The Baby Factory

Delivering a baby at the convenience of the physician can be traumatic for the mother.

Before my daughter was born all was well. I was thirty years old and pregnant with my second child. I had chosen a reputabie doctor who was to de-liver my baby at a hospital that I was sure offered the finest obstetrical care in Fort Worth – Harris Hospital. I looked forward to the birth with confidence.

But that was before my baby was born. Today, almost three years later, I still feel cheated. My physician’s indifference, and his eventual resentment of my needs, stole a precious moment from me. The memory is painfully vivid.

My husband and I had gone to pre-. pared childbirth classes so we could share the experience. It had never been an important issue to me; I had read extensively about pregnancy and childbirth, and saw the classes as just another source of information. But it turned out to be much more. The class put me in touch with my changing body. I decided that I wanted to be awake during the birth and to use minimal medication. I was prepared for childbirth.

But I was not prepared for the change in my doctor’s attitude in the last three weeks of my pregnancy. From the beginning he had assured me that my pregnancy would be a happy event. Although he was not completely familiar with all aspects of prepared childbirth, he said that, barring emergencies, he approved of my plans. Then, as the time for my confinement approached, he seemed to forget everything we had agreed on; he recommended the use of medication to control my labor, so that the baby would arrive at a convenient time. When I reminded him that I wanted spontaneous labor and as few drugs as possible, his irritation was obvious.

The night my labor began and I checked into Harris Hospital, I was relieved to learn that my doctor was not on call. I liked the physician who examined me, and I was pleased that he would deliver my baby. But my labor was very slow. In the morning, he came to say goodbye and to tell me my own doctor would be there soon. He wished me good luck and left.

I was exhausted from laboring all night. My husband was with me, timing my contractions and helping me with breathing techniques. But I was in pain, and I felt the need for some medication. Our confidence shaken, my husband and I needed reassurance and understanding. We waited.

I was in the middle of a contraction when my doctor burst into my room, throwing the swinging doors wide open, whistling. His abrupt entrance broke my concentration and breathing pattern, and I began to writhe with the contraction. He showed no concern. He examined me and confirmed that I was progressing slowly. He informed me that I could continue in my present state or I could “get the show on the road” by allowing him to speed up my labor chemically. My spirit broken, I decided to have my baby his way.

I had placed responsibility for my labor and delivery in his hands. He abused that trust.

It began with the administering of an anesthetic. When I leaned over the edge of the bed, ready to receive the epidural (an anesthetic administered in the lower spine), I felt a contraction begin. I was afraid that I might move or jerk from the pain so I told him of it. He stopped whistling long enough to tell me, facetiously, that one contraction does indeed follow another. He then continued with both the whistling and the needle.

As I was positioned on the edge of the bed still receiving fluid, my doctor left the room without uttering a word. The medication had not yet taken effect. I didn’t see him again until after my baby’s birth.

I was now deadened from my waist down, and the head nurse laid me back on the bed. She began an intravenous drip of Pitocin to hasten my labor. Now I had one tube in my arm and another in my spine. The head nurse left the room and a younger nurse remained to monitor my blood pressure. When I complained to her of a pain high under my ribs, she summoned help. She explained that this was her first day on duty and that she was unfamiliar with this procedure.

The head nurse returned. Without checking me, she decided to give me another dose of anesthetic. She went to get authorization from my doctor, who was in the hospital lounge. The nurse, not my doctor, returned and injected more fluid into my spine, then left.

The extra dose was unnecessary be-cause my lower body was already completely deadened. The pressure under my ribs increased and I complained again. The young nurse became alarmed as I began to arch my back. She ran for help.

This time the head nurse was openly impatient. She informed me that there was nothing more she could do. My husband suggested that she check my progress. In a half-bored, half-patronizing manner, she complied. When she pulled back the sheets, she saw my daughter struggling to be born.

