"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.

Monday, December 24, 2012

Dissecting the Ethics of the Ethicist

Merry Christmas and much hope for a honest and healthy new year in 2013. As I mentioned in a previous blog there was an opinion piece in the American Journal of Obstetrics and Gynecology online version from November by Chervenak with which I took issue. Its titled, "Planned home birth: the professional responsibility response" and is intended to make the argument for health practitioners to use against those who desire or support out of hospital birthing. It would be all too easy for practitioners to read this, consider the source and trust it as gospel. Critical reading of this article, however, shows it to be flawed and biased and even on occasion purposely deceitful. It is deserving of a point by point review and rebuttal but to do so by prose I found too lengthy and confusing. I could not figure how to respond to the AJOG in a letter with an acceptable word count. So, the past few weeks I have been working on a power point presentation which has the ability to present Dr. Chervenak's positions and evidence based counterarguments in a meaningful and comprehensible manner. I intend to begin to offer lectures and gatherings so that this paper does not go unchallenged. Please spread the word to your local groups and let me know if you would like me to come and speak. Ideally, obstetricians uninformed or against home birthing would be a great audience but it would be an honor to present this debate to all interested parties. Warmly, Dr. F

Tuesday, November 13, 2012

The Battle Against Home Birth Choice Escalates

Another anti-home birth article was published in this months American Journal of Ob/Gyn. I want to stress that this is an OPINION piece and not a study. I have already seen many news articles that refer to a new "study" out against the safety of home birth. I cannot link it directly but I am certain it will continue to get lots of play from home birth detractors. This one is specifically written to assist obstetricians in developing arguments and reasons not to support the option of home birth. Planned home birth: the professional responsibility response. Chervenak, et al. AJOG Clinical Opinion November 2012 The positions and arguments presented there are worthy of point by point review in the proper forum. For now, here are some of my quick insights: This is nothing new from Dr. Chervenak. In my opinion he gets lost in his own glow on this subject into which he has put an inordinate amount of time and effort. I am still confused how he places fetal rights above those of the mother in todays society. While I agree that the fetus has rights it would seem the abortion without restriction argument has won the day in the recent election cycle making that argument questionable at best. He cherry picks much of his data and suggests a model of professional responsibility ethics that fits his purpose while excluding the beneficence model he has supported in the past. He still relies on the disputed Wax paper and a lot of data from Southern Australia. I know nothing about southern Australia but I highly doubt it is as filled with proximate medical centers as is Los Angeles County or other large urban areas in America. Quoted rates of transfer from the Netherlands study seem high relative to my own 26 years of experience working with home birth midwives. Nonetheless, a nonemergent transfer, as most of them are, is not a reason to deny a woman the option. I read some of his data and examples and anecdotes and come to completely different conclusions as to the decision process. Clearly, we both have a bias. Chervenak is a bright man who considers his opinions to be truth and unassailable. I do agree with his recommendation that doctors and hospitals become more friendly and nurturing to women and offer a full course of options. Until that day comes, however, there is no place like home as a legitimate choice for some women. Dr. F

Term Breech Trial R.I.P.

