"All that is necessary for the triumph of evil is for good men to do nothing" Edmund Burke, 18th century Philospher.

"A long habit of not thinking a thing wrong gives it a superficial appearance of it being right." Thomas Paine

"The welfare of humanity is always the alibi of tyrants." Albert Camus

"Choice is the essence of ethics: if there were no choice there would be no ethics, no good, no evil; good and evil have meaning only insofar as man is free to choose." Margaret Thatcher, March 14, 1977

“It is difficult to get a man to understand something, when his salary depends on his not understanding it.” ― Upton Sinclair

Explaining the Cause

I am a practicing obstetrician who is a strong supporter of patients rights to informed consent and refusal. I believe a patient has the right to choose her own path given true and not skewed informed consent. Following that tenet, just as a woman should be able to choose to have an elective c/section she should be able to choose not to have one, as well. The American system of hospital based obstetric practice has been eroding those choices for women for quite some time. Due to concerns of economics, expediency and fears of litigation women are being coerced to make choices that may not be in their best interest.

I have had a long relationship collaborating with midwives and find the midwifery model of care to be evidenced based and successful. I was well trained at Cedars-Sinai Medical Center in the mid 80's to perform breech deliveries, twin deliveries, operative vaginal deliveries and VBACs, and despite evidence supporting their continued value, hospitals are "banning" these options. Organized medicine is also doing its best to restrict the availability of access to midwives.

Home birthing is not for everyone but informed choice is. Medical ethics dictates that doctors have a responsibility and a fiduciary duty to their patients to provide true, not skewed, informed consent and to respect patient autonomy in decision making. Countries with the best outcomes in birthing have collaboration between doctors and midwives. This is not what has been happening in the hospitals of America. Its time for a change and the return of common sense.

The midwifery model of care supports pregnancy as a normal function of the female body and gives a legitimate and reasonable alternative to the over-medicalized model of birth that dominates our culture. Through this blog I hope to do my part to illuminate what is wrong with our maternity care system and what is right with it. I do not expect all to agree and that is OK. We must all understand that given honest data it is not always reasonable to expect two people to come to the same conclusion. Our differences should be respected.

Thursday, October 15, 2009

Breech Forum - Afternoon session

Heard from Dr. Savas Menticoglou, one of the principle authors of the recent SOGC (Society of Ob/Gyn Canada) guideline paper. He went through how and why the Canadian society has changed its position from its rigid stance against breech birth to a more tolerant, although not enthusiastic support of, this option for selected women. I am optimistic that he represents a growing wave in academia that agrees with the basic right of informed consent and allowing women the dignity of choosing their own course. Change will only come slowly, however. He pointed out some significant flaws in the 2004 Term Breech Trial paper and affirmed that the 2006 two year followup showed no difference in outcomes for breech babies born by vaginal vs. cesarian section.

We also heard from Jane Evans, a midwife practicing breech birth in England. She gave a talk on the mechanics of the breech baby as it comes through the pelvis and expoused the virtues of the kneeling position in facilitating the unassisted delivery of breech babies.

Tomorrow, Dr Louwen and Dr. Reitter will be showing us some amazing footage of this practice in action as done successfully at a center in Frankfurt, Germany. I will be speaking on the challenges of offering Breech birth in the Hospital. When I listen to these knowledgeable people talk with such energy and common sense it does give me hope that positive change for women will come. Probably agonizingly slowly but come it will.

Patricia Grube asked me if I think things will ever change here in the U.S. Here is what I wrote to her earlier today:
"Practically, I believe change will only come when market forces make it a necessity for hospitals to alter their economic approach. In other words, if patients demand choice and can find it elsewhere and start leaving hospital settings for more deisrable delivery options it might change. That is why we are going to try to get a birthing center up and running by next year. Not that it will be for everyone but women deserve options. I think the free market competition model will be the only way to give choice back to women. My experience with the hospitals I deal with is that they do not like to be challenged, they dig in their heels and they try to silence any opposition. Besides, unless we retrain practitioners to do breeches they can always argue that a c/section is all they know. So how to encourage programs to train them and how to get enough cases for future doctors and midwives to feel comfortable is another barrier. I would hope if we can get a center running and be a referral for breeches from all over the SoCal area then we can offer training, too."

I am hopeful that the day will come where others care to learn these skills that are being maintained by vigilant and honest practitioners. For the loss of the knowledge to perform breech deliveries will inevitably lead to preventable tragedies. Dr. F

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