Symptoms are often called a gallstone "attack" because they occur suddenly -- often following fatty meals and during the night. According to the NIDDK, symptoms typically include:

  • Steady pain in the upper abdomen that increases rapidly and lasts 30 minutes to several hours
  • Pain in the back between the shoulder blades
  • Pain under the right shoulder
  • Nausea or vomiting
  • Abdominal bloating
  • Recurring intolerance of fatty foods
  • Belching
  • Gas and indigestion

If, in addition, you experience any of the following symptoms, you need to see a doctor immediately:

  • Sweating
  • Chills
  • Low-grade fever
  • Yellowish skin or whites of eyes
  • Clay-colored stools

During an attack, the the stone gets in the way, and the gall bladder "pushes against the blockage of the stone, which causes pain. Then the gall bladder relaxes, and the pain goes away," Bowen says. "After a while, if the gall bladder continues to be inflamed, the patient may get intermittent episodes of abdominal discomfort causing nausea, belching, etc. Then the gall bladder is scarred and inflamed even further. [It] gets worse over time."

Diane Fahy of Sacramento, California, compared her pain to that of childbirth. "I thought that I was dying. It hurts as much as childbirth, but unlike contractions, the pain doesn't go away," she says. "It continues and continues. There was excruciating pain in my stomach region that couldn't be relieved." She says most of her attacks were set off by fatty foods. And though she says it took six weeks to diagnose her condition, her gall bladder was eventually removed.

For Sandie Reverski of Delaware City, Delaware, the pain felt as though "someone was running a red hot poker back and forth through the right side of my abdomen. At first, it just felt like a stomachache or gas. As time wore on, my back ached with shooting pains, and I felt like I was being ripped apart from the inside out." She had her gall bladder removed about five months after her baby was born.

Surgery to remove the gall bladder (cholecystectomy) is the most common treatment for stones; more than 500,000 Americans undergo the procedure each year. (Those who have gallstones but no symptoms usually do not need treatment.)

Most commonly, the surgery is done with a laparoscope, using a procedure that can be performed during pregnancy. The surgeon makes several tiny incisions in the abdomen and inserts surgical instruments and a miniature video camera into the abdomen. Outside of pregnancy and when a laparoscope can't be used, a large incision across the abdomen is necessary. This is called "open surgery," and is required in only about 5% of gall bladder operations.


A History of HELLP Syndrome

HELLP syndrome, which is a unique variant of preeclampsia (toxemia), was named by Louis Weinstein in 1982 after its characteristics: 

H (hemolysis, which is the breaking down of red blood cells), 

EL (elevated liver enzymes) and 

LP (low platelet count).         

It can be fatal to both the mother and the baby. HELLP Syndrome occurs in tandem with preeclampsia, but because HELLP Syndrome's symptoms may happen before preeclampsia's three findings (high blood pressure, protein in the urine, and swelling), they may be misdiagnosed as symptoms of gastritis, disseminated intravascular coagulation (DIC), acute hepatitis, gall bladder disease, and other conditions. As a result, the mother may not get the right treatment, leaving both mother and baby that much more at risk.

Five to seven percent of all pregnant women in the United States develop preeclampsia and between two and 12 percent go on to suffer from HELLP Syndrome. Best estimates are that HELLP Syndrome occurs in one per 150 live births (about one half of one percent), with a maternal mortality rate of 3.50 percent.

     These numbers will vary with attention to the mothers care.  If preeclampsia is diagnosed early and the baby is delivered, HELLP may not develop.  The rate of HELLP and the mortality will then be lower than stated.  Just how often does HELLP Syndrome happen? The exact number is unknown, because doctors may or may not catch it and have a difference of opinion as to what exact lab values constitute when a woman develops HELLP.  If the diagnosis of preeclampsia was delayed or it was managed too conservatively, a woman's likelihood of developing HELLP Syndrome is even higher. 

    According to statistics obtained from a central database maintained by the National Center for Health Statistics for the year 2000, there were 4,065,674 live births in the United States.  If one half of one percent of these births were to result in HELLP Syndrome, that means approximately twenty thousand women per year will develop HELLP. 

 Studies vary on their estimates of HELLP occurring again. One study (Sibai, et al, 1995) places the risk at 5%. Another one (Sullivan, et al, 1994) finds it to be between 19% and 27%.

 Both studies agree that HELLP mothers have increased risk (40-50%) for pregnancy-related complications in general with any future pregnancies. Some of these complications might include (but aren't limited to) gestational diabetes, high maternal blood pressure (that doesn't lead to HELLP Syndrome), and premature birth of the baby.

