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January 1,2012. Well, its a new Year! It began with a home visit this afternoon on a new client referred by Mary Lou O'Brien. Alison's second pregnancy was persistent frank breech at 38 1/2 weeks. Her 1st delivery was a beautiful home birth with Mary Lou. As always required, Alison and Dave, her husband, had the right mental "stuff" and no physical problems. We discussed her option of external version after more natural methods had been unsuccessful. However, the cost of going to the hospital for this family was prohibitive so they accepted the very small risk and great benefit of trying to flip the baby at home in bed. Without medication but with warm olive oil, nurturing surroundings and a portable ultrasound available, not to mention a very cooperative baby, the version took less than 30 seconds. An easy forward roll put the baby's head down to the delight of mom, dad & little brother Ocean. We were all overjoyed for them and proud to be able to offer choice, informed consent and alternatives such as external version and breech delivery options. Thanks Mary Lou. Be sure to let us know what happens next. A peaceful 2012 to all.

Blog Talk Radio with Gena Kirby

Last Monday I had the privilege of being interviewed by Internet Radio personality, Gena Kirby. We met in person last month at the premiere of "More Business of Being Born" in Santa Monica. Gena, who resides in Texas, asked if I would come on her weekly program to discuss the reality of breech birthing in America. We had a great 90 minute chat on this subject and, of course, many others and took a couple of questions from listeners. You can find the full podcast at: http://www.blogtalkradio.com/progressive-parenting/2011/12/20/breech-birth-a-reality-a-conversation-with-dr-fischbein
Listening will not be time wasted and comments here or on Gena's site would be appreciated. Merry Christmas to all. Dr. F

We can all learn something from Ibu Robin

Inspired! One cannot spend time with midwife Robin Lim and not come away with a sense of peace and inspiration. For over 20 years Robin has cared for women at her clinics in Bali, Indonesia. Providing health and maternity services to all women regardless of economic status in a country in desperate need. For her tireless efforts she was awarded the CNN Hero of the Year award this past week.

http://www.cnn.com/video/?/video/bestoftv/2011/12/11/heroes-hero-of-the-year.cnn#/video/bestoftv/2011/12/11/heroes-hero-of-the-year.cnn

I was fortunate enough to have a few minutes with her last evening at a gathering in Montecito, CA. What wonderful, and sometimes tragic, stories she has to tell. So much love and nurturing affection in the room full of people eager for such sanity in the world of birthing. In the midst of all the deserved attention and accolades that Robin is receiving I read an article written by Stacia Guzzo titled, "The Paradoxical Perception of Midwifery in American Culture". The contrast it presents is startling and disturbing and speaks for itself. Please take a moment to read.


http://feminismandreligion.com/2011/12/13/1722/

Thank you Robin and Wil and Mary Jackson and all my colleagues and friends who, by example, bring peace, common sense and respect for the individual back to birth. Dr F

Breech Birth, a Reality

I was watching the brilliant movie "Inception" for the umpteenth time and saw a parallel for what those of us who believe that breech birth is just a variation of normal are up against. Like a virus, an idea, once implanted, is very hard to eradicate. Whether true or false, if this idea takes hold it changes the participant and the playing field and, thus, the world we live in.

Up until the early 90's delivering selective vaginal breech babies was taught in residency programs and practiced by obstetricians in the real world. When I trained there were studies supporting this idea including the pivotal work of Martin Gimovsky, MD in the early '80s.

Obstet Gynecol. 1980 Dec ;56 (6):687-91 7443110 Cit:22 Neonatal performance of the selected term vaginal breech delivery.
[My paper] M L Gimovsky, R H Petrie, W D Todd
Several authorities have recommended cesarean section for all intrapartum breech presentations. The present study documents that judiciously selected fetuses at term in breech presentation may be safely delivered vaginally by a selective management protocol that requires cesarean section when mandated criteria are not met. The outcome and performance of 6 years of vaginal breech deliveries were evaluated. Those in the control groups were delivered by spontaneous vertex vaginal and elective repeat cesarean section procedures. Morbidity was not different in the protocol breech vaginal delivery group and in the controls. Mortality was found only in the nonprotocol-managed breech vaginal delivery group, which also had a morbidity 5 times greater than that of controls. Approximately half the term breech presentations that are properly selected and managed may be safely delivered vaginally, thereby avoiding a significant number of cesarean sections and subsequent inherent risks.