1 was rushed to the delivery room where a surgical nurse, already scrubbed and gowned, was waiting. The other nurses tried to keep my husband out in the hall, but they were unable to lift me without his aid. Once in the room, he remained with me. As soon as I was placed on the table, my baby was born. The surgical nurse expertly untangled the umbilical cord from around my baby’s neck and delivered her safely. Only 40 minutes had passed since my doctor had come to my room.

When my doctor finally arrived, still unscrubbed, he stood outside the door, joking. I looked away. When he entered the room to carry out post-delivery procedures, I fell silent. I held my husband’s hand, my eyes fixed on my new-born daughter.

Then I was wheeled to recovery, where my husband and baby were rushed away from me. My doctor told me that the anesthetic would wear off in a couple of hours, and then I would be taken to my room.

Five hours later I began to feel scared. I was still completely dead from the waist down. When I noticed my doctor leaving the recovery room, I told him I still could not move my legs. Without breaking his pace, he walked to the door, then turned and struck the final blow. Shaking a scolding finger, he yelled, “If you had done what I told you to do in the first place, this never would have happened.”

I wanted to scream for help, but I was too stunned to even speak. I lay quietly for three more hours. Although the anesthetic had not completely worn off, a concerned nurse decided to allow me to go to my room. Fourteen hours after I had received the anesthetic, the feeling in my legs returned. I finally cried.

The day 1 left the hospital, I left my doctor too. But 1 am unable to leave the memory behind.

HHarris began its rise as a leader in obstetrical services during the baby boom of the 1950s. Because Harris was oriented toward specialized med-icine, it drew doctors who practiced the new obstetrical specialty. An obvious attraction for both doctors and patients appeared in 1963, when Harris opened the Mary Gibbs Jones building for maternity patients. In the same year, Harris Hospital joined with Fort Worth Children’s Hospital to form the Fort Worth Medical Center. In 1970, when the obstetrical unit at Harris was financially sound, the psychiatric unit was not. Since these same units at Saint Joseph’s Hospital were showing the opposite trend, the hospitals cooperated in closing their losing facilities. Harris’s maternity unit grew even larger. Three years ago Fort Worth Children’s Hospital established a neonatal unit, with special staff and facilities to provide care for the distressed newborn – the only such unit in a private Fort Worth hospital and an added incentive to giving birth at Harris.

Now Harris Hospital is considered the baby factory of Fort Worth. More babies are born there each year (4668 in 1977) and more obstetricians practice there (40) than at any other North Texas hospital. The facilities are excellent: Other hospitals often refer high-risk patients to Harris for obstetric and pediatric care.

But there are disadvantages to having a baby in the largest and best birthing hospital in Fort Worth. Women may be processed through the “baby factory” without receiving the individual attention they need. And some obstetricians who practice at Harris have practices far larger than they can properly handle. I talked with three nurses at Harris – I’ll call them Linda, Betty, and Diane – who are troubled by these practices and policies:

●Induction of labor-a risky medicalprocedure which is necessary for somemothers and infants-is being used atHarris by some obstetricians for their ownconvenience in scheduling deliveries, according to these nurses.

●Scopolamine, a hallucinogenic whichcauses a woman to forget the pain ofchildbirth, is rarely used at other hospitalsbecause it is believed to have more disadvantages than benefits. According tothese nurses, the drug is used regularly bysome doctors at Harris.

●A new policy, unique to Harris in thisarea, allows an obstetrician to instruct anurse to administer Pitocin, the drug usedto initiate or speed up labor, in the physician’s absence.

●Harris, unlike most area hospitals,allows an obstetrician to leave the hospitalafter initiating a regional anesthetic, suchas an epidural.

Induction of labor is sometimes necessary. If a woman does not deliver after 42 weeks, the placenta (the tissue that nourishes the fetus) begins to dry up and the fetus becomes malnourished. Women with such conditions as high blood pressure, toxemia, and diabetes also warrant a medical induction.