“Hands off the bum” was the message at this year’s Heads Up International Breech Conference. It was quite a gathering in Chevy Chase, Maryland. I want to express my most sincere gratitude to Robin Guy and her whole team for putting together a marvelous weekend. I attended as a moderator and panelist and feel very fortunate to share the spotlight with luminaries in the field. We were honored to have doctors Anke Reiter from Frankfurt, Germany, Andrew Bisits from Sydney, Australia, Marek Glezerman from Israel, Martin Gimovsky from Newark Beth Israel Hospital in New Jersey, Michael Hall from Colorado and Dennis Hartung from Wisconsin. Midwives Ina May Gaskin, Ibu Robin Lim, Jane Evans and Betty Anne Daviss were amongst a host of experts and educators in the world of breech delivery. It was a marvelous weekend with so many nurturing people supporting the reasonable option of selected vaginal breech delivery. Research was presented from 3 major academic centers that support the safety of vaginal breech as a reasonable and evidenced based choice and putting to rest, hopefully forever, the Term Breech Trial as something to be relied on as a basis for denying the breech option. There seems to be no significant difference in neonatal morbidity between vaginal and cesarean section for breech. There is a greater risk for the mother in this and future pregnancies when c/section is performed. All agreed that a change is needed in education for young physicians and midwives. Reintroducing breech delivery will not be easy as the skill and willingness has waned. We all believe the leaders of our profession including ACOG in the U.S. need to take a more active role in encouraging this movement. Ideally, specialized breech training centers such as exists in Frankfurt, Germany will open up creating the volume needed for interested doctors and midwives to learn the skills. Dr. Reiter presented her and Dr. Frank Leuwen’s techniques of delivering breech babies meeting their selection criteria in the all-fours position. They use MRI to measure the pelvic conjugate as their main criteria for inclusion. Other presenters used more traditional inclusion criteria but all agreed that selected vaginal breech delivery in experienced hands is a reasonable choice with a 60-70% chance of success. As with VBAC, if this option is dismissed by hospitals and doctors then they are wrongly condemning that percentage of women to surgery and the greater risk that incurs. Choice belongs to the informed woman! We were treated to videos and testimonials and birth stories from professionals and from some brave women willing to share their personal histories. Never let it be said that a healthy baby is all that matters. Some of these women still shed tears when they recall their births and how they had to struggle against skewed informed consent and a system that had failed them. We as a profession can do better. A special thanks to my colleague Beth Cannon, LM for her support of my bid to bring breech back to Southern California. And to Kimberley Van Der Beek for taking 4 days away from her family to share her breech experience, speak on two panels and host movie night. Changing old habits, especially those that are bolstered by convenience, economics and liability concerns will not be easy. But honesty and ethics must prevail to maintain the respect our profession deserves. Selected vaginal breech delivery is an evidenced based option that should be honored. This means offering it should attempts to turn the baby fail if the practitioner is comfortable and competent or referral to someone who is if they are not. For it is inevitable that some women will present in advanced labor with the breech presenting. Best we all relearn the skills as to be an obstetrician means more than just being proficient with a scalpel and a pap smear. I look forward to spreading the word and the skill. Thank you Coalition for Breech Birth!