The good news is, in the majority of cases, the babies born to mothers with HELLP Syndrome do remarkably well. In a survey of babies born to mothers with HELLP Syndrome at WVU Children's Hospital, the most important thing is the size of the baby.

If the baby weighs over 1000 grams (approx. 2 lbs.), at birth, his or her survival rate and length of hospital stay is similar to non-HELLP babies of comparable sizes, and there doesn't seem to be many long-term adverse outcome. West Virginia University is studying long-term medical and developmental outcome of these babies.

 If the baby weighs than 1000 grams at delivery, the news is not so good. Several studies have suggested longer hospital stays and more chance of needing ventilator care. Data from WVU Children's Hospital suggests that these small babies have a decreased chance of survival compared to other babies of the same size. Unfortunately, right now doctors can't predict the scope of the medical problems that these small babies encounter. Research into the effects of HELLP Syndrome on the newborn is ongoing at WVU and elsewhere.

How likely is the baby to die from HELLP Syndrome? Dr. Baha Sibai M.D., a perinatologist from the University of Tennessee in Memphis, notes that the perinatal mortality from HELLP Syndrome, 'ranges from 7.7 to 60 percent.' Most of these deaths are attributed to abruption of the placenta (placenta prematurely separating), intrauterine asphyxia (fetus not getting enough oxygen), and extreme prematurity.

Symptoms of HELLP Syndrome

The physical symptoms of HELLP Syndrome may seem at first like other pregnancy-induced high blood pressure conditions (such as preeclampsia).

Signs for a pregnant woman to look for include one or all of the following:



*epigastric (stomach) tenderness and right upper quadrant pain (from liver distention)

These symptoms may or may not be present:

*severe headache          *bleeding                

*visual disturbances      *swelling  

*high bloodpressure     *protein in the urine

The most common reasons for the mother to die are liver rupture or stroke, (cerebral edema or cerebral hemorrhage). These can be prevented if it's caught in time! If you or someone you know has any of these symptoms, please see a doctor immediately!

The only definitive treatment for women with HELLP Syndrome is delivery, regardless of how far along in the pregnancy the woman is.


The Perineal Debate

Antibiotic prophylaxis improved outcomes of repair for obstetric lacerations, which were more likely to occur after prior episiotomies.

Perineal laceration is a relatively frequent consequence of vaginal delivery, particularly when episiotomy — one of the more common surgical procedures in the U.S. — has been performed. Such trauma is associated with risk for infection and, during subsequent deliveries, recurrent perineal tearing. Can we better manage and prevent obstetric lacerations?

To address the issue of postpartum perineal wound infection, Dr. Duggal’s group conducted a prospective, randomized trial to evaluate prophylactic second-generation cephalosporins or clindamycin compared with placebo, all given intravenously at the time of repair of third-degree (extending into the capsule and muscle of the anal sphincter) or fourth-degree (extending into the rectal mucosa) perineal tears. At 2 weeks postpartum, 107 patients were evaluated for perineal wound complications (defined by abscess, purulent discharge, or breakdown of the repair site). Of 49 patients who received antibiotics, 8% developed perineal wound complications compared with 24% of 58 women who received placebo (P=0.037).

In an observational study, Dr. Alperin and colleagues evaluated retrospectively whether episiotomy performed at first vaginal delivery increased risk for spontaneous perineal tearing during the next vaginal delivery. Among 6052 women with consecutive deliveries at the same hospital, the rate of episiotomy at first deliveries was 48%. At second deliveries, third- or fourth-degree perineal laceration occurred in 5% of women who had undergone prior episiotomies and in 2% of women without prior episiotomies (P<0.001).

Comment: Antibiotic use is not the standard of care for women who sustain third- or fourth-degree obstetric lacerations. Should it be? Dr. Duggal and colleagues noted that the perineal wound complication rate in their study was much higher than they would have predicted. Also, such wound complications are not definitively associated with subsequent incontinence, fistulas, or sexual dysfunction (although this seems plausible). Last, the findings in this patient population might not be generally applicable. Nevertheless, an editorialist — despite reservations about liberal use of antibiotics — suggests that we should consider adopting this strategy for appropriate patients with third- and fourth-degree tears.

The editorialist also cites a Practice Bulletin (Obstet Gynecol 2006; 107:956) in which the American College of Obstetricians and Gynecologists concluded that routine episiotomy has no identified benefits. The findings of Dr. Alperin’s group only reinforce the pivotal query: "Why have clinicians hesitated to discontinue routine use of an intervention that has no proven benefit and that has significant complications?" Overall, the evidence-based medicine arising from these two studies might help us to alter our long-held beliefs and change our approach to managing later stages of labor.