But the nurses I talked to at Harris are concerned about the prevalence of inductions which are not medically indicated – elective inductions, which are done strictly for the convenience of the doctor or the patient.

Some Fort Worth physicians, these nurses say, schedule patients in their ninth month for morning office appointments on the same day that the physician will be on call at the hospital. If the doctor finds the patient ready, he sends her directly to the hospital to induce labor. “Some doctors induce labor in the morning and regulate it [speed it up or slow it down with drugs] so that they can do the delivery in the evening after office hours,” Betty says. When a physician induces labor by rupturing the amnion (the membranous sac surrounding the fetus), the delivery must occur within 24 hours or the fetus risks infection. But, Betty says, “Some women are not ready to deliver and the induction does not work. If the doctor has ruptured the membranes he is committed and is forced to perform a Caesarean section.”

Inductions pose other risks, too. During a normal labor, each contraction reduces the flow of blood to the uterus, cutting down the baby’s oxygen supply. When the uterus relaxes between contractions, the baby’s supply of oxygen is restored. But when Pitocin is used to speed up induced labor, the uterine contractions tend to be longer and harder, with less time between them. The baby could be deprived of oxygen long enough to suffer brain damage. Pitocin can also cause a woman to go into a tetanic (continuous) contraction: The uterus becomes hard and will not relax. A tetanic contraction cuts off the oxygen to the baby. It can also cause the uterus to rupture or the placenta to separate from the uterus prematurely. If a tetanic contraction occurs, the woman must be taken off Pitocin immediately and given oxygen. If the Pitocin is given intravenously, stopping the IV drip can have an immediate effect, but if the drug is taken orally, as a tablet placed under the lip, the effect is less easily reversed. If a tetanic contraction does not cease, a Caesarean section, if performed in time, can save the baby. For the mother, Pitocin increases the risk of tearing the cervix and hem-orrhaging.

Dr. Rose Marie Riber, a neonatologist (a specialist in the care of newborns) at Fort Worth Children’s Hospital, refers to elective inductions as “babies by appointment.” She adds, “I oppose it. There is no reason except convenience, which I do not think is adequate. It is extremely difficult to tell when a baby is really due. There are high risks to inductions, including death. Hyaline membrane disease [immature lungs] is the problem I see most often. The percentage isn’t large; an individual physician might see only one baby like this, and so he won’t see induction as much of a risk. But as a doctor who takes care of newborns, I see only the sick, and I see a fair number of babies born by elective induction that have problems.”

Yet, often, the decision to induce labor is made casually, for the mutual convenience of doctor and patient. Last year, for example, a Fort Worth woman, then pregnant with her second child, chose to have an induced labor at Harris. “It was summer and it was hot,” the woman explains. “I had another baby to worry about – who was going to take care of him’.’ My doctor asked if I would like to be induced, and I said, Yes, I think I can get in tomorrow or the next day. So I did. He said that I was ready, and so I thought I was ready too.”

That decision would not have been possible at some other Fort Worth-area hospitals, at least according to their official policies. Dr. Phellem Staples, head of the department of obstetrics and gynecology at John Peter Smith Hospital, stated, “We do not do elective inductions. We induce some patients when a medical problem dictates the induction.” Fort Worth Osteopathic Hospital representative Mary White said, “Inductions are rarely done and only when medical complications arise.”

These days elective inductions are less frequent than they used to be at most hospitals, including Harris. Many physicians are now reconsidering their use of this procedure. But, according to nurses I interviewed, some doctors continue to send their patients to Harris before labor has begun spontaneously. Then the physician will administer Pitocin, ostensibly to augment labor, when in reality he is initiating labor. In view of all the risks, why would an obstetrician routinely perform elective inductions? Diane remarks, “Some doctors have too large a practice to allow everyone to deliver spontaneously.”


copolamine is often referred to as “twilight sleep.” It causes a woman to forget the pain of labor, without killing the pain itself. Other drugs are administered in combination with Scope to achieve pain relief.

