Challenged

It was a typical night on call, if you can name any night on call for a third year medical student as typical. And as much fun as our obstetrics rotation was, this night was would turn out to be neither fun nor typical.

There were probably a couple of patients in labor. Though I don’t remember, that would have been the usual scene.  What I do remember is one woman I’ll call Maria.  Maria arrived having painful contractions three minutes apart for the prior several hours.  This was going to be her 7th birth, which had the other student and I almost gleeful that one of us would actually get to help with a vaginal delivery that night.  If we were lucky, it might even be early enough to get a little sleep in the call room. The “call room” would be better named the bunk-house, with its four bunks and central location a few uninsulated feet from and not out of earshot of anyone in labor.

When she arrived, Maria said her pregnancy had been quite normal although she didn’t have all the prenatal care that was recommended back in 1977.  She recently moved from El Salvador to San Francisco with her husband and 4 of their children, leaving two behind living with grandparents.  They spoke no English.

She was indeed in labor and her cervix was starting to dilate and with each contraction she would concentrate, close her eyes, wipe some sweat from her face and breathe slowly.  The thing we students could do best was coach a woman in labor, but Maria was a pro and clearly could have taken over our job if she were not busy right in those moments. After a bit she and her husband went for a walk around the ward, stopping for each contraction, hoping the labor would speed up. She went from bed and some fetal monitoring to walking every hour or so for many hours.  She did not dilate further.  After many hours and into the middle of the night, “we” (that would be the resident on the service) decided to augment her labor with oxytocin, a medicine that strengthens uterine contractions. Her contractions got closer together and the continuous fetal heart monitoring showed the baby to be tolerating the stronger and closer together contractions.

The head would not descend in her pelvis.  That’s not too unusual for a woman who has had several pregnancies and births, but at some point the cervix needs to dilate and the head needs to descend.  She made it to 6 centimeters dilation and we realized the head was not in a great position to descend.  Usually the head is either occiput anterior (the baby facing the floor if the mom is on her back) or occiput posterior (the baby facing the ceiling, or sunny side up, if the mom is on her back).  This baby was facing one side, or occiput transverse. Babies in this position often have difficulty navigating the birth canal.  We were not able to rotate the head and the head remained too high to safely break her bag of waters and see if then we could rotate the head or if it would descend on its own.  There was another aspect to this labor. Her other babies, born in El Salvador were in the 6-7 pound range and we estimated this baby to be about 9 pounds.

The senior resident discussed the lack of progress with Maria and her husband and she signed the consent for a caesarian delivery.  The operating room was set up and she was taken back and given an epidural anesthesia. I was a bit glum that there would not be a vaginal birth, but along with my fellow student, I was glad to be there and assist with the surgery.  While walking to the operating room with the chief resident, he was talking us through the steps of the surgery.  And then he said, “While she is open I am going to tie her tubes.  She has had plenty of children and does not need more.”

Game changer.  Here we were mere mice in a sea of dragons.  We had been trained to accept our position in the pecking order (though the women in my class were a bit rebellious about this and the many comments made about women invading medicine).  But we KNEW where the power was.  He was in his fourth or fifth year of residency, a full 6-7 years ahead of us.

And he was saying he was going to sterilize a woman who had not given consent.

The year our class entered medical school 3% of the classes nationally were women.  My class at my school was 30% women.  And we were an older and proud to be there and cantankerous group who knew the laws about reproductive health.  Maria had Medicaid and the federal law had been passed a few years prior that required a 30 day period between signing a consent for tubal ligation and the surgery happening (unless for instance there was a premature delivery).

This is called an ethical crisis in medicine.

What should we do?  What could we do?

We told the resident he could not do this.  He told us it was not our decision.  We told him he could not do this.  He said he would have us fired, kicked out of school if we tried to stop him.

What should we do?  What could we do?

I was visiting with a friend, Steph Cooper, an ER doc who writes beautifully about this work we do and its challenges (she has a great piece in the manuscript I am trying to publish). I hope she will send me the link to the narrative she published recently about ethical crises.  They can be big or small.  They are real.

This story:  to be continued.

 

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