"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.

Sunday, November 8, 2009

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

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