"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."

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