Powerless

“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.