Friday, November 2, 2012

Ethics Under Assault

It’s a story that seems all too common; the recurring harassment of supportive and optimistic doctors willing to collaborate with midwives. Honest and brave doctors who want to provide evidenced based options to women are forced into a choice of business survival vs. professional morality. The power of the big over the small, the bully over the weakling, it’s a story of sham peer review to maintain the status quo. Somewhere along the line the ethical and moral code we swore to uphold gets pushed aside for expediency, economics and fears of liability. The story plays out as good people who remember their fiduciary duty to their patients are harassed and eventually squashed by the behemoth that is conveniently called the “standard of care”......... Because the established medical machine says that something is outside their rigid community standard then the supportive doctor cannot be allowed to individualize his care and support other reasonable options. They believe that “consensus” equates with truth. It does not. And if you are not in their fold then you are a danger to them, their liability and their livelihood and must be coerced into conforming or risk the isolation from colleagues and the threat from hospital committees and administrators. This is happening all over the country and recently to some wonderful local doctors. Having been through this I would not wish it on anybody......... The modern doctor-patient relationship is not the one we grew up with. Although doctors are still expected to treat their patients with the same measure of duty, skill and care that has always existed there are new and powerful outside forces pressuring that relationship. There has always been a duty owed to the patient that remains a “fiduciary” wherein the patient’s interests must be paramount to those of the doctor. This faith and trust placed in the doctor by the patient all too often comes in conflict with the doctor’s own interests. Doctors have many pressures put on them by third parties such as government agencies, malpractice insurance companies, hospital administrations and third party payers. Often these interests directly conflict with the fiduciary duty to the patient.......... As I see it, too many of my colleagues have succumbed to these pressures and thus prioritize not on what is best for the individual patient but what is going to help them survive financially. There is no doubt of the reality of the difficult choice they must make for themselves. If they truly thought about this it would be very painful. But in the mode of groupthink that has overwhelmed my profession the pressuring of the rare nonconformist is understandable. So as to remove themselves from responsibility the majority go along with policies that violate their fiduciary duty but protect them from direct culpability. They use the, “I wish I could honor that choice if only the hospital would allow it”, excuse rather than stand with the few who think decisions should still belong to the informed patient. On the simplest level these brave few who choose to honor Hippocrates make the tyrannical majority look bad and, so, they must be vilified.......... Furthermore, under the American Medical Association’s Code of Ethics there exists the beneficence model to which we are all supposed to adhere. According to Sonya Charles in her recent Medscape article on The Ethics of VBAC, 2012 The Hastings Center the beneficence model makes a peculiar claim: “To interpret reliably the interests of any particular patient from medicine’s perspective. This perspective is provided by accumulated scientific research, clinical experience and reasoned responses to uncertainty. It is thus not a perspective peculiar or idiosyncratic to any particular physician. Based on this model, the physician cannot refuse to accommodate any request for alternative treatment that is supported by scientific research and clinical experience."......... My point is this: Hospitals, medical staffs and groups of physicians that wield power over individual physicians and smaller groups and threaten their livelihood if they do not conform to whatever standard they deem appropriate are violating both their fiduciary duty and their ethical obligation to the people of their community. Doctors who support patients who choose a midwife are honoring their ethical obligation. Doctors who allow for selected breech delivery, VBACs and twins are honoring their fiduciary duty and their ethical obligation to put their patient’s reasonable choice ahead of their own self interest. It would be just as ethical for a doctor to say to a woman that he cannot support that choice but refer her to someone who can. It is also the ethical and, I would say, moral responsibility of those doctors to aggressively advocate for those reasonable choices in the facilities in which they practice and with the insurers who restrict the rights of patients to choose. It is too easy to throw up ones hands and do nothing but it is not right, it is not moral......... What is also not acceptable is for doctors to skew their consenting to funnel patients into choices they prefer. It is a violation of their ethical code to punish doctors who put the fiduciary interests of reasonable patients before their own. Worse, it is immoral to do these things for financial gain or for expediency in lifestyle. Yet, sadly, this goes on every day and has become the accepted norm. I encourage every patient to educate themselves on reasonable choices for their health. Go discuss them with your practitioner. If you are met with skepticism or disdain present the ethical and fiduciary argument and see what response you get. Many doctors have lost sight of these simple tenets and seek retribution when confronted by a colleague who tries to point this out. The power for change lies with the consumer and those of us who honor the doctor-patient relationship as it was once intended are counting on you for help.

Wednesday, August 1, 2012

Events and Updates

A few months back I was interviewed on the internet about my philosophy of birthing. You can view the Skype interview at : http://yourbabybooty.com/interviews/how-to-be-fearless-in-pregnancy-childbirth-dr-stuart-fischbein-interview/ A word of caution about the transcript. There are a lot of obvious transcription errors and such but the content is worthy of your time. Also, want to announce another successful external version this week at the Sanctuary. This first time mom had exhausted all other remedies and using hypnosis by Luree the unmedicated procedure took less than a minute. It feels great to use the skills I learned years ago for the benefit of our clients and the honoring of informed choice. Of the nine deliveries I have attended over the last 3 months there have been 2 breeches and 3 VBACs (Including 1 VBAC after 2 c/sections). All nine families had joyful and amazing out of hospital birthing experiences. Makes one have to stop and think that in my Ventura County community at least 5 of these 9 would have ended up being delivered by the only option available in the hoapitals - a cesarean section. Necessary? Elective? Is that how you would describe the diagnosis placed on their operative reports by the obstetric surgeons who performed them? Tomorrow, Thurday, August 2nd at 11:30 AM I am being interviewed on internet radio by Mary Oscategui's International Maternity Institute. The topic is "Fearless Pregnancy". Please tune in or catch the podcast later. http://maternityinstitute.com/ This Sunday, August 5th, is Boobie Palooza in Los Angeles sponsored by The Berlin Wellness Group amongst many others. I am on a panel that includes Ricki Lake at 12:30. See: http://www.boobie-palooza.com/ Please check these events and interviews out. Thanks, Dr. F

