"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.

Saturday, April 20, 2013

Labor is not a Toothache!

From curvewire.com: Kim Kardashian Wants C-Section Posted by Johnny Robish on April 10, 2013 - 10:18pm..... “Kim Kardashian Wants C-Section: It’s being reported that pregnant Kim Kardashian wants to give birth by C-section as soon she’s 8-months pregnant because she wants her life back. And since Kanye is a musician, I would assume it’ll most likely be a “Middle-C” section.” ..... I was at a dinner party last night in celebration of the recent homebirth of twins in Santa Barbara, CA. During a lovely evening we discussed a lot of topics and the subject of Ms. Kardashian’s choice came up. This blog is not about bashing her obvious narcissism but her choice did produce a dialogue about labor pain. I have given this subject a lot of thought during my metamorphosis from hospital based to home based practitioner. Since epidurals and narcotics are not available at home we rely on other methods to deal with pain. Movement, water, hypnosis, massage and strong support are beneficial and work well for many laboring women. The key is that these things help cope with the pain but don’t remove it. To understand why coping but not eliminating pain is important we need to ask ourselves why labor is painful in the first place. I mean, if we believe in evolution why wouldn’t the pain of labor evolve away since natural selection usually eliminates those things that are detrimental to the survival of the species. There is, of course, the biblical Garden of Eden explanation but let me put that aside for the moment. Just suppose labor pain is not detrimental but is beneficial. I give credit to my colleague, Aleks Evangelidi, LM, for her insight in this regard........ Anyone who has ever had a toothache or a kidney stone will argue there is no benefit to the pain other than to let us know something is wrong. Painkillers are a godsend in these circumstances. But labor is not a toothache and it is time to look at the pain of labor in a different light. All mammals have labor and all mammals have labor pains. The onset of labor contractions usually build slowly but eventually become quite painful lasting 40-60 seconds followed by 2-3 minutes of relief. The mammalian body responds to this pain by releasing its own narcotics and neurotransmitters that nature designed just for that purpose. Endorphins and enkephalins are the body’s natural opiates. Oxytocin release produces warmth and attachment responses and adrenaline helps the body cope with stress and possibly spaces out the next contraction allowing time for rest and recovery. And don't forget Cortisol, which orchestrates all sorts of needed stress responses including blood sugar modulation. It really is a beautiful cocktail that nature has designed just for this purpose............ When a laboring woman is not allowed to cope with pain as nature designed it is easily understood why hospital epidural rates approach 90%. Having to stay flat in bed so continuous fetal monitoring (CFM) can occur does not allow for the natural desire and ability of mammals to move about in labor to diminish discomfort and use their own pain stimulated cocktail. And so, modern obstetrics encourages epidural use to eliminate pain and modern women think this is a good choice because to them: Labor Pain = Toothache........ It gets back to the saying about the long habit of not thinking something wrong gives it the appearance of being right. Nature is pretty smart. And a toothache does not have a baby inside but a pregnant woman does. And when a woman undergoes the stress of labor so does her baby. Her body’s response to pain releases that cyclical cocktail and those substances certainly cross the placenta. And just maybe all those neurotransmitters and hormones that help mom deal with the pain and stress of labor help her baby cope as well. For after 9 months of sitting comfortably in the womb suddenly everything that baby has ever known is changing. Labor has to be stressful and even painful for the baby and the suddenness of delivery by c-section even more so. Mom’s natural opiates, oxytocin and adrenaline clearly serve a purpose in assisting her baby in this transition. Denying the baby these substances through the commonplace use of epidurals or scheduled c-sections is counter to nature’s design. Babies are little sponges absorbing every experience and forging new and sometimes permanent neural pathways that will be used in the future. Altering labor has to mean altering this process as well. I was never taught this way of thinking in residency and in my 31 years as a physician I have never seen this discussed in a grand rounds or an academic journal and yet it is so common sensical. Modern medicine needs a bit of humbling and as we are beginning to discover when you mess with Mother Nature you inevitably get something not intended........... The process of labor is painful for a reason and that reason just may be how it benefits the baby’s transition to extra-uterine life. Women are too often told that the pain of labor need not be endured. And while modern anesthesia is also a godsend and epidurals have a place in some labors, obstetricians need to rethink their unconcerned attitude towards its ubiquitous use. Especially in those cases where they scoff at the woman with a birth plan that states an avoidance of pain medicine. Allowing laboring women the freedom to move about and use other pain coping mechanisms might just be doing future generations a favor. Once again it boils down to informed consent. If Ms. Kardashian still wants her unnecessary c-section so she can have her life back after reading this blog then that is her choice and should be respected. I am willing to bet she has never been taught about or thought of birth in this way. Dr. F


