Birth Models That Work

10. Teamwork: An Obstetrician, a Midwife, and a Doula in Brazil

271 Chapter 10 Teamwork An Obstetrician, a Midwife, and a Doula in Brazil Ricardo Herbert Jones INTRODUCTION My name is Ricardo Herbert Jones, and I am an obstetrician. I live in a city in the extreme south of Brazil named Porto Alegre, in the state of Rio Grande do Sul, and I graduated from the Federal University of Rio Grande do Sul in 1985. I work in private practice; that is, women pay out-of-pocket for my services. My cesarean section rates are low, and I work on a sliding scale. All my clients are middle class; they are the women most likely to have a cesarean in the care of any other doctor in my region. This chapter describes my individual paradigm shift and the options that this shift has created for the women in my practice. This “birth model that works” is a replicable model of simplicity: a doctor, a midwife, and a doula attending births in a setting of the woman’s choice. AWAKENING My initiation into the humanization of childbirth occurred in 1986 when an event in the emergency room of the hospital where I worked as a resident directed my attention (and afterward my whole life) toward the critical questioning of medical assistance at birth. During a weekend shift as a first-year resident, I was called to the emergency room to attend a patient in heavy labor who had walked in from the street. When I opened the door, I saw no one on the table, and I started to scold the nurse for calling me unnecessarily . But she said, “Doctor, please open the door further,” and then I saw the woman squatting on the floor in the corner of the room. My immediate reaction was fury. I yelled at her, “You clumsy woman, what are you doing? You cannot give birth on the floor! Can’t you see how dirty this is? Get up on the table!” But she gave me no heed; she looked not at me, but right 272 r. h. jones through me, as if I were made of glass. I lifted her skirt and saw the baby’s head emerging. I had no time even to put on gloves, and for the first time in my life, I felt the odd sensation of a wet, bloody body in my bare hands. I handed the baby to the nurse as quickly as possible, all the while still yelling at the mother, who was further dirtying the floor with her placenta. The orderlies got the mother onto the stretcher and whisked her away. The baby, of course, was sent to the neonatal intensive care unit (NICU) because it was “contaminated.” Afterward, the nurse said to me, “Doctor, thank goodness you were there! What would have happened without you?” I spent most of the rest of the day feeling annoyed and angry at that woman, and asking myself, “Yes, what would have happened without me?” And then, hours later, the terrible answer hit me: Without me, the birth would have been just fine; in fact, it would have been much better! I had done everything I possibly could to ruin that birth and then had congratulated myself for helping. I felt devastated. My attitude during this “emergency” was driven by the philosophy and ideology transmitted to me during my medical education, which had not taught me to take into account the human dimension of assistance. This birth showed me how much I was separated from a medicine centered on the individual and from what (I later discovered) was the scientific evidence showing the importance of respect for the patient’s subjectivity. The shame I felt ended up obliging me to study and practice alternative forms of birth assistance. I began changing the position of my patients at the moment of birth, encouraging them to adopt vertical positions like that woman in the ER, because it became clear that this position was the most effective physiologically and the best for attending to women’s needs. I began slowly to get rid of “standard obstetrical procedures,” which later, thanks to the work of American anthropologist Robbie Davis-Floyd (1987, 1992), I came to perceive as rituals, unsupported by scientific evidence. In the years that followed, I abandoned enemas, shaving, artificial rupture of the membranes to speed labor, the electronic fetal monitor, routine IVs, the separation of the woman from her partner and family, episiotomies, fasting, and other rigid, standardized forms...