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  • Dr Sean Holland

My blog....sharing the philosophy of an obstetrician

Let me start by admitting first and foremost that this foray into the world of social media is very much an experimental one and by no means intended to have the sophisticated flare of modern blogs. What I do hope to achieve is an opportunity to communicate from time to time my thoughts on developments, issues, controversies and items of interest as they pertain to the field of women's health, and in particular the practice of obstetrics and gynaecology. There will also be the occasional moment of humour (I hope) but very much the focus will be upon exploring topics of conversation that I feel are of interest both to myself and anyone that might have a passing interest in my particular field of medicine. So, without further ado, I welcome you to my blog and hope that you find its offerings worth your time to read.


First, let's start with a brief exploration of what I would consider to be some of the driving philosophies behind the practice of obstetrics. By no means is this a comprehensive outline, but I do feel it is a good place to start as there is no denying a growing tension between misconceptions of what an obstetrician does and the reality of their practice. This is particularly problematic given the explosion in online commentators, some with qualifications and some without, who are actively undermining the role of the obstetrician and the trust of women in the modern healthcare system. In my view, as well-intentioned as these authors may (or may not) be, the fear that they can create in women only undermines good outcomes, at least as far as I have observed the phenomenon. So what is it then that I think are some of the philosophical features of an good obstetrician?


Evidence based practice

This is a loaded phrase as "evidence" is only as good as the studies that underpin it and, regardless of the quality of any study, genuine differences will always exist in the interpretation of evidence. That said, I do believe that all good obstetricians strive to advise their patients in accordance with the best evidence with the aim of ensuring the best outcome for the patient and her unborn child. Note that I use the word advise. This is intentional and is at the heart of good evidence based practice. It requires the obstetrician, where time allows, to have an honest discussion with the woman as regards the limitations of any evidence underpinning their advice and to canvass all reasonable options of care. Rarely are decisions black and white and at all times it must be respected that it is the woman's choice as to what is done, acknowledging that this can pose a challenge when an obstetrician finds themselves strongly at odds with that decision. Ultimately of course, the patient is reliant upon the obstetrician to provide them with the benefit of their knowledge and expertise. The trap for the obstetrician is to go from strongly advising to dictating a course of action. For the good obstetrician, it should be possible to detail the options that are available in a given scenario, the evidence that supports one option over another and, ultimately, reach an accord with the patient so that, at all times, they feel involved and, as far as nature ever allows, in control of their own care.


Management of risk

Obstetricians are often accused of being risk averse with the suggestion being made that fear of poor outcomes, including medico-legal outcomes, drives them towards recommending courses of action that are not necessarily in a woman's best interests. This is a most unfortunate characterisation of how the majority of obstetricians approach maternity care. A more accurate characterisation of good obstetric care is the management of risk. The distinction is perhaps subtle but nonetheless important. Poor obstetric practice is risk averse obstetric practice, often with a dictatorial type approach to patient care. Life is full of risks, and, when it comes to the birth of a child, risks can and do arise. Thankfully, with the benefit of knowledge, experience and attention to detail, risks that may arise in respect of any particular pregnancy can usually be managed proactively so as to reduce the likelihood of a poor outcome. This is not the same, however, as the avoidance of all risks. Rather, the good obstetrician seeks to identify risk and employ strategies that mitigate those risks to the benefit of the woman and her child while respecting the philosophical underpinnings of evidence based practice that I outlined above. The skill of the good obstetrician lies in recognising all of the good options available in a particular scenario and choosing, along with the patient, the one that best achieves the desired outcome.


Ultimately, obstetric care is a partnership between the woman and her treating clinician. For most women the involvement of an obstetrician should be seen to be a positive experience though this is not to say that obstetric led care is the only good model of care. Midwifery care models abound and, particulary in the public sector, are excellent options for a lot of women, especially when the midwives involved have a collegiate relationship with their obstetric colleagues. The choice of care provider is, for some women, a challenging one. My advice in this regard is to ask around and consider the type of support that you want in your pregnancy. Ask your general practitioner and speak to your friends regarding their experiences. And don't be shy to change clinicians if you don't feel comfortable with the person you initially engage with at the start of your pregnancy. After-all, 9 months is a long time and you want to feel confident and comfortable with the person you choose to guide you on your journey to parenthood.

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