  1. I wholeheartedly agree! The pain I experienced during labor was excruciating, but it was also a process. There were waves and stages that led up to the more intense pain, so it didn't happen all at once. By the time things got unbearable, I had a lot of support from you, my husband and everyone else and I was ready for it. I could tell my body knew what it was doing and it was important. I volunteered to go along for this ride and knew it would end up okay in the end. The pain was not fun, but it led to something great and I always felt like the journey was as important as the end result. I know that there are reasons why drugs may be absolutely necessary, but in cases where they're not, I strongly encourage women (and doctors) to trust their bodies more often. Thanks for being open to this idea Dr. Fischbein. As a medical doctor in this day and age, you are truly ahead of your time!

  2. Ok where do I start?!?

    Another great post Dr. Fischbein!

    Here are my thoughts.

    1. Restricting movement during labor- I had mentioned this several time during labor and after. If anyone had told me I had to "sit, stay, lie down" during contractions, they were either getting something thrown at their head, or I was going to need pain meds. Movement made the contractions manageable and made me feel as though I was in control of my labor. I understood that each contraction got me closer to the end and that there were breaks between the pain. Also, I felt better un-medicated as I could MOVE to help the baby get in the right position and alleviate pain. I am so thankful that, due to Dr. Fischbein, I was able to TOLAC at home, with this freedom, and had my successful HBAC.

    2. Un-necessarian. I fully support Kim's freedom to choose her birth, but as long as she is educated on her decision. But, here is my opinion. I feel as though I have a leg to stand on as I've had a necessary c-section after an excruciating and extremely difficult/complicated 1st pregnancy. I was miserable through my entire pregnancy- from all day sickness and flu like symptoms for 4 months, to polyhydramnios and resulting terrible hip pain caused by the over-rapid expansion of my hips. I was in pre-term labor from 26 weeks until 38 weeks when I had my c-section. Never once would I have voluntarily had a c-section early just to "get my life back." Tempting, but I wanted to give my little boy the best start to his life as possible and the best was I could have done that, is to stay pregnant as long as possible. Also, is she unaware of the recovery time with a c-section. That time she thinks she will gain "getting her life back" will instead be spent caring for a baby with a major incision. I am almost 20 months out from my c-section and 7 months out from my HBAC and I still have aches, cramps, twinges from my c-section scar.

    I really hope her doctor fully informs her on the risks for herself and her baby before she makes a decision. Best of Luck to Kim.

    1. Thank you Allison for sharing your wisdom. Your comments are always welcome. Respectfully, Dr. F

  3. My colleague whose insight I respect greatly, Nick Fogelson, MD, has rightly pointed out that there is no scientific studies proving that labor pain in mom's benefits babies. He also points out that common sense is not always right using historical examples of the beliefs during the Dark Ages and that nature doesn't always have a design. He is right on all accounts however I do trust my 30+ years of experience and observation that we have been so wrong about pregnancy and labor and the newborn these last decades that trends and consensus opinion (as my ACOG colleagues so like to rely on) are certainly trending toward trusting nature's design as a better model that what we have been using. Until we have proper studies, if ever, showing that mothers' normal labor assists babies and improves outcomes it would seem that my reasoning that it does is likely prudent and will do less harm than the pattern of continued interventions of which there is growing evidence of poorer outcomes. Dr. F

  4. Do you moderate and only post comments that support your view point?

  5. Dear Something, Thanks for asking. No, any respectfully written opinions and comments are welcome here. Did you have more to say? I would welcome more dialogue and honest debate. The opinions expressed here are based on evidence, experience and/or common sense and, therefore, I am very comfortable and confident in them. Dr. F