A woman who is about to deliver her first child might labor painfully for 12 to 15 hours. But doctors don’t want to interfere with a first labor more than is necessary: A regional anesthetic, if administered too soon, can slow down or even stop labor, and the risks of induction are higher for first pregnancies than for succeeding ones. Most doctors, when dealing with a first labor, will keep medication to a minimum, administering a regional anesthetic when it can do the most good. They will stay with their patients to make these individual medical decisions.

But some doctors don’t want to spend a long time overseeing a first labor. These doctors will administer Scope, allowing their patients to labor as long and as hard as necessary; then they’ll administer a regional anesthetic when they show up for the actual delivery, which may be long after the anesthetic would have been useful. The woman will not remember either the pain of labor or her doctor’s absence.

Linda says that some doctors at Harris will give their patients Scope, then let them thrash, twist, and scream out in pain nearly until the end of their labor. When the baby is about to be born, the doctor comes to the hospital, administers a regional anesthetic, awakens his patient with Antilirium (the antidote to Scope), brings in the father, and delivers the baby. In this way, Linda says, the doctor keeps his promise to deliver the baby and allow the woman to be awake.

Betty recalls, “One baby had crowned (its head was protruding) almost to its ears, but the doctor sat the woman up on the baby’s head, administered the epi-dural, and then woke her up. He delayed the birth so that he could stage a show with her awake and the father there.”

While Scope may ease the doctor’s burden, it has some serious disadvantages. Helen Cox, a registered nurse for 29 years and supervisor of obstetrics at Hurst-Euless-Bedford Hospital, says, “A woman can’t handle herself as well with Scope. She has no control.”

Betty says, “Most of the women given this drug become wild and uncontrollable because it removes inhibitions. Some women become so violent that they must be strapped down, and that only makes them wilder. It is not uncommon for a nurse to lean on a woman to restrain her, and sometimes a nurse has to use almost her whole weight. Then when the woman wakes up all bruised and sore, she doesn’t understand why.”

Several “scopy” women may be laboring in Harris’s large labor ward at one time. “When one womean starts screaming and thrashing, it triggers all the others,” Betty says. “The whole room becomes hysterical and unmanageable. It’s hideous.”

A woman’s reaction to Scope can strain the nurses’ tolerance. Actual mistreatment of patients is rare, but Betty relates the case of one laboring woman who was delivering a posterior baby (face up instead of down). The woman got up on her hands and knees. “This is a normal position for a woman to assume in this kind of labor,” Betty says, “but the nurses in charge of her care wouldn’t allow it. Every time she would pull up, one of the nurses would slap her on the buttocks to knock her down.”

As at other hospitals, no policy governs the use of Scope at Harris; it’s used at the discretion of the physicians. The difference is that some physicians who practice at Harris choose to use Scope regularly, according to my sources, while the physicians at other hospitals use the drug rarely or not at all.

One physician at Harris who uses Scope says, “Practically every doctor uses Sco-polamine at one time or another.” He cites two reasons for his use of the drug on his patients (he calls them “girls” or “gals”): A patient will require less anesthesia with Scope, and it is a good drying agent. (When a woman is under a general anesthetic, it is important to keep the mucus membranes in her nose and throat dry to prevent her from aspirating secretions and drowning.)

A local teaching doctor, though, says that Scope is being taught in medical schools only as a “curiosity.” He said that the drug disassociates the mind from reality. The pain is there, but the woman is not consciously aware of it. “Scope has been superceded by better and more adaptable medication,” the doctor said.

Some of the physicians at All Saints Hospital also use Scope. But at Arlington Memorial Hospital, Scope is rarely used, and then only at the woman’s request that she not remember her labor and delivery. In such a case, the patient is fully informed about the effects of the drug. The physicians at John Peter Smith Hospital, Huguley Hospital, the Osteopathic Hospital, and the Hurst-Euless-Bedford Hospital do not use Scope.

