you can accomplish this without alarming her.

Most important, prenatal care provides opportunities to forge a bond of trust with the patient. In that way you can learn to understand the nature of her fears, educate her about potential risks, and have her understand what to anticipate during her labor. She, in turn, will learn more about you and become comfortable with your communication style. Trust is vital because not every peril or need for intervention can be foreseen. When something unexpected does arise, it is the previously established trust and confidence in you as the practitioner that will help sustain the patient’s composure and equanimity.

Establishing trust can be elusive and difficult for the patient because it requires her to relax her defenses and accept some vulnerability. She is seldom able to give it lightly because it ultimately requires exposure of the most private domains of her mind and body. One of the great virtues of prenatal care that extends for so long over the course of pregnancy is that your repeated meetings and discussions with the patient will serve to enhance her security and facilitate rapport. Needless to say, standards of professionalism require that you honor complete confidentiality in this respect.

Sometimes you may be called upon to form a bond of trust with the patient in a very short period of time. This occurs when you are covering for another physician or midwife, or have taken over at the beginning of a shift, or are functioning strictly as an inpatient “laborist” with no prenatal care responsibilities. As difficult as that process may be for you, it is even more of a problem for the patient, whose anxiety may be heightened by an unfamiliar face and manner. Establishing instant faith in these settings is not easy, but you, with experience, will learn to do so with success.

The key to establishing rapport with your patient involves your clear demonstration of empathy, respect, confidence, and availability. Openly acknowledge that this is a difficult situation for you both, but that you are committed to her comfort and good care. Let her know that you have every confidence in your ability to help manage her labor, that you are interested in her opinions and expectations, and that you will make every effort to meet them. Be approachable and available to answer her questions and those of her companion. Solicit questions from the patient rather than waiting for her to raise them, and be sure she understands that you will take the time to address them. Every woman in labor should feel that she is the most important person in your world at that time. This is only appropriate, because you are indeed filling that role in hers.

Communication skills

Use your powers of observation

Understanding the patient’s needs and responding to her concerns require your rapt attention. It should be clear to her that you are interested in and concentrating on what she has to say. Listen carefully to her concerns and observe her body language as well. A great deal is conveyed by facial expressions and other forms of nonverbal communication. Interviewing the patient while focusing your eyes on the chart or computer screen can be perilous. Not only is your inattention an affront to the patient, but you may miss many vital clues to her medical condition and emotional state.

Try to avoid confrontational or judgmental interactions, even if the patient appears to be challenging you. Make the effort to understand what underlies her obdurate or hostile feelings. They are likely to have arisen out of fear, anxiety, frustration, personal conflicts, or other distress. Remember that your relationship with the patient is bidirectional, and learning to see things from her perspective is vital in developing good communication skills. Part of that process involves recognizing your own reactions to various kinds of patients, especially the difficult ones. Enhancing your sensitivity to the special emotional needs of every patient as a unique individual is crucial to your role as a complete healthcare provider.

With experience, you will learn to tailor the style and content of your discussions with a patient so as to provide a clear explanation of the situation in a manner appropriate to her ability to understand it. The content and nature of such discussions may vary depending upon the patient’s level of education, what you perceive as her style of emotional defense or adaptation, and her interest in participating in the process. It is, under all circumstances, your responsibility to ensure that the patient understands the clinical situation clearly. Remember that, while a patient’s level of education may influence her vocabulary or her scientific sophistication and comprehension, education does not necessarily correlate with intelligence. When you use appropriate language, patients of all educational levels can understand and make reasonable and informed decisions about even very complex clinical issues. This is a difficult skill, but one well worth cultivating.

Disclosure of adversity

One of the things we have learned from the medical malpractice thorn of the past few decades is that patients are often driven to sue because they feel they have been abandoned by their doctor or by the medical system at a time of exceptional vulnerability and need. The residual burden of anger or resentment that spawns a lawsuit is more often born of the desperation and frustration at having been left with doubt and suspicion rather than of a conviction that harm has occurred because of an error in management. Often the search for answers is initially more important to the plaintiff than financial compensation, but that goal becomes subsumed in the legal quagmire of a formally filed tort action.

