Private Practice: It hurts

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It hurts

January 21, 2010 -- In a minor plotline in tonight's Private Practice (ABC), nurse midwife Dell Parker actually shows some autonomy and knowledge in coaching an expectant single mother who is determined to stick to her "natural" birth plan, despite spending three days in labor. The mother ultimately succeeds in her plan and the show displays real sympathy for her. But the plotline also spends time mocking the holistic birth model that she wants and that real midwives follow. And the show gives no real indication of why that birth model might make sense--why, for example, a mother might want to avoid drugs, C-sections, or physicians--offering only the mother's vague statements that she wants to "experience" the birth and to give her baby the "best chance that he can have." The episode also presents Dell less as an expert in natural birth than as someone trying to cope with the mother's odd ideas. And at one point, Dell brings in superstar OB/GYN Addison Montgomery for a consult about the mother's status and options that a real nurse midwife would need no help with, partly undermining the sense that Dell is an autonomous professional. Still, Dell does show psychosocial skill in helping the patient through labor, and he does finally deliver the baby solo with no problems. The plotline ends with the mother looking ecstatic. So we give the show credit for a mildly positive, though deeply flawed, portrayal of a nurse midwife. This episode, "Best Laid Plans," was written by Patti Carr & Lara Olsen.

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We first meet the very pregnant Lynn McDonald at the clinic at which most of the show's characters practice. Pediatrician Cooper tells Dell that a patient is squatting up and down in the hall. Dell responds that this is his patient, who is "committed to natural childbirth." Dell explains that she's been in labor for two days, and her water finally broke last night. From the hallway, Lynn complains that what she's doing is not working, and says that she wants something spicy, like a chimichanga, to speed up her labor. Dell, making an obvious effort to remain patient, says he'll order her something. As Cooper struggles to get past Lynn, who is now partly blocking the doorway, she begins loudly asking the baby to "come out!" Dell suggests they go check out her progress.

The world-class OB/GYN Addison is handling the serious psychosocial issues surrounding the unplanned pregnancy of Maya, the 15-year-old daughter of Addison's friends (and fellow physicians) Naomi and Sam. Both parents are overwhelmed, especially Naomi, who at first runs away, then persistently demands that Addison do an abortion. Over the next day or so, father Sam and Maya herself eventually seem to agree that this is best, though it is very painful for them. After this apparent decision has been reached, Addison prepares to perform the abortion. She is in the midst of getting the teenager ready when, after Addison's careful, non-pushy queries about what Maya really wants, Maya finally decides to keep the baby.

Meanwhile, in caring for Lynn, Dell seeks help from Addison. At this point, Addison is very frustrated in trying to deal with Naomi, and she tells Dell, half-joking, that she hopes his patient needs surgery, because "that, I can do." Next we see Lynn in bed, somewhere between moaning and screaming, as Dell drapes a blue surgical towel across her belly and Addison looks at her chart.

Dell: Lynn's in a lot of pain. She shows no signs of fetal distress, but her labor isn't progressing.

Lynn: I thought after my water broke--

Addison: I can give you Oxytocin to speed up the labor and something for the pain.

Lynn: My birth plan says no drugs.

Dell (handing the plan to Addison): Lynn has a birth plan.

Addison (looking through the plan): Many pages, in...small font.

Lynn: I want to experience my child's birth. I did my homework. I understand that there are procedures that may become necessary, but except in the case of extreme emergency, I want to be given the opportunity to accept or refuse any procedure, and as long as the baby's OK, I want to have a natural childbirth. So, to get the labor going, I'm willing to try walking, or Castor Oil, or nipple stimulation--

Addison (who has been preparing for and doing an ultrasound): Well, it's a little more involved, if you fail to progress in your labor, you might want to consider a C-section.

Lynn: No, no--

Dell (gently): Lynn, look, I know this can be disappointing--

Lynn: I've been in screaming pain for hours, I'm not worried about being disappointed. I married a great guy. I wanted to have kids. He wasn't ready...ever. Then, when the divorce was final, I decided to let loose. You know, having a baby alone, being pregnant by some guy I met at the tequila bar is not every girl's dream. But this is what's happening. I'm having this baby. So is it too much to ask that one thing goes according to plan?

Neither Addison nor Dell has a response.

Later, we see Lynn crouching at the bed and screaming. Dell reassures her that she's doing great, and says they can change the music--they have not listened to the chirping birds yet!

Lynn: I just wanted this to be beautiful. All my books said that the way a child comes into the world shapes them for life. I just want to give him the best chance that he can have, you know? I don't want to shape him to be some angry, or scared... [As the pain returns.] Dammit! I want him to have a good life.

Dell: OK. No matter how today works out, even if you decide you can't take the pain, you're still going to have plenty of opportunities to shape your child's life. So...can I give you something to help with the pain?

Lynn: No, just give me the chirping birds.

Some time later, we see Lynn lying in bed, with Dell sitting at the foot of her bed.

Dell: I know you're tired, but on this next contraction, I'm really gonna need you to push.

Lynn: I can't.

