December 28

As I mentioned in my last post I’ve struggled with practicing as I’ve been taught and believe is best while also trying to respect how my Haitian counterparts were taught and what they believe is best practice.

There was a woman who came in in labor this week and when the doctor examined her he said that she would need an episiotomy (cutting the perineum to make the vaginal opening bigger) in order to give birth (this was long before the baby was even close to being at the perineum when something like that could really be evaluated). I had labored for most of the evening with this woman and thought of her as “my patient,” and was more than a bit frustrated at the prospects of her having an episiotomy. I told the nurses I was working with that I didn’t think she needed an episiotomy—and explained that in the U.S. the literature shows repairing lacerations is better than repairing episiotomies—and that if I caught her baby I wasn’t going to perform one. Needless to say, I was not allowed to catch the baby and she got an episiotomy (and actually had quite severe post-partum bleeding, I believe in part as a result of her episiotomy).

I know that the nurses where just doing what the doctor ordered them to do (as is appropriate), and that they believed that performing an episiotomy was best practice, but it was still very hard for me to watch. I however, see no easy way to reconcile our differences in practice. Although I’ve tried to talk to the nurses about why we in the U.S. don’t perform episiotomies (and various other practices), at least in this type of society behavior change needs to come from the top (i.e. the OB/GYN chief) and not the bottom (i.e. night nurses). And although I feel very strongly about the issue I’m reticent to go to the head of the OB/GYN department and try to lobby for such a change. Part of that that is me being scared and non-confrontational, but it’s also hard given that this is what is believed to be best practice and still taught in the medical/nursing schools, and I’m “just” a visiting foreign new midwife lucky enough to have been allowed to work at HIC for these 2.5 months. So, I’ve done nothing—except never perform an episiotomy and have had many moms with no lacerations (when I was told an episiotomy would be needed) or well repaired ones. I know that’s not enough and that I’m not serving my patients as best I can, but it’s all I feel comfortable with doing at this point.