Saturday, June 2, 2012

ACOG President Respects Choice

Below is a blog from ACOG President James Breeden published this week. On the heels of my article about cognitive dissonance I thought it appropriate to post Dr. Breeden's honest thoughts on collaboration, choice and individuality of decision making. Kudos to Dr. Breeden. While he may not agree with every choice a woman makes nor every option I and many midwives may offer he respects our differences and expresses the ethical position obstetricians should take. This statement will be read by the leadership of the Ventura County Hospitals than ban choice. Hopefully it will not be so easily dismissed. Dr. F http://acogpresident.org/tag/home-birth/ Choosing a Hospital or Home Birth Posted on May 31, 2012 Home or hospital? The question of where to give birth is a topic of ongoing discussion among expectant moms, doctors, midwives, and home birth advocates. As the number of women who give birth at home increases, the sometimes heated debate about which is safer for women, babies, and families will surely continue. The author of a recent New York Times Magazine article wrote “It is unfortunate that the choices and the rhetoric around birth—like many of the choices and rhetoric around motherhood in general—are so polarized.” It’s a big decision. A woman’s health and risk factors should be central considerations in deciding on a birth venue. Although studies have shown that absolute risks of planned home birth are low, home births don’t always go as planned. Planned home birth is associated with increased risk of neonatal death when compared with planned hospital birth. Risks also increase in women with certain medical conditions such as hypertension, breech presentation, or prior cesarean deliveries, or in births where there are inadequately trained attendants. It is important for any woman choosing home birth to have a certified nurse-midwife, certified midwife, or physician practicing within an integrated and regulated health system with ready access to consultation and a plan for safe and quick transportation to a hospital in case of an emergency. While ACOG believes that hospitals and birthing centers are the safest place for labor and delivery, we respect a woman’s right to make a medically informed decision about her birth experience. ACOG also continues to support collaborative practices between physicians and certified nurse-midwives/certified midwives to further improve outcomes for pregnant women and their babies. Ultimately, women have a choice in where to give birth. As ob-gyns, it’s our job to educate our patients on the risks and benefits of hospital vs. home delivery and help them make the best decision for themselves and their families. —James T. Breeden, MD, ACOG President

