Supportive Organization Brings up Important Issue

Received this e-mail today. Points out another rarely mentioned consequence of lack of true informed consent. I was unaware of the extent of this problem and want to thank Jennifer Zimmerman for her good work. Check out her link in the supporters column.

Hello, I am from the non-profit organization Solace for Mothers: Healing After Traumatic Childbirth (http://www.solaceformothers.org/). I am very interested in your case because we have identified a lack of informed consent and the ability to refuse care as a major risk factor in developing traumatic stress (or PTSD) symptoms after childbirth. Women are unable to get a lawyer if their legal rights to informed consent and refusal were violated and caused them PTSD. Lawyers simply will not take these cases, which means that providers are free to trample over women's rights with no punishment for their illegal actions. Having a lack of true informed consent is leading to more and more women suffering from postpartum PTSD, which is often misdiagnosed and treated as postpartum depression. Our organization will soon launch a letter writing campaign to Lynn Rosenthal, the newly appointed Presidential Advisor on Violence Against Women (an office within the Department of Justice). We intend to inform her of the violence that is happening against women in maternity care, and the effect it has on these women. If you would like to add your voice to this campaign, I will inform you of when we begin.

Jennifer Zimmerman
Project Coordinator
Solace for Mothers, Inc.
www.solaceformothers.org

Always question motives.

From: Patricia Sent: Thursday, August 27, 2009 8:57:34 AM

Subject: Re: Couple of things about ACOG

Thanks, Dr. Fischbein, for this recent notice from ACOG. It does seem like we are going back to the Dark Ages! Well, at least, they are putting out a statement that it is "okay" from women to have more than icechips in labor. Really? Who are these people?!

Re: reporting of unsuccessful homebirths. It is curious that there is a need for data collection on numbers. I am suspicious as to the motive for data collection. But I hope that along with collecting the numbers, there is an assessment for the reasons for hospital transfer (i.e. emergency vs. nonemergency).

Have a great day!
Patricia

Dear Patricia, You should be suspicious. Last year they came out and made a statement against homebirth based on Level C evidence (consensus opinion). Now, it seems, they are out to find out if they were correct. This is ass backwards thinking and reeks of bad research technique. "Here is what I think now we will try to find evidence to prove it!!" By the way, if they don't, you will never be told. Completely lacking in objectivity and, as I said before, what do the anecdotal stories mean without comparison to successes? Also, I do not see them asking members to report data on bad outcomes in hospital births as they have already concluded that hospitals or birthing centers attached to hospitals are the safest place to give birth. This is just such a witch hunt. Thanks, Dr.F

What about Successful home Births?

ACOG is asking its members to report failed home births. Maybe I am biased but what good is this registry if there is no registry on successes?

Reporting of Unsuccessful Attempts at Home Delivery with or without Adverse Consequences
In 2006 there were 24,970 home deliveries reported in the United States[1]. Obstetrician-gynecologists and other members of the medical community may be faced with the presentation of an obstetrical patient who has attempted home delivery unsuccessfully. The need exists to quantitate the frequency and information of these events. The goal of this registry is to attempt to quantitate when home delivery is unsuccessful and what the outcomes are. To be HIPPA-compliant, no identifying information will be requested. Data points include the state of occurrence, as well as the month and year of delivery, maternal and gestation age, gravidity and parity and obstetric or neonatal complications. An attempt to identify the home attendant type if known will also be useful data.

ACOG appreciates your recognition of this issue and your utilization of this registry to assist us in data collection.

No progress on Midwive's Privileges

My take: As of today, the hospital's legal counsel is still playing a childish game of semantics which is hurtful to both midwife and patient. We have honored their request for physicians willing to back them on days when I am in my other office. One of the physicians has not been approved because she requires proctoring for obstetric admissions. While this may sound reasonable it is really absurd. Her proctoring requirements have been in place since July of 2008 and have not changed. From July 2008 until January 2009 the midwives and I shared call with her and several other physicians. No one complained then. Since January she has covered several physicians in a call group without restriction. She has also covered me and the midwives when I had to go out of town. And no one complained then. When asked to explain this situation today, the chief of staff told me he would have to discuss this with legal counsel and get back to me tomorrow. It seems clear to me that these decisions are coming from a lawyer who benefits financially each time he can be obstructive and is in no hurry to respond or resolve this dilemma. Meanwhile it has now been 2 weeks since they abruptly restricted the midwives from caring for inpatients. Lets see if they follow through tomorrow and what they will think of next. Thanks for reading. Comments welcome. Dr. F

Consider taking the Birth Survey

http://www.thebirthsurvey.com/AboutProject.html

Here is an opportunity to contribute data on your birth experiences to a large study. Please check it out. Thanks, Dr. F

Milbank Report referenced in Support Letter

Dear M. Murray,

I have become aware that Dr. Stuart J. Fischbein is being threatened with disciplinary action for practicing evidence-based maternity care and defending woman’s autonomy and right to informed choice, as well as supporting midwives and the midwifery model of care.

According to your mission statement, “It is our goal that health care be provided in a holistic way, respecting all dimensions of a person. At a time of extraordinary technological advancement developed to cure disease -- one that focuses on the physical dimension of person -- we need to emphasize and embrace the psychological, social and spiritual dimensions of persons.

Health care is patient-centered. Patients have the right to make medical treatment decisions (including accepting or rejecting treatment), which includes free and informed consent, access to medical and other information regarding their care…”. Apparently your facility says, birthing women are insured and encouraged to make health care decisions autonomysly and are not forced to have procedures done on them and to them that could do harm. In this case I am referring to your policy for vaginal birth after cesarean and the midwifery model of care. Are your employees walking the talk?

