"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, August 27, 2013

Student Intern Experience

For 2 months this summer I had a premed student spend 3 days a week with me as a student intern. I had a great time with Marybeth and it was a learning experience for both of us. What follows is a brief summary of her experience and I am hopeful that more students will follow in her footsteps. I look forward to the day when current medical students and possibly even obstetrical residents will desire to step out of the academic medical bubble and experience another way of doing things. Dr. F

"I started my internship hours on Wednesday, 18JUN13.  I arrived at The Sanctuary Birth and Family Wellness Center for 1300 in order to do requisite confidentiality paperwork and got a brief familiarization with office procedures such as prepping files, keeping track of client due dates, etc.  Dr. Fischbein had 4 clients scheduled for the day.  I got to participate in 2 ultrasounds, both were 20 week anatomy scans and both families wanted to know the sex.  One of his clients is pregnant with twins.  After Dr Fischbein chatted with patients, he referred to me if I had any questions and gave my direct patient contact time.  I also took a fundal height using a tape measure on the twin's mama's belly.  Because one of his clients canceled, I used the most of my hours at the clinic to read up on the twin situation and review the chart to see if the twins were monochorionic and/or monoamnoitic or not.  

Dr Fischbein prefers to sit with patients in his office fully clothed first and discuss their concerns before they go to an exam room.  He likes to take his time with patients.  So we did another ultrasound, this time a vaginal one to try to get a gestational date because they are more accurate for crown rump length that early than the belly ultrasounds.  It's was a struggling pregnancy and before the end of my internship it did result in a miscarriage.  Then there were 3 pap smears with 3 CBCs and 3 breast exams.  

The internship continued in this fashion. In order to meet my first goal of learning about the birthing process, I attended on home visit with Dr. Fischbein, one homebirth, and one post-partum visit.  The homebirth was very intense for me.  Initially I just observed quietly while she labored and pushed in the birth pool.  Occasionally the midwives asked me to fetch warm water for them and such.  Dr. Fischbein mostly hung back on the couch so that the midwives could do their thing without him interfering as he is there for backup.   This mama had been laboring for many hours and was getting tired so they called Dr. Fischbein into action.  After mama did some solid pushing in the tub, on the birth stool, seated in her husbands lap, and in their bed, everyone agreed it was an ok time to help with some forceps.  Dr. Fischbein always found a way to pull me in and give me lessons on things, so while mama was pushing from her own bed, she was at the edge with a foot up on my shoulder and I held her leg so I was right up close and personal with this birth.  He first assessed the head by finding the sulcus because he told me you can only use forceps when baby is in certain positions, otherwise it is too dangerous. He explained the risks like bulldogging shoulders and dystocia to the mama and daddy. Once he determined baby was in a good position for what type of forceps he would be using, he numbed mama with some novocaine in case he ended up doing an episiotomy.  I got to see him get the forceps in place, again right up close and personal with a foot on my shoulder and her leg in my hands, and with each contraction mama pushed, he wedged the forceps with baby out a little more, and I had a front row seat to all of this.  He did end up doing the episiotomy, a quick clean cut which gave more room for the forceps and within seconds baby was out and on mama's chest and she had the drug free homebirth that she wanted after all.  It was amazing.  The cord stayed attached for quite awhile as it finished pulsing so that baby could get all her good oxygen and blood from there.  The family had their time to be gentle and relax and the midwives went back to work with the rest of it, helping the placenta, etc, and then Dr. Fischbein was back in the game to repair the tear.  He explained that sometimes mamas get tears along the sides from forceps but this mama luckily didn't.  I held the spotlight while he repaired the cut.  I'm not going to lie, it was a lot of blood.  A lot of blood.  Once he got done with the repair, it hardly looked like much had gone on down there at all.  

Overall I participated in over 20 ultrasounds, some for pregnancy, some for fibroids, some for cysts.  By the end of the internship, I was able to start making out images on my own.  Like anything, it is its own language in a way, and you have to develop fluency in it.  Ergo, I was easily able to meet my goal of learning how to use ultrasound as a diagnostic tool.  

In order to achieve my third objective, like all the previous objectives, it depended upon what the patients presented.  Nobody needed an external version and nobody ended up being a breech vaginal delivery.  I did, however, do urine tests, which is really simple and just involved dipping a color-changing wand into the urine and comparing the results to the answer key if the urine had any protein or sugar in it.  I also attended LE Leche gatherings and was able to assist pre-natal mamas in preparing for breastfeeding.  One mama asked if drinking beer really helped to increase supply and I was able to provide her with sound, good guidance.  It was pretty nice that Dr. Fischbein would just refer to me when any of his patients had breastfeeding questions.