Sunday, May 27, 2012

Safety or Cognitive Dissonance

(Posted with permission) A couple months ago I cared for a woman in labor who strongly desired a VBAC. In the two years since the birth of her daughter by cesarean section for breech she had struggled with anxiety and some mild depression. This lovely woman had done her research and educated herself about breech delivery. She realized that she had not been given true informed consent about her reasonable options and her hopes for allowing her body to work as nature intended were not respected. She had valid concerns that her depressive symptoms were exacerbated by her feeling of helplessness and by some resentment towards the medical system that had failed her. Upon the good news that a second baby was on the way she was determined to empower herself and find a way to affirm her body’s ability to deliver vaginally. One major obstacle stood in her way. She lives in Ventura, California. In a county where VBAC is truly treated as a four-letter word. Community Memorial hospital, Ventura County Medical Center, Simi Valley hospital, St. John’s Regional Medical Center in Oxnard, Pleasant Valley Hospital and, even, Cottage Hospital in nearby Santa Barbara all “ban” VBAC. At the one institution where it might be possible to have a VBAC in Thousand Oaks, the protocols and restrictions are so rigid that they, themselves, limit the chances of success. I met this couple early in their pregnancy when they came to me as an option for the reasonable choice of a VBAC out of the hospital. Since they live up in the hills of Ventura and their home is under construction they happily chose to birth with me and a licensed midwife at a Birth Center in Ventura. Given true informed consent of the benefits and risks of VBAC and repeat cesarean section derived from much of the information in the NIH VBAC Consensus Statement from 2010, the decision was well informed and an easy one for them to make. Her chances of avoiding a surgical birth and all the joys of an un-medicated vaginal birth were 75-80% and her risks of a problematic outcome were about 0.33%. As the pregnancy progressed it was evident that, like her first baby, this baby was going to remain frank breech. She tried all the usual remedies including acupuncture, chiropractic and external version with no success. We then spent much time reviewing the options when a baby is breech. She was fully aware that the problems of finding a practitioner willing to perform a breech delivery extended far beyond Ventura County. Despite the refutation of the 2000 Hannah paper by many authors. The more recent PREMODA study, Glezerman article and the 2009 statement by the Society of OB/GYN of Canada supporting the retraining of selective vaginal breech delivery it is pretty much a given that breech = c/section in most parts of the country. I have discussed the breech issue before and suffice it to say that most doctors of my generation were trained to perform selected breech deliveries but have given it up. The reasons given are always “safety”. Safety is often a canard for something else when it flies in the face of obvious academic disagreement on this issue. I have also written on the trinity of expediency, economics and litigation-mitigation as one possible explanation. Younger physicians do have the excuse that they were never trained in breech and therefore, for them, c/section is the only option. However they should honor the ethical duty to at least inform women of the data and offer to refer them to someone who may be able to offer them a vaginal choice. In a recent conversation with another client about these issues I began to formulate a theory as to why knowledgeable physicians so quickly condemn, obscure and ridicule the choices of VBAC, breech, often twin vaginal birth and home delivery. I think my colleagues are good people. They are certainly intelligent and most keep up on the academic literature. They must be aware that at the very least there is good evidence by reputable researchers and institutions that support the safety of these choices. Ethics and true informed consent would dictate that at least they give patients unbiased information and options even if they are not comfortable with them. Yet there is the common scenario of physician certainty that to choose one of the options is dangerous and deserving of ridicule. Ridicule of the choice and derision of those of us who would offer it. How does one justify doing only surgical births as a matter of policy when they must know otherwise? Physicians of my age in their fifties tend to be the leadership of the Obstetric Departments of hospitals. They were almost certainly trained to do twin and breech deliveries. VBACs were the norm and require no special skill. They must know of the phrase, “Primum Non Nocere”, first, do no harm. Yet they skew their counseling to convince women of the safety of a surgical birth, sometimes say really mean things to women who question this and act unprofessionally towards their colleagues who differ with them. Why? My theory: COGNITIVE DISSONANCE! The term cognitive dissonance is used to describe the feeling of discomfort that results from holding two conflicting beliefs. When there is a discrepancy between beliefs and behaviors, something must change in order to eliminate or reduce the dissonance. There are three key strategies to reduce or minimize cognitive dissonance: • Focus on more supportive beliefs that outweigh the dissonant belief or behavior. • Reduce the importance of the conflicting belief. • Change the conflicting belief so that it is consistent with other beliefs or behaviors. http://psychology.about.com/od/cognitivepsychology/f/dissonance.htm Let’s examine what is happening in light of this definition. A physician or group of physicians is subject to a hospital policy banning VBACs, breeches and many twin vaginal births. This policy may or may not have been their own creation or they may have succumbed to pressures from other departments like anesthesia or risk management. Nonetheless, it is a policy of the hospital to which they must comply in order to continue to practice there. When evidence in the literature clearly conflicts with that policy it must be very difficult to justify that evidence with what they are doing. Rationalizing and reliance on only those papers that support the policies satisfies strategy 1 in reducing cognitive dissonance. Ridiculing those, like me, who offer options based on that ignored evidence and dismissing patient’s honest inquiries as ill-informed helps to satisfy strategy 2. Finally, emphasizing only the risks of the banned choices and diminishing or ignoring the risks of surgical birth helps to make the information fit their belief and fulfill strategy 3. I submit that a good and moral person would have a very hard time living with themselves when performing c/sections they knew were not necessary. Especially when they are fully aware that there are other evidenced based choices that women may choose. This inner struggle with truth cannot be reconciled without the theory of cognitive dissonance. Living and working in a community where its conformity or ostracism is an awful choice. Good men and women in such a setting may have to alter their values in order to survive. One explanation is to believe it’s a form of the Stockholm Syndrome where the hostage begins to identify with his/her kidnapper. Believing, despite evidence and training, that the policies you are upholding are absolutely right complies with my theory as to why so many doctors and institutions are able to ban reasonable choices and vehemently condemn and vilify those that think or act otherwise. When my client found out she was breech again we sat down and had an hour long conversation about choices. We discussed the risks of home birth, VBAC and breech. None of which, on the merits alone, were reason to give up her only hope of a vaginal birth that was so important to her psyche. We came to the conclusion that she wanted to try and since obviously no hospital would even let her, an out of hospital birth became the reasonable option. She went into labor in the early morning hours and over the day progressed and, with contractions spacing out, then stalled out at 8 cm. Had she been a primip and vertex she would have been a great candidate for pitocin augmentation and possibly an epidural. But because she was breech and a VBAC we knew that transfer meant a c/section. The doctor on call at one of the local hospitals had a reputation for being most unfriendly toward home birth transfers so we decided to go to Ventura County Medical Center and accept whichever doctor was on call. They preferred to stay local and not to drive 60 miles to a friendlier back-up scenario. Pleasantly surprised, we were well received by the doctor and staff at VCMC and after a couple hours of admission proceedings she had a repeat c/section, a healthy baby and an uneventful postpartum stay. At a home visit a few days later we revisited her birth experience and she felt much better about the end result because she knew she had been given the opportunity to try. About 2 months postpartum around 10 AM on a Friday she had a knock on her door from an investigator from the Medical Board of California. They were seeking her signature on a release of records to investigate a complaint about my care as a possible violation of the California Medical Practice Act. The patient and her family were delighted with her care and had no complaints so politely refused to cooperate with the investigator. Clearly the complaint came from someone outside of the mother's primary care providers with knowledge of the circumstances of this birth. Since that information is kept confidential I can only speculate that someone without the background of history and factual procedures specific to this case felt that “safety” and standard of care was at issue here. They knew what I offered her was not within community standard since no one in the area allows VBACs or vaginal breeches and home delivery, in every case, is frowned upon. While this complaint was recently closed as unfounded by the Medical Board it is likely that every transfer of care in this community may well generate another letter. It is unlikely there will be any revelation that the care offered to this family was within reason. That would disturb the bubble of cognitive dissonance in which they live. Whereas writing the letter strengthens the delusion that only their model of care is the correct one. In an ideal world the evidenced based, literature supported option of VBAC and/or selected breech delivery would be something best performed in a supportive hospital environment. But since the same people who complain about me do not offer these choices women are left with skewed options that are often less safe and certainly less nurturing. Writing indignant letters of complaint makes those that deny choice feel better about themselves. Self-reflection is not a value or a virtue in these physicians and institutions. They fail to teach future generations of obstetricians the skills needed to deal with breeches and twins. They seem to accept as safe and normal that 33% of all women need c/sections. They believe that normal human birth need be treated as an illness. They selectively choose which science fits their model and conveniently ignore anything else. They vilify and harass those that provide common sense choices they do not approve of. And they use fear and derision as a tactic to convince patients they are foolish to question their authority. I remain hopeful that women and families will demand options and that organized medicine will see the error in their ways and return to accepting common sense and evidenced based care. I have no doubt that my colleagues who have drifted away from this reality can wake up and be kind and accepting of alternatives. Only if their world continues to be filled with cognitive dissonance could good, moral men and women deny informed consent and still go to bed at peace each night To continue in this fog is unthinkable. Happy Memorial Day, Dr. F

