"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.

Wednesday, December 7, 2011

Breech Birth, a Reality

I was watching the brilliant movie "Inception" for the umpteenth time and saw a parallel for what those of us who believe that breech birth is just a variation of normal are up against. Like a virus, an idea, once implanted, is very hard to eradicate. Whether true or false, if this idea takes hold it changes the participant and the playing field and, thus, the world we live in.

Up until the early 90's delivering selective vaginal breech babies was taught in residency programs and practiced by obstetricians in the real world. When I trained there were studies supporting this idea including the pivotal work of Martin Gimovsky, MD in the early '80s.

Obstet Gynecol. 1980 Dec ;56 (6):687-91 7443110 Cit:22 Neonatal performance of the selected term vaginal breech delivery.
[My paper] M L Gimovsky, R H Petrie, W D Todd


Several authorities have recommended cesarean section for all intrapartum breech presentations. The present study documents that judiciously selected fetuses at term in breech presentation may be safely delivered vaginally by a selective management protocol that requires cesarean section when mandated criteria are not met. The outcome and performance of 6 years of vaginal breech deliveries were evaluated. Those in the control groups were delivered by spontaneous vertex vaginal and elective repeat cesarean section procedures. Morbidity was not different in the protocol breech vaginal delivery group and in the controls. Mortality was found only in the nonprotocol-managed breech vaginal delivery group, which also had a morbidity 5 times greater than that of controls. Approximately half the term breech presentations that are properly selected and managed may be safely delivered vaginally, thereby avoiding a significant number of cesarean sections and subsequent inherent risks.


http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1021563/?page=1

As residents we were eager to learn and excited for the opportunity to practice this skilled art and at Cedars-Sinai Medical Center in Los Angeles selective vaginal breech deliveries were the norm.

But in the 1990's the idea began to grow that maybe delivering breeches vaginally was risky. This thought culminated with the publication of the "Term Breech Trial" by Mary Hannah, MD in 2000.


Lancet. 2000 Oct 21;356(9239):1375-83.
Planned caesarean section versus planned vaginal birth for breech presentation at term: a randomised multicentre trial. Term Breech Trial Collaborative Group.
Hannah ME, Hannah WJ, Hewson SA, Hodnett ED, Saigal S, Willan AR.
SourceDepartment of Obstetrics and Gynaecology, Sunnybrook and Women's College Health Sciences Centre, Toronto, Ontario, Canada. mary.hannah@utoronto.ca

Abstract
BACKGROUND: For 3-4% of pregnancies, the fetus will be in the breech presentation at term. For most of these women, the approach to delivery is controversial. We did a randomised trial to compare a policy of planned caesarean section with a policy of planned vaginal birth for selected breech-presentation pregnancies.

METHODS: At 121 centres in 26 countries, 2088 women with a singleton fetus in a frank or complete breech presentation were randomly assigned planned caesarean section or planned vaginal birth. Women having a vaginal breech delivery had an experienced clinician at the birth. Mothers and infants were followed-up to 6 weeks post partum. The primary outcomes were perinatal mortality, neonatal mortality, or serious neonatal morbidity; and maternal mortality or serious maternal morbidity. Analysis was by intention to treat.

FINDINGS: Data were received for 2083 women. Of the 1041 women assigned planned caesarean section, 941 (90.4%) were delivered by caesarean section. Of the 1042 women assigned planned vaginal birth, 591 (56.7%) delivered vaginally. Perinatal mortality, neonatal mortality, or serious neonatal morbidity was significantly lower for the planned caesarean section group than for the planned vaginal birth group (17 of 1039 [1.6%] vs 52 of 1039 [5.0%]; relative risk 0.33 [95% CI 0.19-0.56]; p<0>


INTERPRETATION: Planned caesarean section is better than planned vaginal birth for the term fetus in the breech presentation; serious maternal complications are similar between the groups.

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(00)02840-3/abstract

Finally, those that were against teaching or performing term vaginal breech deliveries and did not want to investigate further had their evidence. Never mind, that within 2 years after the paper was published there were a slew of articles and papers critical of and refuting Dr. Hannah's research and conclusions.

Well summarized here: http://www.breechbaby.info/termbreechtrial.pdf

Too late! The seeds of the IDEA that breech vaginal birth is dangerous had been planted. And this idea was rooted in welcoming fertile ground as it justified the easier, less time consuming, more lucrative and thought to be less liability ridden c/section as standard of care for frank or complete breech at term. An idea, regardless of its validity, is made all the more powerful when it fits the current trend in the medicalization of birth and the fear based model that restricts individual choice. It infects the population and the profession to the core and has led to a stoppage of even teaching the knowledge and technique of vaginal breech delivery to future practitioners. Our halls of higher learning have no shame in denying future mothers this option due to a simple idea based in fear.