Your own on-line statement says “A woman may or may not be able to have a vaginal birth with a future pregnancy, called a vaginal birth after cesarean (VBAC). Depending on the type of uterine incision used for the cesarean birth, the scar may not be strong enough to hold together during labor contractions”.

ACOG’s brochure on VBAC states:

Today, doctors know that many women who have had a cesarean delivery can later safely give birth though the vagina. This is called vaginal birth after cesarean (VBAC) delivery. VBAC can be a safe option for many women.

Of women who try VBAC, 60–80% succeed and are able to give birth vaginally.

There are some reasons why a woman may want to try VBAC over cesarean delivery:

· No abdominal surgery

· Shorter hospital stay

· Lower risk of infection

· Less blood loss



I will add to this; more success with breastfeeding.

It is your responsibility to know that uterine rupture happens less than 1% of the time. This is far less that the risks of other serious events in labor. If a hospital is not safe to have VBAC, it is not safe to give birth.

In 1987, Angela Carder, a pregnant cancer patient, died along with her baby at George Washington University Medical Center after a court-ordered Cesarean Section. As a result of this case, beginning in the early 1990s, hospitals began to set policies stating that decisions regarding pregnant patients would be made by the patient herself, her family, and her doctors.

When medicine is practiced primarily for profit, convenience and out of fear of litigation it is not good medical practice nor is it evidence-based medicine.

The c/section rate in this country is nearing 1/3 of all births. While the current hospital model will profit from this trend you must ask at what cost? Evidence is clear that repeated c/sections put women at greater risk and the evidence mounts that babies born this way have higher rates of breathing difficulties, breastfeeding difficulties and learning disabilities. Doctors and midwives who stand up for patients rights are often the target of ridicule and harassment by the very hospitals and organizations that their hard work supports. Does this sound like what is happening at your facility??

Losing Dr. Fischbein will have a devastating effect on the ability of midwives to continue to care for patients and for patients to have options other than c/section. Many believe that hospital policies that force women into surgery, deny them informed consent or tell them they must go to a different institution are unethical, in violation of EMTALA and even possibly illegal.

What other medical modality forces a healthy person to undergo major abdominal surgery against their wishes? Name one please.

Your policy is an assault on a woman's right to self determination, likely for economics, expediency and litigation mitigation, plain and simple.

I encourage you and your entire OB staff to get better informed by reading the Milbank Report – Evidence-Based maternity Care: What It Is and What It Can Achieve http://www.childbirthconnection.org/pdfs/evidence-based-maternity-care.pdf . There is no excuse for ignorance and no room for arrogance in providing stellar maternity care.

Sincerely,

Jeanne Batacan
Jeannie Batacan
Help bring transparency to maternity care. Take The Birth Survey! Share, Connect and Learn. www.thebirthsurvey.com
Watch this video! www.reducinginfantmortality.com

NY woman seeks VBAC provider

Dear Dr. Fischbein,
I just found out today that I am about 4 weeks pregnant! We are very
excited except that my OB, who delivered my two daughters, now nearly
13(emergency CS - due to distress of baby) and 11(VBAC) now tells me today
that a VBAC is "not allowed" because it is too dangerous. I am floored. I
do not want to have a c-section. The recovery from the first one so long
ago was very difficult. And since I did the VBAC successfully before, I
would like to do it again. However, now I must find another OB and
hospital that will allow it. I am having trouble finding a VBAC
supportive OB on the web. Perhaps you could help me - or at least tell me
a website that can help me locate one? I am located in Orange County, NY -
my zipcode is 10990. Thank you in advance for your help. Jen Emm
jensmail@warwick.net

Dear readers: "Too dangerous" is routinely being substituted for true evidenced based informed consent. This sort of subjective counseling for a variety of motives is becoming pervasive and part of the culture. It is a prime example of the well known propaganda technique of, "Tell a lie, tell it often, tell it loud and it becomes truth". If you have any ideas for Jen please comment below and feel free to e-mail her. Thanks, Dr.F

Physician Group Pulls the Plug on Women’s Autonomy

Physician Group Pulls the Plug on Women’s Autonomy

ACOG Issues Policy Statement About What Women in Labor Will Be "Allowed" to Eat and Drink

FOR IMMEDIATE RELEASE

WASHINGTON, D.C. (August 25, 2009) – Displaying a stunning lack of regard for patient autonomy, the American College of Obstetricians and Gynecologists (ACOG) issued a statement this week declaring that the group will "allow" laboring women to drink "modest amounts" of clear fluids during labor while continuing to prohibit access to solid food.

"Once again ACOG has issued a position statement with little regard for the evidence or for the ability of women to make decisions for themselves," said Susan Jenkins, Legal Counsel for The Big Push for Midwives Campaign. "It's insulting that ACOG actually believes that laboring women should be grateful that they will now be 'allowed' to have more than just ice chips, when we have long known how vital nutritional sustenance is to mothers and babies not only during pregnancy, but during labor as well."

Hospitals routinely adopt ACOG position statements as standard policy governing the treatment of pregnant and laboring women, despite the fact that a number of the organization's position statements do not acknowledge all of the risks and benefits associated with common procedures.

"ACOG is asking laboring women to do the physical equivalent of a marathon on the power of a 'modest' amount of clear liquid," said Sabrina McIntyre, mother of two. "Thanks but no thanks. I'll stick with my midwife and her wisdom of keeping up my physical stamina for such a monumental event."