Ann J. Davis, MD

Published in Journal Watch Women's Health July 24, 2008


Duggal N et al. Antibiotic prophylaxis for prevention of postpartum perineal wound complications: A randomized controlled trial. Obstet Gynecol 2008 Jun; 111:1268.


My behaviour during my 12 years as a nurse in L&D and postpartum was not sterling. We were trained not to use the word pain and we were trained to act cool and dismissive in the face of a woman’s suffering.  I was not the only female kapo* in the business by any means.  It wasn’t just nurses.  I am not defending my internalized misogyny and I am not defending the other Nurse Ratchet clones out there but I do want you to know that nurses contend with misogyny too.  I’m including an article about a piece published in the Edmonton Journal and I hope you will publish it on your website.  This isn’t rare; it was contempt and hatred we dealt with on a daily basis and is why many women leave nursing. These medical students, and many others just like them, will treat women patients just like they treat nurses.  It is unlikely the hatred will be so in-your-face as this but subtle is still perceptible, right?


*Kapo – A term used during WWII to refer to those, usually of Jewish descent, guilty of complicit behaviour with the Nazis to feed false hope/control/degrade/report on members of their own people in exchange for a more privileged position, usually in terms of perceived acceptance by the SS, privacy and access to better goods and services, within the Jewish population of Nazi concentration camps.  Many were eventually murdered and replaced as time went on by their Nazi masters.


Strangeways, Here We Come: University of Alberta medical students have something important to say about nurses--especially their breasts!

July 8, 2005 -- The Edmonton Journal published a fair piece by Jodie Sinnema on May 19 about the recent controversy surrounding the lyrics of a "Nurses' Song" performed by University of Alberta medical students at their annual "Medshow." It seems that nursing professors, the university provost, and even the medical school dean found something objectionable about the song's assertions that nurses were "whores" and "bitches" whose "incompetence" threatened to "make our patients die." But at least the medical students felt nurses were qualified to "fill up my coffeepot" and "give good head," and the refrain urged nurses to "show me those boobs." The song seems to reflect virulent misogyny, ignorance of nursing, and professional insecurity, a perfect storm of dysfunction that persists in many clinical settings, harming patients and contributing to nursing burnout and the global nursing shortage. To the extent the song and the medical students' apparent non-apology are indicators of their career trajectory, it's bad news for patients and colleagues. But the students' conduct does suggest that the business outlook may be good for local malpractice and personal injury lawyers--and possibly even those who work in the criminal justice system!

The Edmonton Journal piece is headlined "Medical students' show offends nurses." It reports that the university's dean of nursing, Genevieve Gray, has asked the university provost to conduct an investigation of the "raunchy, sexist lyrics" in the song. The "Medshow" is an annual three-day fundraiser for the medical school's graduating class held at a local theater in late March. The piece notes that it is "considered infamous by some for its perennial risqué material, but is liked by others who see the black humour as a way to release stress while studying to become doctors." The "Nurses' Song" was reportedly sung to the tune of one of the songs from "Jesus Christ Superstar."
Most of the Journal piece consists of quotes from distressed university officials. Dean Gray found a written "apology" from the medical students unacceptable, noting that it was "pretty weak": "They made no attempt to really come and make time to see me or talk to me about this and what they really said was, 'Well, look, if you don't like it, tell your students not to actually come to the show next year.'" Gray noted that the song was "a very serious depiction of nursing and women." She did not think the school should be "sending medical graduates into the workforce who have these attitudes," and she minced no words about her preferred outcome: "Quite frankly, I don't think those students ought to be on board with us."

University provost Carl Amrhein is quoted as saying that the lyrics were "way beyond the line of being acceptable," and that the dean of medicine was "waiting to receive a clear, written plan from the students on how they will be accountable for their actions next year." Tom Marrie, the dean of medicine, did ask the students to offer an apology to the dean of nursing. He is also quoted as saying that the show "doesn't reflect well on us as a faculty of medicine" and that he "wasn't proud" of the students, though "they are a really good bunch of kids in almost everything else they do." The article does not include any comment from the medical students responsible for the song, or any other medical students. Such comments might have shed light on how the song developed, and how widely shared its sentiments are. We would be especially interested in the views of female medical students.

