"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, November 19, 2009

Mid November Update

Several weeks have passed and nothing new on the breech privilege front. I have patiently waited for the promised formation of a committee to discuss a breech protocol at my 2 hospitals. I have e-mails from September telling me the chairman would be in touch with me shortly. Well, at yesterdays OB Department meeting I did present my breech protocol and again reminded the chairman of the importance of addressing this issue. Patient's deserve the choice. We shall see how soon a meeting is set up.

I was interviewed by a writer from the Washington Post this week. She is doing a story on breech deliveries. She was introduced to me by Robin Guy, from the Coalition for Breech Birth in Ottawa, Canada. I will link the story when it comes out. She was very interested in what has happened at my hospitals and the process, or lack of process, that led to the banning of elective breech deliveries.

A group I have put together continues to research the options for a free standing maternity center. A place where the midwifery model of care and patient choice can occur free from the encumbrances of modern day hospitals. We are very excited about the project and have a highly motivated group. Anyone with any thoughts or suggestions feel free to contact me or Amy Tinney.

I will be going to Washington, DC again on December 9th for less than 12 hours to meet with our California Senators. I was asked by Docs4patientcare to lobby for reason and sanity in the healthcare debate. I plan to focus on just a couple of key points including the value of midwifery and the need for less special interest regulation that stifles innovative ideas that would lower cost and improve outcomes. There is so much about the massive health care bills circulating in the Senate and House that is just plain wrong that I don't even know where to start. So I will concentrate on just a couple of things. I am honored to go to represent the patient and practicing doctor. I have no delusion that anyone will actually listen but try, I must.

To all, a peaceful and loving Thanksgiving holiday. Stuart

Sunday, November 8, 2009

AARP and the House Bill

Those of you who know me know that I am fervently against the house bill on "health care reform" that apparently passed yesterday. This abomination of a piece of mutating legislation that no one has read and no one understands has been called by the Wall Street Journal editorial page as "one of the worst pieces of legislation in American history". If you are not well informed on this issue please consider checking out www.docs4patientcare.org and soon because it will negatively alter the basic nature of America . For the determination of Congress and the President to just do something, no matter if it makes no sense, is cost prohibitive, destructive to patient care and decried by the majority of Americans, should be frightening and maddening to all of us.

For AARP (the American Association of Retired Persons)to publically endorse this bill is baffling. Almost all experts agree this bill will hurt the elderly. So why would they endorse anything at this time. Why not wait until it has been reviewed, critiqued and examined by the CBO and the public? Why would they endorse a bill that is still changing and no one understands? Some claim that AARP has an economic interest in the billions from insurance policies they sell and that this piece of legislation will benefit them. Whatever the reason, their decison to endorse is premature and seems to throw their constituents under the bus. I called and had a cordial conversation with a representative of AARP. She had no answer for the question of "why now?". I told her that because they could not explain their position I could no longer support AARP and would not be renewing my membership. I would encourage you to call and ask questions for yourself.

Practice Update

It has been a while since I blogged on the local situation. I was waiting for clarifcation of a written discrepancy from my hospital regarding breech deliveries. One letter says patients must have a c/section unless delivery was imminent and another letter said they could choose to have them performed at the Oxnard facility. I finally received written notice this past Thursday that the unwritten ban on elective breech deliveries is correct. Women who are breech are to be told that they cannot labor at these facilities. Apparently, if they choose an option that is considered well within the norms of worldwide obstetrical practice, the attending practitioner will be disciplined.

The reasoning for this position seems to be a circuitous argument against choice. They selectively quote ACOG recommendations for breeches (Committee Opinion #340) to be performed "under hospital-specific protocol guidelines for both eligibility and labor management". Yet they have no protocols or guidelines so therefore elective breech deliveries cannot be performed. Also, they do not seem to be in any hurry to write them. It has been suggested that I work with the OB department to develop such guidelines. I have written a set of simple guidelines for this most natural of processes. I have extended an offer in writing, both in the past and presently, to contribute to the process but have yet to have any invitation from the OB committee. Meanwhile, patients have to wait in limbo.