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1021563/?page=1

As residents we were eager to learn and excited for the opportunity to practice this skilled art and at Cedars-Sinai Medical Center in Los Angeles selective vaginal breech deliveries were the norm.

But in the 1990's the idea began to grow that maybe delivering breeches vaginally was risky. This thought culminated with the publication of the "Term Breech Trial" by Mary Hannah, MD in 2000.


Lancet. 2000 Oct 21;356(9239):1375-83.
Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group.
Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR.
SourceDepartment of Obstetrics and Gynaecology, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada. mary.hannah@utoronto.ca

Abstract
BACKGROUND: For 3-4% of pregnancies, the fetus will be in the breech presentation at term. For most of these women, the approach to delivery is controversial. We did a randomised trial to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breech-presentation pregnancies.

METHODS: At 121 centres in 26 countries, 2088 women with a singleton fetus in a frank or complete breech presentation were randomly assigned planned caesarean section or planned vaginal birth. Women having a vaginal breech delivery had an experienced clinician at the birth. Mothers and infants were followed-up to 6 weeks post partum. The primary outcomes were perinatal mortality, neonatal mortality, or serious neonatal morbidity; and maternal mortality or serious maternal morbidity. Analysis was by intention to treat.

FINDINGS: Data were received for 2083 women. Of the 1041 women assigned planned caesarean section, 941 (90.4%) were delivered by caesarean section. Of the 1042 women assigned planned vaginal birth, 591 (56.7%) delivered vaginally. Perinatal mortality, neonatal mortality, or serious neonatal morbidity was significantly lower for the planned caesarean section group than for the planned vaginal birth group (17 of 1039 [1.6%] vs 52 of 1039 [5.0%]; relative risk 0.33 [95% CI 0.19-0.56]; p<0.0001). There were no differences between groups in terms of maternal mortality or serious maternal morbidity (41 of 1041 [3.9%] vs 33 of 1042 [3.2%]; 1.24 [0.79-1.95]; p=0.35).

INTERPRETATION: Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(00)02840-3/abstract

Finally, those that were against teaching or performing term vaginal breech deliveries and did not want to investigate further had their evidence. Nevermind, that within 2 years after the paper was published there were a slew of articles and papers critical of and refuting Dr. Hannah's research and conclusions.

Well summarized here: http://www.breechbaby.info/termbreechtrial.pdf

Too late! The seeds of the IDEA that breech vaginal birth is dangerous had been planted. And this idea was rooted in welcoming fertile ground as it justified the easier, less time consuming, more lucrative and thought to be less liability ridden c/section as standard of care for frank or complete breech at term. An idea, regardless of its validity, is made all the more powerful when it fits the current trend in the medicalization of birth and the fear based model that restricts individual choice. It infects the population and the profession to the core and has led to a stoppage of even teaching the knowledge and technique of vaginal breech delivery to future practitioners. Our halls of higher learning have no shame in denying future mothers this option due to a simple idea based in fear.

Fortunately, some forces are beginning to wake up from the nightmare and realize that "inception" has taken place. Maybe they have a "totem" of their own or just maybe common sense is an antedote to the viral model of a long festering idea. The Royal College of Ob/Gyn in England and The Society of Ob/Gyn of Canada have issued statements in the last couple of years in support of retraining new doctors in the methods of vaginal breech delivery. Even the American College of Ob/Gyn has a clinical guideline paper in support of selective vaginal breech delivery as a reasonable choice for the skilled practitioner and the informed woman.

Those of you who know of my work are aware that I have supported true informed consent and birth choices including the option of vaginal breech delivery. I have been ostracized in my former local community for many of my views and this has led me to choose the path of supporting women's choices in the home and birthing center setting where I do believe that common sense, individuality and evidenced based medical practice can freely occur. With the help of social networking, celebrity advocates and a growing number of devoted maternal care givers an old idea, that normal birth is not a disease and that selected vaginal breech is just a variation of normal, is being resown. I believe we can awaken my colleagues and the American populace from "limbo" even if it is one person at a time. A good idea need not be a virus. It may awaken us, as in Christopher Nolan's incredible movie, to the sanity and reality of the beauty of home and family and natural birth.