Policies restricting food and liquid intake date from an era when laboring women were routinely given general anesthesia and risked aspirating food into the lungs. Modern anesthetic techniques have virtually eliminated this risk, which is further reduced by the fact that only a tiny minority of laboring women, even among those who deliver via cesarean section, actually receive general anesthesia.

"The women I care for eat when they are hungry and drink when they are thirsty, all without asking for ACOG's permission first," said Elizabeth Allemann, MD. "Women deserve to be fully informed about what the evidence actually shows, and it's time that the medical profession abandoned policies based on the outdated and paternalistic idea that patients should play no role whatsoever in the decision-making process."

The Big Push for Midwives Campaign represents thousands of grassroots advocates in the United States who support expanding access to Certified Professional Midwives and out-of-hospital maternity care. The mission of The Big Push includes educating national policymakers about the reduced costs and improved outcomes associated with out-of-hospital birth and advocating for including the services of Certified Professional Midwives in health care reform. Media inquiries: Katherine Prown (414) 550-8025, katie@thebigpushformidwives.org

From the Coalition for Breech Birth

http://www.breechbirth.ca/Welcome.html

Respecting the Choices of Women

Vaginal breech birth was practically banned following a significant international research study in 2000. This study, the "Term Breech Trial" or TBT, appeared to prove that caesarean section was substantially safer for the delivery of all breech babies. The trial was highly criticized, but many birth care providers took this opportunity to do what they wanted to do anyway - to stop offering vaginal breech birth to their clients, and to insist instead upon a surgical delivery. Very few centres continued to offer vaginal birth. To read the original TBT report, click here.

In addition to all the professional criticism, the TBT's own two year follow up negated the original results, suggesting that any difference in safety between vaginal and surgical birth of a breech baby is negligible - for both mother and child. Despite this evidence, many Birth Care Providers (BCPs) still avoid balanced informed choice discussions with their clients, denying them the opportunity to make an informed choice. Most frequently, it is flatly stated that surgical birth is the standard of care, and that is what is going to happen - regardless of that mother's individual circumstances. If vaginal birth is mentioned at all, it is brushed off as an inferior, unsafe choice. However, caesarean surgery, while it presents many advantages for the surgeon, has lifelong ramifications for the birthing woman and her family, including issues with subsequent pregnancies, secondary infertility, Vaginal Birth After Caesarean (VBAC) availability, and depression, not to mention a risk of death in childbirth increased threefold over vaginal birth.

Women should not be obliged to accept these serious risks as "standard of care" when clinical research clearly demonstrates that vaginal birth of a breech baby does not pose an increased level of risk. In addition, the recommendations of professional organizations such as The Society of Obstetricians and Gynecologists of Canada do not support automatic caesarean for breech. Yet, time and again, vaginal breech birth is presented as tremendously difficult and dangerous, and caesarean risks glossed over.

Our mission is to fill the gap in the informed choice discussion by offering women the evidence-based information and the vital support they need to make their own decisions.

Another Support Letter

August 24, 2009

Mr. Michael T. Murray,

I am disappointed to hear about your hospital’s actions against Dr. Stuart Fischbein and his supporting CNMs. I believe it is wrong to punish them for helping women achieve the safe vaginal birth they desire. Those women would have been subject to a major surgery they were opposed to, and proved unnecessary, otherwise.
As an expectant mother, I hope to have freedom of choice, informed consent, and informed refusal during my birth experience. I consider this a basic human right. If I were in need of an obstetrician to safely deliver my breech or VBAC baby, I would hope the opportunity would not be denied for me to have a vaginal birth. I hope I would have the support of the medical community on my side to help me through.
I am not anti-cesarean. I believe there is a time and a place for it, and it has saved many lives. I am thankful to live in a society where such things are readily available to me and my child should the need arise.

However, I also believe in women’s ability to give birth safely, even in less than optimal circumstances. I believe a woman should have the right to review the available data without fear-mongering and make a decision that fits her beliefs and preferences. I also believe that once she makes her choice, it should be supported by the medical system. I believe the medical community is here to serve us, the people.

We are not to be held hostage to a system over our own bodies for monetary or legal concerns. Incidentally, failure to recognize and support my wishes concerning my own body is a more serious offense to me than the fact that some babies die. It is a fact of life that death cannot be thwarted. Heartbreaking as that may be, we cannot control the element of life. What can be controlled is how you treat those in your care. Dignity and respect are called for, even if their choices differ from what yours would be.

That being said, vaginal birth has not been proven more dangerous or life threatening than cesarean section. The statistics demand freedom of choice. VBAC and breech vaginal birth have happened safely and should continue to do so. Obstetricians should be trained to handle these events safely so that women can chose what to do with their own bodies.

I appreciate the efforts of Dr. Stuart Fischbein. He is a hero to me for safely supporting vaginal birth for those who wish for it. I hope you’ll train and hire more people with his character and skill set. Without skilled obstetricians, women who feel strongly about birth and their choices will resort to birthing at home without the immediate back-up and monitoring they should have the right to. Is this not more dangerous than allowing vaginal delivery in the hospital?

I urge you to revise your hospital policies to allow more freedom of choice.

Sincerely,

KB

Thanks from Breech birth parents

June 4th 2009

Dear St. John's Pleasant Valley Hospital Administrator,

I wanted to relay our birth and patient care experience at your hospital.