You can dissipate many of these concerns by frank and open communication with your patient during labor and afterwards, regardless of the outcome. It is regrettable that this does not always occur, particularly when there have been complications—the very time when discussion is most important.

Good communication includes involvement of the patient and, when appropriate, her family in decision making. It is vital for you to explain what is happening at every step of the process, even if there are complications or uncertainty. To repeat, you should tailor the timing, content, and tenor of these discussions to each patient and situation. As a general guiding principle, full disclosure of events is almost always the best path. As noted, explanations need to be individualized to comport with the patient’s educational level, language abilities, and most importantly, her coping style.

Many of us who care for women through their pregnancies tend to be especially poor conveyers of bad news. Perhaps one thing that appeals to some of us is that the vast majority of our cases have happy outcomes. Students who are uncomfortable discussing grave complications or prognoses with patients may for that reason be attracted to obstetrics. This is understandable but unfortunate, as bad outcomes in obstetrics are experienced with singular pain and are given special significance by families. The primary source of such pain probably arises from primal psychological forces, and is aggravated because adverse results are uncommon and because expectations are high. Moreover, the grief-averse practitioner may have a tendency (real or simply perceived by the patient) to ignore the problem or, worse, to trivialize obstetric loss.

Some of us tend to dismiss fetal deaths, whether through early miscarriage or even late pregnancy stillbirth, as insignificant life losses because the patient has an opportunity to redress them with another (presumably more successful) pregnancy. This is a regrettable, self-serving, and ultimately destructive attitude that serves mainly to absolve us from dealing with the emotional consequences of the loss. While the death or injury of a fetus is certainly felt and coped with differently than, say, the unexpected illness or death of a child or of an ailing aged parent, the loss of each may be felt with equal intensity. There is thus a special need for you to develop keen skills for communicating adversity. Fortunately, this can be learned, and practiced. It is an ability as important as communicating and sharing joy in response to a good outcome.

Dealing with family or companions

If your patient has a partner present during her labor, he can often be very helpful in providing emotional support and helping to communicate with you and the rest of the staff. Occasionally, however, the partner acts just like another patient, requiring his own support and reassurance. This may tax the patience of the staff. It will sometimes even divert personnel from their primary goal of serving the parturient. Always discuss with the patient when she is alone what her desires are regarding the role of her labor companion. This discussion helps avoid ambiguity, conflict, and confusion later as the labor progresses.

Sometimes, a large cadre of family and friends is allowed or even encouraged to attend the birth, a norm in some cultures. Under these circumstances you must ensure that the patient’s best interests and wishes are fulfilled, regardless of who is present with her. It is also useful for you to set ground rules and expectations at the very outset. Determine with clarity directly from the patient whom she wants present in the room during the actual delivery. You should also come to an agreement with her in advance as to when and under what circumstances guests may be asked to leave. In the latter regard, the staff may sometimes have to serve as the patient’s strong advocates, even acting forcefully against the contrary wishes of the guests.

Maintaining patient confidentiality in the context of a busy labor unit, especially when there are friends or relatives in the room, can be difficult, but must be honored as a basic priority and right. Bring family members into the discussions only with the direct consent of the patient, and be sure to obtain this consent from her when none of the other observers is present, lest she feel coerced into something with which she is not really comfortable.

Know your limits

Pregnancy is a time of remarkable stability and optimism for some women, and one of emotional upheaval and apprehension for others. The latter may take the form of common anxieties shared by most women: Will the baby be normal? Will labor be too painful? Will I be able to care for a child? Such fears can usually be allayed or modulated by calm explanation, reassurance that they are common if not universal, and by having the patient understand that you will be there during the labor to help her deal with her concerns. Beware, however, the occasional patient whose level of apprehension, ambivalence, and conflict breach the normal envelope. You need an astute eye and a discerning ear to recognize these often subtle manifestations. You should also recognize when the patient’s need for counseling extends beyond your capabilities to handle professionally, and make appropriate referrals. This need to ensure prompt referrals to experts applies, of course, as well to instances in which you are confronted by perplexing medical and obstetric issues that lie beyond your expertise. No one, no matter how experienced or skilled, can be knowledgeable and proficient in all aspects of medicine. A fundamental aspect of caring for patients is, therefore, knowing your limitations and avoiding the temptation to try to exceed them. You are not only being prudent in adhering to this principle, you are serving your patients’ best interests.

