Confirmation of ACOG damage

For the umpteenth time since release of ACOG's Committee Opinion #476 I have seen the propagation of its misinformation. I use Google Alerts to help me review stories around the world on home birth. In story after story having to do with this subject, other "experts", reporters and sources quote its conclusions of a 3-fold increase in neonatal death blindly and as definitive fact. Funny, how it is almost verbatim and the virtues of home birth quoted by ACOG are never equally extolled. I can only assume it is because an organization such as ACOG has a built in gravitas that writers will rely solely on its statement without doing any further research. I have spoken about this to ACOG leaders as a consequence of its standing in the medical community. With great power comes great responsibility. ACOG and Dr. Wax have much to answer for but almost certainly will not.

So, for the umpteenth time I have written to to the writer or posted a thought in the comment section to at least give another perspective. I encourage readers to take a moment to respectfully do the same when they come across a reporter quoting an expert who categorically uses the "3-fold" line. Dr. F

Here is what I wrote this morning in repsonse to an article in The Herald, an Australian newspaper:

Dear Ms. Hadfield, For the record, Dr. Andrew Pence is quoting data that is well known to be incorrect. It is from one flawed study by a researcher named Wax who cherry picked his meta-analysis data to reach his conclusion on the perils of home birth. Dr. Wax's motives for doing so are unclear. The truth is far different. He excluded the largest studies from North America and the Netherlands which showed no such risk and, in fact, in comparable low risk patients showed far less intervention and c/section rates and greater satisfaction in women who had home births. Dr. Pence makes a common mistake in relying on data that is supportive of the established medical position rather than looking critically as a scientist should. Then relaying this misinformation as if it is undisputed fact. Reporters often go to academic sources with a blind trust that they are objective and their advice is evidenced based. Sadly, neither is often true. Home birth in low risk women is a safe alternative and a choice that belongs to them when given true, not skewed, informed consent. I would be happy to discuss this further if you are interested. Warmest regards, Dr. Stuart Fischbein, MD FACOG

Stand & Deliver Offers Breech Skills Workshop

www.rixafreeze.com/pdf/breechflyer.pdf.

I received this e-mail from my colleague, Rixa Freeze, of the great web site Stand & Deliver. Please pass on this info to anyone you know who might be interested in learning or relearning these skills. Good stuff! Dr. F

Hi Dr. Fischbein,

I am thrilled to announce a vaginal breech skills workshop coming to Indianapolis this July! Participants will perform and observe simulated vaginal breech deliveries with Canadian obstetrician J. Peter O'Neill and learn upright (hands & knees) breech techniques from Canadian midwife Betty-Anne Daviss. She will also be giving a free public lecture about upright breech birth on Saturday, July 16th.

I have attached the flyer & registration form (PDF). You may also access it at www.rixafreeze.com/pdf/breechflyer.pdf.

Please circulate this to other physicians or midwives who might be interested in updating their vaginal breech skills. Don't forget to take advantage of the early registration discount before April 15th.

I hope to see you there!

Rixa Freeze, PhD

Rainy Day Philosophy

Living in Southern California has many advantages. One is the absence of snow days and another is the rarity of rainy days. Life slows down for me on a rainy Sunday morning. No place to run to. Horseback riding cancelled. Cat asleep at my feet. The sound of the wind and rain on the roof all cozy in bed with my book momentarily unhooked from the world. It is wonderful to slow down in today’s buzzing world of instantaneous information overload and short attention spans.

Then I open my computer to read the amazing notes of my midwife colleagues at Sanctuary attending 4 separate births in the last 24 hours. Maybe there is something to the super moon thing! They post on the board of the natural progress of labor that comes in so many different forms. With calmness born of wisdom they describe what the families are doing at home. Some resting quietly while others are up walking and talking. Some sit or stand in water while others forage in the kitchen for the perfect nourishment to suit their craving. Fathers and doulas and midwives and apprentices and hypnosis experts and children and pets all are choreographing this dance of life. I was speaking to my great friend and colleague, Heather, in the comfort of The Sanctuary Birth & Family Wellness Center, this past week and the following realization just flowed forth.

I have now attended more than a dozen home births and have noticed many differences from my 28 years of attending hospital births. But none is more striking than how the environment affects the traditions and attitudes of the practitioners. In a hospital based birth the primary care giver is almost always a nurse or possibly a CNM. They are bound by policies and procedures that limit individualization. No matter what the desire of the family dictates there is pressure on the staff to complete forms and data entry. They must document “progress” and even encourage intervention when it does not conform to some standardized norm. To not push the process along can bring the scorn of their supervisor. Nurses are encouraged to monitor all sorts of bodily functions and even the most caring have to deny food and interrupt the primordial place a woman should be for the sake of documentation.