My wife and I had planned on a natural home birth. Unfortunately, our baby was frank breech, and despite trying all the baby turning methods, she remained breech.
We tried everything, Acupuncture, chiropractic techniques, even an External Cephalic Version (at St. Johns Pleasant Valley with Dr. Fischbein, incidentally) but nothing worked. And even though none of these methods seemed to work, and we were draining our pocket books trying everything under the sun, we were still determined to have a natural drug free vaginal birth.

We were lucky enough to find Dr. Fischbein, who after many tests and evaluations determined that, with his expertise, my wife was a good candidate for a vaginal breech birth.

As it so happens Dr. Fischbein is one of very few doctors that have the experience and skill to perform a breech birth. Even though our home birth could not happen, we were thrilled to have the option of a natural birth. Dr. Fischbein, along with the help of his midwives, was able to deliver our beautiful daughter. We knew we were in very skilled and capable hands. Our birth experience was wonderful thanks to the nurses, midwives and Dr. Stuart Fischbein, at St. Johns Pleasant Valley.

As I understand, many hospitals will not allow breech births. We are so glad that St. John's Pleasant Valley Hospital is progressive enough and values patient choice to have allowed Dr. Fischbein to perform a breech delivery. After the successful birth of our beautiful daughter, the nursing staff took terrific care of us. We are so incredibly grateful to Dr. Fischbein and the staff at your hospital. We were so impressed with the care we received.

With much gratitude,

Jeff and Martinique Lin (and daughter Lexington Lin)

The Squeezing of Midwives and further loss of Choice

www.starnewsonline.com/article/20090810/ARTICLES/908109956/1004?Title=Demonstrators-upset-about-midwives-being-phased-out

Received this article from my colleague Susan Jenkins back east. Seems like this is going on all over. Pretty obvious to me that unseemly economic forces are coercing supportive doctors to make Sophie's Choice. Ultimately surrendering and reluctantly hurting midwives and the patients they serve. Once again the unseen bullies are the hospitals and their risk manager lawyers responding to their malpractice insurance carriers and their risk managers lawyers who fear unreasonable law suits from trial lawyers, of which there are way too many, and a tort system that is completely broken. This has to end and reason must return. The alternative is unthinkable SJF

Does hospital position violate CHW Mission Statement?

This post is taken from the Catholic Healthcare West web site and titled: “Our Mission, Vision and Values”

http://www.chwhealth.org/Who_We_Are/Our_Mission_Vision_And_Values/STGSS047977

CHW's respect for values including the dignity of persons, care for the poor, the common good and responsible stewardship are essential in our ministry of healing. We invite our partners to understand and participate in realizing our values, many of which we believe we hold in common with our partners

The Professional-Patient Relationship
We respect the privacy of the physician-patient relationship. A person in need of health care and the professional health care provider who accepts that person as a patient enter into a relationship that requires, among other things, mutual respect, trust, honesty and appropriate confidentiality. The resulting free exchange of information must avoid manipulation, intimidation, condescension or judgment. Such a relationship enables the patient to disclose personal information needed for effective care and permits the health care provider to use his or her professional competence most effectively to maintain or restore the patient's health. Neither the health care professional nor the patient acts independently of the other -- both participate in the healing process.
Health care is patient-centered. Patients have the right to make medical treatment decisions (including accepting or rejecting treatment), which includes free and informed consent, access to medical and other information regarding their care, the right to make an advance directive and to name a surrogate decision maker. Medical treatment decisions may generate ethical dilemmas for health care providers, patients and their families or surrogate decision-makers. An ethics committee or some alternative form of ethical consultation will be available to assist by advising on particular ethical situations, by offering educational opportunities and by reviewing and recommending policies

Accountable to Our Communities
We’re extremely proud of all we do for our communities, and consider serving those in need to be a privilege, a calling, and a mandate.
Each year we continue our tradition of excellence in patient care, investing in our communities, and supporting the overall, long-term health of those communities.
But how exactly are we doing, you ask?
• Our annual Corporate Social Responsibility Report outlines the many examples and details of CHW’s commitment to sustaining its healing mission within the context of the critical issues confronting our nation and our planet. The report demonstrates our efforts to implement meaningful programs and also recognizes opportunities for improvement, with additional reporting on our economic impacts, our patient quality and safety initiatives. Read all about it.

Friday Meeting - My Take

So, met with the chief of staff, current and future as well as the head of the OB committee today. Bottom line is the OB committee does not want me to even offer the option of elective VBAC or vaginal breech delivery to women at either campus. If I were to agree to this then they seemed to suggest the disciplinary action might just go away. This is going to be a dilemma for me. An intolerable situation facing many private practice physicians today. Compromise your values to pay your overhead or compromise your practice to keep your values. In the meantime they are supposed to reinstate the midwives but I suspect it will not happen until early next week.

One thing was made clear to me today. The hospital believes the OB committee is the final arbiter of standards in this community and since none of them would offer a breech delivery then for me to do so is beneath the standard. Good outcomes and innovation are not relevant. They also essentially said that skewing your informed consent process is OK because allowing patients the option of VBAC affects other personnel such as anesthesia, peds and nursing and puts them at risk. While I do see their point, they did not want to hear that the patient has rights and is the one we are supposed to serve. There was no place for discussion of the risks of repeated c/sections or evidence supporting our midwifery model today. That was my take anyway. Will keep you posted.

