Did I receive substandard care from my OB?

January 31, 2010 8:29 PM

Did I receive substandard care from my OB? Contains discussion of childbirth and related anatomy.

A question for people familiar with OB care or with specific knowledge of (fourth degree) perineal tears...

A year and a half ago, while giving birth, I sustained a 4th degree perineal tear, and although I blamed my OB for having made me push before I thought it was time, I didn't really think much about it once I had recovered from the birth and the tear had healed up.

That is, until last month, when my friend also had a 4th degree perineal tear during childbirth, and the care she received for it was substantially more involved than mine.

Other than my friend, I don't know anybody else who has been through this, so I don't have anyone else with whom to compare notes. But since I'm planning on having more kids, I'm trying to figure out if I'm over-reacting or if I should find a new OB practice [there are more than 10 doctors in the practice, so I don't always see the same doctor and there's no guarantee which one would be in call on any given day].

The facts:
- Second children for both of us
- My friend did not have an epidural; I did
- We both had episiotomies
- We both had very quick pushing stages (< 15 minutes)
- My friend's doctor immediately told her what happened and explained what a fourth degree tear was; I overheard my doctor tell another OB that he had "a four", and he did not volunteer anything about it until I asked what "a four" was.
- We were both told to use stool softeners for a few days
- My friend was counseled by a dietitian about her short term diet, and the hospital's food service was aware of the suggested diet; Nothing like that for me
- My friend was visited by a home nurse a day or two after returning home (to check how her tear was healing); Nope, nothing like that for me
- My friend had follow up appointments with her OB at 2 and 4 weeks post-partum to check how her tear was healing; I just had the standard 6-week post-partum checkup
- We are both in the US (in NJ)

So, did I receive standard care and she received extraordinary care? Or did she receive standard care and I received substandard care?

[Next time, I'm definitely not letting myself get pressured into pushing before I'm ready. I'm a hard core serious pushing machine. I still blame the combination of pushing too early and too hard for the tear (not to mention, the episiotomy)]

posted by ellenaim to health & fitness (14 answers total)

I think the question to ask is do you want the standard of care your friend received, regardless of whether or not it was extraordinary or yours was substandard? If the answer is yes, find a new practice.
posted by cooker girl at 8:38 PM on January 31, 2010 [5 favorites]

Agree. Either way, I would be changing OBs, especially if I had a kid and thought the doc had me push before I thought my body was ready!

And when you look for a new OB, I would interview them, and tell them about your experiences as well as how your friend had substantially different care. Their responses would be very important to me if I had been through all that!

So, let me guess, did you have Blue Cross/Blue Shield? grim lol....
posted by Jinx of the 2nd Law at 9:03 PM on January 31, 2010

Did the doctor explain why the episiotomy? That alone would bother me enough to change doctors, if there was no sign of fetal distress, and the pushing lasted less than 15 minutes.
posted by palliser at 9:21 PM on January 31, 2010 [1 favorite]

IANAMD & especially IANAOBGYN, but it seems to me like the answer to your question lies in knowing what the general protocol is for treatment and care of 4th degree perineal tears during childbirth.

I don't know anything about childbirth protocols, but I've seen enough medicine practiced to know that there seems to be a shockingly huge lack of agreed-upon standards of care. Every condition seems to have three competing treatments with 5 different followup protocols to choose from, and noone seems willing to agree on the one consistent way to do things.

Yes, your friend definitely got more TLC than you did. The question becomes whether her care was above-and-beyond what's considered necessary, or whether you got the short shrift. I'm afraid I don't know enough to help you find that answer.
posted by swngnmonk at 10:26 PM on January 31, 2010 [1 favorite]

I wonder more about whether the two of you have the same insurance. The dietitian, home nurse visits, and extra follow-up appointments sound more like insurance issues than doctor issues. Otherwise, it does sound a little bit like you were treated differently but the reasons for that may have something to do with other than the doctor.
posted by otherwordlyglow at 11:07 PM on January 31, 2010

Aftercare/ follow up care for tears and other injuries not uncommonly sustained during childbirth varies widely. Unfortunately, I think your friend's experience receiving proper care, not pampering, was the more unusual of the two you described.

There are practices that prioritize developing staff expertise in strategies that can help to avoid severe tears and educating the mother-to-be on various scenarios that can occur, and what to expect if they do.

But you have to hunt for them... I think all pregnant women should expect that standard instead of the neglect and chronic problems they can suffer from after a healthy birth... For as many friends as I have who healed/recovered from birth without complications, I have the same amount who have had to cope with longer term after-affects from perhaps avoidable major tears and pelvic floor damage. Anecdotal, but, not a single one of my friends who used a midwifery practice (they take tears and vaginal damage seriously) and birthed at home or at a birthing center, suffered more than very minor tearing.
posted by hellboundforcheddar at 11:31 PM on January 31, 2010

I am not an OB, and certainly cannot comment on standard or substandard care, but just to consider:

1) Depending on the location/strength of the epidural, some women may not really be able to feel when they're "ready" to be pushing.

