Wednesday, February 3, 2010

“Lack of Patient Preparation for the Postpartum Period and Patient’s Satisfaction With Their Obstetric Clinicians”

When I read the title of this article in this month’s Journal of OB/GYN (the ‘green’ journal), I literally laughed out loud. This could be because, at the time I was holding a fussy 2 month in my left arm while holding my green journal in my right hand, walking the room. I was trying to read, console baby and keep 6 year old entertained, all at the same time, so husband could finish working on a project upstairs. How can I prepare my patients better for their ‘postpartum experience’ when I can’t prepare myself, I thought?

As I read the article further, it mainly discussed the physical symptoms associated with post partum such as bleeding, hemorrhoids and breast tenderness, with just a small aside on anxiety and mood swings, written blandly in technical writing. I laughed again. Seeing someone try to quantify the emotions that go along with having a baby in a ‘prospective longitudinal cohort study’ seemed absurd.

There is nothing that can fully prepare you for having a baby. No amount of books or advice. Not even being board certified in OB/GYN. When my oldest was born I was a 3rd year resident. I could rattle of the top of my head the physiology of delivery, risk factors for postpartum depression and I could have resuscitated/intubated my newborn if needed. I thought I knew what I was doing. I had read books on baby care and breast feeding. Then after a difficult delivery, I was home with a newborn, who did not ,in fact, read the same books that I had read on how he was supposed to act! I remember being so sleep deprived I literally couldn’t see straight. I had reasoned before delivery that if ANYTHING could prepare you for postpartum, then it was residency, but the truth is that NOTHING can truly prepare you. I finally let him occasionally take a bottle so I could sleep and recover from my cesarean section. After a couple weeks I got into a flow and he did eventually get on a schedule…. Sort of. I learned to be less anxious and just enjoy every minute with him.

We recently adopted baby #2 and the ‘postpartum’ time has been significantly better. Some of this is the lack of physical recovery of course, but I think a lot of it is just knowing what to expect. Additionally I now live closer to family and have more social support.

In my practice I think the people who have the hardest transition to postpartum are the women who have it the most “together.” The executives with their blackberries who have everything all planned out and the nurses who know it all already and won’t ask for help. These are the patients that I try to take the extra time with to prepare for postpartum. Usually they smile and nod patting their baby books on their lap, thinking NO not me! But at their postpartum visits they almost always say you know, you were right! This is the hardest thing I’ve ever done.

I’m not sure that being a mom makes me a better doctor, but it definitely helps me understand/ counsel the postpartum patient. When my staff asks if I’ll see a postpartum patient that has shown up late for their appointment, I ALWAYS say yes. Just making it out of the house with a baby is difficult, let alone making it on time. Actually, I usually even will see them first, even if others have been waiting longer.

No offense to the author of the article. It was a well done study and she's right we do need to better prepare our patients for postpartum issues. I just don't think an extra brochure is going to do the trick.

I would love to hear our readers input on their personal “preparation” for their postpartum recovery (especially any OB/GYN’s out there).

14 comments:

  1. I heard really good advice from a psych attending who specialized in managing pregnant psych patients.

    Don't plan on doing anything besides taking care of your baby for the first several weeks.

    And to her husband:

    Your job is to cook, clean, do laundry, go to the store, and do everything you can to make your wife's job easier.

    I thought it was fantastic advice. I kind of wish I could have audiotaped it.

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  2. My personal plan for recovery was to move across country at 6 weeks postpartum. That time was taken up with baby care and packing so I didn't have any time to worry about sleep deprivation or anything. I was running on pure adrenalin. This, by the way, was not "planned". My husband got "the job offer of a lifetime" when I was 3 days postpartum.
    I would definately not recommend this for anybody else, and if I had a lick of sense at the time, I would have told the husband-unit to take a flying leap.

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  3. My first maternity leave also came in my third year of residency, and, to be quite honest, it felt like a freaking vacation compared to being a resident. I don't think I did any preparation!