It is with these comforting feelings that I and my birthing Instincts team of Beth and Jaclyn and doula Robin announce the successful home breech birth on 12/5/11 of an 8 pound baby boy to glowing parents Hallie & Michael. Planning a home birth with the great midwives of South Coast Midwifery they found themselves in the not uncommon dilemma of persitent frank breech at term. Having no success with the usual measures to turn the baby they looked for options. Sadly, they could not find a single facility in Orange county willing to allow them a natural birth. C/section only! Lorri from South Coast knew of my practice and my philosphy and referred them for a consult only last week. We spoke several times for several hours and really connected. They had the right stuff and met all the criteria for a selective breech delivery. The very next day labor began and in less than 7 hours Hallie gave birth at home in their bed with grandma present. Congratulations to them on this blessed event and for their conviction.

I do believe that term breech presentation should be treated as just a variation of normal. And if selection criteria are met then informed consent and choice belong to the woman and her loved ones. While a hospital that respects autonomy would be an ideal place for these women to give birth that is not the current reality we live in.
Choices are so extremely limited. That is just one of the most compelling reasons why another birthing option is so needed in America. Under the current medico-legal and economic climate I do not forsee hospitals and physicians currently in practice changing from the "breech is dangerous" idea. The dream of the Sanctuary Birth & Family Wellness Center and I and a few of my colleagues, too, is to build our own maternity facility where individuality and common sense and respect for birthing are, once again, the norm. Dr. F

My response to another rant by Dr. Tuteur

In the November 7th, 2011 online edition of “Time Ideas” internet blogger Amy Tuteur attacks Ricki Lake and Abby Epstein’s sequel to the popular “Business of Being Born” and continues her rant against home birth and the midwives who support this option. Had Dr. Tuteur actually viewed the 4 part DVD, “More Business of Being Born”, she would find that the film was not an advertisement for home birthing but rather a documentary that presented evidenced based medicine and real life experiences in hopes of educating the viewers on their options for birthing in America. In her zeal to critique anything that has to do with the movement she argues, disingenuously, four major points.
As to point #1:
As a board certified and practicing obstetrician who has worked with both CNMs (certified nurse midwives) and LMs (licensed midwives, also called certified professional midwives CPMs), my experience is that they are both consummate professionals in their area of expertise. Licensed midwives in California are licensed by the Medical Board of California, the same agency that licenses physicians. This consumer protection agency sees fit to certify these professionals to care for low risk pregnant women. In my extensive experience spanning 30 years of collaboration with them in California I have direct knowledge of their work. They have extensive didactic education with accredited institutions and are trained in the care of normal birth through the mentoring and supervision process. The model of care they provide is based on prevention and nurturing and the trust that birthing a baby is a normal bodily function.
Dr. Tuteur believes that having a university degree and extensive in-hospital training is required to care for normal pregnant women. I would state without reservation that midwives do normal birth better than most obstetricians who are trained in surgical birth and rarely experience a normal labor from start to finish. By labeling licensed midwives second class, Dr. Tuteur demonstrates for us her pejorative style that is her reputation when confronted with facts and issue she disdains. In other developed nations the model of care of collaboration between midwife and doctor is the norm. Whether to choose a CNM or an LM is a matter of preference for the informed woman.

As to point #2:
Dr. Tuteur says “All the existing scientific studies…show that American planned home has triple the risk of neonatal death”. This is a stance she consistently takes on her blog site and when quoted in articles and is patently false. The use of hyperbole is also a trademark of Dr. Tuteur and strains further her credibility on this subject. Does any reader really believe that “All” the studies of any topic are on one side only? The American College of Obstetrics & Gynecology (ACOG), of which I am a member and Dr. Tuteur is not, has consistently taken a position against home birthing and the basis for their recent opinion relies almost entirely on a meta-analysis of his selection of 11 out of more than 50 studies encompassing several decades by Wax, et al. The criticisms of his conclusions are numerous in the literature and even include some by the authors he has cited. There is certainly no consensus. Dr. Tuteur seems to assume that her statistics end the discussion. Even Wax, himself, admits that if you accept his data as indisputable the overall increased risk of a fetal death at homebirth is 1 in 1,133. While every loss is significant the evaluation of this risk is a personal decision. No pregnancy is without risk and hospital birthing is no exception. Parents must be allowed to weigh the much greater risk of intervention and surgical birth and the multitude of complications that can arise from them in context with their own life experiences. True informed consent and respect for patient autonomy is not a virtue that Dr. Tuteur seems to value.