Continuity of care

There are important virtues to ensuring continuity of intrapartum care, particularly over the course of a long labor. The benefit of serial observations and interactions with the patient is invaluable in decision making. It arguably outweighs the potential addling and dispiriting effects of fatigue in the competent practitioner (although the latter is hotly debated). That being said, it is increasingly uncommon for an individual provider to manage a patient during the entirety of a lengthy labor.

The recent trend to reduced work hours has led to the need to hand over the care of parturients frequently. As a consequence, care during a labor can sometimes span three or more obstetric teams. These changes can be offputting and disorienting to the patient. The ability of the new team to establish a sense of comfort and confidence quickly is important, but seldom easy and sometimes not able to be accomplished within the time constraints. When taking over the care of the patient, therefore, you should be sure to meet with her and her family promptly. Introduce yourself appropriately. Make eye contact with her and answer her questions directly. Avoid being judgmental and be sure you have had a thorough discussion beforehand with the team going off service about every aspect of the labor, no matter how minor it may appear at the time. Let the patient know that you are up-to-date on her situation.

Ethics and maternal–fetal conflict

It is obvious that you and the rest of the obstetric team should always act ethically toward the parturient. This means observing and balancing the principles of beneficence and respect for patient autonomy. Honest and open communication with respect for the patient’s opinions and values are the most important channels through which ethical treatment is driven.

Under most circumstances, the goals of the mother and her obstetric team are coincident, namely, to do what is possible to ensure a healthy outcome for mother and baby. Occasionally, however, there will be conflicts between you and the patient over medical or ethical issues. (These may in a sense be conflicts between mother and fetus.)

For example, a patient might refuse an intervention such as cesarean delivery that you deem to be in the best interests of the fetus. She might refuse blood products because of religious convictions. She might be using illicit drugs that place the fetus at risk, and persist in this behavior despite your admonitions to the contrary. These are challenging ethical dilemmas. Resolving them requires you to have finely honed communication skills. You will need to respect the patient’s autonomy and to balance it against what you perceive to be your beneficence-based obligations to serve the best medical interests of mother and fetus.

Most ethical conflicts are related to clashes of values. In general, it is important not to impose your own values on the patient. Ideally, you have an obligation to understand her value system and to know whether it conflicts with your own. This cannot be accomplished in a short time, emphasizing another virtue of the continuity afforded when prenatal care is provided by the delivering practitioner. Assessment of values through many encounters during gestation and discussions of the patient’s perspectives on challenging issues can avoid difficult contretemps during labor.

Do not expect a resolution of ethical conflicts during labor to make all parties completely comfortable. Despite your differences, remember that you and your patient remain partners in this process. Your role is to address potential conflicts and competing views unhesitatingly so that a satisfactory resolution can be achieved. In so doing, the moral autonomy and personal dignity of the patient will be best preserved and your moral obligations to her best fulfilled. You should expect no more and should abide no less.

Violence

Nothing so defiles the dignity of women as does domestic violence. Be aware that psychological or physical abuse of pregnant women can arise or be exacerbated by the stress of pregnancy. This regrettable fact is true at all levels of society. It is vital that you ask appropriate questions to uncover abusive situations. Obviously, this would be difficult to accomplish unless you have already established the aforementioned trust and confidentiality with your patient. Ideally, the obstetric unit should be a sanctuary for women who have been victims of emotional or physical battering during their pregnancy. The anxiety brought to bear on the labor process in the presence of an abusive partner can be debilitating, taint an otherwise satisfying experience, and even potentially interfere with the normal course of the labor.

Dealing with a person who accompanies your patient and who is known to have abused her can be difficult, to say the least. First, ensure that the patient desires that he be present. If so, he should be carefully observed. Rarely will physical abuse occur during labor, but subtle or overt psychological abuse in the form of unsupportive or denigrating comments is common. Be alert for these and provide extra support to the parturient to try to neutralize his disparagement. A more delicate situation presents itself if your patient does not want the abuser present. Polite entreaties for him to do what is in the patient’s best interest and to leave the premises sometimes work, but may heighten his anger. He may become abusive toward you as well. Avoid getting into a loud (or worse, physical) confrontation. Retain your own dignity and use hospital security in situations in which you feel the patient or staff may be in danger. These interactions are distressing in the extreme to all involved. Most important, they may compromise patient safety, so they cannot be ignored. A departmental meeting to develop a policy for dealing with these situations can be helpful. At the very least, it gets everyone thinking about how to identify and react when a problem is encountered. Having a mental health professional present at these discussions to explain abusive behavior and to suggest ways to cope with it can be helpful.

