L&D: Between the Case Logs

by Dr Ala Nazir, MD - GEIGS DEJ Lead

Labour and delivery has a momentum you can sense even before you step inside.

By the time we arrived for pre-rounds, the ward was already full: about fifteen women on examination tables and another twenty in the waiting room. Their families clustered just beyond the entrance, talking among themselves, settling in for the long hours ahead. Most travel from distant areas to tertiary care centres, carrying exhaustion, patience, and a kind of unspoken trust.

Inside, the work had already begun. Instruments being arranged. Oxytocin drawn. IV lines started. Contractions monitored, vitals charted, fetal heart rates recorded in real time.

The Rhythm of Urgency

In public hospitals across South Asia, patient load often exceeds capacity. Over time, urgency becomes the default. What begins as efficiency slowly changes tone. Attention stays locked on the next step: monitor the tracing, manage the delivery, move on to the next bed.

In that rhythm, obstetric violence rarely looks extreme. It appears in rushed explanations, quiet omission of consent, and in how easily a patient's discomfort is dismissed as normal.

Hierarchy, Annotated

Some memories stay long after the rotation ends. I once saw a male colleague imitate a senior who'd raise their voice at women in labour for making noise. No guideline encourages that. He never did it in other departments, which made it even more striking. It felt as though the ward itself had taught him what being a doctor looked like in that setting.

Disrespect becomes routine because hierarchy rewards imitation, not reflection. What we excuse in labour often mirrors what we normalise everywhere else, not just in healthcare. 

Fatigue is Not an Alibi

Somewhere between urgency and exhaustion, language lost its gentleness, as though fatigue could absolve indifference. In high volume wards, pelvic assessments were sometimes performed with words that failed to match the sensitivity of the procedure. Physical coercion surfaced at times as well.

Few on-call residents, known for such language during our night duties, continued as usual until one shift our unit head joined to observe. He stepped in immediately and later addressed the entire unit on ethics and respectful conduct. It was one of the very few moments when silence broke itself.

When Advocacy is a Costume

Integrity alone can only go so far when the system resists reflection. Even in departments largely led by women, authority often mirrors what generations of training have normalised. It shows how ingrained misogyny can persist despite shifts in representation. When I questioned the tone or procedure, I was called too idealistic. When a male colleague repeated the same concern, it became a valid discussion point.

Some who speak confidently about allyship in formal spaces often echo language women have long used, yet fall back on casual sexism in informal ones. It underscores how performative allyship thrives in environments where reflection is praised, but behaviour remains unchanged. 

In Plain Sight

Systemic strain also revealed itself in subtle ways. During overstretched shifts, when the ward overflowed and the team ran thin, untrained auxiliary staff were occasionally allowed to conduct normal deliveries. It was framed as hands-on experience for future shortages. These moments tended to involve women from marginalised communities or those who spoke non-dominant languages. Consent was seldom discussed. System pressure blurred clinical boundaries, sharpening disparities for those least equipped to question them.

Once we start noticing these patterns, others unravel quickly. It becomes clear who receives detailed explanations and who is expected to comply without dialogue. 

Varied Realities

Routine practices carried the same culture. During my external rotations, episiotomies were not performed indiscriminately, but local anaesthetic before repair was often deemed unnecessary for minor tears. The ease with which pain relief was dismissed showed how discomfort in childbirth had been trivialised.

The atmosphere of the ward was also shaped by the realities women carried with them. Some sought documentation to support reports of intimate partner violence or other forms of domestic abuse. For them, the crowded and relentless ward was one of the few places where they felt safe enough to ask for help.

Others carried a different kind of apprehension rooted in prior encounters with the health system. Some questioned the urgency of caesarean sections through the lens of past inequities. Whereas, a few requested caesarean births simply to avoid labour pain, shaped by limited access to reliable analgesia.

The Labour of Unlearning

Addressing obstetric violence requires more than new guidelines. It demands a shift in culture: training that treats communication and consent as clinical skills, and supervision that values empathy as much as efficiency.

Because the deeper problem may not be what we've failed to unlearn but what we've absorbed; patterns so old they no longer feel like a choice.