"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, May 15, 2011

More on Breech and Informed Consent


For those interested, the Royal College of Obstetrics & Gynecology has put out revised parameters supporting an option of vaginal breech delivery. Based on research that debunked a lot of the information in the earlier Term Breech Trial that organized medicine originally jumped on to recommend c/section for all breeches. The RCOG is way ahead of ACOG in the strength of their statement and the commitment to try to reeducate practitoners in the art of breech delivery. If you are breech or have a client who is breech at 35-36 weeks this would be an excellent educational, calm reasonable website to refer to families who want to know more. Might keep them from surfing the interent in unfiltered and sometimes hysterical sites.

When considering a home breech delivery, as that may be the only option left in many areas, it is important to give true informed consent. The most significant difference in a home birth with a skilled practitioner is the lack of ability to use Piper forceps for my midwife colleagues since this is out of their scope of practice. Trained physicians can use these helpful aids and I carry them in my birth supplies. Once again, showing the collaborative approach of midwife and doctor teaming up can provide optimal care. Of course, we all know how few doctors there are willing to collaborate with the midwife community and the pressure those few are under from their peers. Also, the diminishing number of doctors skilled in breech delivery is concerning. Lastly, home birthing also lacks the immediate availability of general anesthesia in the extremely rare case where complete uterine relaxation is necessary to assist in delivery of an entrapped head. Women need to know these things but they must be presented in the light of the reality that the likelihood of this frightening problem is extremely rare when proper selection criteria labor management for breech delivery are used. In my opinion, the risks of a complication that is life threatening is more common from a surgical birth and these should be discussed as well. Then, whatever decision is accepted by the family should be respected. Where vaginal breech delivery is the preference but not an option, an ethical practitioner should refer that patient to someone who can honor her request.

From the AMA's Code of Ethics:
The patient should make his or her own determination on treatment. The physician's obligation is to present the medical facts accurately to the patient ... and to make recommendations for management in accordance with good medical practice ... Rational, informed patients should not be expected to act uniformly, even under similar circumstances, in agreeing to or refusing treatment

Dr. F

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