“I know it wasn’t really your fault, but I blame you on some level,” said my patient Aisha, sounding husky over the phone. “I’m working on forgiving you, but I’m not there yet.”
Tears sprang to my eyes, but I kept my voice steady as I replied, “I understand. I’m sorry about my role in what happened. Please let me know if you ever feel ready to come back to see me, but I can refer you to another doctor in the meantime.”
What had I done to deserve such harsh words? I hadn’t prevented her traumatic childbirth experience.
I had been Aisha’s doctor since she was a bright teenager, quizzing me on the social determinants of health. When she became pregnant, at age twenty, she knew that as a Black woman she faced a higher risk of perinatal morbidity and mortality. She chose to get her prenatal care with me because she trusted me to prevent that.
I in turn was excited for Aisha, and I looked forward to caring for her and her baby—one of the joys of being a family physician who practices obstetrics. I also felt apprehensive: I had delivered her older sister’s babies, and I knew that Aisha was hoping for a natural labor and a vaginal birth, as her sister had had. I’d promised to do my best to help Aisha have that kind of birth experience, too.
Unfortunately, I failed.
Aisha’s pregnancy went well, until a routine sonogram showed a slight abnormality in her placenta. The sonogram led to more testing, which eventually caught a fall in the baby’s heart rate, which led my high-risk obstetrics colleagues to recommend induction of labor. Despite Aisha’s wishes, her concern for her baby led her to agree that induction was the right course of action.
That’s when the trouble began. As she was being admitted to the labor floor, my obstetrics colleagues immediately put her on edge by mentioning the possibility of a c-section. Her nurse kept encouraging her to get an epidural, which she wished to avoid.
I felt like a referee, mediating between Aisha and the rest of the labor-floor team. I tried to reassure Aisha and her family that the team was just trying to prepare for every possible outcome; I kept explaining to the team that Aisha was not a “difficult patient,” but a woman who felt afraid for herself and her baby as she sensed her control over her body slipping away.
After two days, most of which I spent with Aisha on the labor floor, it became clear that the baby was not tolerating the labor: Its heart rate dipped with each contraction. Eventually I had to concede that, to ensure a healthy baby, we needed to do a c-section.
I discussed this with Aisha, and she agreed. I could tell she was disappointed, as was I, but there wasn’t much choice. Continuing with labor could lead to a sick baby, or worse.
In the operating room, Aisha looked panicked. I imagine that to the untrained eye, it all seemed chaotic. While the OB residents and I covered her lower body with sterile drapes, the anesthesiologist was positioning her upper body on the operating table, the scrub tech was preparing the sterile instruments, and a nurse was getting the baby warmer ready. I knew that the stern voices telling her to lie back or keep her arm extended likely sounded shrill and uncaring to her as she suffered through what might be the most frightening moment in her life.
“I know this is scary,” I said, trying to comfort her, “but we’re going to do our best to make sure everything goes well.”
“You’re not in charge anymore,” she replied accusingly.
It was true. As a family physician who does only vaginal deliveries, I’d relinquished control as soon as we stepped into the OR. This was the obstetricians’ realm. But I was still a member of the team: I assisted in the surgery and was the first to hold Aisha’s healthy, crying baby daughter before passing her to the neonatologist. I also saw the abnormal-looking placenta, the likely cause of the baby’s difficulties during labor.
After the surgery, I helped Aisha try to get her baby to breastfeed. She was happy that the baby was healthy, but her joy was dampened by her long, difficult labor. Her birth experience had been the opposite of what she’d hoped for. When I tried to talk to her about it, she said she was tired and wanted to rest.
At her follow-up visit, Aisha said, “I felt like the OBs pushed me into getting the c-section. They kept talking about it; it’s like they willed it to happen.” She expressed sadness about this and accepted a referral to a therapist.
After a while, Aisha started missing her appointments with me, then stopped scheduling them altogether. That’s what prompted my phone call to her, which had led to our frank conversation.
It’s been several years, and Aisha has not come back to me. I understand why, although I don’t think I could have done anything differently. Even if she’d gone into natural labor, the abnormal placenta wouldn’t have provided the baby with sufficient blood flow, and a c-section would still have been necessary. But that doesn’t change the fact that Aisha felt coerced into a procedure she wasn’t convinced she needed. And because I was involved in that, seeing me again would only remind her once more of that moment of powerlessness.
In obstetrics we view a healthy baby and a healthy birthing parent as the ideal outcome—but that doesn’t take the patient’s overall birth experience into account. I’m left wondering: Perhaps I could have explained things better to Aisha or supported her more somehow. Maybe we were both subconsciously holding me to an unreachable, superhuman standard, and I should have acknowledged all of the variables beyond my control.
I’ll never know.
For now, all I can do is keep on doing my best for my current patients. Caring for pregnant people, being present for their delivery and continuing to care for them and their babies afterwards is a privilege and a joy.
But I will always remember what Aisha taught me: Despite my best efforts, I can’t protect my patients from every negative medical outcome.
And that’s something I still struggle to come to terms with.
14 thoughts on “Powerless”
You did nothing wrong. The circumstances did not allow a natural birth. I understand Aisha’s disappointment, , but she should be profoundly grateful to have a healthy baby—and to have had your support.