As to point #3:
Dr. Tuteur cites a Netherlands study in the 2010 British Medical Journal which had the surprising finding of a higher fetal death rate in low risk women cared for by midwives than for high risk women cared for by obstetricians. The analysis of scientific articles is not a simple task, often comparing apples to oranges and that is the case here. Recall that Dr. Tuteur states that the Netherlands does not allow licensure of CPMs therefore one must conclude that the midwives caring for Dutch women are the equivalent of CNMs, a category of midwife that Dr. Tuteur approves of. Secondly, the study does not clearly define location of labor as a factor, only the care provider. Also, as tragic as a fetal loss is, again, it cannot be used in isolation as the only endpoint when determining models of care. The use of this study as a condemnation of home birthing is, again, disingenuous. The authors’ conclusions are not the condemnation of the midwifery model but that a reevaluation of the Netherlands care system is warranted.

As to point #4:
I agree that if the Midwives Alliance of North America (MANA) has meaningful data they should consider publishing it. Supporters of the midwifery model want the best for their patients and would be accepting of criticism if that is what the statistics showed. For those interested in seeking their data there is a legitimate application process that provides access. Dr. Tuteur seems to be eager to attribute sinister motives to MANA while bathing herself in righteous indignation. Those who know of her antics see her for the internet provocateur she is. One who calls for informed decisions but skews her information, refuses offers to debate opposing views publically, obfuscates her own background and motivation and seems to take pleasure in demeaning those with whom she disagrees. Unlike Dr. Tuteur, I applaud Ms. Lake and Ms. Epstein for bringing the issue of how American women give birth to the forefront. Honest dialogue, true informed consent and individual autonomy in life’s most precious moments are the business for us all.

Stuart J. Fischbein MD, FACOG
www.birthinginstincts.com

(This essay was submitted to the op-ed editors of online Time/Ideas more than a week past. Since I have yet to hear any response from them I have elected to post it here. Dr. F)

You can find the original article by Dr. Tuteur at:
http://ideas.time.com/2011/11/07/what-ricki-lake-doesnt-tell-you-about-homebirth/

Time Ideas did eventually publish an edited version of my comment to Dr. Tuteur. Read it at:
http://ideas.time.com/letters/the-home-birth-debate-continues/?iid=op-main-lettereditor

More hypocrisy from Dr. Stephen Carter

I have not blogged in a while as I have been involved with some other great projects. "More Business of Being Born" premiered a couple weeks ago. I highly recommend this 4-part DVD as an adjunct to Ricki and Abby's BOBB for those who wish to educate themselves in birthing options. It was such a fun gathering of good souls. Great to see my colleagues Glen Elrod from Wasilla, Alaska and Robert Biter up from San Diego along with so many nurturing people who trust birth. I must say I did not know what to expect as we previewed the Celebrity Birth Segment. But I was pleasantly surprised as I found it both entertaining and informative. I have yet to see part 4 on VBAC but colleagues tell me I am in it and did not make a fool of myself so thats reassuring.

My co-author, Victoria Clayton and I were at the Ventura County Book Fair a couple weeks ago promoting "Fearless Pregnancy". I was honored to teach a suturing class to more than 25 birth professionals at the Santa Clarita Birth Center. And of course there is that birthing thing. In the past week I have had my first failed VBAC and another beautiful home delivery of twins. Please check out my summary in the news section of www.birthinginstincts.com

On a very sad note, my friend, mentor and colleague of 30 years passed away early Monday morning. Irwin Frankel was a wonderful physician, very hands on and old school. He was a passionate teacher with knowledge and patience and a calming influence and everyone adored him, patients and colleagues alike. They do not make them like him anymore and his passing signals the end of an era. I will miss him very much.