Friday, April 6, 2012

Art Class or Martial Art Class, a primer on choices

Recently there have been a series of original research papers and some review articles favorable to what I have been advocating for several years. Articles supportive of the safety of home birthing have come out recently. Possibly in response to the flawed Wax paper. The catalyst for these papers could be a return to sanity and evidence based writing or it could be because more investigations are occuring due to rising consumer demand for an alternative to the hospital model. Whatever the reasoning it is good to see well done studies that concur with common sense.

In a recent study of more than 11,000 VBACs looking at outcomes and timing of intervention to prevent fetal injury it was found that the rupture rate was 0.3%, that of those only about 17% suffered serious injury and the success rate for VBAC in this study was 84%!!

Glezerman, et al had a well written paper in Medscape that reviewed the history of breech delivery and clearly defined the damage done by the poorly conducted Term Breech Trial in 2000 by Hannah. “This single piece of research profoundly and ubiquitously changed medical practice and effectively removed planned VBD from delivery wards in the western world.” And, “The TBT was a blatant example of how an inadequate randomized controlled trial can change medical practice.” In the year that followed release of this study the breech c/section rate in the Netherlands went from 57% to 83%.

The subsequent Premoda study from 2006 included 8000 (4 x TBT #s) women with singleton breech. This study found no difference in perinatal morbidity or mortality in breech babies delivered by c/s versus vaginal delivery. Yet nothing has changed as far as hospital policies toward breech nor has residency training in this skill returned.