Perhaps you and your patient would be interested in reading the anthology “My Caesarian” in which 21 women describe their stories; stories of triumph and disappointment and guilt, and stories like mine where my child died because of a delayed caesarian.
You did not fail her in the slightest. You kept her child and her alive.
https://bookshop.org/p/books/my-caesarean-twenty-one-mothers-on-the-c-section-experience-and-after-rachel-moritz/12417336?ean=9781615195527
Robin
Hello Dr. Gervits, I worked as a hospice RN for many years. The majority of families our hospice assisted were so incredibly gracious and thankful for our care. But sometimes a patient would experience a difficult death, or something else would occur that negatively colored their hospice care experience. Those were the cases that left us searching our souls and revisiting what we had done/not done/said/not said, etc. As a hospice nurse I wasn’t perfect, but always tried my best, with the patient and family front of mind. I think we have to forgive ourselves for not being able to always meet all needs of all patients. When the outcome is not what a patient hoped for, sometimes we get the blame but it doesn’t mean we failed to help.
It makes me wonder we as a society have done a great disservice in our portrayal not only of the birth experience, but also breastfeeding and being a new mother. I am a nurse, and of the generation that started making birth plans. But babies can’t read those plans, and they might have shoulder dystopia, resulting in a more complicated delivery. For many reasons, they don’t always nurse well. I recall feeling almost ashamed to tell my childbirth instructor I only nursed several weeks. It was so miserable, that as a newborn nursery nurse I vowed to never shame a mother for using formula. “Breast is best” led to babies not feeding well, not thriving; and maternal guilt for not being able to nourish her child. Thank goodness for “Fed is best”. And yet mothers still agonize over milk supply, returning to work, and supplementing with formula. Our country’s perinatal morbidity and mortality rate is shameful. Just last night I was talking to an old friend who was recounting the story of her first grandchild’s birth. The mother delivered at a well known women’s hospital in the area. She did not know all the facts, but was aware that there was fetal distress from the first contraction requiring surgical delivery. Mother was bleeding and required blood. I think it is hard for us as professionals, as well as patients, to wrap our heads around the fact that with the best of care outcomes can be uncertain. There are no guarantees. So, I then focused on the fact that both mother and baby are alive.
Very good comments. Yes, what else could you have done?
I understand why, particularly a Black woman, would distrust physicians that she didn’t know. Her distrust is warranted, given Black maternal mortality. It’s apparent that you did everything possible to alleviate her suffering. I’m wondering if the obstetricians did the same.
I once performed a C/S for a woman with fetal distress. She later had postpartum depression, blaming herself for making the C/S decision. All I could do was to take the responsibility off of her shoulders, helping her realize that, yes she consented, but the responsibility was on me.
You handled everything with compassion & kindness. Let go of regret & guilt, please.
I am a family physician with 30 years of experience who did OB care in a rural environment. Thank goodness mom and baby did well thanks to your recognition that specialty care was needed. You did nothing wrong. The patient’s reaction does not change this fact.
Dr. Gervits, you participated in the successful delivery of a healthy baby, and the mother survived as well. Regardless, the mother was disappointed in her birth experience and has focused on your part in that experience. You are demonstrating professionalism in accepting your patient’s comments and absorbing them, rather than attempting to defend yourself to her. But you know you served this obstetrical patient well in spite of her comments to you, and I hope the patient eventually realizes that as well. Until then, rest assured that other clinicians (and mothers, too, I
would hope) hearing this story will recognize how selfless were your actions in advocating for your patient, including mediating between her and the surgical staff; that is not often a comfortable place to be, but you stepped in because you cared for your patient. You did everything all of us family doctors were trained to do, and it is an honor to call you colleague.
Thank you for telling the story of how quickly black women are labeled a difficult patient and usually the statement is untrue. It is so disheartening to see that this is a wide-spread issue in healthcare. We want quality care and have a right to ask questions. At least the author in the story reached out to the former patient. It was a learning lesson for both of them.
Thank you for being human, Maria. I’m not a doctor and did not need a C-section with my two deliveries, one high risk. But I’m a patient, and I appreciate the reminder that doctors care about us more than we sometimes realize.
We do know the maternal mortality is high in USA, unfortunately.
Based on your story there was a problem with the placenta and the baby was suffering during the labor period. C-section was a must. The goal for doctors is saving the mother and the baby. I suspect the mother understood later the possibilities on her case. And she had negative feelings about her reaction on that emotional moment.
When patients believe deeply on their doctors they expect miracles from them.
You did your best, you even held that healthy baby on your arms…golden moment you will never forget !
a powerful story and also a sad one.
It has been many years since my first child was born by c-section after fetal distress during an induction, but I remember my disappointment, bewilderment and frustration. I feel for the patient. But as a fellow physician, I know it would be awful to hear a patient say they haven’t been able to forgive.
Even knowing intellectually that there is nothing to forgive, that little voice that whispers ‘you’re never enough’ can sometimes sound pretty loud.
Thanking for discussing an issue all physicians, or health professional face. kWe all have patients where we wish things had gone differently. We go over it again and again; did I miss something, should I have done this or that, earlier or later or never.
Be gentle to yourself.
Long day, sorry for all the typos.