Wednesday, February 13, 2008

Pre-Natal Classes

I have been involved with obstetrics for many years, first as as family doc, then as an anaesthetic resident and lately as a sometimes obstetrical anaesthetists. I actually enjoy obstetrics; I think it is the perverse fascination of dealing with a condition that will never ever happen to me (as opposed to urology for example).

While many people talk about the "miracle of childbirth" however I have to disagree. Firstly childbirth is a completely physiological condition and necessary for the survival of the species. Secondly just about every mammalian species does it; most of them do it much more efficiently and with less fuss that do homo sapiens. Grizzly bears actually have their cubs while they are asleep which unfortunately doesn't do much for their disposition.

But face it, pregnancy, labour and delivery are disgusting processes. Labour for example turns normal pleasant women into desperate, screaming monsters. Normal caring husbands are turned into helpless by-standers. The vaginal delivery process is a miasma of shit, urine, amnitotic fluid frequently with meconium and mucous. 20-30% of women end up having a caesarian section which has got to be the most brutal inelegant operation ever divised; the obstetrician cuts thru multiple tissue layers as fast as he can, rips the baby out, passes him/her off and closes only slightly less quickly. If you don't get a section, there is a good chance your baby may be hauled out by his head using a device which has been used since medieval times (forceps). Even in the 21st century, previously strong healthly women bleed to death, succumb to massive infections, or seize uncontrollably.

None of the above however exists in the alternate universe of the prenatal class.

Prenatal classes teach us that labour is a pleasant process where "tightenings" or "discomfort" can be breathed away aided of course by the husband who will be a willing partner in the whole event which of course will end in the painless delivery of a normal health baby.

I really don't have anything against pre-natal classes; I believe a little knowledge can sometimes be a good as opposed to a bad thing and that is, despite what my wife remembers, I went willingly and cheerfully to our prenatal classes.

I didn't plan my first baby very well. In fact I was at the end of six months of doing 1 in 3 internal medicine call when the conception allegedly took place so I have no recollection of when I found the time or energy. It turned out that my written fellowship exams were in September which was when the pre-natal classes my wife wanted to take started. I of course told her that there was no way I was taking any time away from stuffing my head full of the useless information I thought would be needed to pass my exams. My wife got angry and threatened to hire a labour coach whatever that was. We were able to compromize on classes that started in late October which meant that if our baby was early, we would be without the full benefit of the prenatal classes. I was certain in that contigency we could manage.

So one evening we showed up to a classroom at the hospital for our prenatal classes. Our class had all the usual sterotypes; the perfect couple, the young man with a mullet and his pregant girlfriend, and of course the Expert.

The Expert was a CRNA which is called a LPN in most of the country. Quite early on she introduced herself as an expert on most aspects of healthcare including of course obstetrics. I make a point of not introducing myself as a physician unless for some reason it has to be brought up, my wife likewise did not introduce herself as a registered nurse.

I really enjoyed the prenatal classes, honestly. I hardly ever rolled my eyes and participated in all the exercises. Things went well until the instructor found out that not only was I a doctor but that I was an anaesthesiology resident. Consequently she asked my if I could give a talk on epidural analagesia and also anaesthesia for caesarian section.

I would really rather have not done it but having been asked, I felt that as the now public face of the specialty, I should do a good job. I spent a great deal of time preparing what I thought was a balanced talk that focused on the labour epidural as being only part of a spectrum of labour analgesia and presented what I thought was the information they would need to know about Caesarian section. I made overheads and on the pre-natal night I presented my talk.

It was the worst experience of my life!

As I went on and on, the stunned rapturous expressions faded into frowns and then scowls. I finished my talk and the Expert immediately said, "Well I'm not having one even if I have to have a section." The teacher asked her why, and she stated, "its just not natural." Someone else asked why we wouldn't let the husband in for sections under GA which I didn't have a good answer for (otber than why would you want to to watch a stranger pry your wife's mouth open and try to ram a tube down her throat?). I had mentioned the remote risk of paralysis with an epidural and the husband of the perfect couple asked me something along the lines of "if the incidence of paralysis is 1 in 10000 and say a million are done every year in NA, does that mean there are 100 women paralyzed every year?". The guy with the mullet asked me if it was true that we sometimes put tubes in the baby's lungs because he sure didn't want to watch that happen. The teacher then felt she had to mention that she had in fact invited me and it had not been my idea to present and we adjourned for our nutrition break.

At the nutrition break my wife and I stood by ourselves while everybody looked at me with hatred from as far away in the room as they could get. I had introduced a breach between the alternate universe of the prenatal class and the universe we unfortunately live in.

That may have been the last prenatal class I had to go to. My wife's water broke the next week, she went into labour. I arranged for an epidural and we eventually had a forceps delivery. The baby in question is now 18, in university and, I would like to add, has a 4.0 average.

A year or so later my wife got pregnant. By that time I was a staff anaesthesiologist. I delayed bringing up the topic for a while but finally asked her if she wanted to go to prenatal classes again.

And she said no.

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