Finally, in the context of the breech discussion, the hospital administration states that their facilities are not suited for procedures that challenge established professional norms. Once again, clarifying their position that a patient's choice of a breech delivery is outside the norm for a trained, skilled practitioner. Those of us that perform breech deliveries and keep up on the current literature and evidence know that there is nothing special about this "procedure". Breech labors progress or don't like any other labors. They succeed or stall like any other vertex labor. On occasion they require urgent intervention like any other labor. They do not require any special staffing or equipment. Any unit that can do vertex deliveries, high risk obstetrics and elective c/sections can surely handle the laboring woman with a frank or complete breech.

I must respect their position even though I disagree with it. Hospital's have the right to make choices for whatever reason and to have those choices honored. I just wish they felt the same about the patients they profess to serve. In my opinion, they are missing out on a great marketing opportunity. I have expressed this to the CEO but his options are limited as he defers medical decisions to the OB committee. So, what to do? Well, they say, "If you can't beat them, join them." However, what if joining them is out of the question because it compromises your values? My hope is to compete with them. To provide another model to deliver obstetric care in a facility that is midwifery model and patient friendly. This is what I am working on and will keep you posted. Have a good week. SJF

Sunday, November 1, 2009

Excerpts from an essay by Rich Winkel

Hi All, I was scheduled to do a webcast on "Thought Crime Radio" with Janel Miranda and her co-host Rich Winkel last Monday but came down with the flu. Janel sent me some of Rich's writngs and literature searching which I found provocative and certainly worth sharing. Please take a moment to read:

The American Way of Birth: Trauma and Brain Damage

(excerpt from a letter to a legislator)
by Rich Winkel

Munchausen Obstetrics

... I've been horrified to discover a pattern of wholesale
institutionalized medical malpractice and quackery surrounding the
business of birth and child health. I can't account for how this
could have come to pass, but the science is difficult to ignore.

First let me mention the epidemiology: a steadily rising rate of
symptoms of trauma and brain damage, including ADHD, autism, mental
illness and addiction among US-born people, a trend dating back to
the post-WWII period when certain obstetrical practices became

These practices are now thoroughly entrenched and seem to be immune
from appeals to science, human rights or common sense. It appears
that medicine views the bodies of women and children as some kind
of empty wilderness waiting to be conquered and colonized.......

The huge dinosaur of american obstetrics is
creating generation after generation of unconsciously traumatized
and often subtly brain-damaged people, people whose lives are often
subsequently burdened with criminal behavior, learning difficulties,
ADHD, addiction, depression and other mental illnesses and symptoms
of brain damage. These iatrogenic outcomes are entirely preventable,
in fact in most cases can be avoided at less cost than the procedures
which cause them. The question of whose interests are served by
making birth needlessly difficult I'll leave to your imagination........

Furthermore, most of the medical "heroics" which lead to these
iatrogenic outcomes are a product of legal pressures
and medical culture and incentives rather than responses
to actual medical crises. For instance:

1) "The majority of hospitals and obstetricians in this country (still)
insist on a birthing position that quite literally makes the baby,
following the curve of the birth canal, be born heading upwards.
States Williams: "The most widely used and often the most satisfactory
(position for delivery) is the dorsal lithotomy position on a
delivery table with leg supports" (Cunningham et al. 1989:315). No
reasons why this position is "the most satisfactory" are given, but
a strong clue is provided in an earlier text:

The lithotomy position is the best. Here the patient lies with
her legs in stirrups and her buttocks close to the lower edge
of the table. The patient is in the ideal position for the
attendant to deal with any complications which may arise (Oxorn
and Foote 1975:110)

"This position, in other words, is the easiest for performing obstetric
interventions, including maintaining sterility, monitoring fetal
heart rate, administering anesthetics, and performing and repairing
episiotomies (McKay and Mahan 1984:111).........