The Big Picture

Dear supporters of choices in childbirth,
Many, but not all, of you are aware that a woman's right to informed consent and refusal and the ability to self determine the path of her pregnancy and birth are rapidly eroding. Very personal decisions that belong to a woman, her family and her health practitioner have and continue to be usurped by outside forces. Medical organizations, hospital administrators and their lawyers, malpractice insurance carriers, government agencies and, yes, even physicians have intruded on the once sacred doctor-patient relationship. Policies that deny patients legal and ethical rights have formed despite a lack of evidenced based medicine. Although "patient safety" is always the tag line associated with these policies, when scrutinized, it is clear that they are about economics, expediency and litigation mitigation.
The banning of VBACs, the push against midwives and out of hospital births and the lack of training new physicians in techniques such as selected breech delivery have not only limited the choices of women across the country but evidence would support that it has put them at more risk. The c/section rate in this country is nearing 1/3 of all births. While the current hospital model will profit from this trend you must ask at what cost? Evidence is clear that repeated c/sections put women at greater risk and the evidence mounts that babies born this way have higher rates of breathing difficulties and learning disabilities. We believe that the current trend is dangerous and needs to be exposed and confronted. Doctors and midwives who stand up for patients rights are often the target of ridicule and harassment by the very hospitals and organizations that their hard work supports. The decision of how to birth must be returned to informed women. The time has come to push back against the system that profits from fear and expediency before there are no health practitioners left willing to stand up.
One of our own, Dr. Stuart Fischbein, has long been a voice of reason for the rights of patients to true, not skewed, informed consent and informed refusal. He has written a highly publicized letter to the American College of Ob/Gyn, co-authored "Fearless Pregnancy, Wisdom and Reassurance from a Doctor, a Midwife and a Mom", been a featured speaker at The Contoversies in Childbirth Conference last March in Fort Worth, Texas and is a multiple award winner from the Doulas Association of Southern California. He has also walked the walk and supported patients who chose to attempt VBACs, home births and breech deliveries. One of only a few doctors left willing to support midwifery. In the past several months he has done 3 successful VBACs, allowed 3 first time moms to deliver vaginal breeches and accepted home birth transfers from licensed midwives. For that he is now being threatened with a disciplinary process by the hospital where he works in Camarillo, California for violating hospital policies. A process that threatens his practice and his livelihood. His loss would have a devastating effect on the ability of midwives to continue to care for patients and for patients to have options other than c/section. Many of us believe that hospital policies that force women into surgery, deny them informed consent or tell them they must go to a different institution are unethical, in violation of EMTALA and even possibly illegal. Being a dedicated obstetrician is a calling. The hours are long, the life is disruptive and there is not much money to be made. This bullying of doctors and midwives who do not conform will most certainly spread across the country. Many have just given up unable or unwilling to mount the energy and funds to fight back. On behalf of Dr. Fischbein, the midwifery model of care and pregnant women present and future we are asking for your help.
That is why we are forming the "Birth Choices" legal defense fund. We can wait no longer. The only effective way to regain choices for women is to go to the media and put together a legal team. This is an expensive process that no individual can sustain. Confronting large institutions backed by corporate money is an uphill battle. Lobbying Congress for legal protection for women will require funds and hopefully some pro bono legal experts. Please give generously by clicking on the PayPal link, code: angelfischs at yahoo.com and pass this message on to every family and friend you know. For the wonder and joy of giving birth should remain a very personal liberty and a special gift that touches everyone. We need you. Please help. Thank you.

Support for Debby Takikawa's new film

www.reducinginfantmortality.com

With health care issues at the forefront of the news and legitimate concerns about cost effective care, I highly recommend Debby's new film. We can do better and the midwifery model of obstetrics can go a long way to getting us there. S

Letter of Gratitude for Breech birth

Dear Mr. Murray,
I recently had the pleasure of bringing my daughter, Isabella, into the world in your hospital. I hadn’t planned or wanted to give birth in a hospital but because my baby was in a breech position and nothing was going to make her turn, being in a hospital was the responsible thing to do. All four nurses who attended to me during our stay, Elaine, Meredith, Becky and Brooke, were fantastic as well as Midwife Lynn who works with Dr. Fischbein. Lynn and Meredith were particularly amazing. They were extremely attentive and caring and were very respectful of the requests I made in my birth plan. I would also like to say that Dr. Rao was really great as Isabella’s pediatrician and did her best to accommodate my birth plan, which was all I could ask for.
But the main reason for my letter is to express my profound gratitude for being able to deliver my baby naturally and it’s all because of Dr. Stuart Fischbein. We even drove up from Hollywood so he could deliver her. There aren’t many obstetricians today who are willing, and many who aren’t qualified, to deliver a breech baby. It’s truly regretful that knowing how to deliver these babies is becoming a lost art. There is a wealth of evidence of the benefits of normal, spontaneous labor and vaginal delivery to both mother and baby, which shouldn’t be a surprise as the best way has always been the natural way. The routine use of cesarean sections circumvents this beneficial process. Of course, not all breeches are good candidates for vaginal delivery but many are.
I have become very passionate about this issue and am getting more involved with other ‘Breech Baby Advocates’, as I call them. I am pleased that there has recently been a shift in the way breech presentations are being viewed. Canada’s Society of Obstetricians and Gynecologists (SOGC) has released new guidelines stating that c-section for breech babies is no longer considered the safest way. The new approach was prompted by a reassessment of earlier trials. ‘It now appears that there is no difference in complication rates between vaginal and cesarean section deliveries in the case of breech births.’
“Our primary purpose is to offer choice to women,” said André Lalonde, executive vice-president of the SOGC. With the release of the new guidelines, the SOGC will launch a nationwide training program to ensure that doctors will be adequately prepared to offer vaginal breech births. We should follow suit. Dr. Fischbein makes it possible for women delivering in your hospital to have that choice and that alone puts St. John’s Pleasant Valley Hospital at an advantage over other hospitals. We are deeply grateful for our experience there.