I enjoyed everything about this internship.  It was an absolutely amazing experience.  The only thing I really felt disappointed by was that I didn’t get to see more breech work or a breech delivery. I’m very grateful to SMC for having such an opportunity to design one’s own internship and incredibly grateful to Dr. Fischbein for patiently allowing me to walk in his shadow for two months. I am also amazed by how much I learned and did in just 2 short months with Dr. Fischbein.  He was an incredible mentor."

Monday, August 26, 2013

VBAC is Normal

All you have to do is look at Beth's face to understand the miracle of normal birth. Baby Maiya, born by VBAC today at the Santa Clarita Birth Center in Newhall, CA. Keeping it positive. No other words necessary! Congratulations Beth & Robert. Thank you Renee, Juli & Victoria.  Dr. F

Wednesday, August 21, 2013

Acceptance yes, but not Acquiescence!

(Printed with permission)
Yesterday I flew to Minneapolis for a family gathering and to honor my father on his upcoming 93rd birthday. And, yesterday a lovely couple in southern California had their beautiful baby born breech....by cesarean section.

Flashback to 10 days ago: I received a call from a couple living in San Diego about to have their first baby. Planning a home birth all along they discovered at 38 weeks their baby was in the breech position. Their midwives suggested many of the usual techniques such as chiropractic adjustment, acupuncture with moxi and position changes but to no avail. They were referred to a very nice doctor in the area who scheduled them for a cesarean section. They were never given the option of a vaginal breech birth. Typical of the home birthing culture they were well informed and looked into this option on their own via an internet search which is how I came to meet them.

10 days ago they drove up to Los Angeles for a consultation. We talked for an hour and a half about options and discussed the current literature as well as risks and benefits of both cesarean and vaginal delivery. I gave them copies of Dr. Marek Glezerman's great review on the subject and did an exam and ultrasound to be sure she met the criteria necessary for a safe vaginal birth. Their baby was in the complete breech presentation, flexed head, 7+ pounds, normal anatomy and clinically generous pelvis. And, of course, they truly had the right "mental stuff". Perfect! And even better, they had family in nearby Thousand Oaks, California who were happy to allow them to stay and have their baby at home. So all we had to do was wait for labor to ensue. The only hiccup in the plan was that for months now I had a vacation with my daughter planned and so purposely did not take any regular clients at that time. But breech babies are determined late and, surprise, like many aspects of pregnancy they don't know there is a plan.

So, they moved in to the sister's home and we all crossed our fingers. On the day before I was to leave she came to the office at 38 6/7 weeks announcing she probably passed her mucus plug (oh oh, we could see where this was going). We already knew there were no options she could find in San Diego and the only other breech supportive doctor in Los Angeles, a city of 4 million people, over 100 hospitals and 10 million in the whole metro area was not an option for this family. Two obstetricians in a city of that size who openly and willingly support the evidenced based option of selected vaginal breech delivery. One supporting home delivery and only one supporting hospital birth. Shameful!

Aware of my travel plans, together, we came up with the backup plan of going back down to San Diego while I was away and if labor happened, well, that was baby's decision and they would have a cesarean section with the nice doctor they had met near home in familiar surroundings and close to their midwives. Sure enough, about 7 hours before I was to leave my cell phone rang to say she broke her bag of waters. "Clear fluid!", she proudly announced in her always optimistic and cheerful voice, "But feeling no contractions". We had a nice but brief talk in her car on the freeway back to San Diego. By sunrise she was being prepped for her cesarean and when I reached Denver to change planes I had a beautiful picture of her baby on my phone and a lovely message of thanks. A happy ending and a great lesson in acceptance from a very special couple. So then why did I feel so sad?