Similar papers have come out in the last decade about the safety of term vaginal twin delivery. Surprisingly, and little known, was a paper published in 2000 in the Green Journal by Blickstein, et al which concluded, "There was no evidence that vaginal birth is unsafe, in terms of depressed Apgar scores and neonatal mortality, for breech first twins that weighed at least 1500 g.” So there is even evidence in ACOG's own journal about the safety of first twin breeches and yet more than 80% of all twins and nearly 100% of breech first twins are delivered by c/section in the United States. Even more surprising was this conclusion: “We did not see any intrapartum fetal entanglement, one of the most frequently cited specific complications of vaginal birth of breech first twins despite its overall rarity.”Our series that combined the experience of 13 centers and was five to eight times larger than previous reports, cast doubts on the relevance of the locked twins as a contraindication to vaginal birth.” Yet for as long as I can recall until present day, midwives and physicians are taught to fear the dreaded interlocking head scenario of Breech/vertex twins. While there are anecdotal cases, usually in premies, there is no hard data to support this ubiquitous premise.

Some who advocate for hospital birthing and condemn any and all who participate in home birthing are quick to point to the "safety" argument. The "what if something goes wrong" crowd will always use fear and blame to make their point. This blog is not to discuss the open argument about the safety of home vs. hospital birthing. I have done that before and will again. My point today is to reiterate the AMA code of ethics that supports respect for patient autonomy and decision making. “Conflicts of interest should be resolved in accordance with the best interest of the patient, respecting a woman’s autonomy to make health care decisions.”

What are the risks of the choice? What are the benefits of the choice? Whose choice is it? What is the role of the practitioner to give true informed consent based on evidenced based science? What is the role of the practioner when the patients choice differs from the practitioner's bias? These are very important questions and should always be analyzed with respect to a code of ethics. If I cannot support what a patient desires I am free to refer her elsewhere but I should not deny her information or skew my counseling to funnel her down a path of my choosing.

How we interpret risk vs benefit may be quite different from family to family. Differing life experiences and levels of education make blanket policies inadequate and dishonest. Something that carries a risk of 0.3% (or 1/333) also means that there is a 99.7% chance it will not happen. To have policies or adminstrators or insurers or writers condemn a woman for choosing a path based on her own risk assessment is totalitarian and not ethical. Banning VBAC, outlawing midwifery, skewing counseling on breech or twin deliveries for reasons (true or false) of safety is disingenuous at best. Is it not safer to put your child in art class than martial arts? Tennis is safer than football. Watching National Geographic Channel carries less risk that SCUBA diving or rock climbing. Should some higher authority decide which activites are allowed under the canard of safety? Would we allow or lives to be restricted in this way? I wouldn't want that sort of restraint on my liberty.

When it comes to choices such as home birthing, VBAC, breech and twins we must continue to respect the individuality of the decision. Same goes for choice of caregiver. Patients have the right to be educated. Educated people cannot be expected to always come to the same conclusions. Ethics dictates allowing for personal choice and responsibility. Decisions concerning one of life's most memorable events are personal and big government, big business and busy body know-it-alls (yes, you Dr. Amy) should just shut up and respect our differences.

Warmly, Dr. F

Tuesday, April 3, 2012

Breaking the Silence

April 3, 2012
Its been 3 months since my last post after taking a hiatus from blogging. It's not for a lack of events but just a needed break. Much has happened in the birthing world since 2012 began. I have been remiss is not writing a tribute to my dear friend and colleague, David Kline, who passed away suddenly on February 6th saddening us all. His imprint on the midwifery and home birthing world in Los Angeles was widespread and his passing left a huge hole in so many of us. There does not exist a more consumate professional, dedicated physician nor loving husband and father than David. I was at his home for some comraderie and chile the day before his passing watching as his team beat my choice in the Superbowl. I expected to have about 30 more annual Superbowl gatherings with my friend. I think of him every day and feel a sadness every time I walk past his empty office and recall his grumpy exterior hiding that mischievous sense of humor. He was taken way before his time and he will be missed.