Sincerely,
Lindsay Sauvé

Letter to ACOG on Home Birth

Stuart J. Fischbein's Letter to ACOG, with responses
Fri, 06/27/2008 - 07:03 — admin
From:
Stuart J. Fischbein, MD FACOG
To:
Douglas H. Kirkpatrick, MD, President, American College of Obstetricians and Gynecologists
Date sent:
Monday, June 23, 2008
Douglas H. Kirkpatrick, MDThe American College of Obstetricians and GynecologistsPO Box 96920Washington, DC 20090-2188Dear Sir:I am a practicing OB/GYN in southern California and Fellow of ACOG and recently was informed by midwife colleagues of your recommendation and encouragement for the AMA to lobby Congress for a law banning out of hospital birth. It is disturbing to me that I had to hear of this decision from outside sources and was never approached by my college to see how I or my local colleagues felt about it. I have grave concerns regarding my organization taking such a stand. I think we are all agreed that ACOG has a statement regarding patients’ rights to informed consent and informed refusal. Yet, it seems with every decision our organization moves further away from that basic tenet. ACOG’s little "guideline" paper on VBAC in 2004 where the word readily was changed to immediately has had the chilling effect of doing away with VBAC options at hundreds of hospitals. Not due to patient safety, or the ideal of giving true informed consent but really, let’s be honest, due to fear of litigation. I have seen how patients have become counseled by obstetricians at facilities where VBAC has been banned. They are clearly given a skewed view of the risks of VBAC but rarely told of the risks of multiple surgeries. If you think this is untrue you are, sadly, out of touch with real clinical medicine.As to out of hospital birthing, please give me the courtesy of an explanation as to the evidenced-based data you used and the process by which an organization which is supposed to represent me came to this conclusion. Any statement saying that it is as simple as patient safety and that one-size fits all hospital births under the "obstetric model" of practice should be applied to all patients is, putting it nicely, not really in line with what best serves all our patients. In many instances, hospitals are not safe, certainly not nurturing and have a far worse track record for disasters than home birth. Even when emergency help is nearby this is true. The focus of all of us in medicine should be on reigning in trial lawyers and tort reform and lobbying Congress for that. The best interest of the college members and the patients we serve would be for my organization to spend its time and energy on something that has true benefit. Removing choices from well-informed patients and caring doctors and midwives is wholly un-American. So please send me detailed information on how ACOG decided outlawing home birth would be a wise thing to do. You must have conclusive scientific data to take such a drastic stand. Please make it available to me so that I may share it with likeminded colleagues. I would also like to know the process by which this came to pass. Who first raised this issue and why? What committee reviewed all the data and did its due diligence in interviewing those of us with longstanding experience in backing midwives who perform out of hospital births. There must be a clear and concise, non-confidential paper trail you can share with your members. Specific names of committee members who voted for this would be enlightening and I am requesting this information. I would like to know the background and expertise regarding out of hospital birth for each member who had a hand in the decision to go to the AMA.We live in an odd era where once something is said or recommended by a legitimate organization such as ACOG it has deep ramifications never intended such as becoming fodder for trial lawyers trying to squeeze the lifeblood and dignity out of your members. In this case these ramifications have had the undesirable effect of forcing women to travel hundreds of miles in labor to find a supportive facility. Or even worse, to have them arrive in a VBAC banned hospital and refuse surgery or be coerced into it. Can this be the best we can do for our patients? Remember, your VBAC statement was meant to be only a recommendation but quickly became the rule by which hospital administrators, risk managers and anesthesia departments of smaller hospital banned this option for thousands of women. An option, which in proper hands, was the safe and accepted standard of care for 30 years. In fact, you still have an ACOG VBAC brochure that recommends this option! For those of us working at smaller hospitals where VBAC was banned due to lack of emergency help (anesthesia, OR crews, etc.) there is a big question that has perplexed us that no administrator seems to be willing or able to answer. That question is: "If a hospital cannot handle an emergency c/section for VBACs, and most obstetrical emergencies are for fetal bradycardia, hemorrhage (i.e. abruption) or shoulder dystocia not for ruptured uteri, then how can they do obstetrics at all?" For they seem to still be able to have a maternity ward without in house anesthesia. Will someday ACOG, in their great wisdom but seeming disconnect from reality, make a "recommendation" that little hospitals unable to afford 24-hour coverage stop providing obstetric services all together? Will this better serve women and their communities throughout America? I am frightened and angered by what you have done in my name. Now I ask you to defend your position in encouraging the AMA to lobby Congress for another restriction on the freedom of choice that belongs to women and their families. Those choices include midwifery and the right to have the most beautiful and life changing event occur wherever best fits their desire. I am baffled that my college thinks this should be a criminal act. Midwives are well trained and required to have obstetrical backup. They have very special relationships with their patients and want the very best outcomes for them. They do not need me or you to police them. We have a habit in out country over the past 40 years of thinking we can legislate out stupidity. All that has done is erode the individual freedoms that belong, by birthright, to each of us. I would hope you trust your Fellows to know their specialty, their colleagues, and what is best for the patient as an individual. These decisions do not belong to politicians or faceless committees. You should have more faith in your members to give balanced informed consent. Again, my recommendation to you is to put all your considerable energy into changing our legal malpractice system. Those of us actually practicing medicine and caring for patients know this to be the greatest threat to the mission and responsibility we have chosen to undertake.I look forward to your response and possibly the beginning of a meaningful dialogue.
Sincerely,Stuart J. Fischbein, MD FACOGMedical Advisor, Birth Action Coalition