    I did not have a C-section, so I did not have the extra recuperation from major surgery to contend with, but I did have a baby with severe reflux/colic-type screaming who would not sleep for more than 15 minutes on her back.

    So I had to struggle with the mommy (and doctor) guilt of putting my sweet precious baby on her (COVER YOUR EYES, PEOPLE) tummy to sleep. I did learn about how babies did not always follow the rule book, and we figured it out together.

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  4. I loved this post. It is so true that nothing can quite prepare you. I remember thinking, hey, I KNOW what to do at work. I don't know what to do here! Sitting there covered in breast milk, both the baby and I crying... I think learning how to be a mom makes you a better doctor, because you learn how to go forward in the face of uncertainty.

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  5. Kellie (General surgeon)February 5, 2010 at 5:03 PM

    Oh, I so agree with this post. I am a general surgeon who did a hell residency. Worked at least 100 hours a week, usually 120. I also was in the military and survived basic training (regular basic, not officer basic). Thought if those things didn't kill me a newborn would be nothing.

    Was I ever WRONG. Sleep deprivation and knowing that little babe is depending on you 24/7 is so much more difficult than any of the above. I seriously thought about how could I send him back.

    Now? Wouldn't even think of trading him. The first 2-3 weeks I wanted to go back to work becuase work was easier. Finally things started settling and by 8 weeks when I was going back to work, I didn't want to.

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  6. Me too, me too! I am a psychiatrist and my first colicky baby was a complete shock. We used to call her the planned parenthood poster child. Then the second one was so quiet, I worried (until she got to college) that might grow up stupid. So there was no pleasing me, either way. I try to warn pregnant medical students not to come back too early, as several have and failed their exams.
    I actually want to study motherbrain--which the research community has dismissed in cavalier fashion, but which I know from experience is quite real. My friend who delivered just before me described it as "it's like someone took out my brain, kicked it a few time, and reinserted it rotated 45 degrees!" It is important to warn people, but do they listen--nah!

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  7. Oh my goodness - yes yes yes. I was *shocked* by how difficult it was for me to adjust to being a mother. All my life I'd wanted to be a mom; I'd planned the conception years in advance (can't be before x date, has to be before y date, etc.); read all the books; and in a pinch thought I could probably deliver myself. I thought that I was as prepared as a person could be.

    And then there was the actual labor. And the actual delivery. And the actual post-partum hormone shifts. And the challenges of breastfeeding, a horribly unhappy/colicky baby, a husband who was having trouble adjusting, the insane sleep deprivation that far outweighed my worse months of residency, and most frustrating of all, things not happening on schedule... Like someone else said, I was ready to send her back!!

    Luckily I stuck it out and am now actually considering a 2nd. (Although I expect that it's the same experience the 2nd time around - "wait? It's *this* hard?! How is it possible that I can't handle this?!")

    I think in retrospect it would have been good for someone to tell me exactly what the OP said: it's tougher for those of us who are high achievers, because babies don't achieve. Or follow instructions. Etc.

    And if someone had told me: don't feel bad because you feel like you're drowning while other moms seem to be blissful.

    And, most of all, if someone had said: Don't worry. The first months will pass. You will NOT permanently scar your child in this time. And within a year, you will have your mind (and part of your life) back...

    PS: As context - I am an ER doc - thought that the sleep deprivation would be no problem - hahahaha!

    PPS: The thought of doing a quantitative cohort study on this issue cracks me up, in its total inability to capture what's really going on during the postpartum period. That study must have been designed by a non-mother, or a man?!

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  8. I remember riding home from the hospital, with my first - a daughter, and thinking I had entered a different planet. Old familiar stores and streets carried a new aura, as if they had been painted in a different light.

    The struggles that ensued - nursing challenges, colic, etc., were beyond belief. I remember watching a commercial of a baby laughing while their diaper was being changed and thinking - is this fake? Did they stage this? My daughter just screamed and screamed. During the two hours a day when she managed to poop 16 times. After that, I had relief for a couple of hours, then more screaming. Little did I know what a difference a few months could make.