2) Some risk of tearing is simply related to your perineal anatomy. Some women have very posterior-ending vaginas, leaving very little room between the vagina and the anus/rectum (ie: very little perineum), and others have a lot more. If you don't have any room between the two, more likely you'll get a 4th degree.
posted by gramcracker at 12:26 AM on February 1, 2010 [1 favorite]

Tell me that you at least got some stitches? They didn't stitch me up 'outside' but had to 'inside' because I had an amazing tear. It was my bad anyway, the midwife told me to slow down. All healed perfectly fine without special diets or 'pampering' (I went home as soon as I could), but in hindsight I wouldn't have minded more stitches as it could have sped up the healing process.
posted by dabitch at 1:14 AM on February 1, 2010

Seconding what gramcracker said about the epidural substantially interfering with your ability to know when to push; the fact that you only pushed for 15 minutes would seem to indicate that you were ready. I also agree that care for this and many other medical issues can vary widely; defining "standard" would be difiicult and probably not only vary among practitioners but in different parts of the country. Did you heal well? Are you having any problems related to your laceration? Probably the most important factor in determining how well you did is the skill of the obstetrician at repairing the damage; I do not know what the relative contribution of post-op care to a good outcome is.
posted by TedW at 5:57 AM on February 1, 2010

If you're trying to decide whether to switch practices, it really doesn't matter whether in some objective sense your care was "good enough" and your friend's was "extra TLC," or whether hers was "good enough" and yours was "not enough." What matters is that you are comfortable with and trust your doctor. Feeling like you could have used more information and support post-partum is a fine reason to switch, as is wishing for a smaller practice (though those can be hard to fine, IME).

On the other hand, if you were satisfied with your care at the time and not unhappy with how you healed, maybe you're fine where you are. The kind of situation you're describing seems like the kind of thing where there could be wide variance from practice to practice without anyone necessarily being "wrong."

I don't know what you mean by ready to push, but I have had two epidural-free births with short pushing stages, without ever feeling the urge to push that many women talk about; I knew when I was having contractions, but had to rely on the nurse to tell me when I was fully dilated. Once, I began pushing immediately, and once I took a short break first. Just tossing that out as a bit of anecdata.
posted by not that girl at 7:34 AM on February 1, 2010

I would say that this is really the big difference:

My friend's doctor immediately told her what happened and explained what a fourth degree tear was; I overheard my doctor tell another OB that he had "a four", and he did not volunteer anything about it until I asked what "a four" was.

and probably worth exploring a different doctor next time.

Pieces and parts of both of your stories match what my wife experienced, and I imagine that a lot of the post-partum care is based on how good your (or your friend's) insurance is. Basic communication, however, is free. My wife's experience and your friend's experience match up on this point, and I can't imagine not being given good information about a level four tear by your OB at the time (and for future reference also having it come up when/if you have additional kids).
posted by togdon at 12:18 PM on February 1, 2010

I had a third degree tear with a midwife (CNM) and an epidural (in a hospital, of course). The tearing was directly attributed to the baby's positioning (sunnyside up and twisted to about 1-2 o'clock), but the midwife still apologized EXTENSIVELY for the degree of damage. She was supporting the perineum and massaging throughout the end stage of pushing to try to minimize damage. An OB was called in to help with the stitches as repairs were apparently complicated. My epidural wasn't really a factor as it didn't work at all AUGGGHHHH for the crowning stage and I had to have anesthesia readministered for the repairs to be performed.

I didn't have an episiotomy and it it's my understanding that they do not meet standards of evidence-based care except in situations where speeding up delivery is an emergency (usually vacuum extraction). The midwifery practice I went to doesn't perform them in routine births as there's no evidence they have any benefit. Very anecdotally, all the women I have ever heard of with 4th degree tears did have episiotomies.

The worst thing that happened to me is that I heard someone say 'he really tore a path out of there' right after the birth, which made me afraid that my guts were all over the table. I was quickly reassured and otherwise care was great. They told me it was third degree right away and I had my stitches checked several times before I left the hospital. I believe I had one additonal checkup in the hospital from the on-call midwife because of the tearing. They also scheduled a 1 week appointment with the midwifery practice specifically to check healing. At my six week I was checked again and was specifically told to keep them up to date on any longer term issues with the scar, etc, as further pelvic repair options were available if I had any complaints. They seemed very concerned specifically that my sex life not be impaired, which at six weeks.. HA HA. I am a big advocate of CNM type care as it seems very sensible and evidence based, but at the same time focused on the needs of the individual.
posted by pekala at 4:13 PM on February 1, 2010

For what it's worth, insurance was not an issue. If anything, my insurance coverage is more generous than my friend's. It's sad to hear the suggestion some of you have made that a doctor might make decisions based solely on perceived insurance coverage, without informing the patient.

I received stitches and healed well (since you asked, I'll add that it healed with a little bump, but it does not bother me in any way).

As for my expectation of an urge to push, it was based entirely on my prior childbirth experience. My two labor and delivery experiences were very similar, except that during the first one I had the irresistible urge to push (even with an epidural block). I acknowledge that some women don't feel the urge when they have an epidural, and that may indeed have been the case for me this last time. But I also have read about the positive effects of delayed pushing (waiting for some time after full dilation and effacement until that urge appears).

I agree with those of you who suggest that my primary concerns should be the trust I have in my physician and to seek out the best care I can find. For the future, I'm going to seek out a smaller practice where I can have multiple visits with a single doctor over the course of a pregnancy. This practice was so large that I hadn't even met all of the doctors prior to delivery, even though I tried to see a different one at each pre-natal visit.

Thank you, all.
posted by ellenaim at 6:12 PM on February 1, 2010

Just as a data point, I have a solo practitioner OB-GYN and adore her -- she's a fantastic labor coach and very conservative about interventions, with an attitude more similar to those I hear about good midwives. So small practices do still exist, and you would necessarily have more luck finding a small practice with a cohesive practice philosophy than a large one.
posted by palliser at 5:13 AM on February 2, 2010