"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, February 24, 2013

Trusting Nature....Again

Just as she had hoped for she began having regular contractions every 15-20 minutes on the evening of her assigned due date. This couple had a history of several recent pregnancy losses and was so happy expecting their first baby. But like most parents in our fear based society they were frightened of what they had read about birth and especially about hospital birthing. Also, mom worked in a health care facility and what she experienced made her wary of western medicine. Mom has a phobia for hospitals and for needles and so sought out the option of home birthing. They had been referred to me by a midwife colleague in her first pregnancy which had ended in a miscarriage. We had spent much time together over the past two years and the trust necessary for a successful birth was the result. As part of our many conversations we discussed the midwifery approach to pregnancy and birth as well as the medical model and the care that resulted was a hybrid of both. My experience with both models of care gave her the confidence to overcome some mental and physical obstacles. She had to take medication through the first trimester because of her previous miscarriages. In the medical model she would have been labeled “high risk”. But once the milestone was passed and her medication stopped she was as normal as any other mother. Many physicians would have continued to carry the high risk label with all the subsequent fear and over-testing that comes with such a label. There is no doubt in my mind that doing so would have written a much different story of her labor and birth. Add to that the positive group B Strep carrier state and frightening stories of babies gone awry that so often accompanies that scenario and a perfect storm for interventions would be brewing. Through the night her contractions increased in intensity and came every 4-5 minutes. We spoke just after midnight and again at 3:30AM and just after dawn. I cancelled my day in the office as she lived about 50 miles from there and waited. After sunrise and as the morning passed her contractions spaced out. I have become acutely aware of the power of the higher brain over the primitive brain. My lectures about the mammalian nature of birth make the understanding of distractions and the effect on labor so obvious and clear. This family is highly educated and as mentioned tends to think too much on the “what ifs” and so I was not surprised that as the day wore on labor malingered with her contractions coming every 7-20 minutes all day long. My midwife and I stopped over about 7:00PM to take some vital signs and give reassurance and suggestions for comfort, rest and patience. It was likely that if she was not given these things that she would be up another full night and eventually become exhausted. We put her to bed after a warm shower and some fluids and suggested that she not try to walk her baby out. She was able to get some rest and sleep through the night and awoke on the third day still with regular but infrequent contractions and a bit of bloody show. I went to work this time at my much closer office feeling a bit foolish for missing the previous day. But understanding labor and predicting its course is not a fruitful activity. Trusting it, however, has proven reliable. Gradually, her contractions picked up in intensity and frequency to the point where the next phone call just after 7:00PM came from her husband. For those of us practicing the home birth model the call from the husband is a sure sign of things progressing. Mom is now too inwardly focused to make the call. The birth team arrived at 8PM to loud noises and concerned looks from Grandma and relief from dad. A quick assessment showed all to be as it should be and a requested exam was 7 cm. and still intact. I started an IV which drew loud protests. Reminded of her needle phobia I used a little lidocaine first. 2 grams of Ampicillin were administered and we prepared our equipment while mom walked, paced, sat on the toilet, knelt on all fours supported by her man. Around 10PM her membranes spontaneously ruptured and just before 11PM the incredible urge to push could not be resisted. A gentle exam showed baby to be at +2 station with no cervix left. In less than an hour they were holding their baby in their own bed with emotions of relief and exuberance and joy! Having seen birth in hospitals and birth at homes there is no comparison. To call them by the same name, “birth”, does not do justice to the differences. Just over 48 hours had passed from the time of the first regular contraction. I was confident that labor would progress here in its own time. If not, nothing would have been lost with conscientious observation and eventual transfer of care. I have little doubt that my hospital based colleagues would never have allowed nature to follow its own path. The first morning she would be told to go to the hospital. Here she would have gone through the usual litany of tests, consents, interruptions and indignities. Labor cannot function well in that setting. Her contractions spacing out would have precipitated an IV, CFM and either Pitocin augmentation or AROM, likely the former considering the group B strep status. Unable to move or shower would have meant an epidural and eventual AROM likely with fetal scalp electrode and, of course, NPO. If she made it to complete she would have likely been too numb to push effectively leading to a longer second stage and possible operative vaginal birth and laceration or episiotomy. Who does not believe she had at least a 40% chance of a c/section? There is little if any room in the hospital model for patience and trust in the wisdom of the natural labor process. Now, at home, holding her baby for the first time, no lacerations, placenta out, and husband next to her with her own mother looking on there was this amazing smile on her face. A face that earlier had the look of determination mixed with panic that so often appears in transition. Never separated from her baby and a realization of what she had accomplished, her life and that of her child’s will never be the same. The stories they will tell and the admiration husband will have for wife are so different than they might have been had not the process of labor been respected. My experience and wisdom for understanding the variances of the birth process did not come from books or residency training. It is not something I or any obstetrician can glean from watching hospital birthing. There is too much hustle and bustle and timetables and interruptions and fear in that setting to learn to trust birth. I am so fortunate that my journey has taken this path and that I allowed myself to be open to learning. I and the women I care for are grateful to the midwives and visionaries who have taught me well.


  1. Couldn't have said it better myself. You remind me of someone I know and love dearly. ;)

    This also reminds me of a G8 I recently supported as a doula during her unmedicated vaginal birth. All previous babies had been born at home, with the assistance of a midwife. As she was expecting twins this time around, she was not "allowed" the option of having a midwife-attended homebirth (per the state of Alaska).
    We arrived at the hospital and upon requested exam she was 8cm and contracting beautifully. However, the chaos and disruption that ensued soon put an end to her every 2 minute contractions and they stopped entirely. It wasn't until after the fuss was eliminated (a story in and of itself...), hours of waiting intently for things to pick back up again, and requested AROM, that this mom's contractions came back and ultimately led to the healthy, uncomplicated vaginal delivery of her twins.

    Environment is powerful.

  2. Beautiful work. As midwives we so often wish that OBs could see the normal rythyms , the waxing and waning of labour that we see when it is undisturbed and well supported.

    This piece should be required reading for all medical/OB students.

    I had a similar birth a few weeks ago, where baby was born 40 hours post SROM in a multip, where patience (and IVABs after 18hrs) enabled us to experience a joyous and triumphant homebirth at home in water. An everyday miracle but not one commonly experienced by the OBs who only know/see pressure, clock-watching, 'high risk', syntocinon and coercion/distress.

    Again, I salute you.