While the nurses’ concerns about elective induction and Scope apply only to the way some obstetricians at Harris choose to practice medicine, they are also concerned about some policies at Harris that are not found at other hospitals in the area.

A new policy, in effect only a few months, allows a nurse to initiate a Pito-cin drip in the physician’s absence. A physician does not have to examine his patient before instructing a nurse to initiate or speed up her labor. The nurse takes responsibility for the procedure and for the condition of the patient. An aide (called a sitter) stays with the patient to monitor the Pitocin drip. Mary Moore, a nurse at Harris, says that a sitter might be a nurse or only a nurse’s aide. A nurse’s aide, with only on-the-job training and little formal education, might therefore be responsible for detecting any complications that might arise when sitting with a patient. Every other hospital in Dallas and Fort Worth requires a physician to be present to begin a Pitocin drip.

An older policy at Harris allows a physician to leave the hospital after he has administered a regional anesthetic such as an epidural. (The epidural was once used only for difficult labors because of the skill required to administer it and because it posed the risk of a sudden drop in the mother’s blood pressure. Today, however, the epidural is used in nearly 80 percent of all deliveries in the United States.) The hospital staff assumes responsibility for monitoring the patient in the doctor’s absence, and a nurse may administer additional doses with the doctor’s authorization.

Arlington Hospital also allows a physician to leave after administering a regional anesthetic, but he must first stabilize the patient and return to give additional dosages as needed. The hospital staff is responsible for monitoring only, and the doctors at Arlington who take advantage of this policy have offices within a block of the hospital. At All Saints, Os-teopathic, and Hurst-Euless-Bedford, a physician must remain at the hospital while his patient is under any anesthetic. Nurse Helen Cox of Hurst-Euless-Bedford says that, although she feels capable of monitoring and regulating an anesthetic, she would not feel comfortable accepting that responsibility, even with her 29 years of nursing experience.

Although most of the obstetricians at Harris have at times left the hospital after initiating an anesthetic, the nurses are concerned mainly about a few doctors who abuse this privilege. “Some doctors let the nurses do it all,” Linda says.

Ron Smith, executive director of Harris Hospital, responds to the nurses’ criticism by saying that the uses of Scopolamine and elective induction are as varied as the physicians’ views and techniques. He also says that the hospital’s in-service training program assures that the staff is capable of handling its broadened responsibilities. The medical results are the same as at hospitals where more restrictive policies prevail: Harris has a low infant mortality rate.

Smith recognizes the need for a patient representative system, and he says the administration is considering establishing such a system. He says that the administration is kept aware of patient complaints through evaluation forms sent to all patients after they leave the hospital. The hospital is making progress in dealing with the emotional trauma of childbirth. Fathers can be present during normal deliveries if they attend prepared childbirth classes with their wives. A mother can have her baby with her in her room; her other children can see her and the new baby in the visiting area. But a woman who is about to give birth needs more than procedures such as these. She needs her physician. Harris Hospital’s acceptance and support of its physicians’ methods of delivering large numbers of babies may be promoting efficient childbirth at the expense of the mother’s psychological heath.

Dr. Richard Yentis, director of the adolescent unit at the Psychiatric Institute of Fort Worth, says, “Some women have difficulty handling the many changes which pregnancy and childbirth bring. The problem and its intensity are different for every woman, but the stress such problems can bring is universal.”

Dr. Yentis believes that a realistic ex-planation of the natural process of pregnancy and labor and of medicine’s role in this process can help allay a woman’s anxiety about her body. He cites the benefits of prepared childbirth classes: “The classes provide information but they also provide emotional support. A woman makes an enormous adjustment to her new baby; the more prepared she is, the better the adjustment will be.”

The doctor’s role in this process is paramount. “When a woman becomes pregnant and puts herself in the care of an obstetrician,” Dr. Yentis says, “she enters a bond with him based on trust. For nine months they will try to build understanding and rapport into their relationship.”

Too often, though, neither the physician nor the hospital delivers all that has been promised.


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