Dell: Yes, you can.

Lynn: It hurts!

Dell: C'mon, Lynn, this is what you wanted, OK? You can do it.

Lynn: I was wrong, OK? My birth plan is stupid, it's not working, I've been awake for three days, I feel like I've been run over by a train. Can you just turn off the hippie-ass flute music and give me some drugs now?

Dell: I can't give you drugs--

Lynn (grabbing him): I want drugs, OK? You said I could change my mind!

Dell: OK, I know it hurts, but we're almost there, and that's why I can't give you any drugs. You had a plan, and you stuck to it. Not everyone can do that. But you did. And I am here with you, and we are going to get through this. I promise. Now...push.

She does push, and things seem to be progressing. But before long, Naomi bursts in, dragging her daughter Maya, who has just refused the abortion, with Addison trailing behind. Naomi wants to show Maya what she'll go through if she delivers the child. Dell asks them to leave, but without much force, since he's busy taking care of Lynn, who is about to deliver.

Naomi (to Maya): Is that what you want? I am not gonna let you ruin your life, little girl, you have no idea, you have no idea what you want, look at that. Look at that!

But it's bad timing on Naomi's part, because just then Dell delivers the apparently healthy baby. Dell immediately hands the newborn to the exhausted Lynn, who is beaming.

Maya (with wonder): But look at that!

Maya seems set on delivering her baby.

On the whole, the plotline presents Dell as a professional with a reasonable amount of autonomy and good psychosocial skills, getting Lynn through her difficult labor and offering her options as appropriate. He has the skills to assess her progress, and seems to have some authority to give her drugs. He helps her to stick with her birth plan, even as she falters at the end, and she ultimately gets what she really wants--as the final scene makes clear. Dell delivers her baby by himself (Addison is present only because she is trailing Naomi and Maya) and the show makes no suggestion that Dell is unqualified to do that. He even hands the baby to her mother for some skin-to-skin contact right away! Unlike some of the show's early episodes, there is no overt mockery of midwifery. And over the course of the plotline, the natural childbirth process that Dell oversees at least comes to seem less bizarre.

On the other hand, parts of the plotline, especially early on, do paint natural birth as a bit of a freak show, and this is never fully refuted, despite the sympathy the plotline shows for the mother. We can understand why Lynn would make this choice. But viewers might come away ascribing the choice more to Lynn's desperation as someone who has divorced over the issue of children, who is facing single motherhood not really by choice, and who seems to be alone. She seems to have no one but Dell to help her. So we see why Lynn embraces this New Age stuff, but would anyone who had more support? It's possible to see the plotline as part of Hollywood's tendency to mock progressive health trends that many physicians have not fully embraced, such as recognition of the importance of breastfeeding support and, of course, midwifery itself. In fairness, Private Practice is far more open to alternative health care than its sister show Grey's Anatomy, which presents surgery as a religion that supercedes all other health strategies.

The episode's overall depiction of midwifery is weak, despite the positive elements noted above. The scene in which Addison examines Lynn and explains the options for inducing labor may suggest subtly that Dell is operating under Addison's direction, and that he needs her to do these tasks, which is not the case. And Dell's almost eye-rolling early reactions to the birth plan send a terrible message about what nurse midwives know and do. No one would understand from this episode that there are potential health benefits in choosing a natural birth and rejecting the illness-oriented approach that has become the norm in the United States. Other developed nations achieve better outcomes at a lower cost using a less interventionist, midwife-directed birth model, as explained in Abby Epstein's 2008 film The Business of Being Born. Minimizing the use of powerful drugs is not just a goal of desperate freaks, but a way to reduce the risk of certain complications. And avoiding C-sections helps patients avoid the risk of serious surgical complications. Nurse-midwives offer the benefits of a holistic approach, while still bringing to bear advanced health expertise, with access to the full range of emergency care if needed. It's worth nothing that the episode's writers were careful to have the patient note that she would accept such care in an "extreme emergency," as if it was more important to explain that the patient could get access to high-tech interventions than to explain why it might make sense to try to avoid them.

In any case, it's hard to imagine Dell explaining any of this, not just because he's not that assertive or experienced, but also because it would be an implicit critique of Addison's own hyper-interventionist approach, and the show's need to stress that she is a surgical god. The show's presentation of Dell's midwifery has ranged from outright mockery to indications that it's kinda helpful. But there has never been a suggestion that he is actually pursuing a path that is difficult to harmonize with the practice models of Addison and fertility specialist Naomi, both of whom are glorified for their cutting-edge, technology-driven interventions. Ironically, the measure of Dell's clinical worth on Private Practice has often been the extent to which he can impress these two physicians by competently performing tasks that the show sees as being among the most basic in their vast repertoire, like low-risk births and pap smears. And while that remains true, no serious portrayal of nurse-midwifery is possible.

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Shonda Rhimes, Lauren Schmidt, Mark Tinker
Executive Producers, Private Practice
Raleigh Studios
5300 Melrose Avenue
East Office Building, 4th Fl.
Hollywood, CA 90038-5111

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