Friction: The Cowgirl Obstetrician, High Volume, Low Patience, Zero Protocols

Dr. Chen was fast. Her patients labored efficiently, delivered vaginally at rates that made our metrics look good, and generally loved her.

The Cowgirl Obstetrician, High Volume, Low Patience, Zero Protocols

Every hospital safety reform meets resistance—not from villains but from professionals protecting what they value most. This series explores how that resistance, when examined honestly, exposes the cultural, ethical, and structural barriers that stand between evidence and safer care.

Dr. Chen delivered 380 babies last year. She knew this because she told me the number, frequently, usually in the context of explaining why our new oxytocin protocol was going to “destroy patient throughput” and “create a cesarean epidemic.”

She had a point, or at least the shadow of one. Dr. Chen was fast. Her patients labored efficiently, delivered vaginally at rates that made our metrics look good, and generally loved her. She was in-house for her deliveries, didn’t dump complicated cases on colleagues, and had that rare combination of surgical skill and clinical confidence that made her the attending everyone wanted on a busy night.

She also ran oxytocin like she was trying to set land-speed records.

Start at 4 milliunits per minute. Increase by 4 milliunits every fifteen minutes until “something happens.” Her patients contracted beautifully—seven, eight, nine times every ten minutes. They dilated fast. They delivered fast. And their babies went to the NICU at rates that, when I finally showed her the data, made her actually pause mid-sentence.

Our new protocol was everything she hated: Start at 2 milliunits per minute. Increase by 2 milliunits every thirty minutes. Maximum rate of 20 milliunits for augmentation, 30 for induction. And here was the part that made her threaten to admit patients to the competing hospital across town: nurses were empowered to reduce or stop oxytocin for tachystole, defined strictly as more than five contractions in ten minutes, or any Category II tracing with recurrent decelerations, without calling the physician first.

“You’re turning my nurses into obstetricians,” she said during the protocol roll-out meeting. “And you’re going to double my cesarean rate when they panic and stop oxytocin every time a baby hiccups.”

I understood her fear. High-volume obstetricians live and die by efficiency. Dr. Chen had morning clinic, afternoon OR, and deliveries scattered throughout. Her practice model required labor to move at a predictable pace. The new protocol felt like someone had installed speed bumps on a highway—sure, maybe safer, but at what cost to actually getting anywhere?

And there was a deeper concern she articulated better than most: “These babies aren’t actually sick when they’re born. Look at my outcomes. I’m not sending brain-injured babies to the NICU. I’m delivering healthy babies efficiently. You’re about to make me intervene more, cut more, and for what?”

So I showed her what “for what” meant. Her NICU admission rate: 18.7%. Department average: 11.2%. Her babies needing positive pressure ventilation: 14.3%. Department average: 8.1%. They weren’t seizing, weren’t getting cooled, but they were being born stunned, requiring resuscitation, spending days in observation that could have been prevented.

She stared at the data for a long time. Then: “But my cesarean rate is better than average.”

She was right. Her cesarean rate was 24.1% in a department averaging 32.3%. She was achieving vaginal deliveries by pushing through marginal strips, trusting tachystole to be temporary, and, usually, being right that babies would tolerate it.

The protocol went live despite her objections. She complied with maximum dosing limits but fought every other element. She told nurses to “use clinical judgment” about stopping oxytocin, which they correctly interpreted as “don’t stop it unless the baby is dying.” She scheduled patients at the competing hospital for three weeks until their medical director called me to ask what the hell was happening.

Then something unexpected occurred. Six months post-implementation, our NICU admission rate dropped from 11.2% to 8.1%. Our cesarean rate dropped from 27.3% to 24.8%.

Wait. The cesarean rate went down?

Here’s what we’d missed: aggressive oxytocin was creating tachystole that led to concerning tracings that led to crash cesareans for “non-reassuring fetal status.” The slower, controlled approach gave babies time to recover between contractions. Category II tracings improved with simple interventions—reducing oxytocin, repositioning, oxygen—before they became Category III emergencies requiring operative delivery.

Dr. Chen’s outcomes improved most dramatically. Her NICU admissions dropped to 7.2%. Her cesarean rate dropped to 21.4%. She was still the highest-volume obstetrician in the department, still fast, still efficient—just measurably safer.

At our nine-month review, she said: “The nurses are actually pretty good at this.”

It wasn’t quite an apology. But it was something better: provisional respect for a system that turned out to improve efficiency and outcomes simultaneously.

Was she entirely wrong to resist? No. Her concerns about nurse autonomy and intervention cascades were legitimate. But she was wrong that speed and safety were opposing values. Sometimes the fastest way through labor is the one that lets the baby rest between contractions.