    I felt guilty for the relief I experienced when turning over the daytime duties to a nanny. Returning to work so I could have a little adult and breathing room. Before being up all night nursing and singing in the rocking chair, downstairs.

    Postpartum number 2 was easier, in some ways, cause I had "been there, done that," but also more challenging, because there were two to manage - a toddler and a baby. Sleep deprivation took on a whole new meaning.

    Now my daughter is almost 7 and my son, 4.5. Time sure flies. Yes, it was worth it. But (echo) much more difficult than med school, residency, job transition, etc.

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  9. Ditto everything above. I was completely clueless. Not to mention, I wasn't ready to be a "parent" - how uncool! Took me several years to settle into that new identity.

    Now they;re 19 and 14 - where did the time go?

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  10. TBTAM- I'm a Huge Fan of your blog! Thanks for your comments.

    MLR- The study was done by a woman, but not sure if she is a mom.

    I may modify this entry and send it in as a letter to the editor.

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  11. RH+ - yes, yes, you should!!

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  12. Kind of late to this entry, but I thought I could give another perspective. Although I was completely overwhelmed w/ babies 1 and 2, I had expected to be overwhelmed and exhausted and cranky. The true surprise came after my 3rd pregnancy (w/ twins which may have impacted the post-partum to make it more difficult). I was entirely unprepared for the emotional upheaval I experienced after the birth of the twins. I had always been a pretty practical person and even-keeled, but after the twins I became an emotional lunatic. I remember being in the hospital and catching a stranger's eye and I would just start bawling. For no reason whatsoever!!! I literally had no control over my emotions at all. Within seconds I would swing from catastrophic depression to giddiness without any in-between emotions. After 2-3 weeks of this, i finally began evening out again and, although exhausted, did not have the emotional chaos that had defined the previous month. No amount of reading about baby-blues or post-partum depression prepared me or my husband (also a physician) for the reality of my complete emotional upheaval. And I honestly don't know how I could have prepared for the experience.

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  13. Oh, mercy! My first baby was born soon after I finished FP residency and I also thought that 3 years of every 2nd or 3rd night call (little/no sleep, hospital had a busy OB and Medicine service and we covered both) was preparation. Nope, babies wake up every single night,if they ever go to sleep in the first place. Colic, difficult breast feeding, it was a relief to go back to work. I remember looking at my mom over the head of that poor crying child and telling her,"If this baby wasn't breathing or was dying with meningitis I'd know exactly what do do for her, but I have no idea what to do with a healthy kid." She's grown now (as is her sister) and has a kid of her own, and doesn't seem to be scarred in any way. Wish I'd known that then.

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  14. Oh man, what great comments. I know I'm late as well posting on this, but I decided for God knows what reasons that having a baby and starting FM residency at nearly the same time would be fine. One emergent C-section for pre-eclampsia, breastfeeding nightmares turning to exclusive pumping for 7 weeks, and probably some post-partum depression later, I've got a 7 month old and have finished 4.5 months of residency. I'm hanging on, but some days just barely. I actually sent in a question to MiM--was posted in the "Mailbag" section back October of 2008 regarding what people thought about having a baby and doing residency etc during the time. Most of my responses were negative-people called me crazy, and now I see why. My husband and I had never taken care of a baby a day in our lives. Thanks to all the women who are being honest out there-- I feel like there's this lie that women perpetuate by cooing and ahhing over babies, making it seem like it's the best thing in the world and is stress-free to have a baby. Those women neglect to remember the tears, the worry the stress...or maybe they just don't want to admit they went through it too? I must agree, the "over-acheiving" types may have the hardest time...I was first in my med school class, AOA all of that stuff, but when I didn't have the "right" answer for every situation with my baby, it made me an absolute wreck...something that I realize is now especially hard for me in residency-- I can give you the right answers to tests, but the "right" answers for patients don't work that way, just like in motherhood. I'm working on both motherhood and medicine, but obviously I've learned that sometimes there are no ABSOLUTE right answers, you have to do what feels right, and that's enough sometimes.

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