Both the provost and the medical dean appear to be talking about how to avoid similar debacles in the future, including cancelling the show. But the article contains no information about any plans to educate or discipline the students responsible for this year's show or future medical students. Indeed, the Provost and a medical school public relations official recently told the Center that since the Medshow was created by a student group, any disciplinary action would also be directed at the group. Of course, it is difficult to imagine that a group of transient medical students would care much about any action directed at some student group, as opposed to, say, something that would appear on their permanent records, or that might otherwise come to the attention of future employers or colleagues.

But enough of this. Let's get to the University of Alberta medical students' song lyrics, which the Center has obtained. They are reproduced below in full:

Nurses' Song

Nurses we are overjoyed
To meet you face to face
You've been getting quite a name
All around the place
Being bitches
Screwing up meds
Now we understand you're whores
But at least you give good head

So you are a nurse
You're a wonderful nurse
Prove to me that you're the best
Let me look upon your breasts
If that you will do
Then my hats off to you
Come on show me those boobs

Nurses you just won't believe
The shit you've stirred up here
Your incompetence is all
So very fucking clear
Oh telling Doctors
What they ought to try
When in fact your management
Would make our patients die

So you are a nurse
You're a competent nurse
Show me all that you were taught
Go fill up my coffeepot
And then go berserk
When I ask you to work
Come on show me those boobs

Nurses like to bitch and moan
They often go on strike
They somehow think their job is more
Than just the village bike
Oh... if you really
Want to get respect
Come right here
And tell me why
The vitals aren't done yet

So you are a nurse
Yes a superstar nurse
Prove that you're as good as me
Do this Neurosurgery
Or maybe instead
You should just change the bed
Come on show me those boobs

DISCLAIMER: We couldn't have
done it without you nurses.

Bracing, isn't it? This seems like male insecurity in its crack form--the braying, self-pitying ignorance, the profound, menacing misogyny, the ego run amok. We doubt any physician or medical student who was secure in his abilities would feel such an insatiable need to tear into nurses' character and professional skills. Consider the lyrics' constant, imperious demand for the breast, like that of a pampered but colicky baby boy.

And consider this scenario. A young man has spent his life being treated as an academic golden boy, constantly told that he is the best, smartest and most valuable person around. Imagine the reaction when his family, friends and complete strangers learn that he will attend medical school. At medical school, however, he is introduced to a rigidly hierarchical, arguably sadomasochistic system in which he is the lowest player--a system in which he is overwhelmed with difficult academic work and tossed into demanding clinical settings in which he knows little of any use. In those settings, he not only confronts esteemed physicians to whom he must defer--however abusive some may be--but also a variety of nurses, some of whom may have been practicing for decades. Some of these nurses, stretched to the breaking point trying to save lives in a short-staffed system that shows them little regard, may not have gotten the memo about how this medical student is the most wonderful thing anyone who knows him has ever seen. Instead, they may simply see someone who doesn't have a clue what he's doing in a hospital, but who is firmly convinced of his own mastery and superiority, and of the ignorance and inferiority of all nurses. Not exactly a recipe for success, is it? Of course, this kind of interaction is hardly unique to the health care setting. History offers many examples of groups who feel disempowered directing aggression toward groups they perceive to be inferior and even weaker.

We understand that these song lyrics probably do not reflect the views of most medical students. We assume most would not be part of something this hateful. But we are not surprised that this occurred, especially given the venom some medical students have sent our way. Nor are we surprised at the apparently inadequate reaction of the university and the medical school, nor at the medical students' apparent failure to apologize.

Let's look at some of the specific song lyrics. The name calling and sex talk reflect the naughty nurse stereotype, but a very aggressive version. This level of verbal abuse, even under the cover of a "joke," would certainly make a rational person wonder if physical abuse was far away. The care-related stereotyping is also interesting. Note the resentment of nurses who would have the effrontery to tell "Doctors what they ought to try." However, those who wrote this were apparently not doctors. What the lyric may really mean is that the medical students can't stand the idea that even nurses--those ignorant "village bikes"--seem to think they know more about patient care. Of course, one of nurses' most important duties is to do just what bothers these students most: to weigh in on physician care plans and advocate for better ones if needed. Countless lives are saved through nurses' detection of medication errors alone. But the song is obsessed with the fact that some nurses actually think they're experts; thus, the mocking references to "superstar nurse" and so on. The suggestion that "your management would make our patients die" is a curious one for a medical student to make to a nurse. In most cases, veteran nurses know far more about the proper management for patients than medical students, who tend to be assigned the most menial tasks in most rotations. But in order to put nurses in their place, it's important to rub their faces in the stereotypes of just those apparently menial tasks. Thus, the song instructs nurses to--at least when they find time in between breast exposures--fill up the coffeepot and change the bed.