The contrast between an honorable man like Dr. Frankel and Pleasant Valley Hospital's own Dr. Carter could not be more stark. Some people actually fool themselves into believing what they say and some are just fools. I do not pretend to know the motivation of Dr. Carter and will leave that up to the reader. For those who have followed the antics of the obstetric committee and administration at PVH and St. John's in Oxnard in this blog and in the Ventura County Star towards midwifery you will know what I am talking about. In a recent article regarding the debate over closure of the maternity ward at PVH Dr. Carter, once again, stepped in it. Please take a moment to read the recent article "St John's Pleasant Valley Hospital Postpones Decisionon Closing OB Unit"

I commented on the article as follows:

Dr. Carter says, "I've worked here since '98 and I've never felt the lack of an NICU was a big deal. It's nine miles away." Yet Dr. Carter was an integral part of the OB committee that agreed on a year long ban of midwives for just that reason. Former CEO, Mike Murray, echoed Dr. Carter's position in a story in this paper at the time. Citing "safety" as the reason for the midwife ban. It would seem from Dr. Carter's words here that safety was never the issue. Which we all really knew anyway. The motivation for keeping or closing the unit will remain economics. Also, the reporter should try to see how much the anesthesia and pediatric departments have brought pressure to bear for closure. It is hypocritical to argue safety then but not now. The policies in place at that hospital over that past several years are what have destroyed the census. I agree with Ms. Graf that closure of the woman's unit at Pleasant Valley would be a blow to the community. Sadly, with the unexplained departure of the supportive Mr. Bibby and the current economic forces in the medical industry it would be surprising to see our little haven survive.

.

The health care system is set up to create and protect the Dr. Carters of the world while what is really needed are the Dr. Frankels. Irwin held himself to such high standards that he did not need administrators and lawyers and confidential peer review committees and investigative journalists to inspire him to do the right thing. While those at Pleasant Valley Hospital impersonally debate the future of the women's unit surrounded by syncophants and protected from liability let's not pretend you and I don't really know what is going on there. Dr F

More thoughts on the "Affordable" Heathcare Act

Last April I gave a speech at a tax day rally here in Thousand Oaks, CA expressing my opinions on some of the chilling effects of the government getting into the healthcare business. The text of that speech can be found in the April 2011 archives on this blog. On October 12th I will be a member of a panel speaking on this same subject at a dinner in North Ranch, CA. I will post the details here as the date draws closer for anyone locally who would like to attend.

One of my biggest criticisms of the health care bill is the intrusion of immense government into the realm of the very personal issues of healthcare and the expansion of the administrative state well beyond its scope granted by the U.S. Constitution. Taking a closer look at what this legislation is about reveals it has almost nothing to do with the distribution of medical care and is simply about control and bean-counting of our lives and enrichment of some favored groups.

Writing in the September 2011 publication, "Imprimus", of Hillsdale College, author Edward J. Erler has this to say:

"The administrative state, of course, always seeks to extend its reach and power. This is an intrinsic feature of a system where administration and regulation replace politics as the ordinary means of making policy....This is tantamount to denying that legitimate government derives from the consent of the governed...(taken from The Declaration of Independence). Obamacare certainly fits the description of the activities denounced in the Declaration. The number of regulations and the horde of administrators (not to mention lawyers) necessary to execute the scheme are staggering. We have only to think here of the Independent Payment Advisory Board. It is commission of 15 members appointed by the President, charged with the task of reducing Medicare spending. This commission has rule-making power which carries the force of law. The Senate, it is true, will have the power to override its decisions--but only with a three-fifths majority. There are no procedures that allow citizens or doctors to appeal the Board's decision. The administrative state--here in the guise of providing health care for all--will surely reduce the people under a kind of tyranny that will insinuate itself into all aspects of American life, destroying liberty by stages until liberty itself becomes only a distant memory."

As a concrete example it has been announced that diagnosis coding, required by Medicare and all insurance companies, will be changed in 2013. Currently, ICD-9 coding has about 12,000 diagnoses. The new ICD-10 coding to go along with the mandated electronic medical records provision of the bill will have 140,000 diagnosis codes. Is this for the betterment of health care or will it be used for micromanaging and regulation and eventual rationing of health care resources? What do you think? You know what I think! Dr. F