Boundaries

An important aspect of medical care relates to the maintenance of appropriate boundaries to ensure that the provider–patient relationship remains professional and not unacceptably personal. The practitioner (or patient) who crosses that frontier does so at great hazard for both parties. That is not to imply that you must be distant, impersonal, or avoid sensitive and potentially disturbing issues. Quite to the contrary, a meaningful professional relationship should be one of sensitivity, compassion, and emotional closeness.

The boundary of appropriate behavior shifts with the prevailing social mores. It may be difficult to identify, and is today often approached with trepidation because of fears that your words or actions will be misinterpreted. To our thinking, the professional nature of your relationship with a patient can be preserved while its empathetic and emotional qualities are drawn upon to advantage. To do this properly requires skill and experience, but in doing so, you will enhance the richness of your relationship with the patient, a benefit for both parties.

Does gender matter?

Midwifery and obstetric nursing have always been professions comprised overwhelmingly of female practitioners, whereas, until recently, physicians were mostly men. In recent decades, women have increasingly entered medicine in general and obstetrics and gynecology in particular. A field previously dominated by male physicians has now changed so that half of practicing obstetricians and upwards of 80% of residents are women. This has changed the culture of the specialty in many unexpected and interesting ways. One often-asked question is whether men should even enter the discipline.

There is in fact a general perception that women prefer obstetric practitioners of their own sex, although this has not been supported by objective studies of the issue. In truth, men and women are generally skillful empathetic practitioners, and an equivalent (fortunately small) proportion of each group is insensitive, unfeeling, and callous. Sensible patients avoid the latter, regardless of their sex, and choose doctors based on their medical skills, professionalism, and compatibility.

If a patient, for personal, cultural, or other reasons prefers a female to provide her care, that wish should be respected when possible. That advice notwithstanding, allowing a patient to reject a provider based on sex may leave you (and your institution) on a slippery moral slope if a patient desires to shun a caretaker because of some other demographic feature. Most women’s choices are, fortunately, quality- and compassion-based, and tend to be gender-independent.

Goals

Labor endows a unique emotional amalgam of fear and hope, anxiety and high expectations, in an admixture unique to each patient’s experience. A woman’s attitude toward and expectations concerning pregnancy are influenced by her social, psychological, and cultural background and by her experiences during gestation. No universal formula exists for the provision of emotional support; rather, you as the practitioner must respond to the patient’s needs, encouraging her to express her questions, fears or concerns, and discussing them in an honest and reassuring manner. Sensitivity to her emotional and physical needs is foremost in a nurturing, supporting relationship that avoids paternalism.

You cannot promise a perfect outcome or an emotionally enriching birth experience in every case. You can, however, pledge to seek the best outcome possible for mother and fetus in the safest available manner. This will always involve your treating the laboring mother with the requisite gentleness, dignity, and compassion she warrants in the birth process.

Key points

A woman’s emotional and physical response to labor and delivery is conditioned by her cultural and religious background, personality traits, and other aspects of her psychosocial context and history.Labor and delivery can provoke feelings of vulnerability, apprehension, and physical and emotional discomfort.Begin to assuage anxiety about labor during the prenatal course, when there are opportunities for you to forge a bond of trust with the patient. Learn about her concerns and educate her about what to anticipate during labor.The key to establishing patient rapport involves showing empathy, respect, confidence, and availability.Listen carefully to the parturient and also observe her body language. A great deal is conveyed by nonverbal communication.Modify the style and content of your discussions with patients to provide clear explanations in a manner appropriate to their ability to understand and to interpret the information.There is a special need for obstetric practitioners to develop keen skills for communicating adversity.Be aware that psychological or physical abuse of women by family members or others can arise or be exacerbated during pregnancy.Always act ethically toward the parturient, balancing the principles of beneficence and respect for patient autonomy. Open communication that shows due regard for the patient’s opinions and personal views is most important.Most ethical conflicts are related to clashes of values. Do not impose your values on the patient. Help her to make decisions in the context of her own mores.

