Every day at a high volume Labor and Delivery (L&D) unit is different, but also the same. There are postpartum rounds, inductions to start, babies to deliver, C-sections to perform, triages to see, discharge orders to place. Usually, you know why a patient is there before you see them — their name, Gs and Ps, and gestational age has popped up on the board. You can look in their chart, see what the triage nurse wrote, or see the little white hills of each contraction on the uterine tocometer from the resident workroom. But sometimes a patient name will pop up with no gestational age, and as a “G1P0.” and when we click on their chart, it is empty. Sometimes it’s because they are visiting the area, and had an acute obstetric issue. Sometimes it’s someone who has had no prenatal care.
In many of these situations, I think back to college, when I joined a biomechanics research lab. My professor and I would sit in his office, discussing different terminology that was necessary for me to learn before I began work. I knew most of them — elasticity, force, pressure — but the word “compliance” was new to me. Compliance is how “bendy” something is, my professor explained to me. I went on to med school, where in physiology, we learned that compliance is equal to the volume divided by the pressure. The more pressure, the lower the compliance is, or put more simply, the more pressure you put on an object, the less likely it is to bend.
The reason why a patient may choose (or not choose) to come to prenatal care is always different. COVID-19 fears may keep someone from the doctor, or they may say they didn’t know they were pregnant. Frequently, we have patients who utilize recreational drugs, and thought they would be judged, arrested, or forced to give up the pregnancy. Compliance has a different, yet similar meaning now that I am a doctor. The more pressure we put on patients to show up for appointments, to take their dozens of expensive medications, and to follow the strict diet and exercise plans we give them, the less likely they are to actually show up to care or put in work. We want our patients to be healthy, but the sheer volume of tasks we are asking them to do decreases compliance. Studies have even shown that compliance is influenced by dosing frequency and amount of total medications, sometimes called “pill burden.” For every additional medication or appointment that a patient is prescribed or recommended, the less likely they are to take them or show up, and subsequently earn the label “non-compliant.” As profession, many of us have moved away from this label, using instead “non-adherent with treatment.” But it essentially means the same thing.
If someone who has used drugs recreationally throughout their pregnancy without prenatal care presents to us in labor, they have a lot to catch up on, and so do we. About 40 weeks, in fact. So when Ms. A presents to L&D, I order a slew of bloodwork, a prenatal panel, and a rapid HIV test. I collect a gonorrhea and chlamydia swab, a group B strep swab, and perform a urine drug screen. I ask the nurse to take a few blood sugars to make sure she’s not diabetic, and return with the ultrasound where I try to guess the gestational age of the baby by doing some fetal biometry. She reveals to me that she has been using heroin throughout the pregnancy, and that’s why she never came to care. She was scared. I reassure her that she did the right thing coming to the hospital, and because of that, she likely saved her baby’s life. We can talk about the heroin later. I don’t think about her being “non-compliant” for the last 9 to 10 months. I think about how I can help her and the baby now.
In fact, I am the one who has to be compliant in these sorts of situations. This is outside of the realm of my normal L&D care. I am used to all sorts of information about someone’s pregnancy. I don’t have access to the fancy perinatology ultrasounds, lab work that tells me if I am allowed to utilize internal monitors such as a fetal scalp electrode and an intrauterine pressure catheter, or need to start penicillin to protect the baby against group B strep infection. I don’t know if this baby is even term, so we often place a neonatology consult to discuss different signs and symptoms at birth that would lead a baby being admitted to the NICU after delivery. I often have to counsel on the fly, based on what is in front of me. Surprise twins, stillborn babies, and unexpected breech presentations are all things I have encountered along the road.
Ms. A delivers a few hours later, and the baby is measuring term. Everyone is healthy. Once she is down on postpartum, I go talk to her about starting buprenorphine, or medication assisted treatment. She’s interested, and we titrate her up to a dose where she is stable. We start talking about discharge. I want to wrap this story up with a nice little ending. She then followed up with me in the outpatient setting, stopped using recreational drugs, raised a healthy baby, and we all lived happily ever after. But that isn’t what happened. A few days later, she wants to leave, and we tell her that this will be against medical advice, which she signs the paperwork to do, leaving the baby behind in the NICU. I rack my brains for a way to help her make the intrinsic change to take control of her health, but come up short. I have to monitor the pressure I push her with. Before she leaves, I encourage her to reach out to us often, so that we can help her do what is going to be necessary for her to be healthy both physically and mentally. I don’t have the fix to everything, which frustrates me. I have no control over the financial, social, or transportation barriers that limit this patient to getting the health care she needs.
There are times when people have experiences that don’t fit neatly into a storyline, a narrative of what happened. But still, I have learned a lesson from this patient — in addition to being flexible in the care I provide on L&D, maybe I also need to be more flexible in my expectations. So whatever kind of doctor I turn out to be, whether it’s a full spectrum ob/gyn, a minimally invasive gynecologic surgeon, or a maternal-fetal medicine specialist, I hope that I, too, can be compliant — compliant enough to adapt to the individual needs of each of my patients.
How have you practiced compliance recently? Share your feats of flexibility in the comments.
Kathleen Ackert is a resident physician in obstetrics & gynecology at St. Luke’s University Health Network. She is a graduate of the Philadelphia College of Osteopathic Medicine and Siena College. When she is not in the hospital, she can be found in coffee shops writing narrative medicine pieces or eating in restaurants that offer low-lit dining experiences. She enjoys exploring the latest fitness craze, watering her house plants, and instagramming pictures of fancy lattes at @caffeinewithkathleen. She is a 2021—2022 Doximity Op-Med Fellow.
All names and identifying information have been modified to protect patient privacy.
Illustration by Jennifer Bogartz