The song also reflects impatience with nurses' purported failure to do their more technical work properly. These nurses screw up the meds and don't get the vitals done on time. No doubt this has occurred, especially given the short-staffing that is now endemic. But we loved the implication that nurses are doing their work for the benefit of medical students, rather than their own practice for their patients. Indeed, the students can't quite seem to believe that the nurses don't hop to it "when I ask you to work," "going berserk," bitching and moaning and even going on strike, as if they had any legitimate complaints, or anything to do besides cater to the demands of medical students. In fact, nurses do not report to medical students or to physicians. Nurses are autonomous professionals who work in collaboration with physicians and others on the health care team. We won't bother asking the students to appreciate the superhuman patient loads many nurses confront today, loads that have contributed to the shortage and that will hamper the students' own practice.

The medical students reserve what they no doubt view as the coup de grace for last: "Prove that you're as good as me / Do this Neurosurgery." Of course, the medical students can't do neurosurgery either, and neither can the vast majority of physicians. But none of them can do nursing unless they've graduated from a multi-year college-level nursing program. And it's hard to believe that anyone responsible for this maladroit song would be able to do that.

In fact, the attitudes in the song reflect serious threats to nursing practice and to patient wellbeing, and they may violate medical ethics as well. Research shows that poor relations with physicians, including physician disruptive behavior, are one of the leading causes of nursing burnout, and a factor in the nursing shortage that threatens patients in Canada and worldwide. Moreover, physicians who do not respect or listen to nurses pose an even more direct danger to their patients. This is because as noted above, a critical part of nurses' jobs is to alert the health care team to changes in patient conditions or problems with care plans, and to advocate for better care when needed. Have any doubts that ignoring nurses' patient advocacy can kill people? Five words: Jayant Patel and Jonah Odim. For those not familiar with these heartbreaking cases, these were surgeons whose incompetence allegedly contributed to many deaths (in Australia and Winnipeg, respectively), despite the increasingly dire warnings of nurses. In addition, one of nurses' critical roles in hospitals is informal teaching of young physicians. Physicians who do not listen do not learn, and they make mistakes, sometimes very serious ones. Perhaps in recognition of this, provisions of the Canadian Medical Association's Code of Ethics require physicians to learn from health colleagues and to treat them with respect. Practicing physicians should be concerned that their new colleagues have the views expressed in this song. Nurses, of course, may reasonably be concerned about their emotional and even physical wellbeing.

The Edmonton Journal article's description of Medshow as a way for the students to relieve the stress of medical school is a telling one. Unfortunately, the medical students just might be confronting a bit of stress after they graduate as well. If this is how they react to it--with what would almost certainly be considered sexual harassment in an employment setting--their patients and colleagues will suffer, to say the least.

We salute Dean Gray for her courage.

Our executive director's initial letter to the University of Alberta is below.

Dear Provost Amrhein and Medical School Dean Marrie:

On behalf of the Center for Nursing Advocacy, an international nonprofit whose board and membership includes many Canadians, I am writing to express my grave concern at the reported conduct of the University medical students responsible for the "Nurses' Song" at this year's "Medshow." We understand that the song included assertions that nurses were "whores" and "bitches" whose "incompetence" threatened to "make our patients die," though the medical students did at least feel that nurses were qualified to "fill up my coffeepot," to "give good head," and to "show me those boobs."

We urge you to take the corrective measures below to protect nurses and the public from the serious threats to nursing practice and patient wellbeing posed by the attitudes reflected in this song. Physicians who treat nurses as ignorant sex objects with no business speaking up about care plans are likely to provide dangerously poor care, as recent reports in the world media have made clear. Moreover, such physicians are a major cause of nursing burnout, which is itself a key factor in the nursing shortage that threatens lives worldwide. We note that such conduct also appears to violate Canadian medical ethics.

First, we urge you to ask that all of those responsible for the song (all writers and performers) be directed to issue unqualified, written public apologies--unique, individual apologies made in individual capacities--to all nurses. If any person fails to do so promptly, we believe that his permanent academic record, and any future release of that record, should include a letter about this incident by Dean of Nursing Genevieve Gray.

In addition, we urge you to require any of those responsible who are still students or employees of the University to attend in-depth counseling in gender relations/sexual harassment and the basic nature of nursing, including the autonomy and professional qualifications of nurses, and their obligation to engage in patient advocacy. This training should occur under the direction of Dean Gray or her successor Dr. Beth Horsburgh. We suggest that it include shadowing hospital nurses for at least 24 total hours.