Fortunately, some forces are beginning to wake up from the nightmare and realize that "inception" has taken place. Maybe they have a "totem" of their own or just maybe common sense is an antidote to the viral model of a long festering idea. The Royal College of Ob/Gyn in England and The Society of Ob/Gyn of Canada have issued statements in the last couple of years in support of retraining new doctors in the methods of vaginal breech delivery. Even the American College of Ob/Gyn has a clinical guideline paper in support of selective vaginal breech delivery as a reasonable choice for the skilled practitioner and the informed woman.

Those of you who know of my work are aware that I have supported true informed consent and birth choices including the option of vaginal breech delivery. I have been ostracized in my former local community for many of my views and this has led me to choose the path of supporting women's choices in the home and birthing center setting where I do believe that common sense, individuality and evidenced based medical practice can freely occur. With the help of social networking, celebrity advocates and a growing number of devoted maternal care givers an old idea, that normal birth is not a disease and that selected vaginal breech is just a variation of normal, is being re-sown. I believe we can awaken my colleagues and the American populace from "limbo" even if it is one person at a time. A good idea need not be a virus. It may awaken us, as in Christopher Nolan's incredible movie, to the sanity and reality of the beauty of home and family and natural birth.

It is with these comforting feelings that I and my birthing Instincts team of Beth and Jaclyn and doula Robin announce the successful home breech birth on 12/5/11 of an 8 pound baby boy to glowing parents Hallie & Michael. Planning a home birth with the great midwives of South Coast Midwifery they found themselves in the not uncommon dilemma of persistent frank breech at term. Having no success with the usual measures to turn the baby they looked for options. Sadly, they could not find a single facility in Orange county willing to allow them a natural birth. C/section only! Lorri from South Coast knew of my practice and my philosophy and referred them for a consult only last week. We spoke several times for several hours and really connected. They had the right stuff and met all the criteria for a selective breech delivery. The very next day labor began and in less than 7 hours Hallie gave birth at home in their bed with grandma present. Congratulations to them on this blessed event and for their conviction.

I do believe that term breech presentation should be treated as just a variation of normal. And if selection criteria are met then informed consent and choice belong to the woman and her loved ones. While a hospital that respects autonomy would be an ideal place for these women to give birth that is not the current reality we live in.
Choices are so extremely limited. That is just one of the most compelling reasons why another birthing option is so needed in America. Under the current medico-legal and economic climate I do not foresee hospitals and physicians currently in practice changing from the "breech is dangerous" idea. The dream of the Sanctuary Birth & Family Wellness Center and I and a few of my colleagues, too, is to build our own maternity facility where individuality and common sense and respect for birthing are, once again, the norm. Dr. F

6 comments:

  1. I'm currently training to be a midwife in southern California and I hope to be trained in breech and twin deliveries at some point in the near future. While it seems that these births ~might~ be safer in a hospital setting, the hospital settings are not currently safer due to attitudes and inexperience with these types of births. Hopefully one day I can learn from you!

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  2. I appreciate your perspective. Every time you post, you floor me in two ways- 1. That there is hope and 2. That not all doctors are brainwashed. Thank you.

    (Degrees in progress- ASN/BSN/CNM/OBGYN

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  3. As the mother of the above glowing new momma, Hallie, I can testify to the amazing experience of watching my first grandchild being born. Dr. Fischbein was stellar in his calm approach to helping Hallie deliver her beautiful baby boy. The entire atmosphere in the home was peaceful, organized, loving, and again, calm. God's design of woman to give birth was manifested Dec. 5th, 2011 in their bedroom, the way that Michael and Hallie had envisioned it, and if it were not for Dr. Fischbein, (and Hallie's pre-qualifications) she would have delivered in hospital via c-section. Thank you Dr. Fischbein and the team for having faith in Hallie and Michael, and God's design. God bless your continued work.

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  5. Thank you all for your supportive comments. I hope to develop a free standing facility which can act as a referral center for women who want to deliver breech and twins in natural way. I do not foresee any epiphany for acceptance and change in the hospital based birthing arena. Thus the need for another option. I had a recent stellar conversation with a chief resident from Kansas who is asking all the right questions of the establishment. She gives me hope that common sense will slowly win out. And Barb, it was an honor for Beth and I to share in your family's blessed event. Dr. F

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