2) "Immediate clamping of the umbilical cord at birth has become a
standard procedure during the past two decades. This merits
investigation as the cause of increased incidence of autism. Clamping
of the umbilical cord before the lungs function induces a period
of total asphyxia and produces severe hypovolemia by preventing
placental transfusion - a 30% to 50% loss of blood volume - resulting
in a hypoxic, ischemic neonate at risk for brain damage.
As in circulatory arrest and other factors that disrupt aerobic
metabolism, damage of brainstem nuclei and the cerebellum can result.
Visible damage seen in some cases of autism also involves brainstem
nuclei and the cerebellum. The brainstem auditory pathway is
especially vulnerable to brief total asphyxia. Impairment of the
auditory system can be linked to verbal auditory agnosia, which
underlies the language disorder in some children with autism.
Due to blood loss into the placenta, the immediately clamped neonate
is very prone to develop infant anemia that has been widely correlated
with mental deficiency and learning / behavior disorders that become
evident in grade school.
We propose that increased incidence of autism, infant anemia,
childhood mental disorders and hypoxic ischemic brain damage, all
originate at birth from one cause - immediate umbilical cord clamping.
This deserves to be investigated as extensively as genetics or
exposure to toxic substances as an etiological factor for autism.
Normal cord closure, with placental oxygenation and transfusion,
prevents asphyxia and ischemia. Allowing physiological cord closure
at every delivery could at least reduce the incidence of birth brain

... "Immediate clamping of the umbilical cord before the child has
breathed (ICC) has been condemned in obstetrical literature for
over 200 years. [1] [2] In the 1970s, primate research [A][3][4]
using ICC to produce neonatal asphyxia resulted in brain lesions
similar to those of human neonatal asphyxia.".........

The trauma of being asphyxiated at birth after losing half your
blood to the placenta can only be imagined.

3) "In 1975, the College Entrance Examination Board commissioned an
advisory panel to examine the possible reasons for an alarming
continuing decline in the scores of high school students on the
Scholastic Aptitude Tests or, "SAT's," a decline which had started
with the 18-year-olds born in 1945 and thereafter. From 1963 to
1977, the score average on the verbal part of the SAT's fell 49
points. The mathematical scores declined 31 points. (1) (...)

"The SAT is designed to be an unchanging measurement. Considerable
effort has been made to keep the test a sufficiently constant measure
so that any particular score received on a current test indicates
the same level of ability to do college work that the same score
did 36 or 20 or 5 or 2 years ago. The SAT measures individual
students' capacities not only in comparison with their peers in the
particular group but also in comparison with those who took the
test in earlier years .... The SAT score decline does not result
from changes in the test or in the methods of scoring it." (2) (...)

"What happened around 1945 that might have contributed to declining
academic performance in the United States in the years that followed?
Consider this brief history: According to figures from the National
Center for Health Statistics, hospitals were the setting for only
36.9% of American births in 1936. By 1945 that figure had more than
doubled to 78.8%. In 1950, 88% of Americans were born in hospitals.
In 1960 the figure was 96.6% and in 1970, 99.4%. (...)

"A reading of the obstetric literature indicates that there had
always been philosophic differences among doctors regarding normal
childbirth. There were those who felt it was best to allow nature
to take its course and there were those who felt that intervention
was better. In the years following the 40s and under the stresses
of the population explosion, there was a tremendous acceleration
of intervention in obstetric care. Instead of adapting to the
time-consuming demands of normal childbirth, the obstetric community
(with very few exceptions) changed normal childbirth to conform to
the comfort of the mothers and the convenience of the doctors,
hospital staffs and hospital routines -- all at the expense of the
fetus and newborn."........

