HCR -- A Normal Pregnancy is a Retrospective Diagnosis

By John Ballard

Reader advisory -- this one's heavy reading. Not scientifically dense or lacking in passion, but just plain long.  An already long post plus the comments thread runs over twelve thousand-plus words. And growing as the author politely and patiently responds to even the most agenda-loaded comments.

My earlier link, HCR -- When Health Care Doesn't Care (with link repaired), is a first-person account of what happened when a medical professional received the worst diagnosis any patient can face, the death sentence of inoperable, metastasized, aggressive terminal cancer. The story is a fairly short glimpse into the challenges of how best to deliver caring care but the core of the study is in the comments thread. It is there where the real substance of health care reform is to be found.

Today's post is a possible sequel. Together they underscore yet again the complicated challenges medical professionals face every day. As if the problems of their profession are not enough, they get unbelievably messy when political, social and legal issues enter the picture. These and others are reflected in the variety of comments that follow the post.

A Normal Pregnancy is a Retrospective Diagnosis by Dr. J.D. Kleinke, is not only longer (3000+ words) but with the author's responses to comments becomes almost tedious as unresolved opinions and issues are batted back and forth. He is publishing a novel cleverly titled Catching Babies and approaches the complexities of pregnancy and delivery with extraordinary insight. The reader can be forgiven who doesn't want to plow through the comments, but the doctor's post is a must-read.

Hannah�s growth has stalled in the final month of her pregnancy, and she has actually lost a small amount of weight. And even though ultrasound and all available tests indicate no other problems with what, at 39 weeks, is no longer a fetus but a baby boy with an emotionally charged family name, the protocols at Kaiser call for immediate admission and an induction of labor. There could be a problem with the placenta or umbilical cord, and �Baby Sam� - as we started calling him months ago - might be slowly starving. Or he might just be small. As the homily from internal medicine would have it, Baby Sam has a classic case of �GOK,� or �God Only Knows."

Which is why I am frantically calling around the country for help, before Hannah gives the final go-ahead for the induction. �GOK� rankles and infuriates me, even if it is honest, even if it is not gussied up for our side of the medical curtain like �idiopathic� - a term meant to sound clinically authoritative by physicians who would rather not admit in plain English that they are clueless about what is happening with a patient, i.e., that they have been reduced by the case, literally, to idiots. But not knowing anything about Baby Sam�s status - other than he sits at the 7th percentile for fetal weight, he is still active, and his heart rate is normal - is especially frustrating, given the freefall Hannah is about to take into the world of cascade birth interventions and potential complications.

My first callback is from Meg, a CNM with 30 years� experience delivering babies and training other midwives. �She is right on the edge,� Meg says. �She really could go either way. I would not induce her. I�d have her stop all activity, monitor her closely, and let her deliver naturally.�

A few minutes after we hang up, I get a callback from Tom, Meg�s colleague, also a friend, and a professor of high-risk obstetrics at one of the most celebrated academic medical centers in the country.

�She is right on the edge,� Tom agrees. �At 39 weeks and 7th percentile, she could go either way. Could be serious IUGR [intrauterine growth restriction] or nothing. And the risks of waiting, though they�re extremely remote, are developmental delay and retardation. I�d go ahead and induce and deliver her.�

Wonderful. IUGR. Developmental delay and retardation. Not an option. I already know what Hannah and her husband are going to do; extremely remote is not remote enough. An induction, on the other hand, does not guarantee a good outcome either - and it is fraught with the potential for bad outcomes that are not all that remote. An induction, or the forcing of labor with drugs and procedures, often triggers downstream interventions, most notably emergency c-sections, which are already done with hair-trigger frequency throughout the US obstetrical care system; these in turn lead to numerous other complications, including the need for more interventions and c-sections in subsequent pregnancies. The blessing and the curse of modern medicine, from the NICU to the oncology unit, is its ability to stimulate its own demand, and obstetrical practice is the quintessence of this cost-curve-sustaining paradox.