Finally, we urge you to establish and maintain mandatory training programs to educate all future medical students in these areas, again in close consultation with Deans Gray and/or Horsburgh. Such training might focus on the specific roles nurses play in patient outcomes, the effects on their practice of recent resource limitations, including nurse short-staffing, and the fact that nurses are autonomous professionals with their own scope of practice who do not report to physicians. It might also include a version of the shadowing element noted above. It is critical that every pernicious view reflected in this song be addressed. We understand the medical students currently receive some training in collaborating with other health professionals. This training does not appear to have been sufficient.

We doubt that any disciplinary action directed solely at a student group will have meaning to transient medical students or physicians, or real impact on the underlying attitudes that resulted in this incident. Likewise, actions related to Medshow will do little to address the real problem. Only public, individual discipline and significant educational changes will prevent such unfounded but toxic attitudes from threatening the public in the future.

I attach below a detailed analysis of the "Nurses' Song" which appears on the Center for Nursing Advocacy's web site. We would be happy to discuss further how important it is to our future health that the attitudes reflected in this song be confronted and eliminated. Thank you.

Sandy Summers, RN, MSN, MPH
Executive Director


Feminism & Psychology, Vol. 8, No. 3, 285-302 (1998)
DOI: 10.1177/0959353598083004
© 1998 SAGE Publications

The Impact of Medical and Sexual Politics on Women's Health

Linda Gannon

Department of Psychology, Southern Illinois University, Carbondale, Illinois 62901 USA

Hidden agendas impacting women's health care are explored in the context of the intersecting effects of capitalism as the ideology of medical politics, and patriarchy as the ideology of sexual politics. The mutually enhancing forces of medical and sexual politics collide in scientific reductionism - biological determinism for her'. Women are valued according to their ability and willingness to bear and raise children; illnesses and remedies for those women who are unwilling or unable to conform are invented. Thus, the `raging hormones' of puberty and pregnancy tend to be viewed as good and healthy while those associated with the menstrual cycle and menopause are portrayed as unhealthy and in need of alteration. The medical and psychological professions maintain and enhance their power, prestige and profits and serve the patriarchy by labeling events in the normal life course of women as illnesses, reinforcing social misogyny with medical misogyny, emphasizing reproduction rather than health in prioritizing empirical and clinical research, and attributing women's emotions and behaviors to hormonal fluctuations rather than economic, political and social causes.


Medical Rape and the Medicalization of Childbirth

Posted by: Jill in Assholes, Medicine, Reproductive Rights, Sexual Assault

On medical rape: This is one of those inter-blogular stories that I inevitably end up misrepresenting because I haven’t followed most of it, but from what I can tell, it’s ugly.

Here’s the general run-down: A radical feminist blogger named Debs put up a post about undergoing a gynecological procedure with a new doctor. She consented to the procedure initially, but it became increasingly painful and she repeatedly asked her doctor to stop. She ended up screaming and in tears, and the doctor still wouldn’t quit. She posted about it on her blog, and said that it felt like “medical rape.” The post is now down, but from what I can tell from reading excerpts, her point wasn’t the terminology — it was the need to discuss how the medical establishment treats women, especially in the context of gynecological care, and how doctors imposing their will on you in that setting is a deep and painful violation. Well, Dr. John Crippen, who writes for the NHS weblog, came across her post and promptly decided it was his place to emphasize that she was not “medically raped.” Nevermind that the terminology really wasn’t the point; he takes offense at women (not just this blogger) comparing what he calls “bad obstetric experiences” to rape. And so he rips Debs to shreds — claiming that she doesn’t understand the female anatomy, that she’s hysterical (shocker), that she’s psychologically ill, that she’s obsessed. He wonders how she managed to get pregnant in the first place (because, ya know, she hates having things in her vagina, and an invasive medical procedure is just like sex). He calls her and another feminist activist “coffee-shop feminists” and “disgrace[s] to feminism.”

Apparently the “childbirth can feel like rape” line of argument is occasionally used by home-birth activists — that women want control over their own birthing processes, and that this may be especially true for women who have experienced sexual assault. This is a big issue in both the U.S. and the U.K., as the medical establishment attempts to limit and sometimes even outlaw home births. So the “Medical procedures can be traumatic when women remove their consent or don’t consent in the first place” line isn’t just striking a nerve about the particular procedure that the blogger had; it’s getting to a bigger policy question of who should be in charge of women’s bodies.

