Poop is Part of Parturition

I was reading a post by another blogger today that addressed the delicate issue of feces in the delivery room. I sort of chuckled at the report of the writer’s (a neonatologist’s) repulsion with the situation (guess most babies in the NICU don’t poop very much, or maybe it just doesn’t smell so bad, and when they do, they are probably ready for discharge from the NICU anyway), but fully realize, and have commented to the effect on many occasions, that the only reason I have survived all of these years in OB is because my sense of smell is very blunted. That was one of the advantages of having been raised in New Jersey. More intriguing to me about the post was the collection of comments that followed bemoaning the generally abysmal state of the typical delivery experience in the U.S. today. I happen to agree (with some of them) and started to post a comment myself, but thought I had more to say than would be appropriate in that context, so I have linked interested readers back to here to get a whiff of my thoughts (and nothing else, I promise).

I have practiced OB for more than 27 years. I too am dismayed by the atmosphere (and I am not talking about the smell) present in many delivery rooms around the U.S. today. A little bit of poop is not the problem, and has, indeed, been well-documented to be a 'natural' bodily function (and, besides, we could easily fix that by going back to the days of the enema, which probably isn’t such a bad idea for lots of reasons!). There often are too many people in the delivery room, family, friends, and nursing staff shouting exhortations at the top of their lungs (as if that will compensate for the fact that the patient cannot feel anything to push and hoping sound waves might accelerate or at least provide an immersion crash course regarding the process), the room is brightly lit (how can you chart in the dark?), the patient is laying on her back because she demanded an epidural at 2 cm and asks for a ‘top off’ whenever she senses any return of discomfort and is, therefore, ‘paralyzed’ from the diaphragm down, the incessant counting to 10 goes on to the point of distraction (even when the patient isn’t having a contraction, or isn’t making any effort to push because “I’m too tired, haven’t had anything to eat, and American Idol is on”), empty containers from various fast food chains are stacked in several locations around the room, the fetal monitor has the volume maxed out, the television is on (as already mentioned), and there is usually a collection of cell phones (with every imaginable ring tone), cameras, and video equipment that rivals major production companies. This is not delivery “medicalized,” it is delivery completely depersonalized. It’s show time, Papa John’s garnished with meconium, and remember to get your popcorn before you sit down to watch. Does this situation sound familiar to any of you out there who actually get up to your elbows in the blood, poop, and other bodily fluids that characterize a normal delivery? The whole scene needs to be treated with Ritalin.

I have also pondered long about how things have gotten to this point. Even during my training, in nonemergent situations, we tried to keep the room quiet, dimmed the lights, eliminated external distractions, and limited the peanut gallery. Maybe we had to do this because most deliveries were actually done in an operating room. But, there was some sense of intimacy, control, and quiet anticipation. (Incidentally, cesarean section rates back then were less than 10%). Nowadays, physicians rarely spend enough time in the room with the patient (they may not even be at the hospital) to have sole responsibility for the current state of affairs, but we are to blame for being tacitly complicit in allowing things to have evolved to this degree. We have become impatient bystanders, distracted by liability concerns, burgeoning paperwork, other patients at other hospitals, and in the process, have relinquished control, or acquiesced, rather than taking the time and effort to improve things. (Incidentally, today the cesarean section rate is 35%).

My greatest disappointment has been from the nursing side, and some of this may have gotten beyond their control. I remember when the routine was for a nurse to sit with her patient throughout labor (and sometimes into the next shift), taking her under wing, and maintaining control over the environment by offering support, camaraderie, explanation, and reassurance (and contributing immensely to my own education). I imagine the good ones still do, or would if they could. But, there are many times now I see nurses sitting in a central monitoring room, observing mother and baby from a distance (fetal heart rate monitor, contraction monitor, automated blood pressure cuff, pulse oximeter), only going into the room when the call light is illuminated, the fetal heart tracing deteriorates, a monitor falls off, or it’s time to start pushing (“1, 2, 3, 4…,10”). Admittedly, some may have too many other patients (due to staffing shortages, hospital cutbacks, and excessive requirements for documentation) to keep tabs on things in any other way. Unfortunately, I have been around long enough to watch more senior nursing staff successfully pass on these bad habits to junior staff (who don’t know anything different and think that this is the way things are supposed to be), so the whole process is now self-perpetuating. During the same time period, the relationship between physicians and nurses seems to have shifted from protagonists to antagonists. Then again, I may just be getting old and could just be viewing things in the past through the rose-colored lenses of the retrospectoscope.

Patients contribute their share to perpetuating this scenario as well. In the U.S., we still have high teen pregnancy rates, an extraordinarily high rate of pregnancies that are 'unplanned' (even among women in stable relationships), poorly prepared (“I didn’t have time to get to the classes”), but demanding, patients, insistence on completely”painless” deliveries, and a sense that everything must be accomplished on some predetermined schedule (“Mom, I will push if you can tape Grey’s Anatomy for me or you will have to wait to become a grandmother”). The apparent lack of concern or understanding of the magnitude of the moment seems lost and as unreal to me as ‘reality’ television! The focus is often not on the baby but on the comfort, convenience, and style of the central actor in this performance. Unfortunately, reality really will set in, but only after the baby is taken home.

Now, I know I will take some flak for these comments from many different sides; and, I readily admit that I am prone to hyperbole. I also know there are places around the country where nothing I have said is true, but there are many other places where things are even worse. The real tragedy is that, the scenario I have laid out seems to be more common at busy “teaching institutions” where the OB providers of tomorrow, both nurses and physicians, are being trained. I have worked well with many midwives over the years and, even though I fully believe that learners who will be providing OB care could benefit lots from the skills and experience of a good midwife, I also know that home deliveries are not the answer either. Besides, someday, in the not-to-distant future, when the cesarean section rate approaches 100%, this whole discussion will be moot and these issues will only be a problem for the patient who delivers in the ambulance (or taxi) on the way to the hospital and misses her opportunity for a planned, feces-free, operative delivery. Then she can sue the driver, rather than the physician, for her anal incontinence because he didn’t run the last six red lights on the way to the hospital….

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