Further Reading

Books and reviews

Charles C, Gafni A, Whelan T, O’Brien MA. Cultural influences on the physician–patient encounter: The case of shared treatment decision-making. Patient Educ Couns 2006;63:262–7.

Chervenak FA, McCullough LB. Clinical guide to preventing ethical conflicts between pregnant women and their physicians. Am J Obstet Gynecol 1990;162:303–7.

Cohen WR. Maternal–fetal conflict I. In: Goldworth A, Silverman W, Stevenson DK, Young EWD (eds) Ethics and Perinatology. Oxford University Press, New York, 1995: 10–28.

Dattel JD, Chez RA. Battering. In: Cohen WR (ed) Complications of Pregnancy. Lippincott Williams & Wilkins, Philadelphia, 2000: 171–5.

Danziger S. The uses of expertise in doctor–patient encounters during pregnancy. Soc Sci Med 1978;12:356–67.

Fauci AS, Braunwald E, Kasper DL, Hauser SL, Longo DL, Jameson JL, Loscalzo J. The practice of medicine. In: Fauci AS et al. (eds) Harrison’s Principles of Internal Medicine, 17th edition. McGraw Hill, New York, 2008: 1–6.

Harpham WS. Only 10 Seconds to Care: Help and Hope for Busy Clinicians. ACP Press, Philadelphia, 2009.

Karnieli-Miller O, Eisikovits Z. Physician as partner or salesman? Shared decision-making in real-time encounters. Soc Sci Med 2009;69:1–8.

Macklin R. Maternal–Fetal Conflict II. In: Goldworth A, Silverman W, Stevenson DK, Young EWD (eds) Ethics and Perinatology. Oxford University Press, New York, 1995: 29–46.

Nadelson CC. Ethics, empathy, and gender in health care. Am J Psychiatry 1993;150:1309–14.

Pellegrino ED, Thomasma DC. The Virtues in Medical Practice. Oxford University Press, New York, 1993.

Woods JR, Rozovsky F. What Do I Say? Communicating Intended or Unanticipated Outcomes in Obstetrics. John Wiley & Sons, Hoboken, NJ, 2003.

Primary sources

Cuttini M, Habiba M, Nilstun T, Donfrancesco S, Garel M, Arnaud C, et al. Patient refusal of emergency cesarean delivery. Obstet Gynecol 2006;108:1121–9.

Harris LH. Rethinking maternal–fetal conflict: gender and equality in perinatal ethics. Obstet Gynecol 2000;96:786–91.

Olson DP, Windish DM. Communication discrepancies between physicians and hospitalized patients. Arch Int Med 2010;170:1302–7.

Schnatz PF, Murphy JL, O’Sullivan DM, Sorosky JI. Patient choice: comparing criteria for selecting an obstetrician-gynecologist based on image, gender, and professional attributes. Am J Obstet Gynecol 2007;197:548.e1–7.

Zuckerman M, Navizedeh N, Feldman J, McCalla S, Minkoff H. Determinants of women’s choice of obstetrician/gynecologist. J Womens Health Gend Based Med 2002;11:175–80.

CHAPTER 2

Examining Your Patient

The examination of women during labor shares many skills in common with medical evaluation in general, and also brings some special requirements to the fore. Pregnancy alters physical findings in most organ systems, sometimes in a manner that would be considered pathologic in the nonpregnant state. A full discussion of these changes is beyond the scope of this volume. Suffice it to say that in order for you to become a skilled examiner, you should become thoroughly familiar with the variations in physical findings attributable to pregnancy.

Physical examination skills are acquired slowly, requiring much practice and repetition. Be patient and devote the necessary time and effort to achieve proficiency. It will prove one of your most valuable assets.

General principles

As with all medical examinations, there are several central principles that apply:

1 Always wash your hands prior to the examination. Preferably, do this in view of the patient so that she will have no doubt that your hands have been cleaned.