I had a bad week.
I am an obstetrician-gynecologist, and on most days I love my job. It is a rare privilege for anyone, even physicians, to participate in the most uplifting moments of other people’s lives. Obstetricians and midwives do so nearly every day. Childbirth is every bit as exhilarating to me after 30 years in practice as it was when I was a medical student. In obstetrics, for the most part, we deliver euphoria.
And yet there are occasions in obstetrics when elation turns to despair. Such transformations can occur in an instant. These sudden, usually unpredictable and potentially devastating events can take a heavy toll, not only on families, but also on practitioners. True emergencies are not frequent even in obstetrics, but when they occur, and even if disaster is averted through natural processes or good care, they take a lot out of us. It is natural to question why we subject ourselves to the emotional risks of these events.
It is also rational to reflect on whether our decisions contributed to or failed to avert a traumatic episode. Decision-making in medicine is all about estimating odds: What are the probabilities of each outcome for each therapeutic option? Which course is most likely to lead to more benefit and less risk? In obstetrics, clinical judgment is particularly challenging, because we are usually dealing with at least two patients — mother and fetus. The interests of these two patients, who are inextricably bound, don’t always align.
One challenge obstetricians can face is shoulder dystocia, an emergency occurring in roughly 1% of vaginal deliveries. In a shoulder dystocia, the baby’s shoulders get stuck behind the bones of the mother’s pelvis after the baby’s head has emerged. These obstructions are almost always resolved without harm. However, serious injury to the fetus can occur, including fractures of the baby’s collar or arm bones, nerve injury to its arm or interruption of oxygen flow to its brain. It is essential to skillfully resolve the problem as quickly as possible.
Though shoulder dystocia is associated with large fetuses, it is unpredictable and can occur in any pregnancy. The American College of Obstetricians and Gynecologists recommends diminishing the risk by offering cesarean section in pregnancies with estimated fetal weights of more than 11 pounds. But obstetricians and midwives who have lived through the harrowing experience of a shoulder dystocia might be inclined to lower that cutoff.
That would be a mistake.
The organization notes that for healthy women carrying fetuses with an estimated weight of more than 9.9 pounds, 3,695 cesarean deliveries would be required to prevent one permanent neonatal injury. Performing all those cesareans would exchange one set of adverse outcomes for a catalog of other complications to the mother and baby, some potentially life-threatening.
Similar complex risk-benefit considerations apply to many other problems in obstetrics. Every time an obstetrician, midwife or labor room nurse dons scrubs, they expose themselves to a profound personal risk: that they will be associated with a devastating outcome. Our own anxieties, and the resonance most of us have with our patients, can compel obstetricians to avoid risk in a way that may not align with optimal care.
But if we are to remain true to our oaths, we should suppress our personal feelings and perform a risk-benefit calculation on behalf of our patients.
During my bad week, I had two shoulder dystocias back to back, both thankfully with good outcomes for mothers and babies. Those deliveries wounded me. And though I have recovered, there are more shoulder dystocias in my future, and other scenarios in which I might be tempted to let my own concerns influence my decision-making.
Yet if I wish to continue doing my best, I have no choice but to don my scrubs again and assume the personal risks. I will counsel my patients regarding the relative risks and benefits of each option to help them make the choices that are right for them.
For a physician, the abandonment of objectivity can do harm.
Emmet Hirsch is a clinical professor at the University of Chicago, vice chair of the department of obstetrics and gynecology at NorthShore University HealthSystem and author of “The Education of Doctor Montefiore.”