From: Ralph HaleTo: Stuart J. FischbeinSent: Tuesday, July 1, 2008 2:14:44 PMSubject: Home Births
We have received your email on Home births. The AMA statement is only a repeat of the ACOG statement that was sent to all Fellows in February of this year and is on our website. It is a slight revision of previous ACOG positions on Home births that was developed by a committee of ACOG, reviewed by a document review process involving college members and finally approved by our Executive Board. It is based on good evidence and patient safety concerns. I would correct the statement approves only hospital births. It also approves births in approved out of hospital facilities that have the ability to handle unforseen emergencies. We have received a few concerns, such as yours from our Fellows as well as some from the Media, however the vast majority of our members responding are in support. They include numerous reports of disasters that have resulted in fetal and maternal deaths related to home deliveries. The ACOG VBAC document is again an evidence-based document based on the fact that up to 2% of VBAC’s have a major complication that is life threatening and that, depending upon many factors, 20-40% of attempted VBAC’s fail to deliver. Again patient safety is the issue. ACOG still supports VBAC but only in a situation where immediate care of the complications if they occur can be handled. One of the problems with VBAC is that many hospitals and malpractice insurance carriers believe that any risk over 1 in 100 is too much for them to assume and thus they not ACOG restrict the practice. Thank you for communicating your concerns. I will share them with the practice division.
Ralph W. Hale, MD, FACOGExecutive Vice PresidentACOG409 12th Street, SWWashington, DC 20024-2188

Hello Dr. Hale,
I am so pleased to hear from you so promptly. Thank you. While I can understand ACOGs concerns regarding home birth and warnings about it, I and many of my colleagues have a significant concern that our college suggests making it illegal. America has always been the sort of country where the old saying, "Although I disagree with what you say, I would fight to the death for your right to say it!" defines the spirit of our people. In reading over many of the articles and such from the ACOG web site it seems that ACOG agrees with that saying and understands the right of a woman’s autonomy. I would appreciate your understanding that this current stand of ACOG against out of hospital birthing, even if supported by a majority, seems to defy those premises. I have highlighted some of the relevant articles on informed consent/refusal and autonomy below. I am glad you have acknowledged that in our current system policy is often dictated by third parties such as insurance companies. This resolution on home birth, even if never acted upon by the AMA or the legislature, will likely have the chilling effect of insurers dictating to doctors what they can and cannot do. This seems backwards to me and if midwives cannot find doctors willing and able to supervise them for out of hospital birth, not for their beliefs necessarily but for the "extortion" of loss of their malpractice insurance if they do, it will have the same effect of eliminating this choice for women without the necessity of a law. I do wish our organization’s top priority would be the complete overhaul of the tort/insurance dilemma that seems to be the biggest obstacle to a meaningful doctor-patient relationship. For the autonomy of our patients and the dignity of our profession lies in the balance. I am hopeful you will agree with my point here as well as the articles below and ask the practice division to reconsider its ACOG statement recommending a ban on home birth. Again, I am grateful you have taken the time to sincerely consider my letter.
Sincerely and with respect,
Stuart J. Fischbein, MD FACOG

PS: Is there a possibility you could share with me what "good evidence" was used by committee members. It would go a long way to helping convince those of us who do support a woman’s right to choose where she wants to give birth that the resolution was based on solid evidenced based decision making and those involved used due diligence. I would not ask if we believed the evidence is clear and convincing enough to take such a hard stance. Thanks

From: Ralph HaleTo: Stuart FischbeinSent: Wednesday, July 2, 2008 6:16:33 AMSubject: Re: Home Births

I agree that legislation would be bad. This was not the intent of the ACOG statement nor was it meant to prevent women who chose a home birth from having one. The AMA changes their resolutions by a consent process that involves testimony from reference committees and from the floor so once a resolution has been submitted and it was not submitted by ACOG but referenced our position, the changes were made. I doubt that this will ever be a legislative activity, I know ACOG has no interest in that approach. As regards changing the statement, that would require the committee on obstetrics that drafted it initially being willing to rescind and I doubt that would happen. If it did, then it would go to our review committee of senior physicians and finally the board. Knowing the feelings of both groups although I do not serve on either, I would doubt that they would agree. The emphasis on Patient Safety and the risks of home births are just too great for ACOG to think otherwise. I understand about home births as I have done several earlier in my career of pacific islands and I fully understand when the go right, they can be very rewarding. However when a complication arises, it is difficult and almost impossible to handle in a home situation. Here at ACOG we receive numerous reports from our Fellows on disasters that occur, including deaths, associated with home births that would not have happened in a safe birthing center environment. Last week I received an email from a Fellow who was called to the emergency room to manage a VBAC at home that had resulted in a ruptured uterus. The mother survived after an emergency hysterectomy, the baby did not. Anyway, I do appreciate hearing from you. I doubt home deliveries will stop, in fact they seem to be on the rise so we may be able in the future to have more information.