In another post, Crippen quotes one woman who he thinks is out of line:

I was a victim of rape at 14years old, a virgin. I had a hospital delivery and specifically said no epidural for baby no.1. I had an epidural (against my wishes) during transition. When being on my back and numb from the waist down it gave me flashbacks to the rape.
They call it body memory. It was horrendous, so bad that my partner left me a month after my son was born. He couldn’t handle my PTSD.

I had no anger towards the doctor, only myself. Of course I was angry towards the perpetrator who raped me as a teenager but I just didn’t expect it to come flooding back to me when giving birth. I had no control over this. It just happened. Completely out of the blue.

I believe that many survivors of abuse and rape are reminded of it by feeling out of control. This is what labour can do. For me it was being numbed from the waist down and flat on my back (this is how as a child I disassociated myself from the experience, by numbing and removing myself from my body).”

He then quotes another doctor:

“I am repeatedly struck by the high level of self-reported childhood sexual abuse and rape in homebirth advocates. I put in the words “rape survivor homebirth” into Google and found 15 separate instance of phrases like “since I am a survivor of rape, I wanted a homebirth” or “as a survivor of rape I knew that the way my OB treated me what just like rape”. There definitely seems to be a notable association of these phenomena: a history of previous sexual assault, a bad childbirth experience, and PTSD. Here’s my question:

Why is there such a ferocious insistence that it was the childbirth experience that caused the PTSD and not the previous sexual assault?

There seems to be a large group of women who report being sexually assaulted in some way, and they are adamant in their insistence that the assault did not have serious psychological repercussions. They were fine until they had a baby. The psychological issues became apparent then and, therefore, it must have been the doctor’s fault.

What is going on here? No matter what the doctor did, it could not begin to compare to the original assault. I am almost forcibly struck by the level of anger toward the doctors. Yet there is a curious lack of emotion toward the original assailant. The level of anger directed toward the doctor seems startlingly high, and the level of anger toward the assailant seems curiously low.

It feels like there is a psychological need to blame the doctor INSTEAD of the original attacker. Why should that be?”

It’s not too difficult to see the strawman arguments being made here.

But it gets worse. Crippen seems skeptical when women report almost any kind of rape. He writes:

Change the scenario a little. The room becomes a student bedsitter in a University Hall of Residence. John and Mary voluntarily enter the room together late at night after a party. They have both been drinking. The next morning, Mary leaves the room in tears and tells a friend that John made her have sex against her will. The friend calls the police. John is arrested. John agrees that they had sex, but says it was consensual. How do you establish who is telling the truth?

It is not possible.

He does seem to be under the impression that rape is a matter of opinion and interpretation. No wonder he can’t be bothered to listen to Debs about her experience, or trust women to make their own decisions.

There’s a long tradition of the medical establishment assuming that it knows better than women, and of doctors attempting to fully occupy areas that had traditionally been the realm of women (midwifery, etc). Now, I happen to like doctors and modern medicine quite a bit; if I ever were to have a baby, I would want it in a hospital and jacked up on as many painkillers as you could give me. But that’s because, for me — with my background, my beliefs and my experiences — that’s how I feel safest. And if there’s ever a time you want to feel safe, it’s when you’re giving birth. Women with different experiences and beliefs feel safer in different situations — and there’s a large contingent of women who apparently feel safest when they’re at home, with someone they trust who has helped them through their entire pregnancies, and in a situation where they feel fully in control.

It’s a tough balance, because doctors obviously have an obligation to keep their patients as safe and as healthy as possible, and I do believe that most doctors genuinely think they’re doing the right thing when they push hospital childbirth. For a lot of women — and especially women with high-risk pregnancies or histories of medical problems — it probably is the right thing. But other interests come into play in a corporate system of medicine, and the patients’ best interests are unfortunately not at the forefront (for more reading, check out Paul Starr’s The Social Transformation of American Medicine). There are systematic and institutionalized incentives for the American Medical Association to promote hospital births and to keep childbirth squarely in the realm of a self-regulating medical profession. And there is a long history of a predominantly male medical establishment ignoring women’s concerns and knowledge about their own bodies.

I don’t think it’s bad to have a healthy skepticism towards things like natural remedies, midwifery, or whatever else, just like I don’t think it’s a bad thing to have a healthy skepticism of a modernized medical system that is often more concerned with its economic bottom line than actual health care. I’m personally skeptical of the “get in touch with your body to heal all ills” line, the best example of which I can think of was Inga Muscio in her book Cunt, wherein she argued that women can track their fertility by following the waxing and waning of the moon (she also self-performed an abortion with the help of herbs and massage). I liked Muscio’s book, but in my personal opinion, staring at the moon to track your menstruation is a waste of time, and Muscio’s woman-meets-nature schtick was a little loopy.

