(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
"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
"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.
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.
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I am sad, too, Dr. Stu!! It is so very sad that our country is just not willing to "get it" in terms of birth, and continues to "scare & bully" women into the medical model. YET I am also so very thankful for your insistence, optimism, support, research-based tirades, and your very presence!! Do keep it up, and I support you wherever I can!! In the spirit of true informed consent....doulaSue
ReplyDeleteThanks doulaSue, I intend to. I love the term "research based tirades". May I use that? My cohost Brian will make hay with it on my podcast at www.drstuspodcast.com
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