Ralph W. Hale, MD, FACOGExecutive Vice PresidentACOG409 12th Street, SWWashington, DC 20024-2188

Options when your baby is Breech

Raiders of the Lost Art
Thoughts on Vaginal Breech Delivery
By Stuart J. Fischbein, MD FACOG
Medical Advisor, BAC


Before I can make any comments about this topic it is only fair to disclose my bias. The members of the Birth Action Coalition and I believe that the right of patients and families to informed consent and exercise of their free will is of paramount importance. Along with this right comes the responsibility to accept the consequences of their decision. With this in mind I believe there is still a role for the option of a vaginal breech delivery.

About 3% of women near term will find themselves confronting the dilemma of their baby presenting in breech presentation. As the baby gets closer to term there is a decreasing chance the baby will spontaneously flip to a head first presentation. This is due simply to mechanics of the growing baby having less room. Occasionally, breech babies result from innate abnormalities of the uterus or with the fetus itself. Most of the time, however, there is no obvious explanation as to why the baby ends up in this position.

The current trend in obstetrics is to recommend a c/section for this condition. There is data in the literature to suggest that this may be the safest route overall. Sadly, most resident training institutions no longer teach the skills necessary for safe vaginal breech deliveries. Combined with economics and fears of liability, the availability of a trained specialist in breech delivery will continue to diminish. While this may be expedient for the current times is can pose a danger in that inevitably some women will arrive in labor ready to deliver a breech baby and there will be no one around who knows what to do.

When a woman finds herself at 36 weeks into her pregnancy with a breech baby what should she do? That decision depends on many factors but should start with gathering information. In my practice, I would generally recommend the following advice. An ultrasound should be performed to determine that there are no obvious abnormalities of the baby or the uterus. Ultrasound can give an estimate of fetal weight, head and feet position and general health of the fetal environment. If all appears normal then the option of acupuncture, chiropractic techniques, certain exercises and other noninvasive techniques can be attempted over the next week. Should this fail then I would offer an attempt at external version around 37 weeks. This is done at a hospital delivery unit and I try to turn the baby to a head first position using pressure on the outside. It can be uncomfortable and has a success rate of about 50-70%. Version is easier when the baby is in the complete breech presentation (sitting Indian style) than when in the frank breech presentation (diving pike position).

When version fails then some decisions have to be made. There are certain criteria which studies have shown that, when met, make a trial of vaginal birth in breech presentation a safe option. These include:
1) Estimated fetal weight between 2500 and 4000 grams
2) Frank or Complete Breech Presentation
3) An adequate maternal pelvis (formerly measured by x-ray but can be assessed by exam and is a subjective sizing of the opening of the bony structures of the pelvis)
4) Baby’s head must be flexed and not extended
5) Spontaneous labor and a reassuring fetal heart rate pattern.

If all these criteria are not met then a c/section may well be the only safe option available. This conclusion is supported by the current literature and, although a woman cannot be forced to have surgery, it would be unwise to refuse in my opinion. However, if these criteria are met then you do have the option of asking to wait for labor and see how things progress. The biggest obstacle might be finding an able and willing practitioner as the skills and desire of doctors to conduct a vaginal breech delivery will slowly disappear in the next generation. The Birth Action Coalition believes strongly that consumer demand for these birth choices is the only thing that might reverse this trend and save these skills.

The American College of Ob/Gyn reaffirmed the following opinion in 2008:
Mode of Term Singleton Breech Delivery
ABSTRACT: In light of recent studies that further clarify the long-term risks of vaginal breech delivery, the American College of Obstetricians and Gynecologists recommends that the decision regarding mode of delivery should depend on the experience of the health care provider. Cesarean delivery will be the preferred mode for most physicians because of the diminishing expertise in vaginal breech delivery. Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management. Before a vaginal breech delivery is planned, women should be informed that the risk of perinatal or neonatal mortality or short-term serious neonatal morbidity may be higher than if a cesarean delivery is planned, and the patient's informed consent should be documented.


ACOG opinions may not accurately reflect all our beliefs but we know they have strong influence when it comes to forming national policy. While not for all, I believe the choice for a vaginal breech delivery should remain a viable option. As we have seen with other birth choices, however, there are economic and legal pressures being brought to bear that are severely limiting your birth choices. This trend may not be reversible in the reality of the world we live in here in the United States. It will most certainly disappear if we remain passive and silent. We urge you to continue to speak out for your rights.

Bio / Resume of Dr. Stuart J. Fischbein

Dr. Stuart J. Fischbein, MD FACOG, BAC (Birth Action Coalition) Medical Advisor, Attended University of Minnesota Medical School. He completed his residency at Cedars-Sinai Medical Center, in Los Angeles 1982-86

Dr. Fischbein has been in private practice of Obstetrics and Gynecology since 1986. He has a long history of support for Certified Nurse Midwives and Licensed Midwives. This interest began as a resident rotating through LA County-USC Medical Center where he had the good fortune to be exposed to the midwifery model of care. In the mid 80's he was approached by Nancy McNeese of the Natural Childbirth Institute, formerly in Culver City, to provide back-up support for women choosing alternatives to hospital based birthing. In 1995 he co-founded The Woman's Place, Inc., an innovative model of collaboration between Certified Nurse Midwives and Obstetricians in Camarillo. In 2004 he co-authored, "Fearless Pregnancy, Wisdom and Reassurance From a Doctor, a Midwife and a Mom" Fair Winds Press with long time associate, Joyce Weckl, CNM and writer, Victoria Clayton. He has twice been awarded Physician of the Year by the Doulas Association of Southern California. A long time outspoken advocate of womens' rights to informed consent and right to refusal of treatment and exercise of their free will.