But that’s because I like my hormonal birth control, and because my own body isn’t particularly good at telling me when there’s something wrong (or perhaps because I rarely bother to listen to it — too many other things to do). To each her own. What works for Inga works for Inga, and more power to her.

I don’t have a problem with debating the relative merits of homebirths. I’m all for women having control over their own reproductive lives, whether that means giving birth at home or in the hospital, with a midwife or a doula or a doctor (or some combination of the three), “naturally” or with drugs. I think women have a right to be fully informed of the relative risks and benefits; I think doctors, doulas and midwives have an obligation to deal with women on a case-by-case basis, and to make decisions based on the individual patient’s condition and not ideology. I’ve heard a lot of women complain that their doctors didn’t listen to them, or made their birthing experience more traumatic; I’ve also heard women complain that their birthing assistants, doulas or midwives were determined to do the birth “naturally,” and also didn’t listen when the woman changed her mind or wanted some sort of middle ground. I don’t have a problem discussing the various issues and choices that pregnant women face; I don’t have a problem with people who feel strongly on one side or the other advocating for their position (especially if that advocacy is being done out of a genuine commitment to women’s health).

But I do have a problem with invalidating and actively ignoring women’s experiences, and with telling them what they are and are not allowed to consider personally violating. Doctors are certainly not the only ones who do this, but it does seem particularly condescending and dangerous when it’s coming from people of relative power and influence, whose opinions are largely considered bulletproof. If Dr. Crippen, the UK medical establishment and the AMA think that women shouldn’t feel violated by traumatic childbirth experiences, fine — but that doesn’t change the reality that women are violated by traumatic childbirth experiences, and women who have experienced both rape and powerlessness during childbirth are saying that, to them, the experiences felt similar. It’s condescending asshattery, and it’s the reason that a lot of women are distrustful of doctors (especially male doctors) in the first place — we feel like we are not listened to about our own bodies.

And now Dr. Crippen, who runs a large and widely-read blog, has made his point on the back of a woman who underwent an incredibly traumatizing event and was still strong enough to write about it — until her words were spread ’round the internet, and she was propped up as an example of the hysterical harpie who’s willing to claim that her doctor raped her just because an exam hurt a little bit.

Women do deserve to have choice in childbirth, just like people deserve the choice to opt out of most medical procedures, so long as they are fully informed about their options and the risks and benefits. Women deserve the basic respect to be heard when they say “No, stop” — even to a doctor (assuming, of course, that the procedure is one that can be safely halted at that point). And women deserve better from their doctors than what Dr. Crippen seems to believe.


No Need to Sweep

Whether or not women underwent membrane sweeping, overall rates of induction, postmaturity, and prelabor membrane rupture were similar.

Membrane sweeping to move the membranes off the lower pole of the uterus, routine in obstetric care, is performed to decrease the likelihood of labor induction or postmature delivery (JW Apr 11 2006). However, concerns about premature rupture of membranes and infection have led to debate about the merits of this practice. Investigators randomized 300 women to undergo membrane sweeping at 38 weeks’ gestation (with subsequent weekly sweeping) or no membrane sweeping. Participants had singleton pregnancies with cephalic presentation and anticipated vaginal delivery; women were excluded if they had indications for labor induction or cesarean delivery or had contraindications for membrane sweeping. Participants and researchers were blinded to group allocation with the understanding that this would not constitute full blinding, as patients probably would become aware of their assigned interventions.

Intention-to-treat analysis showed no significant between-group difference in occurrence of prelabor rupture of membranes (7% of women without sweeping vs. 12% of women with sweeping; P=0.19). Among women with cervical dilation ≥1 cm, however, 9% in the sweep group had prelabor membrane rupture versus no patients in the no-sweep group (P<0.05). Other obstetric outcomes, including cesarean delivery, spontaneous labor, induction, or postmaturity, occurred at similar rates in the two groups.

Comment: These data indicate neither great value nor great risk from membrane sweeping starting at 38 weeks. However, subgroup analysis showed that women with cervical dilation ≥1 cm during late pregnancy could be at risk for prelabor membrane rupture in association with sweeping, suggesting that such women might be more sensitive to the procedure. This study excluded women with multiple gestations or those with various obstetric indications. Despite these limitations, the data suggest that there is no need to sweep.

Sandra Ann Carson, MD

Published in Journal Watch Women's Health July 10, 2008