Documenting what and for whom? When and why then? Likely for administrative policy, litigation mitigation for that worst case scenario fear, for the next nurse and doctor coming on in the shift practice model or just one of those long habits of not thinking a thing wrong, thus making it seem right. But that is all the consequence of the dominant trend to look at pregnancy and labor as illness, not wellness.

In this model there is rarely a doctor present until called by the nurse to come in. From experience I think many nurses fear this for woe be unto them for calling the doctor too soon or too late. From my past experience I vividly recall arriving to the labor room from home or office. Invariably, all eyes would now focus on me and I would be expected to do something. Many doctors would feel as if they must do something because they are now there. And so there would be vaginal exams and commands to push when no urge was felt. The nurse would receive orders for pitocin and pressure catheters because labor was not following the curve fast enough. Discomfort is difficult for doctors to observe so the wonders of an epidural would be lauded.

It would almost be inconceivable for the doctor to arrive, sit quietly in the corner observing for a while, whisper a few words of encouragement and then quietly leave the woman and her partner alone. The “I am here now so I must do something” mentality is pervasive. It may be the rescuer in us, the fixer or it could just be an impatience born of long hours, frustration, poor rewards and fear. Whatever the reason it is pervasive and is a startling contrast to the calm, nurturing approach of my experiences with home birth.

When I arrive at a home birth after a gentle knock on the door I quietly enter the space with a whispered greeting to the father or other caregivers. I observe the room, listen to the sounds and look at the faces of those present. There is so much vital information there that no machine can tell me. There is an honoring of the process and the woman in labor is on a pedestal. She is a person not an object. The goal of all those around her is to keep her feeling safe and nurtured and in whatever zone will keep her focused on the primitive, instinctual processes of labor. There is no timetable and no hustle and bustle of disturbances. There are only the sounds of nature and family linking us to all those that came before. We are calmly waiting for another generation to enter the world.

The conversation with Heather clarified what had been just a feeling since joining the home birth community and made it a revelation to me. My midwife colleagues have heard me say that no matter how I am feeling before I enter that sacred space of the nurturing birth world I always leave feeling better then when I came in. That was almost never the case when entering even the parking lot at a hospital. It is a striking difference to enter the world of the laboring woman and not feel like I am obligated or entitled to do something. Trusting birth makes it a better world for everyone involved and returns the joy to my work.

We have all created a safe and cozy space for ourselves. We call it home. On this windy, rainy Sunday there is no place better to be. I am surrounded by familiar sounds, sights and smells and it feels wonderful. It is a metaphor for life and certainly for birth. Building a secure, nurturing support system is good for your life and better for your birth. There is much to be said for returning to the pleasures of sociability and being intentionally unproductive. I would encourage my fellow practitioners to take a deep breath, look about them, walk more slowly and rethink the model which has become so normal and yet so detrimental to the enjoyment of their lives.

Warm Greetings To You All, Dr.F

NY Times article on NICU Costs

Sometimes you have to weed through a pile of junk to find a few pearls of wisdom. Thats my feeling about the majority of junk, called news, in the NY Times. However, this article was forwarded to me from my colleagues at D4PC.
(www.docs4patientcare.org) It has some good points including support for ones of profit motive that I have mentioned in the past when discussing some of the policies of the NICU and its director at St. John's Regional Medical Center in Oxnard. Whatever your take it is food for thought. Dr. F

http://www.nytimes.com/2011/03/20/us/20ttnicus.html?hpw

Scientific American Article worth reading.

Please check out this link to an article in Scientific American that discusses The Wax Meta-analysis Paper that ACOG relied on as justification for its position against home birth and certified professional midwives. It fairly presents an unbiased view that, at best, many experts question its veracity.

http://www.scientificamerican.com/article.cfm?id=home-birth-study-investigated

Garbage in, garbage out. Science is not served when there is an agenda first and then data is cherry picked to bolster that agenda. I have no knowledge of Dr. Wax's agenda but ACOG diminishes themselves by showing theirs in choosing this paper as its sole basis for justification of its opinion on home birth. Readers should do their best to decide for themselves what the evidence and common sense tells us. Dr.F

