"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.

Tuesday, November 13, 2012

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!

1 comment:

  1. Thank you Dr. Fischbein and Beth Cannon, LM for the work you are doing. The information you shared at the conference helped to inspire many to strive to achieve the skill of breech delivery and offering woman a safe choice. You are truly a pioneer and leader in this field and thank you for sharing your knowledge and passion. In appreciation, Michele Sayball, ND