That's a rhetorical question, of course. I am sad that informed and legitimate choice is being denied all over our country. I am sad that the leaders of my profession sit idly by and do nothing to train future doctors in the skills of breech delivery. I am sad that hospitals and obstetricians and committees and administrators discourage a reasonable choice. I am sad that insurers and lawyers, who live symbiotically, continue to be the medical decision makers in America. I am sad that when I take rare and deserved time off there is essentially no one to cover me. And, I am sad that this wonderful couple could not experience what they wished for and may now have to deal with the whole VBAC problem next time. I am sad and I am angry. And you all should be, too.   Dr. Stu

Wednesday, August 14, 2013

Revisiting The Vaccine Question

The to vaccinate or not to vaccinate controversy is far from ended despite a recent statement from the CDC based on an Institute of Medicine (IOM) review that concludes, "the evidence favors rejection of a causal relationship between thimerosal–containing vaccines and autism". I have seen this statement repeated in many recent news items including one in USA Today yesterday. (That just doesn't sound right....USA Today yesterday). I do not profess to have any expertise on this subject other than what I hear and read. Which means I am as confused as you are since the truth does not seem as black and white as the IOM would have us believe. I also, do not think there is any conspiratorial process going on between big Pharma and big Government.

So, when asked my opinion recently by a client I was happy to be able to refer them to Jennifer Margulis' new book, "The Business of Baby". Its subtitle talks of what doctors won't tell you and what companies try to sell you and how to determine what's truthful. She presents an extremely well researched and referenced discussion without a personal agenda. Vaccines have performed miracles in the 20th Century, eradicating polio and small pox and minimizing risks from a variety of illnesses from mumps to measles to tetanus. When I traveled to endemic areas I did not hesitate to get vaccinated for yellow fever.

But, as will all aspects of life and, as I have related to pregnancy, there is nothing that is risk free. In my career I have seen a case of Guillain-Barre Syndrome related to a routine vaccine. We know that if the threat of a small pox epidemic from bioterrorism were ever to occur that the vaccine would save millions of lives but a few people would have an allergic reaction and die. Because of our ridiculously litigious American society this predictable and medically acceptable risk would result in lawsuits and has scared so many small pox vaccine manufacturers that only one company remains. Not having the capability of having this vaccine mass produced could be devastating. But I digress.

Whether to vaccinate or not is a personal decision that each of us has to make for ourselves and our children. What I can say is that in healthy women I see no reason to give universal hepatitis B vaccine to a newborn as is the policy in many hospitals. Always ask about this one. It makes absolutely no sense in families who are not active hepatitis B carriers. And almost every pregnant woman is routinely screened for this. Measles, mumps, Rubella, chicken pox and such options as Guardasil for HPV and the flu shot are never mandatory so do your own research as to the pros and cons. (One article out of Japan has shown that high doses of daily Vitamin D has been more effective against the flu than vaccination. Reminder: This study does not end that debate, either.)

I will end this blog with one last example of the rigidity of the academic-medical model taught to most pediatricians. A story related to me by one of my current pregnant clients and one that I hope most pediatricians would abhor. While searching the area for a supportive pediatrician she asked his position on routine vaccination. He stated that he recommended the standard vaccine regimen but that he would still accept her baby into his practice if she chose not to. This sounded most reasonable until he added that if she chose not to vaccinate her baby that he and his associates would only be available for her phone calls during business hours. He would not care for her baby after hours and on weekends should her baby become ill! Seriously, that is what she was told and I believe her. Off to the emergency room with you! As I think about it I am still shaking my head. How does a person say something like that? Does it not seem a bit unethical to that physician? It would be much more honorable to suggest she go elsewhere. I guess this is the new ethics and there is no vaccine against it. Caveat Emptor!

Friday, August 2, 2013


Ok, so many of my colleagues have noted that I always have an opinion and usually a strong one and a relevant one. They say, and I agree, that I should get out there more and advocate for the good things we do to counter so much of the bloviating that goes on from those against reasonable ideas and choices in birthing. Finally I have taken this advice to heart. It is with excitement and a big smile that I am announcing the creation of my very own podcast with original name of Dr. Stu's Podcast with Brian Whitman at www.drstuspodcast.com

Brian is my friend and an accomplished radio personality currently on morning AM radio 870 in Los Angeles and brings his expertise and wit to the show. We discuss timely medical issues and current events. No topic is off limits from the medical world to politics to current events and, of course, LA Kings hockey. Its an informative, informal conversation and banter so come join us. Your support, as always, is appreciated.

Listen online or download for free on iTunes as Dr. Stu's Podcast. The first 3 episodes are up. I will be adding at least 2 new ones every week. Please pass it on, give it a high "5" ranking. Comments and questions are welcome at drstuspodcast@gmail.com