Collaboration at work

2 Days ago I was asked by one of my midwife colleagues to come to their clients home and assess the mom for a prolonged second stage. The mom had reached that "wall" and could no longer push effectively. After about 4 hours of trying different things in an otherwise healthy, nurturing environment they were talking transport as the standard option. However, now that I am contributing to the out of hospital birthing community we had another choice. I arrived to find the baby doing well and mom leaning on an exhausted but incredibly supportive husband. After talking it over with dad and the amazing team we decided that a vacuum delivery was a good option for them as they did not want to go to the hospital after such heroic efforts at home and for financial reasons. I examined mom and felt the baby to be OA, slightly asynclintic and +2 station. Not much molding or caput. We repositioned to the sofa and with a cooperative baby and a revitalized mom they gave birth by vacuum assisted vaginal delivery to a beautiful baby girl in their living room illuminated by the late afternoon sun. Beautiful relief on parents faces. Birth team, too. It was a great example of combining the skills and knowledge of the midwife-OB-doula in a collaborative effort to give families another choice. Love to Molly, Heather Anne, Kim and the trusting family. Dr. F

Followup Letter to ACOG President

I have found Dr. Waldman to be sincere and I hope I am right. It has been 2 months since I wrote to ACOG regarding Committee Opinion 476 on Home Birth. This e-mail is a followup to my correspondence with ACOG's president and is self explanatory.

3/11/2011

Dear Dr. Waldman, Hope this note finds you well. In your email to me from January 25th you mentioned that Dr. Hale would be passing my letter on to the committee for what I had hoped would be some honest answers to my serious doubts about their science and motivation in releasing Opinion 476. Sadly, my expectations of receiving a response from them were very low from past experience and it seems that low expectations of your Opinion Committee were appropriate. I have the energy, knowledge, evidentiary support and willingness to discuss these issues with my esteemed colleagues who make up this committee. I am disappointed that a committee from my college is assigned the awesome responsibility to make statements that have a powerful effect on practice and policies in America but ignores legitimate questions and dissent from one of its own members. I hope you will accept my offer to contribute to any future discussions inside of or publically made by ACOG regarding the safety of home birthing, licensed midwives and patient's rights to true informed consent with the same sincerity that I voice my concerns to you. I am one of but a very few professionals in the country who have the legitimacy and wisdom of experience living and working in both worlds. Opinion 476 should never have been released based on the Wax paper. It damages the credibility of the College. If we as obstetricians really do care about honesty and truth towards the women we serve then there should be no other motive but those from an organization like ours.

Sincerely, Stuart J. Fischbein MD FACOG

A Comparison - You Decide

When I was on staff at my local hospital in 2009 I posted this data. Needless to say, I got yelled at and was ordered to remove it because it somehow violated confidentiality. No explanation given. Actually, I believe it was too revealing of the differences in practice styles and therefore embarassing to some. Well, I am no longer under threat of administrative retribution and therefore, once again, I feel this data deserves to be discussed. What it does show is that in a population of low risk mothers in 2008, comparing apples to apples, the midwifery collaborative model practiced by The Woman's Place for Health, Inc. had a primary c/section rate of less than 5% while another local large group of doctors adhering to the obstetrical model of medicalizing birth had a primary rate near 17%.
In this group of over 300 women an almost 4-fold risk of having a first time c/section in a comparable group of low risk pregnant women exists when birth is "treated" as a medical problem. In order to respectfully and honestly share the information of my collaborative practice and quell the naysayers I am in the process of compiling data from more than 10 years. I hope to publish "The Experience of an OB-Midwife Collaborative Practice" using statistical analysis and an evidenced based approach this year.
What those of us with common sense and the powers of observation have known for a long time about low risk birthing will benefit from as much objective data as we can get. Patients deserve as much truthful information as they can get to make an informed choice. I look forward to sharing my findings with you and with them. Dr. F

Small Community Hospital Deliveries from 12/1/07 to 11/30/08
Practice Total / # / Rate
Doctor A 75 / 10 / 13.33%
Doctor B 37 / 4 / 10.80%
Doctor C 51 / 12 / 23.50%
Doctor D 20 / 5 / 25.00%

Doctor E 14 / 3 / 21.40%

TWP 124 / 6 / 4.84%(Dr.F & midwives)
Other Large Group Total:
MDs A-D 183 / 33 / 16.9%
Deliveries and c/sections performed at a hospital that cares for almost exclusively low risk patients.

Gotta love Dr. Fogelson

My colleague, Dr. Nicholas Fogelson writes a blog called "Academic Ob/Gyn" at www.academicobgyn.com (see supporters). He is a strong supporter of delayed cord clamping and takes a common sense approach to decision making in our field. He has recently penned a column that expresses one of those pet peeves that nags at those of us who care for pregnant women. With his permission I have posted it below. Dr. F


An open letter to the dentists of the world
March 3, 2011
Nicholas Fogelson
22 comments
Dear Dentist-

Thank you for being there for patients around the world, fixing and cleaning their teeth and gums. Thank you for your training and your wonderful set of skills which we all need.