It may sound a bit prophetic but it does seem that as one door closes, another or several seem to open. Dave supported a lot of the local midwives when others would not. When the news of his death spread throughout the community there were many questions about who would backup all the midwives. The confusion was intense but short-lived as several other doctors stepped forward and offered assistance. Thank you to Drs. Lipedes, Ghozland and Chin for doing the right thing.

Last month I had the honor (and stress) of attending 2 women laboring with breech babies 65 miles apart on the same day. There are not a lot of options for this variation of normal in Los Angeles but I was able to juggle being in 2 places at once despite the famous LA traffic. What a joy to assist in an early morning birth of a baby boy in the Hollywood Hills. thank you Beth, Sara and Yvonne. The other client was a TOLAC and breech who arrested at 8cm. Unfortunately, there was no place to take her where pitocin augmentation would be permitted for a breech and so a repeat c/section was necessary in Ventura. Thank you Karni and Haley for your support. Glad to have you on my team. Someday, soon I hope, many more options will be available in a freestanding facility. The end of February also saw the home delivery of almost 16 pounds of twins born vertex/breech on mom and dad's bedroom floor. Patience is a virtue that midwives have more than OBs. Thank you for the lessons Molly, Katherine and Sheila.

On April 1st I spoke at the Natural Baby Fair in San Diego on VBACs, Twins and Breech delivery. My talk was titled, "Raider of the lost arts", and I reviewed the history of these options in light of some bad science and current evidence based medicine. I enjoyed the audience and the opportunity and got to spend a little time with Ina May to boot. The week before I made the 7 hour drive up to Sacramento to sit in on the California Medical Board Midwife Advisory Council public forum on changing some of the wording in the licensed midwife regulations. The essence of the hearing is to change the requirement of "supervision" to one of "collaboration". The panel consisted of 3 Board administrators, 3 lawyers and no actual Medical Board members. It is a tedious business buried in minutia for what seems to be a simple thing. I am glad I went if only to gain insight into this completely foreign process. By their own admission it may take 2 years to make changes to these 2 paragraphs. How did 2700 pages of Obamacare get passed in 90 days? Sigh! I think it would be very difficult for me to live and work in the administrative world. I prefer hands on in the privacy of a clients home with the immediate gratification of the joy surrounding birth.

I was delighted to create about 23 informational videos for about.com earlier this year on a wide variety of OB and Gyn topics and had a good time speaking at the West LA ICAN meeting on March 4th. Also, did a Skype interview with Sarah and Steve Blight of yourbabybooty.com. Oh, and found time to ride my horses, hang with my kids and cheer on the LA Kings Hockey Club, too.

Which brings me to the last and more serious issue which surfaced today. That of the continuing plight of midwives across the country who are being persecuted and prosecuted for simply helping women who choose to stay home to give birth. The absurdity of the idea that it is OK for a woman to give birth at home alone but in certain states if they ask someone experienced and trained to help them then that assistant may be arrested. Rhetorically speaking, how did we get here? If a neighbor or cab driver assists you it is a good samaritan but if someone who actually knows what they are doing assists it is a crime. Where are the feminists on this issue? Please spread the word that women and families need to start screaming and pounding the table if necessary to be heard by lawmakers. Civil disobedience can be a good thing but lives will be ruined. Bad laws need to be revoked, not just broken. Dr. F

Wednesday, January 4, 2012

Home External Version

January 1,2012. Well, its a new Year! It began with a home visit this afternoon on a new client referred by Mary Lou O'Brien. Alison's second pregnancy was persistent frank breech at 38 1/2 weeks. Her 1st delivery was a beautiful home birth with Mary Lou. As always required, Alison and Dave, her husband, had the right mental "stuff" and no physical problems. We discussed her option of external version after more natural methods had been unsuccessful. However, the cost of going to the hospital for this family was prohibitive so they accepted the very small risk and great benefit of trying to flip the baby at home in bed. Without medication but with warm olive oil, nurturing surroundings and a portable ultrasound available, not to mention a very cooperative baby, the version took less than 30 seconds. An easy forward roll put the baby's head down to the delight of mom, dad & little brother Ocean. We were all overjoyed for them and proud to be able to offer choice, informed consent and alternatives such as external version and breech delivery options. Thanks Mary Lou. Be sure to let us know what happens next. A peaceful 2012 to all.