"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, March 31, 2013

Cesarean Section & Newborn Immunity

With the proliferation of unnatural birth by cesarean section in the United States it is only to be expected that new data on the consequences of this intervention will be forthcoming. We have now had about 30 or more years of rising “elective” cesarean section rates in the U.S. which gives us a good petri dish from which to see good scientific evidence of its effects. One of the negative effects seems to be the rise in respiratory ailments in neonates and children. In a recent review by Cho and Norman, (Cho CE , Norman M. Cesarean section and development of the immune system in the offspring . Am J Obstet Gynecol. 2013;208:249–254), they conclude: “Recent epidemiological studies provide evidence that elective cesarean section (CS) is associated with aberrant short-term immune responses in the newborn infant, and a greater risk of developing immune diseases such as asthma, allergies, type 1 diabetes, and celiac disease. However, it is still unknown whether CS causes a long-term effect on the immune system of the offspring that contributes to compromised immune health.” They conclude that more emphasis should be placed on discussion and counseling amongst professionals and childbearing women. In the same issue of the AJOG is a corresponding article by Romero and Korzeniewski from Wayne State University that discusses the likely causation of Cho’s findings. http://www.ajog.org/article/S0002-9378(12)02261-2/abstract?elsca1=etoc&elsca2=email&elsca3=0002-9378_201304_208_4&elsca4=obstetrics_and_gynecology I strongly suggest reading the full article as it goes into depth explaining the importance of microbial exposure at birth and its correlation to the newborn’s immune response. They cite a sentinel work by Hugo Lagercrantz and Theodore Slotkin that emphasized the importance and adaptive value of intrapartum stress in their seminal article “The ‘Stress’ of Being Born.” In it, “The authors described 4 main transitions that occur at birth: (1) emergence from an aquatic environment where oxygen is acquired through the placenta to a dry environment in which respiratory exchange occurs through the lungs, (2) change from a warm environment in which the fetus has a temperature that is 1 degree higher than the mother on average to a cooler environment at room temperature, (3) moving from a continuous supply of nutrients through the placenta to intermittent feeding in the neonatal period, and (4) going from a sterile bacterial environment to the establishment of the neonatal microbiome (eg, skin, respiratory tract, gut). Lagercrantz and Slotkin's views have gained relevance with time and are now buttressed by a considerable body of work suggesting that the microbiome plays an important role in the developing immune system.” It would seem the body of evidence is beginning to weigh heavily that there are consequences to the route of birth. For those of us that support vaginal birth options this comes as no surprise. Nature does have common sense sometimes. The ethics of informed consent should imply that obstetricians include this information when counseling patients on the RISKS and benefits of an elective cesarean section. One final article in the same edition of the AJOG takes a different tack. Authors Lynch and Iams state: “we fear that their (Cho, et al) limited review of a very complex literature leads the reader to a na├»ve conclusion: that the cesarean procedure itself might be bad for infants and children.” http://www.ajog.org/article/S0002-9378(12)02262-4/abstract?elsca1=etoc&elsca2=email&elsca3=0002-9378_201304_208_4&elsca4=obstetrics_and_gynecology They take a critical look at the methodology and cannot agree with Cho’s conclusions. It seems they think that prematurity and its effects on the immune system may play a role in skewing the data and that cesarean section cannot be isolated as having a direct role in causation. While I applaud the AJOG for publishing all three of these articles and bringing the problem of a rising cesarean section rate into the limelight, I cannot ignore the contradiction to when the Wax paper was published. If you recall, the Wax paper criticized the safety of home birthing and was immediately adopted as gospel by ACOG and critics of home birth. There was no such corresponding critique of its methodology in the same issue of the Green Journal despite a myriad of cited authors who found great flaws in his methodology and conclusions. Maybe I am overly sensitive but it seems clear that these two articles, one critical of elective cesarean section and one critical of home birthing, are being responded to in different fashions, both of which seem to favor and support the expediency of the current medical model of obstetrics. I mean, here you have compelling data of the risk of surgical birth on newborns and whether or not scientists and researchers believe it fully isn’t it worthy of informing mothers of this research and letting them decide? A peaceful Easter to you. Dr. F

Sunday, March 17, 2013

Cholestasis & The Rule of Threes!

One of the oddities and urban legends haunting the halls of medical schools and centers of learning is the theory that bad things often come in sets of three. It may be years before you see an ectopic pregnancy and suddenly you have three. Months go by and suddenly you have three clients in a week who have abnormal Pap smears. Some of us go a long time without having a set of twins in our practice and, then, there are three in one month. No explanation, probably coincidence, but perplexing all the same. The rule of threes has struck again! This past month in my practice I have three women, two of them with twins, who developed cholestasis of pregnancy. Cholestasis of pregnancy usually manifests itself in the third trimester of pregnancy with the symptom of intense itching usually on the belly. Cholestasis of Pregnancy Here is a reference to a relatively simple explanation of this disorder which has an incidence of about 1-2/1000 pregnancies. I thought I would use this blog to illuminate some of the research and thought for my colleagues and me. It is rarely predictable and the major theory is that high levels of certain pregnancy hormones slow or block the flow of bile from the gallbladder. This backup then causes some of the bile salts to be absorbed in the bloodstream and eventually deposited in the skin. Diagnosis is usually suspected by the symptom of a rashless itching and confirmed by laboratory testing. Treatment is discussed in the links I have provided and supplemental Vitamin K has been suggested for the mother while pregnant and nursing and for the baby after birth. There are numerous case reports in the literature of bad fetal outcomes from this disorder, and while not the norm, these have led to the suggestion that the treatment for cholestasis of pregnancy at term is delivery. (Not by cesarean section unless for other indications). Here are a few suggested links: Ursodeoxycholic acid in the treatment of cholestasis of pregnancy: a randomized, double-blind study controlled with placebo. http://www.ncbi.nlm.nih.gov/pubmed/18006244? http://www.ncbi.nlm.nih.gov/pubmed/16449148? http://www.ncbi.nlm.nih.gov/pubmed/19155945? In my practice, so far 2 of the 3 women have been delivered. One set of twins with elevated liver tests was fortunate to have Dr. Wu in Glendale induce her and have a vaginal birth of her vertex/vertex twins. Another was breech and, sadly, had no option of induction so had a primary cesarean section. The third client with twins is still holding on with stable labs, well informed consent and hopes of her home vaginal birth. I hope none of you ever experience this rare problem but am of the philosophy that being well informed is a good thing. Dr. F