But today I have a bone to pick with you.

For the one thousandth time today I was asked to write a note for a patient with an obviously infected tooth, giving my permission for you to treat her. For the one thousandth time, I sat before my suffering patient, cursing your name, and wrote this ridiculous note. And now my patient can go back to you, and now you can do the job you should have done when she first came to you with her painful tooth.

As an obstetrician, I am expected to be expert in all things pregnancy. Not only that, but I am expected to understand how all things not pregnancy affect all things pregnancy. It was for this that I went to medical school and trained long in my field.

You are much the same.

As a dentist, you are expected to know all things oral cavity, and furthermore how all things not oral cavity affect all things oral cavity. It was for this that you went to dental school and trained long in your field.

And in this training, you no doubt learned something about the dental care of pregnant women. You probably learned that local anesthetics are not harmful to a pregnancy, and that the narcotics you prescribe for pain and the penicillin based antibiotics you use for infection are also safe. You probably learned that the millirads of radiation your oral films use are trivial compared the amount of radiation it would take to harm a fetus, and if you’re really on it you might even know that an obstetrician would do a 3 rad cat scan right through the fetus if he or she thought it was important enough. At the least, you know that the big lead apron you use is going to block anything that might get to the fetus anyway. You might have read that obstetricians are actually quite interested in oral health, and that we think that chronic oral disease may ironically be a contributing factor to the preterm labor you hope to avoid involvement with by refusing to treat oral disease in pregnancy women.

At the very least, you know that a fetus is kept in the uterine cavity, not in the oral cavity.

Since you already know these things, really what is going on is that you want your ass covered if under some strange coincidence something bad happens to a pregnancy after you treat a patient.

This is bullshit, and I am tired of it.

So forever more, here is a note for all the pregnant ladies of the world.



1. There is nothing you can do under local anesthesia that will hurt a fetus.

2. Penicillin antibiotics are safe in pregnancy

3. Local anesthetics are safe in pregnancy.

4. Narcotics are safe in pregnancy.

5. Oral xrays are safe in pregnancy. Shield the baby like you would any patient.



If after reading this you ever again send away a pregnant patient in pain because they need a note from their obstetrician, I have only this to say:

Grow a pair. You are doing your patient a disservice. Excercise the wonderful skills you spent years cultivating, and help your patient.

Special Delivery

With permission from the family, it is with great joy and pride that I can announce my first home twin delivery. On Valentine's day my multiparous client went into labor at 37+ weeks with known breech/breech twins. The family had previously had 2 successful home VBACs and knew that no hospital would have allowed her desire to deliver breech twins vaginally. She approached the Sanctuary Birth and Family Wellness Center in Los Angeles several months ago and we agreed to care for her. She was a wonderful candidate, well-informed and highly motivated with a background in the natural birth community. Her labor started with ruptured membranes about 3AM. She finally kicked into high gear just after dinner. The little girls behaved smashingly in utero giving mom her opportunity. Baby A was born breech on all fours in water at 10:05PM on February 14th, 2011. Things then settled down with contractions spacing out and Baby B happy as a clam. Meanwhile mom tried nursing and dad and big sister took turns skin to skin with Baby A when mom needed a break. Shortly after midnight labor kicked back in and at 12:20 AM on February 15th Baby B was born breech on all fours on land. The family was amazing as was the birth team assembled. Much is possible with an informed patient with the right attitude and confidence in her body. Trusting the birth process and allowing nature to do its thing will often win out if we let it. I have to admit it feels wonderful to be freed from rigid policies and restrictive protocols, often void of common sense or evidenced based support. If hospitals will not allow women the right of true informed consent and refusal, I and the Sanctuary Midwives are proud to give them another option. Regards to all, Dr. F

"Fearless Pregnancy" - Spread the Word

Facebook Post

A reminder to all that fears and anxieties are a barrier to a joyous birth. "Fearless Pregnancy" is now in its second addition and available for purchase or download. Expousing midwife philosophy while explaining medical issues, this book alleviates doubts that interfere with a natural birth. Please consider recommending our book. Your clients will thank you for the reassurance it provides and your thoughtful wisdom. Thanks, Dr. F

www.fearlesspregnancy.net

“I am such a huge fan of yours — have bought your book for every pregnant friend since someone gave it to me when I was expecting. It is by far the best book out there!!" – Beth Lipton, mom, cookbook author and blogger at Cookie Pie