4) "ABSTRACT: Twenty years of clinical and behavioral observation
indicate that cesarean births cause considerable trauma to babies.
The physical and psychological effects are subtle and powerful,
occurring at the unconscious level of the infant psyche. Negative
impacts include excessive crying, feeding difficulties, sleeping
difficulties, colic, and tactile defensiveness. There also may be
long-term psychological effects such as rescue complexes, inferiority
complexes, poor self-esteem, and other dysfunctional behaviors and


"Prima Non Nocere: Iatrogenic Cesareans

"When used inappropriately, medical interventions interfere with the
normal process of birth and increase the risk of complications and
cesarean deliveries.28, 29 A US national survey of birth practices
revealed that 93 percent of women had electronic fetal monitoring,
86 percent had intravenous fluids administered through a blood
vessel in their arm (an IV), 55 percent had their amniotic sac
membranes artificially ruptured, 53 percent had oxytocin to strengthen
contractions, and 63 percent had epidurals for pain relief. More
than a third of labors were artificially induced. Almost three
quarters of the women were restricted to bed, and three out of four
were on their backs while pushing their babies out.30

Personal accounts from women who have had a cesarean, as well as
emerging research, suggest that despite a healthy baby and a timely
physical recovery, some women experience cesarean birth as a
traumatic event. An unanticipated cesarean is more likely to
increase the risk for postpartum depression and post-traumatic
stress disorder (PTSD). As in other traumatic human experiences,
the symptoms of birth-related PTSD may emerge weeks, months, or years
after the event.9,11 Women re-experience the birth and the emotions
associated with it in dreams or thought intrusions. They avoid
places or people that remind them of the event. Some mothers have
difficulty relating to their infants, and some will avoid sexual
contact that may result in pregnancy. They will also exhibit
symptoms of hyperarousal, such as difficulty sleeping or concentrating,
irritability, and an excessive startle response. Untreated
post-traumatic stress often leads to clinical depression.12".......

"Flat earth obstetrics is a 21st century version of a medical Dark
Ages, in which contemporary medicine has forgotten or ignored the
traditional knowledge base and physiological principles necessary
for normal labor and safe, spontaneous birth. Flat Earth Obstetrics
is the belief that medical and surgical interventions are necessary
in every normal childbirth, despite evidence that such a policy is
harmful. The term is derived from the insistence by religious and
political leaders during the Dark Ages that the earth was flat
despite evidence to the contrary.

"The problem with the current form of obstetrical care in the United
States is the uncritical acceptance of an unscientific method --
the routine use of interventionist obstetrics for healthy women
with normal pregnancies.

"Medicalizing normal childbearing in healthy women makes childbirth
unnecessarily and artificially dangerous."

"Obstetrics has been rated as the least scientifically-based specialty
in medicine" [Dr. Ian Chalmers 1987........

A letter from Leilah McCracken

Early organized medicine saw midwifery was successfully competing
with them in terms of safety and affordability while undermining their
claims to scientific authority, so they mounted a campaign to
force them out of the birthing business in the early 20th century

The next thing our altruistic medical profession did, after eliminating
one of the few professional opportunities available to women at the
time, was to discard their accumulated wisdom and pathologize and
try to control the whole process, rather than let nature take its
course. The results have been disasterous.

It seems medicine's appreciation for its own level of ignorance and
incentives to interfere is inspired by the chemical industry's
approach to the safety of its own products: innocent until
proven guilty. But while the economically conflicted medical
research establishment is busy catching up with monkeys and dogs
in its understanding of birth and child care, children are being
hurt, with often life-long consequences.

I urge you to investigate this issue. Once you crack open this
pandora's box, I guarantee your life will never be the same. But
you will have many allies, and as public awareness is raised, this
country will experience a time of self-reflection that will profoundly
change it for the better.

Thank you.

Rich Winkel

I have been temporarily reschedule to appear on "Thought Crime Radio" on December 28th, 2009. Will keep you posted. Stu